Damian McNamara

Attention-deficit/hyperactivity disorder significantly impairs long-term school outcomes, according to a large, retrospective, population-based study. In addition, stimulant treatment makes a difference and significantly improves some school performance measures, a second study from the same researchers shows.

Previous studies of ADHD have demonstrated a detrimental effect on school performance, but most reports focused on short-term or assessed referred patients. To get a longer perspective in a more naturalistic population, researchers at the Mayo Clinic in Rochester, Minn., compared the health and school records of 370 children who developed ADHD and 740 matched controls without ADHD.

They reported differences in reading achievement scores, absenteeism, grade retention, and school dropout rates (J. Dev. Behav. Pediatr. 2007;28:265-73). All participants were identified from a cohort born in the area between 1976 and 1982. Mean follow-up was 18 years. Boys comprised about 75% of the ADHD group.

Median reading score on the California Achievement Test was 45 for the ADHD group, compared with 75 for controls, a statistically significant difference.

Based on an estimated school year of 175 days, those in the ADHD group had a median of 1 more day absent, compared with the control group in sixth grade. Although this absolute difference was small, a cumulative increased incidence of absenteeism and grade retention was observed as participants progressed through their school years. By 9th and 12th grades, for example, the median difference in absenteeism was 2.4 days greater among those with ADHD.

Children with ADHD were three times more likely to be retained at least one grade. By age 12 years, cumulative incidence of grade retention was 9% in the ADHD group, versus 2% in the control group.

“These findings are consistent with the notion that early academic problems may be magnified by the increased demands associated with middle school and high school, including cognitive demands, decreased adult supervision, increased volume and complexity of assignments, and instruction from multiple teachers,” the authors wrote.

It is, therefore, not surprising to find that the burden imposed by academic underachievement, absenteeism, and grade retention is ultimately manifested in significantly higher rates of high school dropout among ADHD cases, compared with non-ADHD controls, the authors said.

The majority of children (70%) graduated from high school. Another 17% moved from the area prior to graduation. Among the remaining 301 in the ADHD group, 23% dropped out, compared with 10% of the remaining 609 in the control group. Therefore, children with ADHD were 2.7 times more likely to drop out of high school. The difference was statistically significant between boys but not girls.

Because the potential of stimulant treatment to modify these long-term outcomes is unclear, researchers performed a second study with the same birth cohorts. Stimulant treatment during childhood was associated with more favorable long-term school outcomes, with some statistically significant differences, they reported (J. Dev. Behav. Pediatr. 2007;28:274-87).

Average reading achievement scores at last assessment were similar between ADHD groups treated and not treated with stimulants. Their reading scores were significantly lower than non-ADHD controls.

In terms of absenteeism, any treatment with stimulants, level of maternal education at birth, presence of comorbid learning disability and psychiatric disorder, and receipt of an educational intervention were associated with a significantly higher percentage of days absent.

Stimulants had a positive effect on grade retention. Treated children were 1.8 times less likely to be retained a grade, compared with non-stimulant-treated children. Dropout rates, however, were not significantly different. The proportions were similar between those treated (22%) and not treated (26%) with stimulants.

“Our findings should serve as a reminder to clinicians that both boys and girls with ADHD are at risk of poor school outcomes and should be provided with appropriate long-term treatment with stimulant medications,” the authors wrote.

Attention-deficit/hyperactivity disorder significantly impairs long-term school outcomes, according to a large, retrospective, population-based study. In addition, stimulant treatment makes a difference and significantly improves some school performance measures, a second study from the same researchers shows.

Previous studies of ADHD have demonstrated a detrimental effect on school performance, but most reports focused on short-term or assessed referred patients. To get a longer perspective in a more naturalistic population, researchers at the Mayo Clinic in Rochester, Minn., compared the health and school records of 370 children who developed ADHD and 740 matched controls without ADHD.

They reported differences in reading achievement scores, absenteeism, grade retention, and school dropout rates (J. Dev. Behav. Pediatr. 2007;28:265-73). All participants were identified from a cohort born in the area between 1976 and 1982. Mean follow-up was 18 years. Boys comprised about 75% of the ADHD group.

Median reading score on the California Achievement Test was 45 for the ADHD group, compared with 75 for controls, a statistically significant difference.

Based on an estimated school year of 175 days, those in the ADHD group had a median of 1 more day absent, compared with the control group in sixth grade. Although this absolute difference was small, a cumulative increased incidence of absenteeism and grade retention was observed as participants progressed through their school years. By 9th and 12th grades, for example, the median difference in absenteeism was 2.4 days greater among those with ADHD.

Children with ADHD were three times more likely to be retained at least one grade. By age 12 years, cumulative incidence of grade retention was 9% in the ADHD group, versus 2% in the control group.

“These findings are consistent with the notion that early academic problems may be magnified by the increased demands associated with middle school and high school, including cognitive demands, decreased adult supervision, increased volume and complexity of assignments, and instruction from multiple teachers,” the authors wrote.

It is, therefore, not surprising to find that the burden imposed by academic underachievement, absenteeism, and grade retention is ultimately manifested in significantly higher rates of high school dropout among ADHD cases, compared with non-ADHD controls, the authors said.

The majority of children (70%) graduated from high school. Another 17% moved from the area prior to graduation. Among the remaining 301 in the ADHD group, 23% dropped out, compared with 10% of the remaining 609 in the control group. Therefore, children with ADHD were 2.7 times more likely to drop out of high school. The difference was statistically significant between boys but not girls.

Because the potential of stimulant treatment to modify these long-term outcomes is unclear, researchers performed a second study with the same birth cohorts. Stimulant treatment during childhood was associated with more favorable long-term school outcomes, with some statistically significant differences, they reported (J. Dev. Behav. Pediatr. 2007;28:274-87).

Average reading achievement scores at last assessment were similar between ADHD groups treated and not treated with stimulants. Their reading scores were significantly lower than non-ADHD controls.

In terms of absenteeism, any treatment with stimulants, level of maternal education at birth, presence of comorbid learning disability and psychiatric disorder, and receipt of an educational intervention were associated with a significantly higher percentage of days absent.

Stimulants had a positive effect on grade retention. Treated children were 1.8 times less likely to be retained a grade, compared with non-stimulant-treated children. Dropout rates, however, were not significantly different. The proportions were similar between those treated (22%) and not treated (26%) with stimulants.

“Our findings should serve as a reminder to clinicians that both boys and girls with ADHD are at risk of poor school outcomes and should be provided with appropriate long-term treatment with stimulant medications,” the authors wrote.

Attention-deficit/hyperactivity disorder significantly impairs long-term school outcomes, according to a large, retrospective, population-based study. In addition, stimulant treatment makes a difference and significantly improves some school performance measures, a second study from the same researchers shows.

Previous studies of ADHD have demonstrated a detrimental effect on school performance, but most reports focused on short-term or assessed referred patients. To get a longer perspective in a more naturalistic population, researchers at the Mayo Clinic in Rochester, Minn., compared the health and school records of 370 children who developed ADHD and 740 matched controls without ADHD.

They reported differences in reading achievement scores, absenteeism, grade retention, and school dropout rates (J. Dev. Behav. Pediatr. 2007;28:265-73). All participants were identified from a cohort born in the area between 1976 and 1982. Mean follow-up was 18 years. Boys comprised about 75% of the ADHD group.

Median reading score on the California Achievement Test was 45 for the ADHD group, compared with 75 for controls, a statistically significant difference.

Based on an estimated school year of 175 days, those in the ADHD group had a median of 1 more day absent, compared with the control group in sixth grade. Although this absolute difference was small, a cumulative increased incidence of absenteeism and grade retention was observed as participants progressed through their school years. By 9th and 12th grades, for example, the median difference in absenteeism was 2.4 days greater among those with ADHD.

Children with ADHD were three times more likely to be retained at least one grade. By age 12 years, cumulative incidence of grade retention was 9% in the ADHD group, versus 2% in the control group.

“These findings are consistent with the notion that early academic problems may be magnified by the increased demands associated with middle school and high school, including cognitive demands, decreased adult supervision, increased volume and complexity of assignments, and instruction from multiple teachers,” the authors wrote.

It is, therefore, not surprising to find that the burden imposed by academic underachievement, absenteeism, and grade retention is ultimately manifested in significantly higher rates of high school dropout among ADHD cases, compared with non-ADHD controls, the authors said.

The majority of children (70%) graduated from high school. Another 17% moved from the area prior to graduation. Among the remaining 301 in the ADHD group, 23% dropped out, compared with 10% of the remaining 609 in the control group. Therefore, children with ADHD were 2.7 times more likely to drop out of high school. The difference was statistically significant between boys but not girls.

Because the potential of stimulant treatment to modify these long-term outcomes is unclear, researchers performed a second study with the same birth cohorts. Stimulant treatment during childhood was associated with more favorable long-term school outcomes, with some statistically significant differences, they reported (J. Dev. Behav. Pediatr. 2007;28:274-87).

Average reading achievement scores at last assessment were similar between ADHD groups treated and not treated with stimulants. Their reading scores were significantly lower than non-ADHD controls.

In terms of absenteeism, any treatment with stimulants, level of maternal education at birth, presence of comorbid learning disability and psychiatric disorder, and receipt of an educational intervention were associated with a significantly higher percentage of days absent.

Stimulants had a positive effect on grade retention. Treated children were 1.8 times less likely to be retained a grade, compared with non-stimulant-treated children. Dropout rates, however, were not significantly different. The proportions were similar between those treated (22%) and not treated (26%) with stimulants.

“Our findings should serve as a reminder to clinicians that both boys and girls with ADHD are at risk of poor school outcomes and should be provided with appropriate long-term treatment with stimulant medications,” the authors wrote.

HOLLYWOOD, FLA. — Women who smoke cigarettes are at more than four times greater risk for type 1 mesh erosion following abdominal sacrocolpopexy or sacrocolpoperineopexy, compared with those who do not smoke, according to data from a case-control study.

“Mesh erosion, although uncommon, can be quite distressing for patient and physician alike,” Dr. Joye Lowman said in an interview.

“We noticed that many patients in our population who developed mesh erosion were smokers.”

Detrimental effects of smoking on wound healing have previously been demonstrated by significant data in orthopedics, dentistry, and plastic and reconstructive surgery.

“We hypothesized that if smoking has been shown to impair healing after mastectomy, face-lifts, abdominoplasty, and spinal surgery, perhaps it impairs the healing of vaginal wounds as well,” said Dr. Lowman, who is a third-year fellow in female pelvic medicine and reconstructive surgery at Indiana University, Indianapolis.

No risk factors have been shown conclusively to increase mesh erosion risk because the number of cases of mesh erosion is small, with an overall incidence of 3.4% (Obstet. Gynecol. 2004;104:805–23), Dr. Lowman said.

Another challenge is that mesh erosion can occur up to 2 years after an abdominal sacralcolpopexy (ASC).

In a previous study, researchers evaluated risk factors for mesh erosion after ASC and found a higher proportion of smokers in cases of mesh erosion, but the findings were not statistically significant (Obstet. Gynecol. 1998;92:999–1004).

To assess current smoking in a larger study, researchers retrospectively compared all cases of vaginal mesh erosion between October 2003 and June 2006. These 27 women were compared with 81 controls matched for age, menopausal status, hormone therapy use, and other factors.

All of the participants were treated at Urogynecology Associates in Indianapolis. The findings were presented at the annual meeting of the American Urogynecologic Society.

A total of seven cases (26%) and six controls (7%) reported current tobacco smoking. The risk of mesh erosion was significantly greater among the smokers, compared with nonsmokers (odds ratio 4.4).

“I was surprised that we detected such a large effect. To find an effect of this magnitude with a sample size of only 108 patients and an extensive match emphasizes the strength of this association,” Dr. Lowman said.

Erosion occurred a mean of 12 months after surgery. The most common presenting symptoms were vaginal discharge and spotting, which were reported by 96% of the participants who had mesh erosion. The type 1 propylene mesh included SoftPro (Ethicon, Somerville, N.J.) and ProLite (Atrium Medical Corp., Hudson, N.H.). Dr. Lowman has no affiliation with the companies that manufacture these mesh products.

The association between smoking and mesh erosion remained significant when the six cases and four controls who had laparoscopic surgery were excluded (OR 8.0).

So what is the physiologic link between smoking and mesh erosion? Collagen synthesis is the most significant effect. Collagen is essential to optimal tensile strength of a healing wound. Nicotine's antiestrogen effect is probably another significant effect. Vaginal atrophy and slower healing of vaginal wounds might ensue with lower estrogen levels.

Nicotine increases platelet aggregation; decreases microvascular prostacyclin levels, and inhibits fibroblast, macrophage, and red blood cell function. In addition, nicotine and carbon monoxide in cigarettes can increase cardiac workload and decrease tissue oxygen tension.

Physicians should counsel patients before an ASC or ASCP surgery of an increased risk of mesh erosion if they smoke, Dr. Lowman said.

“The effort must be made to reiterate the effects of smoking at every visit. We all know that smoking affects the heart and lungs. Broaden the discussion to include its affects on wound healing, skin—premature wrinkles, and bone—increased osteoporosis. Tell your female patients that smoking causes premature aging—that will get them motivated!”

Only 19% of participants with mesh erosion had successful medical management of their condition, defined as office excision or hormone therapy. The remaining patients were taken back to the operating room to excise the mesh vaginally.

The sample size may have been too small to detect any effect of smoking on time to diagnosis of erosion or the success rate of medical management, a possible limitation of the study.

Other factors that might reduce the risk of mesh erosion, including use of hormone therapy and perioperative antibiotics, are areas for future research, Dr. Lowman said.

“We noticed that many patients in our population who developed mesh erosion were smokers.” Lolita Jones/Elsevier Global Medical News

HOLLYWOOD, FLA. — Women who smoke cigarettes are at more than four times greater risk for type 1 mesh erosion following abdominal sacrocolpopexy or sacrocolpoperineopexy, compared with those who do not smoke, according to data from a case-control study.

“Mesh erosion, although uncommon, can be quite distressing for patient and physician alike,” Dr. Joye Lowman said in an interview.

“We noticed that many patients in our population who developed mesh erosion were smokers.”

Detrimental effects of smoking on wound healing have previously been demonstrated by significant data in orthopedics, dentistry, and plastic and reconstructive surgery.

“We hypothesized that if smoking has been shown to impair healing after mastectomy, face-lifts, abdominoplasty, and spinal surgery, perhaps it impairs the healing of vaginal wounds as well,” said Dr. Lowman, who is a third-year fellow in female pelvic medicine and reconstructive surgery at Indiana University, Indianapolis.

No risk factors have been shown conclusively to increase mesh erosion risk because the number of cases of mesh erosion is small, with an overall incidence of 3.4% (Obstet. Gynecol. 2004;104:805–23), Dr. Lowman said.

Another challenge is that mesh erosion can occur up to 2 years after an abdominal sacralcolpopexy (ASC).

In a previous study, researchers evaluated risk factors for mesh erosion after ASC and found a higher proportion of smokers in cases of mesh erosion, but the findings were not statistically significant (Obstet. Gynecol. 1998;92:999–1004).

To assess current smoking in a larger study, researchers retrospectively compared all cases of vaginal mesh erosion between October 2003 and June 2006. These 27 women were compared with 81 controls matched for age, menopausal status, hormone therapy use, and other factors.

All of the participants were treated at Urogynecology Associates in Indianapolis. The findings were presented at the annual meeting of the American Urogynecologic Society.

A total of seven cases (26%) and six controls (7%) reported current tobacco smoking. The risk of mesh erosion was significantly greater among the smokers, compared with nonsmokers (odds ratio 4.4).

“I was surprised that we detected such a large effect. To find an effect of this magnitude with a sample size of only 108 patients and an extensive match emphasizes the strength of this association,” Dr. Lowman said.

Erosion occurred a mean of 12 months after surgery. The most common presenting symptoms were vaginal discharge and spotting, which were reported by 96% of the participants who had mesh erosion. The type 1 propylene mesh included SoftPro (Ethicon, Somerville, N.J.) and ProLite (Atrium Medical Corp., Hudson, N.H.). Dr. Lowman has no affiliation with the companies that manufacture these mesh products.

The association between smoking and mesh erosion remained significant when the six cases and four controls who had laparoscopic surgery were excluded (OR 8.0).

So what is the physiologic link between smoking and mesh erosion? Collagen synthesis is the most significant effect. Collagen is essential to optimal tensile strength of a healing wound. Nicotine's antiestrogen effect is probably another significant effect. Vaginal atrophy and slower healing of vaginal wounds might ensue with lower estrogen levels.

Nicotine increases platelet aggregation; decreases microvascular prostacyclin levels, and inhibits fibroblast, macrophage, and red blood cell function. In addition, nicotine and carbon monoxide in cigarettes can increase cardiac workload and decrease tissue oxygen tension.

Physicians should counsel patients before an ASC or ASCP surgery of an increased risk of mesh erosion if they smoke, Dr. Lowman said.

“The effort must be made to reiterate the effects of smoking at every visit. We all know that smoking affects the heart and lungs. Broaden the discussion to include its affects on wound healing, skin—premature wrinkles, and bone—increased osteoporosis. Tell your female patients that smoking causes premature aging—that will get them motivated!”

Only 19% of participants with mesh erosion had successful medical management of their condition, defined as office excision or hormone therapy. The remaining patients were taken back to the operating room to excise the mesh vaginally.

The sample size may have been too small to detect any effect of smoking on time to diagnosis of erosion or the success rate of medical management, a possible limitation of the study.

Other factors that might reduce the risk of mesh erosion, including use of hormone therapy and perioperative antibiotics, are areas for future research, Dr. Lowman said.

“We noticed that many patients in our population who developed mesh erosion were smokers.” Lolita Jones/Elsevier Global Medical News

HOLLYWOOD, FLA. — Women who smoke cigarettes are at more than four times greater risk for type 1 mesh erosion following abdominal sacrocolpopexy or sacrocolpoperineopexy, compared with those who do not smoke, according to data from a case-control study.

“Mesh erosion, although uncommon, can be quite distressing for patient and physician alike,” Dr. Joye Lowman said in an interview.

“We noticed that many patients in our population who developed mesh erosion were smokers.”

Detrimental effects of smoking on wound healing have previously been demonstrated by significant data in orthopedics, dentistry, and plastic and reconstructive surgery.

“We hypothesized that if smoking has been shown to impair healing after mastectomy, face-lifts, abdominoplasty, and spinal surgery, perhaps it impairs the healing of vaginal wounds as well,” said Dr. Lowman, who is a third-year fellow in female pelvic medicine and reconstructive surgery at Indiana University, Indianapolis.

No risk factors have been shown conclusively to increase mesh erosion risk because the number of cases of mesh erosion is small, with an overall incidence of 3.4% (Obstet. Gynecol. 2004;104:805–23), Dr. Lowman said.

Another challenge is that mesh erosion can occur up to 2 years after an abdominal sacralcolpopexy (ASC).

In a previous study, researchers evaluated risk factors for mesh erosion after ASC and found a higher proportion of smokers in cases of mesh erosion, but the findings were not statistically significant (Obstet. Gynecol. 1998;92:999–1004).

To assess current smoking in a larger study, researchers retrospectively compared all cases of vaginal mesh erosion between October 2003 and June 2006. These 27 women were compared with 81 controls matched for age, menopausal status, hormone therapy use, and other factors.

All of the participants were treated at Urogynecology Associates in Indianapolis. The findings were presented at the annual meeting of the American Urogynecologic Society.

A total of seven cases (26%) and six controls (7%) reported current tobacco smoking. The risk of mesh erosion was significantly greater among the smokers, compared with nonsmokers (odds ratio 4.4).

“I was surprised that we detected such a large effect. To find an effect of this magnitude with a sample size of only 108 patients and an extensive match emphasizes the strength of this association,” Dr. Lowman said.

Erosion occurred a mean of 12 months after surgery. The most common presenting symptoms were vaginal discharge and spotting, which were reported by 96% of the participants who had mesh erosion. The type 1 propylene mesh included SoftPro (Ethicon, Somerville, N.J.) and ProLite (Atrium Medical Corp., Hudson, N.H.). Dr. Lowman has no affiliation with the companies that manufacture these mesh products.

The association between smoking and mesh erosion remained significant when the six cases and four controls who had laparoscopic surgery were excluded (OR 8.0).

So what is the physiologic link between smoking and mesh erosion? Collagen synthesis is the most significant effect. Collagen is essential to optimal tensile strength of a healing wound. Nicotine's antiestrogen effect is probably another significant effect. Vaginal atrophy and slower healing of vaginal wounds might ensue with lower estrogen levels.

Nicotine increases platelet aggregation; decreases microvascular prostacyclin levels, and inhibits fibroblast, macrophage, and red blood cell function. In addition, nicotine and carbon monoxide in cigarettes can increase cardiac workload and decrease tissue oxygen tension.

Physicians should counsel patients before an ASC or ASCP surgery of an increased risk of mesh erosion if they smoke, Dr. Lowman said.

“The effort must be made to reiterate the effects of smoking at every visit. We all know that smoking affects the heart and lungs. Broaden the discussion to include its affects on wound healing, skin—premature wrinkles, and bone—increased osteoporosis. Tell your female patients that smoking causes premature aging—that will get them motivated!”

Only 19% of participants with mesh erosion had successful medical management of their condition, defined as office excision or hormone therapy. The remaining patients were taken back to the operating room to excise the mesh vaginally.

The sample size may have been too small to detect any effect of smoking on time to diagnosis of erosion or the success rate of medical management, a possible limitation of the study.

Other factors that might reduce the risk of mesh erosion, including use of hormone therapy and perioperative antibiotics, are areas for future research, Dr. Lowman said.

“We noticed that many patients in our population who developed mesh erosion were smokers.” Lolita Jones/Elsevier Global Medical News

HOLLYWOOD, FLA. — More adverse gastrointestinal events and wound complications may be in store for women who undergo stress incontinence surgery and other procedures concomitantly, according to findings reported at the annual meeting of the American Urogynecologic Society.

“While [we would expect] to see more frequent adverse events occurring in patients with concomitant surgeries as compared to those who underwent index surgeries only, we wanted to determine which organ systems were more affected by concomitant surgery,” said Dr. Toby Chai, a professor in the urology department at the University of Maryland, Baltimore.

Other types of surgery included posterior colporrhaphy, sacrospinous ligament suspension, uterosacral ligament suspension, sacrocolpopexy, enterocele repair, and hysterectomy.

Previous results from the Stress Incontinence Surgical Treatment Efficacy (SISTEr) trial found an overall success rate of 47% with the autologous rectus fascial sling procedure versus a 38% rate of success with the Burch colposuspension after 24 months (N. Engl. J. Med. 2007;35:2198–200).

Stress-type symptoms of urinary incontinence improved for 66% of the sling group, compared with 49% for the Burch group, a significant difference. However, women in the sling group reported more urinary tract infections, difficulty with voiding, and urge incontinence.

Dr. Chai and his associates conducted a second study as part of the SISTEr trial to assess these adverse events further. They found that only wound and gastrointestinal complications had statistically higher rates in the concomitant surgical group at 2 years. There were 7 GI complications in the Burch group and 8 in the sling group, all in women who had undergone another procedure; a total of 24 wound complications occurred, 13 in the Burch group, and 11 in the sling group. Of the 24 events, 22 occurred in the concomitant surgery group.

Up to postoperative week 6, there were 91 reports of cystitis among the 326 women who had a sling procedure, compared with 39 reports among the 329 others who had a Burch procedure. This increased infection rate was associated with a higher rate of clean intermittent self-catheterization (CISC) in the sling group.

At 2 years, there were a total of 290 cystitis events in the sling group, compared with 206 in the Burch group. “Interestingly, genitourinary complications, including cystitis, were not statistically different between those with and those without concomitant surgeries,” Dr. Chai said in an interview.

“We were surprised by the number of patients, even in the Burch arm, that had cystitis episodes. We of course do not know the preoperative cystitis rate in our population. It is unlikely that this rate was as high as 8%–10%,” he stated, adding that a relatively high number of these patients are treated with oral antibiotics beyond the typical postoperative period.

“The take-home message is that adverse events after Burch and sling are relatively uncommon, except for symptoms of cystitis,” Dr. Chai said.

Investigators at each study site were required to report complications. Therefore, one possible limitation of the study is that adverse event rates were not based on a chart review. Also, cystitis was defined not by a positive urine culture, but by clinical symptoms suggestive of a urinary tract infection that led to an antibiotic prescription.

Whether prophylactic antibiotics will reduce the prevalence of cystitis remains to be seen, Dr. Chai said. In the future, a randomized trial to assess prophylactic antibiotics among patients who require CISC after the sling procedure might be beneficial. However, “there are insufficient data currently to recommend routine antibiotic prophylaxis in all patients who start self-catheterization,” he said.

“Overall, the surgeries are safe and … patients have to balance the risk of these minor complications against their decreased quality of life from stress urinary incontinence,” Dr. Chai concluded.

HOLLYWOOD, FLA. — More adverse gastrointestinal events and wound complications may be in store for women who undergo stress incontinence surgery and other procedures concomitantly, according to findings reported at the annual meeting of the American Urogynecologic Society.

“While [we would expect] to see more frequent adverse events occurring in patients with concomitant surgeries as compared to those who underwent index surgeries only, we wanted to determine which organ systems were more affected by concomitant surgery,” said Dr. Toby Chai, a professor in the urology department at the University of Maryland, Baltimore.

Other types of surgery included posterior colporrhaphy, sacrospinous ligament suspension, uterosacral ligament suspension, sacrocolpopexy, enterocele repair, and hysterectomy.

Previous results from the Stress Incontinence Surgical Treatment Efficacy (SISTEr) trial found an overall success rate of 47% with the autologous rectus fascial sling procedure versus a 38% rate of success with the Burch colposuspension after 24 months (N. Engl. J. Med. 2007;35:2198–200).

Stress-type symptoms of urinary incontinence improved for 66% of the sling group, compared with 49% for the Burch group, a significant difference. However, women in the sling group reported more urinary tract infections, difficulty with voiding, and urge incontinence.

Dr. Chai and his associates conducted a second study as part of the SISTEr trial to assess these adverse events further. They found that only wound and gastrointestinal complications had statistically higher rates in the concomitant surgical group at 2 years. There were 7 GI complications in the Burch group and 8 in the sling group, all in women who had undergone another procedure; a total of 24 wound complications occurred, 13 in the Burch group, and 11 in the sling group. Of the 24 events, 22 occurred in the concomitant surgery group.

Up to postoperative week 6, there were 91 reports of cystitis among the 326 women who had a sling procedure, compared with 39 reports among the 329 others who had a Burch procedure. This increased infection rate was associated with a higher rate of clean intermittent self-catheterization (CISC) in the sling group.

At 2 years, there were a total of 290 cystitis events in the sling group, compared with 206 in the Burch group. “Interestingly, genitourinary complications, including cystitis, were not statistically different between those with and those without concomitant surgeries,” Dr. Chai said in an interview.

“We were surprised by the number of patients, even in the Burch arm, that had cystitis episodes. We of course do not know the preoperative cystitis rate in our population. It is unlikely that this rate was as high as 8%–10%,” he stated, adding that a relatively high number of these patients are treated with oral antibiotics beyond the typical postoperative period.

“The take-home message is that adverse events after Burch and sling are relatively uncommon, except for symptoms of cystitis,” Dr. Chai said.

Investigators at each study site were required to report complications. Therefore, one possible limitation of the study is that adverse event rates were not based on a chart review. Also, cystitis was defined not by a positive urine culture, but by clinical symptoms suggestive of a urinary tract infection that led to an antibiotic prescription.

Whether prophylactic antibiotics will reduce the prevalence of cystitis remains to be seen, Dr. Chai said. In the future, a randomized trial to assess prophylactic antibiotics among patients who require CISC after the sling procedure might be beneficial. However, “there are insufficient data currently to recommend routine antibiotic prophylaxis in all patients who start self-catheterization,” he said.

“Overall, the surgeries are safe and … patients have to balance the risk of these minor complications against their decreased quality of life from stress urinary incontinence,” Dr. Chai concluded.

HOLLYWOOD, FLA. — More adverse gastrointestinal events and wound complications may be in store for women who undergo stress incontinence surgery and other procedures concomitantly, according to findings reported at the annual meeting of the American Urogynecologic Society.

“While [we would expect] to see more frequent adverse events occurring in patients with concomitant surgeries as compared to those who underwent index surgeries only, we wanted to determine which organ systems were more affected by concomitant surgery,” said Dr. Toby Chai, a professor in the urology department at the University of Maryland, Baltimore.

Other types of surgery included posterior colporrhaphy, sacrospinous ligament suspension, uterosacral ligament suspension, sacrocolpopexy, enterocele repair, and hysterectomy.

Previous results from the Stress Incontinence Surgical Treatment Efficacy (SISTEr) trial found an overall success rate of 47% with the autologous rectus fascial sling procedure versus a 38% rate of success with the Burch colposuspension after 24 months (N. Engl. J. Med. 2007;35:2198–200).

Stress-type symptoms of urinary incontinence improved for 66% of the sling group, compared with 49% for the Burch group, a significant difference. However, women in the sling group reported more urinary tract infections, difficulty with voiding, and urge incontinence.

Dr. Chai and his associates conducted a second study as part of the SISTEr trial to assess these adverse events further. They found that only wound and gastrointestinal complications had statistically higher rates in the concomitant surgical group at 2 years. There were 7 GI complications in the Burch group and 8 in the sling group, all in women who had undergone another procedure; a total of 24 wound complications occurred, 13 in the Burch group, and 11 in the sling group. Of the 24 events, 22 occurred in the concomitant surgery group.

Up to postoperative week 6, there were 91 reports of cystitis among the 326 women who had a sling procedure, compared with 39 reports among the 329 others who had a Burch procedure. This increased infection rate was associated with a higher rate of clean intermittent self-catheterization (CISC) in the sling group.

At 2 years, there were a total of 290 cystitis events in the sling group, compared with 206 in the Burch group. “Interestingly, genitourinary complications, including cystitis, were not statistically different between those with and those without concomitant surgeries,” Dr. Chai said in an interview.

“We were surprised by the number of patients, even in the Burch arm, that had cystitis episodes. We of course do not know the preoperative cystitis rate in our population. It is unlikely that this rate was as high as 8%–10%,” he stated, adding that a relatively high number of these patients are treated with oral antibiotics beyond the typical postoperative period.

“The take-home message is that adverse events after Burch and sling are relatively uncommon, except for symptoms of cystitis,” Dr. Chai said.

Investigators at each study site were required to report complications. Therefore, one possible limitation of the study is that adverse event rates were not based on a chart review. Also, cystitis was defined not by a positive urine culture, but by clinical symptoms suggestive of a urinary tract infection that led to an antibiotic prescription.

Whether prophylactic antibiotics will reduce the prevalence of cystitis remains to be seen, Dr. Chai said. In the future, a randomized trial to assess prophylactic antibiotics among patients who require CISC after the sling procedure might be beneficial. However, “there are insufficient data currently to recommend routine antibiotic prophylaxis in all patients who start self-catheterization,” he said.

“Overall, the surgeries are safe and … patients have to balance the risk of these minor complications against their decreased quality of life from stress urinary incontinence,” Dr. Chai concluded.

BIRMINGHAM, ENGLAND — Early diagnosis and prompt treatment of juvenile idiopathic arthritis can prevent complications and improve quality of life for affected children. A thorough clinical examination and the recognition of behavioral and other symptoms in young patients are essential to proper diagnosis and management.

Prediction of which one-third or so of children with oligoarthritis will progress to polyarthritis is difficult. In the absence of really accurate prognostic indicators, clinical presentation gives the most precise data on which to estimate likelihood of whether the disjoint involvement will worsen, said Dr. Helen Foster at the annual meeting of the British Society for Rheumatology.

Examine all joints. Look for extra-articular features, such as eye and skin involvement. Uveitis can arise at any time and is usually without symptoms, so close monitoring is warranted. “We need to screen children's eyes regularly.”

Pain is not commonly reported in children with juvenile idiopathic arthritis (JIA). “It's not a universal symptom, and in making a diagnosis of JIA, doctors can't be reassured by a lack of pain,” said Dr. Foster, a pediatric rheumatologist at Newcastle University, Newcastle upon Tyne (England). With a young child, it is important to ask parents about behavior, irritability, and sleep quality, as these signs—rather than the child's complaints of pain—are often present. In addition, teachers might provide insight into behavior and other effects, such as any difficulty with handwriting.

Given the uncertainty regarding clinical course, careful counseling, education, and support are essential for all patients and families. “Often parents want to know what their child can and cannot do,” Dr. Foster said.

Earlier initiation of medical therapy is another advantage with earlier diagnosis, Dr. Foster said. “The sooner JIA is diagnosed, the sooner treatment can start and the better the outcome.”

In treating JIA, methotrexate is often used and is very effective. For older children taking methotrexate, it is important to start discussions sooner (at 10 years of age and older) rather than later about avoiding alcohol and pregnancy, Dr. Foster said. Methotrexate is a teratogen. It is important to document the discussions carefully, and from a medicolegal point of view.

Some physicians are resistant to prescribing methotrexate in children, Dr. Foster said. “Many general practitioners refuse to prescribe and monitor. It's an unlicensed use for this age group. We have to negotiate with them.”

Dr. Foster cited the case of a young girl who presented with pain and stiffness. She had two swollen fingers. “That is bad news. She is likely to progress.” Small-joint and upper-limb involvement can indicate psoriasis; in such cases, ask about relatives with psoriatic arthritis, she advised.

The patient was prescribed about 10 mg/m

The patient fared well on oral methotrexate and achieved clinical remission, but stopped because of significant nausea. If this is anticipatory nausea and vomiting, take a break from methotrexate and then start it again, Dr. Foster said. Other options include splitting the dose, prescribing it at night, or switching the patient to subcutaneous methotrexate.

The patient had only a partial response to subcutaneous methotrexate, and was switched to a combination of oral methotrexate and etanercept. “We tend to combine these two—methotrexate and etanercept—and watch them very carefully,” Dr. Foster said.

A meeting attendee asked when Dr. Foster takes a patient off methotrexate. “We wait until they are symptom free for at least 1 year. [Children] with one joint affected tend to do well. But those who require methotrexate, they tend to stay on it for a long time.”

BIRMINGHAM, ENGLAND — Early diagnosis and prompt treatment of juvenile idiopathic arthritis can prevent complications and improve quality of life for affected children. A thorough clinical examination and the recognition of behavioral and other symptoms in young patients are essential to proper diagnosis and management.

Prediction of which one-third or so of children with oligoarthritis will progress to polyarthritis is difficult. In the absence of really accurate prognostic indicators, clinical presentation gives the most precise data on which to estimate likelihood of whether the disjoint involvement will worsen, said Dr. Helen Foster at the annual meeting of the British Society for Rheumatology.

Examine all joints. Look for extra-articular features, such as eye and skin involvement. Uveitis can arise at any time and is usually without symptoms, so close monitoring is warranted. “We need to screen children's eyes regularly.”

Pain is not commonly reported in children with juvenile idiopathic arthritis (JIA). “It's not a universal symptom, and in making a diagnosis of JIA, doctors can't be reassured by a lack of pain,” said Dr. Foster, a pediatric rheumatologist at Newcastle University, Newcastle upon Tyne (England). With a young child, it is important to ask parents about behavior, irritability, and sleep quality, as these signs—rather than the child's complaints of pain—are often present. In addition, teachers might provide insight into behavior and other effects, such as any difficulty with handwriting.

Given the uncertainty regarding clinical course, careful counseling, education, and support are essential for all patients and families. “Often parents want to know what their child can and cannot do,” Dr. Foster said.

Earlier initiation of medical therapy is another advantage with earlier diagnosis, Dr. Foster said. “The sooner JIA is diagnosed, the sooner treatment can start and the better the outcome.”

In treating JIA, methotrexate is often used and is very effective. For older children taking methotrexate, it is important to start discussions sooner (at 10 years of age and older) rather than later about avoiding alcohol and pregnancy, Dr. Foster said. Methotrexate is a teratogen. It is important to document the discussions carefully, and from a medicolegal point of view.

Some physicians are resistant to prescribing methotrexate in children, Dr. Foster said. “Many general practitioners refuse to prescribe and monitor. It's an unlicensed use for this age group. We have to negotiate with them.”

Dr. Foster cited the case of a young girl who presented with pain and stiffness. She had two swollen fingers. “That is bad news. She is likely to progress.” Small-joint and upper-limb involvement can indicate psoriasis; in such cases, ask about relatives with psoriatic arthritis, she advised.

The patient was prescribed about 10 mg/m

The patient fared well on oral methotrexate and achieved clinical remission, but stopped because of significant nausea. If this is anticipatory nausea and vomiting, take a break from methotrexate and then start it again, Dr. Foster said. Other options include splitting the dose, prescribing it at night, or switching the patient to subcutaneous methotrexate.

The patient had only a partial response to subcutaneous methotrexate, and was switched to a combination of oral methotrexate and etanercept. “We tend to combine these two—methotrexate and etanercept—and watch them very carefully,” Dr. Foster said.

A meeting attendee asked when Dr. Foster takes a patient off methotrexate. “We wait until they are symptom free for at least 1 year. [Children] with one joint affected tend to do well. But those who require methotrexate, they tend to stay on it for a long time.”

BIRMINGHAM, ENGLAND — Early diagnosis and prompt treatment of juvenile idiopathic arthritis can prevent complications and improve quality of life for affected children. A thorough clinical examination and the recognition of behavioral and other symptoms in young patients are essential to proper diagnosis and management.

Prediction of which one-third or so of children with oligoarthritis will progress to polyarthritis is difficult. In the absence of really accurate prognostic indicators, clinical presentation gives the most precise data on which to estimate likelihood of whether the disjoint involvement will worsen, said Dr. Helen Foster at the annual meeting of the British Society for Rheumatology.

Examine all joints. Look for extra-articular features, such as eye and skin involvement. Uveitis can arise at any time and is usually without symptoms, so close monitoring is warranted. “We need to screen children's eyes regularly.”

Pain is not commonly reported in children with juvenile idiopathic arthritis (JIA). “It's not a universal symptom, and in making a diagnosis of JIA, doctors can't be reassured by a lack of pain,” said Dr. Foster, a pediatric rheumatologist at Newcastle University, Newcastle upon Tyne (England). With a young child, it is important to ask parents about behavior, irritability, and sleep quality, as these signs—rather than the child's complaints of pain—are often present. In addition, teachers might provide insight into behavior and other effects, such as any difficulty with handwriting.

Given the uncertainty regarding clinical course, careful counseling, education, and support are essential for all patients and families. “Often parents want to know what their child can and cannot do,” Dr. Foster said.

Earlier initiation of medical therapy is another advantage with earlier diagnosis, Dr. Foster said. “The sooner JIA is diagnosed, the sooner treatment can start and the better the outcome.”

In treating JIA, methotrexate is often used and is very effective. For older children taking methotrexate, it is important to start discussions sooner (at 10 years of age and older) rather than later about avoiding alcohol and pregnancy, Dr. Foster said. Methotrexate is a teratogen. It is important to document the discussions carefully, and from a medicolegal point of view.

Some physicians are resistant to prescribing methotrexate in children, Dr. Foster said. “Many general practitioners refuse to prescribe and monitor. It's an unlicensed use for this age group. We have to negotiate with them.”

Dr. Foster cited the case of a young girl who presented with pain and stiffness. She had two swollen fingers. “That is bad news. She is likely to progress.” Small-joint and upper-limb involvement can indicate psoriasis; in such cases, ask about relatives with psoriatic arthritis, she advised.

The patient was prescribed about 10 mg/m

The patient fared well on oral methotrexate and achieved clinical remission, but stopped because of significant nausea. If this is anticipatory nausea and vomiting, take a break from methotrexate and then start it again, Dr. Foster said. Other options include splitting the dose, prescribing it at night, or switching the patient to subcutaneous methotrexate.

The patient had only a partial response to subcutaneous methotrexate, and was switched to a combination of oral methotrexate and etanercept. “We tend to combine these two—methotrexate and etanercept—and watch them very carefully,” Dr. Foster said.

A meeting attendee asked when Dr. Foster takes a patient off methotrexate. “We wait until they are symptom free for at least 1 year. [Children] with one joint affected tend to do well. But those who require methotrexate, they tend to stay on it for a long time.”

BIRMINGHAM, ENGLAND — Metabolic changes in the basal ganglia that can be detected with magnetic resonance spectroscopy may precede irreversible changes from neuropsychiatric lupus, according to a pilot study.

“Why look at basal ganglia? They are highly prone to hypoxic damage and have recently been linked with the frontal lobe regarding cognitive function,” Dr. Pamela L. Peterson explained at the annual meeting of the British Society for Rheumatology.

In Parkinson disease “and other diseases, there is increasing recognition of the role of basal ganglia,” she added.

There are at least four circuits that link the basal ganglia to the cerebral cortex. Although less common, movement disorders are a well-accepted complication of neuropsychiatric systemic lupus erythematosus (NPSLE) and may be mediated by the basal ganglia, said Dr. Peterson, a rheumatology fellow at St. George's Hospital, London.

Clinicians more commonly order MRI scans to detect abnormalities in the periventricular region and subcortical white matter of patients with NPSLE. However, magnetic resonance spectroscopy of the basal ganglia might prove useful for earlier clinical intervention.

“Magnetic resonance spectroscopy is noninvasive, cheap, and easily added to an MRI protocol,” Dr. Peterson said.

Preliminary findings of the study are based on 24 patients with NPSLE, eight patients with active lupus but without neurologic symptoms, and four healthy controls. Participants are recruited for the ongoing study from St. George's University of London; St. Thomas' Hospital, London; and University College London. The age range is 17–54 years.

Blood tests indicated absolute concentrations of N-acetylaspartate (NAA), choline, creatine, and myoinositol. The metabolite NAA is a marker for neuronal loss or dysfunction, Dr. Peterson said. Study participants had a combination of MRI, magnetic resonance spectroscopy, and diffusion tensor imaging, as well as an interview, clinical assessment, and psychometric testing.

The researchers found a statistically significant correlation between decreases in NAA in the basal ganglia and frontal white matter.

Also, levels were significantly lower in these regions, compared with healthy controls. “There was a step-wise deterioration in NAA with worsening neurologic effects,” Dr. Peterson said.

Participants with non-neuropsychiatric lupus also had decreases in the metabolite, but the reductions were not significantly different, compared with controls.

“This correlation may simply indicate a global reduction of NAA in patients with NPSLE or it may reflect abnormalities in the circuits connecting the frontal white matter with the basal ganglia,” the researchers noted. NPSLE may alter the cortical striatal fibers that connect basal ganglia and frontal lobe, Dr. Peterson added.

Although the pilot data from the study included only magnetic resonance spectroscopy findings, Dr. Peterson said changes in myoinositol in these two regions also appear to be correlated. In addition, initial psychometry results suggest “a possible relationship between NAA reduction in the basal ganglia and processing speed.”

“My results are tentative. This is a small data set,” Dr. Peterson said. “We want bigger numbers in the future.”

BIRMINGHAM, ENGLAND — Metabolic changes in the basal ganglia that can be detected with magnetic resonance spectroscopy may precede irreversible changes from neuropsychiatric lupus, according to a pilot study.

“Why look at basal ganglia? They are highly prone to hypoxic damage and have recently been linked with the frontal lobe regarding cognitive function,” Dr. Pamela L. Peterson explained at the annual meeting of the British Society for Rheumatology.

In Parkinson disease “and other diseases, there is increasing recognition of the role of basal ganglia,” she added.

There are at least four circuits that link the basal ganglia to the cerebral cortex. Although less common, movement disorders are a well-accepted complication of neuropsychiatric systemic lupus erythematosus (NPSLE) and may be mediated by the basal ganglia, said Dr. Peterson, a rheumatology fellow at St. George's Hospital, London.

Clinicians more commonly order MRI scans to detect abnormalities in the periventricular region and subcortical white matter of patients with NPSLE. However, magnetic resonance spectroscopy of the basal ganglia might prove useful for earlier clinical intervention.

“Magnetic resonance spectroscopy is noninvasive, cheap, and easily added to an MRI protocol,” Dr. Peterson said.

Preliminary findings of the study are based on 24 patients with NPSLE, eight patients with active lupus but without neurologic symptoms, and four healthy controls. Participants are recruited for the ongoing study from St. George's University of London; St. Thomas' Hospital, London; and University College London. The age range is 17–54 years.

Blood tests indicated absolute concentrations of N-acetylaspartate (NAA), choline, creatine, and myoinositol. The metabolite NAA is a marker for neuronal loss or dysfunction, Dr. Peterson said. Study participants had a combination of MRI, magnetic resonance spectroscopy, and diffusion tensor imaging, as well as an interview, clinical assessment, and psychometric testing.

The researchers found a statistically significant correlation between decreases in NAA in the basal ganglia and frontal white matter.

Also, levels were significantly lower in these regions, compared with healthy controls. “There was a step-wise deterioration in NAA with worsening neurologic effects,” Dr. Peterson said.

Participants with non-neuropsychiatric lupus also had decreases in the metabolite, but the reductions were not significantly different, compared with controls.

“This correlation may simply indicate a global reduction of NAA in patients with NPSLE or it may reflect abnormalities in the circuits connecting the frontal white matter with the basal ganglia,” the researchers noted. NPSLE may alter the cortical striatal fibers that connect basal ganglia and frontal lobe, Dr. Peterson added.

Although the pilot data from the study included only magnetic resonance spectroscopy findings, Dr. Peterson said changes in myoinositol in these two regions also appear to be correlated. In addition, initial psychometry results suggest “a possible relationship between NAA reduction in the basal ganglia and processing speed.”

“My results are tentative. This is a small data set,” Dr. Peterson said. “We want bigger numbers in the future.”

BIRMINGHAM, ENGLAND — Metabolic changes in the basal ganglia that can be detected with magnetic resonance spectroscopy may precede irreversible changes from neuropsychiatric lupus, according to a pilot study.

“Why look at basal ganglia? They are highly prone to hypoxic damage and have recently been linked with the frontal lobe regarding cognitive function,” Dr. Pamela L. Peterson explained at the annual meeting of the British Society for Rheumatology.

In Parkinson disease “and other diseases, there is increasing recognition of the role of basal ganglia,” she added.

There are at least four circuits that link the basal ganglia to the cerebral cortex. Although less common, movement disorders are a well-accepted complication of neuropsychiatric systemic lupus erythematosus (NPSLE) and may be mediated by the basal ganglia, said Dr. Peterson, a rheumatology fellow at St. George's Hospital, London.

Clinicians more commonly order MRI scans to detect abnormalities in the periventricular region and subcortical white matter of patients with NPSLE. However, magnetic resonance spectroscopy of the basal ganglia might prove useful for earlier clinical intervention.

“Magnetic resonance spectroscopy is noninvasive, cheap, and easily added to an MRI protocol,” Dr. Peterson said.

Preliminary findings of the study are based on 24 patients with NPSLE, eight patients with active lupus but without neurologic symptoms, and four healthy controls. Participants are recruited for the ongoing study from St. George's University of London; St. Thomas' Hospital, London; and University College London. The age range is 17–54 years.

Blood tests indicated absolute concentrations of N-acetylaspartate (NAA), choline, creatine, and myoinositol. The metabolite NAA is a marker for neuronal loss or dysfunction, Dr. Peterson said. Study participants had a combination of MRI, magnetic resonance spectroscopy, and diffusion tensor imaging, as well as an interview, clinical assessment, and psychometric testing.

The researchers found a statistically significant correlation between decreases in NAA in the basal ganglia and frontal white matter.

Also, levels were significantly lower in these regions, compared with healthy controls. “There was a step-wise deterioration in NAA with worsening neurologic effects,” Dr. Peterson said.

Participants with non-neuropsychiatric lupus also had decreases in the metabolite, but the reductions were not significantly different, compared with controls.

“This correlation may simply indicate a global reduction of NAA in patients with NPSLE or it may reflect abnormalities in the circuits connecting the frontal white matter with the basal ganglia,” the researchers noted. NPSLE may alter the cortical striatal fibers that connect basal ganglia and frontal lobe, Dr. Peterson added.

Although the pilot data from the study included only magnetic resonance spectroscopy findings, Dr. Peterson said changes in myoinositol in these two regions also appear to be correlated. In addition, initial psychometry results suggest “a possible relationship between NAA reduction in the basal ganglia and processing speed.”

“My results are tentative. This is a small data set,” Dr. Peterson said. “We want bigger numbers in the future.”

MIAMI – In people with co-occurring substance use and mental health disorders, optimal treatment consists of brief screening and ongoing monitoring by primary care physicians, coupled with addiction psychiatry assessment and treatment, according to a presentation at the annual conference of the American Society of Addiction Medicine.

There are 14.9 million adults in the United States who meet criteria for a substance use disorder, and 19.4 million who meet criteria for serious psychological distress; 5.2 million meet criteria for both, according to the 2005 National Survey on Drug Use and Health.

“Of this 5.2 million, a remarkably small amount are coming into our treatment services,” said Charlene E. Le Fauve, Ph.D., clinical psychologist and chief of the Co-Occurring and Homeless Activities Branch at the Substance Abuse and Mental Health Services Administration.

Almost half (48%) of this co-occurring disorder (COD) group gets no treatment at all. Approximately 5% get substance use treatment only, and about 6% get treatment for both substance use and a mental health disorder. Another 41% get treatment only for mental health problems, “but how many have positive, long-acting outcomes while treating one disorder and ignoring the other?” Dr. Le Fauve asked.

All individuals presenting for treatment for substance use should be screened for mental health problems and vice versa, Dr. Le Fauve said, because the presence of one type of disorder puts an individual at higher risk for developing the other type. For example, mood disorders, especially anxiety and depression, are very common in the addiction population.

Relationships between mental health and substance use disorders are often complex and challenging, Dr. Le Fauve said. Acute and chronic substance use can create psychiatric symptoms; substance withdrawal can cause psychiatric symptoms; and/or substance use can mask psychiatric symptoms. Consequences of substance use in patients with untreated psychosis include decreased compliance in all categories, increased psychotic symptoms, frequent use of health care services, increased tardive dyskinesia, violent behavior, and early mortality, Dr. Le Fauve said.

“We've talked to the primary care docs, and they don't have much time. The screening instruments have to be brief,” Dr. Le Fauve said. Ongoing assessment of the person with CODs is another essential component. Always check on compliance and reasons for noncompliance, ask how their medications are affecting them, and acknowledge that they have a right not to take medications, she said.

Conduct a very extensive interview about all substances, including age at first use, patterns over time, periods of abstinence, and consequences of use, Dr. Le Fauve said. “We have people bring in everything. This gives you the opportunity to look at bottles, how much is left, and who prescribed it. You will be amazed at what you find out. Amazed.”

Homeless people with CODs are a particular challenge to treat, and they are at higher risk for adverse outcomes, Dr. Le Fauve said. Once homeless, people with CODs require more services and are more likely to remain homeless than are other types of homeless people, she said. In addition, among homeless veterans, one-third to one-half have co-occurring mental illnesses and substance use disorders. “I say this right now in the context of our current war situation, but it's always an important issue.”

Therefore, access to psychiatric care is necessary for clients presenting for treatment in substance use programs, Dr. Le Fauve said. Also, treatment will be more effective if clients have a sense of control and ownership over the treatment process. “This sounds preachy and canned, but it's true,” she remarked.

MIAMI – In people with co-occurring substance use and mental health disorders, optimal treatment consists of brief screening and ongoing monitoring by primary care physicians, coupled with addiction psychiatry assessment and treatment, according to a presentation at the annual conference of the American Society of Addiction Medicine.

There are 14.9 million adults in the United States who meet criteria for a substance use disorder, and 19.4 million who meet criteria for serious psychological distress; 5.2 million meet criteria for both, according to the 2005 National Survey on Drug Use and Health.

“Of this 5.2 million, a remarkably small amount are coming into our treatment services,” said Charlene E. Le Fauve, Ph.D., clinical psychologist and chief of the Co-Occurring and Homeless Activities Branch at the Substance Abuse and Mental Health Services Administration.

Almost half (48%) of this co-occurring disorder (COD) group gets no treatment at all. Approximately 5% get substance use treatment only, and about 6% get treatment for both substance use and a mental health disorder. Another 41% get treatment only for mental health problems, “but how many have positive, long-acting outcomes while treating one disorder and ignoring the other?” Dr. Le Fauve asked.

All individuals presenting for treatment for substance use should be screened for mental health problems and vice versa, Dr. Le Fauve said, because the presence of one type of disorder puts an individual at higher risk for developing the other type. For example, mood disorders, especially anxiety and depression, are very common in the addiction population.

Relationships between mental health and substance use disorders are often complex and challenging, Dr. Le Fauve said. Acute and chronic substance use can create psychiatric symptoms; substance withdrawal can cause psychiatric symptoms; and/or substance use can mask psychiatric symptoms. Consequences of substance use in patients with untreated psychosis include decreased compliance in all categories, increased psychotic symptoms, frequent use of health care services, increased tardive dyskinesia, violent behavior, and early mortality, Dr. Le Fauve said.

“We've talked to the primary care docs, and they don't have much time. The screening instruments have to be brief,” Dr. Le Fauve said. Ongoing assessment of the person with CODs is another essential component. Always check on compliance and reasons for noncompliance, ask how their medications are affecting them, and acknowledge that they have a right not to take medications, she said.

Conduct a very extensive interview about all substances, including age at first use, patterns over time, periods of abstinence, and consequences of use, Dr. Le Fauve said. “We have people bring in everything. This gives you the opportunity to look at bottles, how much is left, and who prescribed it. You will be amazed at what you find out. Amazed.”

Homeless people with CODs are a particular challenge to treat, and they are at higher risk for adverse outcomes, Dr. Le Fauve said. Once homeless, people with CODs require more services and are more likely to remain homeless than are other types of homeless people, she said. In addition, among homeless veterans, one-third to one-half have co-occurring mental illnesses and substance use disorders. “I say this right now in the context of our current war situation, but it's always an important issue.”

Therefore, access to psychiatric care is necessary for clients presenting for treatment in substance use programs, Dr. Le Fauve said. Also, treatment will be more effective if clients have a sense of control and ownership over the treatment process. “This sounds preachy and canned, but it's true,” she remarked.

MIAMI – In people with co-occurring substance use and mental health disorders, optimal treatment consists of brief screening and ongoing monitoring by primary care physicians, coupled with addiction psychiatry assessment and treatment, according to a presentation at the annual conference of the American Society of Addiction Medicine.

There are 14.9 million adults in the United States who meet criteria for a substance use disorder, and 19.4 million who meet criteria for serious psychological distress; 5.2 million meet criteria for both, according to the 2005 National Survey on Drug Use and Health.

“Of this 5.2 million, a remarkably small amount are coming into our treatment services,” said Charlene E. Le Fauve, Ph.D., clinical psychologist and chief of the Co-Occurring and Homeless Activities Branch at the Substance Abuse and Mental Health Services Administration.

Almost half (48%) of this co-occurring disorder (COD) group gets no treatment at all. Approximately 5% get substance use treatment only, and about 6% get treatment for both substance use and a mental health disorder. Another 41% get treatment only for mental health problems, “but how many have positive, long-acting outcomes while treating one disorder and ignoring the other?” Dr. Le Fauve asked.

All individuals presenting for treatment for substance use should be screened for mental health problems and vice versa, Dr. Le Fauve said, because the presence of one type of disorder puts an individual at higher risk for developing the other type. For example, mood disorders, especially anxiety and depression, are very common in the addiction population.

Relationships between mental health and substance use disorders are often complex and challenging, Dr. Le Fauve said. Acute and chronic substance use can create psychiatric symptoms; substance withdrawal can cause psychiatric symptoms; and/or substance use can mask psychiatric symptoms. Consequences of substance use in patients with untreated psychosis include decreased compliance in all categories, increased psychotic symptoms, frequent use of health care services, increased tardive dyskinesia, violent behavior, and early mortality, Dr. Le Fauve said.

“We've talked to the primary care docs, and they don't have much time. The screening instruments have to be brief,” Dr. Le Fauve said. Ongoing assessment of the person with CODs is another essential component. Always check on compliance and reasons for noncompliance, ask how their medications are affecting them, and acknowledge that they have a right not to take medications, she said.

Conduct a very extensive interview about all substances, including age at first use, patterns over time, periods of abstinence, and consequences of use, Dr. Le Fauve said. “We have people bring in everything. This gives you the opportunity to look at bottles, how much is left, and who prescribed it. You will be amazed at what you find out. Amazed.”

Homeless people with CODs are a particular challenge to treat, and they are at higher risk for adverse outcomes, Dr. Le Fauve said. Once homeless, people with CODs require more services and are more likely to remain homeless than are other types of homeless people, she said. In addition, among homeless veterans, one-third to one-half have co-occurring mental illnesses and substance use disorders. “I say this right now in the context of our current war situation, but it's always an important issue.”

Therefore, access to psychiatric care is necessary for clients presenting for treatment in substance use programs, Dr. Le Fauve said. Also, treatment will be more effective if clients have a sense of control and ownership over the treatment process. “This sounds preachy and canned, but it's true,” she remarked.

TORONTO — A common fear of corticosteroid use and heavy reliance on the Internet for research are among the findings of a large online survey about eczema awareness, treatment, and quality of life, Isaiah J. Day said at the annual conference of the Canadian Dermatology Association.

The survey of 1,071 English- and French-speaking Canadians included 767 people with eczema and another 304 close relatives of someone affected by the condition. Assessment of self-education about eczema and opinions about corticosteroids and topical immunomodulators were among the goals of the Eczema Awareness, Support, and Education (EASE) database Web survey.

Respondents were asked if they were concerned about using topical steroids. A total of 77% indicated yes, with thinning of the skin cited as the No. 1 reason. "There is steroid phobia—it is pervasive—and this may influence compliance," said Mr. Day, a third-year medical student at the University of Alberta, Edmonton.

"Patients may not be aware that steroids come in different potencies," he said.

A total of 632 respondents (59%) reported use of topical corticosteroids by themselves or a relative. Only 44% were aware of topical immunomodulators as a treatment option. Of these, 251 participants (24% of 1,071) reported use of Protopic (tacrolimus) and 150 (14%) reported use of Elidel (pimecrolimus). Three percent did not specify treatment.

The survey was conducted between August 2005 and January 2006. The research was sponsored by Astellas Pharma Inc., which manufactures Protopic. Mr. Day had no disclosure, but his supervisor, Dr. Marlene Dytoc, received funding from Astellas in the past.

"Some fascinating data came when we asked about where they go for information," he said. The leading source was the Internet, cited by 66%, followed by a family physician (55%), dermatologist (50%), and brochures (39%).

"The Internet—hate it or love it. Patients will increasingly turn to the Internet for information," Mr. Day said. Physicians can help patients with eczema by previewing Web sites and recommending those with credible and accurate information.

Another 36% of respondents said that they get information on eczema from articles in newspapers and/or magazines. "This emphasizes the importance of physicians being aware of what is printed in the lay press. It will affect patients accepting or rejecting certain therapies," he said.

The quality of eczema information that respondents received from their doctor was another survey item. A total of 21% felt it was excellent or very good, but 46% felt it was fair or poor, which "suggests there is still room for improvement in delivery of information to patients," Mr. Day noted.

TORONTO — A common fear of corticosteroid use and heavy reliance on the Internet for research are among the findings of a large online survey about eczema awareness, treatment, and quality of life, Isaiah J. Day said at the annual conference of the Canadian Dermatology Association.

The survey of 1,071 English- and French-speaking Canadians included 767 people with eczema and another 304 close relatives of someone affected by the condition. Assessment of self-education about eczema and opinions about corticosteroids and topical immunomodulators were among the goals of the Eczema Awareness, Support, and Education (EASE) database Web survey.

Respondents were asked if they were concerned about using topical steroids. A total of 77% indicated yes, with thinning of the skin cited as the No. 1 reason. "There is steroid phobia—it is pervasive—and this may influence compliance," said Mr. Day, a third-year medical student at the University of Alberta, Edmonton.

"Patients may not be aware that steroids come in different potencies," he said.

A total of 632 respondents (59%) reported use of topical corticosteroids by themselves or a relative. Only 44% were aware of topical immunomodulators as a treatment option. Of these, 251 participants (24% of 1,071) reported use of Protopic (tacrolimus) and 150 (14%) reported use of Elidel (pimecrolimus). Three percent did not specify treatment.

The survey was conducted between August 2005 and January 2006. The research was sponsored by Astellas Pharma Inc., which manufactures Protopic. Mr. Day had no disclosure, but his supervisor, Dr. Marlene Dytoc, received funding from Astellas in the past.

"Some fascinating data came when we asked about where they go for information," he said. The leading source was the Internet, cited by 66%, followed by a family physician (55%), dermatologist (50%), and brochures (39%).

"The Internet—hate it or love it. Patients will increasingly turn to the Internet for information," Mr. Day said. Physicians can help patients with eczema by previewing Web sites and recommending those with credible and accurate information.

Another 36% of respondents said that they get information on eczema from articles in newspapers and/or magazines. "This emphasizes the importance of physicians being aware of what is printed in the lay press. It will affect patients accepting or rejecting certain therapies," he said.

The quality of eczema information that respondents received from their doctor was another survey item. A total of 21% felt it was excellent or very good, but 46% felt it was fair or poor, which "suggests there is still room for improvement in delivery of information to patients," Mr. Day noted.

TORONTO — A common fear of corticosteroid use and heavy reliance on the Internet for research are among the findings of a large online survey about eczema awareness, treatment, and quality of life, Isaiah J. Day said at the annual conference of the Canadian Dermatology Association.

The survey of 1,071 English- and French-speaking Canadians included 767 people with eczema and another 304 close relatives of someone affected by the condition. Assessment of self-education about eczema and opinions about corticosteroids and topical immunomodulators were among the goals of the Eczema Awareness, Support, and Education (EASE) database Web survey.

Respondents were asked if they were concerned about using topical steroids. A total of 77% indicated yes, with thinning of the skin cited as the No. 1 reason. "There is steroid phobia—it is pervasive—and this may influence compliance," said Mr. Day, a third-year medical student at the University of Alberta, Edmonton.

"Patients may not be aware that steroids come in different potencies," he said.

A total of 632 respondents (59%) reported use of topical corticosteroids by themselves or a relative. Only 44% were aware of topical immunomodulators as a treatment option. Of these, 251 participants (24% of 1,071) reported use of Protopic (tacrolimus) and 150 (14%) reported use of Elidel (pimecrolimus). Three percent did not specify treatment.

The survey was conducted between August 2005 and January 2006. The research was sponsored by Astellas Pharma Inc., which manufactures Protopic. Mr. Day had no disclosure, but his supervisor, Dr. Marlene Dytoc, received funding from Astellas in the past.

"Some fascinating data came when we asked about where they go for information," he said. The leading source was the Internet, cited by 66%, followed by a family physician (55%), dermatologist (50%), and brochures (39%).

"The Internet—hate it or love it. Patients will increasingly turn to the Internet for information," Mr. Day said. Physicians can help patients with eczema by previewing Web sites and recommending those with credible and accurate information.

Another 36% of respondents said that they get information on eczema from articles in newspapers and/or magazines. "This emphasizes the importance of physicians being aware of what is printed in the lay press. It will affect patients accepting or rejecting certain therapies," he said.

The quality of eczema information that respondents received from their doctor was another survey item. A total of 21% felt it was excellent or very good, but 46% felt it was fair or poor, which "suggests there is still room for improvement in delivery of information to patients," Mr. Day noted.

TORONTO — Closely observe a baby with a hemangioma in the first few weeks to months to monitor for any progression, and be cautious with laser treatment, Dr. Alfons Krol said at the annual conference of the Canadian Dermatology Association.

Knowing whether a malformation is likely to rapidly involute will help to guide management. Lasers, he said, can increase complications and should be reserved for the final stage of a multimodal approach.

Classification is important. A rapidly involuting congenital hemangioma (RICH) can be fully formed at birth. "These things can rapidly disappear. They regress and deflate very rapidly," Dr. Krol said. "I use the cooking analogy of a soufflé that collapses in the center."

Hemangiomas in distal areas such as the fingers and feet tend to involute more rapidly than lesions elsewhere. "This is something that has not been well appreciated in the literature," he said.

Some hemangiomas involute slowly, taking anywhere from 2 to 10 years to spontaneously curl inward. Others are not apparent at birth, and postnatal growth may start at 3–12 months. For example, perineal or lip ulcerations that present shortly after birth almost always turn out to be hemangiomas, said Dr. Krol, director of pediatric dermatology at Oregon Health & Science University, Portland.

Hemangiomas "can be small but of great concern to parents. Make sure parents understand they should report any sudden growth between appointments," he said.

In contrast, noninvoluting congenital hemangiomas (NICH) "behave more like a malformation. They tend to grow with the child and do not involute [Plast. Reconstr. Surg. 2001;107:1647–54]," Dr. Krol said. "The only way to treat them is to remove them with surgery."

Dr. Bernice Krafchik of the Hospital for Sick Children in Toronto asked Dr. Krol if he could tell the difference between a RICH and a NICH.

"They can look similar," he replied. "Basically, one starts off large and never gets better—it grows with the patient. You can say that is a NICH."

The clinical implications of a hemangioma go beyond the skin, and can include the liver, central nervous system, and gastrointestinal tract. "The teaching point here is with the 5-point scoring system," Dr. Krol said. If the score is 4 or greater, 63% have airway involvement and about 40% will require tracheostomy. He recommended starting oral steroids while these patients are on their way to an otolaryngology consultation.

"If patients have multiple hemangiomas—more than five or six present—there is an increased risk of hemangioma in other areas, such as the liver," Dr. Krol said. Scan other areas, including the central nervous system, if the liver is positive, he suggested.

Treatment of hemangiomas includes topical or intralesional steroids for select focal lesions. Oral steroids are indicated for life-threatening or function-threatening lesions, 2–4 mg/kg for 4–8 weeks, with a gradual reduction tapered over 2–3 months.

"Alpha interferon is another option, but there are more side effects," Dr. Krol said. Petrolatum applied daily to the surface can minimize secondary changes, including ulceration, he said.

Pulsed-dye lasers held early promise for treatment of hemangiomas, "but we now understand that if the lesion is destined to have that deep component, lasers are of little benefit. This makes sense because the laser goes superficially," he said.

In one study, 121 patients treated with pulsed-dye laser experienced improved redness on the surface, but there was no difference in complete clearing or resolution for laser group versus observation (Lancet 2002;360:521–7). Skin atrophy and hypopigmentation were significantly higher in the laser treatment group. "So certainly [laser treatment] has the potential to increase complications," Dr. Krol said.

"Lasers are best as part of a multimodal approach to 'mop up' after completion of other therapy," he said. One potential indication is after surgery for debulking of a hemangioma to improve any significant telangiectasia.

There are some surgeons who will approach these hemangiomas early in life, Dr. Krol said "If you have a good surgeon and it's technically feasible, I don't think we have to wait as long as we told patients in the past for surgery," he said. "Children become self-aware around age 3 years, so I use that as a guide."

TORONTO — Closely observe a baby with a hemangioma in the first few weeks to months to monitor for any progression, and be cautious with laser treatment, Dr. Alfons Krol said at the annual conference of the Canadian Dermatology Association.

Knowing whether a malformation is likely to rapidly involute will help to guide management. Lasers, he said, can increase complications and should be reserved for the final stage of a multimodal approach.

Classification is important. A rapidly involuting congenital hemangioma (RICH) can be fully formed at birth. "These things can rapidly disappear. They regress and deflate very rapidly," Dr. Krol said. "I use the cooking analogy of a soufflé that collapses in the center."

Hemangiomas in distal areas such as the fingers and feet tend to involute more rapidly than lesions elsewhere. "This is something that has not been well appreciated in the literature," he said.

Some hemangiomas involute slowly, taking anywhere from 2 to 10 years to spontaneously curl inward. Others are not apparent at birth, and postnatal growth may start at 3–12 months. For example, perineal or lip ulcerations that present shortly after birth almost always turn out to be hemangiomas, said Dr. Krol, director of pediatric dermatology at Oregon Health & Science University, Portland.

Hemangiomas "can be small but of great concern to parents. Make sure parents understand they should report any sudden growth between appointments," he said.

In contrast, noninvoluting congenital hemangiomas (NICH) "behave more like a malformation. They tend to grow with the child and do not involute [Plast. Reconstr. Surg. 2001;107:1647–54]," Dr. Krol said. "The only way to treat them is to remove them with surgery."

Dr. Bernice Krafchik of the Hospital for Sick Children in Toronto asked Dr. Krol if he could tell the difference between a RICH and a NICH.

"They can look similar," he replied. "Basically, one starts off large and never gets better—it grows with the patient. You can say that is a NICH."

The clinical implications of a hemangioma go beyond the skin, and can include the liver, central nervous system, and gastrointestinal tract. "The teaching point here is with the 5-point scoring system," Dr. Krol said. If the score is 4 or greater, 63% have airway involvement and about 40% will require tracheostomy. He recommended starting oral steroids while these patients are on their way to an otolaryngology consultation.

"If patients have multiple hemangiomas—more than five or six present—there is an increased risk of hemangioma in other areas, such as the liver," Dr. Krol said. Scan other areas, including the central nervous system, if the liver is positive, he suggested.

Treatment of hemangiomas includes topical or intralesional steroids for select focal lesions. Oral steroids are indicated for life-threatening or function-threatening lesions, 2–4 mg/kg for 4–8 weeks, with a gradual reduction tapered over 2–3 months.

"Alpha interferon is another option, but there are more side effects," Dr. Krol said. Petrolatum applied daily to the surface can minimize secondary changes, including ulceration, he said.

Pulsed-dye lasers held early promise for treatment of hemangiomas, "but we now understand that if the lesion is destined to have that deep component, lasers are of little benefit. This makes sense because the laser goes superficially," he said.

In one study, 121 patients treated with pulsed-dye laser experienced improved redness on the surface, but there was no difference in complete clearing or resolution for laser group versus observation (Lancet 2002;360:521–7). Skin atrophy and hypopigmentation were significantly higher in the laser treatment group. "So certainly [laser treatment] has the potential to increase complications," Dr. Krol said.

"Lasers are best as part of a multimodal approach to 'mop up' after completion of other therapy," he said. One potential indication is after surgery for debulking of a hemangioma to improve any significant telangiectasia.

There are some surgeons who will approach these hemangiomas early in life, Dr. Krol said "If you have a good surgeon and it's technically feasible, I don't think we have to wait as long as we told patients in the past for surgery," he said. "Children become self-aware around age 3 years, so I use that as a guide."

TORONTO — Closely observe a baby with a hemangioma in the first few weeks to months to monitor for any progression, and be cautious with laser treatment, Dr. Alfons Krol said at the annual conference of the Canadian Dermatology Association.

Knowing whether a malformation is likely to rapidly involute will help to guide management. Lasers, he said, can increase complications and should be reserved for the final stage of a multimodal approach.

Classification is important. A rapidly involuting congenital hemangioma (RICH) can be fully formed at birth. "These things can rapidly disappear. They regress and deflate very rapidly," Dr. Krol said. "I use the cooking analogy of a soufflé that collapses in the center."

Hemangiomas in distal areas such as the fingers and feet tend to involute more rapidly than lesions elsewhere. "This is something that has not been well appreciated in the literature," he said.

Some hemangiomas involute slowly, taking anywhere from 2 to 10 years to spontaneously curl inward. Others are not apparent at birth, and postnatal growth may start at 3–12 months. For example, perineal or lip ulcerations that present shortly after birth almost always turn out to be hemangiomas, said Dr. Krol, director of pediatric dermatology at Oregon Health & Science University, Portland.

Hemangiomas "can be small but of great concern to parents. Make sure parents understand they should report any sudden growth between appointments," he said.

In contrast, noninvoluting congenital hemangiomas (NICH) "behave more like a malformation. They tend to grow with the child and do not involute [Plast. Reconstr. Surg. 2001;107:1647–54]," Dr. Krol said. "The only way to treat them is to remove them with surgery."

Dr. Bernice Krafchik of the Hospital for Sick Children in Toronto asked Dr. Krol if he could tell the difference between a RICH and a NICH.

"They can look similar," he replied. "Basically, one starts off large and never gets better—it grows with the patient. You can say that is a NICH."

The clinical implications of a hemangioma go beyond the skin, and can include the liver, central nervous system, and gastrointestinal tract. "The teaching point here is with the 5-point scoring system," Dr. Krol said. If the score is 4 or greater, 63% have airway involvement and about 40% will require tracheostomy. He recommended starting oral steroids while these patients are on their way to an otolaryngology consultation.

"If patients have multiple hemangiomas—more than five or six present—there is an increased risk of hemangioma in other areas, such as the liver," Dr. Krol said. Scan other areas, including the central nervous system, if the liver is positive, he suggested.

Treatment of hemangiomas includes topical or intralesional steroids for select focal lesions. Oral steroids are indicated for life-threatening or function-threatening lesions, 2–4 mg/kg for 4–8 weeks, with a gradual reduction tapered over 2–3 months.

"Alpha interferon is another option, but there are more side effects," Dr. Krol said. Petrolatum applied daily to the surface can minimize secondary changes, including ulceration, he said.

Pulsed-dye lasers held early promise for treatment of hemangiomas, "but we now understand that if the lesion is destined to have that deep component, lasers are of little benefit. This makes sense because the laser goes superficially," he said.

In one study, 121 patients treated with pulsed-dye laser experienced improved redness on the surface, but there was no difference in complete clearing or resolution for laser group versus observation (Lancet 2002;360:521–7). Skin atrophy and hypopigmentation were significantly higher in the laser treatment group. "So certainly [laser treatment] has the potential to increase complications," Dr. Krol said.

"Lasers are best as part of a multimodal approach to 'mop up' after completion of other therapy," he said. One potential indication is after surgery for debulking of a hemangioma to improve any significant telangiectasia.

There are some surgeons who will approach these hemangiomas early in life, Dr. Krol said "If you have a good surgeon and it's technically feasible, I don't think we have to wait as long as we told patients in the past for surgery," he said. "Children become self-aware around age 3 years, so I use that as a guide."

TORONTO — Scar revision can be a challenge for dermatologists.

Many patients who are dissatisfied with their postsurgical result expect immediate improvement. Others request topical treatments recommended by a friend or the Internet. However, clinical efficacy varies widely. Lack of substantial evidence compounds the challenge, Dr. David Zloty said at the annual conference of the Canadian Dermatology Association.

Topical treatments, "pressure therapy," injectable agents, cryotherapy, lasers, and surgical revision are among the many choices for scar management. Although scarring can be minimized through good surgical technique, some patients seek to improve the appearance, making patient education and expectation management important. Some patients might have to adopt a wait-and-see approach because it can take up to 2 years to reach final scar appearance and strength, said Dr. Zloty of the University of British Columbia, Vancouver.

Only minimal strength returns immediately postprocedure, "so when you take stitches out at 1–2 weeks, the site only has 5%–10% of its final strength," he said.

Adhesive tape or semiocclusive dressings are an option, but "I rarely use this except for women on the upper back or chest," Dr. Zloty said.

Topical imiquimod (Aldara) is another possibility. One study in a small number of patients showed efficacy when it was applied following shave excision of earlobe keloids (Dermatol. Surg. 2006;32:380–6), but Dr. Zloty said he does not use imiquimod for scar revision.

He is more likely to suggest Cicaplast epidermal recovery accelerator. "It's reasonably priced and may help reduce scar erythema. I don't want to lead you to believe it's a great compound, but minimal improvement is still something," said Dr. Zloty, who disclosed that he was previously paid to lecture on this product.

Another topical, Dermatix C (a formulation available in Canada from Valeant Pharmaceuticals International) is a combination of silicone gel and vitamin C ester. It costs $40–$50 (in U.S. dollars) per tube in British Columbia, so it is expensive, said Dr. Zloty, who is also director of the skin care surgery centre at Vancouver General Hospital.

Mederma is a topical gel with allium cepa (onion extract). A prospective, double-blind study indicated that Mederma did not improve scar cosmesis or symptoms compared with Aquaphor petrolatum-based ointment (Dermatol. Surg. 2006;32:193–7).

Many fair-skinned patients are distressed by the redness of postsurgical scarring. "Don't forget use of makeup as a topical. Sometimes you have to teach them how to put it on correctly," Dr. Zloty said.

Dermatologists sometimes forget to mention sunscreen in their postsurgical instructions. "I am very strict about sunscreen use, recommending broad spectrum, [with] at least SPF 30, as soon as the site heals over."

Vitamin E "is one of the few topicals that I will say no to," Dr. Zloty said, citing insufficient evidence of its efficacy. This stance can be challenging, though, because many patients specifically ask for vitamin E.

Silicone sheets are another postsurgical scar option, but they "had their heyday about 5 years ago," Dr. Zloty said. He will still suggest the sheets for scars on the chest, back, and shoulders of young women to minimize redness. They must be used 24 hours per day for up to 6 months for best results, so compliance is an issue. A meeting attendee commented that the sheets are difficult to use and often fall off.

"Pressure therapy" for scars is used primarily for earlobes, but can be used anywhere. Massage can aid small scars by altering wound tension. Start 2–3 weeks after suture removal, he suggested. "This is an accepted part of our scar armamentarium."

Cryotherapy can be 50%–80% effective for keloids, Dr. Zloty said. However, he added, "I've never used cryo as a direct modality, but I use it to get steroid in a scar."

Steroid injections can take up to six injections. "Go into the heart of the scar," not too shallow or too deep, Dr. Zloty said.

Dr. Zloty does not use laser treatments like pulse dye or fractional resurfacing as initial therapy for scars. "I use the pulse dye after everything else is done to improve erythema." It is usually effective after one or two treatments. He also refers patients with hypopigmented facial scars for fractional resurfacing to help blend the area between hypopigmented and normal skin.

Surgical scar revision can be very effective. Dr. Zloty uses dermabrasion, direct scar excision, Z-plasty, or W-plasty.

There can be about a 50%–60% improvement with dermabrasion, but it can take up to 1 year for erythema to resolve. Dr. Zloty reserves the technique primarily for scars from full-thickness skin grafts on the nose or elsewhere on the face.

Direct surgical excision of the initial scar can "get a better scar with less shadow," he said. Z-plasty, W-plasty, and other surgical techniques change scar direction or reduce the straight line of a scar to make visual recognition of a scar more difficult.

Direct surgical excision can "get a better scar with less shadow," said Dr. David Zloty. The patient above is shown before and 3 months after revision using the W-plasty technique. Photos courtesy Dr. David Zloty

TORONTO — Scar revision can be a challenge for dermatologists.

Many patients who are dissatisfied with their postsurgical result expect immediate improvement. Others request topical treatments recommended by a friend or the Internet. However, clinical efficacy varies widely. Lack of substantial evidence compounds the challenge, Dr. David Zloty said at the annual conference of the Canadian Dermatology Association.

Topical treatments, "pressure therapy," injectable agents, cryotherapy, lasers, and surgical revision are among the many choices for scar management. Although scarring can be minimized through good surgical technique, some patients seek to improve the appearance, making patient education and expectation management important. Some patients might have to adopt a wait-and-see approach because it can take up to 2 years to reach final scar appearance and strength, said Dr. Zloty of the University of British Columbia, Vancouver.

Only minimal strength returns immediately postprocedure, "so when you take stitches out at 1–2 weeks, the site only has 5%–10% of its final strength," he said.

Adhesive tape or semiocclusive dressings are an option, but "I rarely use this except for women on the upper back or chest," Dr. Zloty said.

Topical imiquimod (Aldara) is another possibility. One study in a small number of patients showed efficacy when it was applied following shave excision of earlobe keloids (Dermatol. Surg. 2006;32:380–6), but Dr. Zloty said he does not use imiquimod for scar revision.

He is more likely to suggest Cicaplast epidermal recovery accelerator. "It's reasonably priced and may help reduce scar erythema. I don't want to lead you to believe it's a great compound, but minimal improvement is still something," said Dr. Zloty, who disclosed that he was previously paid to lecture on this product.

Another topical, Dermatix C (a formulation available in Canada from Valeant Pharmaceuticals International) is a combination of silicone gel and vitamin C ester. It costs $40–$50 (in U.S. dollars) per tube in British Columbia, so it is expensive, said Dr. Zloty, who is also director of the skin care surgery centre at Vancouver General Hospital.

Mederma is a topical gel with allium cepa (onion extract). A prospective, double-blind study indicated that Mederma did not improve scar cosmesis or symptoms compared with Aquaphor petrolatum-based ointment (Dermatol. Surg. 2006;32:193–7).

Many fair-skinned patients are distressed by the redness of postsurgical scarring. "Don't forget use of makeup as a topical. Sometimes you have to teach them how to put it on correctly," Dr. Zloty said.

Dermatologists sometimes forget to mention sunscreen in their postsurgical instructions. "I am very strict about sunscreen use, recommending broad spectrum, [with] at least SPF 30, as soon as the site heals over."

Vitamin E "is one of the few topicals that I will say no to," Dr. Zloty said, citing insufficient evidence of its efficacy. This stance can be challenging, though, because many patients specifically ask for vitamin E.

Silicone sheets are another postsurgical scar option, but they "had their heyday about 5 years ago," Dr. Zloty said. He will still suggest the sheets for scars on the chest, back, and shoulders of young women to minimize redness. They must be used 24 hours per day for up to 6 months for best results, so compliance is an issue. A meeting attendee commented that the sheets are difficult to use and often fall off.

"Pressure therapy" for scars is used primarily for earlobes, but can be used anywhere. Massage can aid small scars by altering wound tension. Start 2–3 weeks after suture removal, he suggested. "This is an accepted part of our scar armamentarium."

Cryotherapy can be 50%–80% effective for keloids, Dr. Zloty said. However, he added, "I've never used cryo as a direct modality, but I use it to get steroid in a scar."

Steroid injections can take up to six injections. "Go into the heart of the scar," not too shallow or too deep, Dr. Zloty said.

Dr. Zloty does not use laser treatments like pulse dye or fractional resurfacing as initial therapy for scars. "I use the pulse dye after everything else is done to improve erythema." It is usually effective after one or two treatments. He also refers patients with hypopigmented facial scars for fractional resurfacing to help blend the area between hypopigmented and normal skin.

Surgical scar revision can be very effective. Dr. Zloty uses dermabrasion, direct scar excision, Z-plasty, or W-plasty.

There can be about a 50%–60% improvement with dermabrasion, but it can take up to 1 year for erythema to resolve. Dr. Zloty reserves the technique primarily for scars from full-thickness skin grafts on the nose or elsewhere on the face.

Direct surgical excision of the initial scar can "get a better scar with less shadow," he said. Z-plasty, W-plasty, and other surgical techniques change scar direction or reduce the straight line of a scar to make visual recognition of a scar more difficult.

Direct surgical excision can "get a better scar with less shadow," said Dr. David Zloty. The patient above is shown before and 3 months after revision using the W-plasty technique. Photos courtesy Dr. David Zloty

TORONTO — Scar revision can be a challenge for dermatologists.

Many patients who are dissatisfied with their postsurgical result expect immediate improvement. Others request topical treatments recommended by a friend or the Internet. However, clinical efficacy varies widely. Lack of substantial evidence compounds the challenge, Dr. David Zloty said at the annual conference of the Canadian Dermatology Association.

Topical treatments, "pressure therapy," injectable agents, cryotherapy, lasers, and surgical revision are among the many choices for scar management. Although scarring can be minimized through good surgical technique, some patients seek to improve the appearance, making patient education and expectation management important. Some patients might have to adopt a wait-and-see approach because it can take up to 2 years to reach final scar appearance and strength, said Dr. Zloty of the University of British Columbia, Vancouver.

Only minimal strength returns immediately postprocedure, "so when you take stitches out at 1–2 weeks, the site only has 5%–10% of its final strength," he said.

Adhesive tape or semiocclusive dressings are an option, but "I rarely use this except for women on the upper back or chest," Dr. Zloty said.

Topical imiquimod (Aldara) is another possibility. One study in a small number of patients showed efficacy when it was applied following shave excision of earlobe keloids (Dermatol. Surg. 2006;32:380–6), but Dr. Zloty said he does not use imiquimod for scar revision.

He is more likely to suggest Cicaplast epidermal recovery accelerator. "It's reasonably priced and may help reduce scar erythema. I don't want to lead you to believe it's a great compound, but minimal improvement is still something," said Dr. Zloty, who disclosed that he was previously paid to lecture on this product.

Another topical, Dermatix C (a formulation available in Canada from Valeant Pharmaceuticals International) is a combination of silicone gel and vitamin C ester. It costs $40–$50 (in U.S. dollars) per tube in British Columbia, so it is expensive, said Dr. Zloty, who is also director of the skin care surgery centre at Vancouver General Hospital.

Mederma is a topical gel with allium cepa (onion extract). A prospective, double-blind study indicated that Mederma did not improve scar cosmesis or symptoms compared with Aquaphor petrolatum-based ointment (Dermatol. Surg. 2006;32:193–7).

Many fair-skinned patients are distressed by the redness of postsurgical scarring. "Don't forget use of makeup as a topical. Sometimes you have to teach them how to put it on correctly," Dr. Zloty said.

Dermatologists sometimes forget to mention sunscreen in their postsurgical instructions. "I am very strict about sunscreen use, recommending broad spectrum, [with] at least SPF 30, as soon as the site heals over."

Vitamin E "is one of the few topicals that I will say no to," Dr. Zloty said, citing insufficient evidence of its efficacy. This stance can be challenging, though, because many patients specifically ask for vitamin E.

Silicone sheets are another postsurgical scar option, but they "had their heyday about 5 years ago," Dr. Zloty said. He will still suggest the sheets for scars on the chest, back, and shoulders of young women to minimize redness. They must be used 24 hours per day for up to 6 months for best results, so compliance is an issue. A meeting attendee commented that the sheets are difficult to use and often fall off.

"Pressure therapy" for scars is used primarily for earlobes, but can be used anywhere. Massage can aid small scars by altering wound tension. Start 2–3 weeks after suture removal, he suggested. "This is an accepted part of our scar armamentarium."

Cryotherapy can be 50%–80% effective for keloids, Dr. Zloty said. However, he added, "I've never used cryo as a direct modality, but I use it to get steroid in a scar."

Steroid injections can take up to six injections. "Go into the heart of the scar," not too shallow or too deep, Dr. Zloty said.

Dr. Zloty does not use laser treatments like pulse dye or fractional resurfacing as initial therapy for scars. "I use the pulse dye after everything else is done to improve erythema." It is usually effective after one or two treatments. He also refers patients with hypopigmented facial scars for fractional resurfacing to help blend the area between hypopigmented and normal skin.

Surgical scar revision can be very effective. Dr. Zloty uses dermabrasion, direct scar excision, Z-plasty, or W-plasty.

There can be about a 50%–60% improvement with dermabrasion, but it can take up to 1 year for erythema to resolve. Dr. Zloty reserves the technique primarily for scars from full-thickness skin grafts on the nose or elsewhere on the face.

Direct surgical excision of the initial scar can "get a better scar with less shadow," he said. Z-plasty, W-plasty, and other surgical techniques change scar direction or reduce the straight line of a scar to make visual recognition of a scar more difficult.

Direct surgical excision can "get a better scar with less shadow," said Dr. David Zloty. The patient above is shown before and 3 months after revision using the W-plasty technique. Photos courtesy Dr. David Zloty

TORONTO — "Survival of the fittest" might be the best way to explain the genetic and molecular machinery behind cancer metastasis.

Researchers believe that overexpression of some genes in melanoma and other cancers allows some cells to survive the very harsh conditions that occur as they leave a primary tumor, travel to a distant site, and establish a new location for malignancy. "It is a similar theme to Darwin with natural selection, although it works out in a microenvironment," Dr. Youwen Zhou said.

"Why do I think this is a big deal? We still do not have a cure for metastatic melanoma, and next year another 900 or so patients [in Canada] will die from melanoma," Dr. Zhou said.

Melanoma was the sixth most common solid cancer for men in Canada in 2005 and 2006. There were 3,900 new cases last year. Of 840 deaths in 2006 from melanoma, 90% involved metastatic disease, said Dr. Zhou, who is on the faculty in the department of dermatology and skin science at the University of British Columbia, Vancouver.

There are some reasons for optimism, however. Understanding the molecular machinery might permit earlier intervention through better diagnostic or prognostic tools, Dr. Zhou said at the annual conference of the Canadian Dermatology Association.

Serum protein testing, for example, might lead to more accurate estimates of prognosis. The melanoma-inhibiting activity (MIA) protein is detected in high amounts in 100% of patients with metastatic melanoma so far. "About 20% of patients with primary melanoma will have signs of this protein in their serum. If they are negative for MIA protein, not one of them developed metastasis over time," he said.

Genetic insights also may lead to new therapeutic targets. "Selective gene silencing may work to cause metastatic cells to die," Dr. Zhou said.

So how do invasive tumors develop? Metastasis occurs when genetically unstable cancer cells adapt to a tissue microenvironment distant from the primary tumor (Cell 2006;127:679–95).

Other investigators have identified individual genes that are amplified in metastatic melanoma (Cell 2006;125:1269–81).

A high degree of heterogeneity in melanoma tumor cells may in part explain why aggressive gene clones arise.

"If you look at a melanoma clinically, it has signs of molecular and cellular heterogeneity, for example, irregular borders. On a cellular level, pathologists use variation in cell size as a diagnostic factor," he said.

Dominant genetic clones can cause a higher resistance to apoptosis, greater tolerance to hypoxia and nutrient deprivation, altered cell adherence, and increased genomic instability.

The vast majority of the most aberrantly upregulated genes work in concert to modify the microenvironment to their advantage.

Before these breakaway cells become "little tumor thrombi," they must break through local physical barriers, he explained. They do this in part by degrading the collagen matrix. Then they have to overcome the vascular wall and survive the harsh sheering and other forces of the vasculature.

Some will survive intravasation with the right molecular defense mechanisms. Extravasation occurs when they arrive at a destination, change adhesion properties, and again pass through the vascular wall. Finally, the cells must continue to defend themselves against host defenses for distant colonization to be successful, Dr. Zhou said.

Development of novel targeting strategies against this genetic and molecular machinery is needed, he said. Once those strategies are identified, the next step would be large scale trials to assess these therapeutic targets.

TORONTO — "Survival of the fittest" might be the best way to explain the genetic and molecular machinery behind cancer metastasis.

Researchers believe that overexpression of some genes in melanoma and other cancers allows some cells to survive the very harsh conditions that occur as they leave a primary tumor, travel to a distant site, and establish a new location for malignancy. "It is a similar theme to Darwin with natural selection, although it works out in a microenvironment," Dr. Youwen Zhou said.

"Why do I think this is a big deal? We still do not have a cure for metastatic melanoma, and next year another 900 or so patients [in Canada] will die from melanoma," Dr. Zhou said.

Melanoma was the sixth most common solid cancer for men in Canada in 2005 and 2006. There were 3,900 new cases last year. Of 840 deaths in 2006 from melanoma, 90% involved metastatic disease, said Dr. Zhou, who is on the faculty in the department of dermatology and skin science at the University of British Columbia, Vancouver.

There are some reasons for optimism, however. Understanding the molecular machinery might permit earlier intervention through better diagnostic or prognostic tools, Dr. Zhou said at the annual conference of the Canadian Dermatology Association.

Serum protein testing, for example, might lead to more accurate estimates of prognosis. The melanoma-inhibiting activity (MIA) protein is detected in high amounts in 100% of patients with metastatic melanoma so far. "About 20% of patients with primary melanoma will have signs of this protein in their serum. If they are negative for MIA protein, not one of them developed metastasis over time," he said.

Genetic insights also may lead to new therapeutic targets. "Selective gene silencing may work to cause metastatic cells to die," Dr. Zhou said.

So how do invasive tumors develop? Metastasis occurs when genetically unstable cancer cells adapt to a tissue microenvironment distant from the primary tumor (Cell 2006;127:679–95).

Other investigators have identified individual genes that are amplified in metastatic melanoma (Cell 2006;125:1269–81).

A high degree of heterogeneity in melanoma tumor cells may in part explain why aggressive gene clones arise.

"If you look at a melanoma clinically, it has signs of molecular and cellular heterogeneity, for example, irregular borders. On a cellular level, pathologists use variation in cell size as a diagnostic factor," he said.

Dominant genetic clones can cause a higher resistance to apoptosis, greater tolerance to hypoxia and nutrient deprivation, altered cell adherence, and increased genomic instability.

The vast majority of the most aberrantly upregulated genes work in concert to modify the microenvironment to their advantage.

Before these breakaway cells become "little tumor thrombi," they must break through local physical barriers, he explained. They do this in part by degrading the collagen matrix. Then they have to overcome the vascular wall and survive the harsh sheering and other forces of the vasculature.

Some will survive intravasation with the right molecular defense mechanisms. Extravasation occurs when they arrive at a destination, change adhesion properties, and again pass through the vascular wall. Finally, the cells must continue to defend themselves against host defenses for distant colonization to be successful, Dr. Zhou said.

Development of novel targeting strategies against this genetic and molecular machinery is needed, he said. Once those strategies are identified, the next step would be large scale trials to assess these therapeutic targets.

TORONTO — "Survival of the fittest" might be the best way to explain the genetic and molecular machinery behind cancer metastasis.

Researchers believe that overexpression of some genes in melanoma and other cancers allows some cells to survive the very harsh conditions that occur as they leave a primary tumor, travel to a distant site, and establish a new location for malignancy. "It is a similar theme to Darwin with natural selection, although it works out in a microenvironment," Dr. Youwen Zhou said.

"Why do I think this is a big deal? We still do not have a cure for metastatic melanoma, and next year another 900 or so patients [in Canada] will die from melanoma," Dr. Zhou said.

Melanoma was the sixth most common solid cancer for men in Canada in 2005 and 2006. There were 3,900 new cases last year. Of 840 deaths in 2006 from melanoma, 90% involved metastatic disease, said Dr. Zhou, who is on the faculty in the department of dermatology and skin science at the University of British Columbia, Vancouver.

There are some reasons for optimism, however. Understanding the molecular machinery might permit earlier intervention through better diagnostic or prognostic tools, Dr. Zhou said at the annual conference of the Canadian Dermatology Association.

Serum protein testing, for example, might lead to more accurate estimates of prognosis. The melanoma-inhibiting activity (MIA) protein is detected in high amounts in 100% of patients with metastatic melanoma so far. "About 20% of patients with primary melanoma will have signs of this protein in their serum. If they are negative for MIA protein, not one of them developed metastasis over time," he said.

Genetic insights also may lead to new therapeutic targets. "Selective gene silencing may work to cause metastatic cells to die," Dr. Zhou said.

So how do invasive tumors develop? Metastasis occurs when genetically unstable cancer cells adapt to a tissue microenvironment distant from the primary tumor (Cell 2006;127:679–95).

Other investigators have identified individual genes that are amplified in metastatic melanoma (Cell 2006;125:1269–81).

A high degree of heterogeneity in melanoma tumor cells may in part explain why aggressive gene clones arise.

"If you look at a melanoma clinically, it has signs of molecular and cellular heterogeneity, for example, irregular borders. On a cellular level, pathologists use variation in cell size as a diagnostic factor," he said.

Dominant genetic clones can cause a higher resistance to apoptosis, greater tolerance to hypoxia and nutrient deprivation, altered cell adherence, and increased genomic instability.

The vast majority of the most aberrantly upregulated genes work in concert to modify the microenvironment to their advantage.

Before these breakaway cells become "little tumor thrombi," they must break through local physical barriers, he explained. They do this in part by degrading the collagen matrix. Then they have to overcome the vascular wall and survive the harsh sheering and other forces of the vasculature.

Some will survive intravasation with the right molecular defense mechanisms. Extravasation occurs when they arrive at a destination, change adhesion properties, and again pass through the vascular wall. Finally, the cells must continue to defend themselves against host defenses for distant colonization to be successful, Dr. Zhou said.

Development of novel targeting strategies against this genetic and molecular machinery is needed, he said. Once those strategies are identified, the next step would be large scale trials to assess these therapeutic targets.