Damian McNamara

MONTREAL — Formation of an international confocal microscopy group, software that aids the detection and mapping of skin lesions, and introduction of a handheld device are among recent advances to aid in the diagnosis of lentigo maligna and other lesions in real time.

Researchers hope widespread adoption of confocal laser microscopy progress will permit further early diagnoses of cutaneous melanoma and other lesions at the bedside. "It is critical to do biopsies early. If you believe cancer starts from a single cell, you can diagnose it early [with confocal laser microscopy]. That is what we are working on now," Dr. Richard Langley said.

Described as a "living skin biopsy" by some, microscopy is not new. Pathologists have employed the intensely focused light to examine tissue specimens since the 1950s, he said. There is a limitation in live patients, however. "We cannot go through a patient's skin, so we deal with reflective light. We still have confocal concepts, but we have real-time results," Dr. Langley said at the annual conference of the Canadian Dermatology Association.

Dr. Langley and his colleagues were the first to report use of confocal laser microscopy in a series of 40 dermatology patients with superficial melanoma (J. Am. Acad. Dermatol. 2001;45:365–76).

Others have since validated that microscopy distinguishes between malignant and benign lesions in vivo. To date, studies include more than 400 patients, said Dr. Langley of Dalhousie University, Halifax, N.S.

Last year, he and his associates published the first prospective study to compare microscopy with dermoscopy. "We decided to see if we can do a prospective, blinded, single-institution study," he said.

They assessed 125 patients with suspicious pigmented lesions using both technologies, followed by a confirmatory biopsy (Dermatology 2007;215:365–72). They detected a total of 88 melanotic nevi and 37 melanomas. "Sensitivity was higher with confocal versus dermoscopy [97% vs. 89%, respectively]. The specificity was about the same [83% vs. 84%]," Dr. Langley said. "We missed one melanoma with the confocal technology, so it was not perfect."

For dermatologists accustomed to reading cross-sectional biopsies, it may take an adjustment to recognize the clusters of melanocytes, Dr. Langley said. "You have to retrain your eye to look differently—you are looking from above. Also, it is in black and white, not color, like we're used to."

Indicative of the growing interest in this technology is the formation of the International Confocal Microscopy Working Group, launched at the February 2008 American Academy of Dermatology annual meeting in San Antonio. The group aims to form an international network of medical professionals working with confocal laser microscopy and to promote education, training, and additional research about the technology.

New software for microscopy also emerged in the past year (Electronic Zoom, Lucid Inc.). The video-capture software allows dermatologists or dermatopathologists to map a lesion and tag an area of interest. "You start with a macro image and, if you see an area you want to focus on, the software can be engaged," Dr. Langley said.

Another advance is the availability of a hand-held confocal microscopy device (VivaScope 3000, Lucid). Dr. Langley had no relevant financial disclosures.

A hand-held confocal microscopy device is one recent dermoscopy advancement. ©Lucid, Inc.

MONTREAL — Formation of an international confocal microscopy group, software that aids the detection and mapping of skin lesions, and introduction of a handheld device are among recent advances to aid in the diagnosis of lentigo maligna and other lesions in real time.

Researchers hope widespread adoption of confocal laser microscopy progress will permit further early diagnoses of cutaneous melanoma and other lesions at the bedside. "It is critical to do biopsies early. If you believe cancer starts from a single cell, you can diagnose it early [with confocal laser microscopy]. That is what we are working on now," Dr. Richard Langley said.

Described as a "living skin biopsy" by some, microscopy is not new. Pathologists have employed the intensely focused light to examine tissue specimens since the 1950s, he said. There is a limitation in live patients, however. "We cannot go through a patient's skin, so we deal with reflective light. We still have confocal concepts, but we have real-time results," Dr. Langley said at the annual conference of the Canadian Dermatology Association.

Dr. Langley and his colleagues were the first to report use of confocal laser microscopy in a series of 40 dermatology patients with superficial melanoma (J. Am. Acad. Dermatol. 2001;45:365–76).

Others have since validated that microscopy distinguishes between malignant and benign lesions in vivo. To date, studies include more than 400 patients, said Dr. Langley of Dalhousie University, Halifax, N.S.

Last year, he and his associates published the first prospective study to compare microscopy with dermoscopy. "We decided to see if we can do a prospective, blinded, single-institution study," he said.

They assessed 125 patients with suspicious pigmented lesions using both technologies, followed by a confirmatory biopsy (Dermatology 2007;215:365–72). They detected a total of 88 melanotic nevi and 37 melanomas. "Sensitivity was higher with confocal versus dermoscopy [97% vs. 89%, respectively]. The specificity was about the same [83% vs. 84%]," Dr. Langley said. "We missed one melanoma with the confocal technology, so it was not perfect."

For dermatologists accustomed to reading cross-sectional biopsies, it may take an adjustment to recognize the clusters of melanocytes, Dr. Langley said. "You have to retrain your eye to look differently—you are looking from above. Also, it is in black and white, not color, like we're used to."

Indicative of the growing interest in this technology is the formation of the International Confocal Microscopy Working Group, launched at the February 2008 American Academy of Dermatology annual meeting in San Antonio. The group aims to form an international network of medical professionals working with confocal laser microscopy and to promote education, training, and additional research about the technology.

New software for microscopy also emerged in the past year (Electronic Zoom, Lucid Inc.). The video-capture software allows dermatologists or dermatopathologists to map a lesion and tag an area of interest. "You start with a macro image and, if you see an area you want to focus on, the software can be engaged," Dr. Langley said.

Another advance is the availability of a hand-held confocal microscopy device (VivaScope 3000, Lucid). Dr. Langley had no relevant financial disclosures.

A hand-held confocal microscopy device is one recent dermoscopy advancement. ©Lucid, Inc.

MONTREAL — Formation of an international confocal microscopy group, software that aids the detection and mapping of skin lesions, and introduction of a handheld device are among recent advances to aid in the diagnosis of lentigo maligna and other lesions in real time.

Researchers hope widespread adoption of confocal laser microscopy progress will permit further early diagnoses of cutaneous melanoma and other lesions at the bedside. "It is critical to do biopsies early. If you believe cancer starts from a single cell, you can diagnose it early [with confocal laser microscopy]. That is what we are working on now," Dr. Richard Langley said.

Described as a "living skin biopsy" by some, microscopy is not new. Pathologists have employed the intensely focused light to examine tissue specimens since the 1950s, he said. There is a limitation in live patients, however. "We cannot go through a patient's skin, so we deal with reflective light. We still have confocal concepts, but we have real-time results," Dr. Langley said at the annual conference of the Canadian Dermatology Association.

Dr. Langley and his colleagues were the first to report use of confocal laser microscopy in a series of 40 dermatology patients with superficial melanoma (J. Am. Acad. Dermatol. 2001;45:365–76).

Others have since validated that microscopy distinguishes between malignant and benign lesions in vivo. To date, studies include more than 400 patients, said Dr. Langley of Dalhousie University, Halifax, N.S.

Last year, he and his associates published the first prospective study to compare microscopy with dermoscopy. "We decided to see if we can do a prospective, blinded, single-institution study," he said.

They assessed 125 patients with suspicious pigmented lesions using both technologies, followed by a confirmatory biopsy (Dermatology 2007;215:365–72). They detected a total of 88 melanotic nevi and 37 melanomas. "Sensitivity was higher with confocal versus dermoscopy [97% vs. 89%, respectively]. The specificity was about the same [83% vs. 84%]," Dr. Langley said. "We missed one melanoma with the confocal technology, so it was not perfect."

For dermatologists accustomed to reading cross-sectional biopsies, it may take an adjustment to recognize the clusters of melanocytes, Dr. Langley said. "You have to retrain your eye to look differently—you are looking from above. Also, it is in black and white, not color, like we're used to."

Indicative of the growing interest in this technology is the formation of the International Confocal Microscopy Working Group, launched at the February 2008 American Academy of Dermatology annual meeting in San Antonio. The group aims to form an international network of medical professionals working with confocal laser microscopy and to promote education, training, and additional research about the technology.

New software for microscopy also emerged in the past year (Electronic Zoom, Lucid Inc.). The video-capture software allows dermatologists or dermatopathologists to map a lesion and tag an area of interest. "You start with a macro image and, if you see an area you want to focus on, the software can be engaged," Dr. Langley said.

Another advance is the availability of a hand-held confocal microscopy device (VivaScope 3000, Lucid). Dr. Langley had no relevant financial disclosures.

A hand-held confocal microscopy device is one recent dermoscopy advancement. ©Lucid, Inc.

MONTREAL — Regression of a thin melanoma should not be the sole criterion to justify a sentinel lymph node biopsy, according to a retrospective study.

Regression alone is insufficient in the absence of other recognized high-risk predictors of sentinel lymph node (SLN) involvement, Dr. Pierre-Luc Dion said. More established risk factors include Breslow thickness greater than 1 mm, Clark level IV or V, and lesion ulceration.

Prognosis generally is better with thinner melanoma. Identification of the minority of thin melanoma patients who are at high risk for metastasis, however, remains a clinical challenge.

"There is an ongoing debate if regression is good news or bad news for patients. Some think it shows an immune response against tumor cells, but others say it can lead to an underestimation of the real thickness," Dr. Dion said at the annual conference of the Canadian Dermatology Association.

There is no consensus in the literature. One study of 65 thin melanomas with regression found that only 2 lesions (3%) had a positive SLN biopsy result (Ann. Surg. Oncol. 2003;10:558–61).

Another study found only 1 patient with a positive SLN biopsy among 344 who had thin melanomas (mean Breslow thickness of 1.1 mm) that had shown histologic regression (Ann. Surg. Oncol. 2008;15:316–22).

Other investigators have proposed that tumor regression predicts a higher risk of sentinel node involvement in thin melanomas (Br. J. Dermatol. 2003;149:662–3).

Dr. Dion and his colleagues assessed 693 patients treated at the melanoma clinics for Le Centre Hospitalier Universitaire de Québec-L'Hôtel-Dieu de Québec in Saint-Nicolas and Québec City. All of the patients underwent sentinel lymph node biopsy between 1996 and 2007. The median Breslow thickness was 2.28 mm and mean age was 55 years.

A total of 653 patients had a lesion that was greater than 1 mm. Their prognoses were compared with those of a group of 40 others with thinner melanoma and regression. Regression was determined by a pathologist, who found at least a 15% reduction in the lesion size on multiple slides.

Among the patients with regression, none had a positive lymph node, compared with 146 (22%) in the control group, suggesting regression alone is not a reliable predictor, said Dr. Dion of the hospital in Saint-Nicolas.

Of the 40 patients, 1 experienced complete regression. Another six patients in this group developed in situ melanoma. The median Breslow thickness among the remaining 33 patients was 0.6 mm. At a mean follow-up of almost 4 years, recurrence occurred in two patients, including one local recurrence and one transit metastasis, Dr. Dion said.

MONTREAL — Regression of a thin melanoma should not be the sole criterion to justify a sentinel lymph node biopsy, according to a retrospective study.

Regression alone is insufficient in the absence of other recognized high-risk predictors of sentinel lymph node (SLN) involvement, Dr. Pierre-Luc Dion said. More established risk factors include Breslow thickness greater than 1 mm, Clark level IV or V, and lesion ulceration.

Prognosis generally is better with thinner melanoma. Identification of the minority of thin melanoma patients who are at high risk for metastasis, however, remains a clinical challenge.

"There is an ongoing debate if regression is good news or bad news for patients. Some think it shows an immune response against tumor cells, but others say it can lead to an underestimation of the real thickness," Dr. Dion said at the annual conference of the Canadian Dermatology Association.

There is no consensus in the literature. One study of 65 thin melanomas with regression found that only 2 lesions (3%) had a positive SLN biopsy result (Ann. Surg. Oncol. 2003;10:558–61).

Another study found only 1 patient with a positive SLN biopsy among 344 who had thin melanomas (mean Breslow thickness of 1.1 mm) that had shown histologic regression (Ann. Surg. Oncol. 2008;15:316–22).

Other investigators have proposed that tumor regression predicts a higher risk of sentinel node involvement in thin melanomas (Br. J. Dermatol. 2003;149:662–3).

Dr. Dion and his colleagues assessed 693 patients treated at the melanoma clinics for Le Centre Hospitalier Universitaire de Québec-L'Hôtel-Dieu de Québec in Saint-Nicolas and Québec City. All of the patients underwent sentinel lymph node biopsy between 1996 and 2007. The median Breslow thickness was 2.28 mm and mean age was 55 years.

A total of 653 patients had a lesion that was greater than 1 mm. Their prognoses were compared with those of a group of 40 others with thinner melanoma and regression. Regression was determined by a pathologist, who found at least a 15% reduction in the lesion size on multiple slides.

Among the patients with regression, none had a positive lymph node, compared with 146 (22%) in the control group, suggesting regression alone is not a reliable predictor, said Dr. Dion of the hospital in Saint-Nicolas.

Of the 40 patients, 1 experienced complete regression. Another six patients in this group developed in situ melanoma. The median Breslow thickness among the remaining 33 patients was 0.6 mm. At a mean follow-up of almost 4 years, recurrence occurred in two patients, including one local recurrence and one transit metastasis, Dr. Dion said.

MONTREAL — Regression of a thin melanoma should not be the sole criterion to justify a sentinel lymph node biopsy, according to a retrospective study.

Regression alone is insufficient in the absence of other recognized high-risk predictors of sentinel lymph node (SLN) involvement, Dr. Pierre-Luc Dion said. More established risk factors include Breslow thickness greater than 1 mm, Clark level IV or V, and lesion ulceration.

Prognosis generally is better with thinner melanoma. Identification of the minority of thin melanoma patients who are at high risk for metastasis, however, remains a clinical challenge.

"There is an ongoing debate if regression is good news or bad news for patients. Some think it shows an immune response against tumor cells, but others say it can lead to an underestimation of the real thickness," Dr. Dion said at the annual conference of the Canadian Dermatology Association.

There is no consensus in the literature. One study of 65 thin melanomas with regression found that only 2 lesions (3%) had a positive SLN biopsy result (Ann. Surg. Oncol. 2003;10:558–61).

Another study found only 1 patient with a positive SLN biopsy among 344 who had thin melanomas (mean Breslow thickness of 1.1 mm) that had shown histologic regression (Ann. Surg. Oncol. 2008;15:316–22).

Other investigators have proposed that tumor regression predicts a higher risk of sentinel node involvement in thin melanomas (Br. J. Dermatol. 2003;149:662–3).

Dr. Dion and his colleagues assessed 693 patients treated at the melanoma clinics for Le Centre Hospitalier Universitaire de Québec-L'Hôtel-Dieu de Québec in Saint-Nicolas and Québec City. All of the patients underwent sentinel lymph node biopsy between 1996 and 2007. The median Breslow thickness was 2.28 mm and mean age was 55 years.

A total of 653 patients had a lesion that was greater than 1 mm. Their prognoses were compared with those of a group of 40 others with thinner melanoma and regression. Regression was determined by a pathologist, who found at least a 15% reduction in the lesion size on multiple slides.

Among the patients with regression, none had a positive lymph node, compared with 146 (22%) in the control group, suggesting regression alone is not a reliable predictor, said Dr. Dion of the hospital in Saint-Nicolas.

Of the 40 patients, 1 experienced complete regression. Another six patients in this group developed in situ melanoma. The median Breslow thickness among the remaining 33 patients was 0.6 mm. At a mean follow-up of almost 4 years, recurrence occurred in two patients, including one local recurrence and one transit metastasis, Dr. Dion said.

Asthma is more often a secondary reason for hospitalization than a principal cause in the United States, and the rate of secondary diagnoses is increasing, said a report from the Agency for Healthcare Research and Quality.

From 1997 to 2005, adult hospital stays specifically for asthma remained stable, whereas the number of secondary asthma diagnoses more than doubled. Asthma hospital stays also varied by socioeconomic status, age, and gender, according to “Hospital Stays Related to Asthma for Adults, 2005,” a statistical brief released by AHRQ.

Between 2000 and 2005, hospitalizations for asthma increased 18%, from 247,200 to 290,600. However, the number of hospital stays in which asthma was secondary went from 753,800 to 1,609,200, a rise of 113%.

Pneumonia by far led the list of primary diagnoses for hospital stays with a secondary asthma coding in 2005, accounting for 123,100 or nearly 7.6% of these stays, Chaya T. Merril and colleagues at the agency's Healthcare Cost and Utilization Project (HCUP) reported.

Heart failure and nonspecific chest pain were the next most common principal diagnoses, accounting for 121,100 hospital stays or 7.5% with a secondary asthma diagnosis. Osteoarthritis (specifically, degenerative joint disease) and mood disorders (depression and bipolar disorder) were each noted in 53,000, or 3.3%, of these stays.

Hospitalizations increased with age. Compared with younger patients, those aged 65 years and older had more than three times the rate of asthma-related hospitalizations. Rates were about 2.5 times greater in women than in men.

Of the 1.9 million asthma-related adult hospital stays in 2005, asthma was a principal diagnosis for 15% and a secondary diagnosis for the other 85%. Mean length of stay was 4.1 days for the primary asthma group and 4.9 days for the secondary group.

Data came from the 2005 Nationwide Inpatient Sample, similar nationally representative samples from 1997-2004, and supplemental sources. The database includes patients regardless of insurance type or uninsured status admitted to short-term, nonfederal hospitals, including obstetric and gynecologic facilities; ear, nose, and throat, as well as orthopedic, cancer, public, and academic medical hospitals.

Of the primary asthma inpatient stays, 74% were admissions through an emergency department, compared with 51% of the secondary diagnosis stays, whereas of the more than 30 million hospital stays in 2005 with no mention of asthma, 48% were emergency department admissions.

Asthma hospitalization rates were higher in poorer areas, compared with richer regions. For example, adults living in a zip code with a median annual income below $36,000 had a 63% higher rate of asthma-related hospital stays, compared with those residing in a zip code with a higher median income. Medicare and Medicaid were billed for about 60% of asthma-related stays, the report noted.

After accounting for differences in length of stay, hospitalizations principally for asthma cost an average $1,400 a day, or about $400 less than the estimated $1,800 a day for hospital stays with secondary asthma. There was little regional variation in hospitalizations.

The AHRQ has also released a second report on pediatric asthma-related hospital stays. The full report is available at www.hcup-us.ahrq.gov/reports/statbriefs/sb54.pdf

ELSEVIER GLOBAL MEDICAL NEWS

Asthma is more often a secondary reason for hospitalization than a principal cause in the United States, and the rate of secondary diagnoses is increasing, said a report from the Agency for Healthcare Research and Quality.

From 1997 to 2005, adult hospital stays specifically for asthma remained stable, whereas the number of secondary asthma diagnoses more than doubled. Asthma hospital stays also varied by socioeconomic status, age, and gender, according to “Hospital Stays Related to Asthma for Adults, 2005,” a statistical brief released by AHRQ.

Between 2000 and 2005, hospitalizations for asthma increased 18%, from 247,200 to 290,600. However, the number of hospital stays in which asthma was secondary went from 753,800 to 1,609,200, a rise of 113%.

Pneumonia by far led the list of primary diagnoses for hospital stays with a secondary asthma coding in 2005, accounting for 123,100 or nearly 7.6% of these stays, Chaya T. Merril and colleagues at the agency's Healthcare Cost and Utilization Project (HCUP) reported.

Heart failure and nonspecific chest pain were the next most common principal diagnoses, accounting for 121,100 hospital stays or 7.5% with a secondary asthma diagnosis. Osteoarthritis (specifically, degenerative joint disease) and mood disorders (depression and bipolar disorder) were each noted in 53,000, or 3.3%, of these stays.

Hospitalizations increased with age. Compared with younger patients, those aged 65 years and older had more than three times the rate of asthma-related hospitalizations. Rates were about 2.5 times greater in women than in men.

Of the 1.9 million asthma-related adult hospital stays in 2005, asthma was a principal diagnosis for 15% and a secondary diagnosis for the other 85%. Mean length of stay was 4.1 days for the primary asthma group and 4.9 days for the secondary group.

Data came from the 2005 Nationwide Inpatient Sample, similar nationally representative samples from 1997-2004, and supplemental sources. The database includes patients regardless of insurance type or uninsured status admitted to short-term, nonfederal hospitals, including obstetric and gynecologic facilities; ear, nose, and throat, as well as orthopedic, cancer, public, and academic medical hospitals.

Of the primary asthma inpatient stays, 74% were admissions through an emergency department, compared with 51% of the secondary diagnosis stays, whereas of the more than 30 million hospital stays in 2005 with no mention of asthma, 48% were emergency department admissions.

Asthma hospitalization rates were higher in poorer areas, compared with richer regions. For example, adults living in a zip code with a median annual income below $36,000 had a 63% higher rate of asthma-related hospital stays, compared with those residing in a zip code with a higher median income. Medicare and Medicaid were billed for about 60% of asthma-related stays, the report noted.

After accounting for differences in length of stay, hospitalizations principally for asthma cost an average $1,400 a day, or about $400 less than the estimated $1,800 a day for hospital stays with secondary asthma. There was little regional variation in hospitalizations.

The AHRQ has also released a second report on pediatric asthma-related hospital stays. The full report is available at www.hcup-us.ahrq.gov/reports/statbriefs/sb54.pdf

ELSEVIER GLOBAL MEDICAL NEWS

Asthma is more often a secondary reason for hospitalization than a principal cause in the United States, and the rate of secondary diagnoses is increasing, said a report from the Agency for Healthcare Research and Quality.

From 1997 to 2005, adult hospital stays specifically for asthma remained stable, whereas the number of secondary asthma diagnoses more than doubled. Asthma hospital stays also varied by socioeconomic status, age, and gender, according to “Hospital Stays Related to Asthma for Adults, 2005,” a statistical brief released by AHRQ.

Between 2000 and 2005, hospitalizations for asthma increased 18%, from 247,200 to 290,600. However, the number of hospital stays in which asthma was secondary went from 753,800 to 1,609,200, a rise of 113%.

Pneumonia by far led the list of primary diagnoses for hospital stays with a secondary asthma coding in 2005, accounting for 123,100 or nearly 7.6% of these stays, Chaya T. Merril and colleagues at the agency's Healthcare Cost and Utilization Project (HCUP) reported.

Heart failure and nonspecific chest pain were the next most common principal diagnoses, accounting for 121,100 hospital stays or 7.5% with a secondary asthma diagnosis. Osteoarthritis (specifically, degenerative joint disease) and mood disorders (depression and bipolar disorder) were each noted in 53,000, or 3.3%, of these stays.

Hospitalizations increased with age. Compared with younger patients, those aged 65 years and older had more than three times the rate of asthma-related hospitalizations. Rates were about 2.5 times greater in women than in men.

Of the 1.9 million asthma-related adult hospital stays in 2005, asthma was a principal diagnosis for 15% and a secondary diagnosis for the other 85%. Mean length of stay was 4.1 days for the primary asthma group and 4.9 days for the secondary group.

Data came from the 2005 Nationwide Inpatient Sample, similar nationally representative samples from 1997-2004, and supplemental sources. The database includes patients regardless of insurance type or uninsured status admitted to short-term, nonfederal hospitals, including obstetric and gynecologic facilities; ear, nose, and throat, as well as orthopedic, cancer, public, and academic medical hospitals.

Of the primary asthma inpatient stays, 74% were admissions through an emergency department, compared with 51% of the secondary diagnosis stays, whereas of the more than 30 million hospital stays in 2005 with no mention of asthma, 48% were emergency department admissions.

Asthma hospitalization rates were higher in poorer areas, compared with richer regions. For example, adults living in a zip code with a median annual income below $36,000 had a 63% higher rate of asthma-related hospital stays, compared with those residing in a zip code with a higher median income. Medicare and Medicaid were billed for about 60% of asthma-related stays, the report noted.

After accounting for differences in length of stay, hospitalizations principally for asthma cost an average $1,400 a day, or about $400 less than the estimated $1,800 a day for hospital stays with secondary asthma. There was little regional variation in hospitalizations.

The AHRQ has also released a second report on pediatric asthma-related hospital stays. The full report is available at www.hcup-us.ahrq.gov/reports/statbriefs/sb54.pdf

ELSEVIER GLOBAL MEDICAL NEWS

MONTREAL — Clobetasol propionate and tacrolimus ointments offer similar efficacy for treatment of pediatric vitiligo, according to a prospective, randomized, double-blind clinical trial.

Both topicals were superior to placebo in this study of 100 pediatric patients. In addition, facial lesions responded quicker than did nonfacial ones to either active treatment in the 6-month study, Dr. Nhung Ho said at the annual conference of the Canadian Dermatology Association.

Fifty boys and 50 girls were randomized to one of three groups. Thirty-three applied clobetasol propionate 0.05% ointment (available as a generic) for 2 months, then placebo ointment for 2 months, followed by clobetasol again for 2 months. The on-and-off cycle design was used to minimize safety concerns, said Dr. Ho, a pediatric dermatologist at the Hospital for Sick Children in Toronto.

The second group, which had 34 patients, applied tacrolimus 0.1% ointment (Protopic, Astellas Pharma US Inc.) for 6 months, and the remaining 33 patients applied a placebo for 6 months.

Participants were aged 2-16 years and vitiligo affected less than 20% of their body surface area at baseline. They were enrolled at either a dermatology outpatient clinic or a private office between June 2005 and December 2007. A research grant from Astellas Pharmaceuticals funded the study.

Three assessors reviewed standardized photos at baseline, 2, 4, and 6 months. Successful response was defined as more than 50% repigmentation of lesions.

There were 45 participants with facial vitiligo and 55 others with nonfacial lesions. In the facial group, 58% responded to clobetasol propionate and 58% responded to tacrolimus. The effect was lower for those with nonfacial lesions, with 39% responding to clobetasol propionate and 23% to tacrolimus. Both active treatments were significantly better than placebo. A total of 24% of the placebo patients—7 of 29 who completed the study—responded, 5 partially and 2 with greater than 50% repigmentation, she said.

There were no significant adverse events reported. Some patients experienced transient erythema but no atrophy occurred.

Possible limitations of the study include its short duration and small number of patients, Dr. Ho said.

Vitiligo affects an estimated 1%-4% of the world's population. It presents in children of all races, with predominance in girls, and about 50% of lesions develop before age 20 years. The pathogenesis of childhood vitiligo is still unknown, she noted.

Evidence supports the use of topical therapies for localized pediatric vitiligo. In one retrospective study, moderate- to high-potency topical cortico-steroids caused repigmentation of vitiligo lesions for 45 of 70 children (64%). Another 24% (17 children) showed no change, and 11% (8) had their vitiligo worsen. Systemic absorption (29% of participants had abnormally high cortisol levels) was a caveat in this study (J. Am. Acad. Dermatol. 2007;56:236-41).

In another retrospective study of 57 pediatric patients, tacrolimus ointment caused at least a partial response in 89% of facial vitiligo lesions (J. Am. Acad. Dermatol. 2004:51:760-6). Response to the topical was lower for lesions on the trunk and extremities, with at least a partial response reported by 63% of patients.

MONTREAL — Clobetasol propionate and tacrolimus ointments offer similar efficacy for treatment of pediatric vitiligo, according to a prospective, randomized, double-blind clinical trial.

Both topicals were superior to placebo in this study of 100 pediatric patients. In addition, facial lesions responded quicker than did nonfacial ones to either active treatment in the 6-month study, Dr. Nhung Ho said at the annual conference of the Canadian Dermatology Association.

Fifty boys and 50 girls were randomized to one of three groups. Thirty-three applied clobetasol propionate 0.05% ointment (available as a generic) for 2 months, then placebo ointment for 2 months, followed by clobetasol again for 2 months. The on-and-off cycle design was used to minimize safety concerns, said Dr. Ho, a pediatric dermatologist at the Hospital for Sick Children in Toronto.

The second group, which had 34 patients, applied tacrolimus 0.1% ointment (Protopic, Astellas Pharma US Inc.) for 6 months, and the remaining 33 patients applied a placebo for 6 months.

Participants were aged 2-16 years and vitiligo affected less than 20% of their body surface area at baseline. They were enrolled at either a dermatology outpatient clinic or a private office between June 2005 and December 2007. A research grant from Astellas Pharmaceuticals funded the study.

Three assessors reviewed standardized photos at baseline, 2, 4, and 6 months. Successful response was defined as more than 50% repigmentation of lesions.

There were 45 participants with facial vitiligo and 55 others with nonfacial lesions. In the facial group, 58% responded to clobetasol propionate and 58% responded to tacrolimus. The effect was lower for those with nonfacial lesions, with 39% responding to clobetasol propionate and 23% to tacrolimus. Both active treatments were significantly better than placebo. A total of 24% of the placebo patients—7 of 29 who completed the study—responded, 5 partially and 2 with greater than 50% repigmentation, she said.

There were no significant adverse events reported. Some patients experienced transient erythema but no atrophy occurred.

Possible limitations of the study include its short duration and small number of patients, Dr. Ho said.

Vitiligo affects an estimated 1%-4% of the world's population. It presents in children of all races, with predominance in girls, and about 50% of lesions develop before age 20 years. The pathogenesis of childhood vitiligo is still unknown, she noted.

Evidence supports the use of topical therapies for localized pediatric vitiligo. In one retrospective study, moderate- to high-potency topical cortico-steroids caused repigmentation of vitiligo lesions for 45 of 70 children (64%). Another 24% (17 children) showed no change, and 11% (8) had their vitiligo worsen. Systemic absorption (29% of participants had abnormally high cortisol levels) was a caveat in this study (J. Am. Acad. Dermatol. 2007;56:236-41).

In another retrospective study of 57 pediatric patients, tacrolimus ointment caused at least a partial response in 89% of facial vitiligo lesions (J. Am. Acad. Dermatol. 2004:51:760-6). Response to the topical was lower for lesions on the trunk and extremities, with at least a partial response reported by 63% of patients.

MONTREAL — Clobetasol propionate and tacrolimus ointments offer similar efficacy for treatment of pediatric vitiligo, according to a prospective, randomized, double-blind clinical trial.

Both topicals were superior to placebo in this study of 100 pediatric patients. In addition, facial lesions responded quicker than did nonfacial ones to either active treatment in the 6-month study, Dr. Nhung Ho said at the annual conference of the Canadian Dermatology Association.

Fifty boys and 50 girls were randomized to one of three groups. Thirty-three applied clobetasol propionate 0.05% ointment (available as a generic) for 2 months, then placebo ointment for 2 months, followed by clobetasol again for 2 months. The on-and-off cycle design was used to minimize safety concerns, said Dr. Ho, a pediatric dermatologist at the Hospital for Sick Children in Toronto.

The second group, which had 34 patients, applied tacrolimus 0.1% ointment (Protopic, Astellas Pharma US Inc.) for 6 months, and the remaining 33 patients applied a placebo for 6 months.

Participants were aged 2-16 years and vitiligo affected less than 20% of their body surface area at baseline. They were enrolled at either a dermatology outpatient clinic or a private office between June 2005 and December 2007. A research grant from Astellas Pharmaceuticals funded the study.

Three assessors reviewed standardized photos at baseline, 2, 4, and 6 months. Successful response was defined as more than 50% repigmentation of lesions.

There were 45 participants with facial vitiligo and 55 others with nonfacial lesions. In the facial group, 58% responded to clobetasol propionate and 58% responded to tacrolimus. The effect was lower for those with nonfacial lesions, with 39% responding to clobetasol propionate and 23% to tacrolimus. Both active treatments were significantly better than placebo. A total of 24% of the placebo patients—7 of 29 who completed the study—responded, 5 partially and 2 with greater than 50% repigmentation, she said.

There were no significant adverse events reported. Some patients experienced transient erythema but no atrophy occurred.

Possible limitations of the study include its short duration and small number of patients, Dr. Ho said.

Vitiligo affects an estimated 1%-4% of the world's population. It presents in children of all races, with predominance in girls, and about 50% of lesions develop before age 20 years. The pathogenesis of childhood vitiligo is still unknown, she noted.

Evidence supports the use of topical therapies for localized pediatric vitiligo. In one retrospective study, moderate- to high-potency topical cortico-steroids caused repigmentation of vitiligo lesions for 45 of 70 children (64%). Another 24% (17 children) showed no change, and 11% (8) had their vitiligo worsen. Systemic absorption (29% of participants had abnormally high cortisol levels) was a caveat in this study (J. Am. Acad. Dermatol. 2007;56:236-41).

In another retrospective study of 57 pediatric patients, tacrolimus ointment caused at least a partial response in 89% of facial vitiligo lesions (J. Am. Acad. Dermatol. 2004:51:760-6). Response to the topical was lower for lesions on the trunk and extremities, with at least a partial response reported by 63% of patients.

MIAMI — Working on Florida's Child Protection Team produces a great deal of anxiety for physicians, according to Dr. Jefry L. Biehler.

The multidisciplinary group of clinicians is mandated by the state to investigate reports of child abuse or unsafe conditions for children.

Although the work is rewarding, it can cause significant angst. “Even when you do your best to protect children, you might be putting them at even greater risk,” Dr. Biehler said. “About 98% of the time when you remove a child from a home, you put them in a better place. But there are cases of multiple abuses in foster care homes. And every time something bad happens, we hear about it on the evening news.”

Dealing with an imperfect judicial system is another source of frustration. “Sometimes, even when you do your best to protect children, you cannot do your job. Sometimes it's a bad judge or a district attorney who does not take the time to review the case. Or you get a defense attorney who gets parents reunited with children, and the children are at risk,” said Dr. Biehler, attending physician in the division of emergency medicine, Miami Children's Hospital.

“Understand, the system is not perfect, but we protect thousands of children and I think we do a pretty good job,” Dr. Biehler said at a pediatric update sponsored by Miami Children's Hospital. He had no disclosures related to this talk.

Clinical conditions that can mimic physical abuse in a child are another source of anguish for the Child Protection Team.

For example, osteogenesis imperfecta (OI) “is the bane of our existence,” Dr. Biehler said.

“Are multiple fractures abuse, or [are they] from this condition? We have trouble sleeping at night because of fear of confusing OI with child abuse.” He suggested pediatricians “really work to keep up on” the differential diagnosis between OI and child abuse.

Also, consult with geneticists, he added. “Our geneticists tell us there are genes that can be identified in about 90% of cases.”

Dr. Biehler and the rest of the team work closely with Florida's Department of Children and Families (DCF). The clinicians follow mandatory referral criteria. “I cannot accept a referral for child abuse from a nurse [or] doctor. … I can only take referrals from the DCF.”

Physicians need to know their state's reporting laws regarding children in danger, Dr. Biehler said.

“I made a mistake years ago,” he said. He consulted on the case of a 7-month-old who presented to the emergency department following a reported fall at home. The case did not sit well with him, and about 2-3 weeks later, Dr. Biehler said, “I woke up in a cold sweat. I got up in the middle of the night, went to the hospital, and reviewed the chart and x-ray at 1:30 in the morning.” There were 15 other fractures on his survey, so it was suggestive of abuse.

“You can imagine how unhappy DCF was to hear about this [in the middle of the night]. We saw him at 4 or 5 that morning. There was domestic violence in this home. My mistake was I let my colleague think she was referring the case to DCF, but she referred to me,” Dr. Biehler said.

“Make sure you do not report suspected abuse to anyone else other than your state hotline.”

Incorrect reporting of suspected abuse by a pediatrician in the Bronx may have contributed to the death of a 2-year-old girl (New York Times, Aug. 1, 2006).

It was reported that the pediatrician suspected abuse because the girl was bruised and unresponsive, and appeared beaten.

He referred the girl to Montefiore Medical Center, New York, but did not alert child welfare officials, as required by law. He allegedly believed it was sufficient to notify the hospital. The next day, the girl was discharged into the care of her mother and the mother's companion. The patient returned to the hospital unconscious, and died 8 days later from a brain hemorrhage. Police arrested the companion, who reportedly admitted shaking the girl and dropping her on her head. He was charged with homicide.

Physicians should err on the side of overreporting rather than underreporting their suspicions of abuse, Dr. Biehler said.

He cited other media reports of children dying, for example, in Kentucky and in Seattle after suspected abuse was not reported.

Another tip is for physicians to be cautious about providing expert legal opinion in child abuse cases.

“Be very careful about making statements as an expert, even when you are one,” Dr. Biehler said. “You have to be careful that your statements come from your expertise.”

He added, “Keeping up with child abuse literature is extremely hard, but if you are going to be an expert, you need to really keep up to date.”

MIAMI — Working on Florida's Child Protection Team produces a great deal of anxiety for physicians, according to Dr. Jefry L. Biehler.

The multidisciplinary group of clinicians is mandated by the state to investigate reports of child abuse or unsafe conditions for children.

Although the work is rewarding, it can cause significant angst. “Even when you do your best to protect children, you might be putting them at even greater risk,” Dr. Biehler said. “About 98% of the time when you remove a child from a home, you put them in a better place. But there are cases of multiple abuses in foster care homes. And every time something bad happens, we hear about it on the evening news.”

Dealing with an imperfect judicial system is another source of frustration. “Sometimes, even when you do your best to protect children, you cannot do your job. Sometimes it's a bad judge or a district attorney who does not take the time to review the case. Or you get a defense attorney who gets parents reunited with children, and the children are at risk,” said Dr. Biehler, attending physician in the division of emergency medicine, Miami Children's Hospital.

“Understand, the system is not perfect, but we protect thousands of children and I think we do a pretty good job,” Dr. Biehler said at a pediatric update sponsored by Miami Children's Hospital. He had no disclosures related to this talk.

Clinical conditions that can mimic physical abuse in a child are another source of anguish for the Child Protection Team.

For example, osteogenesis imperfecta (OI) “is the bane of our existence,” Dr. Biehler said.

“Are multiple fractures abuse, or [are they] from this condition? We have trouble sleeping at night because of fear of confusing OI with child abuse.” He suggested pediatricians “really work to keep up on” the differential diagnosis between OI and child abuse.

Also, consult with geneticists, he added. “Our geneticists tell us there are genes that can be identified in about 90% of cases.”

Dr. Biehler and the rest of the team work closely with Florida's Department of Children and Families (DCF). The clinicians follow mandatory referral criteria. “I cannot accept a referral for child abuse from a nurse [or] doctor. … I can only take referrals from the DCF.”

Physicians need to know their state's reporting laws regarding children in danger, Dr. Biehler said.

“I made a mistake years ago,” he said. He consulted on the case of a 7-month-old who presented to the emergency department following a reported fall at home. The case did not sit well with him, and about 2-3 weeks later, Dr. Biehler said, “I woke up in a cold sweat. I got up in the middle of the night, went to the hospital, and reviewed the chart and x-ray at 1:30 in the morning.” There were 15 other fractures on his survey, so it was suggestive of abuse.

“You can imagine how unhappy DCF was to hear about this [in the middle of the night]. We saw him at 4 or 5 that morning. There was domestic violence in this home. My mistake was I let my colleague think she was referring the case to DCF, but she referred to me,” Dr. Biehler said.

“Make sure you do not report suspected abuse to anyone else other than your state hotline.”

Incorrect reporting of suspected abuse by a pediatrician in the Bronx may have contributed to the death of a 2-year-old girl (New York Times, Aug. 1, 2006).

It was reported that the pediatrician suspected abuse because the girl was bruised and unresponsive, and appeared beaten.

He referred the girl to Montefiore Medical Center, New York, but did not alert child welfare officials, as required by law. He allegedly believed it was sufficient to notify the hospital. The next day, the girl was discharged into the care of her mother and the mother's companion. The patient returned to the hospital unconscious, and died 8 days later from a brain hemorrhage. Police arrested the companion, who reportedly admitted shaking the girl and dropping her on her head. He was charged with homicide.

Physicians should err on the side of overreporting rather than underreporting their suspicions of abuse, Dr. Biehler said.

He cited other media reports of children dying, for example, in Kentucky and in Seattle after suspected abuse was not reported.

Another tip is for physicians to be cautious about providing expert legal opinion in child abuse cases.

“Be very careful about making statements as an expert, even when you are one,” Dr. Biehler said. “You have to be careful that your statements come from your expertise.”

He added, “Keeping up with child abuse literature is extremely hard, but if you are going to be an expert, you need to really keep up to date.”

MIAMI — Working on Florida's Child Protection Team produces a great deal of anxiety for physicians, according to Dr. Jefry L. Biehler.

The multidisciplinary group of clinicians is mandated by the state to investigate reports of child abuse or unsafe conditions for children.

Although the work is rewarding, it can cause significant angst. “Even when you do your best to protect children, you might be putting them at even greater risk,” Dr. Biehler said. “About 98% of the time when you remove a child from a home, you put them in a better place. But there are cases of multiple abuses in foster care homes. And every time something bad happens, we hear about it on the evening news.”

Dealing with an imperfect judicial system is another source of frustration. “Sometimes, even when you do your best to protect children, you cannot do your job. Sometimes it's a bad judge or a district attorney who does not take the time to review the case. Or you get a defense attorney who gets parents reunited with children, and the children are at risk,” said Dr. Biehler, attending physician in the division of emergency medicine, Miami Children's Hospital.

“Understand, the system is not perfect, but we protect thousands of children and I think we do a pretty good job,” Dr. Biehler said at a pediatric update sponsored by Miami Children's Hospital. He had no disclosures related to this talk.

Clinical conditions that can mimic physical abuse in a child are another source of anguish for the Child Protection Team.

For example, osteogenesis imperfecta (OI) “is the bane of our existence,” Dr. Biehler said.

“Are multiple fractures abuse, or [are they] from this condition? We have trouble sleeping at night because of fear of confusing OI with child abuse.” He suggested pediatricians “really work to keep up on” the differential diagnosis between OI and child abuse.

Also, consult with geneticists, he added. “Our geneticists tell us there are genes that can be identified in about 90% of cases.”

Dr. Biehler and the rest of the team work closely with Florida's Department of Children and Families (DCF). The clinicians follow mandatory referral criteria. “I cannot accept a referral for child abuse from a nurse [or] doctor. … I can only take referrals from the DCF.”

Physicians need to know their state's reporting laws regarding children in danger, Dr. Biehler said.

“I made a mistake years ago,” he said. He consulted on the case of a 7-month-old who presented to the emergency department following a reported fall at home. The case did not sit well with him, and about 2-3 weeks later, Dr. Biehler said, “I woke up in a cold sweat. I got up in the middle of the night, went to the hospital, and reviewed the chart and x-ray at 1:30 in the morning.” There were 15 other fractures on his survey, so it was suggestive of abuse.

“You can imagine how unhappy DCF was to hear about this [in the middle of the night]. We saw him at 4 or 5 that morning. There was domestic violence in this home. My mistake was I let my colleague think she was referring the case to DCF, but she referred to me,” Dr. Biehler said.

“Make sure you do not report suspected abuse to anyone else other than your state hotline.”

Incorrect reporting of suspected abuse by a pediatrician in the Bronx may have contributed to the death of a 2-year-old girl (New York Times, Aug. 1, 2006).

It was reported that the pediatrician suspected abuse because the girl was bruised and unresponsive, and appeared beaten.

He referred the girl to Montefiore Medical Center, New York, but did not alert child welfare officials, as required by law. He allegedly believed it was sufficient to notify the hospital. The next day, the girl was discharged into the care of her mother and the mother's companion. The patient returned to the hospital unconscious, and died 8 days later from a brain hemorrhage. Police arrested the companion, who reportedly admitted shaking the girl and dropping her on her head. He was charged with homicide.

Physicians should err on the side of overreporting rather than underreporting their suspicions of abuse, Dr. Biehler said.

He cited other media reports of children dying, for example, in Kentucky and in Seattle after suspected abuse was not reported.

Another tip is for physicians to be cautious about providing expert legal opinion in child abuse cases.

“Be very careful about making statements as an expert, even when you are one,” Dr. Biehler said. “You have to be careful that your statements come from your expertise.”

He added, “Keeping up with child abuse literature is extremely hard, but if you are going to be an expert, you need to really keep up to date.”

MIAMI — Pediatricians typically undervalue themselves with managed care organizations but need to negotiate and fight for all the money owed them, according to Dr. Richard Lander.

“Yes, you can make money today in the world of managed care,” Dr. Lander said. “In the real world, we the pediatricians are the fools because we undervalue ourselves every day. Don't forget that managed care organizations need us.”

As with ob.gyns., families first look for pediatricians in a network, which gives the physicians leverage with managed care companies. “They need us to take care of the patients in their network,” he said at a pediatric update sponsored by Miami Children's Hospital.

Pediatricians also save managed care organizations money, Dr. Lander said. “We provide evening and Saturday hours, and are available 24/7, so there are less ED visits.” Provision of in-office services also reduces emergency department utilization. “You are not referring every headache to neurology or every stomach pain patient to a GI.”

Therefore, you should get tough with a company that denies claims for in-office services, Dr. Lander said. “I once had a denial for nebulizer treatments in my office. They might expect the good pediatrician will still give nebulizer treatments and just eat the cost. Don't do it.” He added, “I called and said I would refer all my asthmatics to pediatric pulmonologists or to the ED.”

“Since you save them money, you want money. But you have to negotiate—it's a business like any other,” said Dr. Lander, who is a pediatrician in private practice in Livingston, N.J.

“I love the kids. But I realized a long time ago this is a business. I still have to pay staff and vaccine bills.” Vaccines account for only 2% of managed care organization budgets, but if that figure was increased to 2.5%, each pediatrician would make about a 25% profit above acquisition cost, he said.

“Across the country more and more pediatricians are no longer vaccinating children,” Dr. Lander said. “If the insurance company only pays us $19 and the vaccines cost $20 or more, it doesn't make sense.”

Prepare a spreadsheet with vaccine purchase costs and reimbursement without administration fees, Dr. Lander suggested. “Figure out what percentage above cost you are getting. I don't accept 5% above cost or 3% above cost. I'm comfortable with 12%, not happy, but comfortable for vaccines.” He added, “If they offer me 10%, I say no.”

In addition, do not permit managed care organizations to pay you less on vaccine costs because they pay better on vaccine administration fees, Dr. Lander said. “These are two separate areas.”

A meeting attendee asked for advice on what to say when an insurance company asks to see vaccine charges. “We get that request all the time,” he replied. “Just say no—it's none of their darn business. What if I have a great negotiated rate?”

Knowing your “walk-away point” is the most important element of negotiating a managed care contract, Dr. Lander said. “If 110% of Medicaid is your bottom cut-off, and they offer 109.5%, walk away. If 110% is your floor, what is your ceiling? No one knows. But don't start at your floor level.”

Securing one rate for all charges is another tip. “The managed care company might say they will give you 115% on your asthma counseling changes, which we don't do frequently, and 100% on more frequently used charges, and it's not fair.”

Consult your current contract for the Medicaid rate, Dr. Lander said. “We all have contracts that keep 'evergreening' year after year. There have been slight increases in the past several years. Make sure you are using the most current rates so you can maximize your profits.” In addition, do not sign a contract longer than 2 years, he advised.

To gain experience with negotiations, begin with some of your smaller payers, he suggested. “Even if you walk away, you won't lose as much.”

Sometimes the best negotiation comes after a termination letter, Dr. Lander said. “If you are smart, notify your patients ahead of time what is happening [and tell them] the plan is going to be dropped.” Instruct unhappy patients to contact their human resources department staff, who can then contact the insurer.

“Most of the time we pediatricians cave in,” he said. “The managed care organizations figure we are bluffing.”

But if you are not happy, “go out and get a better contract. Don't be afraid of managed care.”

MIAMI — Pediatricians typically undervalue themselves with managed care organizations but need to negotiate and fight for all the money owed them, according to Dr. Richard Lander.

“Yes, you can make money today in the world of managed care,” Dr. Lander said. “In the real world, we the pediatricians are the fools because we undervalue ourselves every day. Don't forget that managed care organizations need us.”

As with ob.gyns., families first look for pediatricians in a network, which gives the physicians leverage with managed care companies. “They need us to take care of the patients in their network,” he said at a pediatric update sponsored by Miami Children's Hospital.

Pediatricians also save managed care organizations money, Dr. Lander said. “We provide evening and Saturday hours, and are available 24/7, so there are less ED visits.” Provision of in-office services also reduces emergency department utilization. “You are not referring every headache to neurology or every stomach pain patient to a GI.”

Therefore, you should get tough with a company that denies claims for in-office services, Dr. Lander said. “I once had a denial for nebulizer treatments in my office. They might expect the good pediatrician will still give nebulizer treatments and just eat the cost. Don't do it.” He added, “I called and said I would refer all my asthmatics to pediatric pulmonologists or to the ED.”

“Since you save them money, you want money. But you have to negotiate—it's a business like any other,” said Dr. Lander, who is a pediatrician in private practice in Livingston, N.J.

“I love the kids. But I realized a long time ago this is a business. I still have to pay staff and vaccine bills.” Vaccines account for only 2% of managed care organization budgets, but if that figure was increased to 2.5%, each pediatrician would make about a 25% profit above acquisition cost, he said.

“Across the country more and more pediatricians are no longer vaccinating children,” Dr. Lander said. “If the insurance company only pays us $19 and the vaccines cost $20 or more, it doesn't make sense.”

Prepare a spreadsheet with vaccine purchase costs and reimbursement without administration fees, Dr. Lander suggested. “Figure out what percentage above cost you are getting. I don't accept 5% above cost or 3% above cost. I'm comfortable with 12%, not happy, but comfortable for vaccines.” He added, “If they offer me 10%, I say no.”

In addition, do not permit managed care organizations to pay you less on vaccine costs because they pay better on vaccine administration fees, Dr. Lander said. “These are two separate areas.”

A meeting attendee asked for advice on what to say when an insurance company asks to see vaccine charges. “We get that request all the time,” he replied. “Just say no—it's none of their darn business. What if I have a great negotiated rate?”

Knowing your “walk-away point” is the most important element of negotiating a managed care contract, Dr. Lander said. “If 110% of Medicaid is your bottom cut-off, and they offer 109.5%, walk away. If 110% is your floor, what is your ceiling? No one knows. But don't start at your floor level.”

Securing one rate for all charges is another tip. “The managed care company might say they will give you 115% on your asthma counseling changes, which we don't do frequently, and 100% on more frequently used charges, and it's not fair.”

Consult your current contract for the Medicaid rate, Dr. Lander said. “We all have contracts that keep 'evergreening' year after year. There have been slight increases in the past several years. Make sure you are using the most current rates so you can maximize your profits.” In addition, do not sign a contract longer than 2 years, he advised.

To gain experience with negotiations, begin with some of your smaller payers, he suggested. “Even if you walk away, you won't lose as much.”

Sometimes the best negotiation comes after a termination letter, Dr. Lander said. “If you are smart, notify your patients ahead of time what is happening [and tell them] the plan is going to be dropped.” Instruct unhappy patients to contact their human resources department staff, who can then contact the insurer.

“Most of the time we pediatricians cave in,” he said. “The managed care organizations figure we are bluffing.”

But if you are not happy, “go out and get a better contract. Don't be afraid of managed care.”

MIAMI — Pediatricians typically undervalue themselves with managed care organizations but need to negotiate and fight for all the money owed them, according to Dr. Richard Lander.

“Yes, you can make money today in the world of managed care,” Dr. Lander said. “In the real world, we the pediatricians are the fools because we undervalue ourselves every day. Don't forget that managed care organizations need us.”

As with ob.gyns., families first look for pediatricians in a network, which gives the physicians leverage with managed care companies. “They need us to take care of the patients in their network,” he said at a pediatric update sponsored by Miami Children's Hospital.

Pediatricians also save managed care organizations money, Dr. Lander said. “We provide evening and Saturday hours, and are available 24/7, so there are less ED visits.” Provision of in-office services also reduces emergency department utilization. “You are not referring every headache to neurology or every stomach pain patient to a GI.”

Therefore, you should get tough with a company that denies claims for in-office services, Dr. Lander said. “I once had a denial for nebulizer treatments in my office. They might expect the good pediatrician will still give nebulizer treatments and just eat the cost. Don't do it.” He added, “I called and said I would refer all my asthmatics to pediatric pulmonologists or to the ED.”

“Since you save them money, you want money. But you have to negotiate—it's a business like any other,” said Dr. Lander, who is a pediatrician in private practice in Livingston, N.J.

“I love the kids. But I realized a long time ago this is a business. I still have to pay staff and vaccine bills.” Vaccines account for only 2% of managed care organization budgets, but if that figure was increased to 2.5%, each pediatrician would make about a 25% profit above acquisition cost, he said.

“Across the country more and more pediatricians are no longer vaccinating children,” Dr. Lander said. “If the insurance company only pays us $19 and the vaccines cost $20 or more, it doesn't make sense.”

Prepare a spreadsheet with vaccine purchase costs and reimbursement without administration fees, Dr. Lander suggested. “Figure out what percentage above cost you are getting. I don't accept 5% above cost or 3% above cost. I'm comfortable with 12%, not happy, but comfortable for vaccines.” He added, “If they offer me 10%, I say no.”

In addition, do not permit managed care organizations to pay you less on vaccine costs because they pay better on vaccine administration fees, Dr. Lander said. “These are two separate areas.”

A meeting attendee asked for advice on what to say when an insurance company asks to see vaccine charges. “We get that request all the time,” he replied. “Just say no—it's none of their darn business. What if I have a great negotiated rate?”

Knowing your “walk-away point” is the most important element of negotiating a managed care contract, Dr. Lander said. “If 110% of Medicaid is your bottom cut-off, and they offer 109.5%, walk away. If 110% is your floor, what is your ceiling? No one knows. But don't start at your floor level.”

Securing one rate for all charges is another tip. “The managed care company might say they will give you 115% on your asthma counseling changes, which we don't do frequently, and 100% on more frequently used charges, and it's not fair.”

Consult your current contract for the Medicaid rate, Dr. Lander said. “We all have contracts that keep 'evergreening' year after year. There have been slight increases in the past several years. Make sure you are using the most current rates so you can maximize your profits.” In addition, do not sign a contract longer than 2 years, he advised.

To gain experience with negotiations, begin with some of your smaller payers, he suggested. “Even if you walk away, you won't lose as much.”

Sometimes the best negotiation comes after a termination letter, Dr. Lander said. “If you are smart, notify your patients ahead of time what is happening [and tell them] the plan is going to be dropped.” Instruct unhappy patients to contact their human resources department staff, who can then contact the insurer.

“Most of the time we pediatricians cave in,” he said. “The managed care organizations figure we are bluffing.”

But if you are not happy, “go out and get a better contract. Don't be afraid of managed care.”

ORLANDO — Metastasis occurs after surgical removal of low-grade prostate cancer in some men, suggesting that close follow-up is warranted.

Although there is an overall 30% recurrence rate a decade after prostatectomy, a man with a Gleason score of 6 or less generally has a more favorable prognosis, Dr. Marc Birkhahn said.

He and his associates assessed 3,235 consecutive patients who had a radical prostatectomy and bilateral lymphadenectomy for prostate cancer between 1972 and 2005 in the University of Southern California/Norris Comprehensive Cancer Center database. From this group, they identified 1,383 men with a Gleason score of 6 or less.

Of the 1,383 men, 70% had a Gleason score of 6, 24% had a score of 5, 4% had a score of 4, and 2% had a score 3 or 2. Only 2% had node-positive disease. The cancer stages were pT2 (83%), pT3 (16%), and pT4 (1%). This is noteworthy because “tumor stage and Gleason score are the most important predictors of recurrence,” Dr. Birkhahn said at the annual meeting of the American Urologic Association.

Biochemical recurrence occurred in 147 patients a mean of 4 years after surgery. Clinical recurrence (metastasis) occurred in 45 men a mean of 8 years postoperatively. Metastasis-free survival in the entire cohort of 3,235 men was 96% after 10 years and 94% after 15 years.

Among all patients in the total database with metastasis or recurrence after radical prostatectomy, “26% of PSA recurrences and 20% of clinical recurrences occurred in men with a Gleason score of 6 or less,” said Dr. Birkhahn of the University of Southern California, Los Angeles. “Tumors with a Gleason score of 6 or lower are low risk but not no risk.”

ORLANDO — Metastasis occurs after surgical removal of low-grade prostate cancer in some men, suggesting that close follow-up is warranted.

Although there is an overall 30% recurrence rate a decade after prostatectomy, a man with a Gleason score of 6 or less generally has a more favorable prognosis, Dr. Marc Birkhahn said.

He and his associates assessed 3,235 consecutive patients who had a radical prostatectomy and bilateral lymphadenectomy for prostate cancer between 1972 and 2005 in the University of Southern California/Norris Comprehensive Cancer Center database. From this group, they identified 1,383 men with a Gleason score of 6 or less.

Of the 1,383 men, 70% had a Gleason score of 6, 24% had a score of 5, 4% had a score of 4, and 2% had a score 3 or 2. Only 2% had node-positive disease. The cancer stages were pT2 (83%), pT3 (16%), and pT4 (1%). This is noteworthy because “tumor stage and Gleason score are the most important predictors of recurrence,” Dr. Birkhahn said at the annual meeting of the American Urologic Association.

Biochemical recurrence occurred in 147 patients a mean of 4 years after surgery. Clinical recurrence (metastasis) occurred in 45 men a mean of 8 years postoperatively. Metastasis-free survival in the entire cohort of 3,235 men was 96% after 10 years and 94% after 15 years.

Among all patients in the total database with metastasis or recurrence after radical prostatectomy, “26% of PSA recurrences and 20% of clinical recurrences occurred in men with a Gleason score of 6 or less,” said Dr. Birkhahn of the University of Southern California, Los Angeles. “Tumors with a Gleason score of 6 or lower are low risk but not no risk.”

ORLANDO — Metastasis occurs after surgical removal of low-grade prostate cancer in some men, suggesting that close follow-up is warranted.

Although there is an overall 30% recurrence rate a decade after prostatectomy, a man with a Gleason score of 6 or less generally has a more favorable prognosis, Dr. Marc Birkhahn said.

He and his associates assessed 3,235 consecutive patients who had a radical prostatectomy and bilateral lymphadenectomy for prostate cancer between 1972 and 2005 in the University of Southern California/Norris Comprehensive Cancer Center database. From this group, they identified 1,383 men with a Gleason score of 6 or less.

Of the 1,383 men, 70% had a Gleason score of 6, 24% had a score of 5, 4% had a score of 4, and 2% had a score 3 or 2. Only 2% had node-positive disease. The cancer stages were pT2 (83%), pT3 (16%), and pT4 (1%). This is noteworthy because “tumor stage and Gleason score are the most important predictors of recurrence,” Dr. Birkhahn said at the annual meeting of the American Urologic Association.

Biochemical recurrence occurred in 147 patients a mean of 4 years after surgery. Clinical recurrence (metastasis) occurred in 45 men a mean of 8 years postoperatively. Metastasis-free survival in the entire cohort of 3,235 men was 96% after 10 years and 94% after 15 years.

Among all patients in the total database with metastasis or recurrence after radical prostatectomy, “26% of PSA recurrences and 20% of clinical recurrences occurred in men with a Gleason score of 6 or less,” said Dr. Birkhahn of the University of Southern California, Los Angeles. “Tumors with a Gleason score of 6 or lower are low risk but not no risk.”

MONTREAL — Psoriasis is an independent risk factor for increased cardiovascular morbidity and mortality, according to a growing number of studies and new guidelines from the American Academy of Dermatology.

Based on this evidence, it is important to screen and regularly monitor psoriasis patients for cardiovascular disease risk factors, said Dr. Lyn C. Guenther, professor and chair of the division of dermatology at the University of Western Ontario, London.

An increased prevalence of cardiovascular disease among people with psoriasis—especially more severe forms—is not new. “I thought it was all related to their [increased] weight,” Dr. Guenther said. “Psoriasis appears to be an independent risk factor now.”

The American Academy of Dermatology addressed increased cardiovascular risk among people with psoriasis in guidelines released in May.

Studies also have suggested that the increased prevalence of hypertension and diabetes among people with psoriasis (J. Am. Acad. Derm. 2006;55:829–35) contributes to the risk, as does a typically atherogenic lipoprotein profile at the onset of skin disease (J. Am. Acad. Dermatol. 2007;56:629–34).

“This is something we cannot ignore any longer,” Dr. Guenther said during a symposium sponsored by Abbott at the annual conference of the Canadian Dermatology Association. “I am not necessarily suggesting we are the ones who have to address this, but [we should] make sure these comorbidities are addressed.”

Psoriasis is associated not only with increased cardiovascular morbidity, but also with increased mortality. “This theme comes up repeatedly,” said Dr. Guenther, who has worked as a researcher, consultant, and speaker for Abbott, Amgen/Wyeth, Schering Plough, Astellas, and Leo Pharma. People with severe psoriasis have a 50% increased risk of death and tend to die earlier than do those without psoriasis (males 3.5 years earlier, females 4.4 years earlier). These figures do not apply to mild disease, she noted.

Not surprisingly, people with psoriasis also have an increased prevalence of metabolic syndrome, Dr. Guenther said.

In one case-control study, 30% of 338 adults with chronic plaque psoriasis and 21% of 334 adults with other skin diseases met criteria for metabolic syndrome—a difference that was statistically significant (Br. J. Dermatol. 2007;157:68–73).

In addition, younger patients with more severe psoriasis appear to be the group at greatest relative risk for a myocardial infarction (JAMA 2006;296:1735–41). Those with severe psoriasis at age 30 years had more than three times the risk (relative risk, 3.1) of having a myocardial infarction, compared with the general population. Risk was lower but still elevated for 30-year-olds with mild psoriasis (RR, 1.29). In 60-year-olds, however, severe psoriasis conferred a 1.36 relative risk for an MI and mild psoriasis conferred a 1.08 relative risk.

Inflammation may be the common culprit in both psoriasis and increased cardiovascular disease. “Tumor necrosis factor-α [TNF-α] is involved in cardiovascular disease and is a target for many of our therapies. High TNF levels are an independent predictor of cardiovascular morbidity and mortality, and TNF levels are high in psoriasis,” Dr. Guenther said.

Elevated C-reactive protein levels may be an important link between psoriasis and cardiovascular disease as well, as was suggested in an editors' roundtable in the American Journal of Cardiology (Am. J. Cardiol. 2008;101:1119–26). “C-reactive protein is something we are starting to measure in our patients,” said Dr. Guenther, who called the marker a very sensitive indicator of inflammation.

There are also immunologic similarities between atherosclerosis and psoriasis. Cell activation, inactive immunity, and adaptive immunity indicate that pathogenesis is similar between these two diseases, she said.

The good news is that treatment of psoriasis might reduce cardiovascular disease and death. “If you reduce inflammation, CRP, and TNF, it might reduce cardiovascular morbidity and mortality,” Dr. Guenther said, citing as an example, a study of rheumatoid arthritis patients, in which methotrexate decreased the incidence of cardiovascular disease and mortality (Lancet 2002:359:1173–7).

MONTREAL — Psoriasis is an independent risk factor for increased cardiovascular morbidity and mortality, according to a growing number of studies and new guidelines from the American Academy of Dermatology.

Based on this evidence, it is important to screen and regularly monitor psoriasis patients for cardiovascular disease risk factors, said Dr. Lyn C. Guenther, professor and chair of the division of dermatology at the University of Western Ontario, London.

An increased prevalence of cardiovascular disease among people with psoriasis—especially more severe forms—is not new. “I thought it was all related to their [increased] weight,” Dr. Guenther said. “Psoriasis appears to be an independent risk factor now.”

The American Academy of Dermatology addressed increased cardiovascular risk among people with psoriasis in guidelines released in May.

Studies also have suggested that the increased prevalence of hypertension and diabetes among people with psoriasis (J. Am. Acad. Derm. 2006;55:829–35) contributes to the risk, as does a typically atherogenic lipoprotein profile at the onset of skin disease (J. Am. Acad. Dermatol. 2007;56:629–34).

“This is something we cannot ignore any longer,” Dr. Guenther said during a symposium sponsored by Abbott at the annual conference of the Canadian Dermatology Association. “I am not necessarily suggesting we are the ones who have to address this, but [we should] make sure these comorbidities are addressed.”

Psoriasis is associated not only with increased cardiovascular morbidity, but also with increased mortality. “This theme comes up repeatedly,” said Dr. Guenther, who has worked as a researcher, consultant, and speaker for Abbott, Amgen/Wyeth, Schering Plough, Astellas, and Leo Pharma. People with severe psoriasis have a 50% increased risk of death and tend to die earlier than do those without psoriasis (males 3.5 years earlier, females 4.4 years earlier). These figures do not apply to mild disease, she noted.

Not surprisingly, people with psoriasis also have an increased prevalence of metabolic syndrome, Dr. Guenther said.

In one case-control study, 30% of 338 adults with chronic plaque psoriasis and 21% of 334 adults with other skin diseases met criteria for metabolic syndrome—a difference that was statistically significant (Br. J. Dermatol. 2007;157:68–73).

In addition, younger patients with more severe psoriasis appear to be the group at greatest relative risk for a myocardial infarction (JAMA 2006;296:1735–41). Those with severe psoriasis at age 30 years had more than three times the risk (relative risk, 3.1) of having a myocardial infarction, compared with the general population. Risk was lower but still elevated for 30-year-olds with mild psoriasis (RR, 1.29). In 60-year-olds, however, severe psoriasis conferred a 1.36 relative risk for an MI and mild psoriasis conferred a 1.08 relative risk.

Inflammation may be the common culprit in both psoriasis and increased cardiovascular disease. “Tumor necrosis factor-α [TNF-α] is involved in cardiovascular disease and is a target for many of our therapies. High TNF levels are an independent predictor of cardiovascular morbidity and mortality, and TNF levels are high in psoriasis,” Dr. Guenther said.

Elevated C-reactive protein levels may be an important link between psoriasis and cardiovascular disease as well, as was suggested in an editors' roundtable in the American Journal of Cardiology (Am. J. Cardiol. 2008;101:1119–26). “C-reactive protein is something we are starting to measure in our patients,” said Dr. Guenther, who called the marker a very sensitive indicator of inflammation.

There are also immunologic similarities between atherosclerosis and psoriasis. Cell activation, inactive immunity, and adaptive immunity indicate that pathogenesis is similar between these two diseases, she said.

The good news is that treatment of psoriasis might reduce cardiovascular disease and death. “If you reduce inflammation, CRP, and TNF, it might reduce cardiovascular morbidity and mortality,” Dr. Guenther said, citing as an example, a study of rheumatoid arthritis patients, in which methotrexate decreased the incidence of cardiovascular disease and mortality (Lancet 2002:359:1173–7).

MONTREAL — Psoriasis is an independent risk factor for increased cardiovascular morbidity and mortality, according to a growing number of studies and new guidelines from the American Academy of Dermatology.

Based on this evidence, it is important to screen and regularly monitor psoriasis patients for cardiovascular disease risk factors, said Dr. Lyn C. Guenther, professor and chair of the division of dermatology at the University of Western Ontario, London.

An increased prevalence of cardiovascular disease among people with psoriasis—especially more severe forms—is not new. “I thought it was all related to their [increased] weight,” Dr. Guenther said. “Psoriasis appears to be an independent risk factor now.”

The American Academy of Dermatology addressed increased cardiovascular risk among people with psoriasis in guidelines released in May.

Studies also have suggested that the increased prevalence of hypertension and diabetes among people with psoriasis (J. Am. Acad. Derm. 2006;55:829–35) contributes to the risk, as does a typically atherogenic lipoprotein profile at the onset of skin disease (J. Am. Acad. Dermatol. 2007;56:629–34).

“This is something we cannot ignore any longer,” Dr. Guenther said during a symposium sponsored by Abbott at the annual conference of the Canadian Dermatology Association. “I am not necessarily suggesting we are the ones who have to address this, but [we should] make sure these comorbidities are addressed.”

Psoriasis is associated not only with increased cardiovascular morbidity, but also with increased mortality. “This theme comes up repeatedly,” said Dr. Guenther, who has worked as a researcher, consultant, and speaker for Abbott, Amgen/Wyeth, Schering Plough, Astellas, and Leo Pharma. People with severe psoriasis have a 50% increased risk of death and tend to die earlier than do those without psoriasis (males 3.5 years earlier, females 4.4 years earlier). These figures do not apply to mild disease, she noted.

Not surprisingly, people with psoriasis also have an increased prevalence of metabolic syndrome, Dr. Guenther said.

In one case-control study, 30% of 338 adults with chronic plaque psoriasis and 21% of 334 adults with other skin diseases met criteria for metabolic syndrome—a difference that was statistically significant (Br. J. Dermatol. 2007;157:68–73).

In addition, younger patients with more severe psoriasis appear to be the group at greatest relative risk for a myocardial infarction (JAMA 2006;296:1735–41). Those with severe psoriasis at age 30 years had more than three times the risk (relative risk, 3.1) of having a myocardial infarction, compared with the general population. Risk was lower but still elevated for 30-year-olds with mild psoriasis (RR, 1.29). In 60-year-olds, however, severe psoriasis conferred a 1.36 relative risk for an MI and mild psoriasis conferred a 1.08 relative risk.

Inflammation may be the common culprit in both psoriasis and increased cardiovascular disease. “Tumor necrosis factor-α [TNF-α] is involved in cardiovascular disease and is a target for many of our therapies. High TNF levels are an independent predictor of cardiovascular morbidity and mortality, and TNF levels are high in psoriasis,” Dr. Guenther said.

Elevated C-reactive protein levels may be an important link between psoriasis and cardiovascular disease as well, as was suggested in an editors' roundtable in the American Journal of Cardiology (Am. J. Cardiol. 2008;101:1119–26). “C-reactive protein is something we are starting to measure in our patients,” said Dr. Guenther, who called the marker a very sensitive indicator of inflammation.

There are also immunologic similarities between atherosclerosis and psoriasis. Cell activation, inactive immunity, and adaptive immunity indicate that pathogenesis is similar between these two diseases, she said.

The good news is that treatment of psoriasis might reduce cardiovascular disease and death. “If you reduce inflammation, CRP, and TNF, it might reduce cardiovascular morbidity and mortality,” Dr. Guenther said, citing as an example, a study of rheumatoid arthritis patients, in which methotrexate decreased the incidence of cardiovascular disease and mortality (Lancet 2002:359:1173–7).

People who have sleep-disordered breathing are less likely to experience a normal nighttime decrease in systolic blood pressure, and they are at increased risk of adverse cardiac and other outcomes, according to the results of a new prospective study.

Most people experience a 10%-20% dip in their blood pressure at nighttime (Hypertension 1995;26:60-9). Previously, researchers showed an association between sleep apnea syndrome and a failure to experience that beneficial nighttime decrease in blood pressure, but evidence so far is limited to cross-sectional studies (Am. J. Hypertens. 2001;14:887-92; Chest 2002;122:1148-55).

The new study's findings are important because “nocturnal nondipping” associated with sleep-disordered breathing (SDB) has been linked to target organ damage and to a poor cardiovascular prognosis (Can. J. Cardiol. 2007;23:132-8; JAMA 1999;282:539-46).

Dr. Khin Mae Hla and her associates assessed 328 adults in the ongoing Wisconsin Sleep Cohort Study. All of the participants had a baseline polysomnography study and at least two 24-hour ambulatory blood pressure monitoring assessments during an average of 7.2 years of follow-up. Dr. Hla and her colleagues of the departments of medicine and population health sciences at the University of Wisconsin, Madison, reported their findings in Sleep (2008;31:795-800).

A total of 18% of participants developed systolic nondipping, and 11% developed diastolic nondipping. Although the researchers did not find an association between SDB and diastolic nondipping, the longitudinal association with systolic BP alterations was significant.

“This failure to experience normal dipping adds to the amassing evidence that sleep-disordered breathing has a causal role in cardiovascular disease, possibly via multiple pathways [JAMA 2003;290:1906-14; J. Clin. Sleep Med. 2007;3:409-15],” the researchers wrote.

The chances of developing systolic nondipping were significantly correlated with baseline severity of SDB in a dose-response fashion.

Patients who scored less than 5 on the Apnea-Hypopnea Index (no or minimal SDB) were used as a reference group. In comparison, those with mild SDB (score from 5 to 15) were three times as likely to develop systolic nondipping (adjusted odds ratio, 3.1). In addition, patients with moderate to severe SDB (score of 15 or greater) were more than four times as likely to develop systolic nondipping (OR, 4.4).

Mean patient age was 49 years, 63% were men, and the mean body mass index was 29 kg/m

Grants from the National Institutes of Health helped to fund the study. The authors had no financial relationships to disclose.

Patients using CPAP were included because researchers were unable to determine whether treatment was optimal. That was a possible limitation of the study, the researchers noted, as was a failure to follow all participants who had a baseline 24-hour blood pressure study.

“Our findings of a strong longitudinal association of SDB with nocturnal systolic nondipping of BP have clinical and public health relevance, since SDB and hypertension both are very prevalent in the general population,” the authors wrote.

“The development of systolic BP nondipping, a well-established cardiovascular disease risk, in those with mild to moderate SDB underscores the importance of diagnosing SDB even in its milder forms,” they said.

People who have sleep-disordered breathing are less likely to experience a normal nighttime decrease in systolic blood pressure, and they are at increased risk of adverse cardiac and other outcomes, according to the results of a new prospective study.

Most people experience a 10%-20% dip in their blood pressure at nighttime (Hypertension 1995;26:60-9). Previously, researchers showed an association between sleep apnea syndrome and a failure to experience that beneficial nighttime decrease in blood pressure, but evidence so far is limited to cross-sectional studies (Am. J. Hypertens. 2001;14:887-92; Chest 2002;122:1148-55).

The new study's findings are important because “nocturnal nondipping” associated with sleep-disordered breathing (SDB) has been linked to target organ damage and to a poor cardiovascular prognosis (Can. J. Cardiol. 2007;23:132-8; JAMA 1999;282:539-46).

Dr. Khin Mae Hla and her associates assessed 328 adults in the ongoing Wisconsin Sleep Cohort Study. All of the participants had a baseline polysomnography study and at least two 24-hour ambulatory blood pressure monitoring assessments during an average of 7.2 years of follow-up. Dr. Hla and her colleagues of the departments of medicine and population health sciences at the University of Wisconsin, Madison, reported their findings in Sleep (2008;31:795-800).

A total of 18% of participants developed systolic nondipping, and 11% developed diastolic nondipping. Although the researchers did not find an association between SDB and diastolic nondipping, the longitudinal association with systolic BP alterations was significant.

“This failure to experience normal dipping adds to the amassing evidence that sleep-disordered breathing has a causal role in cardiovascular disease, possibly via multiple pathways [JAMA 2003;290:1906-14; J. Clin. Sleep Med. 2007;3:409-15],” the researchers wrote.

The chances of developing systolic nondipping were significantly correlated with baseline severity of SDB in a dose-response fashion.

Patients who scored less than 5 on the Apnea-Hypopnea Index (no or minimal SDB) were used as a reference group. In comparison, those with mild SDB (score from 5 to 15) were three times as likely to develop systolic nondipping (adjusted odds ratio, 3.1). In addition, patients with moderate to severe SDB (score of 15 or greater) were more than four times as likely to develop systolic nondipping (OR, 4.4).

Mean patient age was 49 years, 63% were men, and the mean body mass index was 29 kg/m

Grants from the National Institutes of Health helped to fund the study. The authors had no financial relationships to disclose.

Patients using CPAP were included because researchers were unable to determine whether treatment was optimal. That was a possible limitation of the study, the researchers noted, as was a failure to follow all participants who had a baseline 24-hour blood pressure study.

“Our findings of a strong longitudinal association of SDB with nocturnal systolic nondipping of BP have clinical and public health relevance, since SDB and hypertension both are very prevalent in the general population,” the authors wrote.

“The development of systolic BP nondipping, a well-established cardiovascular disease risk, in those with mild to moderate SDB underscores the importance of diagnosing SDB even in its milder forms,” they said.

People who have sleep-disordered breathing are less likely to experience a normal nighttime decrease in systolic blood pressure, and they are at increased risk of adverse cardiac and other outcomes, according to the results of a new prospective study.

Most people experience a 10%-20% dip in their blood pressure at nighttime (Hypertension 1995;26:60-9). Previously, researchers showed an association between sleep apnea syndrome and a failure to experience that beneficial nighttime decrease in blood pressure, but evidence so far is limited to cross-sectional studies (Am. J. Hypertens. 2001;14:887-92; Chest 2002;122:1148-55).

The new study's findings are important because “nocturnal nondipping” associated with sleep-disordered breathing (SDB) has been linked to target organ damage and to a poor cardiovascular prognosis (Can. J. Cardiol. 2007;23:132-8; JAMA 1999;282:539-46).

Dr. Khin Mae Hla and her associates assessed 328 adults in the ongoing Wisconsin Sleep Cohort Study. All of the participants had a baseline polysomnography study and at least two 24-hour ambulatory blood pressure monitoring assessments during an average of 7.2 years of follow-up. Dr. Hla and her colleagues of the departments of medicine and population health sciences at the University of Wisconsin, Madison, reported their findings in Sleep (2008;31:795-800).

A total of 18% of participants developed systolic nondipping, and 11% developed diastolic nondipping. Although the researchers did not find an association between SDB and diastolic nondipping, the longitudinal association with systolic BP alterations was significant.

“This failure to experience normal dipping adds to the amassing evidence that sleep-disordered breathing has a causal role in cardiovascular disease, possibly via multiple pathways [JAMA 2003;290:1906-14; J. Clin. Sleep Med. 2007;3:409-15],” the researchers wrote.

The chances of developing systolic nondipping were significantly correlated with baseline severity of SDB in a dose-response fashion.

Patients who scored less than 5 on the Apnea-Hypopnea Index (no or minimal SDB) were used as a reference group. In comparison, those with mild SDB (score from 5 to 15) were three times as likely to develop systolic nondipping (adjusted odds ratio, 3.1). In addition, patients with moderate to severe SDB (score of 15 or greater) were more than four times as likely to develop systolic nondipping (OR, 4.4).

Mean patient age was 49 years, 63% were men, and the mean body mass index was 29 kg/m

Grants from the National Institutes of Health helped to fund the study. The authors had no financial relationships to disclose.

Patients using CPAP were included because researchers were unable to determine whether treatment was optimal. That was a possible limitation of the study, the researchers noted, as was a failure to follow all participants who had a baseline 24-hour blood pressure study.

“Our findings of a strong longitudinal association of SDB with nocturnal systolic nondipping of BP have clinical and public health relevance, since SDB and hypertension both are very prevalent in the general population,” the authors wrote.

“The development of systolic BP nondipping, a well-established cardiovascular disease risk, in those with mild to moderate SDB underscores the importance of diagnosing SDB even in its milder forms,” they said.

ORLANDO — Independent risk predictors have been identified that help to target the 1% of patients who develop acute renal failure following general surgery.

Eleven independent risk factors predicted acute renal failure in a logistic regression model performed by Dr. Sachin Kheterpal and his colleagues at the University of Michigan, Ann Arbor.

The researchers reviewed 150,490 operations in the American College of Surgeons' National Surgical Quality Improvement Program data set performed over a 1-year period (2005–2006) and calculated hazard ratios to compare the likelihood of acute renal failure between patients with and without each risk factor.

Preoperative renal insufficiency was associated with the greatest hazard ratio, 8.5. Other risk factors were heart failure (HR 7.6), ascites (HR 6.4), myocardial infarction within 6 months (HR 5.7), high-risk surgery (HR 3.8), aged 58 years or older (HR 3.2), hypertension requiring chronic medication (HR 3.1), male sex (HR 1.9), diabetes mellitus (HR 2.6), previous cardiac procedure (HR 2.2), and emergency surgery (HR 2.7), Dr. Kheterpal said during a poster discussion session at the annual meeting of the American Society of Anesthesiologists.

Dr. Kheterpal and his associates then took the list one step further.

They developed a “robust” risk-prediction model—an index based on the number of preoperative risk factors. The association between these risk factors and ARF incidence was as follows: one to two risk factors, 0.2% ARF incidence; three risk factors, 1% incidence; four factors, 2% incidence; five factors, 3.3% incidence; and six factors, 9% incidence.

“This is really surprising when you look at how many older patients we have, who are also men, and have hypertension and diabetes—[they] have a fairly good chance of acute renal failure,” Dr. Kheterpal said. The prediction index could be the foundation for informed consent in these patients, he added.

The investigators based their conclusions on information prospectively gathered by trained nurse data collectors from 121 centers, including community and academic centers.

“The data collection system is very detailed. It includes 30-day outcomes, even if the patient leaves and dies at another hospital,” said Dr. Kheterpal of the department of anesthesiology at the university.

Excluded from the study were patients with preexisting acute renal failure or those requiring dialysis; patients undergoing any nongeneral surgery procedures, including cases performed by vascular, cardiac, urology, ophthalmology, podiatry, or obstetric services; outpatients; and general surgery patients on whom concurrent urology procedures were performed.

Data for 68,147 operations were assessed further. Of these, 712 patients (1%) experienced acute renal failure (ARF) postoperatively. ARF was defined as progressive renal insufficiency—an increase in serum creatinine of 2 mg/dL or more above baseline—or a requirement for postoperative dialysis.

This 1% incidence of acute kidney injury is very close to a previously reported incidence of 0.8% (Anesthesiology 2007;107:892–902). The use of vasopressors and diuretics was among the factors associated with ARF in this single-center study of more than 65,000 noncardiac procedures. In addition, patients who experienced ARF had increased 30-day, 60-day, and 1-year all-cause mortality.

A meeting attendee asked Dr. Kheterpal if he and other physicians at the University of Michigan are doing anything different based on the study findings. “Yes, we are very aggressive now about hydration. And we're very aggressive now about not using diuretics intraoperatively. I've gotten into fights about that,” he said.

Having a study with nearly 70,000 general surgery cases allowed Dr. Kheterpal and his associates to do an internal validation study.

He acknowledged that there are also many limitations because the study is based on a national data set. For example, intraoperative data beyond length of each procedure were “very limited,” and there was no information on the use of preoperative medications.

“Next at our institution we will be looking at alternative serum and urinary biomarkers of ARF,” Dr. Kheterpal said.

ORLANDO — Independent risk predictors have been identified that help to target the 1% of patients who develop acute renal failure following general surgery.

Eleven independent risk factors predicted acute renal failure in a logistic regression model performed by Dr. Sachin Kheterpal and his colleagues at the University of Michigan, Ann Arbor.

The researchers reviewed 150,490 operations in the American College of Surgeons' National Surgical Quality Improvement Program data set performed over a 1-year period (2005–2006) and calculated hazard ratios to compare the likelihood of acute renal failure between patients with and without each risk factor.

Preoperative renal insufficiency was associated with the greatest hazard ratio, 8.5. Other risk factors were heart failure (HR 7.6), ascites (HR 6.4), myocardial infarction within 6 months (HR 5.7), high-risk surgery (HR 3.8), aged 58 years or older (HR 3.2), hypertension requiring chronic medication (HR 3.1), male sex (HR 1.9), diabetes mellitus (HR 2.6), previous cardiac procedure (HR 2.2), and emergency surgery (HR 2.7), Dr. Kheterpal said during a poster discussion session at the annual meeting of the American Society of Anesthesiologists.

Dr. Kheterpal and his associates then took the list one step further.

They developed a “robust” risk-prediction model—an index based on the number of preoperative risk factors. The association between these risk factors and ARF incidence was as follows: one to two risk factors, 0.2% ARF incidence; three risk factors, 1% incidence; four factors, 2% incidence; five factors, 3.3% incidence; and six factors, 9% incidence.

“This is really surprising when you look at how many older patients we have, who are also men, and have hypertension and diabetes—[they] have a fairly good chance of acute renal failure,” Dr. Kheterpal said. The prediction index could be the foundation for informed consent in these patients, he added.

The investigators based their conclusions on information prospectively gathered by trained nurse data collectors from 121 centers, including community and academic centers.

“The data collection system is very detailed. It includes 30-day outcomes, even if the patient leaves and dies at another hospital,” said Dr. Kheterpal of the department of anesthesiology at the university.

Excluded from the study were patients with preexisting acute renal failure or those requiring dialysis; patients undergoing any nongeneral surgery procedures, including cases performed by vascular, cardiac, urology, ophthalmology, podiatry, or obstetric services; outpatients; and general surgery patients on whom concurrent urology procedures were performed.

Data for 68,147 operations were assessed further. Of these, 712 patients (1%) experienced acute renal failure (ARF) postoperatively. ARF was defined as progressive renal insufficiency—an increase in serum creatinine of 2 mg/dL or more above baseline—or a requirement for postoperative dialysis.

This 1% incidence of acute kidney injury is very close to a previously reported incidence of 0.8% (Anesthesiology 2007;107:892–902). The use of vasopressors and diuretics was among the factors associated with ARF in this single-center study of more than 65,000 noncardiac procedures. In addition, patients who experienced ARF had increased 30-day, 60-day, and 1-year all-cause mortality.

A meeting attendee asked Dr. Kheterpal if he and other physicians at the University of Michigan are doing anything different based on the study findings. “Yes, we are very aggressive now about hydration. And we're very aggressive now about not using diuretics intraoperatively. I've gotten into fights about that,” he said.

Having a study with nearly 70,000 general surgery cases allowed Dr. Kheterpal and his associates to do an internal validation study.

He acknowledged that there are also many limitations because the study is based on a national data set. For example, intraoperative data beyond length of each procedure were “very limited,” and there was no information on the use of preoperative medications.

“Next at our institution we will be looking at alternative serum and urinary biomarkers of ARF,” Dr. Kheterpal said.

ORLANDO — Independent risk predictors have been identified that help to target the 1% of patients who develop acute renal failure following general surgery.

Eleven independent risk factors predicted acute renal failure in a logistic regression model performed by Dr. Sachin Kheterpal and his colleagues at the University of Michigan, Ann Arbor.

The researchers reviewed 150,490 operations in the American College of Surgeons' National Surgical Quality Improvement Program data set performed over a 1-year period (2005–2006) and calculated hazard ratios to compare the likelihood of acute renal failure between patients with and without each risk factor.

Preoperative renal insufficiency was associated with the greatest hazard ratio, 8.5. Other risk factors were heart failure (HR 7.6), ascites (HR 6.4), myocardial infarction within 6 months (HR 5.7), high-risk surgery (HR 3.8), aged 58 years or older (HR 3.2), hypertension requiring chronic medication (HR 3.1), male sex (HR 1.9), diabetes mellitus (HR 2.6), previous cardiac procedure (HR 2.2), and emergency surgery (HR 2.7), Dr. Kheterpal said during a poster discussion session at the annual meeting of the American Society of Anesthesiologists.

Dr. Kheterpal and his associates then took the list one step further.

They developed a “robust” risk-prediction model—an index based on the number of preoperative risk factors. The association between these risk factors and ARF incidence was as follows: one to two risk factors, 0.2% ARF incidence; three risk factors, 1% incidence; four factors, 2% incidence; five factors, 3.3% incidence; and six factors, 9% incidence.

“This is really surprising when you look at how many older patients we have, who are also men, and have hypertension and diabetes—[they] have a fairly good chance of acute renal failure,” Dr. Kheterpal said. The prediction index could be the foundation for informed consent in these patients, he added.

The investigators based their conclusions on information prospectively gathered by trained nurse data collectors from 121 centers, including community and academic centers.

“The data collection system is very detailed. It includes 30-day outcomes, even if the patient leaves and dies at another hospital,” said Dr. Kheterpal of the department of anesthesiology at the university.

Excluded from the study were patients with preexisting acute renal failure or those requiring dialysis; patients undergoing any nongeneral surgery procedures, including cases performed by vascular, cardiac, urology, ophthalmology, podiatry, or obstetric services; outpatients; and general surgery patients on whom concurrent urology procedures were performed.

Data for 68,147 operations were assessed further. Of these, 712 patients (1%) experienced acute renal failure (ARF) postoperatively. ARF was defined as progressive renal insufficiency—an increase in serum creatinine of 2 mg/dL or more above baseline—or a requirement for postoperative dialysis.

This 1% incidence of acute kidney injury is very close to a previously reported incidence of 0.8% (Anesthesiology 2007;107:892–902). The use of vasopressors and diuretics was among the factors associated with ARF in this single-center study of more than 65,000 noncardiac procedures. In addition, patients who experienced ARF had increased 30-day, 60-day, and 1-year all-cause mortality.

A meeting attendee asked Dr. Kheterpal if he and other physicians at the University of Michigan are doing anything different based on the study findings. “Yes, we are very aggressive now about hydration. And we're very aggressive now about not using diuretics intraoperatively. I've gotten into fights about that,” he said.

Having a study with nearly 70,000 general surgery cases allowed Dr. Kheterpal and his associates to do an internal validation study.

He acknowledged that there are also many limitations because the study is based on a national data set. For example, intraoperative data beyond length of each procedure were “very limited,” and there was no information on the use of preoperative medications.

“Next at our institution we will be looking at alternative serum and urinary biomarkers of ARF,” Dr. Kheterpal said.