Damian McNamara

MIAMI BEACH — More information on risk-adjusted mortality, a greater focus on patient satisfaction, and a better user experience are coming to online hospital quality comparison sites, according to a physician specializing in quality improvement.

Current comparison systems are imperfect, Dr. Peter Lindenauer said. “Even relatively strong proponents of public reporting [think] that the information we have available today is insufficient to make the decisions, and many continue to rely on word of mouth recommendations from doctors who are familiar with the hospitals themselves.”

Enhancements are planned for Leapfroggroup.orgwhynotthebest.orgHospitalCompare.hhs.gov

“Once we have risk-adjusted mortality, process-based measures, and patient satisfaction ratings, it will get harder and harder to ignore the ratings,” said Dr. Lindenauer, director of the Center for Quality of Care Research at Baystate Medical Center, Springfield, Mass.

Many quality comparisons are based on hospital mortality, but “there is limited power to discriminate good and bad hospitals on the basis of mortality,” Dr. Lindenauer said. One study, for example, found that hospital caseloads of most surgical procedures—with the exception of coronary artery bypass grafting—were not high enough to show a statistically significant difference in surgical mortality between institutions (JAMA 2004;292:847–51).

Risk adjustment of outcomes would provide more accurate comparisons of mortality and other outcomes, but “it's hard to do and it's expensive,” said Dr. Lindenauer, who is also on the medicine faculty at Tufts University, Boston.

Often, patients are not aware of the value of risk-adjusted outcomes data or make choices based on other factors. For example, when former President Bill Clinton had quadruple bypass surgery in September 2004, he chose New York-Presbyterian Hospital/Columbia University Medical Center, even though the institution's risk-adjusted CABG mortality was about two times the state average. “Like other patients, he did not choose his hospital based on publicly reported data. It's likely that his decision was influenced by the usual referral patterns from the local hospital at which he was first admitted,” Dr. Lindenauer said.

Debate continues over the relative importance for hospital performance reviews of outcome measures, structural measures (such as the availability of intensivists or computerized physician order entry), or processes (such as use of beta blockers for acute MI), Dr. Lindenauer said. The Pennsylvania Health Care Cost Containment Council, for example, focuses on outcomes and reports all hospital-acquired infections in the state. In contrast, the Leapfrog hospital ratings are structure based and examine such factors as intensive care unit staff, nursing staff, and use of electronic medical records. Whynotthebest.org

Dr. Amir Jaffer, chief of the division of hospital medicine at the University of Miami, asked Dr. Lindenauer if he would recommend one Web site as best for consumers. “At this point in time, I don't think there is any one site,” Dr. Lindenauer replied. “The HospitalCompare site is a key one, but not the most user friendly. The California Hospital Outcomes project [CalHospitalCompare.org

The effects of publicly reported quality ratings on a hospital's reputation can go both ways. “Hospitals want to avoid embarrassment, but it's becoming increasingly common for hospitals to promote their performance ratings on their Web sites,” Dr. Lindenauer said, citing Aventura (Fla.) Hospital and Medical Center as an example. On its Web site (www.aventurahospital.com

Increasingly, hospitals are promoting their performance ratings on their Web sites. DR. LINDENAUER

MIAMI BEACH — More information on risk-adjusted mortality, a greater focus on patient satisfaction, and a better user experience are coming to online hospital quality comparison sites, according to a physician specializing in quality improvement.

Current comparison systems are imperfect, Dr. Peter Lindenauer said. “Even relatively strong proponents of public reporting [think] that the information we have available today is insufficient to make the decisions, and many continue to rely on word of mouth recommendations from doctors who are familiar with the hospitals themselves.”

Enhancements are planned for Leapfroggroup.orgwhynotthebest.orgHospitalCompare.hhs.gov

“Once we have risk-adjusted mortality, process-based measures, and patient satisfaction ratings, it will get harder and harder to ignore the ratings,” said Dr. Lindenauer, director of the Center for Quality of Care Research at Baystate Medical Center, Springfield, Mass.

Many quality comparisons are based on hospital mortality, but “there is limited power to discriminate good and bad hospitals on the basis of mortality,” Dr. Lindenauer said. One study, for example, found that hospital caseloads of most surgical procedures—with the exception of coronary artery bypass grafting—were not high enough to show a statistically significant difference in surgical mortality between institutions (JAMA 2004;292:847–51).

Risk adjustment of outcomes would provide more accurate comparisons of mortality and other outcomes, but “it's hard to do and it's expensive,” said Dr. Lindenauer, who is also on the medicine faculty at Tufts University, Boston.

Often, patients are not aware of the value of risk-adjusted outcomes data or make choices based on other factors. For example, when former President Bill Clinton had quadruple bypass surgery in September 2004, he chose New York-Presbyterian Hospital/Columbia University Medical Center, even though the institution's risk-adjusted CABG mortality was about two times the state average. “Like other patients, he did not choose his hospital based on publicly reported data. It's likely that his decision was influenced by the usual referral patterns from the local hospital at which he was first admitted,” Dr. Lindenauer said.

Debate continues over the relative importance for hospital performance reviews of outcome measures, structural measures (such as the availability of intensivists or computerized physician order entry), or processes (such as use of beta blockers for acute MI), Dr. Lindenauer said. The Pennsylvania Health Care Cost Containment Council, for example, focuses on outcomes and reports all hospital-acquired infections in the state. In contrast, the Leapfrog hospital ratings are structure based and examine such factors as intensive care unit staff, nursing staff, and use of electronic medical records. Whynotthebest.org

Dr. Amir Jaffer, chief of the division of hospital medicine at the University of Miami, asked Dr. Lindenauer if he would recommend one Web site as best for consumers. “At this point in time, I don't think there is any one site,” Dr. Lindenauer replied. “The HospitalCompare site is a key one, but not the most user friendly. The California Hospital Outcomes project [CalHospitalCompare.org

The effects of publicly reported quality ratings on a hospital's reputation can go both ways. “Hospitals want to avoid embarrassment, but it's becoming increasingly common for hospitals to promote their performance ratings on their Web sites,” Dr. Lindenauer said, citing Aventura (Fla.) Hospital and Medical Center as an example. On its Web site (www.aventurahospital.com

Increasingly, hospitals are promoting their performance ratings on their Web sites. DR. LINDENAUER

MIAMI BEACH — More information on risk-adjusted mortality, a greater focus on patient satisfaction, and a better user experience are coming to online hospital quality comparison sites, according to a physician specializing in quality improvement.

Current comparison systems are imperfect, Dr. Peter Lindenauer said. “Even relatively strong proponents of public reporting [think] that the information we have available today is insufficient to make the decisions, and many continue to rely on word of mouth recommendations from doctors who are familiar with the hospitals themselves.”

Enhancements are planned for Leapfroggroup.orgwhynotthebest.orgHospitalCompare.hhs.gov

“Once we have risk-adjusted mortality, process-based measures, and patient satisfaction ratings, it will get harder and harder to ignore the ratings,” said Dr. Lindenauer, director of the Center for Quality of Care Research at Baystate Medical Center, Springfield, Mass.

Many quality comparisons are based on hospital mortality, but “there is limited power to discriminate good and bad hospitals on the basis of mortality,” Dr. Lindenauer said. One study, for example, found that hospital caseloads of most surgical procedures—with the exception of coronary artery bypass grafting—were not high enough to show a statistically significant difference in surgical mortality between institutions (JAMA 2004;292:847–51).

Risk adjustment of outcomes would provide more accurate comparisons of mortality and other outcomes, but “it's hard to do and it's expensive,” said Dr. Lindenauer, who is also on the medicine faculty at Tufts University, Boston.

Often, patients are not aware of the value of risk-adjusted outcomes data or make choices based on other factors. For example, when former President Bill Clinton had quadruple bypass surgery in September 2004, he chose New York-Presbyterian Hospital/Columbia University Medical Center, even though the institution's risk-adjusted CABG mortality was about two times the state average. “Like other patients, he did not choose his hospital based on publicly reported data. It's likely that his decision was influenced by the usual referral patterns from the local hospital at which he was first admitted,” Dr. Lindenauer said.

Debate continues over the relative importance for hospital performance reviews of outcome measures, structural measures (such as the availability of intensivists or computerized physician order entry), or processes (such as use of beta blockers for acute MI), Dr. Lindenauer said. The Pennsylvania Health Care Cost Containment Council, for example, focuses on outcomes and reports all hospital-acquired infections in the state. In contrast, the Leapfrog hospital ratings are structure based and examine such factors as intensive care unit staff, nursing staff, and use of electronic medical records. Whynotthebest.org

Dr. Amir Jaffer, chief of the division of hospital medicine at the University of Miami, asked Dr. Lindenauer if he would recommend one Web site as best for consumers. “At this point in time, I don't think there is any one site,” Dr. Lindenauer replied. “The HospitalCompare site is a key one, but not the most user friendly. The California Hospital Outcomes project [CalHospitalCompare.org

The effects of publicly reported quality ratings on a hospital's reputation can go both ways. “Hospitals want to avoid embarrassment, but it's becoming increasingly common for hospitals to promote their performance ratings on their Web sites,” Dr. Lindenauer said, citing Aventura (Fla.) Hospital and Medical Center as an example. On its Web site (www.aventurahospital.com

Increasingly, hospitals are promoting their performance ratings on their Web sites. DR. LINDENAUER

MIAMI BEACH — Early identification of surgical patients who could benefit from postoperative consults minimizes complications, a pilot study has shown.

After an administrative review showed that hospitalists were being consulted late in the perioperative period, Dr. Elizabeth Marlow and Dr. Chad Whelan, both of the University of Chicago, designed a system to preoperatively identify patients at a higher risk of postoperative complications. “We were getting called a few days after we should have been consulted. This got me to think—is there a way to identify patients earlier to avoid complications?” Dr. Marlow said.

The researchers conducted the pilot study to see whether surgeons would be receptive to the offer to consult on these patients before their procedures, and if earlier consults would improve outcomes. To test the system, they contacted two high-volume orthopedic surgeons (doing primarily joint replacement surgery) at the university, Dr. Marlow said during a poster session at a meeting on perioperative medicine sponsored by the University of Miami.

Using patient data spanning 6 months, they screened 58, and identified 35, patients before elective surgery who could benefit from a consult. Then Dr. Marlow and Dr. Whelan accessed the patients' electronic medical records (EMRs) to identify risk factors—including age over 75, use of chronic anticoagulation, stage 3 kidney disease, diabetes, hypertension, and heart failure—associated with postoperative complications in orthopedic surgery patients. In addition, some consultations were suggested based on subjective assessment by the hospitalist or surgeon.

“We get a list of scheduled patients, and we review their labs or notes, sometimes 3 months in advance,” said Dr. Marlow, an instructor in the university's hospital medicine section. The surgeons, who can choose to opt out, are informed the week of the planned surgery via the EMR system that they have a patient scheduled who could benefit from a hospitalist consult.

The screening system helped fully identify patient medications preoperatively and has minimized the occurrence of postoperative delirium, for example, Dr. Marlow said. “We can also help with diabetes management and patients on long-term blood thinners.”

The researchers plan to refine their clinical criteria to improve the screening system. The pilot project helped them improve communication among hospitalists and consultative practices by members of their group.

They want to expand this service to other areas of the hospital and are negotiating with vascular surgeons and urologists. Cystectomy patients, for example, could benefit from preoperative screening and postoperative consult. “These patients tend to be older men and women, and they have a lot of comorbidities,” Dr. Marlow said.

Geriatricians at the medical center also are interested in this service. “A lot of orthopedic patients are older,” Dr. Marlow said, adding that some issues are better addressed by a geriatrician.

'We were getting called a few days after we should have been consulted.' DR. MARLOW

MIAMI BEACH — Early identification of surgical patients who could benefit from postoperative consults minimizes complications, a pilot study has shown.

After an administrative review showed that hospitalists were being consulted late in the perioperative period, Dr. Elizabeth Marlow and Dr. Chad Whelan, both of the University of Chicago, designed a system to preoperatively identify patients at a higher risk of postoperative complications. “We were getting called a few days after we should have been consulted. This got me to think—is there a way to identify patients earlier to avoid complications?” Dr. Marlow said.

The researchers conducted the pilot study to see whether surgeons would be receptive to the offer to consult on these patients before their procedures, and if earlier consults would improve outcomes. To test the system, they contacted two high-volume orthopedic surgeons (doing primarily joint replacement surgery) at the university, Dr. Marlow said during a poster session at a meeting on perioperative medicine sponsored by the University of Miami.

Using patient data spanning 6 months, they screened 58, and identified 35, patients before elective surgery who could benefit from a consult. Then Dr. Marlow and Dr. Whelan accessed the patients' electronic medical records (EMRs) to identify risk factors—including age over 75, use of chronic anticoagulation, stage 3 kidney disease, diabetes, hypertension, and heart failure—associated with postoperative complications in orthopedic surgery patients. In addition, some consultations were suggested based on subjective assessment by the hospitalist or surgeon.

“We get a list of scheduled patients, and we review their labs or notes, sometimes 3 months in advance,” said Dr. Marlow, an instructor in the university's hospital medicine section. The surgeons, who can choose to opt out, are informed the week of the planned surgery via the EMR system that they have a patient scheduled who could benefit from a hospitalist consult.

The screening system helped fully identify patient medications preoperatively and has minimized the occurrence of postoperative delirium, for example, Dr. Marlow said. “We can also help with diabetes management and patients on long-term blood thinners.”

The researchers plan to refine their clinical criteria to improve the screening system. The pilot project helped them improve communication among hospitalists and consultative practices by members of their group.

They want to expand this service to other areas of the hospital and are negotiating with vascular surgeons and urologists. Cystectomy patients, for example, could benefit from preoperative screening and postoperative consult. “These patients tend to be older men and women, and they have a lot of comorbidities,” Dr. Marlow said.

Geriatricians at the medical center also are interested in this service. “A lot of orthopedic patients are older,” Dr. Marlow said, adding that some issues are better addressed by a geriatrician.

'We were getting called a few days after we should have been consulted.' DR. MARLOW

MIAMI BEACH — Early identification of surgical patients who could benefit from postoperative consults minimizes complications, a pilot study has shown.

After an administrative review showed that hospitalists were being consulted late in the perioperative period, Dr. Elizabeth Marlow and Dr. Chad Whelan, both of the University of Chicago, designed a system to preoperatively identify patients at a higher risk of postoperative complications. “We were getting called a few days after we should have been consulted. This got me to think—is there a way to identify patients earlier to avoid complications?” Dr. Marlow said.

The researchers conducted the pilot study to see whether surgeons would be receptive to the offer to consult on these patients before their procedures, and if earlier consults would improve outcomes. To test the system, they contacted two high-volume orthopedic surgeons (doing primarily joint replacement surgery) at the university, Dr. Marlow said during a poster session at a meeting on perioperative medicine sponsored by the University of Miami.

Using patient data spanning 6 months, they screened 58, and identified 35, patients before elective surgery who could benefit from a consult. Then Dr. Marlow and Dr. Whelan accessed the patients' electronic medical records (EMRs) to identify risk factors—including age over 75, use of chronic anticoagulation, stage 3 kidney disease, diabetes, hypertension, and heart failure—associated with postoperative complications in orthopedic surgery patients. In addition, some consultations were suggested based on subjective assessment by the hospitalist or surgeon.

“We get a list of scheduled patients, and we review their labs or notes, sometimes 3 months in advance,” said Dr. Marlow, an instructor in the university's hospital medicine section. The surgeons, who can choose to opt out, are informed the week of the planned surgery via the EMR system that they have a patient scheduled who could benefit from a hospitalist consult.

The screening system helped fully identify patient medications preoperatively and has minimized the occurrence of postoperative delirium, for example, Dr. Marlow said. “We can also help with diabetes management and patients on long-term blood thinners.”

The researchers plan to refine their clinical criteria to improve the screening system. The pilot project helped them improve communication among hospitalists and consultative practices by members of their group.

They want to expand this service to other areas of the hospital and are negotiating with vascular surgeons and urologists. Cystectomy patients, for example, could benefit from preoperative screening and postoperative consult. “These patients tend to be older men and women, and they have a lot of comorbidities,” Dr. Marlow said.

Geriatricians at the medical center also are interested in this service. “A lot of orthopedic patients are older,” Dr. Marlow said, adding that some issues are better addressed by a geriatrician.

'We were getting called a few days after we should have been consulted.' DR. MARLOW

MIAMI BEACH — Obstructive sleep apnea is an emerging risk factor for postoperative pulmonary complications, and although evidence does not yet support universal screening, it may be worthwhile to test some elective surgery patients for apnea, Dr. Gerald W. Smetana said.

“If it's not urgent surgery, take a time out and test to confirm sleep apnea,” Dr. Smetana said. “The evidence is more compelling now.”

In one study, researchers prospectively assessed 172 patients with at least two risk factors for obstructive sleep apnea before surgery and measured clinical severity using home nocturnal oximetry (Chest 2008;133:1128–34). They found that patients who experienced five or more oxygen desaturations per hour had significantly higher rates of postoperative pulmonary complications, compared with those with fewer episodes (15% vs. 3%, adjusted odds ratio 7.2).

Postop complications in the study were respiratory (nine patients), cardiovascular (five patients), bleeding (two patients), and gastrointestinal (one patient). Although the numbers were small, results were “pretty significant” for pulmonary complications, Dr. Smetana said at a meeting on perioperative medicine sponsored by the University of Miami.

Older age, American Society of Anesthesiologists' class of 2 or greater, chronic obstructive pulmonary disorder, and heart failure are other risk factors identified in the American College of Physicians guidelines on “risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing non-cardiothoracic surgery” (Ann. Intern. Med. 2006;144:575–80).

“There is class A evidence that these are risk factors,” said Dr. Smetana, a coauthor of the ACP guidelines and an attending physician in the division of general medicine and primary care at Beth Israel Deaconess Medical Center in Boston.

“Pulmonary vary from cardiovascular risks in an important way—procedural risks are more important than patient risk factors. Even relatively healthy patients can have risk of pulmonary complications,” Dr. Smetana said. Pulmonary complications include pneumonia, respiratory failure, atelectasis, bronchospasm, and exacerbation of COPD.

A meeting attendee asked about asthma. “If it is well controlled, surprisingly, it is not a risk factor for postoperative pulmonary complications,” said Dr. Smetana, who is also on the medicine faculty at Harvard Medical School, Boston.

In terms of risk reduction, lung expansion modalities are the only intervention with good evidence, he said.

Active muscle training before surgery reduces pulmonary complications in high-risk patients, according to a randomized, controlled trial of 279 elective coronary artery bypass graft patients (JAMA 2006;296:1851–7). Preoperative inspiratory muscle training reduced postoperative high-grade pulmonary complications (OR 0.52) and pneumonia (OR 0.40), compared with a usual care group.

A meta-analysis indicated that postoperative continuous positive airway pressure lowers the overall pulmonary complication rate after abdominal surgery (Ann. Surg. 2008;247:617–24), making it “a good option for patients who cannot tolerate active muscle training,” he said.

'If it's not urgent surgery, take a time out and test to confirm sleep apnea.' DR. SMETANA

MIAMI BEACH — Obstructive sleep apnea is an emerging risk factor for postoperative pulmonary complications, and although evidence does not yet support universal screening, it may be worthwhile to test some elective surgery patients for apnea, Dr. Gerald W. Smetana said.

“If it's not urgent surgery, take a time out and test to confirm sleep apnea,” Dr. Smetana said. “The evidence is more compelling now.”

In one study, researchers prospectively assessed 172 patients with at least two risk factors for obstructive sleep apnea before surgery and measured clinical severity using home nocturnal oximetry (Chest 2008;133:1128–34). They found that patients who experienced five or more oxygen desaturations per hour had significantly higher rates of postoperative pulmonary complications, compared with those with fewer episodes (15% vs. 3%, adjusted odds ratio 7.2).

Postop complications in the study were respiratory (nine patients), cardiovascular (five patients), bleeding (two patients), and gastrointestinal (one patient). Although the numbers were small, results were “pretty significant” for pulmonary complications, Dr. Smetana said at a meeting on perioperative medicine sponsored by the University of Miami.

Older age, American Society of Anesthesiologists' class of 2 or greater, chronic obstructive pulmonary disorder, and heart failure are other risk factors identified in the American College of Physicians guidelines on “risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing non-cardiothoracic surgery” (Ann. Intern. Med. 2006;144:575–80).

“There is class A evidence that these are risk factors,” said Dr. Smetana, a coauthor of the ACP guidelines and an attending physician in the division of general medicine and primary care at Beth Israel Deaconess Medical Center in Boston.

“Pulmonary vary from cardiovascular risks in an important way—procedural risks are more important than patient risk factors. Even relatively healthy patients can have risk of pulmonary complications,” Dr. Smetana said. Pulmonary complications include pneumonia, respiratory failure, atelectasis, bronchospasm, and exacerbation of COPD.

A meeting attendee asked about asthma. “If it is well controlled, surprisingly, it is not a risk factor for postoperative pulmonary complications,” said Dr. Smetana, who is also on the medicine faculty at Harvard Medical School, Boston.

In terms of risk reduction, lung expansion modalities are the only intervention with good evidence, he said.

Active muscle training before surgery reduces pulmonary complications in high-risk patients, according to a randomized, controlled trial of 279 elective coronary artery bypass graft patients (JAMA 2006;296:1851–7). Preoperative inspiratory muscle training reduced postoperative high-grade pulmonary complications (OR 0.52) and pneumonia (OR 0.40), compared with a usual care group.

A meta-analysis indicated that postoperative continuous positive airway pressure lowers the overall pulmonary complication rate after abdominal surgery (Ann. Surg. 2008;247:617–24), making it “a good option for patients who cannot tolerate active muscle training,” he said.

'If it's not urgent surgery, take a time out and test to confirm sleep apnea.' DR. SMETANA

MIAMI BEACH — Obstructive sleep apnea is an emerging risk factor for postoperative pulmonary complications, and although evidence does not yet support universal screening, it may be worthwhile to test some elective surgery patients for apnea, Dr. Gerald W. Smetana said.

“If it's not urgent surgery, take a time out and test to confirm sleep apnea,” Dr. Smetana said. “The evidence is more compelling now.”

In one study, researchers prospectively assessed 172 patients with at least two risk factors for obstructive sleep apnea before surgery and measured clinical severity using home nocturnal oximetry (Chest 2008;133:1128–34). They found that patients who experienced five or more oxygen desaturations per hour had significantly higher rates of postoperative pulmonary complications, compared with those with fewer episodes (15% vs. 3%, adjusted odds ratio 7.2).

Postop complications in the study were respiratory (nine patients), cardiovascular (five patients), bleeding (two patients), and gastrointestinal (one patient). Although the numbers were small, results were “pretty significant” for pulmonary complications, Dr. Smetana said at a meeting on perioperative medicine sponsored by the University of Miami.

Older age, American Society of Anesthesiologists' class of 2 or greater, chronic obstructive pulmonary disorder, and heart failure are other risk factors identified in the American College of Physicians guidelines on “risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing non-cardiothoracic surgery” (Ann. Intern. Med. 2006;144:575–80).

“There is class A evidence that these are risk factors,” said Dr. Smetana, a coauthor of the ACP guidelines and an attending physician in the division of general medicine and primary care at Beth Israel Deaconess Medical Center in Boston.

“Pulmonary vary from cardiovascular risks in an important way—procedural risks are more important than patient risk factors. Even relatively healthy patients can have risk of pulmonary complications,” Dr. Smetana said. Pulmonary complications include pneumonia, respiratory failure, atelectasis, bronchospasm, and exacerbation of COPD.

A meeting attendee asked about asthma. “If it is well controlled, surprisingly, it is not a risk factor for postoperative pulmonary complications,” said Dr. Smetana, who is also on the medicine faculty at Harvard Medical School, Boston.

In terms of risk reduction, lung expansion modalities are the only intervention with good evidence, he said.

Active muscle training before surgery reduces pulmonary complications in high-risk patients, according to a randomized, controlled trial of 279 elective coronary artery bypass graft patients (JAMA 2006;296:1851–7). Preoperative inspiratory muscle training reduced postoperative high-grade pulmonary complications (OR 0.52) and pneumonia (OR 0.40), compared with a usual care group.

A meta-analysis indicated that postoperative continuous positive airway pressure lowers the overall pulmonary complication rate after abdominal surgery (Ann. Surg. 2008;247:617–24), making it “a good option for patients who cannot tolerate active muscle training,” he said.

'If it's not urgent surgery, take a time out and test to confirm sleep apnea.' DR. SMETANA

MIAMI BEACH — A soon-to-be-published Cochrane review is expected to indicate the superiority of intraoperative initiation of fluid management protocols and to quantify the link between perioperative complications and postoperative survival, according to one of the study's coauthors.

The review, “Perioperative Increases in Global Blood Flow to Explicit Defined Goals and Outcomes Following Surgery,” gives evidence-based guidance on these two controversial issues, gleaned from “very different” studies with a total of 4,546 patients, Dr. Mark Hamilton reported at a meeting on perioperative medicine sponsored by the University of Miami.

The 22 studies in the review included elective and emergency patients undergoing general, vascular, or cardiac surgery. Overall perioperative mortality was 10.6%.

Use of a fluid protocol was associated with 216 perioperative deaths. There were 265 deaths among patients treated without a protocol (odds ratio, 0.82). This statistically significant reduction in mortality was “quite clear” for the protocol groups vs. controls, Dr. Hamilton said.

The timing of the intervention is significantly more protective if flow-directed therapy is intraoperative vs. preoperative or postoperative, according to the review, although the final answer on the optimal management strategy remains elusive, said Dr. Hamilton, consultant and honorary senior lecturer in anesthesia and intensive care medicine at St. George's Hospital in London. He had no relevant financial disclosures.

Fundamental problems of perioperative fluid therapy include an inability to accurately evaluate blood volume, identify fluid overload, identify hypovolemia, or precisely evaluate tissue perfusion, Dr. Hamilton said.

Multiple organizations have developed guidelines to steer hospitalists, surgeons, and other perioperative clinicians regarding fluid management, but they are backed by varying levels of evidence, he said.

Dr. Hamilton recommended the British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (www.ebpom.org

Another finding is that significant perioperative complications can have a long-term effect on surgery patients.

“This is where it gets more interesting,” Dr. Hamilton said. “This is the most consistent theme in the studies.” A lack of a standard definition for perioperative complications worldwide has impeded previous efforts to compile overall complication rates, he said.

In one study, any of 22 complications in the National Surgical Quality Improvement Program database within 30 days of surgery was the most important factor associated with decreased postoperative survival (Ann. Surg. 2005;242:326–41).

Postoperative complications were associated with a 69% reduction in median survival among 105,951 patients who had surgery between 1991 and 1999, and were more indicative of survival after major surgery than were preoperative or perioperative risk factors.

MIAMI BEACH — A soon-to-be-published Cochrane review is expected to indicate the superiority of intraoperative initiation of fluid management protocols and to quantify the link between perioperative complications and postoperative survival, according to one of the study's coauthors.

The review, “Perioperative Increases in Global Blood Flow to Explicit Defined Goals and Outcomes Following Surgery,” gives evidence-based guidance on these two controversial issues, gleaned from “very different” studies with a total of 4,546 patients, Dr. Mark Hamilton reported at a meeting on perioperative medicine sponsored by the University of Miami.

The 22 studies in the review included elective and emergency patients undergoing general, vascular, or cardiac surgery. Overall perioperative mortality was 10.6%.

Use of a fluid protocol was associated with 216 perioperative deaths. There were 265 deaths among patients treated without a protocol (odds ratio, 0.82). This statistically significant reduction in mortality was “quite clear” for the protocol groups vs. controls, Dr. Hamilton said.

The timing of the intervention is significantly more protective if flow-directed therapy is intraoperative vs. preoperative or postoperative, according to the review, although the final answer on the optimal management strategy remains elusive, said Dr. Hamilton, consultant and honorary senior lecturer in anesthesia and intensive care medicine at St. George's Hospital in London. He had no relevant financial disclosures.

Fundamental problems of perioperative fluid therapy include an inability to accurately evaluate blood volume, identify fluid overload, identify hypovolemia, or precisely evaluate tissue perfusion, Dr. Hamilton said.

Multiple organizations have developed guidelines to steer hospitalists, surgeons, and other perioperative clinicians regarding fluid management, but they are backed by varying levels of evidence, he said.

Dr. Hamilton recommended the British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (www.ebpom.org

Another finding is that significant perioperative complications can have a long-term effect on surgery patients.

“This is where it gets more interesting,” Dr. Hamilton said. “This is the most consistent theme in the studies.” A lack of a standard definition for perioperative complications worldwide has impeded previous efforts to compile overall complication rates, he said.

In one study, any of 22 complications in the National Surgical Quality Improvement Program database within 30 days of surgery was the most important factor associated with decreased postoperative survival (Ann. Surg. 2005;242:326–41).

Postoperative complications were associated with a 69% reduction in median survival among 105,951 patients who had surgery between 1991 and 1999, and were more indicative of survival after major surgery than were preoperative or perioperative risk factors.

MIAMI BEACH — A soon-to-be-published Cochrane review is expected to indicate the superiority of intraoperative initiation of fluid management protocols and to quantify the link between perioperative complications and postoperative survival, according to one of the study's coauthors.

The review, “Perioperative Increases in Global Blood Flow to Explicit Defined Goals and Outcomes Following Surgery,” gives evidence-based guidance on these two controversial issues, gleaned from “very different” studies with a total of 4,546 patients, Dr. Mark Hamilton reported at a meeting on perioperative medicine sponsored by the University of Miami.

The 22 studies in the review included elective and emergency patients undergoing general, vascular, or cardiac surgery. Overall perioperative mortality was 10.6%.

Use of a fluid protocol was associated with 216 perioperative deaths. There were 265 deaths among patients treated without a protocol (odds ratio, 0.82). This statistically significant reduction in mortality was “quite clear” for the protocol groups vs. controls, Dr. Hamilton said.

The timing of the intervention is significantly more protective if flow-directed therapy is intraoperative vs. preoperative or postoperative, according to the review, although the final answer on the optimal management strategy remains elusive, said Dr. Hamilton, consultant and honorary senior lecturer in anesthesia and intensive care medicine at St. George's Hospital in London. He had no relevant financial disclosures.

Fundamental problems of perioperative fluid therapy include an inability to accurately evaluate blood volume, identify fluid overload, identify hypovolemia, or precisely evaluate tissue perfusion, Dr. Hamilton said.

Multiple organizations have developed guidelines to steer hospitalists, surgeons, and other perioperative clinicians regarding fluid management, but they are backed by varying levels of evidence, he said.

Dr. Hamilton recommended the British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (www.ebpom.org

Another finding is that significant perioperative complications can have a long-term effect on surgery patients.

“This is where it gets more interesting,” Dr. Hamilton said. “This is the most consistent theme in the studies.” A lack of a standard definition for perioperative complications worldwide has impeded previous efforts to compile overall complication rates, he said.

In one study, any of 22 complications in the National Surgical Quality Improvement Program database within 30 days of surgery was the most important factor associated with decreased postoperative survival (Ann. Surg. 2005;242:326–41).

Postoperative complications were associated with a 69% reduction in median survival among 105,951 patients who had surgery between 1991 and 1999, and were more indicative of survival after major surgery than were preoperative or perioperative risk factors.

MIAMI BEACH — Offer discounts, combine products and procedures into packages, and offer value-added products or services—these are among the strategies an aesthetic dermatologist can use to survive the economic downturn, according to a panel of dermatologists.

A recession also is an important time to optimize customer service and marketing efforts.

Monitor costs closely, keep inventory at a minimum, and negotiate deals with suppliers, dermatologists nationwide recommended during the South Beach Symposium.

Know your patient population and demographics, said Dr. David E. Bank, who is in private practice in Mount Kisco, N.Y. "The country is so diverse—disposable income is so different, job loss is so different. Where we are in Westchester [N.Y.], we have a lot of Wall Streeters who have lost their jobs, so you have to be cognizant of that."

"Reports say plastic surgery [business] is down 25%-50%, and dermatologists are down 10%-50%," said Dr. Michael H. Gold, a private practice dermatologist in Nashville, Tenn.

Medical dermatology generally is suffering less while aesthetic procedures, especially higher-priced offerings like breast augmentation, are down overall, according to a report in the New York Times ("Vanity's Downturn: Botox Use, and Allergan Sales, Dip," Feb. 4, 2009).

"In this economy, even noninvasive procedures are down," Dr. Gold said.

Sales of Botox (botulinum toxin type A, made by Allergan) dropped 3% in the last quarter of 2008 versus the year prior, and the company's dermal filler business was down almost 9%, according to the report.

"I occasionally offer 10% off Botox, but I will not compete with the $9.99 special from a spa," Dr. Gold said. Work with patients to bundle procedures and products, he advised.

"I don't like discounting," said Dr. Doris J. Day, a dermatologist in private practice in New York. "I find you become a discounter and patients wait for the discount. Instead, I believe in value added. Provide an extra product, and then they are trying a new product or service they can continue [using] down the road," she said.

"I'm an optimist—a good recession is a terrible thing to waste. You have time to make changes now," Dr. Day said. For example, assess the fiscal health of your practice, train your staff to optimize customer care, spend the time to update your Web site and online marketing, and focus on your existing customers, she suggested.

Carefully watch every penny you spend during a recession, Dr. Gold said, especially "those of us who like expensive toys." If you own your own building, turn off the lights at night, he said. Also, discuss cost-saving measures with your office staff to make them a part of the process.

"Ask companies about any special offers—such as 'buy one syringe, get one half price,' " Dr. Gold added. "Companies are negotiating, and if you are in the market to buy a laser with cash, this may be the best time."

"Keep overhead low and inventory low," Dr. Bank said. "This may not be what some of the companies want to hear, but you really do not need to keep tons of supplies on hand." Most items can be shipped within 24 hours.

He also suggested increased marketing. "In this market a lot of your competition may be cutting back on marketing, and you may want to run in the opposite direction." Internal marketing to existing patients is always the strongest strategy, he said.

Keep your practice Web site up to date and professional. "See what your colleagues are doing," Dr. Gold said. "I spend a lot of time on their Web sites."

A diverse dermatology practice—with both medical and aesthetic services—is an advantage, Dr. Gold said. "Medical derm will not go away—acne patients and eczema patients will always be there. And this economic global crisis will come to an end—hopefully sooner than later."

MIAMI BEACH — Offer discounts, combine products and procedures into packages, and offer value-added products or services—these are among the strategies an aesthetic dermatologist can use to survive the economic downturn, according to a panel of dermatologists.

A recession also is an important time to optimize customer service and marketing efforts.

Monitor costs closely, keep inventory at a minimum, and negotiate deals with suppliers, dermatologists nationwide recommended during the South Beach Symposium.

Know your patient population and demographics, said Dr. David E. Bank, who is in private practice in Mount Kisco, N.Y. "The country is so diverse—disposable income is so different, job loss is so different. Where we are in Westchester [N.Y.], we have a lot of Wall Streeters who have lost their jobs, so you have to be cognizant of that."

"Reports say plastic surgery [business] is down 25%-50%, and dermatologists are down 10%-50%," said Dr. Michael H. Gold, a private practice dermatologist in Nashville, Tenn.

Medical dermatology generally is suffering less while aesthetic procedures, especially higher-priced offerings like breast augmentation, are down overall, according to a report in the New York Times ("Vanity's Downturn: Botox Use, and Allergan Sales, Dip," Feb. 4, 2009).

"In this economy, even noninvasive procedures are down," Dr. Gold said.

Sales of Botox (botulinum toxin type A, made by Allergan) dropped 3% in the last quarter of 2008 versus the year prior, and the company's dermal filler business was down almost 9%, according to the report.

"I occasionally offer 10% off Botox, but I will not compete with the $9.99 special from a spa," Dr. Gold said. Work with patients to bundle procedures and products, he advised.

"I don't like discounting," said Dr. Doris J. Day, a dermatologist in private practice in New York. "I find you become a discounter and patients wait for the discount. Instead, I believe in value added. Provide an extra product, and then they are trying a new product or service they can continue [using] down the road," she said.

"I'm an optimist—a good recession is a terrible thing to waste. You have time to make changes now," Dr. Day said. For example, assess the fiscal health of your practice, train your staff to optimize customer care, spend the time to update your Web site and online marketing, and focus on your existing customers, she suggested.

Carefully watch every penny you spend during a recession, Dr. Gold said, especially "those of us who like expensive toys." If you own your own building, turn off the lights at night, he said. Also, discuss cost-saving measures with your office staff to make them a part of the process.

"Ask companies about any special offers—such as 'buy one syringe, get one half price,' " Dr. Gold added. "Companies are negotiating, and if you are in the market to buy a laser with cash, this may be the best time."

"Keep overhead low and inventory low," Dr. Bank said. "This may not be what some of the companies want to hear, but you really do not need to keep tons of supplies on hand." Most items can be shipped within 24 hours.

He also suggested increased marketing. "In this market a lot of your competition may be cutting back on marketing, and you may want to run in the opposite direction." Internal marketing to existing patients is always the strongest strategy, he said.

Keep your practice Web site up to date and professional. "See what your colleagues are doing," Dr. Gold said. "I spend a lot of time on their Web sites."

A diverse dermatology practice—with both medical and aesthetic services—is an advantage, Dr. Gold said. "Medical derm will not go away—acne patients and eczema patients will always be there. And this economic global crisis will come to an end—hopefully sooner than later."

MIAMI BEACH — Offer discounts, combine products and procedures into packages, and offer value-added products or services—these are among the strategies an aesthetic dermatologist can use to survive the economic downturn, according to a panel of dermatologists.

A recession also is an important time to optimize customer service and marketing efforts.

Monitor costs closely, keep inventory at a minimum, and negotiate deals with suppliers, dermatologists nationwide recommended during the South Beach Symposium.

Know your patient population and demographics, said Dr. David E. Bank, who is in private practice in Mount Kisco, N.Y. "The country is so diverse—disposable income is so different, job loss is so different. Where we are in Westchester [N.Y.], we have a lot of Wall Streeters who have lost their jobs, so you have to be cognizant of that."

"Reports say plastic surgery [business] is down 25%-50%, and dermatologists are down 10%-50%," said Dr. Michael H. Gold, a private practice dermatologist in Nashville, Tenn.

Medical dermatology generally is suffering less while aesthetic procedures, especially higher-priced offerings like breast augmentation, are down overall, according to a report in the New York Times ("Vanity's Downturn: Botox Use, and Allergan Sales, Dip," Feb. 4, 2009).

"In this economy, even noninvasive procedures are down," Dr. Gold said.

Sales of Botox (botulinum toxin type A, made by Allergan) dropped 3% in the last quarter of 2008 versus the year prior, and the company's dermal filler business was down almost 9%, according to the report.

"I occasionally offer 10% off Botox, but I will not compete with the $9.99 special from a spa," Dr. Gold said. Work with patients to bundle procedures and products, he advised.

"I don't like discounting," said Dr. Doris J. Day, a dermatologist in private practice in New York. "I find you become a discounter and patients wait for the discount. Instead, I believe in value added. Provide an extra product, and then they are trying a new product or service they can continue [using] down the road," she said.

"I'm an optimist—a good recession is a terrible thing to waste. You have time to make changes now," Dr. Day said. For example, assess the fiscal health of your practice, train your staff to optimize customer care, spend the time to update your Web site and online marketing, and focus on your existing customers, she suggested.

Carefully watch every penny you spend during a recession, Dr. Gold said, especially "those of us who like expensive toys." If you own your own building, turn off the lights at night, he said. Also, discuss cost-saving measures with your office staff to make them a part of the process.

"Ask companies about any special offers—such as 'buy one syringe, get one half price,' " Dr. Gold added. "Companies are negotiating, and if you are in the market to buy a laser with cash, this may be the best time."

"Keep overhead low and inventory low," Dr. Bank said. "This may not be what some of the companies want to hear, but you really do not need to keep tons of supplies on hand." Most items can be shipped within 24 hours.

He also suggested increased marketing. "In this market a lot of your competition may be cutting back on marketing, and you may want to run in the opposite direction." Internal marketing to existing patients is always the strongest strategy, he said.

Keep your practice Web site up to date and professional. "See what your colleagues are doing," Dr. Gold said. "I spend a lot of time on their Web sites."

A diverse dermatology practice—with both medical and aesthetic services—is an advantage, Dr. Gold said. "Medical derm will not go away—acne patients and eczema patients will always be there. And this economic global crisis will come to an end—hopefully sooner than later."

MIAMI BEACH — Sure, it's nice to tell patients that laser-assisted lipolysis will tighten their skin, but now there is evidence to prove it.

Dr. Bruce E. Katz and his colleagues demonstrated the tightening effects of laser-assisted lipolysis by tattooing a 4-by 4-cm square on the abdomen, arms, hips, or thighs of 30 patients.

At 3 months' follow-up, a mean 18% reduction was observed in an ongoing, multicenter study, accroding to Dr. Katz.

"This is the first evidence of skin tightening," he said at the South Beach Symposium. "And we've seen similar findings out to 6 months."

The investigators also performed punch biopsies to examine the histology at treated sites. Results showed new fibrosis, adipocytes, histiocytes, and markers of fat-cell lysis, said Dr. Katz of the department of dermatology at Mount Sinai School of Medicine, New York.

Patients were treated using the Smartlipo system (Cynosure Inc.), which features a hollow, 1- to 2-mm cannula inserted through a small incision to deliver Nd:YAG laser energy. After the laser liquefies fat cells, they are drained away through the same cannula.

This device combines a 1,064-nm wavelength for a gradual thermal effect and to mediate coagulation of blood vessels, as well as a 1,320-nm wavelength to promote energy absorption by fat and water. For this study, Dr. Katz set the system to deliver 20 W of the 1,064-nm energy and 12 W of the 1,320-nm wavelength.

The tightening results are supported by another study in process by Dr. Barry E. DiBernardo, a plastic surgeon in private practice in Montclair, N.J. Dr. DiBernardo compared laser-assisted lipolysis with liposuction in a split-treatment study of 10 women.

Dr. DiBernardo tattooed a 5- by 5-cm square on areas to be treated and found 37% greater skin tightening with laser-assisted lipolysis versus liposuction alone at 1 month. "At 3 months, he found 54% greater tightening with laser lipolysis," Dr. Katz said.

In addition to a stand-alone treatment for skin tightening, the system could be a nice alternative for patients who are candidates for face and neck tightening surgery, Dr. Katz said. Laser lipolysis is indicated for all areas with localized adipocyte deposits, as well as places where liposuction is indicated but the treatment could worsen skin laxity.

With any technology it is important to ask: "Do the risks outweigh the benefits?" Dr. Katz said. "We saw this in ultrasonic liposuction years ago."

To find out, he and a colleague assessed the incidence of adverse events and touch-up treatments required by 537 patients treated over 18 months at a single center (J. Cosmet. Laser Ther. 2008;10:231–3). They found a 1% complication rate, including one local infection and three minor burns, all of which resolved, Dr. Katz said at the meeting.

There were 19 touch-up procedures for a 3.4% rate, versus the 10%-12% reported in the liposuction literature. "The most important finding was there were no serious side effects at all," he said.

Dr. Katz disclosed that he is a Cynosure stockholder.

Two studies provide the "first evidence of skin tightening," with laser-assisted lipolysis. The above patient is shown before and after undergoing the procedure. Photos courtesy Dr. Bruce E. Katz

MIAMI BEACH — Sure, it's nice to tell patients that laser-assisted lipolysis will tighten their skin, but now there is evidence to prove it.

Dr. Bruce E. Katz and his colleagues demonstrated the tightening effects of laser-assisted lipolysis by tattooing a 4-by 4-cm square on the abdomen, arms, hips, or thighs of 30 patients.

At 3 months' follow-up, a mean 18% reduction was observed in an ongoing, multicenter study, accroding to Dr. Katz.

"This is the first evidence of skin tightening," he said at the South Beach Symposium. "And we've seen similar findings out to 6 months."

The investigators also performed punch biopsies to examine the histology at treated sites. Results showed new fibrosis, adipocytes, histiocytes, and markers of fat-cell lysis, said Dr. Katz of the department of dermatology at Mount Sinai School of Medicine, New York.

Patients were treated using the Smartlipo system (Cynosure Inc.), which features a hollow, 1- to 2-mm cannula inserted through a small incision to deliver Nd:YAG laser energy. After the laser liquefies fat cells, they are drained away through the same cannula.

This device combines a 1,064-nm wavelength for a gradual thermal effect and to mediate coagulation of blood vessels, as well as a 1,320-nm wavelength to promote energy absorption by fat and water. For this study, Dr. Katz set the system to deliver 20 W of the 1,064-nm energy and 12 W of the 1,320-nm wavelength.

The tightening results are supported by another study in process by Dr. Barry E. DiBernardo, a plastic surgeon in private practice in Montclair, N.J. Dr. DiBernardo compared laser-assisted lipolysis with liposuction in a split-treatment study of 10 women.

Dr. DiBernardo tattooed a 5- by 5-cm square on areas to be treated and found 37% greater skin tightening with laser-assisted lipolysis versus liposuction alone at 1 month. "At 3 months, he found 54% greater tightening with laser lipolysis," Dr. Katz said.

In addition to a stand-alone treatment for skin tightening, the system could be a nice alternative for patients who are candidates for face and neck tightening surgery, Dr. Katz said. Laser lipolysis is indicated for all areas with localized adipocyte deposits, as well as places where liposuction is indicated but the treatment could worsen skin laxity.

With any technology it is important to ask: "Do the risks outweigh the benefits?" Dr. Katz said. "We saw this in ultrasonic liposuction years ago."

To find out, he and a colleague assessed the incidence of adverse events and touch-up treatments required by 537 patients treated over 18 months at a single center (J. Cosmet. Laser Ther. 2008;10:231–3). They found a 1% complication rate, including one local infection and three minor burns, all of which resolved, Dr. Katz said at the meeting.

There were 19 touch-up procedures for a 3.4% rate, versus the 10%-12% reported in the liposuction literature. "The most important finding was there were no serious side effects at all," he said.

Dr. Katz disclosed that he is a Cynosure stockholder.

Two studies provide the "first evidence of skin tightening," with laser-assisted lipolysis. The above patient is shown before and after undergoing the procedure. Photos courtesy Dr. Bruce E. Katz

MIAMI BEACH — Sure, it's nice to tell patients that laser-assisted lipolysis will tighten their skin, but now there is evidence to prove it.

Dr. Bruce E. Katz and his colleagues demonstrated the tightening effects of laser-assisted lipolysis by tattooing a 4-by 4-cm square on the abdomen, arms, hips, or thighs of 30 patients.

At 3 months' follow-up, a mean 18% reduction was observed in an ongoing, multicenter study, accroding to Dr. Katz.

"This is the first evidence of skin tightening," he said at the South Beach Symposium. "And we've seen similar findings out to 6 months."

The investigators also performed punch biopsies to examine the histology at treated sites. Results showed new fibrosis, adipocytes, histiocytes, and markers of fat-cell lysis, said Dr. Katz of the department of dermatology at Mount Sinai School of Medicine, New York.

Patients were treated using the Smartlipo system (Cynosure Inc.), which features a hollow, 1- to 2-mm cannula inserted through a small incision to deliver Nd:YAG laser energy. After the laser liquefies fat cells, they are drained away through the same cannula.

This device combines a 1,064-nm wavelength for a gradual thermal effect and to mediate coagulation of blood vessels, as well as a 1,320-nm wavelength to promote energy absorption by fat and water. For this study, Dr. Katz set the system to deliver 20 W of the 1,064-nm energy and 12 W of the 1,320-nm wavelength.

The tightening results are supported by another study in process by Dr. Barry E. DiBernardo, a plastic surgeon in private practice in Montclair, N.J. Dr. DiBernardo compared laser-assisted lipolysis with liposuction in a split-treatment study of 10 women.

Dr. DiBernardo tattooed a 5- by 5-cm square on areas to be treated and found 37% greater skin tightening with laser-assisted lipolysis versus liposuction alone at 1 month. "At 3 months, he found 54% greater tightening with laser lipolysis," Dr. Katz said.

In addition to a stand-alone treatment for skin tightening, the system could be a nice alternative for patients who are candidates for face and neck tightening surgery, Dr. Katz said. Laser lipolysis is indicated for all areas with localized adipocyte deposits, as well as places where liposuction is indicated but the treatment could worsen skin laxity.

With any technology it is important to ask: "Do the risks outweigh the benefits?" Dr. Katz said. "We saw this in ultrasonic liposuction years ago."

To find out, he and a colleague assessed the incidence of adverse events and touch-up treatments required by 537 patients treated over 18 months at a single center (J. Cosmet. Laser Ther. 2008;10:231–3). They found a 1% complication rate, including one local infection and three minor burns, all of which resolved, Dr. Katz said at the meeting.

There were 19 touch-up procedures for a 3.4% rate, versus the 10%-12% reported in the liposuction literature. "The most important finding was there were no serious side effects at all," he said.

Dr. Katz disclosed that he is a Cynosure stockholder.

Two studies provide the "first evidence of skin tightening," with laser-assisted lipolysis. The above patient is shown before and after undergoing the procedure. Photos courtesy Dr. Bruce E. Katz

MIAMI BEACH — Phosphatidylcholine injections were found to effectively dissolve submental fat deposits associated with a "double chin" appearance without any significant adverse effects.

Up to five injections of phosphatidylcholine (PC) over 6 months yielded a 40%-50% clinical fat reduction in patients, said Dr. Glynis R. Ablon at the South Beach Symposium.

PC is a linoleic acid with anticollagenase activity that provides antioxidant and antifibrotic benefits in both in vitro and in vivo studies, Dr. Ablon said. PC also has been used to treat hyperlipidemia, cardiac ischemia, and liver disease.

Lipolysis injections are often a combination of PC and deoxycholic acid (DC), a bile acid converted to a sodium salt that lyses fat cells. DC also is used in medications to reduce gallstones.

Dr. Ablon randomized 44 patients—38 women and 6 men—to a mixture of PC and DC, a DC solution, or bacteriostatic saline. Participants were aged 25–60 years and had mild, moderate, or severe submental fat deposits.

Caliper measurements of fat were made at a point midway between the submental crease and the hyoid bone. Injections alternated to the right or left side with up to five treatments over 6 months.

"We had great results with no significant complications. Patients were extremely happy," said Dr. Ablon of the University of California, Los Angeles.

This limited study showed 100% improvement and long-term benefit, she added.

All patients experienced some mild burning and edema. The burning lasted 15 minutes or less. The submental edema resolved within 8 days for 96% of participants, she said.

In addition, 28% of the patients reported submental erythema lasting 15 minutes or less; 16% reported discomfort; and 14% reported short-term paresthesia or numbness. No patient experienced hematoma, headache, or systemic complaints.

Additional studies are warranted, said Dr. Ablon, especially large, randomized trials with histologic images to confirm the dissolution of fat. "We are also doing studies of PC and DC for hips and thighs, as well as for anterior axillae," she said.

She pointed out that injection lipolysis differs from mesotherapy. With mesotherapy there are "no standard formulations, injection techniques or therapeutic doses, and that is a little frightening."

"Not only are non-MDs performing this procedure, there are people with no training doing this [mesotherapy]," Dr. Ablon added.

"In our practice, since 2003, we are doing strictly injection lipolysis with PC/DC or DC," she said.

Advantages of injection lipolysis include no downtime, typically minimal side effects, and use as an adjunct to liposuction.

She disclosed having no relevant conflicts of interest.

MIAMI BEACH — Phosphatidylcholine injections were found to effectively dissolve submental fat deposits associated with a "double chin" appearance without any significant adverse effects.

Up to five injections of phosphatidylcholine (PC) over 6 months yielded a 40%-50% clinical fat reduction in patients, said Dr. Glynis R. Ablon at the South Beach Symposium.

PC is a linoleic acid with anticollagenase activity that provides antioxidant and antifibrotic benefits in both in vitro and in vivo studies, Dr. Ablon said. PC also has been used to treat hyperlipidemia, cardiac ischemia, and liver disease.

Lipolysis injections are often a combination of PC and deoxycholic acid (DC), a bile acid converted to a sodium salt that lyses fat cells. DC also is used in medications to reduce gallstones.

Dr. Ablon randomized 44 patients—38 women and 6 men—to a mixture of PC and DC, a DC solution, or bacteriostatic saline. Participants were aged 25–60 years and had mild, moderate, or severe submental fat deposits.

Caliper measurements of fat were made at a point midway between the submental crease and the hyoid bone. Injections alternated to the right or left side with up to five treatments over 6 months.

"We had great results with no significant complications. Patients were extremely happy," said Dr. Ablon of the University of California, Los Angeles.

This limited study showed 100% improvement and long-term benefit, she added.

All patients experienced some mild burning and edema. The burning lasted 15 minutes or less. The submental edema resolved within 8 days for 96% of participants, she said.

In addition, 28% of the patients reported submental erythema lasting 15 minutes or less; 16% reported discomfort; and 14% reported short-term paresthesia or numbness. No patient experienced hematoma, headache, or systemic complaints.

Additional studies are warranted, said Dr. Ablon, especially large, randomized trials with histologic images to confirm the dissolution of fat. "We are also doing studies of PC and DC for hips and thighs, as well as for anterior axillae," she said.

She pointed out that injection lipolysis differs from mesotherapy. With mesotherapy there are "no standard formulations, injection techniques or therapeutic doses, and that is a little frightening."

"Not only are non-MDs performing this procedure, there are people with no training doing this [mesotherapy]," Dr. Ablon added.

"In our practice, since 2003, we are doing strictly injection lipolysis with PC/DC or DC," she said.

Advantages of injection lipolysis include no downtime, typically minimal side effects, and use as an adjunct to liposuction.

She disclosed having no relevant conflicts of interest.

MIAMI BEACH — Phosphatidylcholine injections were found to effectively dissolve submental fat deposits associated with a "double chin" appearance without any significant adverse effects.

Up to five injections of phosphatidylcholine (PC) over 6 months yielded a 40%-50% clinical fat reduction in patients, said Dr. Glynis R. Ablon at the South Beach Symposium.

PC is a linoleic acid with anticollagenase activity that provides antioxidant and antifibrotic benefits in both in vitro and in vivo studies, Dr. Ablon said. PC also has been used to treat hyperlipidemia, cardiac ischemia, and liver disease.

Lipolysis injections are often a combination of PC and deoxycholic acid (DC), a bile acid converted to a sodium salt that lyses fat cells. DC also is used in medications to reduce gallstones.

Dr. Ablon randomized 44 patients—38 women and 6 men—to a mixture of PC and DC, a DC solution, or bacteriostatic saline. Participants were aged 25–60 years and had mild, moderate, or severe submental fat deposits.

Caliper measurements of fat were made at a point midway between the submental crease and the hyoid bone. Injections alternated to the right or left side with up to five treatments over 6 months.

"We had great results with no significant complications. Patients were extremely happy," said Dr. Ablon of the University of California, Los Angeles.

This limited study showed 100% improvement and long-term benefit, she added.

All patients experienced some mild burning and edema. The burning lasted 15 minutes or less. The submental edema resolved within 8 days for 96% of participants, she said.

In addition, 28% of the patients reported submental erythema lasting 15 minutes or less; 16% reported discomfort; and 14% reported short-term paresthesia or numbness. No patient experienced hematoma, headache, or systemic complaints.

Additional studies are warranted, said Dr. Ablon, especially large, randomized trials with histologic images to confirm the dissolution of fat. "We are also doing studies of PC and DC for hips and thighs, as well as for anterior axillae," she said.

She pointed out that injection lipolysis differs from mesotherapy. With mesotherapy there are "no standard formulations, injection techniques or therapeutic doses, and that is a little frightening."

"Not only are non-MDs performing this procedure, there are people with no training doing this [mesotherapy]," Dr. Ablon added.

"In our practice, since 2003, we are doing strictly injection lipolysis with PC/DC or DC," she said.

Advantages of injection lipolysis include no downtime, typically minimal side effects, and use as an adjunct to liposuction.

She disclosed having no relevant conflicts of interest.

HOLLYWOOD, FLA. — The differential diagnosis and management of primary cutaneous lymphoma rely to a great extent on whether lesions appear on the leg or elsewhere, according to the first guidelines released by the National Comprehensive Cancer Network.

"Diffuse B-cell lymphoma on the leg often leads to death," Dr. Steven M. Horwitz said. In contrast, other forms of primary cutaneous lymphoma, including follicle center and marginal zone disease, generally are indolent, and a majority of patients survive a decade or more after diagnosis.

"One of the questions is: Why have a guideline? Why not just treat this like other lymphomas?" Dr. Horwitz said at the annual conference of the National Comprehensive Cancer Network (NCCN). "A take-home point is there are notable differences between cutaneous B-cell lymphomas that affect treatment."

The genesis of the first guidelines was an observational study that found 5-year survival was 94% for non-leg-type cutaneous lymphoma patients versus 52% for leg-type disease (J. Clin. Oncol. 2001;19:3602–10). "Keep in mind the leg patients tend to be older," Dr. Horwitz said. Another study by the European Organization for Research and Treatment of Cancer (EORTC) confirmed this overall survival disparity out to 11 years (Curr. Opin. Oncol. 2006;18:425–31).

Clinical presentation, pathology, imaging, and "more and more" immunophenotyping can aid diagnosis, he said. For example, primary cutaneous follicle center lymphoma (FCL) is more common than the deadlier primary cutaneous diffuse large B-cell lymphoma (DLBCL), leg type. "In lymphoma we are not shy about giving things really long names," said Dr. Horwitz of Memorial Sloan-Kettering Cancer Center, New York.

FCL is typically an erythematous nodule with smooth skin on top. "And it doesn't have to be a small lesion, even though it's indolent," Dr. Horwitz said. In addition, FCL has a predilection for the scalp and forehead and tends to grow slowly and spontaneously regress.

In contrast, DLBCL leg-type is associated with rapid growth and features frequent mitosis. "But be a little careful. It could be a pseudolymphoma. Just a high proliferation rate only does not automatically mean leg disease," said Dr. Horwitz.

Histopathology differences are outlined in the guidelines. It is essential that a pathologist with expertise in diagnosis of primary cutaneous B-cell lymphoma review all tumor slides. A punch, incisional, or excisional biopsy is recommended. "Shave biopsies we don't like because the infiltrate is dermal," said Dr. Horwitz, a member of the NCCN panel that developed the guidelines.

Also essential to differential diagnosis is an immunophenotyping panel. For example, "A CD5 positive result means it is probably a skin manifestation of a systemic lymphoma," Dr. Horwitz said. Primary cutaneous lymphoma is a definition of exclusion, diagnosed when there is no evidence of extracutaneous disease on complete staging with physical examination, CT, bone marrow biopsy, and/or PET scan.

Diagnostic methods "useful in certain circumstances" include peripheral blood flow cytometry, molecular genetic testing for antigen receptor gene rearrangements, and cytogenetics or fluorescent in situ hybridization assays.

Work-up is also divided into essential and sometimes useful strategies. Complete history and physical examination, including a complete skin exam, are essential, for example. "I know it slows you down, but you really want to get patients to take all their clothes off and look at all of their skin. Even ask them to take their socks off and examine their feet," Dr. Horwitz said.

Order a complete blood count with differential, comprehensive metabolic panel, lactase dehydrogenase assay, and test for hepatitis B, if treatment includes rituximab (Rituxan, Genenetch).

Essential imaging includes a chest/abdominal/pelvic CT scan. A PET-CT scan is useful in certain circumstances. Dr. Horwitz said, "If you really think the person has local disease, PET is probably better for finding evidence of extracutaneous disease."

A bone marrow biopsy is considered essential with DLBCL, leg type. It also is useful for patients with FCL but is optional if the patient has marginal zone lymphoma (MZL), the other major form of indolent primary cutaneous disease.

The NCCN guidelines include a section to identify appropriate candidates for localized radiation therapy. Solitary skin involvement, regional disease, and systemic disease are differentiated according to clinical judgment. For solitary or regional T1-T2 FCL and MZL disease, for example, "almost all patients will respond" to locoregional radiation therapy or excision, he said.

Dr. Horwitz is a consultant for Eisai, Genenetch Inc., Merck & Co., and Therakos. He also is on the speakers bureau for Merck and receives grant and research support from Allos Therapeutics, Genzyme Corp., and Gloucester Pharmaceuticals.

'I know it slows you down, but you really want to get patients to take all their clothes off and look at all of their skin.' DR. HORWITZ

HOLLYWOOD, FLA. — The differential diagnosis and management of primary cutaneous lymphoma rely to a great extent on whether lesions appear on the leg or elsewhere, according to the first guidelines released by the National Comprehensive Cancer Network.

"Diffuse B-cell lymphoma on the leg often leads to death," Dr. Steven M. Horwitz said. In contrast, other forms of primary cutaneous lymphoma, including follicle center and marginal zone disease, generally are indolent, and a majority of patients survive a decade or more after diagnosis.

"One of the questions is: Why have a guideline? Why not just treat this like other lymphomas?" Dr. Horwitz said at the annual conference of the National Comprehensive Cancer Network (NCCN). "A take-home point is there are notable differences between cutaneous B-cell lymphomas that affect treatment."

The genesis of the first guidelines was an observational study that found 5-year survival was 94% for non-leg-type cutaneous lymphoma patients versus 52% for leg-type disease (J. Clin. Oncol. 2001;19:3602–10). "Keep in mind the leg patients tend to be older," Dr. Horwitz said. Another study by the European Organization for Research and Treatment of Cancer (EORTC) confirmed this overall survival disparity out to 11 years (Curr. Opin. Oncol. 2006;18:425–31).

Clinical presentation, pathology, imaging, and "more and more" immunophenotyping can aid diagnosis, he said. For example, primary cutaneous follicle center lymphoma (FCL) is more common than the deadlier primary cutaneous diffuse large B-cell lymphoma (DLBCL), leg type. "In lymphoma we are not shy about giving things really long names," said Dr. Horwitz of Memorial Sloan-Kettering Cancer Center, New York.

FCL is typically an erythematous nodule with smooth skin on top. "And it doesn't have to be a small lesion, even though it's indolent," Dr. Horwitz said. In addition, FCL has a predilection for the scalp and forehead and tends to grow slowly and spontaneously regress.

In contrast, DLBCL leg-type is associated with rapid growth and features frequent mitosis. "But be a little careful. It could be a pseudolymphoma. Just a high proliferation rate only does not automatically mean leg disease," said Dr. Horwitz.

Histopathology differences are outlined in the guidelines. It is essential that a pathologist with expertise in diagnosis of primary cutaneous B-cell lymphoma review all tumor slides. A punch, incisional, or excisional biopsy is recommended. "Shave biopsies we don't like because the infiltrate is dermal," said Dr. Horwitz, a member of the NCCN panel that developed the guidelines.

Also essential to differential diagnosis is an immunophenotyping panel. For example, "A CD5 positive result means it is probably a skin manifestation of a systemic lymphoma," Dr. Horwitz said. Primary cutaneous lymphoma is a definition of exclusion, diagnosed when there is no evidence of extracutaneous disease on complete staging with physical examination, CT, bone marrow biopsy, and/or PET scan.

Diagnostic methods "useful in certain circumstances" include peripheral blood flow cytometry, molecular genetic testing for antigen receptor gene rearrangements, and cytogenetics or fluorescent in situ hybridization assays.

Work-up is also divided into essential and sometimes useful strategies. Complete history and physical examination, including a complete skin exam, are essential, for example. "I know it slows you down, but you really want to get patients to take all their clothes off and look at all of their skin. Even ask them to take their socks off and examine their feet," Dr. Horwitz said.

Order a complete blood count with differential, comprehensive metabolic panel, lactase dehydrogenase assay, and test for hepatitis B, if treatment includes rituximab (Rituxan, Genenetch).

Essential imaging includes a chest/abdominal/pelvic CT scan. A PET-CT scan is useful in certain circumstances. Dr. Horwitz said, "If you really think the person has local disease, PET is probably better for finding evidence of extracutaneous disease."

A bone marrow biopsy is considered essential with DLBCL, leg type. It also is useful for patients with FCL but is optional if the patient has marginal zone lymphoma (MZL), the other major form of indolent primary cutaneous disease.

The NCCN guidelines include a section to identify appropriate candidates for localized radiation therapy. Solitary skin involvement, regional disease, and systemic disease are differentiated according to clinical judgment. For solitary or regional T1-T2 FCL and MZL disease, for example, "almost all patients will respond" to locoregional radiation therapy or excision, he said.

Dr. Horwitz is a consultant for Eisai, Genenetch Inc., Merck & Co., and Therakos. He also is on the speakers bureau for Merck and receives grant and research support from Allos Therapeutics, Genzyme Corp., and Gloucester Pharmaceuticals.

'I know it slows you down, but you really want to get patients to take all their clothes off and look at all of their skin.' DR. HORWITZ

HOLLYWOOD, FLA. — The differential diagnosis and management of primary cutaneous lymphoma rely to a great extent on whether lesions appear on the leg or elsewhere, according to the first guidelines released by the National Comprehensive Cancer Network.

"Diffuse B-cell lymphoma on the leg often leads to death," Dr. Steven M. Horwitz said. In contrast, other forms of primary cutaneous lymphoma, including follicle center and marginal zone disease, generally are indolent, and a majority of patients survive a decade or more after diagnosis.

"One of the questions is: Why have a guideline? Why not just treat this like other lymphomas?" Dr. Horwitz said at the annual conference of the National Comprehensive Cancer Network (NCCN). "A take-home point is there are notable differences between cutaneous B-cell lymphomas that affect treatment."

The genesis of the first guidelines was an observational study that found 5-year survival was 94% for non-leg-type cutaneous lymphoma patients versus 52% for leg-type disease (J. Clin. Oncol. 2001;19:3602–10). "Keep in mind the leg patients tend to be older," Dr. Horwitz said. Another study by the European Organization for Research and Treatment of Cancer (EORTC) confirmed this overall survival disparity out to 11 years (Curr. Opin. Oncol. 2006;18:425–31).

Clinical presentation, pathology, imaging, and "more and more" immunophenotyping can aid diagnosis, he said. For example, primary cutaneous follicle center lymphoma (FCL) is more common than the deadlier primary cutaneous diffuse large B-cell lymphoma (DLBCL), leg type. "In lymphoma we are not shy about giving things really long names," said Dr. Horwitz of Memorial Sloan-Kettering Cancer Center, New York.

FCL is typically an erythematous nodule with smooth skin on top. "And it doesn't have to be a small lesion, even though it's indolent," Dr. Horwitz said. In addition, FCL has a predilection for the scalp and forehead and tends to grow slowly and spontaneously regress.

In contrast, DLBCL leg-type is associated with rapid growth and features frequent mitosis. "But be a little careful. It could be a pseudolymphoma. Just a high proliferation rate only does not automatically mean leg disease," said Dr. Horwitz.

Histopathology differences are outlined in the guidelines. It is essential that a pathologist with expertise in diagnosis of primary cutaneous B-cell lymphoma review all tumor slides. A punch, incisional, or excisional biopsy is recommended. "Shave biopsies we don't like because the infiltrate is dermal," said Dr. Horwitz, a member of the NCCN panel that developed the guidelines.

Also essential to differential diagnosis is an immunophenotyping panel. For example, "A CD5 positive result means it is probably a skin manifestation of a systemic lymphoma," Dr. Horwitz said. Primary cutaneous lymphoma is a definition of exclusion, diagnosed when there is no evidence of extracutaneous disease on complete staging with physical examination, CT, bone marrow biopsy, and/or PET scan.

Diagnostic methods "useful in certain circumstances" include peripheral blood flow cytometry, molecular genetic testing for antigen receptor gene rearrangements, and cytogenetics or fluorescent in situ hybridization assays.

Work-up is also divided into essential and sometimes useful strategies. Complete history and physical examination, including a complete skin exam, are essential, for example. "I know it slows you down, but you really want to get patients to take all their clothes off and look at all of their skin. Even ask them to take their socks off and examine their feet," Dr. Horwitz said.

Order a complete blood count with differential, comprehensive metabolic panel, lactase dehydrogenase assay, and test for hepatitis B, if treatment includes rituximab (Rituxan, Genenetch).

Essential imaging includes a chest/abdominal/pelvic CT scan. A PET-CT scan is useful in certain circumstances. Dr. Horwitz said, "If you really think the person has local disease, PET is probably better for finding evidence of extracutaneous disease."

A bone marrow biopsy is considered essential with DLBCL, leg type. It also is useful for patients with FCL but is optional if the patient has marginal zone lymphoma (MZL), the other major form of indolent primary cutaneous disease.

The NCCN guidelines include a section to identify appropriate candidates for localized radiation therapy. Solitary skin involvement, regional disease, and systemic disease are differentiated according to clinical judgment. For solitary or regional T1-T2 FCL and MZL disease, for example, "almost all patients will respond" to locoregional radiation therapy or excision, he said.

Dr. Horwitz is a consultant for Eisai, Genenetch Inc., Merck & Co., and Therakos. He also is on the speakers bureau for Merck and receives grant and research support from Allos Therapeutics, Genzyme Corp., and Gloucester Pharmaceuticals.

'I know it slows you down, but you really want to get patients to take all their clothes off and look at all of their skin.' DR. HORWITZ

SINT MAARTEN, NETHERLANDS ANTILLES — The North American Contact Dermatitis Group removed 5 allergens from its 2007–2008 standard North American patch test tray and replaced them with 10 new substances to test for in 2009–2010.

The group removed imidazolidinyl urea, 2%; dimethylol dimethyl hydantoin, 1%; diazolidinyl urea, 1%; bisphenol F epoxy resin, 0.025%; and triamcinolone acetonide, 1%, Dr. Kathryn A. Zug reported at the Caribbean Dermatology Symposium.

The 10 allergens added are:

▸ Dimethylaminopropylamine (DMAPA), 1%. “You may be hearing more about this allergen. DMAPA is found in body wash, shampoos, and detergents and can cause face, neck, and eyelid dermatitis,” said Dr. Zug, a dermatologist at Dartmouth-Hitchcock Medical Center in Lebanon, N.H. She said she had no relevant disclosures to report.

▸ D-Limonene, 3%.

▸ Shellac, 20%. “This has been described previously for eyelid dermatitis from mascara,” Dr. Zug said.

▸ Majantole, 5%. She described this as “a new, important fragrance allergen” from a synthetic source.

▸ Oleamidopropyl dimethylamine, 0.1%.

▸ Carvone, 5%.

▸ Lavandula angustifolia (lavender) oil, 2%.

▸ Decyl glucoside, 5%. “This plant-derived surfactant is included in more 'natural' products,” Dr. Zug said. “It's an uncommon allergen, but the North American Contact Dermatitis Group is now monitoring it.”

▸ Jasminum officionale oil (Jasminum grandiflorum), 2%.

▸ Mentha piperita (peppermint) oil, 2%.

An allergen that sounds new, but is not, is Myroxylon pereirae resin. “This is one of our familiar allergens, balsam of Peru,” Dr. Zug said. “What has happened? We've taken a simple name—balsam of Peru—and made it more complicated by adopting the botanical name.”

She added, “Hopefully you will all be familiar with it when you see it on a standard tray.”

In discussing the results of a study of allergies to fragrances, Dr. Zug noted that a Lyral sensitization frequency of 2.3% was reported in a comprehensive study of 26 fragrances patch tested in a total of 21,325 patients in Germany (Contact Derm. 2007;57:1–10). Lyral is a component of fragrances and detergents included in the Fragrance Mix II patch test kit.

“Europeans are very interested in figuring out the frequency of [fragrance] allergies,” Dr. Zug said.

Other fragrances not on the standard series that were associated with stronger or more frequent patch test results in the study included tree moss (2.4%), oak moss (2.0%), hydroxycitronellal (1.3%), isoeugenol (1.1%), and cinnamic aldehyde (1.0%).

Because of studies like this, Dr. Zug said, “we may be able to better hone down which fragrance components our patients are allergic to, rather than just telling them they have a fragrance allergy.”

Products Recommended For Very Sensitive Skin

Creams

Aveeno

Vanicream

Deodorant

Almay

Lotions

Aveeno

DML

Theraplex emollient

Ointments

Hydrolatum

Vaseline petroleum jelly

Shampoos and Conditioners

DHS Clear

Free and Clear

Soaps

All liquid washes

Glycerin soap

Vanicream bar

Aveeno bar

Source: Dr. Zug

SINT MAARTEN, NETHERLANDS ANTILLES — The North American Contact Dermatitis Group removed 5 allergens from its 2007–2008 standard North American patch test tray and replaced them with 10 new substances to test for in 2009–2010.

The group removed imidazolidinyl urea, 2%; dimethylol dimethyl hydantoin, 1%; diazolidinyl urea, 1%; bisphenol F epoxy resin, 0.025%; and triamcinolone acetonide, 1%, Dr. Kathryn A. Zug reported at the Caribbean Dermatology Symposium.

The 10 allergens added are:

▸ Dimethylaminopropylamine (DMAPA), 1%. “You may be hearing more about this allergen. DMAPA is found in body wash, shampoos, and detergents and can cause face, neck, and eyelid dermatitis,” said Dr. Zug, a dermatologist at Dartmouth-Hitchcock Medical Center in Lebanon, N.H. She said she had no relevant disclosures to report.

▸ D-Limonene, 3%.

▸ Shellac, 20%. “This has been described previously for eyelid dermatitis from mascara,” Dr. Zug said.

▸ Majantole, 5%. She described this as “a new, important fragrance allergen” from a synthetic source.

▸ Oleamidopropyl dimethylamine, 0.1%.

▸ Carvone, 5%.

▸ Lavandula angustifolia (lavender) oil, 2%.

▸ Decyl glucoside, 5%. “This plant-derived surfactant is included in more 'natural' products,” Dr. Zug said. “It's an uncommon allergen, but the North American Contact Dermatitis Group is now monitoring it.”

▸ Jasminum officionale oil (Jasminum grandiflorum), 2%.

▸ Mentha piperita (peppermint) oil, 2%.

An allergen that sounds new, but is not, is Myroxylon pereirae resin. “This is one of our familiar allergens, balsam of Peru,” Dr. Zug said. “What has happened? We've taken a simple name—balsam of Peru—and made it more complicated by adopting the botanical name.”

She added, “Hopefully you will all be familiar with it when you see it on a standard tray.”

In discussing the results of a study of allergies to fragrances, Dr. Zug noted that a Lyral sensitization frequency of 2.3% was reported in a comprehensive study of 26 fragrances patch tested in a total of 21,325 patients in Germany (Contact Derm. 2007;57:1–10). Lyral is a component of fragrances and detergents included in the Fragrance Mix II patch test kit.

“Europeans are very interested in figuring out the frequency of [fragrance] allergies,” Dr. Zug said.

Other fragrances not on the standard series that were associated with stronger or more frequent patch test results in the study included tree moss (2.4%), oak moss (2.0%), hydroxycitronellal (1.3%), isoeugenol (1.1%), and cinnamic aldehyde (1.0%).

Because of studies like this, Dr. Zug said, “we may be able to better hone down which fragrance components our patients are allergic to, rather than just telling them they have a fragrance allergy.”

Products Recommended For Very Sensitive Skin

Creams

Aveeno

Vanicream

Deodorant

Almay

Lotions

Aveeno

DML

Theraplex emollient

Ointments

Hydrolatum

Vaseline petroleum jelly

Shampoos and Conditioners

DHS Clear

Free and Clear

Soaps

All liquid washes

Glycerin soap

Vanicream bar

Aveeno bar

Source: Dr. Zug

SINT MAARTEN, NETHERLANDS ANTILLES — The North American Contact Dermatitis Group removed 5 allergens from its 2007–2008 standard North American patch test tray and replaced them with 10 new substances to test for in 2009–2010.

The group removed imidazolidinyl urea, 2%; dimethylol dimethyl hydantoin, 1%; diazolidinyl urea, 1%; bisphenol F epoxy resin, 0.025%; and triamcinolone acetonide, 1%, Dr. Kathryn A. Zug reported at the Caribbean Dermatology Symposium.

The 10 allergens added are:

▸ Dimethylaminopropylamine (DMAPA), 1%. “You may be hearing more about this allergen. DMAPA is found in body wash, shampoos, and detergents and can cause face, neck, and eyelid dermatitis,” said Dr. Zug, a dermatologist at Dartmouth-Hitchcock Medical Center in Lebanon, N.H. She said she had no relevant disclosures to report.

▸ D-Limonene, 3%.

▸ Shellac, 20%. “This has been described previously for eyelid dermatitis from mascara,” Dr. Zug said.

▸ Majantole, 5%. She described this as “a new, important fragrance allergen” from a synthetic source.

▸ Oleamidopropyl dimethylamine, 0.1%.

▸ Carvone, 5%.

▸ Lavandula angustifolia (lavender) oil, 2%.

▸ Decyl glucoside, 5%. “This plant-derived surfactant is included in more 'natural' products,” Dr. Zug said. “It's an uncommon allergen, but the North American Contact Dermatitis Group is now monitoring it.”

▸ Jasminum officionale oil (Jasminum grandiflorum), 2%.

▸ Mentha piperita (peppermint) oil, 2%.

An allergen that sounds new, but is not, is Myroxylon pereirae resin. “This is one of our familiar allergens, balsam of Peru,” Dr. Zug said. “What has happened? We've taken a simple name—balsam of Peru—and made it more complicated by adopting the botanical name.”

She added, “Hopefully you will all be familiar with it when you see it on a standard tray.”

In discussing the results of a study of allergies to fragrances, Dr. Zug noted that a Lyral sensitization frequency of 2.3% was reported in a comprehensive study of 26 fragrances patch tested in a total of 21,325 patients in Germany (Contact Derm. 2007;57:1–10). Lyral is a component of fragrances and detergents included in the Fragrance Mix II patch test kit.

“Europeans are very interested in figuring out the frequency of [fragrance] allergies,” Dr. Zug said.

Other fragrances not on the standard series that were associated with stronger or more frequent patch test results in the study included tree moss (2.4%), oak moss (2.0%), hydroxycitronellal (1.3%), isoeugenol (1.1%), and cinnamic aldehyde (1.0%).

Because of studies like this, Dr. Zug said, “we may be able to better hone down which fragrance components our patients are allergic to, rather than just telling them they have a fragrance allergy.”

Products Recommended For Very Sensitive Skin

Creams

Aveeno

Vanicream

Deodorant

Almay

Lotions

Aveeno

DML

Theraplex emollient

Ointments

Hydrolatum

Vaseline petroleum jelly

Shampoos and Conditioners

DHS Clear

Free and Clear

Soaps

All liquid washes

Glycerin soap

Vanicream bar

Aveeno bar

Source: Dr. Zug

LAKE BUENA VISTA, FLA. — Menopause symptoms vary significantly by ethnic group, based on data emerging from a longitudinal study.

Acculturation of women immigrants to the United States and socioeconomic status are two of the factors that might account for these differences, said Dr. Nanette F. Santoro, an endocrinologist who has coauthored multiple studies based on the Study of Women's Health Across the Nation (SWAN) data.

The study included women from seven sites: Boston; Newark, N.J.; Pittsburgh; Detroit; Chicago; Oakland, Calif.; and Los Angeles. Each site recruited white women and women from one ethnic minority group: black, Hispanic, Chinese, or Japanese. More than 10 years later, about 85% of the participants remain in the study. “We found differences by ethnicity—very intriguing differences,” Dr. Santoro said.

For example, in one study of 11,652 women from SWAN, Dr. Santoro and her colleagues found that 126 participants (1.1%) reported onset of menopause before age 40 years, also known as premature ovarian failure (Human Reprod. 2003;18:199–206). This occurred in 1.0% of white women, 1.4% each of black and Hispanic women, 0.5% of Chinese women, and 0.1% of Japanese women. (See box.) These differences were statistically significant.

Acculturation of immigrants is “a double-edged sword,” Dr. Santoro said at the annual meeting of the North American Menopause Society. It can improve socioeconomic status, access to health care, and attainment of higher education, but also worsen health through a less-nutritious diet.

In contrast to other minorities, Hispanic women in SWAN and similar studies tend to improve little or even worsen in terms of health once they are assimilated, she said. Watch for the “Hispanic paradox”: Health outcomes are worse among this population with increased acculturation, despite better socioeconomic status, because of factors such as higher rates of teen pregnancy and cigarette smoking, said Dr. Santoro, director of the division of reproductive endocrinology and infertility, Albert Einstein College of Medicine, New York.

She cautioned that the Hispanic population is heterogeneous and cannot be addressed as a single entity. The Hispanic SWAN participants came from many different countries and cultures and displayed some internal differences. For example, women from Puerto Rico were more vulnerable to acculturation and reported more menopause-related sleep problems and depressive symptoms than did other Hispanics.

Meanwhile, acculturation of Japanese women was associated with fewer menopausal symptoms than were seen in Hispanics. Similarly, Chinese participants reported fewer symptoms compared with white, black, and Hispanic women in SWAN.

“There are clear-cut differences in symptom reporting by ethnicity,” Dr. Santoro said.

Hispanic and black women were more likely to report depressive symptoms, and Chinese and Japanese women were less likely to do so. “This is confounded, possibly, by lower socioeconomic status in the African American and Hispanic groups and a higher socioeconomic status in Chinese and especially Japanese women,” she said.

Black women in SWAN reported the most hot flashes. Dr. Santoro proposed that increased adiposity among these women might provide more insulation and make them less heat tolerant. Black women, however, were less bothered by hot flashes, compared with Hispanic women, who reported more embarrassment with vasomotor symptoms.

SWAN is supported by grants from the Department of Health and Human Services.

ELSEVIER GLOBAL MEDICAL NEWS

LAKE BUENA VISTA, FLA. — Menopause symptoms vary significantly by ethnic group, based on data emerging from a longitudinal study.

Acculturation of women immigrants to the United States and socioeconomic status are two of the factors that might account for these differences, said Dr. Nanette F. Santoro, an endocrinologist who has coauthored multiple studies based on the Study of Women's Health Across the Nation (SWAN) data.

The study included women from seven sites: Boston; Newark, N.J.; Pittsburgh; Detroit; Chicago; Oakland, Calif.; and Los Angeles. Each site recruited white women and women from one ethnic minority group: black, Hispanic, Chinese, or Japanese. More than 10 years later, about 85% of the participants remain in the study. “We found differences by ethnicity—very intriguing differences,” Dr. Santoro said.

For example, in one study of 11,652 women from SWAN, Dr. Santoro and her colleagues found that 126 participants (1.1%) reported onset of menopause before age 40 years, also known as premature ovarian failure (Human Reprod. 2003;18:199–206). This occurred in 1.0% of white women, 1.4% each of black and Hispanic women, 0.5% of Chinese women, and 0.1% of Japanese women. (See box.) These differences were statistically significant.

Acculturation of immigrants is “a double-edged sword,” Dr. Santoro said at the annual meeting of the North American Menopause Society. It can improve socioeconomic status, access to health care, and attainment of higher education, but also worsen health through a less-nutritious diet.

In contrast to other minorities, Hispanic women in SWAN and similar studies tend to improve little or even worsen in terms of health once they are assimilated, she said. Watch for the “Hispanic paradox”: Health outcomes are worse among this population with increased acculturation, despite better socioeconomic status, because of factors such as higher rates of teen pregnancy and cigarette smoking, said Dr. Santoro, director of the division of reproductive endocrinology and infertility, Albert Einstein College of Medicine, New York.

She cautioned that the Hispanic population is heterogeneous and cannot be addressed as a single entity. The Hispanic SWAN participants came from many different countries and cultures and displayed some internal differences. For example, women from Puerto Rico were more vulnerable to acculturation and reported more menopause-related sleep problems and depressive symptoms than did other Hispanics.

Meanwhile, acculturation of Japanese women was associated with fewer menopausal symptoms than were seen in Hispanics. Similarly, Chinese participants reported fewer symptoms compared with white, black, and Hispanic women in SWAN.

“There are clear-cut differences in symptom reporting by ethnicity,” Dr. Santoro said.

Hispanic and black women were more likely to report depressive symptoms, and Chinese and Japanese women were less likely to do so. “This is confounded, possibly, by lower socioeconomic status in the African American and Hispanic groups and a higher socioeconomic status in Chinese and especially Japanese women,” she said.

Black women in SWAN reported the most hot flashes. Dr. Santoro proposed that increased adiposity among these women might provide more insulation and make them less heat tolerant. Black women, however, were less bothered by hot flashes, compared with Hispanic women, who reported more embarrassment with vasomotor symptoms.

SWAN is supported by grants from the Department of Health and Human Services.

ELSEVIER GLOBAL MEDICAL NEWS

LAKE BUENA VISTA, FLA. — Menopause symptoms vary significantly by ethnic group, based on data emerging from a longitudinal study.

Acculturation of women immigrants to the United States and socioeconomic status are two of the factors that might account for these differences, said Dr. Nanette F. Santoro, an endocrinologist who has coauthored multiple studies based on the Study of Women's Health Across the Nation (SWAN) data.

The study included women from seven sites: Boston; Newark, N.J.; Pittsburgh; Detroit; Chicago; Oakland, Calif.; and Los Angeles. Each site recruited white women and women from one ethnic minority group: black, Hispanic, Chinese, or Japanese. More than 10 years later, about 85% of the participants remain in the study. “We found differences by ethnicity—very intriguing differences,” Dr. Santoro said.

For example, in one study of 11,652 women from SWAN, Dr. Santoro and her colleagues found that 126 participants (1.1%) reported onset of menopause before age 40 years, also known as premature ovarian failure (Human Reprod. 2003;18:199–206). This occurred in 1.0% of white women, 1.4% each of black and Hispanic women, 0.5% of Chinese women, and 0.1% of Japanese women. (See box.) These differences were statistically significant.

Acculturation of immigrants is “a double-edged sword,” Dr. Santoro said at the annual meeting of the North American Menopause Society. It can improve socioeconomic status, access to health care, and attainment of higher education, but also worsen health through a less-nutritious diet.

In contrast to other minorities, Hispanic women in SWAN and similar studies tend to improve little or even worsen in terms of health once they are assimilated, she said. Watch for the “Hispanic paradox”: Health outcomes are worse among this population with increased acculturation, despite better socioeconomic status, because of factors such as higher rates of teen pregnancy and cigarette smoking, said Dr. Santoro, director of the division of reproductive endocrinology and infertility, Albert Einstein College of Medicine, New York.

She cautioned that the Hispanic population is heterogeneous and cannot be addressed as a single entity. The Hispanic SWAN participants came from many different countries and cultures and displayed some internal differences. For example, women from Puerto Rico were more vulnerable to acculturation and reported more menopause-related sleep problems and depressive symptoms than did other Hispanics.

Meanwhile, acculturation of Japanese women was associated with fewer menopausal symptoms than were seen in Hispanics. Similarly, Chinese participants reported fewer symptoms compared with white, black, and Hispanic women in SWAN.

“There are clear-cut differences in symptom reporting by ethnicity,” Dr. Santoro said.

Hispanic and black women were more likely to report depressive symptoms, and Chinese and Japanese women were less likely to do so. “This is confounded, possibly, by lower socioeconomic status in the African American and Hispanic groups and a higher socioeconomic status in Chinese and especially Japanese women,” she said.

Black women in SWAN reported the most hot flashes. Dr. Santoro proposed that increased adiposity among these women might provide more insulation and make them less heat tolerant. Black women, however, were less bothered by hot flashes, compared with Hispanic women, who reported more embarrassment with vasomotor symptoms.

SWAN is supported by grants from the Department of Health and Human Services.

ELSEVIER GLOBAL MEDICAL NEWS