Damian McNamara

MIAMI — The overwhelming majority of children with perforated appendicitis do well with immediate antibiotics and delayed surgery—a strategy called interval management, Dr. Cathy A. Burnweit said at a pediatric update sponsored by Miami Children's Hospital.

“It is with great difficulty that I say perforated appendicitis is now a nonsurgical disease, at least in the short term,” said Dr. Burnweit, a pediatric surgeon at the hospital.

Delaying surgery allows time for inflammation to subside. “The surgeon's reward is that appendectomy in 8–10 weeks is usually an easy operation,” she said. Delayed surgery often is done on an ambulatory basis. And with laparoscopic removal, surgery can be virtually scarless.

Interval management improves outcomes and decreases complications compared with an immediate operation for about 90% of children with perforated appendicitis (J. Ped. Surg. 2001;36:165–8). “The problem is the kids who fail, although they are becoming less common,” Dr. Burnweit said. The clinical challenge is early identification of children who fail interval management “so we can do something different—prescribe different antibiotics and/or [perform] an immediate operation.”

The total complication rate is about 7% with interval management. For the 10% of children who fail the protocol, the total complication rate climbs to about 33%, Dr. Burnweit said. Complications associated with the old strategy—an immediate operation for children with perforated appendicitis—include wound infections in approximately 10%–25%, an intra-abdominal abscess in 4%–7%, and intestinal obstruction in 2%–5%.

Patient age can help clinicians determine whether an appendix is perforated. The likelihood of perforation increases with decreasing age. About 65% of those younger than 4 years presenting with appendicitis will have perforation. “Those under 3 years old will almost always be perforated,” Dr. Burnweit said. Also consider the patient's general condition, duration of symptoms, white cell count, C-reactive protein levels, and imaging findings.

Computed tomography and ultrasound of the abdomen and pelvis (for a girl) are the most cost-effective imaging modalities, Dr. Burnweit said. With ultrasound, in particular, “you need great technicians and radiologists” to detect fat stranding, appendiceal formation, and/or free fluid, she added. A CT scan is the best first study in an obese child.

History and physical exam are critical. Also do a gut check—of the surgeon, Dr. Burnweit said. Use your clinical judgment and acumen to diagnose perforated appendicitis. “If the story or exam does not jibe, diagnosis cannot be made. If your work-up indicates appendicitis, but you examine the kid and he's eating chips from the vending machine and bouncing off the wall, send him home.”

Once perforated appendicitis is diagnosed, admit the patient, hydrate, and administer broad-spectrum antibiotics such as gentamicin and clindamycin. Also, place a peripherally inserted central catheter (PICC) and provide pain management.

A patient who is tolerating diet (indicating no bowel obstruction), an appropriate home environment, availability of home nurse care, and a PICC in place are discharge criteria. “Fever is expected, but you should see a downward trend over time,” Dr. Burnweit said.

Antibiotics are administered at home through the PICC for 5–14 days; it is removed when the white blood cell count is normal. If the white blood cell count remains abnormal, the PICC stays in longer, Dr. Burnweit said in an interview.

Unmitigated fever, small bowel obstruction, and/or a worsening overall condition for 2–4 days indicate the child is failing to improve. Undrained sepsis is usually the culprit for prolonged or worsening fever, she added.

Interval management allows for early discharge with oral antibiotics in many cases. Stop antibiotics when the patient is afebrile for 48 hours or longer and/or the white blood cell count is normal.

Laparoscopic removal of an appendix is relatively “scarless” at the hospital. A single incision is made through the umbilicus. “These are done through one port now,” she said. “We started out doing these with three—one for the camera and two for instruments, then went to two, and now it's one. It is pretty amazing.”

MIAMI — The overwhelming majority of children with perforated appendicitis do well with immediate antibiotics and delayed surgery—a strategy called interval management, Dr. Cathy A. Burnweit said at a pediatric update sponsored by Miami Children's Hospital.

“It is with great difficulty that I say perforated appendicitis is now a nonsurgical disease, at least in the short term,” said Dr. Burnweit, a pediatric surgeon at the hospital.

Delaying surgery allows time for inflammation to subside. “The surgeon's reward is that appendectomy in 8–10 weeks is usually an easy operation,” she said. Delayed surgery often is done on an ambulatory basis. And with laparoscopic removal, surgery can be virtually scarless.

Interval management improves outcomes and decreases complications compared with an immediate operation for about 90% of children with perforated appendicitis (J. Ped. Surg. 2001;36:165–8). “The problem is the kids who fail, although they are becoming less common,” Dr. Burnweit said. The clinical challenge is early identification of children who fail interval management “so we can do something different—prescribe different antibiotics and/or [perform] an immediate operation.”

The total complication rate is about 7% with interval management. For the 10% of children who fail the protocol, the total complication rate climbs to about 33%, Dr. Burnweit said. Complications associated with the old strategy—an immediate operation for children with perforated appendicitis—include wound infections in approximately 10%–25%, an intra-abdominal abscess in 4%–7%, and intestinal obstruction in 2%–5%.

Patient age can help clinicians determine whether an appendix is perforated. The likelihood of perforation increases with decreasing age. About 65% of those younger than 4 years presenting with appendicitis will have perforation. “Those under 3 years old will almost always be perforated,” Dr. Burnweit said. Also consider the patient's general condition, duration of symptoms, white cell count, C-reactive protein levels, and imaging findings.

Computed tomography and ultrasound of the abdomen and pelvis (for a girl) are the most cost-effective imaging modalities, Dr. Burnweit said. With ultrasound, in particular, “you need great technicians and radiologists” to detect fat stranding, appendiceal formation, and/or free fluid, she added. A CT scan is the best first study in an obese child.

History and physical exam are critical. Also do a gut check—of the surgeon, Dr. Burnweit said. Use your clinical judgment and acumen to diagnose perforated appendicitis. “If the story or exam does not jibe, diagnosis cannot be made. If your work-up indicates appendicitis, but you examine the kid and he's eating chips from the vending machine and bouncing off the wall, send him home.”

Once perforated appendicitis is diagnosed, admit the patient, hydrate, and administer broad-spectrum antibiotics such as gentamicin and clindamycin. Also, place a peripherally inserted central catheter (PICC) and provide pain management.

A patient who is tolerating diet (indicating no bowel obstruction), an appropriate home environment, availability of home nurse care, and a PICC in place are discharge criteria. “Fever is expected, but you should see a downward trend over time,” Dr. Burnweit said.

Antibiotics are administered at home through the PICC for 5–14 days; it is removed when the white blood cell count is normal. If the white blood cell count remains abnormal, the PICC stays in longer, Dr. Burnweit said in an interview.

Unmitigated fever, small bowel obstruction, and/or a worsening overall condition for 2–4 days indicate the child is failing to improve. Undrained sepsis is usually the culprit for prolonged or worsening fever, she added.

Interval management allows for early discharge with oral antibiotics in many cases. Stop antibiotics when the patient is afebrile for 48 hours or longer and/or the white blood cell count is normal.

Laparoscopic removal of an appendix is relatively “scarless” at the hospital. A single incision is made through the umbilicus. “These are done through one port now,” she said. “We started out doing these with three—one for the camera and two for instruments, then went to two, and now it's one. It is pretty amazing.”

MIAMI — The overwhelming majority of children with perforated appendicitis do well with immediate antibiotics and delayed surgery—a strategy called interval management, Dr. Cathy A. Burnweit said at a pediatric update sponsored by Miami Children's Hospital.

“It is with great difficulty that I say perforated appendicitis is now a nonsurgical disease, at least in the short term,” said Dr. Burnweit, a pediatric surgeon at the hospital.

Delaying surgery allows time for inflammation to subside. “The surgeon's reward is that appendectomy in 8–10 weeks is usually an easy operation,” she said. Delayed surgery often is done on an ambulatory basis. And with laparoscopic removal, surgery can be virtually scarless.

Interval management improves outcomes and decreases complications compared with an immediate operation for about 90% of children with perforated appendicitis (J. Ped. Surg. 2001;36:165–8). “The problem is the kids who fail, although they are becoming less common,” Dr. Burnweit said. The clinical challenge is early identification of children who fail interval management “so we can do something different—prescribe different antibiotics and/or [perform] an immediate operation.”

The total complication rate is about 7% with interval management. For the 10% of children who fail the protocol, the total complication rate climbs to about 33%, Dr. Burnweit said. Complications associated with the old strategy—an immediate operation for children with perforated appendicitis—include wound infections in approximately 10%–25%, an intra-abdominal abscess in 4%–7%, and intestinal obstruction in 2%–5%.

Patient age can help clinicians determine whether an appendix is perforated. The likelihood of perforation increases with decreasing age. About 65% of those younger than 4 years presenting with appendicitis will have perforation. “Those under 3 years old will almost always be perforated,” Dr. Burnweit said. Also consider the patient's general condition, duration of symptoms, white cell count, C-reactive protein levels, and imaging findings.

Computed tomography and ultrasound of the abdomen and pelvis (for a girl) are the most cost-effective imaging modalities, Dr. Burnweit said. With ultrasound, in particular, “you need great technicians and radiologists” to detect fat stranding, appendiceal formation, and/or free fluid, she added. A CT scan is the best first study in an obese child.

History and physical exam are critical. Also do a gut check—of the surgeon, Dr. Burnweit said. Use your clinical judgment and acumen to diagnose perforated appendicitis. “If the story or exam does not jibe, diagnosis cannot be made. If your work-up indicates appendicitis, but you examine the kid and he's eating chips from the vending machine and bouncing off the wall, send him home.”

Once perforated appendicitis is diagnosed, admit the patient, hydrate, and administer broad-spectrum antibiotics such as gentamicin and clindamycin. Also, place a peripherally inserted central catheter (PICC) and provide pain management.

A patient who is tolerating diet (indicating no bowel obstruction), an appropriate home environment, availability of home nurse care, and a PICC in place are discharge criteria. “Fever is expected, but you should see a downward trend over time,” Dr. Burnweit said.

Antibiotics are administered at home through the PICC for 5–14 days; it is removed when the white blood cell count is normal. If the white blood cell count remains abnormal, the PICC stays in longer, Dr. Burnweit said in an interview.

Unmitigated fever, small bowel obstruction, and/or a worsening overall condition for 2–4 days indicate the child is failing to improve. Undrained sepsis is usually the culprit for prolonged or worsening fever, she added.

Interval management allows for early discharge with oral antibiotics in many cases. Stop antibiotics when the patient is afebrile for 48 hours or longer and/or the white blood cell count is normal.

Laparoscopic removal of an appendix is relatively “scarless” at the hospital. A single incision is made through the umbilicus. “These are done through one port now,” she said. “We started out doing these with three—one for the camera and two for instruments, then went to two, and now it's one. It is pretty amazing.”

MIAMI — The field of addiction medicine is preparing to take a major step to enhance its authority and expand its professional ranks.

The American Society of Addiction Medicine plans to form a certification board and seek official recognition from the American Board of Medical Specialties by the end of 2007, physicians said during a panel presentation at the society's annual conference.

Addiction medicine is self-designated as a specialty, “but we need acceptance from all medicine,” ASAM President-Elect Michael M. Miller said, explaining the plan to offer ABMS-recognized certification in addiction medicine. “Patients need to know where to find a doctor who does this, to be assured this doctor has a full array of training and … has passed an examination.”

The anticipated American Board of Addiction Medicine is likely to involve an alliance with one or more of the existing ABMS specialty boards. Details about the board and its relationship with existing boards are being worked out. (See box.)

“There is no other way to do this than to work with psychiatry, internal medicine, family medicine, and other specialists,” said Dr. Kevin Kunz, an addiction medicine specialist in Kona, Hawaii, and cochair of the ASAM Medical Specialty Action Group.

“The need for addiction medicine as a specialty is widely recognized,” Dr. Kunz said. “The science is exploding, and new therapies are available—both biologic and behavioral,” he said. Also, “better funding is possible. Policy makers are understanding that addiction is a disease and treatable.”

As part of the effort, trauma surgeons and emergency physicians also may be consulted, said Dr. Miller, medical director of the NewStart Alcohol/Drug Treatment Program at Meriter Hospital, Madison, Wis. Dr. Miller recently stepped down as cochair of the action group.

A key goal is to expand addiction medicine training beyond addiction psychiatry, said Dr. R. Jeffrey Goldsmith, professor of clinical psychiatry at the University of Cincinnati. “We don't fill all our current addiction psychiatry spots. Psychiatry is not as enthusiastic as I would like,” he said. A total of 55 of the 116 total approved addiction psychiatry residency spots were filled in 2005–2006, according to data from the Accreditation Council for Graduate Medical Education.

Most current ASAM members have board certification in an ABMS-recognized specialty, including 27% who are certified in psychiatry and 26% who are certified in primary care specialties (13% in family medicine, 12% in internal medicine, and 1% in pediatrics).

No specialty board represents addiction medicine, so the 4,162 physicians who have passed the ASAM's certification examination in addiction medicine cannot describe themselves as board certified in this field.

Board certification in addiction medicine “will give me more stature among my colleagues,” said Dr. Mark L. Kraus, an internist whose group practice in Waterbury, Conn., is a referral center for patients with substance abuse disorders. He is a newly elected member of the ASAM board of directors.

“Every primary care physician has to know how to do screening and brief interventions,” said Dr. David Lewis, an internist who is a professor of community health and medicine, and a professor of alcohol and addiction studies, at Brown University, Providence, R.I.

Patient referral “is where the specialty of addiction medicine and certification come in,” he said.

Dr. Kraus agreed: “Without a doubt, this [plan to seek ABMS recognition] will enhance care. … Designated specialists who have learned the evidence-based medicine … can help all primary care docs when they need to take their patient to the next level.”

Dr. Kraus noted that “the government, the Institute of Medicine, the American Medical Association, and some insurance companies are recognizing addiction medicine. There are a lot of outside influences that will help us.”

Two pending bills—one in the House of Representatives and one in the Senate—would provide reimbursement for addiction treatment on a level equal to that for treatment of other medical conditions. Parity in compensation would make it easier to maintain a practice that emphasizes addiction medicine and would help attract more young physicians to the field, Dr. Kraus said.

Logistics of New Addiction Medicine Board Are Likely to Evolve Over Time

The planned addiction medicine board may start out as a conjoint board that is tied to existing boards, according to American Society of Addiction Medicine leaders.

The new board could eventually evolve into an independent one, in the same way that emergency medicine and nuclear medicine did after functioning for an average of 12 years as conjoint boards.

Of the 24 member boards of the American Board of Medical Specialties (ABMS), 23 are primary, meaning that they include members from that specialty only. The only exception is the American Board of Allergy and Immunology, formed in 1971 and the only current conjoint board.

There are 75 ABMS-recognized subspecialties. The newest are hospice and palliative care (pending) and sleep medicine (2006). There is also a precedent for subspecialty fields to evolve to become primary boards, such as radiology.

“We realized addiction medicine would not become a primary board. It would be difficult because of the huge cost involved and a perception of taking physicians from other specialties,” Dr. Kunz said.

The last specialty to form a primary board at inception was medical genetics, which formed in 1991 after 26 years as a self-regulated board.

“Whatever we come up with, we will have to develop a grandfather clause. But it will still have to meet ACGME [Accreditation Council for Graduate Medical Education] and ABMS criteria,” Dr. Goldsmith said.

There are big challenges ahead, he said. “What happens to people with ASAM credentials today? How will we grandfather them in?” He added, “But we realize that an ABMS-recognized specialty of addiction medicine is exactly the direction we need to go.”

MIAMI — The field of addiction medicine is preparing to take a major step to enhance its authority and expand its professional ranks.

The American Society of Addiction Medicine plans to form a certification board and seek official recognition from the American Board of Medical Specialties by the end of 2007, physicians said during a panel presentation at the society's annual conference.

Addiction medicine is self-designated as a specialty, “but we need acceptance from all medicine,” ASAM President-Elect Michael M. Miller said, explaining the plan to offer ABMS-recognized certification in addiction medicine. “Patients need to know where to find a doctor who does this, to be assured this doctor has a full array of training and … has passed an examination.”

The anticipated American Board of Addiction Medicine is likely to involve an alliance with one or more of the existing ABMS specialty boards. Details about the board and its relationship with existing boards are being worked out. (See box.)

“There is no other way to do this than to work with psychiatry, internal medicine, family medicine, and other specialists,” said Dr. Kevin Kunz, an addiction medicine specialist in Kona, Hawaii, and cochair of the ASAM Medical Specialty Action Group.

“The need for addiction medicine as a specialty is widely recognized,” Dr. Kunz said. “The science is exploding, and new therapies are available—both biologic and behavioral,” he said. Also, “better funding is possible. Policy makers are understanding that addiction is a disease and treatable.”

As part of the effort, trauma surgeons and emergency physicians also may be consulted, said Dr. Miller, medical director of the NewStart Alcohol/Drug Treatment Program at Meriter Hospital, Madison, Wis. Dr. Miller recently stepped down as cochair of the action group.

A key goal is to expand addiction medicine training beyond addiction psychiatry, said Dr. R. Jeffrey Goldsmith, professor of clinical psychiatry at the University of Cincinnati. “We don't fill all our current addiction psychiatry spots. Psychiatry is not as enthusiastic as I would like,” he said. A total of 55 of the 116 total approved addiction psychiatry residency spots were filled in 2005–2006, according to data from the Accreditation Council for Graduate Medical Education.

Most current ASAM members have board certification in an ABMS-recognized specialty, including 27% who are certified in psychiatry and 26% who are certified in primary care specialties (13% in family medicine, 12% in internal medicine, and 1% in pediatrics).

No specialty board represents addiction medicine, so the 4,162 physicians who have passed the ASAM's certification examination in addiction medicine cannot describe themselves as board certified in this field.

Board certification in addiction medicine “will give me more stature among my colleagues,” said Dr. Mark L. Kraus, an internist whose group practice in Waterbury, Conn., is a referral center for patients with substance abuse disorders. He is a newly elected member of the ASAM board of directors.

“Every primary care physician has to know how to do screening and brief interventions,” said Dr. David Lewis, an internist who is a professor of community health and medicine, and a professor of alcohol and addiction studies, at Brown University, Providence, R.I.

Patient referral “is where the specialty of addiction medicine and certification come in,” he said.

Dr. Kraus agreed: “Without a doubt, this [plan to seek ABMS recognition] will enhance care. … Designated specialists who have learned the evidence-based medicine … can help all primary care docs when they need to take their patient to the next level.”

Dr. Kraus noted that “the government, the Institute of Medicine, the American Medical Association, and some insurance companies are recognizing addiction medicine. There are a lot of outside influences that will help us.”

Two pending bills—one in the House of Representatives and one in the Senate—would provide reimbursement for addiction treatment on a level equal to that for treatment of other medical conditions. Parity in compensation would make it easier to maintain a practice that emphasizes addiction medicine and would help attract more young physicians to the field, Dr. Kraus said.

Logistics of New Addiction Medicine Board Are Likely to Evolve Over Time

The planned addiction medicine board may start out as a conjoint board that is tied to existing boards, according to American Society of Addiction Medicine leaders.

The new board could eventually evolve into an independent one, in the same way that emergency medicine and nuclear medicine did after functioning for an average of 12 years as conjoint boards.

Of the 24 member boards of the American Board of Medical Specialties (ABMS), 23 are primary, meaning that they include members from that specialty only. The only exception is the American Board of Allergy and Immunology, formed in 1971 and the only current conjoint board.

There are 75 ABMS-recognized subspecialties. The newest are hospice and palliative care (pending) and sleep medicine (2006). There is also a precedent for subspecialty fields to evolve to become primary boards, such as radiology.

“We realized addiction medicine would not become a primary board. It would be difficult because of the huge cost involved and a perception of taking physicians from other specialties,” Dr. Kunz said.

The last specialty to form a primary board at inception was medical genetics, which formed in 1991 after 26 years as a self-regulated board.

“Whatever we come up with, we will have to develop a grandfather clause. But it will still have to meet ACGME [Accreditation Council for Graduate Medical Education] and ABMS criteria,” Dr. Goldsmith said.

There are big challenges ahead, he said. “What happens to people with ASAM credentials today? How will we grandfather them in?” He added, “But we realize that an ABMS-recognized specialty of addiction medicine is exactly the direction we need to go.”

MIAMI — The field of addiction medicine is preparing to take a major step to enhance its authority and expand its professional ranks.

The American Society of Addiction Medicine plans to form a certification board and seek official recognition from the American Board of Medical Specialties by the end of 2007, physicians said during a panel presentation at the society's annual conference.

Addiction medicine is self-designated as a specialty, “but we need acceptance from all medicine,” ASAM President-Elect Michael M. Miller said, explaining the plan to offer ABMS-recognized certification in addiction medicine. “Patients need to know where to find a doctor who does this, to be assured this doctor has a full array of training and … has passed an examination.”

The anticipated American Board of Addiction Medicine is likely to involve an alliance with one or more of the existing ABMS specialty boards. Details about the board and its relationship with existing boards are being worked out. (See box.)

“There is no other way to do this than to work with psychiatry, internal medicine, family medicine, and other specialists,” said Dr. Kevin Kunz, an addiction medicine specialist in Kona, Hawaii, and cochair of the ASAM Medical Specialty Action Group.

“The need for addiction medicine as a specialty is widely recognized,” Dr. Kunz said. “The science is exploding, and new therapies are available—both biologic and behavioral,” he said. Also, “better funding is possible. Policy makers are understanding that addiction is a disease and treatable.”

As part of the effort, trauma surgeons and emergency physicians also may be consulted, said Dr. Miller, medical director of the NewStart Alcohol/Drug Treatment Program at Meriter Hospital, Madison, Wis. Dr. Miller recently stepped down as cochair of the action group.

A key goal is to expand addiction medicine training beyond addiction psychiatry, said Dr. R. Jeffrey Goldsmith, professor of clinical psychiatry at the University of Cincinnati. “We don't fill all our current addiction psychiatry spots. Psychiatry is not as enthusiastic as I would like,” he said. A total of 55 of the 116 total approved addiction psychiatry residency spots were filled in 2005–2006, according to data from the Accreditation Council for Graduate Medical Education.

Most current ASAM members have board certification in an ABMS-recognized specialty, including 27% who are certified in psychiatry and 26% who are certified in primary care specialties (13% in family medicine, 12% in internal medicine, and 1% in pediatrics).

No specialty board represents addiction medicine, so the 4,162 physicians who have passed the ASAM's certification examination in addiction medicine cannot describe themselves as board certified in this field.

Board certification in addiction medicine “will give me more stature among my colleagues,” said Dr. Mark L. Kraus, an internist whose group practice in Waterbury, Conn., is a referral center for patients with substance abuse disorders. He is a newly elected member of the ASAM board of directors.

“Every primary care physician has to know how to do screening and brief interventions,” said Dr. David Lewis, an internist who is a professor of community health and medicine, and a professor of alcohol and addiction studies, at Brown University, Providence, R.I.

Patient referral “is where the specialty of addiction medicine and certification come in,” he said.

Dr. Kraus agreed: “Without a doubt, this [plan to seek ABMS recognition] will enhance care. … Designated specialists who have learned the evidence-based medicine … can help all primary care docs when they need to take their patient to the next level.”

Dr. Kraus noted that “the government, the Institute of Medicine, the American Medical Association, and some insurance companies are recognizing addiction medicine. There are a lot of outside influences that will help us.”

Two pending bills—one in the House of Representatives and one in the Senate—would provide reimbursement for addiction treatment on a level equal to that for treatment of other medical conditions. Parity in compensation would make it easier to maintain a practice that emphasizes addiction medicine and would help attract more young physicians to the field, Dr. Kraus said.

Logistics of New Addiction Medicine Board Are Likely to Evolve Over Time

The planned addiction medicine board may start out as a conjoint board that is tied to existing boards, according to American Society of Addiction Medicine leaders.

The new board could eventually evolve into an independent one, in the same way that emergency medicine and nuclear medicine did after functioning for an average of 12 years as conjoint boards.

Of the 24 member boards of the American Board of Medical Specialties (ABMS), 23 are primary, meaning that they include members from that specialty only. The only exception is the American Board of Allergy and Immunology, formed in 1971 and the only current conjoint board.

There are 75 ABMS-recognized subspecialties. The newest are hospice and palliative care (pending) and sleep medicine (2006). There is also a precedent for subspecialty fields to evolve to become primary boards, such as radiology.

“We realized addiction medicine would not become a primary board. It would be difficult because of the huge cost involved and a perception of taking physicians from other specialties,” Dr. Kunz said.

The last specialty to form a primary board at inception was medical genetics, which formed in 1991 after 26 years as a self-regulated board.

“Whatever we come up with, we will have to develop a grandfather clause. But it will still have to meet ACGME [Accreditation Council for Graduate Medical Education] and ABMS criteria,” Dr. Goldsmith said.

There are big challenges ahead, he said. “What happens to people with ASAM credentials today? How will we grandfather them in?” He added, “But we realize that an ABMS-recognized specialty of addiction medicine is exactly the direction we need to go.”

MIAMI BEACH — Nearly a year after the approval of a contraceptive implant, its advantages and disadvantages are becoming better known, but there are still no data on its efficacy in overweight or obese women, according to a presentation at an ob.gyn. conference sponsored by the University of Miami.

The Food and Drug Administration cleared Implanon (Organon International) for marketing in July 2006. It is the first single-rod, 68-mg etonogestrel, subdermal implant. The core is 40% ethylene vinyl acetate, which provides a slow, steady release of progestin for up to 3 years, according to clinical trials.

However, women who weighed more than 130% of their ideal body weight were excluded from the preapproval studies, said Dr. Paul M. Norris, adding that for physicians, such an exclusion would be “very impractical” in the United States.

Implanon replaces the six-rod Norplant device, which was removed from the market following reports of product migration and side effects, he said. “The data on Norplant suggested it was still efficacious, although less so, in overweight patients. But I am not sure you can apply this finding to Implanon.”

Implanon is inserted in the subepidermal groove of a woman's arm between her biceps and triceps, about 6–8 inches up from the crux of elbow. Physicians can order Implanon only if they have completed a training program on insertion and removal sponsored by the manufacturer.

“The device to insert the implant looks like the Depo Provera syringe,” said Dr. Norris, who is on the obstetrics and gynecology faculty at the University of Miami. He is also on the speakers' bureau for Organon. “The blue placebo injector for practice has a pregnancy rate of about 85% so make sure you are using the white injector with the active ingredient!”

Insertion time is faster than the Norplant, about a mean of 1 minute, compared with 4 minutes for the Norplant, The 4 cm-long, 2 mm-diameter Implanon rod is not radio-opaque. “If you lose an implant, you cannot palpate it 3 years later. It is easy to pick up on ultrasound, but you need at least a 10-MHz wand, which is not common in most [primary care physician] offices,” he said.

Implanon's contraceptive effects are reversible—a woman's fertility quickly returns after removal, according to the manufacturer.

The mean removal time for Implanon is 3 minutes, compared with 11 minutes for Norplant, Dr. Norris said. “This is the mean, and some cases can take almost an hour.” In clinical trials, 1% of 923 participants experienced complications at implant insertion and 1.7% had complications at implant removal.

Contraindications include a known or suspected pregnancy. “It likely won't hurt the pregnancy, but it will not prevent a pregnancy if it is already there,” Dr. Norris said. History of or current thrombotic disease, history of breast cancer, hepatic tumors, active liver disease, and undiagnosed abnormal genital bleeding are other contraindications. “Make sure there is nothing serious going on before you place the Implanon.”

Bleeding changes were the most common reason women chose to stop Implanon treatment in clinical trials (cited by 11% of participants). Irregular bleeding and spotting is a common side effect, Dr. Norris said. In the studies, patients using Implanon reported an average of 18 days of bleeding or spotting every 90 days

Prolonged bleeding occurs in almost 20% of patients, so you will have some patients who are unhappy, Dr. Norris said. “The bottom line is you counsel patients about the unpredictable pattern and frequency of bleeding.”

In terms of contraceptive efficacy, six pregnancies were reported in 20,648 cycles in the clinical trials. These patients were likely to have been already pregnant when they had the implant inserted, Dr. Norris said.

MIAMI BEACH — Nearly a year after the approval of a contraceptive implant, its advantages and disadvantages are becoming better known, but there are still no data on its efficacy in overweight or obese women, according to a presentation at an ob.gyn. conference sponsored by the University of Miami.

The Food and Drug Administration cleared Implanon (Organon International) for marketing in July 2006. It is the first single-rod, 68-mg etonogestrel, subdermal implant. The core is 40% ethylene vinyl acetate, which provides a slow, steady release of progestin for up to 3 years, according to clinical trials.

However, women who weighed more than 130% of their ideal body weight were excluded from the preapproval studies, said Dr. Paul M. Norris, adding that for physicians, such an exclusion would be “very impractical” in the United States.

Implanon replaces the six-rod Norplant device, which was removed from the market following reports of product migration and side effects, he said. “The data on Norplant suggested it was still efficacious, although less so, in overweight patients. But I am not sure you can apply this finding to Implanon.”

Implanon is inserted in the subepidermal groove of a woman's arm between her biceps and triceps, about 6–8 inches up from the crux of elbow. Physicians can order Implanon only if they have completed a training program on insertion and removal sponsored by the manufacturer.

“The device to insert the implant looks like the Depo Provera syringe,” said Dr. Norris, who is on the obstetrics and gynecology faculty at the University of Miami. He is also on the speakers' bureau for Organon. “The blue placebo injector for practice has a pregnancy rate of about 85% so make sure you are using the white injector with the active ingredient!”

Insertion time is faster than the Norplant, about a mean of 1 minute, compared with 4 minutes for the Norplant, The 4 cm-long, 2 mm-diameter Implanon rod is not radio-opaque. “If you lose an implant, you cannot palpate it 3 years later. It is easy to pick up on ultrasound, but you need at least a 10-MHz wand, which is not common in most [primary care physician] offices,” he said.

Implanon's contraceptive effects are reversible—a woman's fertility quickly returns after removal, according to the manufacturer.

The mean removal time for Implanon is 3 minutes, compared with 11 minutes for Norplant, Dr. Norris said. “This is the mean, and some cases can take almost an hour.” In clinical trials, 1% of 923 participants experienced complications at implant insertion and 1.7% had complications at implant removal.

Contraindications include a known or suspected pregnancy. “It likely won't hurt the pregnancy, but it will not prevent a pregnancy if it is already there,” Dr. Norris said. History of or current thrombotic disease, history of breast cancer, hepatic tumors, active liver disease, and undiagnosed abnormal genital bleeding are other contraindications. “Make sure there is nothing serious going on before you place the Implanon.”

Bleeding changes were the most common reason women chose to stop Implanon treatment in clinical trials (cited by 11% of participants). Irregular bleeding and spotting is a common side effect, Dr. Norris said. In the studies, patients using Implanon reported an average of 18 days of bleeding or spotting every 90 days

Prolonged bleeding occurs in almost 20% of patients, so you will have some patients who are unhappy, Dr. Norris said. “The bottom line is you counsel patients about the unpredictable pattern and frequency of bleeding.”

In terms of contraceptive efficacy, six pregnancies were reported in 20,648 cycles in the clinical trials. These patients were likely to have been already pregnant when they had the implant inserted, Dr. Norris said.

MIAMI BEACH — Nearly a year after the approval of a contraceptive implant, its advantages and disadvantages are becoming better known, but there are still no data on its efficacy in overweight or obese women, according to a presentation at an ob.gyn. conference sponsored by the University of Miami.

The Food and Drug Administration cleared Implanon (Organon International) for marketing in July 2006. It is the first single-rod, 68-mg etonogestrel, subdermal implant. The core is 40% ethylene vinyl acetate, which provides a slow, steady release of progestin for up to 3 years, according to clinical trials.

However, women who weighed more than 130% of their ideal body weight were excluded from the preapproval studies, said Dr. Paul M. Norris, adding that for physicians, such an exclusion would be “very impractical” in the United States.

Implanon replaces the six-rod Norplant device, which was removed from the market following reports of product migration and side effects, he said. “The data on Norplant suggested it was still efficacious, although less so, in overweight patients. But I am not sure you can apply this finding to Implanon.”

Implanon is inserted in the subepidermal groove of a woman's arm between her biceps and triceps, about 6–8 inches up from the crux of elbow. Physicians can order Implanon only if they have completed a training program on insertion and removal sponsored by the manufacturer.

“The device to insert the implant looks like the Depo Provera syringe,” said Dr. Norris, who is on the obstetrics and gynecology faculty at the University of Miami. He is also on the speakers' bureau for Organon. “The blue placebo injector for practice has a pregnancy rate of about 85% so make sure you are using the white injector with the active ingredient!”

Insertion time is faster than the Norplant, about a mean of 1 minute, compared with 4 minutes for the Norplant, The 4 cm-long, 2 mm-diameter Implanon rod is not radio-opaque. “If you lose an implant, you cannot palpate it 3 years later. It is easy to pick up on ultrasound, but you need at least a 10-MHz wand, which is not common in most [primary care physician] offices,” he said.

Implanon's contraceptive effects are reversible—a woman's fertility quickly returns after removal, according to the manufacturer.

The mean removal time for Implanon is 3 minutes, compared with 11 minutes for Norplant, Dr. Norris said. “This is the mean, and some cases can take almost an hour.” In clinical trials, 1% of 923 participants experienced complications at implant insertion and 1.7% had complications at implant removal.

Contraindications include a known or suspected pregnancy. “It likely won't hurt the pregnancy, but it will not prevent a pregnancy if it is already there,” Dr. Norris said. History of or current thrombotic disease, history of breast cancer, hepatic tumors, active liver disease, and undiagnosed abnormal genital bleeding are other contraindications. “Make sure there is nothing serious going on before you place the Implanon.”

Bleeding changes were the most common reason women chose to stop Implanon treatment in clinical trials (cited by 11% of participants). Irregular bleeding and spotting is a common side effect, Dr. Norris said. In the studies, patients using Implanon reported an average of 18 days of bleeding or spotting every 90 days

Prolonged bleeding occurs in almost 20% of patients, so you will have some patients who are unhappy, Dr. Norris said. “The bottom line is you counsel patients about the unpredictable pattern and frequency of bleeding.”

In terms of contraceptive efficacy, six pregnancies were reported in 20,648 cycles in the clinical trials. These patients were likely to have been already pregnant when they had the implant inserted, Dr. Norris said.

MIAMI – The field of addiction medicine is preparing to take a major step to enhance its authority and expand its professional ranks.

The American Society of Addiction Medicine plans to form a certification board and seek official recognition from the American Board of Medical Specialties by the end of 2007, physicians said during a panel presentation at the society's annual conference.

Addiction medicine is self-designated as a specialty, “but we need acceptance from all medicine,” ASAM President-Elect Dr. Michael M. Miller said, explaining the plan to offer ABMS-recognized certification in addiction medicine. “Patients need to know where to find a doctor who does this, to be assured this doctor has a full array of training and … has passed an examination.”

The anticipated American Board of Addiction Medicine is likely to involve an alliance with one or more of the existing ABMS specialty boards. Details about the board and its relationship with existing boards are being worked out. (See box.)

“There is no other way to do this than to work with psychiatry, internal medicine, family medicine, and other specialists,” said Dr. Kevin Kunz, an addiction medicine specialist in Kona, Hawaii, and cochair of the ASAM Medical Specialty Action Group.

“The need for addiction medicine as a specialty is widely recognized,” Dr. Kunz said. “The science is exploding, and new therapies are available–both biologic and behavioral,” he said. Also, “better funding is possible. Policy makers are understanding that addiction is a disease and treatable.”

As part of the effort, trauma surgeons and emergency physicians also may be consulted, said Dr. Miller, medical director of the NewStart Alcohol/Drug Treatment Program at Meriter Hospital, Madison, Wis. Dr. Miller recently stepped down as cochair of the action group.

A key goal is to expand addiction medicine training beyond addiction psychiatry, said Dr. R. Jeffrey Goldsmith, professor of clinical psychiatry at the University of Cincinnati. “We don't fill all our current addiction psychiatry spots. Psychiatry is not as enthusiastic as I would like,” he said.

A total of 55 of the 116 total approved addiction psychiatry residency spots were filled in 2005–2006, according to data from the Accreditation Council for Graduate Medical Education.

Most current ASAM members have board certification in an ABMS-recognized specialty, including 27% who are certified in psychiatry and 26% who are certified in primary care specialties (13% in family medicine, 12% in internal medicine, and 1% in pediatrics).

No specialty board represents addiction medicine, so the 4,162 physicians who have passed the ASAM's certification examination in addiction medicine cannot describe themselves as board certified in this field.

Board certification in addiction medicine “will give me more stature among my colleagues,” said Dr. Mark L. Kraus, an internist whose group practice in Waterbury, Conn., is a referral center for patients with substance abuse disorders. He is a newly elected member of the ASAM board of directors.

“Every primary care physician has to know how to do screening and brief interventions,” said Dr. David Lewis, an internist who is a professor of community health and medicine, and a professor of alcohol and addiction studies, at Brown University, Providence, R.I.

Patient referral “is where the specialty of addiction medicine and certification come in,” he said.

Dr. Kraus agreed: “Without a doubt, this [plan to seek ABMS recognition] will enhance care. … Designated specialists who have learned the evidence-based medicine … can help all primary care docs when they need to take their patient to the next level.” Dr. Kraus noted that “the government, the Institute of Medicine, the American Medical Association, and some insurance companies are recognizing addiction medicine. There are a lot of outside influences that will help us.”

Two pending bills–one in the House of Representatives and one in the Senate–would provide reimbursement for addiction treatment on a level equal to that for treatment of other medical conditions.

Parity in compensation would make it easier to maintain a practice that emphasizes addiction medicine and would help attract more young physicians to the field, Dr. Kraus said.

New Board Likely to Piggyback on Others

The planned addiction medicine board might start out as a conjoint board that is tied to existing boards, according to American Society of Addiction Medicine leaders involved in the effort.

The new board could eventually evolve into an independent one, in the same way that emergency medicine and nuclear medicine did after functioning for an average of 12 years as conjoint boards.

Of the 24 member boards of the American Board of Medical Specialties (ABMS), 23 are primary, meaning that they include members from that specialty only. The only exception is the American Board of Allergy and Immunology, formed in 1971 and the only current conjoint board.

There are 75 ABMS-recognized subspecialties. The newest are hospice and palliative care (pending) and sleep medicine (2006). There is also a precedent for subspecialty fields to evolve over time to become primary boards, such as radiology.

“We realized addiction medicine would not become a primary board. It would be difficult because of the huge cost involved and a perception of taking physicians from other specialties,” Dr. Kunz said. The last specialty to form a primary board at inception was medical genetics, which formed in 1991 after 26 years as a self-regulated board.

“Whatever we come up with, we will have to develop a grandfather clause. But it will still have to meet ACGME [Accreditation Council for Graduate Medical Education] and ABMS criteria,” Dr. Goldsmith said.

“We know there are some big challenges out there,” Dr. Miller said. “What happens to people with ASAM credentials today? How will we grandfather them in?” He added, “But we realize that an ABMS-recognized specialty of addiction medicine is exactly the direction we need to go.” There will be an opportunity for residents in addiction psychiatry to take the certification exam as well.

Defining the scope of addiction medicine practice and its core competencies are among the next steps. A dialogue with other physician specialty societies and boards is planned as well, with the ultimate goal of certifying individual physicians starting in 2009.

MIAMI – The field of addiction medicine is preparing to take a major step to enhance its authority and expand its professional ranks.

The American Society of Addiction Medicine plans to form a certification board and seek official recognition from the American Board of Medical Specialties by the end of 2007, physicians said during a panel presentation at the society's annual conference.

Addiction medicine is self-designated as a specialty, “but we need acceptance from all medicine,” ASAM President-Elect Dr. Michael M. Miller said, explaining the plan to offer ABMS-recognized certification in addiction medicine. “Patients need to know where to find a doctor who does this, to be assured this doctor has a full array of training and … has passed an examination.”

The anticipated American Board of Addiction Medicine is likely to involve an alliance with one or more of the existing ABMS specialty boards. Details about the board and its relationship with existing boards are being worked out. (See box.)

“There is no other way to do this than to work with psychiatry, internal medicine, family medicine, and other specialists,” said Dr. Kevin Kunz, an addiction medicine specialist in Kona, Hawaii, and cochair of the ASAM Medical Specialty Action Group.

“The need for addiction medicine as a specialty is widely recognized,” Dr. Kunz said. “The science is exploding, and new therapies are available–both biologic and behavioral,” he said. Also, “better funding is possible. Policy makers are understanding that addiction is a disease and treatable.”

As part of the effort, trauma surgeons and emergency physicians also may be consulted, said Dr. Miller, medical director of the NewStart Alcohol/Drug Treatment Program at Meriter Hospital, Madison, Wis. Dr. Miller recently stepped down as cochair of the action group.

A key goal is to expand addiction medicine training beyond addiction psychiatry, said Dr. R. Jeffrey Goldsmith, professor of clinical psychiatry at the University of Cincinnati. “We don't fill all our current addiction psychiatry spots. Psychiatry is not as enthusiastic as I would like,” he said.

A total of 55 of the 116 total approved addiction psychiatry residency spots were filled in 2005–2006, according to data from the Accreditation Council for Graduate Medical Education.

Most current ASAM members have board certification in an ABMS-recognized specialty, including 27% who are certified in psychiatry and 26% who are certified in primary care specialties (13% in family medicine, 12% in internal medicine, and 1% in pediatrics).

No specialty board represents addiction medicine, so the 4,162 physicians who have passed the ASAM's certification examination in addiction medicine cannot describe themselves as board certified in this field.

Board certification in addiction medicine “will give me more stature among my colleagues,” said Dr. Mark L. Kraus, an internist whose group practice in Waterbury, Conn., is a referral center for patients with substance abuse disorders. He is a newly elected member of the ASAM board of directors.

“Every primary care physician has to know how to do screening and brief interventions,” said Dr. David Lewis, an internist who is a professor of community health and medicine, and a professor of alcohol and addiction studies, at Brown University, Providence, R.I.

Patient referral “is where the specialty of addiction medicine and certification come in,” he said.

Dr. Kraus agreed: “Without a doubt, this [plan to seek ABMS recognition] will enhance care. … Designated specialists who have learned the evidence-based medicine … can help all primary care docs when they need to take their patient to the next level.” Dr. Kraus noted that “the government, the Institute of Medicine, the American Medical Association, and some insurance companies are recognizing addiction medicine. There are a lot of outside influences that will help us.”

Two pending bills–one in the House of Representatives and one in the Senate–would provide reimbursement for addiction treatment on a level equal to that for treatment of other medical conditions.

Parity in compensation would make it easier to maintain a practice that emphasizes addiction medicine and would help attract more young physicians to the field, Dr. Kraus said.

New Board Likely to Piggyback on Others

The planned addiction medicine board might start out as a conjoint board that is tied to existing boards, according to American Society of Addiction Medicine leaders involved in the effort.

The new board could eventually evolve into an independent one, in the same way that emergency medicine and nuclear medicine did after functioning for an average of 12 years as conjoint boards.

Of the 24 member boards of the American Board of Medical Specialties (ABMS), 23 are primary, meaning that they include members from that specialty only. The only exception is the American Board of Allergy and Immunology, formed in 1971 and the only current conjoint board.

There are 75 ABMS-recognized subspecialties. The newest are hospice and palliative care (pending) and sleep medicine (2006). There is also a precedent for subspecialty fields to evolve over time to become primary boards, such as radiology.

“We realized addiction medicine would not become a primary board. It would be difficult because of the huge cost involved and a perception of taking physicians from other specialties,” Dr. Kunz said. The last specialty to form a primary board at inception was medical genetics, which formed in 1991 after 26 years as a self-regulated board.

“Whatever we come up with, we will have to develop a grandfather clause. But it will still have to meet ACGME [Accreditation Council for Graduate Medical Education] and ABMS criteria,” Dr. Goldsmith said.

“We know there are some big challenges out there,” Dr. Miller said. “What happens to people with ASAM credentials today? How will we grandfather them in?” He added, “But we realize that an ABMS-recognized specialty of addiction medicine is exactly the direction we need to go.” There will be an opportunity for residents in addiction psychiatry to take the certification exam as well.

Defining the scope of addiction medicine practice and its core competencies are among the next steps. A dialogue with other physician specialty societies and boards is planned as well, with the ultimate goal of certifying individual physicians starting in 2009.

MIAMI – The field of addiction medicine is preparing to take a major step to enhance its authority and expand its professional ranks.

The American Society of Addiction Medicine plans to form a certification board and seek official recognition from the American Board of Medical Specialties by the end of 2007, physicians said during a panel presentation at the society's annual conference.

Addiction medicine is self-designated as a specialty, “but we need acceptance from all medicine,” ASAM President-Elect Dr. Michael M. Miller said, explaining the plan to offer ABMS-recognized certification in addiction medicine. “Patients need to know where to find a doctor who does this, to be assured this doctor has a full array of training and … has passed an examination.”

The anticipated American Board of Addiction Medicine is likely to involve an alliance with one or more of the existing ABMS specialty boards. Details about the board and its relationship with existing boards are being worked out. (See box.)

“There is no other way to do this than to work with psychiatry, internal medicine, family medicine, and other specialists,” said Dr. Kevin Kunz, an addiction medicine specialist in Kona, Hawaii, and cochair of the ASAM Medical Specialty Action Group.

“The need for addiction medicine as a specialty is widely recognized,” Dr. Kunz said. “The science is exploding, and new therapies are available–both biologic and behavioral,” he said. Also, “better funding is possible. Policy makers are understanding that addiction is a disease and treatable.”

As part of the effort, trauma surgeons and emergency physicians also may be consulted, said Dr. Miller, medical director of the NewStart Alcohol/Drug Treatment Program at Meriter Hospital, Madison, Wis. Dr. Miller recently stepped down as cochair of the action group.

A key goal is to expand addiction medicine training beyond addiction psychiatry, said Dr. R. Jeffrey Goldsmith, professor of clinical psychiatry at the University of Cincinnati. “We don't fill all our current addiction psychiatry spots. Psychiatry is not as enthusiastic as I would like,” he said.

A total of 55 of the 116 total approved addiction psychiatry residency spots were filled in 2005–2006, according to data from the Accreditation Council for Graduate Medical Education.

Most current ASAM members have board certification in an ABMS-recognized specialty, including 27% who are certified in psychiatry and 26% who are certified in primary care specialties (13% in family medicine, 12% in internal medicine, and 1% in pediatrics).

No specialty board represents addiction medicine, so the 4,162 physicians who have passed the ASAM's certification examination in addiction medicine cannot describe themselves as board certified in this field.

Board certification in addiction medicine “will give me more stature among my colleagues,” said Dr. Mark L. Kraus, an internist whose group practice in Waterbury, Conn., is a referral center for patients with substance abuse disorders. He is a newly elected member of the ASAM board of directors.

“Every primary care physician has to know how to do screening and brief interventions,” said Dr. David Lewis, an internist who is a professor of community health and medicine, and a professor of alcohol and addiction studies, at Brown University, Providence, R.I.

Patient referral “is where the specialty of addiction medicine and certification come in,” he said.

Dr. Kraus agreed: “Without a doubt, this [plan to seek ABMS recognition] will enhance care. … Designated specialists who have learned the evidence-based medicine … can help all primary care docs when they need to take their patient to the next level.” Dr. Kraus noted that “the government, the Institute of Medicine, the American Medical Association, and some insurance companies are recognizing addiction medicine. There are a lot of outside influences that will help us.”

Two pending bills–one in the House of Representatives and one in the Senate–would provide reimbursement for addiction treatment on a level equal to that for treatment of other medical conditions.

Parity in compensation would make it easier to maintain a practice that emphasizes addiction medicine and would help attract more young physicians to the field, Dr. Kraus said.

New Board Likely to Piggyback on Others

The planned addiction medicine board might start out as a conjoint board that is tied to existing boards, according to American Society of Addiction Medicine leaders involved in the effort.

The new board could eventually evolve into an independent one, in the same way that emergency medicine and nuclear medicine did after functioning for an average of 12 years as conjoint boards.

Of the 24 member boards of the American Board of Medical Specialties (ABMS), 23 are primary, meaning that they include members from that specialty only. The only exception is the American Board of Allergy and Immunology, formed in 1971 and the only current conjoint board.

There are 75 ABMS-recognized subspecialties. The newest are hospice and palliative care (pending) and sleep medicine (2006). There is also a precedent for subspecialty fields to evolve over time to become primary boards, such as radiology.

“We realized addiction medicine would not become a primary board. It would be difficult because of the huge cost involved and a perception of taking physicians from other specialties,” Dr. Kunz said. The last specialty to form a primary board at inception was medical genetics, which formed in 1991 after 26 years as a self-regulated board.

“Whatever we come up with, we will have to develop a grandfather clause. But it will still have to meet ACGME [Accreditation Council for Graduate Medical Education] and ABMS criteria,” Dr. Goldsmith said.

“We know there are some big challenges out there,” Dr. Miller said. “What happens to people with ASAM credentials today? How will we grandfather them in?” He added, “But we realize that an ABMS-recognized specialty of addiction medicine is exactly the direction we need to go.” There will be an opportunity for residents in addiction psychiatry to take the certification exam as well.

Defining the scope of addiction medicine practice and its core competencies are among the next steps. A dialogue with other physician specialty societies and boards is planned as well, with the ultimate goal of certifying individual physicians starting in 2009.

MIAMI – College is “ground zero” for nonmedical use of prescription stimulants.

But most college students who use stimulants do so only on occasion to enhance studying or boost concentration. More frequent users are at increased risk for abusing other substances and for poor academic performance, according to two studies presented at the annual conference of the American Society for Addiction Medicine.

“A preponderance of use is reported for study, focus, or work, in contrast to 'getting high' or 'feeling good,'” Dr. Robert L. DuPont said.

Another distinction from other drugs of abuse is that most students obtain the stimulants for free from someone else. Researchers for a 2004 Harris Interactive Study compared about 1,900 online survey respondents who reported no nonmedical use of a methylphenidate product with 110 who reported such use. They found that 94% who used Ritalin (methylphenidate) for cognitive enhancement obtained it for free, as did 100% of people who reported taking Concerta (methylphenidate).

“This does not involve drug dealers. The transfer to the user is not related to any cost whatsoever, so it's a different pattern than we see with most drugs of abuse. It's quite striking,” said Dr. DuPont, president of the Institute for Behavior and Health, a nonprofit drug-policy research office.

“I don't think a lot of patients realize that giving controlled substances to someone else is illegal,” said Dr. DuPont, who served as the first director of the National Institute on Drug Abuse. “We need better awareness that there is a medical contract about use.”

Five major conclusions have emerged from a series of meetings held since 2003 by the Institute for Behavior and Health advisory committee on nonmedical use of stimulants:

▸ Nonmedical use of prescription stimulants is a substantial but unique part of drug abuse on college campuses.

▸ More than 75% of college students who report using stimulants nonmedically have done so 10 or fewer times in the previous year.

▸ Most use these agents to facilitate studying or concentration.

▸ More frequent nonmedical users of prescription stimulants on college campuses also use other illegal drugs, drink alcohol excessively, smoke cigarettes, and are likely to have lower grades than nonusers. “These are the people at the bottom of the academic population. They have higher rates of missing classes, and they use stimulants to catch up,” Dr. DuPont said.

▸ Adderall (amphetamine/dextroamphetamine) is associated with a substantially higher rate of nonmedical use, followed by Ritalin and Concerta, Dr. DuPont said. “Concerta is associated with the lowest abuse in this area, possibly because the capsule form is particularly resistant to abuse.”

A higher percentage of Ritalin users, 77%, reported using other drugs nonmedically in the previous 12 months, compared with 46% of Concerta users, according to the Harris study. In addition, 88% reported they used Ritalin for studying, compared with 28% of Concerta users.

Other researchers enrolled 1,253 randomly selected, first-year college students in the College Life Study in the fall of 2004. “This is a more sophisticated, ongoing study,” Dr. DuPont said. “It is a longitudinal look at all drug use over 4 years of college.”

A total of 45 participants were being treated for attention-deficit/hyperactivity disorder at baseline. “A higher percentage of those with ADHD use methylphenidate [nonmedically] more than 10 times per year,” Dr. DuPont said.

Students with an ADHD diagnosis were more likely to inhale a prescription stimulant, with 29% reporting doing so, compared with 14% of those without an ADHD diagnosis. They were also more likely to report marijuana use (77% versus 61%) and cocaine use (14% versus 5%).

“We have a lot of kids on campus complaining of learning disabilities at student health [services] to get stimulant prescriptions to counteract the memory problems associated with marijuana use,” Dr. Mark S. Gold said in another presentation at the meeting. Dr. Gold is professor of psychiatry, neuroscience, and community health and family medicine at the University of Florida, Gainesville. “We have a lot of methylphenidate use on college campuses,” Dr. Gold said. “This can give students an unfair advantage on the SAT and other tests, and could explain some of the disparities in test scores we see in some populations.”

MIAMI – College is “ground zero” for nonmedical use of prescription stimulants.

But most college students who use stimulants do so only on occasion to enhance studying or boost concentration. More frequent users are at increased risk for abusing other substances and for poor academic performance, according to two studies presented at the annual conference of the American Society for Addiction Medicine.

“A preponderance of use is reported for study, focus, or work, in contrast to 'getting high' or 'feeling good,'” Dr. Robert L. DuPont said.

Another distinction from other drugs of abuse is that most students obtain the stimulants for free from someone else. Researchers for a 2004 Harris Interactive Study compared about 1,900 online survey respondents who reported no nonmedical use of a methylphenidate product with 110 who reported such use. They found that 94% who used Ritalin (methylphenidate) for cognitive enhancement obtained it for free, as did 100% of people who reported taking Concerta (methylphenidate).

“This does not involve drug dealers. The transfer to the user is not related to any cost whatsoever, so it's a different pattern than we see with most drugs of abuse. It's quite striking,” said Dr. DuPont, president of the Institute for Behavior and Health, a nonprofit drug-policy research office.

“I don't think a lot of patients realize that giving controlled substances to someone else is illegal,” said Dr. DuPont, who served as the first director of the National Institute on Drug Abuse. “We need better awareness that there is a medical contract about use.”

Five major conclusions have emerged from a series of meetings held since 2003 by the Institute for Behavior and Health advisory committee on nonmedical use of stimulants:

▸ Nonmedical use of prescription stimulants is a substantial but unique part of drug abuse on college campuses.

▸ More than 75% of college students who report using stimulants nonmedically have done so 10 or fewer times in the previous year.

▸ Most use these agents to facilitate studying or concentration.

▸ More frequent nonmedical users of prescription stimulants on college campuses also use other illegal drugs, drink alcohol excessively, smoke cigarettes, and are likely to have lower grades than nonusers. “These are the people at the bottom of the academic population. They have higher rates of missing classes, and they use stimulants to catch up,” Dr. DuPont said.

▸ Adderall (amphetamine/dextroamphetamine) is associated with a substantially higher rate of nonmedical use, followed by Ritalin and Concerta, Dr. DuPont said. “Concerta is associated with the lowest abuse in this area, possibly because the capsule form is particularly resistant to abuse.”

A higher percentage of Ritalin users, 77%, reported using other drugs nonmedically in the previous 12 months, compared with 46% of Concerta users, according to the Harris study. In addition, 88% reported they used Ritalin for studying, compared with 28% of Concerta users.

Other researchers enrolled 1,253 randomly selected, first-year college students in the College Life Study in the fall of 2004. “This is a more sophisticated, ongoing study,” Dr. DuPont said. “It is a longitudinal look at all drug use over 4 years of college.”

A total of 45 participants were being treated for attention-deficit/hyperactivity disorder at baseline. “A higher percentage of those with ADHD use methylphenidate [nonmedically] more than 10 times per year,” Dr. DuPont said.

Students with an ADHD diagnosis were more likely to inhale a prescription stimulant, with 29% reporting doing so, compared with 14% of those without an ADHD diagnosis. They were also more likely to report marijuana use (77% versus 61%) and cocaine use (14% versus 5%).

“We have a lot of kids on campus complaining of learning disabilities at student health [services] to get stimulant prescriptions to counteract the memory problems associated with marijuana use,” Dr. Mark S. Gold said in another presentation at the meeting. Dr. Gold is professor of psychiatry, neuroscience, and community health and family medicine at the University of Florida, Gainesville. “We have a lot of methylphenidate use on college campuses,” Dr. Gold said. “This can give students an unfair advantage on the SAT and other tests, and could explain some of the disparities in test scores we see in some populations.”

MIAMI – College is “ground zero” for nonmedical use of prescription stimulants.

But most college students who use stimulants do so only on occasion to enhance studying or boost concentration. More frequent users are at increased risk for abusing other substances and for poor academic performance, according to two studies presented at the annual conference of the American Society for Addiction Medicine.

“A preponderance of use is reported for study, focus, or work, in contrast to 'getting high' or 'feeling good,'” Dr. Robert L. DuPont said.

Another distinction from other drugs of abuse is that most students obtain the stimulants for free from someone else. Researchers for a 2004 Harris Interactive Study compared about 1,900 online survey respondents who reported no nonmedical use of a methylphenidate product with 110 who reported such use. They found that 94% who used Ritalin (methylphenidate) for cognitive enhancement obtained it for free, as did 100% of people who reported taking Concerta (methylphenidate).

“This does not involve drug dealers. The transfer to the user is not related to any cost whatsoever, so it's a different pattern than we see with most drugs of abuse. It's quite striking,” said Dr. DuPont, president of the Institute for Behavior and Health, a nonprofit drug-policy research office.

“I don't think a lot of patients realize that giving controlled substances to someone else is illegal,” said Dr. DuPont, who served as the first director of the National Institute on Drug Abuse. “We need better awareness that there is a medical contract about use.”

Five major conclusions have emerged from a series of meetings held since 2003 by the Institute for Behavior and Health advisory committee on nonmedical use of stimulants:

▸ Nonmedical use of prescription stimulants is a substantial but unique part of drug abuse on college campuses.

▸ More than 75% of college students who report using stimulants nonmedically have done so 10 or fewer times in the previous year.

▸ Most use these agents to facilitate studying or concentration.

▸ More frequent nonmedical users of prescription stimulants on college campuses also use other illegal drugs, drink alcohol excessively, smoke cigarettes, and are likely to have lower grades than nonusers. “These are the people at the bottom of the academic population. They have higher rates of missing classes, and they use stimulants to catch up,” Dr. DuPont said.

▸ Adderall (amphetamine/dextroamphetamine) is associated with a substantially higher rate of nonmedical use, followed by Ritalin and Concerta, Dr. DuPont said. “Concerta is associated with the lowest abuse in this area, possibly because the capsule form is particularly resistant to abuse.”

A higher percentage of Ritalin users, 77%, reported using other drugs nonmedically in the previous 12 months, compared with 46% of Concerta users, according to the Harris study. In addition, 88% reported they used Ritalin for studying, compared with 28% of Concerta users.

Other researchers enrolled 1,253 randomly selected, first-year college students in the College Life Study in the fall of 2004. “This is a more sophisticated, ongoing study,” Dr. DuPont said. “It is a longitudinal look at all drug use over 4 years of college.”

A total of 45 participants were being treated for attention-deficit/hyperactivity disorder at baseline. “A higher percentage of those with ADHD use methylphenidate [nonmedically] more than 10 times per year,” Dr. DuPont said.

Students with an ADHD diagnosis were more likely to inhale a prescription stimulant, with 29% reporting doing so, compared with 14% of those without an ADHD diagnosis. They were also more likely to report marijuana use (77% versus 61%) and cocaine use (14% versus 5%).

“We have a lot of kids on campus complaining of learning disabilities at student health [services] to get stimulant prescriptions to counteract the memory problems associated with marijuana use,” Dr. Mark S. Gold said in another presentation at the meeting. Dr. Gold is professor of psychiatry, neuroscience, and community health and family medicine at the University of Florida, Gainesville. “We have a lot of methylphenidate use on college campuses,” Dr. Gold said. “This can give students an unfair advantage on the SAT and other tests, and could explain some of the disparities in test scores we see in some populations.”

MIAMI – Co-occurrence of mental health and substance use disorders is a substantial problem among American adolescents, Jorielle R. Brown, Ph.D., said at the annual conference of the American Society of Addiction Medicine.

Many teenagers go untreated for mental health disorders, even though about half of all lifetime mental illness begins by age 14, and some turn to illicit drugs to self-medicate, she said.

Mood disorders top the list of co-occurring disorders (CODs). For example, a major depressive episode is reported by 14% of adolescents with substance use disorders, especially in the older age range. In certain populations, the prevalence is even higher. For example, mood and anxiety disorders are the leading co-occurring mental health conditions in incarcerated youths with a substance use disorder, affecting nearly 33% of these teenagers.

Among 12- to 17-year-olds who report having used illicit drugs in the past year, 32% also have mental health problems, according to 2005 data from the Substance Abuse and Mental Health Services Administration (SAMHSA). Those adolescents who reported a major depressive episode in the past year also were more likely to report illicit drug use in the past year, as well as daily cigarette use and heavy alcohol use in the past month.

Physicians can intervene early and make a difference, Dr. Brown said. For example, there is a need to identify the “diagnostic orphans.” These are the teenagers who meet only one or two criteria for alcohol dependence and none for abuse, but who will later develop a more serious problem. Screening can identify these patients, she said.

“Engagement is critical with adolescents,” Dr. Brown said. “You want them to stay in contact with you so treatment can later take place.”

When working with teenagers, address specific, real-life problems early in treatment; plan for cognitive and functional impairments; and use support systems to maintain and extend treatment effectiveness. “With our youth, we often have to be very creative in finding their support system if their family is not there,” said Dr. Brown, a public health advisor at SAMHSA's Co-Occurring Center for Excellence.

Early identification of adolescents at risk may reduce the number of referrals from the juvenile justice system, Dr. Brown said. The fact that criminal justice is the leading source of adolescent referrals for addiction treatment is “very depressing for me,” she continued. “COD is not addressed until someone does something criminal. We see [it] in schools, but we don't do anything until they steal something or hurt someone.”

Another reason that physicians should screen for CODs is that “treatment works. And the earlier the treatment, the better the outcomes,” Dr. Brown said. Use of medications also must be part of a comprehensive treatment plan that includes nonbiologic interventions, she added.

Although there is paucity of data on medications for COD in adolescents, fluoxetine, for example, appears promising for the treatment of depression with co-occurring alcohol use, Dr. Brown said. In addition, case reports indicate that bupropion might benefit patients with both attention-deficit/hyperactivity disorder and drug dependence. Medications to treat alcohol-related cravings, such as naltrexone, also have been effective in adolescent case reports, she said.

For more information, call SAMHSA's Center for Substance Abuse Treatment National Helpline at 800-662-4357 or visit www.samhsa.gov

MIAMI – Co-occurrence of mental health and substance use disorders is a substantial problem among American adolescents, Jorielle R. Brown, Ph.D., said at the annual conference of the American Society of Addiction Medicine.

Many teenagers go untreated for mental health disorders, even though about half of all lifetime mental illness begins by age 14, and some turn to illicit drugs to self-medicate, she said.

Mood disorders top the list of co-occurring disorders (CODs). For example, a major depressive episode is reported by 14% of adolescents with substance use disorders, especially in the older age range. In certain populations, the prevalence is even higher. For example, mood and anxiety disorders are the leading co-occurring mental health conditions in incarcerated youths with a substance use disorder, affecting nearly 33% of these teenagers.

Among 12- to 17-year-olds who report having used illicit drugs in the past year, 32% also have mental health problems, according to 2005 data from the Substance Abuse and Mental Health Services Administration (SAMHSA). Those adolescents who reported a major depressive episode in the past year also were more likely to report illicit drug use in the past year, as well as daily cigarette use and heavy alcohol use in the past month.

Physicians can intervene early and make a difference, Dr. Brown said. For example, there is a need to identify the “diagnostic orphans.” These are the teenagers who meet only one or two criteria for alcohol dependence and none for abuse, but who will later develop a more serious problem. Screening can identify these patients, she said.

“Engagement is critical with adolescents,” Dr. Brown said. “You want them to stay in contact with you so treatment can later take place.”

When working with teenagers, address specific, real-life problems early in treatment; plan for cognitive and functional impairments; and use support systems to maintain and extend treatment effectiveness. “With our youth, we often have to be very creative in finding their support system if their family is not there,” said Dr. Brown, a public health advisor at SAMHSA's Co-Occurring Center for Excellence.

Early identification of adolescents at risk may reduce the number of referrals from the juvenile justice system, Dr. Brown said. The fact that criminal justice is the leading source of adolescent referrals for addiction treatment is “very depressing for me,” she continued. “COD is not addressed until someone does something criminal. We see [it] in schools, but we don't do anything until they steal something or hurt someone.”

Another reason that physicians should screen for CODs is that “treatment works. And the earlier the treatment, the better the outcomes,” Dr. Brown said. Use of medications also must be part of a comprehensive treatment plan that includes nonbiologic interventions, she added.

Although there is paucity of data on medications for COD in adolescents, fluoxetine, for example, appears promising for the treatment of depression with co-occurring alcohol use, Dr. Brown said. In addition, case reports indicate that bupropion might benefit patients with both attention-deficit/hyperactivity disorder and drug dependence. Medications to treat alcohol-related cravings, such as naltrexone, also have been effective in adolescent case reports, she said.

For more information, call SAMHSA's Center for Substance Abuse Treatment National Helpline at 800-662-4357 or visit www.samhsa.gov

MIAMI – Co-occurrence of mental health and substance use disorders is a substantial problem among American adolescents, Jorielle R. Brown, Ph.D., said at the annual conference of the American Society of Addiction Medicine.

Many teenagers go untreated for mental health disorders, even though about half of all lifetime mental illness begins by age 14, and some turn to illicit drugs to self-medicate, she said.

Mood disorders top the list of co-occurring disorders (CODs). For example, a major depressive episode is reported by 14% of adolescents with substance use disorders, especially in the older age range. In certain populations, the prevalence is even higher. For example, mood and anxiety disorders are the leading co-occurring mental health conditions in incarcerated youths with a substance use disorder, affecting nearly 33% of these teenagers.

Among 12- to 17-year-olds who report having used illicit drugs in the past year, 32% also have mental health problems, according to 2005 data from the Substance Abuse and Mental Health Services Administration (SAMHSA). Those adolescents who reported a major depressive episode in the past year also were more likely to report illicit drug use in the past year, as well as daily cigarette use and heavy alcohol use in the past month.

Physicians can intervene early and make a difference, Dr. Brown said. For example, there is a need to identify the “diagnostic orphans.” These are the teenagers who meet only one or two criteria for alcohol dependence and none for abuse, but who will later develop a more serious problem. Screening can identify these patients, she said.

“Engagement is critical with adolescents,” Dr. Brown said. “You want them to stay in contact with you so treatment can later take place.”

When working with teenagers, address specific, real-life problems early in treatment; plan for cognitive and functional impairments; and use support systems to maintain and extend treatment effectiveness. “With our youth, we often have to be very creative in finding their support system if their family is not there,” said Dr. Brown, a public health advisor at SAMHSA's Co-Occurring Center for Excellence.

Early identification of adolescents at risk may reduce the number of referrals from the juvenile justice system, Dr. Brown said. The fact that criminal justice is the leading source of adolescent referrals for addiction treatment is “very depressing for me,” she continued. “COD is not addressed until someone does something criminal. We see [it] in schools, but we don't do anything until they steal something or hurt someone.”

Another reason that physicians should screen for CODs is that “treatment works. And the earlier the treatment, the better the outcomes,” Dr. Brown said. Use of medications also must be part of a comprehensive treatment plan that includes nonbiologic interventions, she added.

Although there is paucity of data on medications for COD in adolescents, fluoxetine, for example, appears promising for the treatment of depression with co-occurring alcohol use, Dr. Brown said. In addition, case reports indicate that bupropion might benefit patients with both attention-deficit/hyperactivity disorder and drug dependence. Medications to treat alcohol-related cravings, such as naltrexone, also have been effective in adolescent case reports, she said.

For more information, call SAMHSA's Center for Substance Abuse Treatment National Helpline at 800-662-4357 or visit www.samhsa.gov

PALM BEACH, FLA. — A new laser with a unique wavelength holds promise for skin rejuvenation and offers advantages over fractional resurfacing, Dr. David J. Goldberg reported at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

The Pearl 2790-nm yttrium-scandium-gallium-garnet laser (Cutera Inc.) "is different from a fractional device. The laser treats the whole epidermis, so you don't need multiple treatments," said Dr. Goldberg, director of laser research and Mohs surgery at Mount Sinai School of Medicine, New York.

Dermatologists will be able to target uneven skin texture and improve fine lines and photodamage with the new laser, and treatment of mild acne scarring is another potential indication, said Dr. Goldberg, who is a researcher for Cutera.

"It's brand new. I am going to guess no one here has this laser yet," he said at the meeting. The company plans to launch the laser in select cities this summer.

The Pearl 2790-nm laser is indicated for skin types I to III, "with use for skin type IV as a goal," he noted. Fast treatment time is another feature. A full-face treatment takes approximately 30 minutes.

Longer downtime is a tradeoff, however, compared with fractional resurfacing. Patients "are in pain for a while, no question about it. But the results are great," Dr. Goldberg said. "Now more and more people will accept a little downtime if they get a better cosmetic outcome."

In general, flaking begins 2 days after treatment. Peeling starts on day 3 with skin reepithelialization; some erythema will still be seen on day 4. Most patients are ready to return to work and daily activities by this time.

"It is a pretty simple procedure. One pass is required," he said. Apply topical anesthesia for 30–45 minutes beforehand to minimize pain during the procedure.

The energy ranges from about 1 J/cm

The user interface is simple and the 9-ounce hand piece is very lightweight, he said. Also, there are no disposables with this system.

The 2790-nm wavelength is near, but not at, the peak of water absorption in the skin. This allows for a small amount of beneficial thermal effect and controlled ablation of the skin, he explained.

PALM BEACH, FLA. — A new laser with a unique wavelength holds promise for skin rejuvenation and offers advantages over fractional resurfacing, Dr. David J. Goldberg reported at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

The Pearl 2790-nm yttrium-scandium-gallium-garnet laser (Cutera Inc.) "is different from a fractional device. The laser treats the whole epidermis, so you don't need multiple treatments," said Dr. Goldberg, director of laser research and Mohs surgery at Mount Sinai School of Medicine, New York.

Dermatologists will be able to target uneven skin texture and improve fine lines and photodamage with the new laser, and treatment of mild acne scarring is another potential indication, said Dr. Goldberg, who is a researcher for Cutera.

"It's brand new. I am going to guess no one here has this laser yet," he said at the meeting. The company plans to launch the laser in select cities this summer.

The Pearl 2790-nm laser is indicated for skin types I to III, "with use for skin type IV as a goal," he noted. Fast treatment time is another feature. A full-face treatment takes approximately 30 minutes.

Longer downtime is a tradeoff, however, compared with fractional resurfacing. Patients "are in pain for a while, no question about it. But the results are great," Dr. Goldberg said. "Now more and more people will accept a little downtime if they get a better cosmetic outcome."

In general, flaking begins 2 days after treatment. Peeling starts on day 3 with skin reepithelialization; some erythema will still be seen on day 4. Most patients are ready to return to work and daily activities by this time.

"It is a pretty simple procedure. One pass is required," he said. Apply topical anesthesia for 30–45 minutes beforehand to minimize pain during the procedure.

The energy ranges from about 1 J/cm

The user interface is simple and the 9-ounce hand piece is very lightweight, he said. Also, there are no disposables with this system.

The 2790-nm wavelength is near, but not at, the peak of water absorption in the skin. This allows for a small amount of beneficial thermal effect and controlled ablation of the skin, he explained.

PALM BEACH, FLA. — A new laser with a unique wavelength holds promise for skin rejuvenation and offers advantages over fractional resurfacing, Dr. David J. Goldberg reported at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

The Pearl 2790-nm yttrium-scandium-gallium-garnet laser (Cutera Inc.) "is different from a fractional device. The laser treats the whole epidermis, so you don't need multiple treatments," said Dr. Goldberg, director of laser research and Mohs surgery at Mount Sinai School of Medicine, New York.

Dermatologists will be able to target uneven skin texture and improve fine lines and photodamage with the new laser, and treatment of mild acne scarring is another potential indication, said Dr. Goldberg, who is a researcher for Cutera.

"It's brand new. I am going to guess no one here has this laser yet," he said at the meeting. The company plans to launch the laser in select cities this summer.

The Pearl 2790-nm laser is indicated for skin types I to III, "with use for skin type IV as a goal," he noted. Fast treatment time is another feature. A full-face treatment takes approximately 30 minutes.

Longer downtime is a tradeoff, however, compared with fractional resurfacing. Patients "are in pain for a while, no question about it. But the results are great," Dr. Goldberg said. "Now more and more people will accept a little downtime if they get a better cosmetic outcome."

In general, flaking begins 2 days after treatment. Peeling starts on day 3 with skin reepithelialization; some erythema will still be seen on day 4. Most patients are ready to return to work and daily activities by this time.

"It is a pretty simple procedure. One pass is required," he said. Apply topical anesthesia for 30–45 minutes beforehand to minimize pain during the procedure.

The energy ranges from about 1 J/cm

The user interface is simple and the 9-ounce hand piece is very lightweight, he said. Also, there are no disposables with this system.

The 2790-nm wavelength is near, but not at, the peak of water absorption in the skin. This allows for a small amount of beneficial thermal effect and controlled ablation of the skin, he explained.

CHAMPIONSGATE, FLA. — Vaginal prolapse repair with a synthetic propylene mesh kit yields significant improvements in prolapse stage and some quality-of-life variables, according to a study presented at the annual meeting of the Society of Gynecologic Surgeons.

“Surgical mesh kits were first approved in the United States in March 2004. Tens of thousands of kits have been used with little data to support their use,” Dr. Cheryl B. Iglesia said during an oral presentation of her poster.

The limited study findings suggest that there may be problems with mesh exposure in approximately 6%–10% of patients and that there is significant postoperative pain in about 5%, according to Dr. Iglesia, who is director of urogynecology and reconstructive pelvic surgery at Washington Hospital Center.

Dr. Iglesia and her associates prospectively evaluated 25 women undergoing vaginal reconstructive surgery using a synthetic propylene mesh kit (ProLift, Ethicon).

Patients' prolapse stage was assessed at baseline and 3 months using the Pelvic Organ Prolapse Quantification (POP-Q) system.

The researchers also compared preoperative and postoperative quality of life using the short forms of the Pelvic Floor Distress Inventory (PFDI-20), Pelvic Floor Impact Questionnaire (PFIQ-7), and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12).

At study entry, the mean age was 66 years, the mean parity was three, and mean body mass index was 28 kg/m

Most patients, 18 out of 25, had prior surgery, including hysterectomy.

All repairs were performed between July 2005 and April 2006.

Urodynamic stress incontinence, urodynamic detrusor overactivity, and mixed incontinence were among the presenting conditions.

A total of 18 patients had vaginal colpopexies with total ProLift mesh insertions; 5 patients had anterior ProLift placement, and 2 had a posterior ProLift procedure.

At the same time, three patients had a vaginal hysterectomy and four had suburethral tape sling placed.

There were four complications reported.

These included two vaginal mesh erosions that were surgically resected and two seromas with delayed bleeding. There were no mesh infections.

At baseline, the mean POP-Q score was 2.88. Before surgery, a total of 5 patients had stage 2 prolapse, 18 patients had stage 3 prolapse, and 2 had stage 4 prolapse.

The POP-Q mean score decreased to 0.55 at 3 months, Dr. Iglesia said at the meeting, which was jointly sponsored by the American College of Surgeons.

In terms of quality of life, there were statistically significant improvements in mean PFDI-20 summary scores, from136 at baseline to 33 at 3 months.

Researchers also found that baseline PFIQ-7 summary scores significantly decreased from a mean of 78 to 3 at 3 months. Mean PISQ-12 scores dropped from 13 to 9.

The findings of this study warrant further investigation, Dr. Iglesia said. “Longer-term data are needed for mesh complications and patient and partner sexual satisfaction.”

CHAMPIONSGATE, FLA. — Vaginal prolapse repair with a synthetic propylene mesh kit yields significant improvements in prolapse stage and some quality-of-life variables, according to a study presented at the annual meeting of the Society of Gynecologic Surgeons.

“Surgical mesh kits were first approved in the United States in March 2004. Tens of thousands of kits have been used with little data to support their use,” Dr. Cheryl B. Iglesia said during an oral presentation of her poster.

The limited study findings suggest that there may be problems with mesh exposure in approximately 6%–10% of patients and that there is significant postoperative pain in about 5%, according to Dr. Iglesia, who is director of urogynecology and reconstructive pelvic surgery at Washington Hospital Center.

Dr. Iglesia and her associates prospectively evaluated 25 women undergoing vaginal reconstructive surgery using a synthetic propylene mesh kit (ProLift, Ethicon).

Patients' prolapse stage was assessed at baseline and 3 months using the Pelvic Organ Prolapse Quantification (POP-Q) system.

The researchers also compared preoperative and postoperative quality of life using the short forms of the Pelvic Floor Distress Inventory (PFDI-20), Pelvic Floor Impact Questionnaire (PFIQ-7), and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12).

At study entry, the mean age was 66 years, the mean parity was three, and mean body mass index was 28 kg/m

Most patients, 18 out of 25, had prior surgery, including hysterectomy.

All repairs were performed between July 2005 and April 2006.

Urodynamic stress incontinence, urodynamic detrusor overactivity, and mixed incontinence were among the presenting conditions.

A total of 18 patients had vaginal colpopexies with total ProLift mesh insertions; 5 patients had anterior ProLift placement, and 2 had a posterior ProLift procedure.

At the same time, three patients had a vaginal hysterectomy and four had suburethral tape sling placed.

There were four complications reported.

These included two vaginal mesh erosions that were surgically resected and two seromas with delayed bleeding. There were no mesh infections.

At baseline, the mean POP-Q score was 2.88. Before surgery, a total of 5 patients had stage 2 prolapse, 18 patients had stage 3 prolapse, and 2 had stage 4 prolapse.

The POP-Q mean score decreased to 0.55 at 3 months, Dr. Iglesia said at the meeting, which was jointly sponsored by the American College of Surgeons.

In terms of quality of life, there were statistically significant improvements in mean PFDI-20 summary scores, from136 at baseline to 33 at 3 months.

Researchers also found that baseline PFIQ-7 summary scores significantly decreased from a mean of 78 to 3 at 3 months. Mean PISQ-12 scores dropped from 13 to 9.

The findings of this study warrant further investigation, Dr. Iglesia said. “Longer-term data are needed for mesh complications and patient and partner sexual satisfaction.”

CHAMPIONSGATE, FLA. — Vaginal prolapse repair with a synthetic propylene mesh kit yields significant improvements in prolapse stage and some quality-of-life variables, according to a study presented at the annual meeting of the Society of Gynecologic Surgeons.

“Surgical mesh kits were first approved in the United States in March 2004. Tens of thousands of kits have been used with little data to support their use,” Dr. Cheryl B. Iglesia said during an oral presentation of her poster.

The limited study findings suggest that there may be problems with mesh exposure in approximately 6%–10% of patients and that there is significant postoperative pain in about 5%, according to Dr. Iglesia, who is director of urogynecology and reconstructive pelvic surgery at Washington Hospital Center.

Dr. Iglesia and her associates prospectively evaluated 25 women undergoing vaginal reconstructive surgery using a synthetic propylene mesh kit (ProLift, Ethicon).

Patients' prolapse stage was assessed at baseline and 3 months using the Pelvic Organ Prolapse Quantification (POP-Q) system.

The researchers also compared preoperative and postoperative quality of life using the short forms of the Pelvic Floor Distress Inventory (PFDI-20), Pelvic Floor Impact Questionnaire (PFIQ-7), and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12).

At study entry, the mean age was 66 years, the mean parity was three, and mean body mass index was 28 kg/m

Most patients, 18 out of 25, had prior surgery, including hysterectomy.

All repairs were performed between July 2005 and April 2006.

Urodynamic stress incontinence, urodynamic detrusor overactivity, and mixed incontinence were among the presenting conditions.

A total of 18 patients had vaginal colpopexies with total ProLift mesh insertions; 5 patients had anterior ProLift placement, and 2 had a posterior ProLift procedure.

At the same time, three patients had a vaginal hysterectomy and four had suburethral tape sling placed.

There were four complications reported.

These included two vaginal mesh erosions that were surgically resected and two seromas with delayed bleeding. There were no mesh infections.

At baseline, the mean POP-Q score was 2.88. Before surgery, a total of 5 patients had stage 2 prolapse, 18 patients had stage 3 prolapse, and 2 had stage 4 prolapse.

The POP-Q mean score decreased to 0.55 at 3 months, Dr. Iglesia said at the meeting, which was jointly sponsored by the American College of Surgeons.

In terms of quality of life, there were statistically significant improvements in mean PFDI-20 summary scores, from136 at baseline to 33 at 3 months.

Researchers also found that baseline PFIQ-7 summary scores significantly decreased from a mean of 78 to 3 at 3 months. Mean PISQ-12 scores dropped from 13 to 9.

The findings of this study warrant further investigation, Dr. Iglesia said. “Longer-term data are needed for mesh complications and patient and partner sexual satisfaction.”

MIAMI BEACH — Clinical acumen is crucial to diagnosis and management of antepartum hemorrhage of both known and unknown origin, according to a presentation at an ob.gyn. conference sponsored by the University of Miami.

Placenta previa and abruption are more common presentations, whereas vasa previa occurs less frequently.

However, vasa previa—where blood vessels cross the cervical opening—can cause massive hemorrhaging.

Prenatal diagnosis via ultrasound improves survival, compared with diagnosis at delivery.

There are fewer data regarding hemorrhage of unknown origin, but pooled findings from several studies suggest a threefold increased risk of premature birth and twofold increased risk of stillbirth, Dr. Amanda Cotter said.

There is an increased risk of mortality with hemorrhage, Dr. Cotter said. In one study of 108 obstetric maternal deaths in North Carolina, cardiomyopathy was the leading cause of mortality, responsible for 21% (Obstet. Gynecol. 2005;106:1228–34). Hemorrhage was the second leading cause, a culprit in 14% of deaths.

Placenta previa causes approximately 20% of all cases of antepartum hemorrhage, Dr. Cotter said. It has an incidence of 1 in 200 live births. Sentinel bleed at about 30 weeks' gestation is another indicator of placenta previa, Dr. Cotter said. About 10% of women with this condition present without bleeding or pain, making it an ultrasound diagnosis. Another 20% of patients experience contractions with bleeding. The remaining 70% of women with placenta previa present with painless bleeding.

“Some women report standing up and blood runs down their leg and puddles on the floor,” said Dr. Cotter, a faculty member in the division of maternal fetal medicine, University of Miami.

“We must use ultrasound to do this diagnosis—but is it transabdominal or transvaginal?” Dr. Cotter asked. Only an experienced operator should perform transvaginal ultrasound in a bleeding patient, she said. “You have to prevent the probe from entering the cervix and causing any fetal insult.” Therefore, transabdominal is the preferred approach to ultrasound in these patients.

“Rule out placental separation, even with previa, to improve our diagnostic accuracy,” Dr. Cotter said.

Risk for placenta accreta—an abnormally firm attachment of the placenta to the uterine wall—varies depending on a patient's history. For example, a woman with no history of previa or cesarean section has a 5% risk, Dr. Cotter said. If she had a previous previa and one cesarean, the risk is approximately 24%.

The risk increases to 67% for a woman with a previous previa and a history of multiple cesarean deliveries. “This also applies to patients with multiple, previous D&Cs,” she added.

Ultrasound will show placenta previa or low-lying placenta. Dr. Cotter cited the case of a 35-year-old woman who presented for a routine pregnancy exam. She had blood vessels formed across the myometrium from her uterus to her bladder.

“I knew this was a placenta accreta—I left the placenta in without touching it at all—and did a breach delivery via C-section,” Dr. Cotter said. “She did very well, had no bleeding in postpartum period, and had normal resumption of her menses. I performed a tubal ligation with her permission at the same time so she should not be back in the same situation.”

Placental abruption is often associated with substance abuse during pregnancy, particularly cocaine. Ultrasound might show a retroplacental or preplacental hematoma, and increased placental thickness and echogenicity, Dr. Cotter said. “You can also sometimes see a subchorionic collection.”

Vasa previa occurs with an incidence of 1 in 2,500 pregnancies. “We don't see this as often,” Dr. Cotter said. It occurs when blood vessels transverse the internal cervical os.

“Once these membranes rupture, you will have massive bleeding,” she noted.

Early detection is important. In a study of 155 pregnancies complicated by vasa previa, 39% were diagnosed prenatally and the fetal survival rate was 97% (Obstet. Gynecol. 2004;103:937–42). In contrast, in the 61% diagnosed at delivery, survival dropped to 44%.

“Use color flow Doppler to confirm the diagnosis,” Dr. Cotter recommended.

The etiology of antepartum hemorrhage is unknown in 2%–3% of cases, Dr. Cotter said. Bleeding in these cases is associated with adverse outcomes.

“The most likely reason these people are bleeding is they have very tiny abruptions. So we have to monitor for preterm delivery and closely monitor the fetus up to delivery,” she added.

A meeting attendee asked if a physical examination of the cervix should be the first step when a patient presents with bleeding and does not have a diagnosis. “No, I would do an ultrasound first before I do an exam,” Dr. Cotter replied.

There is a paucity of data in the literature regarding this presentation, Dr. Cotter said. Pooled data from four studies suggest a threefold increase in risk of premature birth and twofold increase in risk of stillbirth with bleeding of unknown origin, she said. “It is important to counsel our patients with bleeding of unknown origin that they are at increased risk. I hope you will leave here and have a heightened awareness about increased risk of preterm delivery.”

Another meeting attendee asked about a connection between bleeding and risk of mental retardation. “I always counsel patients with recurrent bleeding that there is an elevated risk of cerebral palsy,” Dr. Cotter said.

MIAMI BEACH — Clinical acumen is crucial to diagnosis and management of antepartum hemorrhage of both known and unknown origin, according to a presentation at an ob.gyn. conference sponsored by the University of Miami.

Placenta previa and abruption are more common presentations, whereas vasa previa occurs less frequently.

However, vasa previa—where blood vessels cross the cervical opening—can cause massive hemorrhaging.

Prenatal diagnosis via ultrasound improves survival, compared with diagnosis at delivery.

There are fewer data regarding hemorrhage of unknown origin, but pooled findings from several studies suggest a threefold increased risk of premature birth and twofold increased risk of stillbirth, Dr. Amanda Cotter said.

There is an increased risk of mortality with hemorrhage, Dr. Cotter said. In one study of 108 obstetric maternal deaths in North Carolina, cardiomyopathy was the leading cause of mortality, responsible for 21% (Obstet. Gynecol. 2005;106:1228–34). Hemorrhage was the second leading cause, a culprit in 14% of deaths.

Placenta previa causes approximately 20% of all cases of antepartum hemorrhage, Dr. Cotter said. It has an incidence of 1 in 200 live births. Sentinel bleed at about 30 weeks' gestation is another indicator of placenta previa, Dr. Cotter said. About 10% of women with this condition present without bleeding or pain, making it an ultrasound diagnosis. Another 20% of patients experience contractions with bleeding. The remaining 70% of women with placenta previa present with painless bleeding.

“Some women report standing up and blood runs down their leg and puddles on the floor,” said Dr. Cotter, a faculty member in the division of maternal fetal medicine, University of Miami.

“We must use ultrasound to do this diagnosis—but is it transabdominal or transvaginal?” Dr. Cotter asked. Only an experienced operator should perform transvaginal ultrasound in a bleeding patient, she said. “You have to prevent the probe from entering the cervix and causing any fetal insult.” Therefore, transabdominal is the preferred approach to ultrasound in these patients.

“Rule out placental separation, even with previa, to improve our diagnostic accuracy,” Dr. Cotter said.

Risk for placenta accreta—an abnormally firm attachment of the placenta to the uterine wall—varies depending on a patient's history. For example, a woman with no history of previa or cesarean section has a 5% risk, Dr. Cotter said. If she had a previous previa and one cesarean, the risk is approximately 24%.

The risk increases to 67% for a woman with a previous previa and a history of multiple cesarean deliveries. “This also applies to patients with multiple, previous D&Cs,” she added.

Ultrasound will show placenta previa or low-lying placenta. Dr. Cotter cited the case of a 35-year-old woman who presented for a routine pregnancy exam. She had blood vessels formed across the myometrium from her uterus to her bladder.

“I knew this was a placenta accreta—I left the placenta in without touching it at all—and did a breach delivery via C-section,” Dr. Cotter said. “She did very well, had no bleeding in postpartum period, and had normal resumption of her menses. I performed a tubal ligation with her permission at the same time so she should not be back in the same situation.”

Placental abruption is often associated with substance abuse during pregnancy, particularly cocaine. Ultrasound might show a retroplacental or preplacental hematoma, and increased placental thickness and echogenicity, Dr. Cotter said. “You can also sometimes see a subchorionic collection.”

Vasa previa occurs with an incidence of 1 in 2,500 pregnancies. “We don't see this as often,” Dr. Cotter said. It occurs when blood vessels transverse the internal cervical os.

“Once these membranes rupture, you will have massive bleeding,” she noted.

Early detection is important. In a study of 155 pregnancies complicated by vasa previa, 39% were diagnosed prenatally and the fetal survival rate was 97% (Obstet. Gynecol. 2004;103:937–42). In contrast, in the 61% diagnosed at delivery, survival dropped to 44%.

“Use color flow Doppler to confirm the diagnosis,” Dr. Cotter recommended.

The etiology of antepartum hemorrhage is unknown in 2%–3% of cases, Dr. Cotter said. Bleeding in these cases is associated with adverse outcomes.

“The most likely reason these people are bleeding is they have very tiny abruptions. So we have to monitor for preterm delivery and closely monitor the fetus up to delivery,” she added.

A meeting attendee asked if a physical examination of the cervix should be the first step when a patient presents with bleeding and does not have a diagnosis. “No, I would do an ultrasound first before I do an exam,” Dr. Cotter replied.

There is a paucity of data in the literature regarding this presentation, Dr. Cotter said. Pooled data from four studies suggest a threefold increase in risk of premature birth and twofold increase in risk of stillbirth with bleeding of unknown origin, she said. “It is important to counsel our patients with bleeding of unknown origin that they are at increased risk. I hope you will leave here and have a heightened awareness about increased risk of preterm delivery.”

Another meeting attendee asked about a connection between bleeding and risk of mental retardation. “I always counsel patients with recurrent bleeding that there is an elevated risk of cerebral palsy,” Dr. Cotter said.

MIAMI BEACH — Clinical acumen is crucial to diagnosis and management of antepartum hemorrhage of both known and unknown origin, according to a presentation at an ob.gyn. conference sponsored by the University of Miami.

Placenta previa and abruption are more common presentations, whereas vasa previa occurs less frequently.

However, vasa previa—where blood vessels cross the cervical opening—can cause massive hemorrhaging.

Prenatal diagnosis via ultrasound improves survival, compared with diagnosis at delivery.

There are fewer data regarding hemorrhage of unknown origin, but pooled findings from several studies suggest a threefold increased risk of premature birth and twofold increased risk of stillbirth, Dr. Amanda Cotter said.

There is an increased risk of mortality with hemorrhage, Dr. Cotter said. In one study of 108 obstetric maternal deaths in North Carolina, cardiomyopathy was the leading cause of mortality, responsible for 21% (Obstet. Gynecol. 2005;106:1228–34). Hemorrhage was the second leading cause, a culprit in 14% of deaths.

Placenta previa causes approximately 20% of all cases of antepartum hemorrhage, Dr. Cotter said. It has an incidence of 1 in 200 live births. Sentinel bleed at about 30 weeks' gestation is another indicator of placenta previa, Dr. Cotter said. About 10% of women with this condition present without bleeding or pain, making it an ultrasound diagnosis. Another 20% of patients experience contractions with bleeding. The remaining 70% of women with placenta previa present with painless bleeding.

“Some women report standing up and blood runs down their leg and puddles on the floor,” said Dr. Cotter, a faculty member in the division of maternal fetal medicine, University of Miami.

“We must use ultrasound to do this diagnosis—but is it transabdominal or transvaginal?” Dr. Cotter asked. Only an experienced operator should perform transvaginal ultrasound in a bleeding patient, she said. “You have to prevent the probe from entering the cervix and causing any fetal insult.” Therefore, transabdominal is the preferred approach to ultrasound in these patients.

“Rule out placental separation, even with previa, to improve our diagnostic accuracy,” Dr. Cotter said.

Risk for placenta accreta—an abnormally firm attachment of the placenta to the uterine wall—varies depending on a patient's history. For example, a woman with no history of previa or cesarean section has a 5% risk, Dr. Cotter said. If she had a previous previa and one cesarean, the risk is approximately 24%.

The risk increases to 67% for a woman with a previous previa and a history of multiple cesarean deliveries. “This also applies to patients with multiple, previous D&Cs,” she added.

Ultrasound will show placenta previa or low-lying placenta. Dr. Cotter cited the case of a 35-year-old woman who presented for a routine pregnancy exam. She had blood vessels formed across the myometrium from her uterus to her bladder.

“I knew this was a placenta accreta—I left the placenta in without touching it at all—and did a breach delivery via C-section,” Dr. Cotter said. “She did very well, had no bleeding in postpartum period, and had normal resumption of her menses. I performed a tubal ligation with her permission at the same time so she should not be back in the same situation.”

Placental abruption is often associated with substance abuse during pregnancy, particularly cocaine. Ultrasound might show a retroplacental or preplacental hematoma, and increased placental thickness and echogenicity, Dr. Cotter said. “You can also sometimes see a subchorionic collection.”

Vasa previa occurs with an incidence of 1 in 2,500 pregnancies. “We don't see this as often,” Dr. Cotter said. It occurs when blood vessels transverse the internal cervical os.

“Once these membranes rupture, you will have massive bleeding,” she noted.

Early detection is important. In a study of 155 pregnancies complicated by vasa previa, 39% were diagnosed prenatally and the fetal survival rate was 97% (Obstet. Gynecol. 2004;103:937–42). In contrast, in the 61% diagnosed at delivery, survival dropped to 44%.

“Use color flow Doppler to confirm the diagnosis,” Dr. Cotter recommended.

The etiology of antepartum hemorrhage is unknown in 2%–3% of cases, Dr. Cotter said. Bleeding in these cases is associated with adverse outcomes.

“The most likely reason these people are bleeding is they have very tiny abruptions. So we have to monitor for preterm delivery and closely monitor the fetus up to delivery,” she added.

A meeting attendee asked if a physical examination of the cervix should be the first step when a patient presents with bleeding and does not have a diagnosis. “No, I would do an ultrasound first before I do an exam,” Dr. Cotter replied.

There is a paucity of data in the literature regarding this presentation, Dr. Cotter said. Pooled data from four studies suggest a threefold increase in risk of premature birth and twofold increase in risk of stillbirth with bleeding of unknown origin, she said. “It is important to counsel our patients with bleeding of unknown origin that they are at increased risk. I hope you will leave here and have a heightened awareness about increased risk of preterm delivery.”

Another meeting attendee asked about a connection between bleeding and risk of mental retardation. “I always counsel patients with recurrent bleeding that there is an elevated risk of cerebral palsy,” Dr. Cotter said.

MIAMI — To successfully evaluate the child who presents with a limb discrepancy, identify the etiology, understand normal limb growth, estimate the ultimate deficiency, and guide the family regarding intervention, Dr. Christopher A. Iobst recommended at a pediatric update sponsored by Miami Children's Hospital.

“Many people have a slight discrepancy in their leg lengths. Leg length discrepancies below 3% are generally not a concern,” Dr. Iobst said. One of the options, therefore, is to do nothing but observe and monitor the child.

“Some kids do fine with a minor discrepancy, others freak out and want something done to correct it. Realistically, any discrepancy greater than 1.5 cm should be treated,” said Dr. Iobst, attending physician in the department of orthopedic surgery at the hospital.

Options include an operation on the shoe or an operation on the child. Shoe lifts correct a length discrepancy without surgery, but most kids don't like wearing shoes with a noticeable lift, Dr. Iobst said. Up to 1 cm can be added inside a shoe. “I don't like prescribing lifts greater than 5 cm because they become dangerous.”

Operations on the patient include techniques to either lengthen or shorten the affected limb. Epiphysiodesis or ablation of the physis is the most common surgery Dr. Iobst performs to shorten a limb. The number of growth plates permanently destroyed depends on the degree of the limb discrepancy.

Epiphysiodesis can be performed as a percutaneous, outpatient procedure. The surgery can be done through a small incision with minimal soft-tissue disruption. “The problem is, I am reducing their overall height, so if they are already [short], they may not want to do this.”

To lengthen a limb, the bone is cut and gradually distracted to produce new bone. For example, with the Ilizarov technique, an external frame is placed around the leg and slowly adjusted to promote natural bone healing and bone growth.

An attendee asked about pain management during limb lengthening. “When we apply fixators and the frame, we leave it alone for 5–7 days at first so the bone starts to repair the fracture we caused,” Dr. Iobst said. “It's not as painful as it looks. We are lengthening about 1 mm/day, so it's not as noticeable to them in terms of pain.” He added that most patients discontinue pain medication by 2–3 weeks.

Immediate physical therapy is essential to postoperative success. “We want them weight bearing as soon as possible.” Patients are instructed on daily pin care and to come for weekly follow-up visits.

“They have to be in these frames a long time. It can take 6–9 months for new growth,” Dr. Iobst said. The duration of wearing the fixator could be shortened by combining the use of an external fixator and an intramedullary nail. “We can save a patient anywhere from 3 to 6 months by using [a] rod along with an outside frame,” he said. “Once the length is achieved, screws are placed in the rod to hold it, and the frame is removed.”

“My practice is pediatric, and these rods go through the growth plates, so one adaptation is to place a plate (instead of a rod) that protects the growth plates when the frame is removed,” Dr. Iobst said.

Hydroxyapatite-coated pins or screws put directly into bone to stimulate growth are another option in development. Researchers are also assessing the Taylor Spatial Frame, which is fitted and adjusted via computer.

When evaluating a child with a leg length discrepancy, most of the time the abnormal limb is obvious, Dr. Iobst said. But sometimes you cannot immediately tell. Many pediatricians were taught to measure from the spine of the pelvis down to the ankle, he said. “Throw away the tape measure—it is a very unreliable way to measure leg lengths. Overall length can vary by as much as 3 cm just by incorrectly positioning the lower extremity by 10 degrees.”

At Miami Children's Hospital, Dr. Iobst and his colleagues place blocks under one foot to normalize the pelvis. If it is difficult to tell if the pelvis is horizontal, use the underwear line as a reference, Dr. Iobst suggested. A radiographic assessment can be helpful, such as a standing anteroposterior view of bilateral lower extremities taken from the hips down.

A scanogram is another option. This imaging modality takes three scans at intervals along the lower extremities. “This gives an accurate length determination, but it's my second choice,” Dr. Iobst said. “You can miss an anomaly in the areas not scanned.”

A thorough physical examination includes observation of alignment while the child stands. Also, observe their gait from different angles because “kids are good at compensating,” Dr. Iobst said. Also, assess joint range of motion and stability; motor strength, sensation, and tone; and limb symmetry.

“We need to see the entire lower extremities, so don't examine patients in jeans or shorts, use a gown,” Dr. Iobst said.

It is often helpful to predict the growth remaining in a child, Dr. Iobst said. It can be challenging because growth is not uniform but is a succession of phases. Keep in mind that height increases an average 350% from birth to adulthood, at which time weight also increases 20 times, the femur and tibia lengths increase 3 times, and the spine length increases 2 times.

Although there are more complicated methods to calculate growth remaining, Dr. Iobst recommended the Menelaus Method. “It is the simplest. You can do it in your office.” The distal femur grows 3/8 inch per year, and the proximal tibia grows 1/4 inch per year. Assume growth cessation at 16 years for boys and 14 years for girls. Use chronologic age, not skeletal age, he added, for the simplest estimate of growth remaining.

A percutaneous osteotomy incision is made while the patient wears the frame.

A circular external fixator is positioned to lengthen the tibia and fibula. Photos courtesy Dr. Christopher A. Iobst

MIAMI — To successfully evaluate the child who presents with a limb discrepancy, identify the etiology, understand normal limb growth, estimate the ultimate deficiency, and guide the family regarding intervention, Dr. Christopher A. Iobst recommended at a pediatric update sponsored by Miami Children's Hospital.

“Many people have a slight discrepancy in their leg lengths. Leg length discrepancies below 3% are generally not a concern,” Dr. Iobst said. One of the options, therefore, is to do nothing but observe and monitor the child.

“Some kids do fine with a minor discrepancy, others freak out and want something done to correct it. Realistically, any discrepancy greater than 1.5 cm should be treated,” said Dr. Iobst, attending physician in the department of orthopedic surgery at the hospital.

Options include an operation on the shoe or an operation on the child. Shoe lifts correct a length discrepancy without surgery, but most kids don't like wearing shoes with a noticeable lift, Dr. Iobst said. Up to 1 cm can be added inside a shoe. “I don't like prescribing lifts greater than 5 cm because they become dangerous.”

Operations on the patient include techniques to either lengthen or shorten the affected limb. Epiphysiodesis or ablation of the physis is the most common surgery Dr. Iobst performs to shorten a limb. The number of growth plates permanently destroyed depends on the degree of the limb discrepancy.

Epiphysiodesis can be performed as a percutaneous, outpatient procedure. The surgery can be done through a small incision with minimal soft-tissue disruption. “The problem is, I am reducing their overall height, so if they are already [short], they may not want to do this.”

To lengthen a limb, the bone is cut and gradually distracted to produce new bone. For example, with the Ilizarov technique, an external frame is placed around the leg and slowly adjusted to promote natural bone healing and bone growth.

An attendee asked about pain management during limb lengthening. “When we apply fixators and the frame, we leave it alone for 5–7 days at first so the bone starts to repair the fracture we caused,” Dr. Iobst said. “It's not as painful as it looks. We are lengthening about 1 mm/day, so it's not as noticeable to them in terms of pain.” He added that most patients discontinue pain medication by 2–3 weeks.

Immediate physical therapy is essential to postoperative success. “We want them weight bearing as soon as possible.” Patients are instructed on daily pin care and to come for weekly follow-up visits.

“They have to be in these frames a long time. It can take 6–9 months for new growth,” Dr. Iobst said. The duration of wearing the fixator could be shortened by combining the use of an external fixator and an intramedullary nail. “We can save a patient anywhere from 3 to 6 months by using [a] rod along with an outside frame,” he said. “Once the length is achieved, screws are placed in the rod to hold it, and the frame is removed.”

“My practice is pediatric, and these rods go through the growth plates, so one adaptation is to place a plate (instead of a rod) that protects the growth plates when the frame is removed,” Dr. Iobst said.

Hydroxyapatite-coated pins or screws put directly into bone to stimulate growth are another option in development. Researchers are also assessing the Taylor Spatial Frame, which is fitted and adjusted via computer.

When evaluating a child with a leg length discrepancy, most of the time the abnormal limb is obvious, Dr. Iobst said. But sometimes you cannot immediately tell. Many pediatricians were taught to measure from the spine of the pelvis down to the ankle, he said. “Throw away the tape measure—it is a very unreliable way to measure leg lengths. Overall length can vary by as much as 3 cm just by incorrectly positioning the lower extremity by 10 degrees.”

At Miami Children's Hospital, Dr. Iobst and his colleagues place blocks under one foot to normalize the pelvis. If it is difficult to tell if the pelvis is horizontal, use the underwear line as a reference, Dr. Iobst suggested. A radiographic assessment can be helpful, such as a standing anteroposterior view of bilateral lower extremities taken from the hips down.

A scanogram is another option. This imaging modality takes three scans at intervals along the lower extremities. “This gives an accurate length determination, but it's my second choice,” Dr. Iobst said. “You can miss an anomaly in the areas not scanned.”

A thorough physical examination includes observation of alignment while the child stands. Also, observe their gait from different angles because “kids are good at compensating,” Dr. Iobst said. Also, assess joint range of motion and stability; motor strength, sensation, and tone; and limb symmetry.

“We need to see the entire lower extremities, so don't examine patients in jeans or shorts, use a gown,” Dr. Iobst said.

It is often helpful to predict the growth remaining in a child, Dr. Iobst said. It can be challenging because growth is not uniform but is a succession of phases. Keep in mind that height increases an average 350% from birth to adulthood, at which time weight also increases 20 times, the femur and tibia lengths increase 3 times, and the spine length increases 2 times.

Although there are more complicated methods to calculate growth remaining, Dr. Iobst recommended the Menelaus Method. “It is the simplest. You can do it in your office.” The distal femur grows 3/8 inch per year, and the proximal tibia grows 1/4 inch per year. Assume growth cessation at 16 years for boys and 14 years for girls. Use chronologic age, not skeletal age, he added, for the simplest estimate of growth remaining.

A percutaneous osteotomy incision is made while the patient wears the frame.

A circular external fixator is positioned to lengthen the tibia and fibula. Photos courtesy Dr. Christopher A. Iobst

MIAMI — To successfully evaluate the child who presents with a limb discrepancy, identify the etiology, understand normal limb growth, estimate the ultimate deficiency, and guide the family regarding intervention, Dr. Christopher A. Iobst recommended at a pediatric update sponsored by Miami Children's Hospital.

“Many people have a slight discrepancy in their leg lengths. Leg length discrepancies below 3% are generally not a concern,” Dr. Iobst said. One of the options, therefore, is to do nothing but observe and monitor the child.

“Some kids do fine with a minor discrepancy, others freak out and want something done to correct it. Realistically, any discrepancy greater than 1.5 cm should be treated,” said Dr. Iobst, attending physician in the department of orthopedic surgery at the hospital.

Options include an operation on the shoe or an operation on the child. Shoe lifts correct a length discrepancy without surgery, but most kids don't like wearing shoes with a noticeable lift, Dr. Iobst said. Up to 1 cm can be added inside a shoe. “I don't like prescribing lifts greater than 5 cm because they become dangerous.”

Operations on the patient include techniques to either lengthen or shorten the affected limb. Epiphysiodesis or ablation of the physis is the most common surgery Dr. Iobst performs to shorten a limb. The number of growth plates permanently destroyed depends on the degree of the limb discrepancy.

Epiphysiodesis can be performed as a percutaneous, outpatient procedure. The surgery can be done through a small incision with minimal soft-tissue disruption. “The problem is, I am reducing their overall height, so if they are already [short], they may not want to do this.”

To lengthen a limb, the bone is cut and gradually distracted to produce new bone. For example, with the Ilizarov technique, an external frame is placed around the leg and slowly adjusted to promote natural bone healing and bone growth.

An attendee asked about pain management during limb lengthening. “When we apply fixators and the frame, we leave it alone for 5–7 days at first so the bone starts to repair the fracture we caused,” Dr. Iobst said. “It's not as painful as it looks. We are lengthening about 1 mm/day, so it's not as noticeable to them in terms of pain.” He added that most patients discontinue pain medication by 2–3 weeks.

Immediate physical therapy is essential to postoperative success. “We want them weight bearing as soon as possible.” Patients are instructed on daily pin care and to come for weekly follow-up visits.

“They have to be in these frames a long time. It can take 6–9 months for new growth,” Dr. Iobst said. The duration of wearing the fixator could be shortened by combining the use of an external fixator and an intramedullary nail. “We can save a patient anywhere from 3 to 6 months by using [a] rod along with an outside frame,” he said. “Once the length is achieved, screws are placed in the rod to hold it, and the frame is removed.”

“My practice is pediatric, and these rods go through the growth plates, so one adaptation is to place a plate (instead of a rod) that protects the growth plates when the frame is removed,” Dr. Iobst said.

Hydroxyapatite-coated pins or screws put directly into bone to stimulate growth are another option in development. Researchers are also assessing the Taylor Spatial Frame, which is fitted and adjusted via computer.

When evaluating a child with a leg length discrepancy, most of the time the abnormal limb is obvious, Dr. Iobst said. But sometimes you cannot immediately tell. Many pediatricians were taught to measure from the spine of the pelvis down to the ankle, he said. “Throw away the tape measure—it is a very unreliable way to measure leg lengths. Overall length can vary by as much as 3 cm just by incorrectly positioning the lower extremity by 10 degrees.”

At Miami Children's Hospital, Dr. Iobst and his colleagues place blocks under one foot to normalize the pelvis. If it is difficult to tell if the pelvis is horizontal, use the underwear line as a reference, Dr. Iobst suggested. A radiographic assessment can be helpful, such as a standing anteroposterior view of bilateral lower extremities taken from the hips down.

A scanogram is another option. This imaging modality takes three scans at intervals along the lower extremities. “This gives an accurate length determination, but it's my second choice,” Dr. Iobst said. “You can miss an anomaly in the areas not scanned.”

A thorough physical examination includes observation of alignment while the child stands. Also, observe their gait from different angles because “kids are good at compensating,” Dr. Iobst said. Also, assess joint range of motion and stability; motor strength, sensation, and tone; and limb symmetry.

“We need to see the entire lower extremities, so don't examine patients in jeans or shorts, use a gown,” Dr. Iobst said.

It is often helpful to predict the growth remaining in a child, Dr. Iobst said. It can be challenging because growth is not uniform but is a succession of phases. Keep in mind that height increases an average 350% from birth to adulthood, at which time weight also increases 20 times, the femur and tibia lengths increase 3 times, and the spine length increases 2 times.

Although there are more complicated methods to calculate growth remaining, Dr. Iobst recommended the Menelaus Method. “It is the simplest. You can do it in your office.” The distal femur grows 3/8 inch per year, and the proximal tibia grows 1/4 inch per year. Assume growth cessation at 16 years for boys and 14 years for girls. Use chronologic age, not skeletal age, he added, for the simplest estimate of growth remaining.

A percutaneous osteotomy incision is made while the patient wears the frame.

A circular external fixator is positioned to lengthen the tibia and fibula. Photos courtesy Dr. Christopher A. Iobst