Betsy Bates

SAN DIEGO — Young women with polycystic ovary syndrome have evidence of endothelial dysfunction and low-grade, chronic inflammatory markers characteristic of much older patients, researchers reported at the annual meeting of the Endocrine Society.

Dr. Evanthia Diamanti-Kandarakis and associates at Laiko Hospital of the University of Athens compared endothelial function and inflammatory cytokines in 25 women with PCOS and 20 age-matched controls with similar body mass index (BMI) measurements and waist-hip ratios. The women were in their mid-to-late 20s and had BMIs of about 26-29 kg/m2.

Endothelial function was assessed by flow-mediated dilatation of the brachial artery on ultrasound, plus plasma endothelin-1. Numerous cytokines were measured to assess arterial inflammation.

Subjects with PCOS had significantly lower percentages of flow-mediated dilatation than controls (3.47% vs 9.26%). Nitrate-induced dilatation, measured to exclude smooth muscle cell injury, was not significantly different in the two groups. Significantly higher levels of endothelin-1, intracellular adhesion molecules, vascular cell adhesion molecules, and C-reactive protein were found in PCOS subjects, compared with controls.

In PCOS “the lining of the arteries is affected and at the same time, the molecules are sticking to each other and to the vessel wall, leading to a compromised circulation as would be seen in a woman much older” than these subjects, Dr. Diamanti-Kandarakis said at a press conference during the meeting.

As expected, testosterone levels were significantly elevated in women with PCOS. When asked to advise clinicians on how to use the information, she pointed out that a multiple regression analysis determined that the best predictors of endothelial damage in PCOS subjects were elevated levels of testosterone and CRP. Young PCOS patients with high levels of both should be closely followed for cardiovascular consequences of the syndrome, particularly if they are obese.

“It they are obese, this risk is multiplied,” she said. “We cannot assume that all women with PCOS have [endothelial dysfunction]. There are different subtypes of the disease,” she said.

SAN DIEGO — Young women with polycystic ovary syndrome have evidence of endothelial dysfunction and low-grade, chronic inflammatory markers characteristic of much older patients, researchers reported at the annual meeting of the Endocrine Society.

Dr. Evanthia Diamanti-Kandarakis and associates at Laiko Hospital of the University of Athens compared endothelial function and inflammatory cytokines in 25 women with PCOS and 20 age-matched controls with similar body mass index (BMI) measurements and waist-hip ratios. The women were in their mid-to-late 20s and had BMIs of about 26-29 kg/m2.

Endothelial function was assessed by flow-mediated dilatation of the brachial artery on ultrasound, plus plasma endothelin-1. Numerous cytokines were measured to assess arterial inflammation.

Subjects with PCOS had significantly lower percentages of flow-mediated dilatation than controls (3.47% vs 9.26%). Nitrate-induced dilatation, measured to exclude smooth muscle cell injury, was not significantly different in the two groups. Significantly higher levels of endothelin-1, intracellular adhesion molecules, vascular cell adhesion molecules, and C-reactive protein were found in PCOS subjects, compared with controls.

In PCOS “the lining of the arteries is affected and at the same time, the molecules are sticking to each other and to the vessel wall, leading to a compromised circulation as would be seen in a woman much older” than these subjects, Dr. Diamanti-Kandarakis said at a press conference during the meeting.

As expected, testosterone levels were significantly elevated in women with PCOS. When asked to advise clinicians on how to use the information, she pointed out that a multiple regression analysis determined that the best predictors of endothelial damage in PCOS subjects were elevated levels of testosterone and CRP. Young PCOS patients with high levels of both should be closely followed for cardiovascular consequences of the syndrome, particularly if they are obese.

“It they are obese, this risk is multiplied,” she said. “We cannot assume that all women with PCOS have [endothelial dysfunction]. There are different subtypes of the disease,” she said.

SAN DIEGO — Young women with polycystic ovary syndrome have evidence of endothelial dysfunction and low-grade, chronic inflammatory markers characteristic of much older patients, researchers reported at the annual meeting of the Endocrine Society.

Dr. Evanthia Diamanti-Kandarakis and associates at Laiko Hospital of the University of Athens compared endothelial function and inflammatory cytokines in 25 women with PCOS and 20 age-matched controls with similar body mass index (BMI) measurements and waist-hip ratios. The women were in their mid-to-late 20s and had BMIs of about 26-29 kg/m2.

Endothelial function was assessed by flow-mediated dilatation of the brachial artery on ultrasound, plus plasma endothelin-1. Numerous cytokines were measured to assess arterial inflammation.

Subjects with PCOS had significantly lower percentages of flow-mediated dilatation than controls (3.47% vs 9.26%). Nitrate-induced dilatation, measured to exclude smooth muscle cell injury, was not significantly different in the two groups. Significantly higher levels of endothelin-1, intracellular adhesion molecules, vascular cell adhesion molecules, and C-reactive protein were found in PCOS subjects, compared with controls.

In PCOS “the lining of the arteries is affected and at the same time, the molecules are sticking to each other and to the vessel wall, leading to a compromised circulation as would be seen in a woman much older” than these subjects, Dr. Diamanti-Kandarakis said at a press conference during the meeting.

As expected, testosterone levels were significantly elevated in women with PCOS. When asked to advise clinicians on how to use the information, she pointed out that a multiple regression analysis determined that the best predictors of endothelial damage in PCOS subjects were elevated levels of testosterone and CRP. Young PCOS patients with high levels of both should be closely followed for cardiovascular consequences of the syndrome, particularly if they are obese.

“It they are obese, this risk is multiplied,” she said. “We cannot assume that all women with PCOS have [endothelial dysfunction]. There are different subtypes of the disease,” she said.

Depression strikes one in five patients hospitalized for myocardial infarction, with severe consequences, including a threefold increased risk of cardiac mortality and significantly elevated mortality from all causes, a comprehensive evidence review has concluded.

The review, conducted by the federal Agency for Healthcare Research and Quality at the behest of the American Academy of Family Physicians, is destined to become the framework for evidence-based clinical practice guidelines, according to the AAFP.

Highlights of the review coordinated by the Johns Hopkins Evidence-Based Practice Center in Baltimore include:

▸ Evidence from 25 trials pointing to a prevalence of depression in one in five patients hospitalized for an MI.

▸ Data from three studies that depression during the initial MI hospitalization persists from 1–4 months in 60%–70% of patients.

▸ “Strikingly consistent” evidence that post-MI depression puts patients at an increased risk for death by cardiac causes (a threefold increased risk) and other causes.

▸ Conclusions from three studies showing that depressed post-MI patients are less likely than are others to take their prescribed medications or to comply with lifestyle modification.

▸ Findings that suggest psychosocial intervention and selective serotonin reuptake inhibitors (SSRIs) improve depression in post-MI patients, but not necessarily other outcomes.

The lengthy analysis pointed out a number of important gaps in scientific knowledge about depression and MI, such as the best way to measure depression in hospitalized MI patients and the true impact of interventions.

For example, SSRIs were found to improve some surrogate markers of cardiac risk, “but no studies of sufficient power address the question of whether this treatment improves survival,” the analysis said.

The Johns Hopkins team, led by Dr. David E. Bush and Dr. Roy C. Ziegelstein, included clinicians and researchers from cardiology, psychiatry, general internal medicine, and cardiac rehabilitation, as well as representatives from the AAFP, the nursing community, and private and government payers.

Six key questions were compiled, several with important subcategories. A literature review was conducted electronically and by hand of 16 specific journals and the electronic databases Medline, Cochrane Central Register of Controlled Trials, the Cochrane Database of Methodology Reviews, the Cumulative Index to Nursing and Allied Health Literature, the Psychological Abstracts, and Embase.

The intensive review unveiled the magnitude of evidence pointing to depression as an important impedance to a full recovery and a return to productive life in many MI patients.

Its conclusions suggest a pivotal role for family physicians, who may be in the best position to oversee “the whole patient” as he or she embarks on the long course of recovery, Dr. Lee A. Green, the AAFP representative to the review panel and a member of the family medicine faculty at the University of Michigan in Ann Arbor, said in a telephone interview.

Patients can survive heart attacks and their hearts can be fine, but they can be disabled by their depression, he said.

The severity of an MI may overshadow less evident aspects of health that should be identified early and managed with the best tools available.

Although the literature review shows that more research is needed to illuminate the best approaches to post-MI depression, it provides ample evidence of the worth of such research.

In the immediate future, the stark findings about the importance of depression following MI may lead to more communication among specialists, including psychiatrists, family physicians, and cardiologists, Dr. Green said.

Depression strikes one in five patients hospitalized for myocardial infarction, with severe consequences, including a threefold increased risk of cardiac mortality and significantly elevated mortality from all causes, a comprehensive evidence review has concluded.

The review, conducted by the federal Agency for Healthcare Research and Quality at the behest of the American Academy of Family Physicians, is destined to become the framework for evidence-based clinical practice guidelines, according to the AAFP.

Highlights of the review coordinated by the Johns Hopkins Evidence-Based Practice Center in Baltimore include:

▸ Evidence from 25 trials pointing to a prevalence of depression in one in five patients hospitalized for an MI.

▸ Data from three studies that depression during the initial MI hospitalization persists from 1–4 months in 60%–70% of patients.

▸ “Strikingly consistent” evidence that post-MI depression puts patients at an increased risk for death by cardiac causes (a threefold increased risk) and other causes.

▸ Conclusions from three studies showing that depressed post-MI patients are less likely than are others to take their prescribed medications or to comply with lifestyle modification.

▸ Findings that suggest psychosocial intervention and selective serotonin reuptake inhibitors (SSRIs) improve depression in post-MI patients, but not necessarily other outcomes.

The lengthy analysis pointed out a number of important gaps in scientific knowledge about depression and MI, such as the best way to measure depression in hospitalized MI patients and the true impact of interventions.

For example, SSRIs were found to improve some surrogate markers of cardiac risk, “but no studies of sufficient power address the question of whether this treatment improves survival,” the analysis said.

The Johns Hopkins team, led by Dr. David E. Bush and Dr. Roy C. Ziegelstein, included clinicians and researchers from cardiology, psychiatry, general internal medicine, and cardiac rehabilitation, as well as representatives from the AAFP, the nursing community, and private and government payers.

Six key questions were compiled, several with important subcategories. A literature review was conducted electronically and by hand of 16 specific journals and the electronic databases Medline, Cochrane Central Register of Controlled Trials, the Cochrane Database of Methodology Reviews, the Cumulative Index to Nursing and Allied Health Literature, the Psychological Abstracts, and Embase.

The intensive review unveiled the magnitude of evidence pointing to depression as an important impedance to a full recovery and a return to productive life in many MI patients.

Its conclusions suggest a pivotal role for family physicians, who may be in the best position to oversee “the whole patient” as he or she embarks on the long course of recovery, Dr. Lee A. Green, the AAFP representative to the review panel and a member of the family medicine faculty at the University of Michigan in Ann Arbor, said in a telephone interview.

Patients can survive heart attacks and their hearts can be fine, but they can be disabled by their depression, he said.

The severity of an MI may overshadow less evident aspects of health that should be identified early and managed with the best tools available.

Although the literature review shows that more research is needed to illuminate the best approaches to post-MI depression, it provides ample evidence of the worth of such research.

In the immediate future, the stark findings about the importance of depression following MI may lead to more communication among specialists, including psychiatrists, family physicians, and cardiologists, Dr. Green said.

Depression strikes one in five patients hospitalized for myocardial infarction, with severe consequences, including a threefold increased risk of cardiac mortality and significantly elevated mortality from all causes, a comprehensive evidence review has concluded.

The review, conducted by the federal Agency for Healthcare Research and Quality at the behest of the American Academy of Family Physicians, is destined to become the framework for evidence-based clinical practice guidelines, according to the AAFP.

Highlights of the review coordinated by the Johns Hopkins Evidence-Based Practice Center in Baltimore include:

▸ Evidence from 25 trials pointing to a prevalence of depression in one in five patients hospitalized for an MI.

▸ Data from three studies that depression during the initial MI hospitalization persists from 1–4 months in 60%–70% of patients.

▸ “Strikingly consistent” evidence that post-MI depression puts patients at an increased risk for death by cardiac causes (a threefold increased risk) and other causes.

▸ Conclusions from three studies showing that depressed post-MI patients are less likely than are others to take their prescribed medications or to comply with lifestyle modification.

▸ Findings that suggest psychosocial intervention and selective serotonin reuptake inhibitors (SSRIs) improve depression in post-MI patients, but not necessarily other outcomes.

The lengthy analysis pointed out a number of important gaps in scientific knowledge about depression and MI, such as the best way to measure depression in hospitalized MI patients and the true impact of interventions.

For example, SSRIs were found to improve some surrogate markers of cardiac risk, “but no studies of sufficient power address the question of whether this treatment improves survival,” the analysis said.

The Johns Hopkins team, led by Dr. David E. Bush and Dr. Roy C. Ziegelstein, included clinicians and researchers from cardiology, psychiatry, general internal medicine, and cardiac rehabilitation, as well as representatives from the AAFP, the nursing community, and private and government payers.

Six key questions were compiled, several with important subcategories. A literature review was conducted electronically and by hand of 16 specific journals and the electronic databases Medline, Cochrane Central Register of Controlled Trials, the Cochrane Database of Methodology Reviews, the Cumulative Index to Nursing and Allied Health Literature, the Psychological Abstracts, and Embase.

The intensive review unveiled the magnitude of evidence pointing to depression as an important impedance to a full recovery and a return to productive life in many MI patients.

Its conclusions suggest a pivotal role for family physicians, who may be in the best position to oversee “the whole patient” as he or she embarks on the long course of recovery, Dr. Lee A. Green, the AAFP representative to the review panel and a member of the family medicine faculty at the University of Michigan in Ann Arbor, said in a telephone interview.

Patients can survive heart attacks and their hearts can be fine, but they can be disabled by their depression, he said.

The severity of an MI may overshadow less evident aspects of health that should be identified early and managed with the best tools available.

Although the literature review shows that more research is needed to illuminate the best approaches to post-MI depression, it provides ample evidence of the worth of such research.

In the immediate future, the stark findings about the importance of depression following MI may lead to more communication among specialists, including psychiatrists, family physicians, and cardiologists, Dr. Green said.

RANCHO MIRAGE, CALIF. – Adenotonsillectomy significantly improved the quality of life, daytime sleepiness, and daytime and nighttime breathing of children with obstructive sleep apnea, but it did not change their behavior, concentration, or school performance, parents reported to Canadian researchers.

Dr. Evelyn Constantin and associates in the departments of pediatrics and psychiatry at Montreal Children's Hospital and McGill University, Montreal, asked parents to assess many aspects of their children's function and behavior before, immediately after, and following recovery from adenotonsillectomy for obstructive sleep apnea (OSA) between 1993 and 2001.

Among 166 questionnaires returned to researchers, 138 were completely filled out. Investigators also assessed behavior changes using the Conners' Parent Rating Scale-Revised for 94 children at least 3 years old.

The results were released at a conference on sleep in infancy and childhood sponsored by the Annenberg Center for Health Sciences.

Significant improvements were reported for quality of life, daytime breathing, sleep breathing, loudness of snoring, and excessive daytime tiredness, the investigators said.

No significant changes were seen after surgery in asthma, bedwetting, concentration, school performance, or intellectual/developmental progress. No short-term or long-term effects of the surgery were seen on any subscale of the Conners' subscales.

Dr. Constantin said during an interview that a prospective study of potential behavioral impacts of adenotonsillectomy for OSA is underway.

RANCHO MIRAGE, CALIF. – Adenotonsillectomy significantly improved the quality of life, daytime sleepiness, and daytime and nighttime breathing of children with obstructive sleep apnea, but it did not change their behavior, concentration, or school performance, parents reported to Canadian researchers.

Dr. Evelyn Constantin and associates in the departments of pediatrics and psychiatry at Montreal Children's Hospital and McGill University, Montreal, asked parents to assess many aspects of their children's function and behavior before, immediately after, and following recovery from adenotonsillectomy for obstructive sleep apnea (OSA) between 1993 and 2001.

Among 166 questionnaires returned to researchers, 138 were completely filled out. Investigators also assessed behavior changes using the Conners' Parent Rating Scale-Revised for 94 children at least 3 years old.

The results were released at a conference on sleep in infancy and childhood sponsored by the Annenberg Center for Health Sciences.

Significant improvements were reported for quality of life, daytime breathing, sleep breathing, loudness of snoring, and excessive daytime tiredness, the investigators said.

No significant changes were seen after surgery in asthma, bedwetting, concentration, school performance, or intellectual/developmental progress. No short-term or long-term effects of the surgery were seen on any subscale of the Conners' subscales.

Dr. Constantin said during an interview that a prospective study of potential behavioral impacts of adenotonsillectomy for OSA is underway.

RANCHO MIRAGE, CALIF. – Adenotonsillectomy significantly improved the quality of life, daytime sleepiness, and daytime and nighttime breathing of children with obstructive sleep apnea, but it did not change their behavior, concentration, or school performance, parents reported to Canadian researchers.

Dr. Evelyn Constantin and associates in the departments of pediatrics and psychiatry at Montreal Children's Hospital and McGill University, Montreal, asked parents to assess many aspects of their children's function and behavior before, immediately after, and following recovery from adenotonsillectomy for obstructive sleep apnea (OSA) between 1993 and 2001.

Among 166 questionnaires returned to researchers, 138 were completely filled out. Investigators also assessed behavior changes using the Conners' Parent Rating Scale-Revised for 94 children at least 3 years old.

The results were released at a conference on sleep in infancy and childhood sponsored by the Annenberg Center for Health Sciences.

Significant improvements were reported for quality of life, daytime breathing, sleep breathing, loudness of snoring, and excessive daytime tiredness, the investigators said.

No significant changes were seen after surgery in asthma, bedwetting, concentration, school performance, or intellectual/developmental progress. No short-term or long-term effects of the surgery were seen on any subscale of the Conners' subscales.

Dr. Constantin said during an interview that a prospective study of potential behavioral impacts of adenotonsillectomy for OSA is underway.

SANTA BARBARA, CALIF. — The melanomas that students are taught to recognize in medical school are often tough to miss—ugly, misshapen, and black, maybe with tinges of blue and red.

In real life, it's not always that easy, Clay J. Cockerell, M.D., said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

“This disease will teach you a lot,” said Dr. Cockerell, president of the American Academy of Dermatology and professor of dermatology and pathology at the University of Texas Southwestern Medical School in Dallas.

Prototypic, evil-looking melanomas do exist, but generally they herald metastatic disease. And while the ABCDs—and now “E” for evolution—can help identify melanomas sooner, the sensitivity for diagnosis by clinical appearance alone still hovers between 48% and 67% in most studies.

“I'd be willing to bet almost every person in this room has missed a melanoma clinically at least once in their career,” Dr. Cockerell surmised.

The diagnostic challenge is only getting more difficult, he said.

“In my own experience looking at hundreds and hundreds of slides under the microscope, there's no question we're seeing far more melanomas than we used to. We're also seeing melanoma at smaller stages in evolution and melanoma that has unusual features,” he said.

These days, if it's black and asymmetrical, “to me, it's melanoma until proven otherwise,” no matter its size, Dr. Cockerell said.

Some entities that can mimic melanoma include a halo nevus, solar lentigo, traumatized blue nevus, seborrheic keratosis, pigmented basal cell carcinoma, pigmented Bowen's disease, pigmented squamous cell carcinoma, and thrombosed angioma.

In a study of 1,784 histologically proven primary melanomas, Dr. Cockerell and associates found 583 that were not clinically suspicious. In these “wolf-in-sheep's-clothing” cases, the presumed diagnoses included nevi, basal cell carcinoma, Bowen's disease, pigmented seborrheic keratosis, and lentigo, among others (Am. J. Dermatopathol. 1991;13:551–6).

Unfortunately, the histologic diagnosis can be murky as well.

Spitz nevus is a well-known mimicker of melanoma, although Dr. Cockerell uses the “Mary Poppins rule” to decide on management. A Spitzlike lesion in a child must be “practically perfect in every way” in terms of meeting criteria for melanoma to draw Dr. Cockerell's concern, while in an adult, the opposite is true.

More perplexing is desmoplastic malignant melanoma, which may have a very “banal” appearance both clinically and under the microscope, he said.

In such a case, characteristic spindle cells may be scarce, while the overall picture is of minimal cytologic atypia. A key to identifying it is nesting within the epidermal component, Dr. Cockerell said.

Photos courtesy Dr. Clay J. Cockerell

Answer Key:

1. irritated blue nevus; 2. nodular melanoma; 3. melanoma with halo; 4. dermatofibroma; 5. pigmented basal cell carcinoma; 6. halo nevus; 7. pigmented basal cell carcinoma; 8. pigmented Bowen's disease

SANTA BARBARA, CALIF. — The melanomas that students are taught to recognize in medical school are often tough to miss—ugly, misshapen, and black, maybe with tinges of blue and red.

In real life, it's not always that easy, Clay J. Cockerell, M.D., said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

“This disease will teach you a lot,” said Dr. Cockerell, president of the American Academy of Dermatology and professor of dermatology and pathology at the University of Texas Southwestern Medical School in Dallas.

Prototypic, evil-looking melanomas do exist, but generally they herald metastatic disease. And while the ABCDs—and now “E” for evolution—can help identify melanomas sooner, the sensitivity for diagnosis by clinical appearance alone still hovers between 48% and 67% in most studies.

“I'd be willing to bet almost every person in this room has missed a melanoma clinically at least once in their career,” Dr. Cockerell surmised.

The diagnostic challenge is only getting more difficult, he said.

“In my own experience looking at hundreds and hundreds of slides under the microscope, there's no question we're seeing far more melanomas than we used to. We're also seeing melanoma at smaller stages in evolution and melanoma that has unusual features,” he said.

These days, if it's black and asymmetrical, “to me, it's melanoma until proven otherwise,” no matter its size, Dr. Cockerell said.

Some entities that can mimic melanoma include a halo nevus, solar lentigo, traumatized blue nevus, seborrheic keratosis, pigmented basal cell carcinoma, pigmented Bowen's disease, pigmented squamous cell carcinoma, and thrombosed angioma.

In a study of 1,784 histologically proven primary melanomas, Dr. Cockerell and associates found 583 that were not clinically suspicious. In these “wolf-in-sheep's-clothing” cases, the presumed diagnoses included nevi, basal cell carcinoma, Bowen's disease, pigmented seborrheic keratosis, and lentigo, among others (Am. J. Dermatopathol. 1991;13:551–6).

Unfortunately, the histologic diagnosis can be murky as well.

Spitz nevus is a well-known mimicker of melanoma, although Dr. Cockerell uses the “Mary Poppins rule” to decide on management. A Spitzlike lesion in a child must be “practically perfect in every way” in terms of meeting criteria for melanoma to draw Dr. Cockerell's concern, while in an adult, the opposite is true.

More perplexing is desmoplastic malignant melanoma, which may have a very “banal” appearance both clinically and under the microscope, he said.

In such a case, characteristic spindle cells may be scarce, while the overall picture is of minimal cytologic atypia. A key to identifying it is nesting within the epidermal component, Dr. Cockerell said.

Photos courtesy Dr. Clay J. Cockerell

Answer Key:

1. irritated blue nevus; 2. nodular melanoma; 3. melanoma with halo; 4. dermatofibroma; 5. pigmented basal cell carcinoma; 6. halo nevus; 7. pigmented basal cell carcinoma; 8. pigmented Bowen's disease

SANTA BARBARA, CALIF. — The melanomas that students are taught to recognize in medical school are often tough to miss—ugly, misshapen, and black, maybe with tinges of blue and red.

In real life, it's not always that easy, Clay J. Cockerell, M.D., said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

“This disease will teach you a lot,” said Dr. Cockerell, president of the American Academy of Dermatology and professor of dermatology and pathology at the University of Texas Southwestern Medical School in Dallas.

Prototypic, evil-looking melanomas do exist, but generally they herald metastatic disease. And while the ABCDs—and now “E” for evolution—can help identify melanomas sooner, the sensitivity for diagnosis by clinical appearance alone still hovers between 48% and 67% in most studies.

“I'd be willing to bet almost every person in this room has missed a melanoma clinically at least once in their career,” Dr. Cockerell surmised.

The diagnostic challenge is only getting more difficult, he said.

“In my own experience looking at hundreds and hundreds of slides under the microscope, there's no question we're seeing far more melanomas than we used to. We're also seeing melanoma at smaller stages in evolution and melanoma that has unusual features,” he said.

These days, if it's black and asymmetrical, “to me, it's melanoma until proven otherwise,” no matter its size, Dr. Cockerell said.

Some entities that can mimic melanoma include a halo nevus, solar lentigo, traumatized blue nevus, seborrheic keratosis, pigmented basal cell carcinoma, pigmented Bowen's disease, pigmented squamous cell carcinoma, and thrombosed angioma.

In a study of 1,784 histologically proven primary melanomas, Dr. Cockerell and associates found 583 that were not clinically suspicious. In these “wolf-in-sheep's-clothing” cases, the presumed diagnoses included nevi, basal cell carcinoma, Bowen's disease, pigmented seborrheic keratosis, and lentigo, among others (Am. J. Dermatopathol. 1991;13:551–6).

Unfortunately, the histologic diagnosis can be murky as well.

Spitz nevus is a well-known mimicker of melanoma, although Dr. Cockerell uses the “Mary Poppins rule” to decide on management. A Spitzlike lesion in a child must be “practically perfect in every way” in terms of meeting criteria for melanoma to draw Dr. Cockerell's concern, while in an adult, the opposite is true.

More perplexing is desmoplastic malignant melanoma, which may have a very “banal” appearance both clinically and under the microscope, he said.

In such a case, characteristic spindle cells may be scarce, while the overall picture is of minimal cytologic atypia. A key to identifying it is nesting within the epidermal component, Dr. Cockerell said.

Photos courtesy Dr. Clay J. Cockerell

Answer Key:

1. irritated blue nevus; 2. nodular melanoma; 3. melanoma with halo; 4. dermatofibroma; 5. pigmented basal cell carcinoma; 6. halo nevus; 7. pigmented basal cell carcinoma; 8. pigmented Bowen's disease

SANTA BARBARA, CALIF. — Add delusions of parasitosis to the list of “red flags” for possible HIV infection, Marcus Conant, M.D., said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

“Every patient I've seen in 2 years with delusions of parasitosis—and I've seen more and more and more of them—is on crystal meth,” said Dr. Conant, a dermatologist in private practice in San Francisco.

What's the connection?

Crystal methamphetamine, a highly addictive drug, undermines judgment, heightens the sex drive, and is popular among populations where the incidence of HIV infection is rising, setting up a perfect formula for rapid HIV spread among users, he said.

Hallucinations are among the psychogenic properties of crystal methamphetamine use, driving many patients to a physician, with complaints of bugs crawling on or within the skin.

Dr. Conant explained that an estimated 1 million Americans are infected with HIV. About half are receiving treatment, a quarter do not require treatment yet or are not receiving drugs for other reasons, and the remaining quarter do not realize they have the disease.

The incidence is rising rapidly among women and minorities, as well as among young gay men who feel detached from the HIV-prevention messages heeded by older men who saw friends die very visible deaths in an era before the availability of antiretroviral drugs.

Crystal methamphetamine users may be having sex with individuals from any of those categories.

“You need to offer them an HIV test,” he advised.

Other “red flags” include presence of any major sexually transmitted disease, including cutaneous STDs such as genital herpes, genital warts, and even crab lice, Dr. Conant said.

He tells patients, “The way you caught this is the way you catch HIV.”

Opportunistic infections such as Kaposi's sarcoma, herpes zoster, and molluscum may also be tip-offs to HIV infection.

Systemic signs may include anemia, a low lymphocyte count, or low cholesterol.

Dr. Conant urged physicians to use their judgment.

“If you miss [suspecting HIV in] a 30-year-old man with a nipple ring and zoster on the chest, don't call me to testify that it was not below standard of care to offer him an HIV test,” he said.

When patients express reluctance to have an HIV test, he suggests telling them that you want “a look at your immune function to make sure cancer or leukemia isn't causing your problem.”

Many patients will then willingly agree to a CD4 count, which, if low, may be enough evidence to persuade them to consent to an HIV test.

SANTA BARBARA, CALIF. — Add delusions of parasitosis to the list of “red flags” for possible HIV infection, Marcus Conant, M.D., said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

“Every patient I've seen in 2 years with delusions of parasitosis—and I've seen more and more and more of them—is on crystal meth,” said Dr. Conant, a dermatologist in private practice in San Francisco.

What's the connection?

Crystal methamphetamine, a highly addictive drug, undermines judgment, heightens the sex drive, and is popular among populations where the incidence of HIV infection is rising, setting up a perfect formula for rapid HIV spread among users, he said.

Hallucinations are among the psychogenic properties of crystal methamphetamine use, driving many patients to a physician, with complaints of bugs crawling on or within the skin.

Dr. Conant explained that an estimated 1 million Americans are infected with HIV. About half are receiving treatment, a quarter do not require treatment yet or are not receiving drugs for other reasons, and the remaining quarter do not realize they have the disease.

The incidence is rising rapidly among women and minorities, as well as among young gay men who feel detached from the HIV-prevention messages heeded by older men who saw friends die very visible deaths in an era before the availability of antiretroviral drugs.

Crystal methamphetamine users may be having sex with individuals from any of those categories.

“You need to offer them an HIV test,” he advised.

Other “red flags” include presence of any major sexually transmitted disease, including cutaneous STDs such as genital herpes, genital warts, and even crab lice, Dr. Conant said.

He tells patients, “The way you caught this is the way you catch HIV.”

Opportunistic infections such as Kaposi's sarcoma, herpes zoster, and molluscum may also be tip-offs to HIV infection.

Systemic signs may include anemia, a low lymphocyte count, or low cholesterol.

Dr. Conant urged physicians to use their judgment.

“If you miss [suspecting HIV in] a 30-year-old man with a nipple ring and zoster on the chest, don't call me to testify that it was not below standard of care to offer him an HIV test,” he said.

When patients express reluctance to have an HIV test, he suggests telling them that you want “a look at your immune function to make sure cancer or leukemia isn't causing your problem.”

Many patients will then willingly agree to a CD4 count, which, if low, may be enough evidence to persuade them to consent to an HIV test.

SANTA BARBARA, CALIF. — Add delusions of parasitosis to the list of “red flags” for possible HIV infection, Marcus Conant, M.D., said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

“Every patient I've seen in 2 years with delusions of parasitosis—and I've seen more and more and more of them—is on crystal meth,” said Dr. Conant, a dermatologist in private practice in San Francisco.

What's the connection?

Crystal methamphetamine, a highly addictive drug, undermines judgment, heightens the sex drive, and is popular among populations where the incidence of HIV infection is rising, setting up a perfect formula for rapid HIV spread among users, he said.

Hallucinations are among the psychogenic properties of crystal methamphetamine use, driving many patients to a physician, with complaints of bugs crawling on or within the skin.

Dr. Conant explained that an estimated 1 million Americans are infected with HIV. About half are receiving treatment, a quarter do not require treatment yet or are not receiving drugs for other reasons, and the remaining quarter do not realize they have the disease.

The incidence is rising rapidly among women and minorities, as well as among young gay men who feel detached from the HIV-prevention messages heeded by older men who saw friends die very visible deaths in an era before the availability of antiretroviral drugs.

Crystal methamphetamine users may be having sex with individuals from any of those categories.

“You need to offer them an HIV test,” he advised.

Other “red flags” include presence of any major sexually transmitted disease, including cutaneous STDs such as genital herpes, genital warts, and even crab lice, Dr. Conant said.

He tells patients, “The way you caught this is the way you catch HIV.”

Opportunistic infections such as Kaposi's sarcoma, herpes zoster, and molluscum may also be tip-offs to HIV infection.

Systemic signs may include anemia, a low lymphocyte count, or low cholesterol.

Dr. Conant urged physicians to use their judgment.

“If you miss [suspecting HIV in] a 30-year-old man with a nipple ring and zoster on the chest, don't call me to testify that it was not below standard of care to offer him an HIV test,” he said.

When patients express reluctance to have an HIV test, he suggests telling them that you want “a look at your immune function to make sure cancer or leukemia isn't causing your problem.”

Many patients will then willingly agree to a CD4 count, which, if low, may be enough evidence to persuade them to consent to an HIV test.

SAN DIEGO — Waist-to-height ratio is more strongly linked to cardiovascular risk than body mass index (BMI), particularly in middle age, according to a large European study presented at the annual meeting of the Endocrine Society.

Harald J. Schneider, M.D., of the Max Planck Institute of Psychiatry in Munich, and associates in Germany and Austria, examined weight, height, and waist and hip circumference and 18 single or combined cardiovascular risk factors in 48,353 primary care patients.

Waist-to-height ratio was most predictive of risk in the entire cohort in both men and women, followed by waist circumference and BMI.

Overall cardiovascular risk was highest at or above a waist-to-height ratio of 0.53 for women and 0.55 for men.

When investigators examined specific age groups, they found that waist-to-height ratio was linked most strongly to cardiovascular risk in men aged 35–54 years and women aged 55–64 years—pivotal ages for the development of cardiovascular disease.

“In the other age groups, the BMI had a better association,” Dr. Schneider told this newspaper following the meeting.

“These findings, however, should be interpreted cautiously because not all differences are significant in the single age groups. Moreover, it should be born in mind that this is a cross-sectional study; therefore, we cannot say which anthropometric parameter best predicts the future occurrence of cardiovascular risk factors and events,” he continued.

He suggested that the cutoffs be considered an “orientation” rather than a strict definition of risk.

SAN DIEGO — Waist-to-height ratio is more strongly linked to cardiovascular risk than body mass index (BMI), particularly in middle age, according to a large European study presented at the annual meeting of the Endocrine Society.

Harald J. Schneider, M.D., of the Max Planck Institute of Psychiatry in Munich, and associates in Germany and Austria, examined weight, height, and waist and hip circumference and 18 single or combined cardiovascular risk factors in 48,353 primary care patients.

Waist-to-height ratio was most predictive of risk in the entire cohort in both men and women, followed by waist circumference and BMI.

Overall cardiovascular risk was highest at or above a waist-to-height ratio of 0.53 for women and 0.55 for men.

When investigators examined specific age groups, they found that waist-to-height ratio was linked most strongly to cardiovascular risk in men aged 35–54 years and women aged 55–64 years—pivotal ages for the development of cardiovascular disease.

“In the other age groups, the BMI had a better association,” Dr. Schneider told this newspaper following the meeting.

“These findings, however, should be interpreted cautiously because not all differences are significant in the single age groups. Moreover, it should be born in mind that this is a cross-sectional study; therefore, we cannot say which anthropometric parameter best predicts the future occurrence of cardiovascular risk factors and events,” he continued.

He suggested that the cutoffs be considered an “orientation” rather than a strict definition of risk.

SAN DIEGO — Waist-to-height ratio is more strongly linked to cardiovascular risk than body mass index (BMI), particularly in middle age, according to a large European study presented at the annual meeting of the Endocrine Society.

Harald J. Schneider, M.D., of the Max Planck Institute of Psychiatry in Munich, and associates in Germany and Austria, examined weight, height, and waist and hip circumference and 18 single or combined cardiovascular risk factors in 48,353 primary care patients.

Waist-to-height ratio was most predictive of risk in the entire cohort in both men and women, followed by waist circumference and BMI.

Overall cardiovascular risk was highest at or above a waist-to-height ratio of 0.53 for women and 0.55 for men.

When investigators examined specific age groups, they found that waist-to-height ratio was linked most strongly to cardiovascular risk in men aged 35–54 years and women aged 55–64 years—pivotal ages for the development of cardiovascular disease.

“In the other age groups, the BMI had a better association,” Dr. Schneider told this newspaper following the meeting.

“These findings, however, should be interpreted cautiously because not all differences are significant in the single age groups. Moreover, it should be born in mind that this is a cross-sectional study; therefore, we cannot say which anthropometric parameter best predicts the future occurrence of cardiovascular risk factors and events,” he continued.

He suggested that the cutoffs be considered an “orientation” rather than a strict definition of risk.

SAN DIEGO — High doses of soy-containing isoflavones were associated with significant improvements in energy, vasomotor symptoms, and psychosocial functioning among postmenopausal women, according to an interim analysis of data from a randomized, placebo-controlled study.

Among the first 35 subjects to complete a 3-month study, the 18 receiving active soy had a 40% reduction in psychosocial symptoms, a 36% reduction in vasomotor symptoms, and a 30% reduction in physical complaints, compared with those receiving placebo.

The study ultimately will enroll 100 healthy women who have not taken hormone therapy for the 6 months prior to enrollment, Kendall Dupree, M.D., said at the annual meeting of the Endocrine Society.

“At this point, we're pretty happy about the results. We think that soy may show an improvement in quality of life in women who have postmenopausal symptoms,” said Dr. Dupree, of the division of endocrinology and metabolism at Johns Hopkins University in Baltimore.

The primary outcome of the study is to determine whether high doses of a carefully studied formulation of a product containing the isoflavonoids genistein and daidzein can produce a quantified impact on quality of life in postmenopausal women.

Results were calculated using the Menopause-Specific Quality of Life questionnaire at baseline, 6 weeks, and 3 months. Within the survey are questions aimed at physical functioning, including energy and activities of daily life; vasomotor symptoms, including hot flashes and night sweats; psychosocial symptoms, including mood and depression; and sexual functioning.

The mean age of the women included in the interim analysis was 55. Despite the improvement in their reported menopausal symptoms, there were no changes in their serum sex hormones.

Previous studies of soy and post-menopausal symptoms have been largely unconvincing, with a systematic review identifying few well-designed trials that show a significant impact on hot flashes or other symptoms (Obstet. Gynecol. 2004;104: 824–36).

However, many previous trials have used relatively low doses of phytoestrogens, often 50 mg/day to about 85 mg/day. The dose in this study was 160 mg/day.

The preparation was dehydrated and did not use alcohol extraction during processing, Dr. Dupree said during a press conference at the meeting.

“Alcohol extraction removes the proteins, which in combination with isoflavones seem to be important,” she said.

A commercial product (Revival Soy, manufactured by Physicians Laboratories Inc., of Kernersville, N.C.) was used in the study.

But study investigators conducted an independent analysis to ensure that the dosages listed on the label were actually contained in the product.

Physicians Laboratories also helped to fund the study in conjunction with the National Center for Complementary and Alternative Medicine within the National Institutes of Health.

“I think this is really hot stuff,” said the moderator of the press conference, Mary Lee Vance, M.D., professor of endocrinology and metabolism and associate director of the General Clinical Research Center at the University of Virginia in Charlottesville.

“Other studies have not shown that soy is very beneficial.”

SAN DIEGO — High doses of soy-containing isoflavones were associated with significant improvements in energy, vasomotor symptoms, and psychosocial functioning among postmenopausal women, according to an interim analysis of data from a randomized, placebo-controlled study.

Among the first 35 subjects to complete a 3-month study, the 18 receiving active soy had a 40% reduction in psychosocial symptoms, a 36% reduction in vasomotor symptoms, and a 30% reduction in physical complaints, compared with those receiving placebo.

The study ultimately will enroll 100 healthy women who have not taken hormone therapy for the 6 months prior to enrollment, Kendall Dupree, M.D., said at the annual meeting of the Endocrine Society.

“At this point, we're pretty happy about the results. We think that soy may show an improvement in quality of life in women who have postmenopausal symptoms,” said Dr. Dupree, of the division of endocrinology and metabolism at Johns Hopkins University in Baltimore.

The primary outcome of the study is to determine whether high doses of a carefully studied formulation of a product containing the isoflavonoids genistein and daidzein can produce a quantified impact on quality of life in postmenopausal women.

Results were calculated using the Menopause-Specific Quality of Life questionnaire at baseline, 6 weeks, and 3 months. Within the survey are questions aimed at physical functioning, including energy and activities of daily life; vasomotor symptoms, including hot flashes and night sweats; psychosocial symptoms, including mood and depression; and sexual functioning.

The mean age of the women included in the interim analysis was 55. Despite the improvement in their reported menopausal symptoms, there were no changes in their serum sex hormones.

Previous studies of soy and post-menopausal symptoms have been largely unconvincing, with a systematic review identifying few well-designed trials that show a significant impact on hot flashes or other symptoms (Obstet. Gynecol. 2004;104: 824–36).

However, many previous trials have used relatively low doses of phytoestrogens, often 50 mg/day to about 85 mg/day. The dose in this study was 160 mg/day.

The preparation was dehydrated and did not use alcohol extraction during processing, Dr. Dupree said during a press conference at the meeting.

“Alcohol extraction removes the proteins, which in combination with isoflavones seem to be important,” she said.

A commercial product (Revival Soy, manufactured by Physicians Laboratories Inc., of Kernersville, N.C.) was used in the study.

But study investigators conducted an independent analysis to ensure that the dosages listed on the label were actually contained in the product.

Physicians Laboratories also helped to fund the study in conjunction with the National Center for Complementary and Alternative Medicine within the National Institutes of Health.

“I think this is really hot stuff,” said the moderator of the press conference, Mary Lee Vance, M.D., professor of endocrinology and metabolism and associate director of the General Clinical Research Center at the University of Virginia in Charlottesville.

“Other studies have not shown that soy is very beneficial.”

SAN DIEGO — High doses of soy-containing isoflavones were associated with significant improvements in energy, vasomotor symptoms, and psychosocial functioning among postmenopausal women, according to an interim analysis of data from a randomized, placebo-controlled study.

Among the first 35 subjects to complete a 3-month study, the 18 receiving active soy had a 40% reduction in psychosocial symptoms, a 36% reduction in vasomotor symptoms, and a 30% reduction in physical complaints, compared with those receiving placebo.

The study ultimately will enroll 100 healthy women who have not taken hormone therapy for the 6 months prior to enrollment, Kendall Dupree, M.D., said at the annual meeting of the Endocrine Society.

“At this point, we're pretty happy about the results. We think that soy may show an improvement in quality of life in women who have postmenopausal symptoms,” said Dr. Dupree, of the division of endocrinology and metabolism at Johns Hopkins University in Baltimore.

The primary outcome of the study is to determine whether high doses of a carefully studied formulation of a product containing the isoflavonoids genistein and daidzein can produce a quantified impact on quality of life in postmenopausal women.

Results were calculated using the Menopause-Specific Quality of Life questionnaire at baseline, 6 weeks, and 3 months. Within the survey are questions aimed at physical functioning, including energy and activities of daily life; vasomotor symptoms, including hot flashes and night sweats; psychosocial symptoms, including mood and depression; and sexual functioning.

The mean age of the women included in the interim analysis was 55. Despite the improvement in their reported menopausal symptoms, there were no changes in their serum sex hormones.

Previous studies of soy and post-menopausal symptoms have been largely unconvincing, with a systematic review identifying few well-designed trials that show a significant impact on hot flashes or other symptoms (Obstet. Gynecol. 2004;104: 824–36).

However, many previous trials have used relatively low doses of phytoestrogens, often 50 mg/day to about 85 mg/day. The dose in this study was 160 mg/day.

The preparation was dehydrated and did not use alcohol extraction during processing, Dr. Dupree said during a press conference at the meeting.

“Alcohol extraction removes the proteins, which in combination with isoflavones seem to be important,” she said.

A commercial product (Revival Soy, manufactured by Physicians Laboratories Inc., of Kernersville, N.C.) was used in the study.

But study investigators conducted an independent analysis to ensure that the dosages listed on the label were actually contained in the product.

Physicians Laboratories also helped to fund the study in conjunction with the National Center for Complementary and Alternative Medicine within the National Institutes of Health.

“I think this is really hot stuff,” said the moderator of the press conference, Mary Lee Vance, M.D., professor of endocrinology and metabolism and associate director of the General Clinical Research Center at the University of Virginia in Charlottesville.

“Other studies have not shown that soy is very beneficial.”

SANTA BARBARA, CALIF. — Men and women are similarly devoted to long-term participation in Alcoholics Anonymous, progressing at about equal rates through the 12 steps that define the voluntary, nonprofit program for problem drinkers.

But a study presented at the annual meeting of the Research Society on Alcoholism found intriguing gender differences in two areas of Alcoholics Anonymous (AA) participation.

Women just starting out in AA tended to place more emphasis on deferring to a higher power for their recovery than women who had spent more than a year in the program.

For men, the pattern was reversed. Newcomers to the program were much less likely than women to place a high degree of importance on a higher power's role in their recovery. But those who had spent more than a year in the program attributed a great deal of importance to a higher power's role, surpassing women's ratings on this measure.

Men, regardless of how long they had participated in AA, were significantly more likely than women to participate in sister AA 12-step programs such as Narcotics Anonymous.

J. Scott Tonigan, Ph.D., of the center on alcoholism, substance abuse, and addictions at the University of New Mexico, Albuquerque, studied the responses of 99 AA members from five AA groups to a series of questionnaires about the program.

The cohort included 73 men and 26 women. Their average age was 44, and they reported an average of 69 months of abstinence.

Most had attended AA for more than 1 year, but 35 were newcomers, allowing Dr. Tonigan to capture differences in participants' outlooks based on their longevity in AA.

Regardless of gender, those who had spent more time in the program were significantly more likely to say they were following the central constructs of AA: making amends to others, believing in a higher power, practicing AA behaviors, and completing steps in the program.

“Perhaps … they had more time to do so relative to the short-term AA members,” Dr. Tonigan wrote in his poster.

In this study, just 3 of 26 women but 28 of 73 men said they had attended sister AA programs. Women who had been involved with AA longer placed less emphasis on a higher power than did women who had just started AA, while for men the reverse was true.

Dr. Tonigan said it is possible that these unexpected findings could be attributable to the cross-sectional nature of the study, to gender differences in substance abuse (with regard to attendance at sister AA program meetings), or to type 1 error, because the number of subjects in the study was small.

He stressed that men and women tend to similarly complete AA steps, read AA literature, and find sponsors—all key elements in the program's proven ability to foster abstinence.

However, he said, a better understanding of what keeps men and women attending AA may help clinicians to assist their patients in benefiting from the mutual-help group.

SANTA BARBARA, CALIF. — Men and women are similarly devoted to long-term participation in Alcoholics Anonymous, progressing at about equal rates through the 12 steps that define the voluntary, nonprofit program for problem drinkers.

But a study presented at the annual meeting of the Research Society on Alcoholism found intriguing gender differences in two areas of Alcoholics Anonymous (AA) participation.

Women just starting out in AA tended to place more emphasis on deferring to a higher power for their recovery than women who had spent more than a year in the program.

For men, the pattern was reversed. Newcomers to the program were much less likely than women to place a high degree of importance on a higher power's role in their recovery. But those who had spent more than a year in the program attributed a great deal of importance to a higher power's role, surpassing women's ratings on this measure.

Men, regardless of how long they had participated in AA, were significantly more likely than women to participate in sister AA 12-step programs such as Narcotics Anonymous.

J. Scott Tonigan, Ph.D., of the center on alcoholism, substance abuse, and addictions at the University of New Mexico, Albuquerque, studied the responses of 99 AA members from five AA groups to a series of questionnaires about the program.

The cohort included 73 men and 26 women. Their average age was 44, and they reported an average of 69 months of abstinence.

Most had attended AA for more than 1 year, but 35 were newcomers, allowing Dr. Tonigan to capture differences in participants' outlooks based on their longevity in AA.

Regardless of gender, those who had spent more time in the program were significantly more likely to say they were following the central constructs of AA: making amends to others, believing in a higher power, practicing AA behaviors, and completing steps in the program.

“Perhaps … they had more time to do so relative to the short-term AA members,” Dr. Tonigan wrote in his poster.

In this study, just 3 of 26 women but 28 of 73 men said they had attended sister AA programs. Women who had been involved with AA longer placed less emphasis on a higher power than did women who had just started AA, while for men the reverse was true.

Dr. Tonigan said it is possible that these unexpected findings could be attributable to the cross-sectional nature of the study, to gender differences in substance abuse (with regard to attendance at sister AA program meetings), or to type 1 error, because the number of subjects in the study was small.

He stressed that men and women tend to similarly complete AA steps, read AA literature, and find sponsors—all key elements in the program's proven ability to foster abstinence.

However, he said, a better understanding of what keeps men and women attending AA may help clinicians to assist their patients in benefiting from the mutual-help group.

SANTA BARBARA, CALIF. — Men and women are similarly devoted to long-term participation in Alcoholics Anonymous, progressing at about equal rates through the 12 steps that define the voluntary, nonprofit program for problem drinkers.

But a study presented at the annual meeting of the Research Society on Alcoholism found intriguing gender differences in two areas of Alcoholics Anonymous (AA) participation.

Women just starting out in AA tended to place more emphasis on deferring to a higher power for their recovery than women who had spent more than a year in the program.

For men, the pattern was reversed. Newcomers to the program were much less likely than women to place a high degree of importance on a higher power's role in their recovery. But those who had spent more than a year in the program attributed a great deal of importance to a higher power's role, surpassing women's ratings on this measure.

Men, regardless of how long they had participated in AA, were significantly more likely than women to participate in sister AA 12-step programs such as Narcotics Anonymous.

J. Scott Tonigan, Ph.D., of the center on alcoholism, substance abuse, and addictions at the University of New Mexico, Albuquerque, studied the responses of 99 AA members from five AA groups to a series of questionnaires about the program.

The cohort included 73 men and 26 women. Their average age was 44, and they reported an average of 69 months of abstinence.

Most had attended AA for more than 1 year, but 35 were newcomers, allowing Dr. Tonigan to capture differences in participants' outlooks based on their longevity in AA.

Regardless of gender, those who had spent more time in the program were significantly more likely to say they were following the central constructs of AA: making amends to others, believing in a higher power, practicing AA behaviors, and completing steps in the program.

“Perhaps … they had more time to do so relative to the short-term AA members,” Dr. Tonigan wrote in his poster.

In this study, just 3 of 26 women but 28 of 73 men said they had attended sister AA programs. Women who had been involved with AA longer placed less emphasis on a higher power than did women who had just started AA, while for men the reverse was true.

Dr. Tonigan said it is possible that these unexpected findings could be attributable to the cross-sectional nature of the study, to gender differences in substance abuse (with regard to attendance at sister AA program meetings), or to type 1 error, because the number of subjects in the study was small.

He stressed that men and women tend to similarly complete AA steps, read AA literature, and find sponsors—all key elements in the program's proven ability to foster abstinence.

However, he said, a better understanding of what keeps men and women attending AA may help clinicians to assist their patients in benefiting from the mutual-help group.

SANTA BARBARA, CALIF. — Severe pruritus may be the first presenting sign of cancer, which most typically turns out to be Hodgkin's disease, Timothy G. Berger, M.D., said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

But the question that always arises is when to suspect cancer and not one of the many neuropathic causes of itch on normal-appearing skin.

When do you work up a patient when there's nothing to see? “The reason all of us are totally paranoid is that you can't do a CT scan on every patient with itch,” said Dr. Berger, professor of clinical dermatology at the University of California, San Francisco.

His advice is to treat the patient conservatively, but to schedule repeat visits if traditional therapies fail to relieve long-standing idiopathic itch.

He is most concerned, he said, when the itching is “disproportionately severe.”

In such a case, he orders tests of liver function, iron and lactic hydrogenase levels, and endocrine function.

Dr. Berger described a patient with a history of years of severe itch whose sedimentation rate and lactic hydrogenase levels were normal, but who had a CD4 count of 180 cells/μL despite a negative HIV test.

He referred the patient to an oncologist to evaluate a bulge in the groin that the patient thought was a hernia, but proved to be a low-grade T-cell lymphoma.

When patients are undergoing radiation and chemotherapy treatments for Hodgkin's disease but continue to suffer from severe pruritus, Dr. Berger recommends systemic corticosteroids; cimetidine (200 mg, four times daily); or mirtazapine (7.5–15 mg each night) possibly in combination with paroxetine (20–40 mg each night). Patients with solid tumors can also experience severe pruritus, and his advice is to “pick from the bag” of effective therapies, including paroxetine (5–20 mg nightly), mirtazapine (7.5–15 mg nightly), a combination of paroxetine and mirtazapine, or thalidomide (100 mg nightly).

Pruritus is a problem for a third to half of patients with the myeloproliferative disorder polycythemia vera as well, Dr. Berger said. For the vast majority of patients, the itch associated with this disease is aquagenic, occurring for 5–120 minutes after bathing.

The standard treatment has been aspirin (81–300 mg/day); however, a recent survey of patients suggests that a good second choice is paroxetine (20 mg up to 40 mg/day). Other SSRIs do not have the same antipruritic effect in polycythemia vera patients, he said.

SANTA BARBARA, CALIF. — Severe pruritus may be the first presenting sign of cancer, which most typically turns out to be Hodgkin's disease, Timothy G. Berger, M.D., said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

But the question that always arises is when to suspect cancer and not one of the many neuropathic causes of itch on normal-appearing skin.

When do you work up a patient when there's nothing to see? “The reason all of us are totally paranoid is that you can't do a CT scan on every patient with itch,” said Dr. Berger, professor of clinical dermatology at the University of California, San Francisco.

His advice is to treat the patient conservatively, but to schedule repeat visits if traditional therapies fail to relieve long-standing idiopathic itch.

He is most concerned, he said, when the itching is “disproportionately severe.”

In such a case, he orders tests of liver function, iron and lactic hydrogenase levels, and endocrine function.

Dr. Berger described a patient with a history of years of severe itch whose sedimentation rate and lactic hydrogenase levels were normal, but who had a CD4 count of 180 cells/μL despite a negative HIV test.

He referred the patient to an oncologist to evaluate a bulge in the groin that the patient thought was a hernia, but proved to be a low-grade T-cell lymphoma.

When patients are undergoing radiation and chemotherapy treatments for Hodgkin's disease but continue to suffer from severe pruritus, Dr. Berger recommends systemic corticosteroids; cimetidine (200 mg, four times daily); or mirtazapine (7.5–15 mg each night) possibly in combination with paroxetine (20–40 mg each night). Patients with solid tumors can also experience severe pruritus, and his advice is to “pick from the bag” of effective therapies, including paroxetine (5–20 mg nightly), mirtazapine (7.5–15 mg nightly), a combination of paroxetine and mirtazapine, or thalidomide (100 mg nightly).

Pruritus is a problem for a third to half of patients with the myeloproliferative disorder polycythemia vera as well, Dr. Berger said. For the vast majority of patients, the itch associated with this disease is aquagenic, occurring for 5–120 minutes after bathing.

The standard treatment has been aspirin (81–300 mg/day); however, a recent survey of patients suggests that a good second choice is paroxetine (20 mg up to 40 mg/day). Other SSRIs do not have the same antipruritic effect in polycythemia vera patients, he said.

SANTA BARBARA, CALIF. — Severe pruritus may be the first presenting sign of cancer, which most typically turns out to be Hodgkin's disease, Timothy G. Berger, M.D., said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

But the question that always arises is when to suspect cancer and not one of the many neuropathic causes of itch on normal-appearing skin.

When do you work up a patient when there's nothing to see? “The reason all of us are totally paranoid is that you can't do a CT scan on every patient with itch,” said Dr. Berger, professor of clinical dermatology at the University of California, San Francisco.

His advice is to treat the patient conservatively, but to schedule repeat visits if traditional therapies fail to relieve long-standing idiopathic itch.

He is most concerned, he said, when the itching is “disproportionately severe.”

In such a case, he orders tests of liver function, iron and lactic hydrogenase levels, and endocrine function.

Dr. Berger described a patient with a history of years of severe itch whose sedimentation rate and lactic hydrogenase levels were normal, but who had a CD4 count of 180 cells/μL despite a negative HIV test.

He referred the patient to an oncologist to evaluate a bulge in the groin that the patient thought was a hernia, but proved to be a low-grade T-cell lymphoma.

When patients are undergoing radiation and chemotherapy treatments for Hodgkin's disease but continue to suffer from severe pruritus, Dr. Berger recommends systemic corticosteroids; cimetidine (200 mg, four times daily); or mirtazapine (7.5–15 mg each night) possibly in combination with paroxetine (20–40 mg each night). Patients with solid tumors can also experience severe pruritus, and his advice is to “pick from the bag” of effective therapies, including paroxetine (5–20 mg nightly), mirtazapine (7.5–15 mg nightly), a combination of paroxetine and mirtazapine, or thalidomide (100 mg nightly).

Pruritus is a problem for a third to half of patients with the myeloproliferative disorder polycythemia vera as well, Dr. Berger said. For the vast majority of patients, the itch associated with this disease is aquagenic, occurring for 5–120 minutes after bathing.

The standard treatment has been aspirin (81–300 mg/day); however, a recent survey of patients suggests that a good second choice is paroxetine (20 mg up to 40 mg/day). Other SSRIs do not have the same antipruritic effect in polycythemia vera patients, he said.

SANTA BARBARA, CALIF. — When a patient comes to you with neuropathic pruritus, the most important thing to do is listen, not just look.

If you see anything on the skin at all, it will be a vague, after-the-fact sign such as erythema or lichenification.

It may be hard for a busy physician to do, but the key to making the diagnosis of neuropathic itch is to “sit there and listen to the patient,” said Timothy G. Berger, M.D., professor of clinical dermatology at the University of California, San Francisco, during the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

The patient's history and description of the sensation contain the clue as to whether the itch is central (multiple sclerosis, polymorphous light eruption); peripheral (brachioradial pruritus, notalgia paresthetica, postherpetic neuralgia, and possibly anogenital pruritus); or cutaneous (lichen simplex, and, in Dr. Berger's opinion, prurigo nodularis).

Although neuropathic pruritus is notoriously difficult to treat, Dr. Berger offered suggestions for specific conditions:

▸ Notalgia paresthetica. This itch occurs lateral to the central spine, often just below the scapula. Research has established an anatomical correlation between the location of the itch and abnormalities on spinal x-rays of many patients. Among the potential treatments are topical capsaicin 0.025% up to 4 times/day, acupuncture, and occlusion, as well as spinal manipulation and treatment of spinal disease.

P Brachioradial pruritus. Patients may enter your office with what Dr. Berger calls “the ice pack sign,” carrying ice to apply to their arms or upper torso in desperation, since “nothing else works.”

The itch associated with this condition can be severe and potentially debilitating and primarily impacts fair-skinned, affluent, middle-aged people, especially women, he said.

This severe itch develops in patients with chronic sun damage. The specific trigger is sun exposure late in the summer. The timing of itch onset (late versus early summer) distinguishes brachioradial pruritus from polymorphous light eruption (PMLE).

The differential diagnosis should include PMLE, cervical spine disease with nerve entrapment, and even a spinal cord tumor.

Once those conditions are ruled out, ice packs provide relief, but there are other effective treatments as well, including avoiding the sun and wearing protective clothing; using topical steroids or capsaicin, and lidocaine patches (for localized disease); applying an Unna's boot medicated gauze bandage to interrupt central sensitization; and prescribing drugs such as gabapentin, doxepin (Sinequan), mirtazapine (Remeron), or paroxetine (Paxil), and in severe cases, thalidomide.

Best of all, though, is physical therapy, according to Dr. Berger.

“These patients will get better with physical therapy, acupuncture, spinal manipulation, and TENS [transcutaneous electrical nerve stimulation],” he said.

▸ Anogenital pruritus. Chronic pruritus of the scrotum, labia majora, and perianal skin that is unrelieved by anti-inflammatories may respond to hygiene measures, Pramosone (hydrocortisone-based) cream, or imidazole.

Another option is a novel therapy pioneered by gastroenterologists in Israel (Gut 2003;52:1323–6). These researchers identified the dose at which topical capsaicin could be applied to the anogenital region without inducing burning—0.006%—and found that two-thirds of their patients were able to tolerate it, with an 80% response rate and 50% reduction in pruritus.

Although the formulation the Israeli physicians used is not available in the United States, Reliable Rexall Compounding Pharmacy in San Francisco can mix 0.006% capsaicin in a hydrophilic ointment base www.reliablerexall.com

▸ Prurigo nodularis. Dr. Berger noted that sensory neural receptors for touch, temperature, pain, and itch are more numerous and the nerves are enlarged in lesions of prurigo nodularis, that mast cells and eosinophils are prolific in these areas of neural hyperplasia, and that these cytokines may be stimulating nerve growth.

“My hypothesis is that prurigo nodularis is a keloid of the nerve,” he said, induced in predisposed patients by rubbing and scratching.

Superpotent topical steroids with occlusion, intralesional triamcinolone acetonide (Kenalog), capsaicin 0.076%–0.3% every 4 hours, and thalidomide 100–200 mg daily are all potential therapies.

“Thalidomide has moved up on my list,” Dr. Berger said. “In this situation, thalidomide has the potential to make patients who have been miserable forever and ever much better.”

Unfortunately, patients with prurigo nodularis are more susceptible than others to neurotoxicity associated with thalidomide, so he prescribes it according to an aggressive protocol that involves a neurologic evaluation at baseline and frequent nerve conduction studies, he said.

“Usually you buy them a few years, but sometimes the patient ends up with neuropathy [and you have to] back down,” he said.

Is Itch Neuropathic? Distinguishing Signs and Symptoms

▸ Itch presents with hypesthesia, a known neurologic disease or a previous injury (such as back injury).

▸ Itch is “too deep to scratch.”

▸ Itch sometimes feels more like burning or pain.

▸ Itch feels as if it is formicating (crawling).

▸ Itch strikes in sharp spasms.

▸ There is no primary cutaneous lesion or is only erythema.

Source: Dr. Berger

SANTA BARBARA, CALIF. — When a patient comes to you with neuropathic pruritus, the most important thing to do is listen, not just look.

If you see anything on the skin at all, it will be a vague, after-the-fact sign such as erythema or lichenification.

It may be hard for a busy physician to do, but the key to making the diagnosis of neuropathic itch is to “sit there and listen to the patient,” said Timothy G. Berger, M.D., professor of clinical dermatology at the University of California, San Francisco, during the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

The patient's history and description of the sensation contain the clue as to whether the itch is central (multiple sclerosis, polymorphous light eruption); peripheral (brachioradial pruritus, notalgia paresthetica, postherpetic neuralgia, and possibly anogenital pruritus); or cutaneous (lichen simplex, and, in Dr. Berger's opinion, prurigo nodularis).

Although neuropathic pruritus is notoriously difficult to treat, Dr. Berger offered suggestions for specific conditions:

▸ Notalgia paresthetica. This itch occurs lateral to the central spine, often just below the scapula. Research has established an anatomical correlation between the location of the itch and abnormalities on spinal x-rays of many patients. Among the potential treatments are topical capsaicin 0.025% up to 4 times/day, acupuncture, and occlusion, as well as spinal manipulation and treatment of spinal disease.

P Brachioradial pruritus. Patients may enter your office with what Dr. Berger calls “the ice pack sign,” carrying ice to apply to their arms or upper torso in desperation, since “nothing else works.”

The itch associated with this condition can be severe and potentially debilitating and primarily impacts fair-skinned, affluent, middle-aged people, especially women, he said.

This severe itch develops in patients with chronic sun damage. The specific trigger is sun exposure late in the summer. The timing of itch onset (late versus early summer) distinguishes brachioradial pruritus from polymorphous light eruption (PMLE).

The differential diagnosis should include PMLE, cervical spine disease with nerve entrapment, and even a spinal cord tumor.

Once those conditions are ruled out, ice packs provide relief, but there are other effective treatments as well, including avoiding the sun and wearing protective clothing; using topical steroids or capsaicin, and lidocaine patches (for localized disease); applying an Unna's boot medicated gauze bandage to interrupt central sensitization; and prescribing drugs such as gabapentin, doxepin (Sinequan), mirtazapine (Remeron), or paroxetine (Paxil), and in severe cases, thalidomide.

Best of all, though, is physical therapy, according to Dr. Berger.

“These patients will get better with physical therapy, acupuncture, spinal manipulation, and TENS [transcutaneous electrical nerve stimulation],” he said.

▸ Anogenital pruritus. Chronic pruritus of the scrotum, labia majora, and perianal skin that is unrelieved by anti-inflammatories may respond to hygiene measures, Pramosone (hydrocortisone-based) cream, or imidazole.

Another option is a novel therapy pioneered by gastroenterologists in Israel (Gut 2003;52:1323–6). These researchers identified the dose at which topical capsaicin could be applied to the anogenital region without inducing burning—0.006%—and found that two-thirds of their patients were able to tolerate it, with an 80% response rate and 50% reduction in pruritus.

Although the formulation the Israeli physicians used is not available in the United States, Reliable Rexall Compounding Pharmacy in San Francisco can mix 0.006% capsaicin in a hydrophilic ointment base www.reliablerexall.com

▸ Prurigo nodularis. Dr. Berger noted that sensory neural receptors for touch, temperature, pain, and itch are more numerous and the nerves are enlarged in lesions of prurigo nodularis, that mast cells and eosinophils are prolific in these areas of neural hyperplasia, and that these cytokines may be stimulating nerve growth.

“My hypothesis is that prurigo nodularis is a keloid of the nerve,” he said, induced in predisposed patients by rubbing and scratching.

Superpotent topical steroids with occlusion, intralesional triamcinolone acetonide (Kenalog), capsaicin 0.076%–0.3% every 4 hours, and thalidomide 100–200 mg daily are all potential therapies.

“Thalidomide has moved up on my list,” Dr. Berger said. “In this situation, thalidomide has the potential to make patients who have been miserable forever and ever much better.”

Unfortunately, patients with prurigo nodularis are more susceptible than others to neurotoxicity associated with thalidomide, so he prescribes it according to an aggressive protocol that involves a neurologic evaluation at baseline and frequent nerve conduction studies, he said.

“Usually you buy them a few years, but sometimes the patient ends up with neuropathy [and you have to] back down,” he said.

Is Itch Neuropathic? Distinguishing Signs and Symptoms

▸ Itch presents with hypesthesia, a known neurologic disease or a previous injury (such as back injury).

▸ Itch is “too deep to scratch.”

▸ Itch sometimes feels more like burning or pain.

▸ Itch feels as if it is formicating (crawling).

▸ Itch strikes in sharp spasms.

▸ There is no primary cutaneous lesion or is only erythema.

Source: Dr. Berger

SANTA BARBARA, CALIF. — When a patient comes to you with neuropathic pruritus, the most important thing to do is listen, not just look.

If you see anything on the skin at all, it will be a vague, after-the-fact sign such as erythema or lichenification.

It may be hard for a busy physician to do, but the key to making the diagnosis of neuropathic itch is to “sit there and listen to the patient,” said Timothy G. Berger, M.D., professor of clinical dermatology at the University of California, San Francisco, during the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

The patient's history and description of the sensation contain the clue as to whether the itch is central (multiple sclerosis, polymorphous light eruption); peripheral (brachioradial pruritus, notalgia paresthetica, postherpetic neuralgia, and possibly anogenital pruritus); or cutaneous (lichen simplex, and, in Dr. Berger's opinion, prurigo nodularis).

Although neuropathic pruritus is notoriously difficult to treat, Dr. Berger offered suggestions for specific conditions:

▸ Notalgia paresthetica. This itch occurs lateral to the central spine, often just below the scapula. Research has established an anatomical correlation between the location of the itch and abnormalities on spinal x-rays of many patients. Among the potential treatments are topical capsaicin 0.025% up to 4 times/day, acupuncture, and occlusion, as well as spinal manipulation and treatment of spinal disease.

P Brachioradial pruritus. Patients may enter your office with what Dr. Berger calls “the ice pack sign,” carrying ice to apply to their arms or upper torso in desperation, since “nothing else works.”

The itch associated with this condition can be severe and potentially debilitating and primarily impacts fair-skinned, affluent, middle-aged people, especially women, he said.

This severe itch develops in patients with chronic sun damage. The specific trigger is sun exposure late in the summer. The timing of itch onset (late versus early summer) distinguishes brachioradial pruritus from polymorphous light eruption (PMLE).

The differential diagnosis should include PMLE, cervical spine disease with nerve entrapment, and even a spinal cord tumor.

Once those conditions are ruled out, ice packs provide relief, but there are other effective treatments as well, including avoiding the sun and wearing protective clothing; using topical steroids or capsaicin, and lidocaine patches (for localized disease); applying an Unna's boot medicated gauze bandage to interrupt central sensitization; and prescribing drugs such as gabapentin, doxepin (Sinequan), mirtazapine (Remeron), or paroxetine (Paxil), and in severe cases, thalidomide.

Best of all, though, is physical therapy, according to Dr. Berger.

“These patients will get better with physical therapy, acupuncture, spinal manipulation, and TENS [transcutaneous electrical nerve stimulation],” he said.

▸ Anogenital pruritus. Chronic pruritus of the scrotum, labia majora, and perianal skin that is unrelieved by anti-inflammatories may respond to hygiene measures, Pramosone (hydrocortisone-based) cream, or imidazole.

Another option is a novel therapy pioneered by gastroenterologists in Israel (Gut 2003;52:1323–6). These researchers identified the dose at which topical capsaicin could be applied to the anogenital region without inducing burning—0.006%—and found that two-thirds of their patients were able to tolerate it, with an 80% response rate and 50% reduction in pruritus.

Although the formulation the Israeli physicians used is not available in the United States, Reliable Rexall Compounding Pharmacy in San Francisco can mix 0.006% capsaicin in a hydrophilic ointment base www.reliablerexall.com

▸ Prurigo nodularis. Dr. Berger noted that sensory neural receptors for touch, temperature, pain, and itch are more numerous and the nerves are enlarged in lesions of prurigo nodularis, that mast cells and eosinophils are prolific in these areas of neural hyperplasia, and that these cytokines may be stimulating nerve growth.

“My hypothesis is that prurigo nodularis is a keloid of the nerve,” he said, induced in predisposed patients by rubbing and scratching.

Superpotent topical steroids with occlusion, intralesional triamcinolone acetonide (Kenalog), capsaicin 0.076%–0.3% every 4 hours, and thalidomide 100–200 mg daily are all potential therapies.

“Thalidomide has moved up on my list,” Dr. Berger said. “In this situation, thalidomide has the potential to make patients who have been miserable forever and ever much better.”

Unfortunately, patients with prurigo nodularis are more susceptible than others to neurotoxicity associated with thalidomide, so he prescribes it according to an aggressive protocol that involves a neurologic evaluation at baseline and frequent nerve conduction studies, he said.

“Usually you buy them a few years, but sometimes the patient ends up with neuropathy [and you have to] back down,” he said.

Is Itch Neuropathic? Distinguishing Signs and Symptoms

▸ Itch presents with hypesthesia, a known neurologic disease or a previous injury (such as back injury).

▸ Itch is “too deep to scratch.”

▸ Itch sometimes feels more like burning or pain.

▸ Itch feels as if it is formicating (crawling).

▸ Itch strikes in sharp spasms.

▸ There is no primary cutaneous lesion or is only erythema.

Source: Dr. Berger