Damian McNamara

FORT LAUDERDALE, FLA. — Pay-for-performance evaluations of physicians will require additional reimbursement codes to justify the provision of some services.

Medicare and private insurers historically have used coding for financial reimbursement, but the government and insurers began “profiling” all physicians based on claims data about 5 years ago, Dr. Barbara Levy said at a meeting on hysterectomy sponsored by the Cleveland Clinic.

“We are designing additional ICD-9 codes because of pay for performance,” said Dr. Levy, a member of the Code and Nomenclature Committee of the American College of Obstetricians and Gynecologists.

For example, one of the quality measures from HEDIS (the Healthcare Effectiveness Data and Information Set) promotes regular pap smears for cervical cancer screening, except for patients who had a hysterectomy for benign disease. “We did not have an ICD-9 code for this until this year: 'Patient no longer has organ.' So now the payers will know that we did not do a pap smear for a good reason. And they are extrapolating this information to judge our quality,” said Dr. Levy, also the medical director of the Women's Health and Breast Center, Franciscan Health System, Federal Way, Wash.

Ob.gyns. should begin collecting their own case data, including outcomes, instead of waiting for the government or others to do it, Dr. Levy said. “We need to learn to be stewards of our resources and pay attention to what things cost.” She calculated a $4,800 overall cost per case for laparoscopic supracervical hysterectomy at her institution, for example. The cost per case for a vaginal hysterectomy is less than $1,000. “We need to think about those things … If we don't do this, someone else will.”

Watch for inequities in physician ratings as pay for performance is implemented, Dr. Levy said. The typical measure of physician efficiency is a ratio of actual resource use to expected resource use, given an equivalent quality of care in a particular geographic area. “My practice is primarily gynecologic surgery, so my patients are typically 15 years older than the average ob.gyn. patient in my area,” she said.

A physician who uses more resources per patient during a period of time will be paid less, according to the program's efficiency measures. Also, if particular physicians are labeled as higher-cost doctors, a patient might have to pay a higher copay to see them, Dr. Levy said.

FORT LAUDERDALE, FLA. — Pay-for-performance evaluations of physicians will require additional reimbursement codes to justify the provision of some services.

Medicare and private insurers historically have used coding for financial reimbursement, but the government and insurers began “profiling” all physicians based on claims data about 5 years ago, Dr. Barbara Levy said at a meeting on hysterectomy sponsored by the Cleveland Clinic.

“We are designing additional ICD-9 codes because of pay for performance,” said Dr. Levy, a member of the Code and Nomenclature Committee of the American College of Obstetricians and Gynecologists.

For example, one of the quality measures from HEDIS (the Healthcare Effectiveness Data and Information Set) promotes regular pap smears for cervical cancer screening, except for patients who had a hysterectomy for benign disease. “We did not have an ICD-9 code for this until this year: 'Patient no longer has organ.' So now the payers will know that we did not do a pap smear for a good reason. And they are extrapolating this information to judge our quality,” said Dr. Levy, also the medical director of the Women's Health and Breast Center, Franciscan Health System, Federal Way, Wash.

Ob.gyns. should begin collecting their own case data, including outcomes, instead of waiting for the government or others to do it, Dr. Levy said. “We need to learn to be stewards of our resources and pay attention to what things cost.” She calculated a $4,800 overall cost per case for laparoscopic supracervical hysterectomy at her institution, for example. The cost per case for a vaginal hysterectomy is less than $1,000. “We need to think about those things … If we don't do this, someone else will.”

Watch for inequities in physician ratings as pay for performance is implemented, Dr. Levy said. The typical measure of physician efficiency is a ratio of actual resource use to expected resource use, given an equivalent quality of care in a particular geographic area. “My practice is primarily gynecologic surgery, so my patients are typically 15 years older than the average ob.gyn. patient in my area,” she said.

A physician who uses more resources per patient during a period of time will be paid less, according to the program's efficiency measures. Also, if particular physicians are labeled as higher-cost doctors, a patient might have to pay a higher copay to see them, Dr. Levy said.

FORT LAUDERDALE, FLA. — Pay-for-performance evaluations of physicians will require additional reimbursement codes to justify the provision of some services.

Medicare and private insurers historically have used coding for financial reimbursement, but the government and insurers began “profiling” all physicians based on claims data about 5 years ago, Dr. Barbara Levy said at a meeting on hysterectomy sponsored by the Cleveland Clinic.

“We are designing additional ICD-9 codes because of pay for performance,” said Dr. Levy, a member of the Code and Nomenclature Committee of the American College of Obstetricians and Gynecologists.

For example, one of the quality measures from HEDIS (the Healthcare Effectiveness Data and Information Set) promotes regular pap smears for cervical cancer screening, except for patients who had a hysterectomy for benign disease. “We did not have an ICD-9 code for this until this year: 'Patient no longer has organ.' So now the payers will know that we did not do a pap smear for a good reason. And they are extrapolating this information to judge our quality,” said Dr. Levy, also the medical director of the Women's Health and Breast Center, Franciscan Health System, Federal Way, Wash.

Ob.gyns. should begin collecting their own case data, including outcomes, instead of waiting for the government or others to do it, Dr. Levy said. “We need to learn to be stewards of our resources and pay attention to what things cost.” She calculated a $4,800 overall cost per case for laparoscopic supracervical hysterectomy at her institution, for example. The cost per case for a vaginal hysterectomy is less than $1,000. “We need to think about those things … If we don't do this, someone else will.”

Watch for inequities in physician ratings as pay for performance is implemented, Dr. Levy said. The typical measure of physician efficiency is a ratio of actual resource use to expected resource use, given an equivalent quality of care in a particular geographic area. “My practice is primarily gynecologic surgery, so my patients are typically 15 years older than the average ob.gyn. patient in my area,” she said.

A physician who uses more resources per patient during a period of time will be paid less, according to the program's efficiency measures. Also, if particular physicians are labeled as higher-cost doctors, a patient might have to pay a higher copay to see them, Dr. Levy said.

FORT LAUDERDALE, FLA. — Lower short-term morbidity and more favorable long-term outcomes are among the advantages of a biodegradable ring used for mitral valve repair in children with rheumatic disease, compared with a traditional rigid ring, according to a study.

Rheumatic mitral valve disease in children is progressive and surgery is the treatment of choice, Dr. Afksendiyos Kalangos said at the annual meeting of the Society of Thoracic Surgeons. To gauge the impact of a biodegradable ring on short- and long-term outcomes for these children, Dr. Kalangos and his associates assessed 220 valve repairs at the University Hospital of Geneva.

The single surgical team's experience included 143 girls and 77 boys with a mean age of 12 years (and a range of 2-16 years). The valve repairs were performed from January 1994 to March 2007. The majority of patients—198, or 90%–had predominant mitral valve deficiency.

“Mitral valve repair can be performed in a significant number of young rheumatic patients, depending on surgical expertise,” said Dr. Kalangos, chairman of the division of cardiovascular surgery and the unit of pediatric cardiology, University Hospital of Geneva.

The surgeons also simultaneously addressed aortic valve insufficiency in 57 patients and tricuspid valve insufficiency in 51 patients.

Echocardiography was performed at 1 week, 3 months, and 6 months postoperatively, and then annually. Complete data were available for 213 participants.

A total of 173 participants received a rigid annuoplasty ring (the Carpentier-Edwards ring, manufactured by Edwards Lifesciences LLC), until 2003. Thereafter, another 40 children received a biodegradable annuoplasty ring (manufactured by Bioring SA). The biodegradable ring has an investigational status with the Food and Drug Administration.

One immediate mitral valve repair failure led to a reoperation, Dr. Kalangos said. There was one late death from septicemia at 9 months. There were no hospital deaths or major postoperative morbidities.

There have been five reoperations during a mean follow-up of 76 months. “All reoperations so far were in the Carpentier-Edwards group,” Dr. Kalangos said. Dr. Kalangos and his colleagues are royalty holders and consultants for Bioring SA.

The mean gradient was significantly lower for the biodegradable ring, compared with the rigid ring, at follow-up: 5.2 mm Hg versus 2.8 mm Hg at 7 days, 6.2 mm Hg versus 3.1 mm Hg at 6 months, and 7.0 mm Hg versus 3.3 mm Hg at 1 year after the procedure.

The researchers also found a statistically significant difference in the percentage of patients who had an unchanged gradient during the first year: 26 of 40 (65%) biodegradable ring patients and 35 of 173 (20%) of the rigid ring participants.

ELSEVIER GLOBAL MEDICAL NEWS

FORT LAUDERDALE, FLA. — Lower short-term morbidity and more favorable long-term outcomes are among the advantages of a biodegradable ring used for mitral valve repair in children with rheumatic disease, compared with a traditional rigid ring, according to a study.

Rheumatic mitral valve disease in children is progressive and surgery is the treatment of choice, Dr. Afksendiyos Kalangos said at the annual meeting of the Society of Thoracic Surgeons. To gauge the impact of a biodegradable ring on short- and long-term outcomes for these children, Dr. Kalangos and his associates assessed 220 valve repairs at the University Hospital of Geneva.

The single surgical team's experience included 143 girls and 77 boys with a mean age of 12 years (and a range of 2-16 years). The valve repairs were performed from January 1994 to March 2007. The majority of patients—198, or 90%–had predominant mitral valve deficiency.

“Mitral valve repair can be performed in a significant number of young rheumatic patients, depending on surgical expertise,” said Dr. Kalangos, chairman of the division of cardiovascular surgery and the unit of pediatric cardiology, University Hospital of Geneva.

The surgeons also simultaneously addressed aortic valve insufficiency in 57 patients and tricuspid valve insufficiency in 51 patients.

Echocardiography was performed at 1 week, 3 months, and 6 months postoperatively, and then annually. Complete data were available for 213 participants.

A total of 173 participants received a rigid annuoplasty ring (the Carpentier-Edwards ring, manufactured by Edwards Lifesciences LLC), until 2003. Thereafter, another 40 children received a biodegradable annuoplasty ring (manufactured by Bioring SA). The biodegradable ring has an investigational status with the Food and Drug Administration.

One immediate mitral valve repair failure led to a reoperation, Dr. Kalangos said. There was one late death from septicemia at 9 months. There were no hospital deaths or major postoperative morbidities.

There have been five reoperations during a mean follow-up of 76 months. “All reoperations so far were in the Carpentier-Edwards group,” Dr. Kalangos said. Dr. Kalangos and his colleagues are royalty holders and consultants for Bioring SA.

The mean gradient was significantly lower for the biodegradable ring, compared with the rigid ring, at follow-up: 5.2 mm Hg versus 2.8 mm Hg at 7 days, 6.2 mm Hg versus 3.1 mm Hg at 6 months, and 7.0 mm Hg versus 3.3 mm Hg at 1 year after the procedure.

The researchers also found a statistically significant difference in the percentage of patients who had an unchanged gradient during the first year: 26 of 40 (65%) biodegradable ring patients and 35 of 173 (20%) of the rigid ring participants.

ELSEVIER GLOBAL MEDICAL NEWS

FORT LAUDERDALE, FLA. — Lower short-term morbidity and more favorable long-term outcomes are among the advantages of a biodegradable ring used for mitral valve repair in children with rheumatic disease, compared with a traditional rigid ring, according to a study.

Rheumatic mitral valve disease in children is progressive and surgery is the treatment of choice, Dr. Afksendiyos Kalangos said at the annual meeting of the Society of Thoracic Surgeons. To gauge the impact of a biodegradable ring on short- and long-term outcomes for these children, Dr. Kalangos and his associates assessed 220 valve repairs at the University Hospital of Geneva.

The single surgical team's experience included 143 girls and 77 boys with a mean age of 12 years (and a range of 2-16 years). The valve repairs were performed from January 1994 to March 2007. The majority of patients—198, or 90%–had predominant mitral valve deficiency.

“Mitral valve repair can be performed in a significant number of young rheumatic patients, depending on surgical expertise,” said Dr. Kalangos, chairman of the division of cardiovascular surgery and the unit of pediatric cardiology, University Hospital of Geneva.

The surgeons also simultaneously addressed aortic valve insufficiency in 57 patients and tricuspid valve insufficiency in 51 patients.

Echocardiography was performed at 1 week, 3 months, and 6 months postoperatively, and then annually. Complete data were available for 213 participants.

A total of 173 participants received a rigid annuoplasty ring (the Carpentier-Edwards ring, manufactured by Edwards Lifesciences LLC), until 2003. Thereafter, another 40 children received a biodegradable annuoplasty ring (manufactured by Bioring SA). The biodegradable ring has an investigational status with the Food and Drug Administration.

One immediate mitral valve repair failure led to a reoperation, Dr. Kalangos said. There was one late death from septicemia at 9 months. There were no hospital deaths or major postoperative morbidities.

There have been five reoperations during a mean follow-up of 76 months. “All reoperations so far were in the Carpentier-Edwards group,” Dr. Kalangos said. Dr. Kalangos and his colleagues are royalty holders and consultants for Bioring SA.

The mean gradient was significantly lower for the biodegradable ring, compared with the rigid ring, at follow-up: 5.2 mm Hg versus 2.8 mm Hg at 7 days, 6.2 mm Hg versus 3.1 mm Hg at 6 months, and 7.0 mm Hg versus 3.3 mm Hg at 1 year after the procedure.

The researchers also found a statistically significant difference in the percentage of patients who had an unchanged gradient during the first year: 26 of 40 (65%) biodegradable ring patients and 35 of 173 (20%) of the rigid ring participants.

ELSEVIER GLOBAL MEDICAL NEWS

Calcium supplementation significantly increased the risk of a myocardial infarction among healthy, postmenopausal women, compared with those taking placebo, in a secondary analysis of an osteoporosis study.

“I would not recommend calcium supplementation based on this finding,” Dr. Rita F. Redberg, who was not involved in the study, said in an interview.

The HDL:LDL cholesterol ratios improved among the 732 women who took daily calcium supplementation, compared with the 739 participants who took placebo. This suggests that a different mechanism spurred the increase in myocardial infarction.

“This is an interesting point. It shows that just improving cholesterol does not reduce the risk of a heart attack,” said Dr. Redberg, a Robert Wood Johnson Foundation health policy fellow and director of women's cardiovascular services at the University of California, San Francisco. “It was the same finding with estrogen: It lowered LDL, increased HDL, but did not reduce the number of heart attacks in studies.”

The current findings contrast with previous suggestions of cardiovascular benefit from calcium supplementation. One study found that calcium increases the HDL:LDL cholesterol ratio by almost 20% (Am. J. Med. 2002;112:343-7).

Moreoover, there was a one-third decrease in deaths from cardiovascular events observed among women who had the greatest intake of calcium from either diet or supplements in the Iowa Women's Health Study (Am. J. Epidemiol. 1999;149:151-61).

Following completion of a 5-year osteoporosis study (Am. J. Med. 2006;1119:777-85), Dr. Mark J. Bolland and his associates at the University of Auckland (New Zealand) reassessed their data to compare cardiovascular events. Women were randomized to 1 g/day of elemental calcium (Citracal) or placebo. All of the 1,471 participants were postmenopausal for at least 5 years and older than age 55 years at baseline, and 10% of those were older than age 80 at baseline.

Death, sudden death, myocardial infarction, angina, other chest pain, stroke, and transient ischemic attacks events were recorded every 6 months. In all, 336 women stopped taking the calcium and 296 stopped taking the placebo before the study end.

A total of 21 of the 732 women in the calcium group experienced 24 myocardial infarctions, a statistically significant difference compared with 10 of the 739 in the placebo group who had 10 such events. A composite end point of sudden death, myocardial infarction, angina, or chest pain was also higher in the calcium group (155 events among 87 women) compared with the placebo group (135 events among 93 women).

No significant differences were found in angina, chest pain, transient ischemic attack, stroke, or sudden death events between groups. There were 34 deaths in the calcium group and 29 in the placebo, a nonsignificant difference.

Dr. Redberg was not surprised by the elevated MI risk. She said research by Dr. Linda Demer, vice chair of medicine at the University of California, Los Angeles, has indicated increased cardiovascular risk associated with calcium.

“It's called the calcium paradox. Women lose calcium from their bones as they get older and it ends up in their arteries and the lining of their vessel walls, leading to accelerated atherosclerosis,” Dr. Redberg said.

“This study is a confirmation of that hypothesis, that calcium can end up in the walls of your arteries.” Dr. Redberg is also a professor of medicine at the University of California, San Francisco.

There is a known paradox: The calcium women lose from their bones ends up in their arteries. DR. REDBERG

Calcium supplementation significantly increased the risk of a myocardial infarction among healthy, postmenopausal women, compared with those taking placebo, in a secondary analysis of an osteoporosis study.

“I would not recommend calcium supplementation based on this finding,” Dr. Rita F. Redberg, who was not involved in the study, said in an interview.

The HDL:LDL cholesterol ratios improved among the 732 women who took daily calcium supplementation, compared with the 739 participants who took placebo. This suggests that a different mechanism spurred the increase in myocardial infarction.

“This is an interesting point. It shows that just improving cholesterol does not reduce the risk of a heart attack,” said Dr. Redberg, a Robert Wood Johnson Foundation health policy fellow and director of women's cardiovascular services at the University of California, San Francisco. “It was the same finding with estrogen: It lowered LDL, increased HDL, but did not reduce the number of heart attacks in studies.”

The current findings contrast with previous suggestions of cardiovascular benefit from calcium supplementation. One study found that calcium increases the HDL:LDL cholesterol ratio by almost 20% (Am. J. Med. 2002;112:343-7).

Moreoover, there was a one-third decrease in deaths from cardiovascular events observed among women who had the greatest intake of calcium from either diet or supplements in the Iowa Women's Health Study (Am. J. Epidemiol. 1999;149:151-61).

Following completion of a 5-year osteoporosis study (Am. J. Med. 2006;1119:777-85), Dr. Mark J. Bolland and his associates at the University of Auckland (New Zealand) reassessed their data to compare cardiovascular events. Women were randomized to 1 g/day of elemental calcium (Citracal) or placebo. All of the 1,471 participants were postmenopausal for at least 5 years and older than age 55 years at baseline, and 10% of those were older than age 80 at baseline.

Death, sudden death, myocardial infarction, angina, other chest pain, stroke, and transient ischemic attacks events were recorded every 6 months. In all, 336 women stopped taking the calcium and 296 stopped taking the placebo before the study end.

A total of 21 of the 732 women in the calcium group experienced 24 myocardial infarctions, a statistically significant difference compared with 10 of the 739 in the placebo group who had 10 such events. A composite end point of sudden death, myocardial infarction, angina, or chest pain was also higher in the calcium group (155 events among 87 women) compared with the placebo group (135 events among 93 women).

No significant differences were found in angina, chest pain, transient ischemic attack, stroke, or sudden death events between groups. There were 34 deaths in the calcium group and 29 in the placebo, a nonsignificant difference.

Dr. Redberg was not surprised by the elevated MI risk. She said research by Dr. Linda Demer, vice chair of medicine at the University of California, Los Angeles, has indicated increased cardiovascular risk associated with calcium.

“It's called the calcium paradox. Women lose calcium from their bones as they get older and it ends up in their arteries and the lining of their vessel walls, leading to accelerated atherosclerosis,” Dr. Redberg said.

“This study is a confirmation of that hypothesis, that calcium can end up in the walls of your arteries.” Dr. Redberg is also a professor of medicine at the University of California, San Francisco.

There is a known paradox: The calcium women lose from their bones ends up in their arteries. DR. REDBERG

Calcium supplementation significantly increased the risk of a myocardial infarction among healthy, postmenopausal women, compared with those taking placebo, in a secondary analysis of an osteoporosis study.

“I would not recommend calcium supplementation based on this finding,” Dr. Rita F. Redberg, who was not involved in the study, said in an interview.

The HDL:LDL cholesterol ratios improved among the 732 women who took daily calcium supplementation, compared with the 739 participants who took placebo. This suggests that a different mechanism spurred the increase in myocardial infarction.

“This is an interesting point. It shows that just improving cholesterol does not reduce the risk of a heart attack,” said Dr. Redberg, a Robert Wood Johnson Foundation health policy fellow and director of women's cardiovascular services at the University of California, San Francisco. “It was the same finding with estrogen: It lowered LDL, increased HDL, but did not reduce the number of heart attacks in studies.”

The current findings contrast with previous suggestions of cardiovascular benefit from calcium supplementation. One study found that calcium increases the HDL:LDL cholesterol ratio by almost 20% (Am. J. Med. 2002;112:343-7).

Moreoover, there was a one-third decrease in deaths from cardiovascular events observed among women who had the greatest intake of calcium from either diet or supplements in the Iowa Women's Health Study (Am. J. Epidemiol. 1999;149:151-61).

Following completion of a 5-year osteoporosis study (Am. J. Med. 2006;1119:777-85), Dr. Mark J. Bolland and his associates at the University of Auckland (New Zealand) reassessed their data to compare cardiovascular events. Women were randomized to 1 g/day of elemental calcium (Citracal) or placebo. All of the 1,471 participants were postmenopausal for at least 5 years and older than age 55 years at baseline, and 10% of those were older than age 80 at baseline.

Death, sudden death, myocardial infarction, angina, other chest pain, stroke, and transient ischemic attacks events were recorded every 6 months. In all, 336 women stopped taking the calcium and 296 stopped taking the placebo before the study end.

A total of 21 of the 732 women in the calcium group experienced 24 myocardial infarctions, a statistically significant difference compared with 10 of the 739 in the placebo group who had 10 such events. A composite end point of sudden death, myocardial infarction, angina, or chest pain was also higher in the calcium group (155 events among 87 women) compared with the placebo group (135 events among 93 women).

No significant differences were found in angina, chest pain, transient ischemic attack, stroke, or sudden death events between groups. There were 34 deaths in the calcium group and 29 in the placebo, a nonsignificant difference.

Dr. Redberg was not surprised by the elevated MI risk. She said research by Dr. Linda Demer, vice chair of medicine at the University of California, Los Angeles, has indicated increased cardiovascular risk associated with calcium.

“It's called the calcium paradox. Women lose calcium from their bones as they get older and it ends up in their arteries and the lining of their vessel walls, leading to accelerated atherosclerosis,” Dr. Redberg said.

“This study is a confirmation of that hypothesis, that calcium can end up in the walls of your arteries.” Dr. Redberg is also a professor of medicine at the University of California, San Francisco.

There is a known paradox: The calcium women lose from their bones ends up in their arteries. DR. REDBERG

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, according to a report.

From 1997 to 2005, adult hospital stays specifically for asthma remained stable, but the number of secondary asthma diagnoses more than doubled, according to “Hospital Stays Related to Asthma for Adults, 2005,” a statistical brief released by the Agency for Healthcare Research and Quality (AHRQ).

Between 2000 and 2005, hospitalizations for asthma increased 18%, from 247,200 to 290,600. However, the number of hospital stays where asthma was secondary rose from 753,800 to 1,609,200, an increase of 113%.

Pneumonia 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 AHRQ's Healthcare Cost and Utilization Project (HCUP) reported.

Heart failure and nonspecific chest pain were the next most common principal diagnoses, collectively 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 (3.3%) of the hospital stays.

Patients aged 65 years and older had more than three times the rate of asthma-related hospitalizations, compared with younger patients. The hospitalization rate per 1,000 population for a primary asthma diagnosis was 0.7 for patients aged 18–44 years, 1.6 for patients aged 45–64, and 2.5 for those aged 65 and older.

Rates also were higher among women—about 2.5 times greater than stays for men. Women had a 1.8 per 1,000 population primary asthma hospitalization rate, compared with 0.7 among 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 to 2004, and supplemental sources. The database includes all patients regardless of insurance type or uninsured status who were admitted to short-term, nonfederal hospitals. Obstetric and gynecologic facilities; ear, nose, and throat hospitals; and orthopedic, cancer, public, and academic medical hospitals are included.

Of the primary asthma inpatient stays, 74% were admissions through an emergency department, compared with 51% of the secondary diagnosis stays. 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 of the United States, compared with richer regions. 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, according to the report.

After accounting for differences in length of stay, hospitalizations principally for asthma cost an average $1,400 per day, or about $400 less than the estimated $1,800 per day for hospital stays with secondary asthma. Aggregate costs were about $1.6 billion for primary asthma admissions in 2005, compared with $14.4 billion for secondary asthma stays.

Researchers found little variation in hospitalizations by region. After adjusting for regional population differences, they found approximately two principal asthma stays per 1,000 population in the Northeast, Midwest, and South. The rate was lower in the West at 1.4 stays per 1,000 population.

The AHRQ is scheduled to release a second report on pediatric asthma-related hospital stays in August 2008.

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, according to a report.

From 1997 to 2005, adult hospital stays specifically for asthma remained stable, but the number of secondary asthma diagnoses more than doubled, according to “Hospital Stays Related to Asthma for Adults, 2005,” a statistical brief released by the Agency for Healthcare Research and Quality (AHRQ).

Between 2000 and 2005, hospitalizations for asthma increased 18%, from 247,200 to 290,600. However, the number of hospital stays where asthma was secondary rose from 753,800 to 1,609,200, an increase of 113%.

Pneumonia 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 AHRQ's Healthcare Cost and Utilization Project (HCUP) reported.

Heart failure and nonspecific chest pain were the next most common principal diagnoses, collectively 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 (3.3%) of the hospital stays.

Patients aged 65 years and older had more than three times the rate of asthma-related hospitalizations, compared with younger patients. The hospitalization rate per 1,000 population for a primary asthma diagnosis was 0.7 for patients aged 18–44 years, 1.6 for patients aged 45–64, and 2.5 for those aged 65 and older.

Rates also were higher among women—about 2.5 times greater than stays for men. Women had a 1.8 per 1,000 population primary asthma hospitalization rate, compared with 0.7 among 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 to 2004, and supplemental sources. The database includes all patients regardless of insurance type or uninsured status who were admitted to short-term, nonfederal hospitals. Obstetric and gynecologic facilities; ear, nose, and throat hospitals; and orthopedic, cancer, public, and academic medical hospitals are included.

Of the primary asthma inpatient stays, 74% were admissions through an emergency department, compared with 51% of the secondary diagnosis stays. 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 of the United States, compared with richer regions. 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, according to the report.

After accounting for differences in length of stay, hospitalizations principally for asthma cost an average $1,400 per day, or about $400 less than the estimated $1,800 per day for hospital stays with secondary asthma. Aggregate costs were about $1.6 billion for primary asthma admissions in 2005, compared with $14.4 billion for secondary asthma stays.

Researchers found little variation in hospitalizations by region. After adjusting for regional population differences, they found approximately two principal asthma stays per 1,000 population in the Northeast, Midwest, and South. The rate was lower in the West at 1.4 stays per 1,000 population.

The AHRQ is scheduled to release a second report on pediatric asthma-related hospital stays in August 2008.

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, according to a report.

From 1997 to 2005, adult hospital stays specifically for asthma remained stable, but the number of secondary asthma diagnoses more than doubled, according to “Hospital Stays Related to Asthma for Adults, 2005,” a statistical brief released by the Agency for Healthcare Research and Quality (AHRQ).

Between 2000 and 2005, hospitalizations for asthma increased 18%, from 247,200 to 290,600. However, the number of hospital stays where asthma was secondary rose from 753,800 to 1,609,200, an increase of 113%.

Pneumonia 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 AHRQ's Healthcare Cost and Utilization Project (HCUP) reported.

Heart failure and nonspecific chest pain were the next most common principal diagnoses, collectively 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 (3.3%) of the hospital stays.

Patients aged 65 years and older had more than three times the rate of asthma-related hospitalizations, compared with younger patients. The hospitalization rate per 1,000 population for a primary asthma diagnosis was 0.7 for patients aged 18–44 years, 1.6 for patients aged 45–64, and 2.5 for those aged 65 and older.

Rates also were higher among women—about 2.5 times greater than stays for men. Women had a 1.8 per 1,000 population primary asthma hospitalization rate, compared with 0.7 among 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 to 2004, and supplemental sources. The database includes all patients regardless of insurance type or uninsured status who were admitted to short-term, nonfederal hospitals. Obstetric and gynecologic facilities; ear, nose, and throat hospitals; and orthopedic, cancer, public, and academic medical hospitals are included.

Of the primary asthma inpatient stays, 74% were admissions through an emergency department, compared with 51% of the secondary diagnosis stays. 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 of the United States, compared with richer regions. 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, according to the report.

After accounting for differences in length of stay, hospitalizations principally for asthma cost an average $1,400 per day, or about $400 less than the estimated $1,800 per day for hospital stays with secondary asthma. Aggregate costs were about $1.6 billion for primary asthma admissions in 2005, compared with $14.4 billion for secondary asthma stays.

Researchers found little variation in hospitalizations by region. After adjusting for regional population differences, they found approximately two principal asthma stays per 1,000 population in the Northeast, Midwest, and South. The rate was lower in the West at 1.4 stays per 1,000 population.

The AHRQ is scheduled to release a second report on pediatric asthma-related hospital stays in August 2008.

The full report is available at www.hcup-us.ahrq.gov/reports/statbriefs/sb54.pdf

ELSEVIER GLOBAL MEDICAL NEWS

MIAMI BEACH — Children's insect repellent products that contain alternative ingredients marketed as "natural" are becoming more widely available, and parents have plenty of questions about their use, Dr. Elizabeth Connelly said at the annual Masters of Pediatrics conference sponsored by the University of Miami.

Efficacy varies among insect repellents that do not contain N,N-diethyl-m-toluamide (DEET). Soybean oil, citronella oil, vanillin, oil of eucalyptus, and picaridin are examples of the active ingredients found in natural products.

The marketing of alternative insect repellents continues to expand. Even Disney has entered the market for children's dermatologic products, she said. Disney's Gentle Naturals product line contains a DEET-free bug repellent.

Dermatologists are likely to get more questions about products they recommend now that DEET-free formulations are available at drugstores, Target, and Wal-Mart.

"I am constantly bombarded with questions by parents about insect repellents, sunscreens, and sun protection products," said Dr. Connelly, a pediatric dermatologist at the University of Miami.

Remember "not all 'natural' repellents are safe," she said. Oil of eucalyptus, for example, should be used only in children 3 years and older.

Picaridin, which comes from black pepper, is odorless, and physicians could recommend it to parents and children who do not like the smell of traditional repellents, but is it not as effective as DEET. Of all the Off! brands, only the Clean Feel repellent contains picaridin. "All other formulations of Off! contain DEET," said Dr. Connelly, who said she has no financial interest in any of the products mentioned in her talk.

"You might be asking: Do these natural oils work? Citronella, patchouli, and clove, especially, work almost as well as DEET," Dr. Connelly said. Patchouli oil is derived from mint.

Apply all insect repellents sparingly, and avoid use under clothing or near open wounds, Dr. Connelly said. Avoid use of combination repellent/sunscreen products. Also, beware of wipes that contain DEET because the DEET gets on the child's hands and fingers go in the mouth or around eyes. "I recommend children wash off DEET before bedtime," Dr. Connelly added.

Products with DEET "should not be applied more than once a day. I don't think that is something parents know," Dr. Connelly said. Parents may be confused because the label advises application every 4 hours for adults. DEET should not be used in infants younger than 2 months. This and other recommendations from the American Academy of Pediatrics 2003 guidelines on use of DEET insect repellents are still valid, she added.

The Food and Drug Administration also provides guidelines at www.fda.gov/cder/emergency/repellants.htm

MIAMI BEACH — Children's insect repellent products that contain alternative ingredients marketed as "natural" are becoming more widely available, and parents have plenty of questions about their use, Dr. Elizabeth Connelly said at the annual Masters of Pediatrics conference sponsored by the University of Miami.

Efficacy varies among insect repellents that do not contain N,N-diethyl-m-toluamide (DEET). Soybean oil, citronella oil, vanillin, oil of eucalyptus, and picaridin are examples of the active ingredients found in natural products.

The marketing of alternative insect repellents continues to expand. Even Disney has entered the market for children's dermatologic products, she said. Disney's Gentle Naturals product line contains a DEET-free bug repellent.

Dermatologists are likely to get more questions about products they recommend now that DEET-free formulations are available at drugstores, Target, and Wal-Mart.

"I am constantly bombarded with questions by parents about insect repellents, sunscreens, and sun protection products," said Dr. Connelly, a pediatric dermatologist at the University of Miami.

Remember "not all 'natural' repellents are safe," she said. Oil of eucalyptus, for example, should be used only in children 3 years and older.

Picaridin, which comes from black pepper, is odorless, and physicians could recommend it to parents and children who do not like the smell of traditional repellents, but is it not as effective as DEET. Of all the Off! brands, only the Clean Feel repellent contains picaridin. "All other formulations of Off! contain DEET," said Dr. Connelly, who said she has no financial interest in any of the products mentioned in her talk.

"You might be asking: Do these natural oils work? Citronella, patchouli, and clove, especially, work almost as well as DEET," Dr. Connelly said. Patchouli oil is derived from mint.

Apply all insect repellents sparingly, and avoid use under clothing or near open wounds, Dr. Connelly said. Avoid use of combination repellent/sunscreen products. Also, beware of wipes that contain DEET because the DEET gets on the child's hands and fingers go in the mouth or around eyes. "I recommend children wash off DEET before bedtime," Dr. Connelly added.

Products with DEET "should not be applied more than once a day. I don't think that is something parents know," Dr. Connelly said. Parents may be confused because the label advises application every 4 hours for adults. DEET should not be used in infants younger than 2 months. This and other recommendations from the American Academy of Pediatrics 2003 guidelines on use of DEET insect repellents are still valid, she added.

The Food and Drug Administration also provides guidelines at www.fda.gov/cder/emergency/repellants.htm

MIAMI BEACH — Children's insect repellent products that contain alternative ingredients marketed as "natural" are becoming more widely available, and parents have plenty of questions about their use, Dr. Elizabeth Connelly said at the annual Masters of Pediatrics conference sponsored by the University of Miami.

Efficacy varies among insect repellents that do not contain N,N-diethyl-m-toluamide (DEET). Soybean oil, citronella oil, vanillin, oil of eucalyptus, and picaridin are examples of the active ingredients found in natural products.

The marketing of alternative insect repellents continues to expand. Even Disney has entered the market for children's dermatologic products, she said. Disney's Gentle Naturals product line contains a DEET-free bug repellent.

Dermatologists are likely to get more questions about products they recommend now that DEET-free formulations are available at drugstores, Target, and Wal-Mart.

"I am constantly bombarded with questions by parents about insect repellents, sunscreens, and sun protection products," said Dr. Connelly, a pediatric dermatologist at the University of Miami.

Remember "not all 'natural' repellents are safe," she said. Oil of eucalyptus, for example, should be used only in children 3 years and older.

Picaridin, which comes from black pepper, is odorless, and physicians could recommend it to parents and children who do not like the smell of traditional repellents, but is it not as effective as DEET. Of all the Off! brands, only the Clean Feel repellent contains picaridin. "All other formulations of Off! contain DEET," said Dr. Connelly, who said she has no financial interest in any of the products mentioned in her talk.

"You might be asking: Do these natural oils work? Citronella, patchouli, and clove, especially, work almost as well as DEET," Dr. Connelly said. Patchouli oil is derived from mint.

Apply all insect repellents sparingly, and avoid use under clothing or near open wounds, Dr. Connelly said. Avoid use of combination repellent/sunscreen products. Also, beware of wipes that contain DEET because the DEET gets on the child's hands and fingers go in the mouth or around eyes. "I recommend children wash off DEET before bedtime," Dr. Connelly added.

Products with DEET "should not be applied more than once a day. I don't think that is something parents know," Dr. Connelly said. Parents may be confused because the label advises application every 4 hours for adults. DEET should not be used in infants younger than 2 months. This and other recommendations from the American Academy of Pediatrics 2003 guidelines on use of DEET insect repellents are still valid, she added.

The Food and Drug Administration also provides guidelines at www.fda.gov/cder/emergency/repellants.htm

MIAMI BEACH — Prevention is the best therapy for patients of color regarding dermatologic procedures with a potential to cause postinflammatory hyperpigmentation changes, according to a presentation at the annual Masters of Pediatrics conference sponsored by the University of Miami.

"There are unique diseases and treatments to consider in children with skin of color. Understanding these differences is essential when treating our patients," said Dr. Heather Woolery-Lloyd, director of ethnic skin care, department of dermatology and cutaneous surgery, University of Miami.

Acne and atopic dermatitis put some patients with skin of color at an increased risk for hyperpigmentation. These changes can be very cosmetically disconcerting. For example, patients are most concerned with pigmentation and not the acne itself when they have acne hyperpigmented macules, Dr. Woolery-Lloyd said.

Retinoids are recommended for patients younger than 16 years of age because they can improve both acne and pigmentation, Dr. Woolery-Lloyd said. Other therapeutic options include azelaic acid 15% gel or 20% cream. In addition, she recommended a moisturizer containing sunscreen and soy. The soy is beneficial because it inhibits melanogenesis, although it works slowly, she said.

For patients 16 years and older with acne and dyschromia, Dr. Woolery-Lloyd recommends hydroquinone applied only as needed to affected areas. Hydroquinone comes in different formulations, including 2% available over the counter, 4% available by prescription, and 6%–8% strengths prepared by a compounding pharmacy. Avoid continuous, long-term use, she advised.

Treatment of acne with hydroquinone can also cause dyschromia in patients of color. Advise patients not to rub hydroquinone in with their fingertips, Dr. Woolery-Lloyd said, to avoid a hypopigmented area around the acne lesion known as a "hydroquinone halo." She suggested instead using a cotton-tipped applicator to spot treat facial lesions. Apply the agent to dark spots first and then apply a retinoid to the entire face.

Postinflammatory hyperpigmentation can also be a challenge to treat in patients of color with atopic dermatitis, Dr. Woolery-Lloyd said. She suggested aggressive treatment to prevent permanent pigment changes. "Emphasize this to parents to improve compliance." Prevention is particularly important because bleaching agents can irritate patients with atopic dermatitis.

Another tip is to educate patients about the expected duration of pigment changes. Remember that postinflammatory hyperpigmentation can take an average of 4 months to clear, Dr. Woolery-Lloyd said.

She had no relevant conflicts of interest to disclose.

The "hydroquinone halo" around the treated area is due to over application. Courtesy Dr. Heather Woolery-Lloyd

MIAMI BEACH — Prevention is the best therapy for patients of color regarding dermatologic procedures with a potential to cause postinflammatory hyperpigmentation changes, according to a presentation at the annual Masters of Pediatrics conference sponsored by the University of Miami.

"There are unique diseases and treatments to consider in children with skin of color. Understanding these differences is essential when treating our patients," said Dr. Heather Woolery-Lloyd, director of ethnic skin care, department of dermatology and cutaneous surgery, University of Miami.

Acne and atopic dermatitis put some patients with skin of color at an increased risk for hyperpigmentation. These changes can be very cosmetically disconcerting. For example, patients are most concerned with pigmentation and not the acne itself when they have acne hyperpigmented macules, Dr. Woolery-Lloyd said.

Retinoids are recommended for patients younger than 16 years of age because they can improve both acne and pigmentation, Dr. Woolery-Lloyd said. Other therapeutic options include azelaic acid 15% gel or 20% cream. In addition, she recommended a moisturizer containing sunscreen and soy. The soy is beneficial because it inhibits melanogenesis, although it works slowly, she said.

For patients 16 years and older with acne and dyschromia, Dr. Woolery-Lloyd recommends hydroquinone applied only as needed to affected areas. Hydroquinone comes in different formulations, including 2% available over the counter, 4% available by prescription, and 6%–8% strengths prepared by a compounding pharmacy. Avoid continuous, long-term use, she advised.

Treatment of acne with hydroquinone can also cause dyschromia in patients of color. Advise patients not to rub hydroquinone in with their fingertips, Dr. Woolery-Lloyd said, to avoid a hypopigmented area around the acne lesion known as a "hydroquinone halo." She suggested instead using a cotton-tipped applicator to spot treat facial lesions. Apply the agent to dark spots first and then apply a retinoid to the entire face.

Postinflammatory hyperpigmentation can also be a challenge to treat in patients of color with atopic dermatitis, Dr. Woolery-Lloyd said. She suggested aggressive treatment to prevent permanent pigment changes. "Emphasize this to parents to improve compliance." Prevention is particularly important because bleaching agents can irritate patients with atopic dermatitis.

Another tip is to educate patients about the expected duration of pigment changes. Remember that postinflammatory hyperpigmentation can take an average of 4 months to clear, Dr. Woolery-Lloyd said.

She had no relevant conflicts of interest to disclose.

The "hydroquinone halo" around the treated area is due to over application. Courtesy Dr. Heather Woolery-Lloyd

MIAMI BEACH — Prevention is the best therapy for patients of color regarding dermatologic procedures with a potential to cause postinflammatory hyperpigmentation changes, according to a presentation at the annual Masters of Pediatrics conference sponsored by the University of Miami.

"There are unique diseases and treatments to consider in children with skin of color. Understanding these differences is essential when treating our patients," said Dr. Heather Woolery-Lloyd, director of ethnic skin care, department of dermatology and cutaneous surgery, University of Miami.

Acne and atopic dermatitis put some patients with skin of color at an increased risk for hyperpigmentation. These changes can be very cosmetically disconcerting. For example, patients are most concerned with pigmentation and not the acne itself when they have acne hyperpigmented macules, Dr. Woolery-Lloyd said.

Retinoids are recommended for patients younger than 16 years of age because they can improve both acne and pigmentation, Dr. Woolery-Lloyd said. Other therapeutic options include azelaic acid 15% gel or 20% cream. In addition, she recommended a moisturizer containing sunscreen and soy. The soy is beneficial because it inhibits melanogenesis, although it works slowly, she said.

For patients 16 years and older with acne and dyschromia, Dr. Woolery-Lloyd recommends hydroquinone applied only as needed to affected areas. Hydroquinone comes in different formulations, including 2% available over the counter, 4% available by prescription, and 6%–8% strengths prepared by a compounding pharmacy. Avoid continuous, long-term use, she advised.

Treatment of acne with hydroquinone can also cause dyschromia in patients of color. Advise patients not to rub hydroquinone in with their fingertips, Dr. Woolery-Lloyd said, to avoid a hypopigmented area around the acne lesion known as a "hydroquinone halo." She suggested instead using a cotton-tipped applicator to spot treat facial lesions. Apply the agent to dark spots first and then apply a retinoid to the entire face.

Postinflammatory hyperpigmentation can also be a challenge to treat in patients of color with atopic dermatitis, Dr. Woolery-Lloyd said. She suggested aggressive treatment to prevent permanent pigment changes. "Emphasize this to parents to improve compliance." Prevention is particularly important because bleaching agents can irritate patients with atopic dermatitis.

Another tip is to educate patients about the expected duration of pigment changes. Remember that postinflammatory hyperpigmentation can take an average of 4 months to clear, Dr. Woolery-Lloyd said.

She had no relevant conflicts of interest to disclose.

The "hydroquinone halo" around the treated area is due to over application. Courtesy Dr. Heather Woolery-Lloyd

MIAMI BEACH — Physicians can prevent traction alopecia in children through early intervention, according to Dr. Heather Woolery-Lloyd.

Although physicians can treat inflammation with topical steroids, the clinical focus should be counseling patients and parents about prevention of future damage. "I would like to see an increase in education to primary care providers to catch it before it starts," Dr. Woolery-Lloyd said. "They should emphasize avoidance of tight hairstyles."

She said that she would also like to see a direct-to-consumer advertising campaign geared to the black community emphasizing that traction alopecia is preventable.

"Kids are more likely to achieve regrowth if you stop the tight hairstyle technique. The prognosis is better if it is caught earlier," said Dr. Woolery-Lloyd at the annual Masters of Pediatrics conference sponsored by the University of Miami.

Although there are no differences in the keratin or amino acid composition among the hair of Asian, white, or black patients, the physical properties of a black patient's hair might explain why traction alopecia is one of the conditions of more concern to children with skin of color. A black patient's hair is more elliptical and flattened on cross section, compared with an Asian or white patient's hair. Most naturally shed hairs of a black patient feature a frayed tip (J. Am. Acad. Dermatol. 2000;43:814–20). Researchers observed more longitudinal splitting, fissures, and breaking of black patients' hair shafts in this study.

Other investigators found decreased tensile strength, resistance to breakage, and hair density, compared with the hair of white and Asian patients (Arch. Dermatol. 1999;135:656–8).

A black patient's hair also features fewer elastic fibers to anchor the hair follicles to the dermis, said Dr. Woolery-Lloyd, director of ethnic skin care, department of dermatology and cutaneous surgery, University of Miami. This is part of the traction alopecia etiology. A tight hairstyle is the other main cause of traction alopecia.

Black children with multitufted braids, for example, are at higher risk, particularly if the braids or multiple ponytails are pulled too tightly. Cornrows are another hairstyle that is more common among black children. Again, traction alopecia can result if these braids along the scalp are pulled too tightly, Dr. Woolery-Lloyd said. The prevalence of traction alopecia is increasing among black boys with the increasing popularity of cornrows.

Chemical relaxers might also increase risk of traction alopecia, according to a South African study of 1,024 school boys and girls (Br. J. Dermatol. 2007;157:106–10). The researchers found a higher prevalence of traction alopecia in children with chemically relaxed hair, compared with the group with untreated hair.

Patients present with hair loss on the frontal or temporal scalp with a rim of short hairs at the hairline. Some patients "with very, very tight hairstyles" also have pustules from inflammation along the hairline, Dr. Woolery-Lloyd said.

Although her presentation addressed traction alopecia in pediatric patients, in the future she would like to see researchers assess the viability of hair transplants in adults with traction alopecia, Dr. Woolery-Lloyd said in an interview.

'Iwould like to see an increase in education to primary care providers to catch it before it starts.' DR. WOOLERY-LLOYD

MIAMI BEACH — Physicians can prevent traction alopecia in children through early intervention, according to Dr. Heather Woolery-Lloyd.

Although physicians can treat inflammation with topical steroids, the clinical focus should be counseling patients and parents about prevention of future damage. "I would like to see an increase in education to primary care providers to catch it before it starts," Dr. Woolery-Lloyd said. "They should emphasize avoidance of tight hairstyles."

She said that she would also like to see a direct-to-consumer advertising campaign geared to the black community emphasizing that traction alopecia is preventable.

"Kids are more likely to achieve regrowth if you stop the tight hairstyle technique. The prognosis is better if it is caught earlier," said Dr. Woolery-Lloyd at the annual Masters of Pediatrics conference sponsored by the University of Miami.

Although there are no differences in the keratin or amino acid composition among the hair of Asian, white, or black patients, the physical properties of a black patient's hair might explain why traction alopecia is one of the conditions of more concern to children with skin of color. A black patient's hair is more elliptical and flattened on cross section, compared with an Asian or white patient's hair. Most naturally shed hairs of a black patient feature a frayed tip (J. Am. Acad. Dermatol. 2000;43:814–20). Researchers observed more longitudinal splitting, fissures, and breaking of black patients' hair shafts in this study.

Other investigators found decreased tensile strength, resistance to breakage, and hair density, compared with the hair of white and Asian patients (Arch. Dermatol. 1999;135:656–8).

A black patient's hair also features fewer elastic fibers to anchor the hair follicles to the dermis, said Dr. Woolery-Lloyd, director of ethnic skin care, department of dermatology and cutaneous surgery, University of Miami. This is part of the traction alopecia etiology. A tight hairstyle is the other main cause of traction alopecia.

Black children with multitufted braids, for example, are at higher risk, particularly if the braids or multiple ponytails are pulled too tightly. Cornrows are another hairstyle that is more common among black children. Again, traction alopecia can result if these braids along the scalp are pulled too tightly, Dr. Woolery-Lloyd said. The prevalence of traction alopecia is increasing among black boys with the increasing popularity of cornrows.

Chemical relaxers might also increase risk of traction alopecia, according to a South African study of 1,024 school boys and girls (Br. J. Dermatol. 2007;157:106–10). The researchers found a higher prevalence of traction alopecia in children with chemically relaxed hair, compared with the group with untreated hair.

Patients present with hair loss on the frontal or temporal scalp with a rim of short hairs at the hairline. Some patients "with very, very tight hairstyles" also have pustules from inflammation along the hairline, Dr. Woolery-Lloyd said.

Although her presentation addressed traction alopecia in pediatric patients, in the future she would like to see researchers assess the viability of hair transplants in adults with traction alopecia, Dr. Woolery-Lloyd said in an interview.

'Iwould like to see an increase in education to primary care providers to catch it before it starts.' DR. WOOLERY-LLOYD

MIAMI BEACH — Physicians can prevent traction alopecia in children through early intervention, according to Dr. Heather Woolery-Lloyd.

Although physicians can treat inflammation with topical steroids, the clinical focus should be counseling patients and parents about prevention of future damage. "I would like to see an increase in education to primary care providers to catch it before it starts," Dr. Woolery-Lloyd said. "They should emphasize avoidance of tight hairstyles."

She said that she would also like to see a direct-to-consumer advertising campaign geared to the black community emphasizing that traction alopecia is preventable.

"Kids are more likely to achieve regrowth if you stop the tight hairstyle technique. The prognosis is better if it is caught earlier," said Dr. Woolery-Lloyd at the annual Masters of Pediatrics conference sponsored by the University of Miami.

Although there are no differences in the keratin or amino acid composition among the hair of Asian, white, or black patients, the physical properties of a black patient's hair might explain why traction alopecia is one of the conditions of more concern to children with skin of color. A black patient's hair is more elliptical and flattened on cross section, compared with an Asian or white patient's hair. Most naturally shed hairs of a black patient feature a frayed tip (J. Am. Acad. Dermatol. 2000;43:814–20). Researchers observed more longitudinal splitting, fissures, and breaking of black patients' hair shafts in this study.

Other investigators found decreased tensile strength, resistance to breakage, and hair density, compared with the hair of white and Asian patients (Arch. Dermatol. 1999;135:656–8).

A black patient's hair also features fewer elastic fibers to anchor the hair follicles to the dermis, said Dr. Woolery-Lloyd, director of ethnic skin care, department of dermatology and cutaneous surgery, University of Miami. This is part of the traction alopecia etiology. A tight hairstyle is the other main cause of traction alopecia.

Black children with multitufted braids, for example, are at higher risk, particularly if the braids or multiple ponytails are pulled too tightly. Cornrows are another hairstyle that is more common among black children. Again, traction alopecia can result if these braids along the scalp are pulled too tightly, Dr. Woolery-Lloyd said. The prevalence of traction alopecia is increasing among black boys with the increasing popularity of cornrows.

Chemical relaxers might also increase risk of traction alopecia, according to a South African study of 1,024 school boys and girls (Br. J. Dermatol. 2007;157:106–10). The researchers found a higher prevalence of traction alopecia in children with chemically relaxed hair, compared with the group with untreated hair.

Patients present with hair loss on the frontal or temporal scalp with a rim of short hairs at the hairline. Some patients "with very, very tight hairstyles" also have pustules from inflammation along the hairline, Dr. Woolery-Lloyd said.

Although her presentation addressed traction alopecia in pediatric patients, in the future she would like to see researchers assess the viability of hair transplants in adults with traction alopecia, Dr. Woolery-Lloyd said in an interview.

'Iwould like to see an increase in education to primary care providers to catch it before it starts.' DR. WOOLERY-LLOYD

MIAMI BEACH — Treatment of molluscum contagiosum can be guided by patient age, lesion location, cosmetic considerations, and the anxiety of the parent and patient, according to two presentations at the annual Masters of Pediatrics conference sponsored by the University of Miami.

"Most warts and molluscum [lesions] go away on their own," Dr. Lawrence Schachner said. "But most of the time, you cannot talk parents into just waiting for a year. They want something done."

Physicians can destroy lesions on the body by using cantharidin, or on the face by using trichloroacetic acid (TCA). Curettage, cryotherapy, and sensitization with squaric acid are other office-based options. Topical treatments and systemic cimetidine are among the home-based strategies, said Dr. Schachner, professor of pediatrics and dermatology and chairman of dermatology at the University of Miami.

"Molluscum treatment varies considerably with the doctor you go to," Dr. Bernice Krafchik, professor emeritus at the University of Toronto, said during a separate presentation at the meeting. "Every doctor believes their treatment is the best."

Lesions are typically 1–5 mm, discrete, shiny, and pearly. "You will always see umbilication and a domed papule if you look, which makes it easy for the differential [diagnosis]," Dr. Schachner said. Incubation takes 2–8 weeks, and spontaneous resolution can take up to 2 years. Molluscum contagiosum accounts for approximately 280,000 physician visits annually (Pediatr. Dermatol. 2004;21:628–32).

Molluscum contagiosum can be spread by skin-to-skin contact, fomites, autoinoculation, or warm pool or bath water. "It also can be an STD in sexually active adolescents or adults," Dr. Schachner said.

"Do no harm," Dr. Krafchik asserted. "I treat molluscum but I don't treat warts. The treatment of molluscum is relatively easy, and you see a lot of inflammation if you leave them alone."

For both Dr. Schachner and Dr. Krafchik, topical cantharidin (an extract from the blister beetle) is the treatment of choice for young children with widespread lesions. It should be initially applied using the blunt end of a cotton-tipped swab or a toothpick to a few lesions. "Do not use it on 25 lesions the first time … because some children are hyperreactors," he added. Cover the treated area with a bandage and soak it off in a bath 3–4 hours later.

Warn parents that bullae can form on treated lesions, Dr. Krafchik said. She instructs parents to leave the blisters alone; however, if the blisters are painful, parents can drain them with a sterile needle and apply an over-the-counter topical antibiotic. Cantharidin cleared the lesions in 90% of 300 children after an average of 2.1 visits in a retrospective study (J. Am. Acad. Dermatol. 2000;43:503–7).

"My conclusion is it is safe and effective," Dr. Schachner said. "But it's an office technique. I would never send a patient home with some cantharidin."

TCA for face or neck lesions is another office-based treatment option. Start at 25% strength and increase as tolerated, Dr. Schachner said.

He did not recommend the use of topical tretinoin or keratolytics for molluscum contagiosum, but imiquimod (Aldara) can be used to treat a limited number of lesions. The agent "works pretty well, but it's awfully irritating anywhere skin may rub on skin," Dr. Schachner said, adding that "it is not my first choice, but it is a choice. It's a little expensive."

"Remember, Aldara is very expensive," Dr. Krafchik said. "Parents get peeved when they come back to your office."

Curettage can be very effective and yields immediate results. "If you put a little nick in it and squeeze it, the viral core will come out," Dr. Schachner said. Curettage is generally reserved for older children with a limited number of lesions.

Dr. Krafchik said that she no longer performs curettage on molluscum contagiosum lesions because "it always bleeds and kids hate the sight of blood." A meeting attendee said that one lesion is easy to remove. "You're right," Dr. Krafchik replied. "It is easy to remove one molluscum … and it's quite a different thing when there are many."

Cryotherapy is another consideration in older children, particularly if the lesions are large or located on the face or neck, Dr. Schachner said. A cotton-tipped application of liquid nitrogen for a 5- to 10-second freeze, repeated at 2- to 4-week intervals, can be effective, but pain, blistering, scarring, and dyspigmentation are potential adverse events.

"Regarding liquid nitrogen: I don't use [it] in children as a rule," Dr. Krafchik said. "It's very painful and you cannot use it long enough to get a good result. It's not fair to the kids."

"Molluscum treatment varies considerably with the doctor," said Dr. Lawrence Schachner whose therapy of choice is cantharidin. Courtesy Dr. Mercedes E. Gonzalez

MIAMI BEACH — Treatment of molluscum contagiosum can be guided by patient age, lesion location, cosmetic considerations, and the anxiety of the parent and patient, according to two presentations at the annual Masters of Pediatrics conference sponsored by the University of Miami.

"Most warts and molluscum [lesions] go away on their own," Dr. Lawrence Schachner said. "But most of the time, you cannot talk parents into just waiting for a year. They want something done."

Physicians can destroy lesions on the body by using cantharidin, or on the face by using trichloroacetic acid (TCA). Curettage, cryotherapy, and sensitization with squaric acid are other office-based options. Topical treatments and systemic cimetidine are among the home-based strategies, said Dr. Schachner, professor of pediatrics and dermatology and chairman of dermatology at the University of Miami.

"Molluscum treatment varies considerably with the doctor you go to," Dr. Bernice Krafchik, professor emeritus at the University of Toronto, said during a separate presentation at the meeting. "Every doctor believes their treatment is the best."

Lesions are typically 1–5 mm, discrete, shiny, and pearly. "You will always see umbilication and a domed papule if you look, which makes it easy for the differential [diagnosis]," Dr. Schachner said. Incubation takes 2–8 weeks, and spontaneous resolution can take up to 2 years. Molluscum contagiosum accounts for approximately 280,000 physician visits annually (Pediatr. Dermatol. 2004;21:628–32).

Molluscum contagiosum can be spread by skin-to-skin contact, fomites, autoinoculation, or warm pool or bath water. "It also can be an STD in sexually active adolescents or adults," Dr. Schachner said.

"Do no harm," Dr. Krafchik asserted. "I treat molluscum but I don't treat warts. The treatment of molluscum is relatively easy, and you see a lot of inflammation if you leave them alone."

For both Dr. Schachner and Dr. Krafchik, topical cantharidin (an extract from the blister beetle) is the treatment of choice for young children with widespread lesions. It should be initially applied using the blunt end of a cotton-tipped swab or a toothpick to a few lesions. "Do not use it on 25 lesions the first time … because some children are hyperreactors," he added. Cover the treated area with a bandage and soak it off in a bath 3–4 hours later.

Warn parents that bullae can form on treated lesions, Dr. Krafchik said. She instructs parents to leave the blisters alone; however, if the blisters are painful, parents can drain them with a sterile needle and apply an over-the-counter topical antibiotic. Cantharidin cleared the lesions in 90% of 300 children after an average of 2.1 visits in a retrospective study (J. Am. Acad. Dermatol. 2000;43:503–7).

"My conclusion is it is safe and effective," Dr. Schachner said. "But it's an office technique. I would never send a patient home with some cantharidin."

TCA for face or neck lesions is another office-based treatment option. Start at 25% strength and increase as tolerated, Dr. Schachner said.

He did not recommend the use of topical tretinoin or keratolytics for molluscum contagiosum, but imiquimod (Aldara) can be used to treat a limited number of lesions. The agent "works pretty well, but it's awfully irritating anywhere skin may rub on skin," Dr. Schachner said, adding that "it is not my first choice, but it is a choice. It's a little expensive."

"Remember, Aldara is very expensive," Dr. Krafchik said. "Parents get peeved when they come back to your office."

Curettage can be very effective and yields immediate results. "If you put a little nick in it and squeeze it, the viral core will come out," Dr. Schachner said. Curettage is generally reserved for older children with a limited number of lesions.

Dr. Krafchik said that she no longer performs curettage on molluscum contagiosum lesions because "it always bleeds and kids hate the sight of blood." A meeting attendee said that one lesion is easy to remove. "You're right," Dr. Krafchik replied. "It is easy to remove one molluscum … and it's quite a different thing when there are many."

Cryotherapy is another consideration in older children, particularly if the lesions are large or located on the face or neck, Dr. Schachner said. A cotton-tipped application of liquid nitrogen for a 5- to 10-second freeze, repeated at 2- to 4-week intervals, can be effective, but pain, blistering, scarring, and dyspigmentation are potential adverse events.

"Regarding liquid nitrogen: I don't use [it] in children as a rule," Dr. Krafchik said. "It's very painful and you cannot use it long enough to get a good result. It's not fair to the kids."

"Molluscum treatment varies considerably with the doctor," said Dr. Lawrence Schachner whose therapy of choice is cantharidin. Courtesy Dr. Mercedes E. Gonzalez

MIAMI BEACH — Treatment of molluscum contagiosum can be guided by patient age, lesion location, cosmetic considerations, and the anxiety of the parent and patient, according to two presentations at the annual Masters of Pediatrics conference sponsored by the University of Miami.

"Most warts and molluscum [lesions] go away on their own," Dr. Lawrence Schachner said. "But most of the time, you cannot talk parents into just waiting for a year. They want something done."

Physicians can destroy lesions on the body by using cantharidin, or on the face by using trichloroacetic acid (TCA). Curettage, cryotherapy, and sensitization with squaric acid are other office-based options. Topical treatments and systemic cimetidine are among the home-based strategies, said Dr. Schachner, professor of pediatrics and dermatology and chairman of dermatology at the University of Miami.

"Molluscum treatment varies considerably with the doctor you go to," Dr. Bernice Krafchik, professor emeritus at the University of Toronto, said during a separate presentation at the meeting. "Every doctor believes their treatment is the best."

Lesions are typically 1–5 mm, discrete, shiny, and pearly. "You will always see umbilication and a domed papule if you look, which makes it easy for the differential [diagnosis]," Dr. Schachner said. Incubation takes 2–8 weeks, and spontaneous resolution can take up to 2 years. Molluscum contagiosum accounts for approximately 280,000 physician visits annually (Pediatr. Dermatol. 2004;21:628–32).

Molluscum contagiosum can be spread by skin-to-skin contact, fomites, autoinoculation, or warm pool or bath water. "It also can be an STD in sexually active adolescents or adults," Dr. Schachner said.

"Do no harm," Dr. Krafchik asserted. "I treat molluscum but I don't treat warts. The treatment of molluscum is relatively easy, and you see a lot of inflammation if you leave them alone."

For both Dr. Schachner and Dr. Krafchik, topical cantharidin (an extract from the blister beetle) is the treatment of choice for young children with widespread lesions. It should be initially applied using the blunt end of a cotton-tipped swab or a toothpick to a few lesions. "Do not use it on 25 lesions the first time … because some children are hyperreactors," he added. Cover the treated area with a bandage and soak it off in a bath 3–4 hours later.

Warn parents that bullae can form on treated lesions, Dr. Krafchik said. She instructs parents to leave the blisters alone; however, if the blisters are painful, parents can drain them with a sterile needle and apply an over-the-counter topical antibiotic. Cantharidin cleared the lesions in 90% of 300 children after an average of 2.1 visits in a retrospective study (J. Am. Acad. Dermatol. 2000;43:503–7).

"My conclusion is it is safe and effective," Dr. Schachner said. "But it's an office technique. I would never send a patient home with some cantharidin."

TCA for face or neck lesions is another office-based treatment option. Start at 25% strength and increase as tolerated, Dr. Schachner said.

He did not recommend the use of topical tretinoin or keratolytics for molluscum contagiosum, but imiquimod (Aldara) can be used to treat a limited number of lesions. The agent "works pretty well, but it's awfully irritating anywhere skin may rub on skin," Dr. Schachner said, adding that "it is not my first choice, but it is a choice. It's a little expensive."

"Remember, Aldara is very expensive," Dr. Krafchik said. "Parents get peeved when they come back to your office."

Curettage can be very effective and yields immediate results. "If you put a little nick in it and squeeze it, the viral core will come out," Dr. Schachner said. Curettage is generally reserved for older children with a limited number of lesions.

Dr. Krafchik said that she no longer performs curettage on molluscum contagiosum lesions because "it always bleeds and kids hate the sight of blood." A meeting attendee said that one lesion is easy to remove. "You're right," Dr. Krafchik replied. "It is easy to remove one molluscum … and it's quite a different thing when there are many."

Cryotherapy is another consideration in older children, particularly if the lesions are large or located on the face or neck, Dr. Schachner said. A cotton-tipped application of liquid nitrogen for a 5- to 10-second freeze, repeated at 2- to 4-week intervals, can be effective, but pain, blistering, scarring, and dyspigmentation are potential adverse events.

"Regarding liquid nitrogen: I don't use [it] in children as a rule," Dr. Krafchik said. "It's very painful and you cannot use it long enough to get a good result. It's not fair to the kids."

"Molluscum treatment varies considerably with the doctor," said Dr. Lawrence Schachner whose therapy of choice is cantharidin. Courtesy Dr. Mercedes E. Gonzalez

FORT LAUDERDALE, FLA. — Outcomes of operative hysteroscopy for uterine leiomyomas can be optimized using tips and techniques presented at a meeting on hysterectomy sponsored by the Cleveland Clinic.

▸ Large fibroids. If a patient has larger fibroids or the case is long or involves a new resident, use a bipolar resection device instead of a unipolar instrument, recommended Dr. Linda Bradley, director of the center for menstrual disorders, fibroids, and hysteroscopic services at the clinic.

“You will have more time to do the procedure. You just continue to shave, shave, shave, always working toward yourself. … Sometimes it's a lot of work,” she said.

New technology targets the tedium of large fibroid resections. For example, perforated roller devices “are good for removal of huge myomas,” Dr. Bradley said. “You step on the pedal and within 10 minutes you can get about half of the volume out.” A hysteroscopic morcellator is another option. This device uses no electricity but quickly removes tissue as it cuts. A third option is a conventional resectoscope. “This will suck 85%–90% of the chips right into the scope. But you have to go a little slower and make smaller bites of the tissue. I still like my conventional hysteroscope, but you can see how this would be less frustrating,” she said.

▸ The “snowstorm.” With traditional hysteroscopy, free-floating tissue pieces in the saline can obscure the view.

“Sometimes at the end you get what we call the 'snowstorm,'” Dr. Bradley said. The pieces can be pulled out with polyp forceps or removed one by one with the loop.

“I have a rule of thumb. If I go three times through and do not catch any, I go back to work. Be careful not to perforate while you are doing this.”

▸ Pressure. Inflation and deflation during hysteroscopy aid visualization, Dr. Bradley said. “When pressure is at 100, everything is really flat. Lower the pressure to 50–80 and a fibroid might pop out of its capsule.” If the visual field gets very bloody, you can turn the pressure back up, she added. “It's a very dynamic process.”

▸ Complications. Reinspect the endometrial cavity a few minutes after removal of the hysteroscope, Dr. Bradley said. Postoperative hysteroscopic complications are infrequent, but malodorous discharge and persistent fever, nausea, vomiting, constipation, or abdominal pain can occur. Instruct patients to call if symptoms are not improving, she added, especially if the pain worsens or there is a new onset of fever.

▸ Contraindications. Contraindications to operative hysteroscopy include fibroids that are completely intramural or subserosal.

“These are much more difficult to remove hysteroscopically,” Dr. Bradley said. Contraindications also include myomas that are larger than 3 cm and/or situated more than 50% within the myometrium.

“Not everything can be done with hysteroscopy,” she said. “You may want to do a laparoscopy or open procedure [in these cases].”

▸ Saline infusion sonography. Hysteroscopy is a complementary procedure to saline infusion sonography, Dr. Bradley said. “Ultrasound can show a large intracavity fibroid, and we can measure and know how deep it goes.”

“Remember volume,” she said. A 1-cm fibroid on ultrasound is approximately 0.5 cm

“A 1-cm [fibroid] you can remove within a few moments. A 5-cm [fibroid] might be a two-stage procedure.”

▸ D&C. Myomas are often missed on a routine dilatation and curettage (D&C). They can be in the submucosal region, for example. If a deep intramural lesion is observed, Dr. Bradley advised waiting a few minutes. In some cases, uterine contractions will expel the myoma into view, in a way similar to the expulsion of a placenta.

Dr. Bradley disclosed that she is a consultant to Gynecare, a researcher for Smith & Nephew, and a consultant for Gyrus/ACMI.

A velvetlike secretory endometrium covers a submucosal fibroid.

A large polyp is shown attached to a submucosal fibroid. Photos courtesy Dr. Linda Bradley

FORT LAUDERDALE, FLA. — Outcomes of operative hysteroscopy for uterine leiomyomas can be optimized using tips and techniques presented at a meeting on hysterectomy sponsored by the Cleveland Clinic.

▸ Large fibroids. If a patient has larger fibroids or the case is long or involves a new resident, use a bipolar resection device instead of a unipolar instrument, recommended Dr. Linda Bradley, director of the center for menstrual disorders, fibroids, and hysteroscopic services at the clinic.

“You will have more time to do the procedure. You just continue to shave, shave, shave, always working toward yourself. … Sometimes it's a lot of work,” she said.

New technology targets the tedium of large fibroid resections. For example, perforated roller devices “are good for removal of huge myomas,” Dr. Bradley said. “You step on the pedal and within 10 minutes you can get about half of the volume out.” A hysteroscopic morcellator is another option. This device uses no electricity but quickly removes tissue as it cuts. A third option is a conventional resectoscope. “This will suck 85%–90% of the chips right into the scope. But you have to go a little slower and make smaller bites of the tissue. I still like my conventional hysteroscope, but you can see how this would be less frustrating,” she said.

▸ The “snowstorm.” With traditional hysteroscopy, free-floating tissue pieces in the saline can obscure the view.

“Sometimes at the end you get what we call the 'snowstorm,'” Dr. Bradley said. The pieces can be pulled out with polyp forceps or removed one by one with the loop.

“I have a rule of thumb. If I go three times through and do not catch any, I go back to work. Be careful not to perforate while you are doing this.”

▸ Pressure. Inflation and deflation during hysteroscopy aid visualization, Dr. Bradley said. “When pressure is at 100, everything is really flat. Lower the pressure to 50–80 and a fibroid might pop out of its capsule.” If the visual field gets very bloody, you can turn the pressure back up, she added. “It's a very dynamic process.”

▸ Complications. Reinspect the endometrial cavity a few minutes after removal of the hysteroscope, Dr. Bradley said. Postoperative hysteroscopic complications are infrequent, but malodorous discharge and persistent fever, nausea, vomiting, constipation, or abdominal pain can occur. Instruct patients to call if symptoms are not improving, she added, especially if the pain worsens or there is a new onset of fever.

▸ Contraindications. Contraindications to operative hysteroscopy include fibroids that are completely intramural or subserosal.

“These are much more difficult to remove hysteroscopically,” Dr. Bradley said. Contraindications also include myomas that are larger than 3 cm and/or situated more than 50% within the myometrium.

“Not everything can be done with hysteroscopy,” she said. “You may want to do a laparoscopy or open procedure [in these cases].”

▸ Saline infusion sonography. Hysteroscopy is a complementary procedure to saline infusion sonography, Dr. Bradley said. “Ultrasound can show a large intracavity fibroid, and we can measure and know how deep it goes.”

“Remember volume,” she said. A 1-cm fibroid on ultrasound is approximately 0.5 cm

“A 1-cm [fibroid] you can remove within a few moments. A 5-cm [fibroid] might be a two-stage procedure.”

▸ D&C. Myomas are often missed on a routine dilatation and curettage (D&C). They can be in the submucosal region, for example. If a deep intramural lesion is observed, Dr. Bradley advised waiting a few minutes. In some cases, uterine contractions will expel the myoma into view, in a way similar to the expulsion of a placenta.

Dr. Bradley disclosed that she is a consultant to Gynecare, a researcher for Smith & Nephew, and a consultant for Gyrus/ACMI.

A velvetlike secretory endometrium covers a submucosal fibroid.

A large polyp is shown attached to a submucosal fibroid. Photos courtesy Dr. Linda Bradley

FORT LAUDERDALE, FLA. — Outcomes of operative hysteroscopy for uterine leiomyomas can be optimized using tips and techniques presented at a meeting on hysterectomy sponsored by the Cleveland Clinic.

▸ Large fibroids. If a patient has larger fibroids or the case is long or involves a new resident, use a bipolar resection device instead of a unipolar instrument, recommended Dr. Linda Bradley, director of the center for menstrual disorders, fibroids, and hysteroscopic services at the clinic.

“You will have more time to do the procedure. You just continue to shave, shave, shave, always working toward yourself. … Sometimes it's a lot of work,” she said.

New technology targets the tedium of large fibroid resections. For example, perforated roller devices “are good for removal of huge myomas,” Dr. Bradley said. “You step on the pedal and within 10 minutes you can get about half of the volume out.” A hysteroscopic morcellator is another option. This device uses no electricity but quickly removes tissue as it cuts. A third option is a conventional resectoscope. “This will suck 85%–90% of the chips right into the scope. But you have to go a little slower and make smaller bites of the tissue. I still like my conventional hysteroscope, but you can see how this would be less frustrating,” she said.

▸ The “snowstorm.” With traditional hysteroscopy, free-floating tissue pieces in the saline can obscure the view.

“Sometimes at the end you get what we call the 'snowstorm,'” Dr. Bradley said. The pieces can be pulled out with polyp forceps or removed one by one with the loop.

“I have a rule of thumb. If I go three times through and do not catch any, I go back to work. Be careful not to perforate while you are doing this.”

▸ Pressure. Inflation and deflation during hysteroscopy aid visualization, Dr. Bradley said. “When pressure is at 100, everything is really flat. Lower the pressure to 50–80 and a fibroid might pop out of its capsule.” If the visual field gets very bloody, you can turn the pressure back up, she added. “It's a very dynamic process.”

▸ Complications. Reinspect the endometrial cavity a few minutes after removal of the hysteroscope, Dr. Bradley said. Postoperative hysteroscopic complications are infrequent, but malodorous discharge and persistent fever, nausea, vomiting, constipation, or abdominal pain can occur. Instruct patients to call if symptoms are not improving, she added, especially if the pain worsens or there is a new onset of fever.

▸ Contraindications. Contraindications to operative hysteroscopy include fibroids that are completely intramural or subserosal.

“These are much more difficult to remove hysteroscopically,” Dr. Bradley said. Contraindications also include myomas that are larger than 3 cm and/or situated more than 50% within the myometrium.

“Not everything can be done with hysteroscopy,” she said. “You may want to do a laparoscopy or open procedure [in these cases].”

▸ Saline infusion sonography. Hysteroscopy is a complementary procedure to saline infusion sonography, Dr. Bradley said. “Ultrasound can show a large intracavity fibroid, and we can measure and know how deep it goes.”

“Remember volume,” she said. A 1-cm fibroid on ultrasound is approximately 0.5 cm

“A 1-cm [fibroid] you can remove within a few moments. A 5-cm [fibroid] might be a two-stage procedure.”

▸ D&C. Myomas are often missed on a routine dilatation and curettage (D&C). They can be in the submucosal region, for example. If a deep intramural lesion is observed, Dr. Bradley advised waiting a few minutes. In some cases, uterine contractions will expel the myoma into view, in a way similar to the expulsion of a placenta.

Dr. Bradley disclosed that she is a consultant to Gynecare, a researcher for Smith & Nephew, and a consultant for Gyrus/ACMI.

A velvetlike secretory endometrium covers a submucosal fibroid.

A large polyp is shown attached to a submucosal fibroid. Photos courtesy Dr. Linda Bradley

FORT LAUDERDALE, FLA. – The walk of a patient with osteoarthritis differs by which knee compartments are affected, according to researchers who linked radiographic findings with sophisticated motion analysis.

Knee osteoarthritis (OA) leads to alterations in gait that can further impair function for patients, Dr. William F. Harvey said at the World Congress on Osteoarthritis. To find out if there are gait alterations unique to the compartments of the knee that are affected by OA, Dr. Harvey and his associates assessed 448 patients in North Carolina enrolled in the Observational Arthritis Study in Seniors (OASIS).

Participants' mean age was 72 years and all were more than 65 years old; all reported knee pain. Just more than half, 51%, were women; 83% were white; and the mean body mass index was 30 kg/m

At baseline, researchers found that 166 patients had grade 0 Kellgren-Lawrence (KL), 51 patients had grade 1 KL, 47 patients had grade 2 KL, 126 patients had grade 3 KL, and 58 patients had grade 4 KL; in general, the higher the KL grade, the worse the meniscal pathology and chondral degradation, Dr. Harvey, a fellow in rheumatology at Boston University, said at the meeting, which was sponsored by the Osteoarthritis Research Society International.

Kinematic measures of gait were performed during self-paced walking in the sagittal plane only, with outcomes based on an average of three trials. Peak angular range of motion, mean angular velocity (of the hip, knee, and ankle joints), stride length, walking velocity, cadence, and stance and swing times were measured. Mean values were compared between groups. Results were adjusted for age, race, gender, body mass index, and walking velocity.

Patients with isolated tibio-femoral (159 participants), and both tibiofemoral and patellofemoral osteoarthritis (72 participants) had a significantly lower knee range of motion and mean angular velocity, compared with those with no osteoarthritis (206 participants), Dr. Harvey said. The mean knee range of motion angle was 54 degrees in the tibiofemoral group and 53 degrees in the combined group, compared with 57 degrees in the unaffected group. The mean value for the patellofemoral osteoarthritis group, 58 degrees, was not statistically significant because of the small number of patients in the category.

In addition, there was a statistically significant difference in mean angular velocity of the knee between the same groups. Those with tibiofemoral osteoarthritis and both compartments affected had a lower mean angular velocity, compared with those without osteoarthritis, Dr. Harvey said. Expressed as degrees per second, the values were 104 in the tibiofemoral group, 100 in the group with both compartments affected, and 117 in the comparison, disease-free, group without disease. Again, the 110 degrees per second finding in the patellofemoral group was not significant.

Stance time was another variable that was significantly different between groups. The patellofemoral group and doubly affected group spent more time in stance versus swing, compared with the tibiofemoral osteoarthritis group or the unaffected patients.

The study was funded by Wake Forest University and a grant from the National Institutes of Health.

ELSEVIER GLOBAL MEDICAL NEWS

FORT LAUDERDALE, FLA. – The walk of a patient with osteoarthritis differs by which knee compartments are affected, according to researchers who linked radiographic findings with sophisticated motion analysis.

Knee osteoarthritis (OA) leads to alterations in gait that can further impair function for patients, Dr. William F. Harvey said at the World Congress on Osteoarthritis. To find out if there are gait alterations unique to the compartments of the knee that are affected by OA, Dr. Harvey and his associates assessed 448 patients in North Carolina enrolled in the Observational Arthritis Study in Seniors (OASIS).

Participants' mean age was 72 years and all were more than 65 years old; all reported knee pain. Just more than half, 51%, were women; 83% were white; and the mean body mass index was 30 kg/m

At baseline, researchers found that 166 patients had grade 0 Kellgren-Lawrence (KL), 51 patients had grade 1 KL, 47 patients had grade 2 KL, 126 patients had grade 3 KL, and 58 patients had grade 4 KL; in general, the higher the KL grade, the worse the meniscal pathology and chondral degradation, Dr. Harvey, a fellow in rheumatology at Boston University, said at the meeting, which was sponsored by the Osteoarthritis Research Society International.

Kinematic measures of gait were performed during self-paced walking in the sagittal plane only, with outcomes based on an average of three trials. Peak angular range of motion, mean angular velocity (of the hip, knee, and ankle joints), stride length, walking velocity, cadence, and stance and swing times were measured. Mean values were compared between groups. Results were adjusted for age, race, gender, body mass index, and walking velocity.

Patients with isolated tibio-femoral (159 participants), and both tibiofemoral and patellofemoral osteoarthritis (72 participants) had a significantly lower knee range of motion and mean angular velocity, compared with those with no osteoarthritis (206 participants), Dr. Harvey said. The mean knee range of motion angle was 54 degrees in the tibiofemoral group and 53 degrees in the combined group, compared with 57 degrees in the unaffected group. The mean value for the patellofemoral osteoarthritis group, 58 degrees, was not statistically significant because of the small number of patients in the category.

In addition, there was a statistically significant difference in mean angular velocity of the knee between the same groups. Those with tibiofemoral osteoarthritis and both compartments affected had a lower mean angular velocity, compared with those without osteoarthritis, Dr. Harvey said. Expressed as degrees per second, the values were 104 in the tibiofemoral group, 100 in the group with both compartments affected, and 117 in the comparison, disease-free, group without disease. Again, the 110 degrees per second finding in the patellofemoral group was not significant.

Stance time was another variable that was significantly different between groups. The patellofemoral group and doubly affected group spent more time in stance versus swing, compared with the tibiofemoral osteoarthritis group or the unaffected patients.

The study was funded by Wake Forest University and a grant from the National Institutes of Health.

ELSEVIER GLOBAL MEDICAL NEWS

FORT LAUDERDALE, FLA. – The walk of a patient with osteoarthritis differs by which knee compartments are affected, according to researchers who linked radiographic findings with sophisticated motion analysis.

Knee osteoarthritis (OA) leads to alterations in gait that can further impair function for patients, Dr. William F. Harvey said at the World Congress on Osteoarthritis. To find out if there are gait alterations unique to the compartments of the knee that are affected by OA, Dr. Harvey and his associates assessed 448 patients in North Carolina enrolled in the Observational Arthritis Study in Seniors (OASIS).

Participants' mean age was 72 years and all were more than 65 years old; all reported knee pain. Just more than half, 51%, were women; 83% were white; and the mean body mass index was 30 kg/m

At baseline, researchers found that 166 patients had grade 0 Kellgren-Lawrence (KL), 51 patients had grade 1 KL, 47 patients had grade 2 KL, 126 patients had grade 3 KL, and 58 patients had grade 4 KL; in general, the higher the KL grade, the worse the meniscal pathology and chondral degradation, Dr. Harvey, a fellow in rheumatology at Boston University, said at the meeting, which was sponsored by the Osteoarthritis Research Society International.

Kinematic measures of gait were performed during self-paced walking in the sagittal plane only, with outcomes based on an average of three trials. Peak angular range of motion, mean angular velocity (of the hip, knee, and ankle joints), stride length, walking velocity, cadence, and stance and swing times were measured. Mean values were compared between groups. Results were adjusted for age, race, gender, body mass index, and walking velocity.

Patients with isolated tibio-femoral (159 participants), and both tibiofemoral and patellofemoral osteoarthritis (72 participants) had a significantly lower knee range of motion and mean angular velocity, compared with those with no osteoarthritis (206 participants), Dr. Harvey said. The mean knee range of motion angle was 54 degrees in the tibiofemoral group and 53 degrees in the combined group, compared with 57 degrees in the unaffected group. The mean value for the patellofemoral osteoarthritis group, 58 degrees, was not statistically significant because of the small number of patients in the category.

In addition, there was a statistically significant difference in mean angular velocity of the knee between the same groups. Those with tibiofemoral osteoarthritis and both compartments affected had a lower mean angular velocity, compared with those without osteoarthritis, Dr. Harvey said. Expressed as degrees per second, the values were 104 in the tibiofemoral group, 100 in the group with both compartments affected, and 117 in the comparison, disease-free, group without disease. Again, the 110 degrees per second finding in the patellofemoral group was not significant.

Stance time was another variable that was significantly different between groups. The patellofemoral group and doubly affected group spent more time in stance versus swing, compared with the tibiofemoral osteoarthritis group or the unaffected patients.

The study was funded by Wake Forest University and a grant from the National Institutes of Health.

ELSEVIER GLOBAL MEDICAL NEWS