Diana Mahoney

MONTREAL – Among children diagnosed with an autism spectrum disorder, those with Asperger's syndrome, minority children, and those whose families do not follow one of the major autism treatment approaches fall behind others when it comes to early intervention services, service intensity, and family involvement in providing treatment services, an analysis shows.

The findings highlight the need to develop family-level interventions for disseminating information, enhancing decision making, and supporting parents to assure adequate access to effective service elements for all children with an autism spectrum disorder (ASD), Kathleen Thomas, Ph.D., said at the 5th International Meeting for Autism Research.

As part of a 4-year study aimed at assessing family and child use of effective autism program elements funded by the National Institute of Mental Health, Dr. Thomas and her colleagues at the University of North Carolina at Chapel Hill recruited a sample of 383 families with a child aged 11 years or younger with an ASD diagnosis to participate in a combined telephone/in-person survey.

Sixty percent of the sample was obtained through the university's Neurodevelopmental Disorders Research Center Subject Registry; forty percent was obtained through direct recruitment from schools and developmental services agencies within the state.

The survey assessed demographics, access to services, use of services, payment for services, and overall satisfaction with services. The response rate among recruited families was 91%. The mean age of the children represented in the survey was 7 years; 71% of the children were white, and 87% were male.

Most families (58%) reported having private insurance, 21% received Medicaid alone, and 8% had both. About 70% of the children had a diagnosis of typical autism, 21% were diagnosed with Asperger's syndrome, and the rest had other diagnoses along the autism spectrum. The average age at diagnosis was 4 years.

Ninety-five percent of the families participating in the survey reported involvement with a major autism treatment approach.

“Because the participants were from North Carolina, most of the families use TEACCH [Treatment and Education of Autistic and Related Communication Handicapped Children, which was developed at the University of North Carolina and was the first statewide program for treatment and services for people with autism], although a fair number also reported using programs built on the 'applied behavior analysis' model, as well as some others,” Dr. Thomas said. “Surprisingly, 5% of the families said they were not really following any formal approach.”

On average, the children were receiving four service sessions per week in school and eight service sessions per week out of school, four of which the family was involved in providing.

An 18-item measure was used to evaluate family well-being as well as use of and satisfaction with different service elements, including social therapies, specialist care providers, medication therapies, and child care.

“Our goal was to look at associations between child/family characteristics and different service elements,” Dr. Thomas said. “What we saw was that children from minority families were getting diagnosed at a later age, they were receiving fewer services, and the proportion of family involvement in services was lower than the average.”

Additionally, among the families who didn't follow one of the major treatment approaches, “there was no association with age at diagnosis, but they also received fewer services overall and had less family involvement,” she said.

Children with Asperger's syndrome were diagnosed later than were those with typical autism, while those with a diagnosis of mental retardation were identified earlier.

Nearly 15% of the respondents reported not being satisfied with the services they were receiving.

“Interestingly, this group was receiving a higher proportion of services and had more family involvement,” Dr. Thomas noted.

Among the enabling characteristics, neither family stress nor ability to pay for services was associated with any differences in the receipt of or family involvement with services, Dr. Thomas said. However, “children who were diagnosed at a younger age were receiving more service sessions in school than those diagnosed later,” she said.

The findings uncover some important barriers to early intervention, “which gives us some idea of where we need to focus attention to be sure to get to kids at an earlier age,” Dr. Thomas said.

“Access to care is more limited for minority children and those whose families are not using a formal approach to care. We need to find a way to focus in on these groups. Clearly, more families need better information about the autism services available and information about how to choose the best treatment option.”

Also, screening efforts need to cast a wider net to include those children who may not fall within the typical autism diagnosis but who could benefit from early identification and intervention, she said.

Finally, “the results demonstrate that families with autistic children are devoting a tremendous amount of time on the provision of services to their children,” Dr. Thomas said.

“This should be taken into account in the design of programs and policies to make sure the families are getting the support and education they need to be able to do this.”

MONTREAL – Among children diagnosed with an autism spectrum disorder, those with Asperger's syndrome, minority children, and those whose families do not follow one of the major autism treatment approaches fall behind others when it comes to early intervention services, service intensity, and family involvement in providing treatment services, an analysis shows.

The findings highlight the need to develop family-level interventions for disseminating information, enhancing decision making, and supporting parents to assure adequate access to effective service elements for all children with an autism spectrum disorder (ASD), Kathleen Thomas, Ph.D., said at the 5th International Meeting for Autism Research.

As part of a 4-year study aimed at assessing family and child use of effective autism program elements funded by the National Institute of Mental Health, Dr. Thomas and her colleagues at the University of North Carolina at Chapel Hill recruited a sample of 383 families with a child aged 11 years or younger with an ASD diagnosis to participate in a combined telephone/in-person survey.

Sixty percent of the sample was obtained through the university's Neurodevelopmental Disorders Research Center Subject Registry; forty percent was obtained through direct recruitment from schools and developmental services agencies within the state.

The survey assessed demographics, access to services, use of services, payment for services, and overall satisfaction with services. The response rate among recruited families was 91%. The mean age of the children represented in the survey was 7 years; 71% of the children were white, and 87% were male.

Most families (58%) reported having private insurance, 21% received Medicaid alone, and 8% had both. About 70% of the children had a diagnosis of typical autism, 21% were diagnosed with Asperger's syndrome, and the rest had other diagnoses along the autism spectrum. The average age at diagnosis was 4 years.

Ninety-five percent of the families participating in the survey reported involvement with a major autism treatment approach.

“Because the participants were from North Carolina, most of the families use TEACCH [Treatment and Education of Autistic and Related Communication Handicapped Children, which was developed at the University of North Carolina and was the first statewide program for treatment and services for people with autism], although a fair number also reported using programs built on the 'applied behavior analysis' model, as well as some others,” Dr. Thomas said. “Surprisingly, 5% of the families said they were not really following any formal approach.”

On average, the children were receiving four service sessions per week in school and eight service sessions per week out of school, four of which the family was involved in providing.

An 18-item measure was used to evaluate family well-being as well as use of and satisfaction with different service elements, including social therapies, specialist care providers, medication therapies, and child care.

“Our goal was to look at associations between child/family characteristics and different service elements,” Dr. Thomas said. “What we saw was that children from minority families were getting diagnosed at a later age, they were receiving fewer services, and the proportion of family involvement in services was lower than the average.”

Additionally, among the families who didn't follow one of the major treatment approaches, “there was no association with age at diagnosis, but they also received fewer services overall and had less family involvement,” she said.

Children with Asperger's syndrome were diagnosed later than were those with typical autism, while those with a diagnosis of mental retardation were identified earlier.

Nearly 15% of the respondents reported not being satisfied with the services they were receiving.

“Interestingly, this group was receiving a higher proportion of services and had more family involvement,” Dr. Thomas noted.

Among the enabling characteristics, neither family stress nor ability to pay for services was associated with any differences in the receipt of or family involvement with services, Dr. Thomas said. However, “children who were diagnosed at a younger age were receiving more service sessions in school than those diagnosed later,” she said.

The findings uncover some important barriers to early intervention, “which gives us some idea of where we need to focus attention to be sure to get to kids at an earlier age,” Dr. Thomas said.

“Access to care is more limited for minority children and those whose families are not using a formal approach to care. We need to find a way to focus in on these groups. Clearly, more families need better information about the autism services available and information about how to choose the best treatment option.”

Also, screening efforts need to cast a wider net to include those children who may not fall within the typical autism diagnosis but who could benefit from early identification and intervention, she said.

Finally, “the results demonstrate that families with autistic children are devoting a tremendous amount of time on the provision of services to their children,” Dr. Thomas said.

“This should be taken into account in the design of programs and policies to make sure the families are getting the support and education they need to be able to do this.”

MONTREAL – Among children diagnosed with an autism spectrum disorder, those with Asperger's syndrome, minority children, and those whose families do not follow one of the major autism treatment approaches fall behind others when it comes to early intervention services, service intensity, and family involvement in providing treatment services, an analysis shows.

The findings highlight the need to develop family-level interventions for disseminating information, enhancing decision making, and supporting parents to assure adequate access to effective service elements for all children with an autism spectrum disorder (ASD), Kathleen Thomas, Ph.D., said at the 5th International Meeting for Autism Research.

As part of a 4-year study aimed at assessing family and child use of effective autism program elements funded by the National Institute of Mental Health, Dr. Thomas and her colleagues at the University of North Carolina at Chapel Hill recruited a sample of 383 families with a child aged 11 years or younger with an ASD diagnosis to participate in a combined telephone/in-person survey.

Sixty percent of the sample was obtained through the university's Neurodevelopmental Disorders Research Center Subject Registry; forty percent was obtained through direct recruitment from schools and developmental services agencies within the state.

The survey assessed demographics, access to services, use of services, payment for services, and overall satisfaction with services. The response rate among recruited families was 91%. The mean age of the children represented in the survey was 7 years; 71% of the children were white, and 87% were male.

Most families (58%) reported having private insurance, 21% received Medicaid alone, and 8% had both. About 70% of the children had a diagnosis of typical autism, 21% were diagnosed with Asperger's syndrome, and the rest had other diagnoses along the autism spectrum. The average age at diagnosis was 4 years.

Ninety-five percent of the families participating in the survey reported involvement with a major autism treatment approach.

“Because the participants were from North Carolina, most of the families use TEACCH [Treatment and Education of Autistic and Related Communication Handicapped Children, which was developed at the University of North Carolina and was the first statewide program for treatment and services for people with autism], although a fair number also reported using programs built on the 'applied behavior analysis' model, as well as some others,” Dr. Thomas said. “Surprisingly, 5% of the families said they were not really following any formal approach.”

On average, the children were receiving four service sessions per week in school and eight service sessions per week out of school, four of which the family was involved in providing.

An 18-item measure was used to evaluate family well-being as well as use of and satisfaction with different service elements, including social therapies, specialist care providers, medication therapies, and child care.

“Our goal was to look at associations between child/family characteristics and different service elements,” Dr. Thomas said. “What we saw was that children from minority families were getting diagnosed at a later age, they were receiving fewer services, and the proportion of family involvement in services was lower than the average.”

Additionally, among the families who didn't follow one of the major treatment approaches, “there was no association with age at diagnosis, but they also received fewer services overall and had less family involvement,” she said.

Children with Asperger's syndrome were diagnosed later than were those with typical autism, while those with a diagnosis of mental retardation were identified earlier.

Nearly 15% of the respondents reported not being satisfied with the services they were receiving.

“Interestingly, this group was receiving a higher proportion of services and had more family involvement,” Dr. Thomas noted.

Among the enabling characteristics, neither family stress nor ability to pay for services was associated with any differences in the receipt of or family involvement with services, Dr. Thomas said. However, “children who were diagnosed at a younger age were receiving more service sessions in school than those diagnosed later,” she said.

The findings uncover some important barriers to early intervention, “which gives us some idea of where we need to focus attention to be sure to get to kids at an earlier age,” Dr. Thomas said.

“Access to care is more limited for minority children and those whose families are not using a formal approach to care. We need to find a way to focus in on these groups. Clearly, more families need better information about the autism services available and information about how to choose the best treatment option.”

Also, screening efforts need to cast a wider net to include those children who may not fall within the typical autism diagnosis but who could benefit from early identification and intervention, she said.

Finally, “the results demonstrate that families with autistic children are devoting a tremendous amount of time on the provision of services to their children,” Dr. Thomas said.

“This should be taken into account in the design of programs and policies to make sure the families are getting the support and education they need to be able to do this.”

DALLAS — Laparoscopic vertical sleeve gastrectomy is a safe first-stage procedure for high-risk, superobese patients whose weight and size complicate biliopancreatic diversion with duodenal switch, Dr. Chrystine M. Lee said at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

Originally conceived as the first stage of a two-stage duodenal switch procedure, laparoscopic vertical sleeve gastrectomy was meant to help high-risk superobese patients lose sufficient weight to make the subsequent procedure more technically feasible. However, vertical sleeve gastrectomy alone may produce enough weight loss in some patients to preclude the need for a second-stage operation, said Dr. Lee of the David Grant U.S. Air Force Medical Center at the Travis (California) AFB.

Vertical sleeve gastrectomy closes off and removes about 85% or more of the stomach and creates a thin, tubelike stomach, without bypassing the intestines.

In a study of 216 obese patients who underwent the procedure between November 2002 and August 2005, the surgery was associated with a mean excess weight loss of 58.5% at 1 year and 83.1% at 2 years, “which is on par with weight loss achieved with the duodenal switch and the Roux-en-Y gastric bypass procedures,” Dr. Lee said. Of the 216 patients, only 9 experienced a weight loss plateau, defined as a loss of less than 10 pounds in a 6-month period, she said.

Patients in the study, 80% of whom were female, were aged 16–64 years (mean 44.7 years). The mean preoperative weight and body mass index (BMI) were 302 pounds and 42 kg/m

No deaths were associated with the surgery, but 20 patients experienced mild complications, 3 had leaks, and 26 required reoperations—rates similar to those associated with gastric banding, Dr. Lee said.

“All six patients whose preoperative BMI was less than 50 achieved BMI less than 35,” she said, eliminating the need for second-stage surgery. “The question with this type of procedure is weight loss durability. The gastroplasties in the past have not had durable weight loss—usually from 60% to 70% at 1 year, dropping down to 30%–40% at 5 years. The question is whether this procedure will follow those footsteps and be associated with rebound weight gain,” she said.

Previous data from a procedure similar to vertical sleeve gastrectomy showed “good results and durable 5-year weight loss,” Dr. Lee said. In that procedure, the stapled portion of the stomach was left instead of removed.

“We think our results will follow that lead,” she said. The fact that vertical sleeve gastrectomy removes the part of the stomach that secretes ghrelin, the hormone associated with appetite, may contribute to long-term durability, she suggested.

“What we've observed is weight loss similar to that seen with the Roux-en-Y and switch procedures, and higher than that associated with gastric banding. Morbidity is lower than the Roux-en-Y bypass and the switch, but comparable to gastric banding, so it's the best of both without some of the disadvantages,” she said.

Dr. Lee reported no conflict of interests with respect to her presentation.

DALLAS — Laparoscopic vertical sleeve gastrectomy is a safe first-stage procedure for high-risk, superobese patients whose weight and size complicate biliopancreatic diversion with duodenal switch, Dr. Chrystine M. Lee said at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

Originally conceived as the first stage of a two-stage duodenal switch procedure, laparoscopic vertical sleeve gastrectomy was meant to help high-risk superobese patients lose sufficient weight to make the subsequent procedure more technically feasible. However, vertical sleeve gastrectomy alone may produce enough weight loss in some patients to preclude the need for a second-stage operation, said Dr. Lee of the David Grant U.S. Air Force Medical Center at the Travis (California) AFB.

Vertical sleeve gastrectomy closes off and removes about 85% or more of the stomach and creates a thin, tubelike stomach, without bypassing the intestines.

In a study of 216 obese patients who underwent the procedure between November 2002 and August 2005, the surgery was associated with a mean excess weight loss of 58.5% at 1 year and 83.1% at 2 years, “which is on par with weight loss achieved with the duodenal switch and the Roux-en-Y gastric bypass procedures,” Dr. Lee said. Of the 216 patients, only 9 experienced a weight loss plateau, defined as a loss of less than 10 pounds in a 6-month period, she said.

Patients in the study, 80% of whom were female, were aged 16–64 years (mean 44.7 years). The mean preoperative weight and body mass index (BMI) were 302 pounds and 42 kg/m

No deaths were associated with the surgery, but 20 patients experienced mild complications, 3 had leaks, and 26 required reoperations—rates similar to those associated with gastric banding, Dr. Lee said.

“All six patients whose preoperative BMI was less than 50 achieved BMI less than 35,” she said, eliminating the need for second-stage surgery. “The question with this type of procedure is weight loss durability. The gastroplasties in the past have not had durable weight loss—usually from 60% to 70% at 1 year, dropping down to 30%–40% at 5 years. The question is whether this procedure will follow those footsteps and be associated with rebound weight gain,” she said.

Previous data from a procedure similar to vertical sleeve gastrectomy showed “good results and durable 5-year weight loss,” Dr. Lee said. In that procedure, the stapled portion of the stomach was left instead of removed.

“We think our results will follow that lead,” she said. The fact that vertical sleeve gastrectomy removes the part of the stomach that secretes ghrelin, the hormone associated with appetite, may contribute to long-term durability, she suggested.

“What we've observed is weight loss similar to that seen with the Roux-en-Y and switch procedures, and higher than that associated with gastric banding. Morbidity is lower than the Roux-en-Y bypass and the switch, but comparable to gastric banding, so it's the best of both without some of the disadvantages,” she said.

Dr. Lee reported no conflict of interests with respect to her presentation.

DALLAS — Laparoscopic vertical sleeve gastrectomy is a safe first-stage procedure for high-risk, superobese patients whose weight and size complicate biliopancreatic diversion with duodenal switch, Dr. Chrystine M. Lee said at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

Originally conceived as the first stage of a two-stage duodenal switch procedure, laparoscopic vertical sleeve gastrectomy was meant to help high-risk superobese patients lose sufficient weight to make the subsequent procedure more technically feasible. However, vertical sleeve gastrectomy alone may produce enough weight loss in some patients to preclude the need for a second-stage operation, said Dr. Lee of the David Grant U.S. Air Force Medical Center at the Travis (California) AFB.

Vertical sleeve gastrectomy closes off and removes about 85% or more of the stomach and creates a thin, tubelike stomach, without bypassing the intestines.

In a study of 216 obese patients who underwent the procedure between November 2002 and August 2005, the surgery was associated with a mean excess weight loss of 58.5% at 1 year and 83.1% at 2 years, “which is on par with weight loss achieved with the duodenal switch and the Roux-en-Y gastric bypass procedures,” Dr. Lee said. Of the 216 patients, only 9 experienced a weight loss plateau, defined as a loss of less than 10 pounds in a 6-month period, she said.

Patients in the study, 80% of whom were female, were aged 16–64 years (mean 44.7 years). The mean preoperative weight and body mass index (BMI) were 302 pounds and 42 kg/m

No deaths were associated with the surgery, but 20 patients experienced mild complications, 3 had leaks, and 26 required reoperations—rates similar to those associated with gastric banding, Dr. Lee said.

“All six patients whose preoperative BMI was less than 50 achieved BMI less than 35,” she said, eliminating the need for second-stage surgery. “The question with this type of procedure is weight loss durability. The gastroplasties in the past have not had durable weight loss—usually from 60% to 70% at 1 year, dropping down to 30%–40% at 5 years. The question is whether this procedure will follow those footsteps and be associated with rebound weight gain,” she said.

Previous data from a procedure similar to vertical sleeve gastrectomy showed “good results and durable 5-year weight loss,” Dr. Lee said. In that procedure, the stapled portion of the stomach was left instead of removed.

“We think our results will follow that lead,” she said. The fact that vertical sleeve gastrectomy removes the part of the stomach that secretes ghrelin, the hormone associated with appetite, may contribute to long-term durability, she suggested.

“What we've observed is weight loss similar to that seen with the Roux-en-Y and switch procedures, and higher than that associated with gastric banding. Morbidity is lower than the Roux-en-Y bypass and the switch, but comparable to gastric banding, so it's the best of both without some of the disadvantages,” she said.

Dr. Lee reported no conflict of interests with respect to her presentation.

BOSTON — Infrared light energy delivered through an intelligent pulsed light handpiece can safely and effectively induce tissue tightening in lax skin of the face, neck, arms, abdomen, and buttocks, suggesting that infrared light technology is a useful tool for nonablative tissue tightening, Dr. Matthew E. Halpern said at the annual meeting of the American Society for Laser Medicine and Surgery.

In a clinical trial designed to evaluate the tissue-tightening capability of the Solera Titan, which achieves dermal heating using infrared light at wavelengths of 1100–1800 nm and provides continuous epidermal cooling, Dr. Halpern and his colleagues at St. Luke's-Roosevelt Hospital, New York, enrolled 42 patients with primary tissue laxity or tissue laxity resulting from a liposuction procedure.

Of the initial 42 patients who underwent the nonablative tissue-tightening treatment of multiple anatomic areas, 32 completed one treatment and follow-up; 14 of the 32 completed additional treatment and follow-up.

The light energy delivery parameters for the project included four passes over each area, for a total of 100–500 pulses depending on the area, and fluences ranging from 35 to 50 J/cm

The observers scored baseline tissue laxity as none, mild, moderate, severe, or extreme. They scored degree of improvement as none if there was less than 10% visible improvement, mild for 10%–25% improvement, moderate for 25%–50% improvement, and significant for 50%–75% improvement.

"After one treatment, 94% of patients had better than 10% improvement and 34% had better than 25% improvement," he reported. "All of the patients who underwent two treatments had better than 10% improvement following the second treatment, approximately 75% of them had better than 25% improvement, and about a third of them had better than 50% improvement."

To determine the characteristics of patients who had the most vigorous response to the infrared treatment, the investigators first looked at patient response by age and then by baseline tissue laxity.

"We found that patients between ages 40 and 50 years tended to have higher improvement scores than older patients after both one and two treatments," Dr. Halpern said. Although these numbers didn't reach statistical significance, the trend toward lower improvement scores among older patients suggests that "perhaps there's something inherent about older fibroblasts, that they respond less well to bulk dermal heating," he said.

In evaluating patient response by baseline tissue laxity, "patients with severe and extreme tissue laxity had higher mean improvement scores after both one and two treatments than patients with mild to moderate tissue laxity," Dr. Halpern noted. "These numbers also did not reach statistical significance, but that is probably a function of the small study size."

Most of the patients had mild erythema and edema that lasted 24–48 hours; three patients developed local blistering, which resolved, with transient hyperpigmentation. "There was no scarring or lipoatrophy in our patients," he said.

The study results suggest that infrared light therapy "is a safe and effective way to induce tissue tightening when used in appropriate settings," said Dr. Halpern, who reported receiving consulting fees and honoraria from Cutera, manufacturer of the Titan product line. "Future studies are needed to confirm whether patient age and baseline tissue laxity are accurate predictors of therapeutic response."

BOSTON — Infrared light energy delivered through an intelligent pulsed light handpiece can safely and effectively induce tissue tightening in lax skin of the face, neck, arms, abdomen, and buttocks, suggesting that infrared light technology is a useful tool for nonablative tissue tightening, Dr. Matthew E. Halpern said at the annual meeting of the American Society for Laser Medicine and Surgery.

In a clinical trial designed to evaluate the tissue-tightening capability of the Solera Titan, which achieves dermal heating using infrared light at wavelengths of 1100–1800 nm and provides continuous epidermal cooling, Dr. Halpern and his colleagues at St. Luke's-Roosevelt Hospital, New York, enrolled 42 patients with primary tissue laxity or tissue laxity resulting from a liposuction procedure.

Of the initial 42 patients who underwent the nonablative tissue-tightening treatment of multiple anatomic areas, 32 completed one treatment and follow-up; 14 of the 32 completed additional treatment and follow-up.

The light energy delivery parameters for the project included four passes over each area, for a total of 100–500 pulses depending on the area, and fluences ranging from 35 to 50 J/cm

The observers scored baseline tissue laxity as none, mild, moderate, severe, or extreme. They scored degree of improvement as none if there was less than 10% visible improvement, mild for 10%–25% improvement, moderate for 25%–50% improvement, and significant for 50%–75% improvement.

"After one treatment, 94% of patients had better than 10% improvement and 34% had better than 25% improvement," he reported. "All of the patients who underwent two treatments had better than 10% improvement following the second treatment, approximately 75% of them had better than 25% improvement, and about a third of them had better than 50% improvement."

To determine the characteristics of patients who had the most vigorous response to the infrared treatment, the investigators first looked at patient response by age and then by baseline tissue laxity.

"We found that patients between ages 40 and 50 years tended to have higher improvement scores than older patients after both one and two treatments," Dr. Halpern said. Although these numbers didn't reach statistical significance, the trend toward lower improvement scores among older patients suggests that "perhaps there's something inherent about older fibroblasts, that they respond less well to bulk dermal heating," he said.

In evaluating patient response by baseline tissue laxity, "patients with severe and extreme tissue laxity had higher mean improvement scores after both one and two treatments than patients with mild to moderate tissue laxity," Dr. Halpern noted. "These numbers also did not reach statistical significance, but that is probably a function of the small study size."

Most of the patients had mild erythema and edema that lasted 24–48 hours; three patients developed local blistering, which resolved, with transient hyperpigmentation. "There was no scarring or lipoatrophy in our patients," he said.

The study results suggest that infrared light therapy "is a safe and effective way to induce tissue tightening when used in appropriate settings," said Dr. Halpern, who reported receiving consulting fees and honoraria from Cutera, manufacturer of the Titan product line. "Future studies are needed to confirm whether patient age and baseline tissue laxity are accurate predictors of therapeutic response."

BOSTON — Infrared light energy delivered through an intelligent pulsed light handpiece can safely and effectively induce tissue tightening in lax skin of the face, neck, arms, abdomen, and buttocks, suggesting that infrared light technology is a useful tool for nonablative tissue tightening, Dr. Matthew E. Halpern said at the annual meeting of the American Society for Laser Medicine and Surgery.

In a clinical trial designed to evaluate the tissue-tightening capability of the Solera Titan, which achieves dermal heating using infrared light at wavelengths of 1100–1800 nm and provides continuous epidermal cooling, Dr. Halpern and his colleagues at St. Luke's-Roosevelt Hospital, New York, enrolled 42 patients with primary tissue laxity or tissue laxity resulting from a liposuction procedure.

Of the initial 42 patients who underwent the nonablative tissue-tightening treatment of multiple anatomic areas, 32 completed one treatment and follow-up; 14 of the 32 completed additional treatment and follow-up.

The light energy delivery parameters for the project included four passes over each area, for a total of 100–500 pulses depending on the area, and fluences ranging from 35 to 50 J/cm

The observers scored baseline tissue laxity as none, mild, moderate, severe, or extreme. They scored degree of improvement as none if there was less than 10% visible improvement, mild for 10%–25% improvement, moderate for 25%–50% improvement, and significant for 50%–75% improvement.

"After one treatment, 94% of patients had better than 10% improvement and 34% had better than 25% improvement," he reported. "All of the patients who underwent two treatments had better than 10% improvement following the second treatment, approximately 75% of them had better than 25% improvement, and about a third of them had better than 50% improvement."

To determine the characteristics of patients who had the most vigorous response to the infrared treatment, the investigators first looked at patient response by age and then by baseline tissue laxity.

"We found that patients between ages 40 and 50 years tended to have higher improvement scores than older patients after both one and two treatments," Dr. Halpern said. Although these numbers didn't reach statistical significance, the trend toward lower improvement scores among older patients suggests that "perhaps there's something inherent about older fibroblasts, that they respond less well to bulk dermal heating," he said.

In evaluating patient response by baseline tissue laxity, "patients with severe and extreme tissue laxity had higher mean improvement scores after both one and two treatments than patients with mild to moderate tissue laxity," Dr. Halpern noted. "These numbers also did not reach statistical significance, but that is probably a function of the small study size."

Most of the patients had mild erythema and edema that lasted 24–48 hours; three patients developed local blistering, which resolved, with transient hyperpigmentation. "There was no scarring or lipoatrophy in our patients," he said.

The study results suggest that infrared light therapy "is a safe and effective way to induce tissue tightening when used in appropriate settings," said Dr. Halpern, who reported receiving consulting fees and honoraria from Cutera, manufacturer of the Titan product line. "Future studies are needed to confirm whether patient age and baseline tissue laxity are accurate predictors of therapeutic response."

DALLAS — Appendicitis in the elderly is not as threatening as it once was, thanks to increased use of computed tomography to aid diagnosis as well as minimally invasive surgery, said Dr. Charudutt Paranjape at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

Historically, older patients with appendicitis have had worse outcomes than younger patients “because they are less likely to present with classic symptoms,” Dr. Paranjape said. This delays diagnosis and treatment, increasing the risk of perforation and associated morbidity and mortality.

To evaluate whether recent diagnostic and treatment advances have influenced outcomes in this patient population, Dr. Paranjape and his colleagues at Akron (Ohio) General Medical Center conducted a retrospective study of 116 patients 60 years and older who underwent appendectomy at the medical center between 1999 and 2004. They compared outcomes of laparoscopic and open surgical procedures, and compared the findings with those of two previously published series from the same institution—one of which looked at results from 1978 to 1988 and the other from 1988 to 1998.

Of the 116 patients, 66 were women. Overall, 68 of the procedures were laparoscopic and 48 were performed via open surgery, including 8 that were converted to open surgery from an initial laparoscopic attempt. When the data were analyzed based on patients with and without perforations, the ratio of laparoscopic to open surgery cases remained consistent, he noted. The appendix was considered perforated if there was free rupture of intraluminal contents, and nonperforated if there was inflammation with or without necrosis without free perforation.

In only 17% of the laparoscopic and 16% of the open surgery patients, the presentation included classic symptoms of right lower quadrant pain, fever, white blood cell count over 10,000 μL, and nausea or vomiting. Similar rates were seen in the earlier studies.

Diagnostic preoperative CT scans were performed in 79% of cases, with a 94% accuracy rate. “This contributed to a high rate of accuracy [87%] of initial diagnosis upon admission in both the laparoscopic and open surgery patients,” he said. In contrast, in the 10-year series concluding in 1998, 44% of the patients underwent preoperative CT scanning, with a 90% accuracy rate. Computed tomography was scarcely used in the first patient series.

Consistent with data from other recent studies, laparoscopic surgery was associated with a significantly shorter length of hospital stay and fewer complications overall, compared with open surgery. The groups had similar rates of postoperative intraabdominal infections; that contradicts findings in earlier studies suggesting an increased number of abscesses associated with laparoscopic appendectomies.

Emergency department to operating room time was similar in both groups, as was total surgery time. The latter finding is of note “because previous studies have suggested that laparoscopic surgery takes longer than the open procedure,” he said.

When broken down by perforated vs. nonperforated, “emergency department to operating room time was less in the perforated group, but surgery time and length of stay was significantly longer, as would be expected,” Dr. Paranjape said.

Compared with the earlier series, significantly fewer cases of perforated appendicitis were seen in the present study, and perforations that were encountered were associated with fewer complications, he noted. Also, mortality decreased from 4% to 1%, although the difference is not statistically significant, he noted.

Although the numbers are limited, the new findings suggest that minimally invasive surgery, along with preoperative CT scanning, has changed the clinical management of acute appendicitis in elderly patients, Dr. Paranjape said.

DALLAS — Appendicitis in the elderly is not as threatening as it once was, thanks to increased use of computed tomography to aid diagnosis as well as minimally invasive surgery, said Dr. Charudutt Paranjape at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

Historically, older patients with appendicitis have had worse outcomes than younger patients “because they are less likely to present with classic symptoms,” Dr. Paranjape said. This delays diagnosis and treatment, increasing the risk of perforation and associated morbidity and mortality.

To evaluate whether recent diagnostic and treatment advances have influenced outcomes in this patient population, Dr. Paranjape and his colleagues at Akron (Ohio) General Medical Center conducted a retrospective study of 116 patients 60 years and older who underwent appendectomy at the medical center between 1999 and 2004. They compared outcomes of laparoscopic and open surgical procedures, and compared the findings with those of two previously published series from the same institution—one of which looked at results from 1978 to 1988 and the other from 1988 to 1998.

Of the 116 patients, 66 were women. Overall, 68 of the procedures were laparoscopic and 48 were performed via open surgery, including 8 that were converted to open surgery from an initial laparoscopic attempt. When the data were analyzed based on patients with and without perforations, the ratio of laparoscopic to open surgery cases remained consistent, he noted. The appendix was considered perforated if there was free rupture of intraluminal contents, and nonperforated if there was inflammation with or without necrosis without free perforation.

In only 17% of the laparoscopic and 16% of the open surgery patients, the presentation included classic symptoms of right lower quadrant pain, fever, white blood cell count over 10,000 μL, and nausea or vomiting. Similar rates were seen in the earlier studies.

Diagnostic preoperative CT scans were performed in 79% of cases, with a 94% accuracy rate. “This contributed to a high rate of accuracy [87%] of initial diagnosis upon admission in both the laparoscopic and open surgery patients,” he said. In contrast, in the 10-year series concluding in 1998, 44% of the patients underwent preoperative CT scanning, with a 90% accuracy rate. Computed tomography was scarcely used in the first patient series.

Consistent with data from other recent studies, laparoscopic surgery was associated with a significantly shorter length of hospital stay and fewer complications overall, compared with open surgery. The groups had similar rates of postoperative intraabdominal infections; that contradicts findings in earlier studies suggesting an increased number of abscesses associated with laparoscopic appendectomies.

Emergency department to operating room time was similar in both groups, as was total surgery time. The latter finding is of note “because previous studies have suggested that laparoscopic surgery takes longer than the open procedure,” he said.

When broken down by perforated vs. nonperforated, “emergency department to operating room time was less in the perforated group, but surgery time and length of stay was significantly longer, as would be expected,” Dr. Paranjape said.

Compared with the earlier series, significantly fewer cases of perforated appendicitis were seen in the present study, and perforations that were encountered were associated with fewer complications, he noted. Also, mortality decreased from 4% to 1%, although the difference is not statistically significant, he noted.

Although the numbers are limited, the new findings suggest that minimally invasive surgery, along with preoperative CT scanning, has changed the clinical management of acute appendicitis in elderly patients, Dr. Paranjape said.

DALLAS — Appendicitis in the elderly is not as threatening as it once was, thanks to increased use of computed tomography to aid diagnosis as well as minimally invasive surgery, said Dr. Charudutt Paranjape at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

Historically, older patients with appendicitis have had worse outcomes than younger patients “because they are less likely to present with classic symptoms,” Dr. Paranjape said. This delays diagnosis and treatment, increasing the risk of perforation and associated morbidity and mortality.

To evaluate whether recent diagnostic and treatment advances have influenced outcomes in this patient population, Dr. Paranjape and his colleagues at Akron (Ohio) General Medical Center conducted a retrospective study of 116 patients 60 years and older who underwent appendectomy at the medical center between 1999 and 2004. They compared outcomes of laparoscopic and open surgical procedures, and compared the findings with those of two previously published series from the same institution—one of which looked at results from 1978 to 1988 and the other from 1988 to 1998.

Of the 116 patients, 66 were women. Overall, 68 of the procedures were laparoscopic and 48 were performed via open surgery, including 8 that were converted to open surgery from an initial laparoscopic attempt. When the data were analyzed based on patients with and without perforations, the ratio of laparoscopic to open surgery cases remained consistent, he noted. The appendix was considered perforated if there was free rupture of intraluminal contents, and nonperforated if there was inflammation with or without necrosis without free perforation.

In only 17% of the laparoscopic and 16% of the open surgery patients, the presentation included classic symptoms of right lower quadrant pain, fever, white blood cell count over 10,000 μL, and nausea or vomiting. Similar rates were seen in the earlier studies.

Diagnostic preoperative CT scans were performed in 79% of cases, with a 94% accuracy rate. “This contributed to a high rate of accuracy [87%] of initial diagnosis upon admission in both the laparoscopic and open surgery patients,” he said. In contrast, in the 10-year series concluding in 1998, 44% of the patients underwent preoperative CT scanning, with a 90% accuracy rate. Computed tomography was scarcely used in the first patient series.

Consistent with data from other recent studies, laparoscopic surgery was associated with a significantly shorter length of hospital stay and fewer complications overall, compared with open surgery. The groups had similar rates of postoperative intraabdominal infections; that contradicts findings in earlier studies suggesting an increased number of abscesses associated with laparoscopic appendectomies.

Emergency department to operating room time was similar in both groups, as was total surgery time. The latter finding is of note “because previous studies have suggested that laparoscopic surgery takes longer than the open procedure,” he said.

When broken down by perforated vs. nonperforated, “emergency department to operating room time was less in the perforated group, but surgery time and length of stay was significantly longer, as would be expected,” Dr. Paranjape said.

Compared with the earlier series, significantly fewer cases of perforated appendicitis were seen in the present study, and perforations that were encountered were associated with fewer complications, he noted. Also, mortality decreased from 4% to 1%, although the difference is not statistically significant, he noted.

Although the numbers are limited, the new findings suggest that minimally invasive surgery, along with preoperative CT scanning, has changed the clinical management of acute appendicitis in elderly patients, Dr. Paranjape said.

BOSTON — A light-based therapy commonly used in cosmetic dermatology minimizes the occurrence and symptom intensity of radiation-induced dermatitis in breast cancer patients undergoing radiation treatment, according to the results of a recent investigation. The preventive therapy not only minimizes patient discomfort, but also prevents treatment interruptions necessitated by severe skin reactions, said Dr. M. Maitland DeLand at the annual meeting of the American Society for Laser Medicine and Surgery.

Postradiation dermatitis can include reactions ranging from mild to moderate dryness and peeling to significant erythema, hyperemia, and moist desquamation with loss of epidermal barrier, said Dr. DeLand, a radiation oncologist in Lafayette, La. The investigators hypothesized that targeting these areas with pulses of nonthermal low-energy light via arrays of light-emitting diodes (LED) would interrupt the postradiation inflammatory process and stimulate collagen synthesis, and by so doing strengthen the skin's defenses, she said.

In the pilot study, 18 of 19 women who received LED photomodulation therapy following radiotherapy for breast cancer had little to no radiation dermatitis, whereas all 28 matched controls who did not receive the light therapy had some degree of skin reaction, Dr. DeLand said.

The women in the study were 35–80 years old. Prior to radiation therapy, all had undergone single lymph node sampling or axillary dissection; some had chemotherapy. The women in the photomodulation group received the LED treatment immediately after their daily radiation therapy, and were allowed to use a neutral pH ointment for dry skin after each session. The women in the control group followed the same radiation therapy protocol without the LED follow-up, and were also allowed to use the ointment.

Of the 19 women in the treatment group, 7 had no skin reactions, 11 had grade 1 reactions, and 1 patient had a grade 2 reaction. In contrast, 4 of the control patients had grade 1 reactions, 18 had grade 2 reactions, and 6 had grade 3 reactions. In the control group, the skin reactions—specifically severe erythema and moist desquamation—led to treatment interruptions in 19 patients.

“Only one patient in the [treatment group] had a reaction severe enough to interrupt therapy,” Dr. DeLand said. “This is an important finding, because the efficacy of radiation therapy is based on a dose/time relationship. You really want to avoid treatment disruptions” to achieve the best biologic response, she said.

The LED therapy also appeared to provide long-lasting skin benefits. At 3 and 6 months post therapy, the skin texture and pigment of irradiated areas in the women in the treatment group were “excellent,” the breast tissue was smooth and supple, and the surgical scars were “barely visible,” Dr. DeLand said. In contrast, the women in the control group showed typical signs of late radiation effects, including some atrophy and pigmentary changes and, in some cases, radiation-induced fibrosis, edema, and dermal thickening.

LED therapy should be made available to all women undergoing breast irradiation, Dr. DeLand concluded.

Dr. DeLand reported that she received free use of the photomodulation device for the investigation but has no financial interest in the manufacturer.

BOSTON — A light-based therapy commonly used in cosmetic dermatology minimizes the occurrence and symptom intensity of radiation-induced dermatitis in breast cancer patients undergoing radiation treatment, according to the results of a recent investigation. The preventive therapy not only minimizes patient discomfort, but also prevents treatment interruptions necessitated by severe skin reactions, said Dr. M. Maitland DeLand at the annual meeting of the American Society for Laser Medicine and Surgery.

Postradiation dermatitis can include reactions ranging from mild to moderate dryness and peeling to significant erythema, hyperemia, and moist desquamation with loss of epidermal barrier, said Dr. DeLand, a radiation oncologist in Lafayette, La. The investigators hypothesized that targeting these areas with pulses of nonthermal low-energy light via arrays of light-emitting diodes (LED) would interrupt the postradiation inflammatory process and stimulate collagen synthesis, and by so doing strengthen the skin's defenses, she said.

In the pilot study, 18 of 19 women who received LED photomodulation therapy following radiotherapy for breast cancer had little to no radiation dermatitis, whereas all 28 matched controls who did not receive the light therapy had some degree of skin reaction, Dr. DeLand said.

The women in the study were 35–80 years old. Prior to radiation therapy, all had undergone single lymph node sampling or axillary dissection; some had chemotherapy. The women in the photomodulation group received the LED treatment immediately after their daily radiation therapy, and were allowed to use a neutral pH ointment for dry skin after each session. The women in the control group followed the same radiation therapy protocol without the LED follow-up, and were also allowed to use the ointment.

Of the 19 women in the treatment group, 7 had no skin reactions, 11 had grade 1 reactions, and 1 patient had a grade 2 reaction. In contrast, 4 of the control patients had grade 1 reactions, 18 had grade 2 reactions, and 6 had grade 3 reactions. In the control group, the skin reactions—specifically severe erythema and moist desquamation—led to treatment interruptions in 19 patients.

“Only one patient in the [treatment group] had a reaction severe enough to interrupt therapy,” Dr. DeLand said. “This is an important finding, because the efficacy of radiation therapy is based on a dose/time relationship. You really want to avoid treatment disruptions” to achieve the best biologic response, she said.

The LED therapy also appeared to provide long-lasting skin benefits. At 3 and 6 months post therapy, the skin texture and pigment of irradiated areas in the women in the treatment group were “excellent,” the breast tissue was smooth and supple, and the surgical scars were “barely visible,” Dr. DeLand said. In contrast, the women in the control group showed typical signs of late radiation effects, including some atrophy and pigmentary changes and, in some cases, radiation-induced fibrosis, edema, and dermal thickening.

LED therapy should be made available to all women undergoing breast irradiation, Dr. DeLand concluded.

Dr. DeLand reported that she received free use of the photomodulation device for the investigation but has no financial interest in the manufacturer.

BOSTON — A light-based therapy commonly used in cosmetic dermatology minimizes the occurrence and symptom intensity of radiation-induced dermatitis in breast cancer patients undergoing radiation treatment, according to the results of a recent investigation. The preventive therapy not only minimizes patient discomfort, but also prevents treatment interruptions necessitated by severe skin reactions, said Dr. M. Maitland DeLand at the annual meeting of the American Society for Laser Medicine and Surgery.

Postradiation dermatitis can include reactions ranging from mild to moderate dryness and peeling to significant erythema, hyperemia, and moist desquamation with loss of epidermal barrier, said Dr. DeLand, a radiation oncologist in Lafayette, La. The investigators hypothesized that targeting these areas with pulses of nonthermal low-energy light via arrays of light-emitting diodes (LED) would interrupt the postradiation inflammatory process and stimulate collagen synthesis, and by so doing strengthen the skin's defenses, she said.

In the pilot study, 18 of 19 women who received LED photomodulation therapy following radiotherapy for breast cancer had little to no radiation dermatitis, whereas all 28 matched controls who did not receive the light therapy had some degree of skin reaction, Dr. DeLand said.

The women in the study were 35–80 years old. Prior to radiation therapy, all had undergone single lymph node sampling or axillary dissection; some had chemotherapy. The women in the photomodulation group received the LED treatment immediately after their daily radiation therapy, and were allowed to use a neutral pH ointment for dry skin after each session. The women in the control group followed the same radiation therapy protocol without the LED follow-up, and were also allowed to use the ointment.

Of the 19 women in the treatment group, 7 had no skin reactions, 11 had grade 1 reactions, and 1 patient had a grade 2 reaction. In contrast, 4 of the control patients had grade 1 reactions, 18 had grade 2 reactions, and 6 had grade 3 reactions. In the control group, the skin reactions—specifically severe erythema and moist desquamation—led to treatment interruptions in 19 patients.

“Only one patient in the [treatment group] had a reaction severe enough to interrupt therapy,” Dr. DeLand said. “This is an important finding, because the efficacy of radiation therapy is based on a dose/time relationship. You really want to avoid treatment disruptions” to achieve the best biologic response, she said.

The LED therapy also appeared to provide long-lasting skin benefits. At 3 and 6 months post therapy, the skin texture and pigment of irradiated areas in the women in the treatment group were “excellent,” the breast tissue was smooth and supple, and the surgical scars were “barely visible,” Dr. DeLand said. In contrast, the women in the control group showed typical signs of late radiation effects, including some atrophy and pigmentary changes and, in some cases, radiation-induced fibrosis, edema, and dermal thickening.

LED therapy should be made available to all women undergoing breast irradiation, Dr. DeLand concluded.

Dr. DeLand reported that she received free use of the photomodulation device for the investigation but has no financial interest in the manufacturer.

BOSTON — The use of medroxyprogesterone may impair insulin and glucose metabolism in obese adolescents, thus increasing the long-term health risks of young women in an already vulnerable population, Dr. Nancy E. Fritz said at the annual meeting of the Society for Adolescent Medicine.

In a small retrospective study, Dr. Fritz and colleagues in the Cook County Bureau of Health Services' division of adolescent medicine in Chicago collected information on height, weight, laboratory values, contraceptive use, and obstetric history from the charts of 56 adolescent girls (mean age 17 years) from three urban school-based health centers who were participating in an obesity management program. With the exception of two Hispanic girls, participants were African American.

All participants had a body mass index of at least 95% for their age and all had at least one additional risk factor for type 2 diabetes mellitus. As part of the obesity management program, all of the young women had undergone screening for fasting glucose, lipids, and insulin levels.

The study participants were sorted into one of three groups based on contraceptive use: 22 medroxyprogesterone (Depo Provera) users, 13 oral contraception users, and 21 women who did not use hormonal contraception, Dr. Fritz reported in a poster presentation.

The three groups did not differ significantly by age, body mass index, glucose, cholesterol, triglyceride, HDL cholesterol, or LDL cholesterol levels.

The medroxyprogesterone group was more likely to have gained weight before the time of blood work than were the other two groups, “which is consistent with data from previous studies showing an association between medroxyprogesterone use and weight gain,” Dr. Fritz noted.

The results also showed significantly higher mean insulin levels in the medroxyprogesterone group compared with both the oral contraceptive and nonhormone groups. Insulin levels tended to be higher among the never-pregnant vs. previously pregnant medroxyprogesterone users, but the finding was not statistically significant.

The insulin increases do not appear to be a function of weight gain in this population, as the insulin levels among oral contraception users and nonusers who were gaining weight were not significantly different from those who were losing weight, Dr. Fritz said. However, the association between insulin increases and weight gain and loss could not be reliably calculated for the medroxyprogesterone users because, she noted, “only three of this group did not gain weight.”

The association between medroxyprogesterone use and both increasing weight and increased insulin levels independent of body mass index in obese at-risk adolescents raises the possibility that the contraceptive also may increase risks for metabolic syndrome and/or diabetes in this subgroup, Dr. Fritz said.

Although enlightening, the data from this study are “too preliminary, too retrospective, and too small” to make a definitive statement about how to address this issue clinically, she said. “We need a larger prospective study looking at this in teenagers of various weights, ethnicities, and other risks. For now we need to keep an open mind.”

Studies already have shown that medroxyprogesterone makes heavy teens heavier, “and that alone probably increases their risks for all of the bad things, so we can tell our patients that,” Dr. Fritz said. “If it also messes with insulin levels and glucose metabolism above and beyond the weight issue, which our work suggests, things get more complicated, as they do when you consider the fact that African American kids, who are already at higher risk for diabetes, are probably the ones most likely to use [medroxyprogesterone] these days, and therefore the ones most likely to get pregnant if we steer them away from it.”

The challenge, she added, “is figuring out how to factor all of those ethical decisions into a discussion with a concrete teenager. Which is worse, teenage pregnancy or increased diabetes mellitus risks? I would say the latter, but not everyone would agree with me.” ?

BOSTON — The use of medroxyprogesterone may impair insulin and glucose metabolism in obese adolescents, thus increasing the long-term health risks of young women in an already vulnerable population, Dr. Nancy E. Fritz said at the annual meeting of the Society for Adolescent Medicine.

In a small retrospective study, Dr. Fritz and colleagues in the Cook County Bureau of Health Services' division of adolescent medicine in Chicago collected information on height, weight, laboratory values, contraceptive use, and obstetric history from the charts of 56 adolescent girls (mean age 17 years) from three urban school-based health centers who were participating in an obesity management program. With the exception of two Hispanic girls, participants were African American.

All participants had a body mass index of at least 95% for their age and all had at least one additional risk factor for type 2 diabetes mellitus. As part of the obesity management program, all of the young women had undergone screening for fasting glucose, lipids, and insulin levels.

The study participants were sorted into one of three groups based on contraceptive use: 22 medroxyprogesterone (Depo Provera) users, 13 oral contraception users, and 21 women who did not use hormonal contraception, Dr. Fritz reported in a poster presentation.

The three groups did not differ significantly by age, body mass index, glucose, cholesterol, triglyceride, HDL cholesterol, or LDL cholesterol levels.

The medroxyprogesterone group was more likely to have gained weight before the time of blood work than were the other two groups, “which is consistent with data from previous studies showing an association between medroxyprogesterone use and weight gain,” Dr. Fritz noted.

The results also showed significantly higher mean insulin levels in the medroxyprogesterone group compared with both the oral contraceptive and nonhormone groups. Insulin levels tended to be higher among the never-pregnant vs. previously pregnant medroxyprogesterone users, but the finding was not statistically significant.

The insulin increases do not appear to be a function of weight gain in this population, as the insulin levels among oral contraception users and nonusers who were gaining weight were not significantly different from those who were losing weight, Dr. Fritz said. However, the association between insulin increases and weight gain and loss could not be reliably calculated for the medroxyprogesterone users because, she noted, “only three of this group did not gain weight.”

The association between medroxyprogesterone use and both increasing weight and increased insulin levels independent of body mass index in obese at-risk adolescents raises the possibility that the contraceptive also may increase risks for metabolic syndrome and/or diabetes in this subgroup, Dr. Fritz said.

Although enlightening, the data from this study are “too preliminary, too retrospective, and too small” to make a definitive statement about how to address this issue clinically, she said. “We need a larger prospective study looking at this in teenagers of various weights, ethnicities, and other risks. For now we need to keep an open mind.”

Studies already have shown that medroxyprogesterone makes heavy teens heavier, “and that alone probably increases their risks for all of the bad things, so we can tell our patients that,” Dr. Fritz said. “If it also messes with insulin levels and glucose metabolism above and beyond the weight issue, which our work suggests, things get more complicated, as they do when you consider the fact that African American kids, who are already at higher risk for diabetes, are probably the ones most likely to use [medroxyprogesterone] these days, and therefore the ones most likely to get pregnant if we steer them away from it.”

The challenge, she added, “is figuring out how to factor all of those ethical decisions into a discussion with a concrete teenager. Which is worse, teenage pregnancy or increased diabetes mellitus risks? I would say the latter, but not everyone would agree with me.” ?

BOSTON — The use of medroxyprogesterone may impair insulin and glucose metabolism in obese adolescents, thus increasing the long-term health risks of young women in an already vulnerable population, Dr. Nancy E. Fritz said at the annual meeting of the Society for Adolescent Medicine.

In a small retrospective study, Dr. Fritz and colleagues in the Cook County Bureau of Health Services' division of adolescent medicine in Chicago collected information on height, weight, laboratory values, contraceptive use, and obstetric history from the charts of 56 adolescent girls (mean age 17 years) from three urban school-based health centers who were participating in an obesity management program. With the exception of two Hispanic girls, participants were African American.

All participants had a body mass index of at least 95% for their age and all had at least one additional risk factor for type 2 diabetes mellitus. As part of the obesity management program, all of the young women had undergone screening for fasting glucose, lipids, and insulin levels.

The study participants were sorted into one of three groups based on contraceptive use: 22 medroxyprogesterone (Depo Provera) users, 13 oral contraception users, and 21 women who did not use hormonal contraception, Dr. Fritz reported in a poster presentation.

The three groups did not differ significantly by age, body mass index, glucose, cholesterol, triglyceride, HDL cholesterol, or LDL cholesterol levels.

The medroxyprogesterone group was more likely to have gained weight before the time of blood work than were the other two groups, “which is consistent with data from previous studies showing an association between medroxyprogesterone use and weight gain,” Dr. Fritz noted.

The results also showed significantly higher mean insulin levels in the medroxyprogesterone group compared with both the oral contraceptive and nonhormone groups. Insulin levels tended to be higher among the never-pregnant vs. previously pregnant medroxyprogesterone users, but the finding was not statistically significant.

The insulin increases do not appear to be a function of weight gain in this population, as the insulin levels among oral contraception users and nonusers who were gaining weight were not significantly different from those who were losing weight, Dr. Fritz said. However, the association between insulin increases and weight gain and loss could not be reliably calculated for the medroxyprogesterone users because, she noted, “only three of this group did not gain weight.”

The association between medroxyprogesterone use and both increasing weight and increased insulin levels independent of body mass index in obese at-risk adolescents raises the possibility that the contraceptive also may increase risks for metabolic syndrome and/or diabetes in this subgroup, Dr. Fritz said.

Although enlightening, the data from this study are “too preliminary, too retrospective, and too small” to make a definitive statement about how to address this issue clinically, she said. “We need a larger prospective study looking at this in teenagers of various weights, ethnicities, and other risks. For now we need to keep an open mind.”

Studies already have shown that medroxyprogesterone makes heavy teens heavier, “and that alone probably increases their risks for all of the bad things, so we can tell our patients that,” Dr. Fritz said. “If it also messes with insulin levels and glucose metabolism above and beyond the weight issue, which our work suggests, things get more complicated, as they do when you consider the fact that African American kids, who are already at higher risk for diabetes, are probably the ones most likely to use [medroxyprogesterone] these days, and therefore the ones most likely to get pregnant if we steer them away from it.”

The challenge, she added, “is figuring out how to factor all of those ethical decisions into a discussion with a concrete teenager. Which is worse, teenage pregnancy or increased diabetes mellitus risks? I would say the latter, but not everyone would agree with me.” ?

BOSTON — Multiple passes of low-fluence radiofrequency delivery can significantly improve overall facial laxity with minimal patient discomfort, Dr. Melissa A. Bogle reported at the annual meeting of the American Society for Laser Medicine and Surgery.

The findings validate the use of this treatment algorithm over single-pass, high-energy radiofrequency skin tightening, which can be unbearably painful and has been associated with skin changes such as burning and scarring in some patients, she said.

In a study of 66 patients who were an average age of 53, with moderate facial laxity, Dr. Bogle and colleagues evaluated the impact of up to five passes over the lower face and neck with low-energy monopolar radiofrequency. "For all of the patients, we used a device with a 1.5-cm tip and performed two full passes over the entire face, then, based on physician discretion, we performed up to three additional passes in certain areas that needed more attention, such as the jowl region, with a slight delay between passes to allow tissue cooling," said Dr. Bogle of the Laser and Cosmetic Surgery Center in Houston. "In all regions, we treated to a clinical end point of visible tightening and contouring."

The average treatment setting was 62 J/cm

"We used patient discomfort as a guide to energy level. If a patient indicated feeling significant discomfort, we'd turn down the energy settings to minimize the pain experienced with each pulse."

Treatment efficacy was assessed using three measures: the Leal laxity classification system, which evaluates the type and degree of skin laxity on a six-point scale; skin stiffness and energy absorption levels obtained by the BTC-2000 dynamic skin analyzer, which measures the elastic deformation of skin at set points on the face during dynamic stress; and independent photographic review by blinded physicians.

At 4 months, with the skin laxity classification system, "95% of the patients had some degree of visible improvement in skin laxity, and at 6 months this number leveled off to 92%," Dr. Bogle said. In terms of the amount of improvement, "at 4 months 65% of the patients were categorized as having improvement in the good to very good category, with good being between 25% and 50% improvement and very good being 50%–75% improvement. At 6 months, this number dropped to 61%," she said. At 4 months and 6 months, respectively, 5% and 8% of patients had no visible results.

Skin stiffness, as measured by the BTC-2000, showed 75% improvement at 4 months and 35% at 6 months, Dr. Bogle said. "Similarly, in terms of energy absorption, or the amount of energy it takes to deform the skin, at 4 months, we saw 60% improvement. This dropped to about 25% at 6 months, but still was better than at baseline, she said.

Finally, according to the independent physician review, the overall 4-month and 6-month improvements were 75% and 84%, respectively, Dr. Bogle noted. "At 4 months, the middle face and the lower face regions showed similar levels of improvement, while at 6 months, the middle face was generally the most improved region, followed by the lower face." At both time points, the treatment was least effective in the upper neck region, with fewer than half the patients showing visible improvement in that area, she said.

In terms of adverse events, three patients had superficial crusting, which resolved in a few days without sequelae, Dr. Bogle noted. "Also, two patients reported numbness along the jawline at the 1-month follow-up, but it was fully resolved by the 2- and 4-month visits."

Although, for the purposes of this investigation, the multiple passes were limited to five total, "in practice we will usually do as many as 5–10 in addition to the initial full face passes," she said. "This gives the greatest cosmetic improvement, while keeping patient discomfort low because of the lower energy being used."

Dr. Bogle received a research grant for this study from Thermage, maker of the ThermaCool radiofrequency device used in the investigation.

BOSTON — Multiple passes of low-fluence radiofrequency delivery can significantly improve overall facial laxity with minimal patient discomfort, Dr. Melissa A. Bogle reported at the annual meeting of the American Society for Laser Medicine and Surgery.

The findings validate the use of this treatment algorithm over single-pass, high-energy radiofrequency skin tightening, which can be unbearably painful and has been associated with skin changes such as burning and scarring in some patients, she said.

In a study of 66 patients who were an average age of 53, with moderate facial laxity, Dr. Bogle and colleagues evaluated the impact of up to five passes over the lower face and neck with low-energy monopolar radiofrequency. "For all of the patients, we used a device with a 1.5-cm tip and performed two full passes over the entire face, then, based on physician discretion, we performed up to three additional passes in certain areas that needed more attention, such as the jowl region, with a slight delay between passes to allow tissue cooling," said Dr. Bogle of the Laser and Cosmetic Surgery Center in Houston. "In all regions, we treated to a clinical end point of visible tightening and contouring."

The average treatment setting was 62 J/cm

"We used patient discomfort as a guide to energy level. If a patient indicated feeling significant discomfort, we'd turn down the energy settings to minimize the pain experienced with each pulse."

Treatment efficacy was assessed using three measures: the Leal laxity classification system, which evaluates the type and degree of skin laxity on a six-point scale; skin stiffness and energy absorption levels obtained by the BTC-2000 dynamic skin analyzer, which measures the elastic deformation of skin at set points on the face during dynamic stress; and independent photographic review by blinded physicians.

At 4 months, with the skin laxity classification system, "95% of the patients had some degree of visible improvement in skin laxity, and at 6 months this number leveled off to 92%," Dr. Bogle said. In terms of the amount of improvement, "at 4 months 65% of the patients were categorized as having improvement in the good to very good category, with good being between 25% and 50% improvement and very good being 50%–75% improvement. At 6 months, this number dropped to 61%," she said. At 4 months and 6 months, respectively, 5% and 8% of patients had no visible results.

Skin stiffness, as measured by the BTC-2000, showed 75% improvement at 4 months and 35% at 6 months, Dr. Bogle said. "Similarly, in terms of energy absorption, or the amount of energy it takes to deform the skin, at 4 months, we saw 60% improvement. This dropped to about 25% at 6 months, but still was better than at baseline, she said.

Finally, according to the independent physician review, the overall 4-month and 6-month improvements were 75% and 84%, respectively, Dr. Bogle noted. "At 4 months, the middle face and the lower face regions showed similar levels of improvement, while at 6 months, the middle face was generally the most improved region, followed by the lower face." At both time points, the treatment was least effective in the upper neck region, with fewer than half the patients showing visible improvement in that area, she said.

In terms of adverse events, three patients had superficial crusting, which resolved in a few days without sequelae, Dr. Bogle noted. "Also, two patients reported numbness along the jawline at the 1-month follow-up, but it was fully resolved by the 2- and 4-month visits."

Although, for the purposes of this investigation, the multiple passes were limited to five total, "in practice we will usually do as many as 5–10 in addition to the initial full face passes," she said. "This gives the greatest cosmetic improvement, while keeping patient discomfort low because of the lower energy being used."

Dr. Bogle received a research grant for this study from Thermage, maker of the ThermaCool radiofrequency device used in the investigation.

BOSTON — Multiple passes of low-fluence radiofrequency delivery can significantly improve overall facial laxity with minimal patient discomfort, Dr. Melissa A. Bogle reported at the annual meeting of the American Society for Laser Medicine and Surgery.

The findings validate the use of this treatment algorithm over single-pass, high-energy radiofrequency skin tightening, which can be unbearably painful and has been associated with skin changes such as burning and scarring in some patients, she said.

In a study of 66 patients who were an average age of 53, with moderate facial laxity, Dr. Bogle and colleagues evaluated the impact of up to five passes over the lower face and neck with low-energy monopolar radiofrequency. "For all of the patients, we used a device with a 1.5-cm tip and performed two full passes over the entire face, then, based on physician discretion, we performed up to three additional passes in certain areas that needed more attention, such as the jowl region, with a slight delay between passes to allow tissue cooling," said Dr. Bogle of the Laser and Cosmetic Surgery Center in Houston. "In all regions, we treated to a clinical end point of visible tightening and contouring."

The average treatment setting was 62 J/cm

"We used patient discomfort as a guide to energy level. If a patient indicated feeling significant discomfort, we'd turn down the energy settings to minimize the pain experienced with each pulse."

Treatment efficacy was assessed using three measures: the Leal laxity classification system, which evaluates the type and degree of skin laxity on a six-point scale; skin stiffness and energy absorption levels obtained by the BTC-2000 dynamic skin analyzer, which measures the elastic deformation of skin at set points on the face during dynamic stress; and independent photographic review by blinded physicians.

At 4 months, with the skin laxity classification system, "95% of the patients had some degree of visible improvement in skin laxity, and at 6 months this number leveled off to 92%," Dr. Bogle said. In terms of the amount of improvement, "at 4 months 65% of the patients were categorized as having improvement in the good to very good category, with good being between 25% and 50% improvement and very good being 50%–75% improvement. At 6 months, this number dropped to 61%," she said. At 4 months and 6 months, respectively, 5% and 8% of patients had no visible results.

Skin stiffness, as measured by the BTC-2000, showed 75% improvement at 4 months and 35% at 6 months, Dr. Bogle said. "Similarly, in terms of energy absorption, or the amount of energy it takes to deform the skin, at 4 months, we saw 60% improvement. This dropped to about 25% at 6 months, but still was better than at baseline, she said.

Finally, according to the independent physician review, the overall 4-month and 6-month improvements were 75% and 84%, respectively, Dr. Bogle noted. "At 4 months, the middle face and the lower face regions showed similar levels of improvement, while at 6 months, the middle face was generally the most improved region, followed by the lower face." At both time points, the treatment was least effective in the upper neck region, with fewer than half the patients showing visible improvement in that area, she said.

In terms of adverse events, three patients had superficial crusting, which resolved in a few days without sequelae, Dr. Bogle noted. "Also, two patients reported numbness along the jawline at the 1-month follow-up, but it was fully resolved by the 2- and 4-month visits."

Although, for the purposes of this investigation, the multiple passes were limited to five total, "in practice we will usually do as many as 5–10 in addition to the initial full face passes," she said. "This gives the greatest cosmetic improvement, while keeping patient discomfort low because of the lower energy being used."

Dr. Bogle received a research grant for this study from Thermage, maker of the ThermaCool radiofrequency device used in the investigation.

BOSTON — A modified, high-energy, variable-pulse-duration, pulsed dye laser safely and effectively treated both vascular and pigmentary changes in patients with photoaged skin, a study has shown.

The findings suggest that what has typically been considered a "vascular" laser can be safely used to treat sun damage and associated pigmentary changes as well, Dr. Nathan Rosen said at the annual meeting of the American Society for Laser Medicine and Surgery.

The pulsed dye laser is considered the laser of choice for most vascular lesions because of its superior clinical efficacy and low risk profile. It has a large spot size, so large lesions can be treated quickly, but the resultant high-energy pulses can cause postoperative bruising and transient pigmentary changes.

The device used in this investigation employs a modified pulse structure, whereby each pulse comprises six uniform micropulses that evenly distribute the pulse energy, reducing the likelihood of bruising, compared with earlier devices, Dr. Rosen explained.

"The purpura threshold is increased because pigment more selectively absorbs the individual micropulses," he said.

In addition, the investigational device includes a compression handpiece that, by removing the competing vascular target, prevents the development of purpura. "The handpiece compresses the blood vessels in the region, allowing all of the energy to be concentrated in the pigmented area," said Dr. Rosen, who is in private practice in New York.

To evaluate the impact of the new technology on vascular and pigmentary changes associated with photodamage and long-term sun exposure, Dr. Rosen, along with his colleagues Dr. Arielle N.B. Kauvar and Dr. Tatiana Khrom, who are also in private practice in New York, considered the outcomes of its use on 24 patients with photoaged, phototype I-IV skin.

Of the 24 subjects who were enrolled in the study, 14 were treated for vascular and pigmented lesions and 10 were treated for pigmented lesions alone. All of the subjects received a total of one to three treatments at 4-week intervals, and all underwent follow-up evaluations at 3 and 12 weeks.

To treat background erythema, the dermatologists used a 10-ms pulse width and a 12-mm spot at a fluence of 7 J/cm

Only the vascular lesions were treated with cryogen spray cooling (30-ms spray, 30-ms delay) before each laser pulse, and none of the patients received a topical anesthetic prior to laser treatment, Dr. Rosen noted.

"All of the patients tolerated the treatment well, and there was no purpura with the parameters that we used," Dr. Rosen said.

Three of the patients developed transient hypopigmented macules, and one patient developed a transient atrophic scar as a result of pulse stacking for treating pigmented lesions.

Using blinded comparisons of 35-mm photographs as well as patient self-reports to assess treatment efficacy, the dermatologists observed improvement in the vascular and pigmentary lesions in all of the patients, "and, more importantly, all of the patients were satisfied with their clinical improvement," he said at the meeting.

The clinical implication of these findings "is that we now are able to use one system, rather than multiple systems, to safely treat both the vascular and pigmentary changes associated with sun damage," said Dr. Rosen, who reported receiving a research grant for this investigation from Candela Corp., manufacturer of the laser device that was used in the study.

BOSTON — A modified, high-energy, variable-pulse-duration, pulsed dye laser safely and effectively treated both vascular and pigmentary changes in patients with photoaged skin, a study has shown.

The findings suggest that what has typically been considered a "vascular" laser can be safely used to treat sun damage and associated pigmentary changes as well, Dr. Nathan Rosen said at the annual meeting of the American Society for Laser Medicine and Surgery.

The pulsed dye laser is considered the laser of choice for most vascular lesions because of its superior clinical efficacy and low risk profile. It has a large spot size, so large lesions can be treated quickly, but the resultant high-energy pulses can cause postoperative bruising and transient pigmentary changes.

The device used in this investigation employs a modified pulse structure, whereby each pulse comprises six uniform micropulses that evenly distribute the pulse energy, reducing the likelihood of bruising, compared with earlier devices, Dr. Rosen explained.

"The purpura threshold is increased because pigment more selectively absorbs the individual micropulses," he said.

In addition, the investigational device includes a compression handpiece that, by removing the competing vascular target, prevents the development of purpura. "The handpiece compresses the blood vessels in the region, allowing all of the energy to be concentrated in the pigmented area," said Dr. Rosen, who is in private practice in New York.

To evaluate the impact of the new technology on vascular and pigmentary changes associated with photodamage and long-term sun exposure, Dr. Rosen, along with his colleagues Dr. Arielle N.B. Kauvar and Dr. Tatiana Khrom, who are also in private practice in New York, considered the outcomes of its use on 24 patients with photoaged, phototype I-IV skin.

Of the 24 subjects who were enrolled in the study, 14 were treated for vascular and pigmented lesions and 10 were treated for pigmented lesions alone. All of the subjects received a total of one to three treatments at 4-week intervals, and all underwent follow-up evaluations at 3 and 12 weeks.

To treat background erythema, the dermatologists used a 10-ms pulse width and a 12-mm spot at a fluence of 7 J/cm

Only the vascular lesions were treated with cryogen spray cooling (30-ms spray, 30-ms delay) before each laser pulse, and none of the patients received a topical anesthetic prior to laser treatment, Dr. Rosen noted.

"All of the patients tolerated the treatment well, and there was no purpura with the parameters that we used," Dr. Rosen said.

Three of the patients developed transient hypopigmented macules, and one patient developed a transient atrophic scar as a result of pulse stacking for treating pigmented lesions.

Using blinded comparisons of 35-mm photographs as well as patient self-reports to assess treatment efficacy, the dermatologists observed improvement in the vascular and pigmentary lesions in all of the patients, "and, more importantly, all of the patients were satisfied with their clinical improvement," he said at the meeting.

The clinical implication of these findings "is that we now are able to use one system, rather than multiple systems, to safely treat both the vascular and pigmentary changes associated with sun damage," said Dr. Rosen, who reported receiving a research grant for this investigation from Candela Corp., manufacturer of the laser device that was used in the study.

BOSTON — A modified, high-energy, variable-pulse-duration, pulsed dye laser safely and effectively treated both vascular and pigmentary changes in patients with photoaged skin, a study has shown.

The findings suggest that what has typically been considered a "vascular" laser can be safely used to treat sun damage and associated pigmentary changes as well, Dr. Nathan Rosen said at the annual meeting of the American Society for Laser Medicine and Surgery.

The pulsed dye laser is considered the laser of choice for most vascular lesions because of its superior clinical efficacy and low risk profile. It has a large spot size, so large lesions can be treated quickly, but the resultant high-energy pulses can cause postoperative bruising and transient pigmentary changes.

The device used in this investigation employs a modified pulse structure, whereby each pulse comprises six uniform micropulses that evenly distribute the pulse energy, reducing the likelihood of bruising, compared with earlier devices, Dr. Rosen explained.

"The purpura threshold is increased because pigment more selectively absorbs the individual micropulses," he said.

In addition, the investigational device includes a compression handpiece that, by removing the competing vascular target, prevents the development of purpura. "The handpiece compresses the blood vessels in the region, allowing all of the energy to be concentrated in the pigmented area," said Dr. Rosen, who is in private practice in New York.

To evaluate the impact of the new technology on vascular and pigmentary changes associated with photodamage and long-term sun exposure, Dr. Rosen, along with his colleagues Dr. Arielle N.B. Kauvar and Dr. Tatiana Khrom, who are also in private practice in New York, considered the outcomes of its use on 24 patients with photoaged, phototype I-IV skin.

Of the 24 subjects who were enrolled in the study, 14 were treated for vascular and pigmented lesions and 10 were treated for pigmented lesions alone. All of the subjects received a total of one to three treatments at 4-week intervals, and all underwent follow-up evaluations at 3 and 12 weeks.

To treat background erythema, the dermatologists used a 10-ms pulse width and a 12-mm spot at a fluence of 7 J/cm

Only the vascular lesions were treated with cryogen spray cooling (30-ms spray, 30-ms delay) before each laser pulse, and none of the patients received a topical anesthetic prior to laser treatment, Dr. Rosen noted.

"All of the patients tolerated the treatment well, and there was no purpura with the parameters that we used," Dr. Rosen said.

Three of the patients developed transient hypopigmented macules, and one patient developed a transient atrophic scar as a result of pulse stacking for treating pigmented lesions.

Using blinded comparisons of 35-mm photographs as well as patient self-reports to assess treatment efficacy, the dermatologists observed improvement in the vascular and pigmentary lesions in all of the patients, "and, more importantly, all of the patients were satisfied with their clinical improvement," he said at the meeting.

The clinical implication of these findings "is that we now are able to use one system, rather than multiple systems, to safely treat both the vascular and pigmentary changes associated with sun damage," said Dr. Rosen, who reported receiving a research grant for this investigation from Candela Corp., manufacturer of the laser device that was used in the study.

BOSTON — Irradiation of benign pigmented nevi with Q-switched laser does not induce malignant transformation of the lesions, said Dr. David J. Goldberg at the annual meeting of the American Society for Laser Medicine and Surgery.

While the use of lasers to treat melanocytic nevi has been the subject of much debate because of concerns about malignant transformation, "to date there has been no study to fully evaluate this theoretical concern," said Dr. Goldberg of the department of dermatology at Mount Sinai School of Medicine, New York.

Toward this end, Dr. Goldberg and colleagues undertook a preliminary study to determine if irradiation with Q-switched laser increases the malignant potential of benign nevi. The investigators analyzed biopsy samples from 10 individuals with laser-treated nevi looking for changes suggestive of malignant transformation.

All participants had multiple benign nevi, one of which was laser irradiated with a Q-switched Nd:Yag laser. "In each patient, the treated nevus was matched with a paired control nevus that was not irradiated," said Dr. Goldberg, who is also in private practice in New York and New Jersey. Twenty-four hours after the laser treatment, both the treated and untreated nevi were excised and biopsy samples were analyzed for three instantaneous markers of malignant transformation: proliferating cell nuclear antigen, pyrimidine dimers, and 8-hydroxydeoxyguanosine. The specimens also were analyzed for p53.

"We didn't find any significant markers for malignant transformation in the laser-treated nevi," said Dr. Goldberg, suggesting not only that Q-switched laser irradiation is a safe option for biopsy-confirmed benign nevi, but also that "any future malignant transformation of such nevi is not the result of the laser treatments."

BOSTON — Irradiation of benign pigmented nevi with Q-switched laser does not induce malignant transformation of the lesions, said Dr. David J. Goldberg at the annual meeting of the American Society for Laser Medicine and Surgery.

While the use of lasers to treat melanocytic nevi has been the subject of much debate because of concerns about malignant transformation, "to date there has been no study to fully evaluate this theoretical concern," said Dr. Goldberg of the department of dermatology at Mount Sinai School of Medicine, New York.

Toward this end, Dr. Goldberg and colleagues undertook a preliminary study to determine if irradiation with Q-switched laser increases the malignant potential of benign nevi. The investigators analyzed biopsy samples from 10 individuals with laser-treated nevi looking for changes suggestive of malignant transformation.

All participants had multiple benign nevi, one of which was laser irradiated with a Q-switched Nd:Yag laser. "In each patient, the treated nevus was matched with a paired control nevus that was not irradiated," said Dr. Goldberg, who is also in private practice in New York and New Jersey. Twenty-four hours after the laser treatment, both the treated and untreated nevi were excised and biopsy samples were analyzed for three instantaneous markers of malignant transformation: proliferating cell nuclear antigen, pyrimidine dimers, and 8-hydroxydeoxyguanosine. The specimens also were analyzed for p53.

"We didn't find any significant markers for malignant transformation in the laser-treated nevi," said Dr. Goldberg, suggesting not only that Q-switched laser irradiation is a safe option for biopsy-confirmed benign nevi, but also that "any future malignant transformation of such nevi is not the result of the laser treatments."

BOSTON — Irradiation of benign pigmented nevi with Q-switched laser does not induce malignant transformation of the lesions, said Dr. David J. Goldberg at the annual meeting of the American Society for Laser Medicine and Surgery.

While the use of lasers to treat melanocytic nevi has been the subject of much debate because of concerns about malignant transformation, "to date there has been no study to fully evaluate this theoretical concern," said Dr. Goldberg of the department of dermatology at Mount Sinai School of Medicine, New York.

Toward this end, Dr. Goldberg and colleagues undertook a preliminary study to determine if irradiation with Q-switched laser increases the malignant potential of benign nevi. The investigators analyzed biopsy samples from 10 individuals with laser-treated nevi looking for changes suggestive of malignant transformation.

All participants had multiple benign nevi, one of which was laser irradiated with a Q-switched Nd:Yag laser. "In each patient, the treated nevus was matched with a paired control nevus that was not irradiated," said Dr. Goldberg, who is also in private practice in New York and New Jersey. Twenty-four hours after the laser treatment, both the treated and untreated nevi were excised and biopsy samples were analyzed for three instantaneous markers of malignant transformation: proliferating cell nuclear antigen, pyrimidine dimers, and 8-hydroxydeoxyguanosine. The specimens also were analyzed for p53.

"We didn't find any significant markers for malignant transformation in the laser-treated nevi," said Dr. Goldberg, suggesting not only that Q-switched laser irradiation is a safe option for biopsy-confirmed benign nevi, but also that "any future malignant transformation of such nevi is not the result of the laser treatments."

DALLAS — The steep decline in antireflux surgery since the 1990s may be caused by skepticism following publication of a study suggesting that most patients who undergo surgery eventually resume taking antireflux medication, said Dr. Jonathan F. Finks at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

Based on data from the Nationwide Inpatient Sample, the number of patients older than age 18 who underwent antireflux surgery in the United States peaked at 32,907 in the year 2000. By 2003, that rate fell 27% to 23,998 patients.

“The rate of decline was approximately three times greater for patients in the 30- to 50-year-old age range than it was for patients older than 60,” said Dr. Finks of the division of gastrointestinal surgery at the University of Michigan in Ann Arbor. The discrepancy may be explained by an increased likelihood on the part of gastroenterologists to recommend surgery for patients who have had problems for a longer time and who have not attained sufficient relief from medication.

On the heels of the antireflux surgery boom, results of a 2-year randomized controlled trial comparing surgical and medical management of gastroesophageal reflux disease (GERD) were published (JAMA 2001;285:2331–8). The study showed that although patients in the surgical treatment group were less likely to regularly use antireflux medications than were patients in the medical antireflux therapy group, the use of antireflux medication in the surgical group was still substantial. In addition, there were no differences between the treatment groups in esophagitis grade, incidence of esophageal cancer, frequency of treatment of esophageal stricture, subsequent antireflux operations, or satisfaction with antireflux therapy.

The findings did not question the efficacy of antireflux surgery—which continues to be performed primarily via laparoscopic techniques, according to the data—but rather the supremacy of surgery over other management options, said Dr. Finks.

“Surgery is considered effective, with stable and low mortality and splenectomy rates, and it is associated with good patient satisfaction, but the study findings gave cause to gastroenterologists to reconsider the indications for surgery,” Dr. Fink noted at the meeting.

The bottom line, he said, is that both surgical and medical management of GERD are reasonable options, but the decision on which approach to use should be based on assessment of the risks and benefits for individual patients.

Dr. Finks reported no conflicts of interest with respect to his presentation.

DALLAS — The steep decline in antireflux surgery since the 1990s may be caused by skepticism following publication of a study suggesting that most patients who undergo surgery eventually resume taking antireflux medication, said Dr. Jonathan F. Finks at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

Based on data from the Nationwide Inpatient Sample, the number of patients older than age 18 who underwent antireflux surgery in the United States peaked at 32,907 in the year 2000. By 2003, that rate fell 27% to 23,998 patients.

“The rate of decline was approximately three times greater for patients in the 30- to 50-year-old age range than it was for patients older than 60,” said Dr. Finks of the division of gastrointestinal surgery at the University of Michigan in Ann Arbor. The discrepancy may be explained by an increased likelihood on the part of gastroenterologists to recommend surgery for patients who have had problems for a longer time and who have not attained sufficient relief from medication.

On the heels of the antireflux surgery boom, results of a 2-year randomized controlled trial comparing surgical and medical management of gastroesophageal reflux disease (GERD) were published (JAMA 2001;285:2331–8). The study showed that although patients in the surgical treatment group were less likely to regularly use antireflux medications than were patients in the medical antireflux therapy group, the use of antireflux medication in the surgical group was still substantial. In addition, there were no differences between the treatment groups in esophagitis grade, incidence of esophageal cancer, frequency of treatment of esophageal stricture, subsequent antireflux operations, or satisfaction with antireflux therapy.

The findings did not question the efficacy of antireflux surgery—which continues to be performed primarily via laparoscopic techniques, according to the data—but rather the supremacy of surgery over other management options, said Dr. Finks.

“Surgery is considered effective, with stable and low mortality and splenectomy rates, and it is associated with good patient satisfaction, but the study findings gave cause to gastroenterologists to reconsider the indications for surgery,” Dr. Fink noted at the meeting.

The bottom line, he said, is that both surgical and medical management of GERD are reasonable options, but the decision on which approach to use should be based on assessment of the risks and benefits for individual patients.

Dr. Finks reported no conflicts of interest with respect to his presentation.

DALLAS — The steep decline in antireflux surgery since the 1990s may be caused by skepticism following publication of a study suggesting that most patients who undergo surgery eventually resume taking antireflux medication, said Dr. Jonathan F. Finks at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

Based on data from the Nationwide Inpatient Sample, the number of patients older than age 18 who underwent antireflux surgery in the United States peaked at 32,907 in the year 2000. By 2003, that rate fell 27% to 23,998 patients.

“The rate of decline was approximately three times greater for patients in the 30- to 50-year-old age range than it was for patients older than 60,” said Dr. Finks of the division of gastrointestinal surgery at the University of Michigan in Ann Arbor. The discrepancy may be explained by an increased likelihood on the part of gastroenterologists to recommend surgery for patients who have had problems for a longer time and who have not attained sufficient relief from medication.

On the heels of the antireflux surgery boom, results of a 2-year randomized controlled trial comparing surgical and medical management of gastroesophageal reflux disease (GERD) were published (JAMA 2001;285:2331–8). The study showed that although patients in the surgical treatment group were less likely to regularly use antireflux medications than were patients in the medical antireflux therapy group, the use of antireflux medication in the surgical group was still substantial. In addition, there were no differences between the treatment groups in esophagitis grade, incidence of esophageal cancer, frequency of treatment of esophageal stricture, subsequent antireflux operations, or satisfaction with antireflux therapy.

The findings did not question the efficacy of antireflux surgery—which continues to be performed primarily via laparoscopic techniques, according to the data—but rather the supremacy of surgery over other management options, said Dr. Finks.

“Surgery is considered effective, with stable and low mortality and splenectomy rates, and it is associated with good patient satisfaction, but the study findings gave cause to gastroenterologists to reconsider the indications for surgery,” Dr. Fink noted at the meeting.

The bottom line, he said, is that both surgical and medical management of GERD are reasonable options, but the decision on which approach to use should be based on assessment of the risks and benefits for individual patients.

Dr. Finks reported no conflicts of interest with respect to his presentation.