Heidi Splete

The direct thrombin inhibitor dabigatran can be used in atrial fibrillation patients as an alternative to warfarin, according to updated guidelines from the American College of Cardiology, the American Heart Association, and the Heart Rhythm Society. The update was published online Feb. 14 in Circulation.

[Dabigatran, Rivaroxaban Vie as Warfarin Alternatives]

The guideline writing committee, which issued a focused update in December (Circulation 2011;123:104-23), noted that the approval of dabigatran by the Food and Drug Administration in October 2010 occurred too late for consideration.

The update to the guidelines summarizes the evidence supporting the FDA approval of dabigatran etexilate to prevent stroke and systemic embolism in patients with nonvalvular atrial fibrillation. In the RE-LY (Randomized Evaluation of Long-Term Anticoagulant Therapy) trial – a noninferiority study of 18,113 patients with nonvalvular atrial fibrillation and at least one other risk factor for stroke – 150 mg of dabigatran twice daily reduced the risk of all types of stroke or systemic embolism by 34%. The average age of the patients in the study was 71 years.

Two dosing regimens (110 mg twice daily or 150 mg twice daily) were evaluated, and the 110-mg dose of dabigatran was noninferior to warfarin for the prevention of stroke or systemic embolism. The 110-mg dose of dabigatran was associated with significantly lower rates of major bleeding than was warfarin, and the rate of major bleeding at the 150-mg dose was noninferior to warfarin. Myocardial infarction was more common in dabigatran patients compared with warfarin patients, but the difference was not significant. The 110-mg dosage was not approved, however; the dosage for all patients except those with severe renal impairment is 150 mg twice daily.

Dr. L. Samuel Wann, a cardiologist at Wheaton Franciscan Healthcare in Wauwatosa, Wis., and chair of the 2011 Writing Group, and colleagues noted that dabigatran is not the best choice for all patients, given the twice-daily dosing regimen and increased risk of side effects. However, patients with atrial fibrillation and at least one additional risk factor for stroke might benefit from dabigatran depending on factors including cost, patient preferences, ability to comply with twice-daily dosing, and availability of an anticoagulation management program to help with routine maintenance, the reviewers wrote (Circulation 2011 Feb. 14 [doi:10.1161/CIR.0b013e31820f14c0]).

[FDA Panel Votes to Approve Dabigatran for Reduction of Stroke Risk]

Dr. Wann had no financial conflicts to disclose. Several of the writing group members disclosed serving as a speaker or consultant for, or receiving research funding from, multiple pharmaceutical companies including Medtronic, Boston Scientific, AstraZeneca, Sanofi-Aventis, and GlaxoSmithKline, as well as Boehringer Ingelheim, which markets dabigatran as Pradaxa.

The direct thrombin inhibitor dabigatran can be used in atrial fibrillation patients as an alternative to warfarin, according to updated guidelines from the American College of Cardiology, the American Heart Association, and the Heart Rhythm Society. The update was published online Feb. 14 in Circulation.

[Dabigatran, Rivaroxaban Vie as Warfarin Alternatives]

The guideline writing committee, which issued a focused update in December (Circulation 2011;123:104-23), noted that the approval of dabigatran by the Food and Drug Administration in October 2010 occurred too late for consideration.

The update to the guidelines summarizes the evidence supporting the FDA approval of dabigatran etexilate to prevent stroke and systemic embolism in patients with nonvalvular atrial fibrillation. In the RE-LY (Randomized Evaluation of Long-Term Anticoagulant Therapy) trial – a noninferiority study of 18,113 patients with nonvalvular atrial fibrillation and at least one other risk factor for stroke – 150 mg of dabigatran twice daily reduced the risk of all types of stroke or systemic embolism by 34%. The average age of the patients in the study was 71 years.

Two dosing regimens (110 mg twice daily or 150 mg twice daily) were evaluated, and the 110-mg dose of dabigatran was noninferior to warfarin for the prevention of stroke or systemic embolism. The 110-mg dose of dabigatran was associated with significantly lower rates of major bleeding than was warfarin, and the rate of major bleeding at the 150-mg dose was noninferior to warfarin. Myocardial infarction was more common in dabigatran patients compared with warfarin patients, but the difference was not significant. The 110-mg dosage was not approved, however; the dosage for all patients except those with severe renal impairment is 150 mg twice daily.

Dr. L. Samuel Wann, a cardiologist at Wheaton Franciscan Healthcare in Wauwatosa, Wis., and chair of the 2011 Writing Group, and colleagues noted that dabigatran is not the best choice for all patients, given the twice-daily dosing regimen and increased risk of side effects. However, patients with atrial fibrillation and at least one additional risk factor for stroke might benefit from dabigatran depending on factors including cost, patient preferences, ability to comply with twice-daily dosing, and availability of an anticoagulation management program to help with routine maintenance, the reviewers wrote (Circulation 2011 Feb. 14 [doi:10.1161/CIR.0b013e31820f14c0]).

[FDA Panel Votes to Approve Dabigatran for Reduction of Stroke Risk]

Dr. Wann had no financial conflicts to disclose. Several of the writing group members disclosed serving as a speaker or consultant for, or receiving research funding from, multiple pharmaceutical companies including Medtronic, Boston Scientific, AstraZeneca, Sanofi-Aventis, and GlaxoSmithKline, as well as Boehringer Ingelheim, which markets dabigatran as Pradaxa.

The direct thrombin inhibitor dabigatran can be used in atrial fibrillation patients as an alternative to warfarin, according to updated guidelines from the American College of Cardiology, the American Heart Association, and the Heart Rhythm Society. The update was published online Feb. 14 in Circulation.

[Dabigatran, Rivaroxaban Vie as Warfarin Alternatives]

The guideline writing committee, which issued a focused update in December (Circulation 2011;123:104-23), noted that the approval of dabigatran by the Food and Drug Administration in October 2010 occurred too late for consideration.

The update to the guidelines summarizes the evidence supporting the FDA approval of dabigatran etexilate to prevent stroke and systemic embolism in patients with nonvalvular atrial fibrillation. In the RE-LY (Randomized Evaluation of Long-Term Anticoagulant Therapy) trial – a noninferiority study of 18,113 patients with nonvalvular atrial fibrillation and at least one other risk factor for stroke – 150 mg of dabigatran twice daily reduced the risk of all types of stroke or systemic embolism by 34%. The average age of the patients in the study was 71 years.

Two dosing regimens (110 mg twice daily or 150 mg twice daily) were evaluated, and the 110-mg dose of dabigatran was noninferior to warfarin for the prevention of stroke or systemic embolism. The 110-mg dose of dabigatran was associated with significantly lower rates of major bleeding than was warfarin, and the rate of major bleeding at the 150-mg dose was noninferior to warfarin. Myocardial infarction was more common in dabigatran patients compared with warfarin patients, but the difference was not significant. The 110-mg dosage was not approved, however; the dosage for all patients except those with severe renal impairment is 150 mg twice daily.

Dr. L. Samuel Wann, a cardiologist at Wheaton Franciscan Healthcare in Wauwatosa, Wis., and chair of the 2011 Writing Group, and colleagues noted that dabigatran is not the best choice for all patients, given the twice-daily dosing regimen and increased risk of side effects. However, patients with atrial fibrillation and at least one additional risk factor for stroke might benefit from dabigatran depending on factors including cost, patient preferences, ability to comply with twice-daily dosing, and availability of an anticoagulation management program to help with routine maintenance, the reviewers wrote (Circulation 2011 Feb. 14 [doi:10.1161/CIR.0b013e31820f14c0]).

[FDA Panel Votes to Approve Dabigatran for Reduction of Stroke Risk]

Dr. Wann had no financial conflicts to disclose. Several of the writing group members disclosed serving as a speaker or consultant for, or receiving research funding from, multiple pharmaceutical companies including Medtronic, Boston Scientific, AstraZeneca, Sanofi-Aventis, and GlaxoSmithKline, as well as Boehringer Ingelheim, which markets dabigatran as Pradaxa.

WASHINGTON – Approximately 40% of the United States population could have some form of cardiovascular disease by the year 2030, based on data from a prediction model created by the American Heart Association. The findings were published online on Jan. 24 in an American Heart Association policy statement in Circulation.

If there’s a silver lining in these figures, it is that they are projections," Nancy Brown, chief executive officer of the AHA, said at a press conference. However, if current policies and prevention strategies go unchanged, the United States is facing "a cardiovascular crisis of alarming proportions," she said.

The aging U.S. population and the increase in medical spending are the main forces driving the disease prevalence and cost, wrote Dr. Paul Heidenreich, of the VA Palo Alto (Calif.) Health Care System, and colleagues.

Without changes in current prevention and treatment trends, the prevalence of cardiovascular disease in the United States will increase by about 10% over the next 20 years, and direct medical costs of cardiovascular disease will triple, from $273 billion to $818 billion, according to the policy statement.

The AHA statement projects an additional 27 million Americans with hypertension, 8 million with coronary heart disease, 4 million with stroke, and 3 million with heart failure between 2010 and 2030 (Circulation 2011 Jan. 24 [Epub doi: 10.1161/CIR.0b013e31820a55f5]).

According to the projections, hypertension will be the most expensive component of cardiovascular disease (CVD), with an estimated annual direct medical cost of $200 billion by 2030. The estimated direct medical cost for stroke is $96 billion, compared with $28 billion in 2010, but stroke represents the greatest relative increase in costs over the next 20 years (238%).

In addition, the indirect costs of all types of cardiovascular disease could increase by 61% (from $172 billion in 2010 to $276 billion in 2030).

However, previous studies have shown that many CVD cases are preventable, and individuals who maintain a healthy lifestyle and favorable levels of atherosclerotic risk are less likely to develop CVD. "Therefore, a greater focus on prevention may alter these CVD projections in the future," according to the statement.

Guidelines have been shown to have "a substantial impact on prevention and treatment and will be an important tool for limiting the burden of CVD," according to the statement. The AHA, the American College of Cardiology, and other organizations have previously published prevention-oriented CVD guidelines, but the implementation of such guidelines is often slow, the writing group noted.

Other factors that could hamper the improvement of CVD risk factors include a reported shortage of cardiologists, they added. Other shortages exist in nursing, pharmacy, and primary care, all of which are needed for a team approach to preventing CVD.

The take-home message for cardiologists is that they can "expect to see more demand for their services," Dr. Heidenreich said in an interview. In addition, primary care physicians will be seeing more patients with forms of heart disease. But the solution includes increasing the number of health professionals across all fields, not only cardiology, said Dr. Heidenreich. "The whole medical complex is insufficient to meet the demand" of the potential increases in CVD, he emphasized.

But, "through a combination of improved prevention of risk factors, and treatment of established risk factors, the dire projection of the health and economic impact of CVD can be diminished," the statement concluded.

The projections of CVD prevalence were based on data from the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2006 and Census Bureau projections from 2010 to 2030. Projections of direct medical costs of CVD were based on data from the Medical Expenditure Panel Survey from 2001 to 2005. Indirect costs of CVD included lost productivity from morbidity and early mortality.

Dr. Heidenreich, chair of the writing group, had no financial conflicts to disclose. Several members of the writing group disclosed research funding from pharmaceutical companies including Boston Scientific, Eli Lilly and Company, Pfizer, Procter & Gamble, and Medtronic. Some members disclosed serving as consultants or advisory board members to companies including Sanofi-Aventis, Bristol Myers Squibb, and Daiichi Sankyo. Some members of the group received research support from organizations including the National Institutes of Health and the National Heart, Lung and Blood Institute.

WASHINGTON – Approximately 40% of the United States population could have some form of cardiovascular disease by the year 2030, based on data from a prediction model created by the American Heart Association. The findings were published online on Jan. 24 in an American Heart Association policy statement in Circulation.

If there’s a silver lining in these figures, it is that they are projections," Nancy Brown, chief executive officer of the AHA, said at a press conference. However, if current policies and prevention strategies go unchanged, the United States is facing "a cardiovascular crisis of alarming proportions," she said.

The aging U.S. population and the increase in medical spending are the main forces driving the disease prevalence and cost, wrote Dr. Paul Heidenreich, of the VA Palo Alto (Calif.) Health Care System, and colleagues.

Without changes in current prevention and treatment trends, the prevalence of cardiovascular disease in the United States will increase by about 10% over the next 20 years, and direct medical costs of cardiovascular disease will triple, from $273 billion to $818 billion, according to the policy statement.

The AHA statement projects an additional 27 million Americans with hypertension, 8 million with coronary heart disease, 4 million with stroke, and 3 million with heart failure between 2010 and 2030 (Circulation 2011 Jan. 24 [Epub doi: 10.1161/CIR.0b013e31820a55f5]).

According to the projections, hypertension will be the most expensive component of cardiovascular disease (CVD), with an estimated annual direct medical cost of $200 billion by 2030. The estimated direct medical cost for stroke is $96 billion, compared with $28 billion in 2010, but stroke represents the greatest relative increase in costs over the next 20 years (238%).

In addition, the indirect costs of all types of cardiovascular disease could increase by 61% (from $172 billion in 2010 to $276 billion in 2030).

However, previous studies have shown that many CVD cases are preventable, and individuals who maintain a healthy lifestyle and favorable levels of atherosclerotic risk are less likely to develop CVD. "Therefore, a greater focus on prevention may alter these CVD projections in the future," according to the statement.

Guidelines have been shown to have "a substantial impact on prevention and treatment and will be an important tool for limiting the burden of CVD," according to the statement. The AHA, the American College of Cardiology, and other organizations have previously published prevention-oriented CVD guidelines, but the implementation of such guidelines is often slow, the writing group noted.

Other factors that could hamper the improvement of CVD risk factors include a reported shortage of cardiologists, they added. Other shortages exist in nursing, pharmacy, and primary care, all of which are needed for a team approach to preventing CVD.

The take-home message for cardiologists is that they can "expect to see more demand for their services," Dr. Heidenreich said in an interview. In addition, primary care physicians will be seeing more patients with forms of heart disease. But the solution includes increasing the number of health professionals across all fields, not only cardiology, said Dr. Heidenreich. "The whole medical complex is insufficient to meet the demand" of the potential increases in CVD, he emphasized.

But, "through a combination of improved prevention of risk factors, and treatment of established risk factors, the dire projection of the health and economic impact of CVD can be diminished," the statement concluded.

The projections of CVD prevalence were based on data from the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2006 and Census Bureau projections from 2010 to 2030. Projections of direct medical costs of CVD were based on data from the Medical Expenditure Panel Survey from 2001 to 2005. Indirect costs of CVD included lost productivity from morbidity and early mortality.

Dr. Heidenreich, chair of the writing group, had no financial conflicts to disclose. Several members of the writing group disclosed research funding from pharmaceutical companies including Boston Scientific, Eli Lilly and Company, Pfizer, Procter & Gamble, and Medtronic. Some members disclosed serving as consultants or advisory board members to companies including Sanofi-Aventis, Bristol Myers Squibb, and Daiichi Sankyo. Some members of the group received research support from organizations including the National Institutes of Health and the National Heart, Lung and Blood Institute.

WASHINGTON – Approximately 40% of the United States population could have some form of cardiovascular disease by the year 2030, based on data from a prediction model created by the American Heart Association. The findings were published online on Jan. 24 in an American Heart Association policy statement in Circulation.

If there’s a silver lining in these figures, it is that they are projections," Nancy Brown, chief executive officer of the AHA, said at a press conference. However, if current policies and prevention strategies go unchanged, the United States is facing "a cardiovascular crisis of alarming proportions," she said.

The aging U.S. population and the increase in medical spending are the main forces driving the disease prevalence and cost, wrote Dr. Paul Heidenreich, of the VA Palo Alto (Calif.) Health Care System, and colleagues.

Without changes in current prevention and treatment trends, the prevalence of cardiovascular disease in the United States will increase by about 10% over the next 20 years, and direct medical costs of cardiovascular disease will triple, from $273 billion to $818 billion, according to the policy statement.

The AHA statement projects an additional 27 million Americans with hypertension, 8 million with coronary heart disease, 4 million with stroke, and 3 million with heart failure between 2010 and 2030 (Circulation 2011 Jan. 24 [Epub doi: 10.1161/CIR.0b013e31820a55f5]).

According to the projections, hypertension will be the most expensive component of cardiovascular disease (CVD), with an estimated annual direct medical cost of $200 billion by 2030. The estimated direct medical cost for stroke is $96 billion, compared with $28 billion in 2010, but stroke represents the greatest relative increase in costs over the next 20 years (238%).

In addition, the indirect costs of all types of cardiovascular disease could increase by 61% (from $172 billion in 2010 to $276 billion in 2030).

However, previous studies have shown that many CVD cases are preventable, and individuals who maintain a healthy lifestyle and favorable levels of atherosclerotic risk are less likely to develop CVD. "Therefore, a greater focus on prevention may alter these CVD projections in the future," according to the statement.

Guidelines have been shown to have "a substantial impact on prevention and treatment and will be an important tool for limiting the burden of CVD," according to the statement. The AHA, the American College of Cardiology, and other organizations have previously published prevention-oriented CVD guidelines, but the implementation of such guidelines is often slow, the writing group noted.

Other factors that could hamper the improvement of CVD risk factors include a reported shortage of cardiologists, they added. Other shortages exist in nursing, pharmacy, and primary care, all of which are needed for a team approach to preventing CVD.

The take-home message for cardiologists is that they can "expect to see more demand for their services," Dr. Heidenreich said in an interview. In addition, primary care physicians will be seeing more patients with forms of heart disease. But the solution includes increasing the number of health professionals across all fields, not only cardiology, said Dr. Heidenreich. "The whole medical complex is insufficient to meet the demand" of the potential increases in CVD, he emphasized.

But, "through a combination of improved prevention of risk factors, and treatment of established risk factors, the dire projection of the health and economic impact of CVD can be diminished," the statement concluded.

The projections of CVD prevalence were based on data from the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2006 and Census Bureau projections from 2010 to 2030. Projections of direct medical costs of CVD were based on data from the Medical Expenditure Panel Survey from 2001 to 2005. Indirect costs of CVD included lost productivity from morbidity and early mortality.

Dr. Heidenreich, chair of the writing group, had no financial conflicts to disclose. Several members of the writing group disclosed research funding from pharmaceutical companies including Boston Scientific, Eli Lilly and Company, Pfizer, Procter & Gamble, and Medtronic. Some members disclosed serving as consultants or advisory board members to companies including Sanofi-Aventis, Bristol Myers Squibb, and Daiichi Sankyo. Some members of the group received research support from organizations including the National Institutes of Health and the National Heart, Lung and Blood Institute.

Approximately 68 million American adults have high blood pressure and 71 million have high cholesterol, and the conditions are uncontrolled in 37 million and 48 million, respectively, according to a Vital Signs report released by the Centers for Disease Control and Prevention.

"Heart disease is the leading killer in America, and the bottom line is that high blood pressure and high cholesterol are out of control for most Americans who have these conditions," CDC director Dr. Thomas R. Frieden said during a teleconference accompanying the report's release.

High blood pressure and high cholesterol remain top risk factors for life-threatening conditions including strokes, heart attacks, and vascular diseases, he added.

Dr. Frieden had a message for physicians: Controlling high blood pressure and cholesterol is one of the most important things you can do for your patients. Know how many of your patients have high blood pressure and high cholesterol, what proportion are controlled, and what can be done to help more patients get these conditions under control, he said.

"We have seen many examples of health systems, health programs, and doctors' offices using information technology to support patients and drastically improve the levels of control, and that's something that is needed throughout health care in this country," he added.

The report was based on data from the National Health and Nutrition Examination Survey (NHANES) on adults aged 18 years and older. The findings also indicate that approximately 20 million U.S. adults with high blood pressure and 37 million with high cholesterol are not being treated for these conditions.

The prevalence of control of high blood pressure was 29% among adults without health insurance, and the control of high cholesterol was less than 15% among those with limited access to health care. But at least 80% of individuals with uncontrolled high blood pressure and high cholesterol have health insurance, Dr. Frieden noted.

For those with health insurance, the characteristics of their specific plan are more likely to affect how likely they are to have high blood pressure or high cholesterol under control than are their personal characteristics, he said.

High blood pressure was defined as blood pressure greater than 140/90 mmHg or reported use of blood pressure–lowering medication. The national prevalence of high blood pressure remained stable over the past decade, although 70% of those with hypertension were being treated and 46% were being controlled, according to the report.

The criteria for high cholesterol included anyone taking cholesterol medication or having a LDL cholesterol level of 100 mg/dL or higher for high-risk individuals, 130 mg/dL or higher for intermediate-risk individuals, and 160 mg/dL for those at low risk.

The proportion of adults treated for high cholesterol increased from 28% to 48% over the past decade, and the proportion of those controlling their high cholesterol increased from less than 20% to more than 30%.

The findings were limited by the lack of data on individuals in nursing homes and other institutions that are not included in NHANES databases, the CDC researchers noted in the report.

"About 100,000 deaths [in the U.S.] are preventable by simple, low-cost improvements in our ability to control high blood pressure and high cholesterol," said Dr. Frieden. "Better control can save lives and save money."

The report is available online at www.cdc.gov/vitalsigns. More detailed information can be found in the Feb. 1 issue of the weekly Morbidity and Mortality Report (MMWR early release/vol. 60; Feb. 1, 2011).

Approximately 68 million American adults have high blood pressure and 71 million have high cholesterol, and the conditions are uncontrolled in 37 million and 48 million, respectively, according to a Vital Signs report released by the Centers for Disease Control and Prevention.

"Heart disease is the leading killer in America, and the bottom line is that high blood pressure and high cholesterol are out of control for most Americans who have these conditions," CDC director Dr. Thomas R. Frieden said during a teleconference accompanying the report's release.

High blood pressure and high cholesterol remain top risk factors for life-threatening conditions including strokes, heart attacks, and vascular diseases, he added.

Dr. Frieden had a message for physicians: Controlling high blood pressure and cholesterol is one of the most important things you can do for your patients. Know how many of your patients have high blood pressure and high cholesterol, what proportion are controlled, and what can be done to help more patients get these conditions under control, he said.

"We have seen many examples of health systems, health programs, and doctors' offices using information technology to support patients and drastically improve the levels of control, and that's something that is needed throughout health care in this country," he added.

The report was based on data from the National Health and Nutrition Examination Survey (NHANES) on adults aged 18 years and older. The findings also indicate that approximately 20 million U.S. adults with high blood pressure and 37 million with high cholesterol are not being treated for these conditions.

The prevalence of control of high blood pressure was 29% among adults without health insurance, and the control of high cholesterol was less than 15% among those with limited access to health care. But at least 80% of individuals with uncontrolled high blood pressure and high cholesterol have health insurance, Dr. Frieden noted.

For those with health insurance, the characteristics of their specific plan are more likely to affect how likely they are to have high blood pressure or high cholesterol under control than are their personal characteristics, he said.

High blood pressure was defined as blood pressure greater than 140/90 mmHg or reported use of blood pressure–lowering medication. The national prevalence of high blood pressure remained stable over the past decade, although 70% of those with hypertension were being treated and 46% were being controlled, according to the report.

The criteria for high cholesterol included anyone taking cholesterol medication or having a LDL cholesterol level of 100 mg/dL or higher for high-risk individuals, 130 mg/dL or higher for intermediate-risk individuals, and 160 mg/dL for those at low risk.

The proportion of adults treated for high cholesterol increased from 28% to 48% over the past decade, and the proportion of those controlling their high cholesterol increased from less than 20% to more than 30%.

The findings were limited by the lack of data on individuals in nursing homes and other institutions that are not included in NHANES databases, the CDC researchers noted in the report.

"About 100,000 deaths [in the U.S.] are preventable by simple, low-cost improvements in our ability to control high blood pressure and high cholesterol," said Dr. Frieden. "Better control can save lives and save money."

The report is available online at www.cdc.gov/vitalsigns. More detailed information can be found in the Feb. 1 issue of the weekly Morbidity and Mortality Report (MMWR early release/vol. 60; Feb. 1, 2011).

Approximately 68 million American adults have high blood pressure and 71 million have high cholesterol, and the conditions are uncontrolled in 37 million and 48 million, respectively, according to a Vital Signs report released by the Centers for Disease Control and Prevention.

"Heart disease is the leading killer in America, and the bottom line is that high blood pressure and high cholesterol are out of control for most Americans who have these conditions," CDC director Dr. Thomas R. Frieden said during a teleconference accompanying the report's release.

High blood pressure and high cholesterol remain top risk factors for life-threatening conditions including strokes, heart attacks, and vascular diseases, he added.

Dr. Frieden had a message for physicians: Controlling high blood pressure and cholesterol is one of the most important things you can do for your patients. Know how many of your patients have high blood pressure and high cholesterol, what proportion are controlled, and what can be done to help more patients get these conditions under control, he said.

"We have seen many examples of health systems, health programs, and doctors' offices using information technology to support patients and drastically improve the levels of control, and that's something that is needed throughout health care in this country," he added.

The report was based on data from the National Health and Nutrition Examination Survey (NHANES) on adults aged 18 years and older. The findings also indicate that approximately 20 million U.S. adults with high blood pressure and 37 million with high cholesterol are not being treated for these conditions.

The prevalence of control of high blood pressure was 29% among adults without health insurance, and the control of high cholesterol was less than 15% among those with limited access to health care. But at least 80% of individuals with uncontrolled high blood pressure and high cholesterol have health insurance, Dr. Frieden noted.

For those with health insurance, the characteristics of their specific plan are more likely to affect how likely they are to have high blood pressure or high cholesterol under control than are their personal characteristics, he said.

High blood pressure was defined as blood pressure greater than 140/90 mmHg or reported use of blood pressure–lowering medication. The national prevalence of high blood pressure remained stable over the past decade, although 70% of those with hypertension were being treated and 46% were being controlled, according to the report.

The criteria for high cholesterol included anyone taking cholesterol medication or having a LDL cholesterol level of 100 mg/dL or higher for high-risk individuals, 130 mg/dL or higher for intermediate-risk individuals, and 160 mg/dL for those at low risk.

The proportion of adults treated for high cholesterol increased from 28% to 48% over the past decade, and the proportion of those controlling their high cholesterol increased from less than 20% to more than 30%.

The findings were limited by the lack of data on individuals in nursing homes and other institutions that are not included in NHANES databases, the CDC researchers noted in the report.

"About 100,000 deaths [in the U.S.] are preventable by simple, low-cost improvements in our ability to control high blood pressure and high cholesterol," said Dr. Frieden. "Better control can save lives and save money."

The report is available online at www.cdc.gov/vitalsigns. More detailed information can be found in the Feb. 1 issue of the weekly Morbidity and Mortality Report (MMWR early release/vol. 60; Feb. 1, 2011).

WASHINGTON – The new Dietary Guidelines for Americans 2010, released Jan. 31, take a four-pronged approach focus to improving American’s dietary habits by recommending balancing calories and exercise to achieve a healthy body weight, restricting sodium and saturated fat, increasing consumption of whole grains and healthy fats, and developing mindful behaviors around eating and food preparation.

"We are putting some of the best information in people’s hands, and that’s a big step forward," said Health and Human Services Secretary Kathleen Sebelius, who presented the guidelines with Department of Agriculture Secretary Tom Vilsack. The guidelines are a joint effort of the U.S. Department of Health and Human Services and the Department of Agriculture.

Photo credit: Courtesy National Cancer Institute

The guidelines, intended for children aged 2 years and older and adults, include 23 recommendations in four categories, plus six additional recommendations for specific population groups. The guidelines are meant to include those at increased risk of chronic disease. The four categories are:

Balancing calories to reduce weight: Recommendations in this category include getting more exercise and balancing it against calorie intake as appropriate for weight maintenance or weight loss.

• Reducing certain foods and food components: The guidelines call for consuming less than 2,300 mg of sodium daily. The recommendation is no more than 1,500 mg for blacks, people aged 51 years and older, as well as anyone regardless of age who has hypertension, diabetes, or chronic kidney disease. Other recommended reductions include having saturated fats comprise less that 10% of daily calories, and consuming less than 300 mg of cholesterol daily.

• Increasing certain foods and nutrients: The recommendations repeat previous dietary guidelines that call for whole-grain foods to comprise half of Americans’ grain intake. Other recommendations include replacing solid fats , eating more seafood in favor of some red meat and poultry, replacing full-fat dairy products with low-fat or fat-free options, and consuming a variety of protein-rich foods including eggs, beans, nuts, and soy.

• Building healthy eating patterns and behaviors: In addition to 20 recommendations relating to diet and exercise, the new guidelines include 3 recommendations that are less food specific: Select an eating pattern that "meets nutrient needs over time at an appropriate calorie level;" and keep a food journal to assess how food and beverage choices fit into a healthy eating pattern; follow food safety recommendations when cooking and eating to reduce the risk of foodborne illness.

Women of child-bearing age should boost iron intake by eating foods with easily absorbed heme iron and vitamin C–rich foods that enhance iron absorption. Additional recommendations include adding 400 mcg of folic acid daily for women, in addition to the folate found in a healthy diet. Recommendations for women who are pregnant or breast-feeding include eating 8-12 ounces of seafood per week, but limiting tuna consumption to 6 ounces per week and avoiding tilefish, shark, swordfish, and king mackerel because of their high mercury content. Pregnant women also are advised to take an iron supplement as recommended by their health care providers.

One additional recommendation for individuals aged 50 years and older: Consume vitamin B12-fortified foods as part of a daily diet or as supplements. However, the guidelines did not recommend a specific amount of daily B12 for this population.

Over the next few months, USDA and HHS will release consumer tips and tools to help Americans follow the guidelines, including a revised food pyramid. The complete guidelines are available online at www.dietaryguidelines.gov.

WASHINGTON – The new Dietary Guidelines for Americans 2010, released Jan. 31, take a four-pronged approach focus to improving American’s dietary habits by recommending balancing calories and exercise to achieve a healthy body weight, restricting sodium and saturated fat, increasing consumption of whole grains and healthy fats, and developing mindful behaviors around eating and food preparation.

"We are putting some of the best information in people’s hands, and that’s a big step forward," said Health and Human Services Secretary Kathleen Sebelius, who presented the guidelines with Department of Agriculture Secretary Tom Vilsack. The guidelines are a joint effort of the U.S. Department of Health and Human Services and the Department of Agriculture.

Photo credit: Courtesy National Cancer Institute

The guidelines, intended for children aged 2 years and older and adults, include 23 recommendations in four categories, plus six additional recommendations for specific population groups. The guidelines are meant to include those at increased risk of chronic disease. The four categories are:

Balancing calories to reduce weight: Recommendations in this category include getting more exercise and balancing it against calorie intake as appropriate for weight maintenance or weight loss.

• Reducing certain foods and food components: The guidelines call for consuming less than 2,300 mg of sodium daily. The recommendation is no more than 1,500 mg for blacks, people aged 51 years and older, as well as anyone regardless of age who has hypertension, diabetes, or chronic kidney disease. Other recommended reductions include having saturated fats comprise less that 10% of daily calories, and consuming less than 300 mg of cholesterol daily.

• Increasing certain foods and nutrients: The recommendations repeat previous dietary guidelines that call for whole-grain foods to comprise half of Americans’ grain intake. Other recommendations include replacing solid fats , eating more seafood in favor of some red meat and poultry, replacing full-fat dairy products with low-fat or fat-free options, and consuming a variety of protein-rich foods including eggs, beans, nuts, and soy.

• Building healthy eating patterns and behaviors: In addition to 20 recommendations relating to diet and exercise, the new guidelines include 3 recommendations that are less food specific: Select an eating pattern that "meets nutrient needs over time at an appropriate calorie level;" and keep a food journal to assess how food and beverage choices fit into a healthy eating pattern; follow food safety recommendations when cooking and eating to reduce the risk of foodborne illness.

Women of child-bearing age should boost iron intake by eating foods with easily absorbed heme iron and vitamin C–rich foods that enhance iron absorption. Additional recommendations include adding 400 mcg of folic acid daily for women, in addition to the folate found in a healthy diet. Recommendations for women who are pregnant or breast-feeding include eating 8-12 ounces of seafood per week, but limiting tuna consumption to 6 ounces per week and avoiding tilefish, shark, swordfish, and king mackerel because of their high mercury content. Pregnant women also are advised to take an iron supplement as recommended by their health care providers.

One additional recommendation for individuals aged 50 years and older: Consume vitamin B12-fortified foods as part of a daily diet or as supplements. However, the guidelines did not recommend a specific amount of daily B12 for this population.

Over the next few months, USDA and HHS will release consumer tips and tools to help Americans follow the guidelines, including a revised food pyramid. The complete guidelines are available online at www.dietaryguidelines.gov.

WASHINGTON – The new Dietary Guidelines for Americans 2010, released Jan. 31, take a four-pronged approach focus to improving American’s dietary habits by recommending balancing calories and exercise to achieve a healthy body weight, restricting sodium and saturated fat, increasing consumption of whole grains and healthy fats, and developing mindful behaviors around eating and food preparation.

"We are putting some of the best information in people’s hands, and that’s a big step forward," said Health and Human Services Secretary Kathleen Sebelius, who presented the guidelines with Department of Agriculture Secretary Tom Vilsack. The guidelines are a joint effort of the U.S. Department of Health and Human Services and the Department of Agriculture.

Photo credit: Courtesy National Cancer Institute

The guidelines, intended for children aged 2 years and older and adults, include 23 recommendations in four categories, plus six additional recommendations for specific population groups. The guidelines are meant to include those at increased risk of chronic disease. The four categories are:

Balancing calories to reduce weight: Recommendations in this category include getting more exercise and balancing it against calorie intake as appropriate for weight maintenance or weight loss.

• Reducing certain foods and food components: The guidelines call for consuming less than 2,300 mg of sodium daily. The recommendation is no more than 1,500 mg for blacks, people aged 51 years and older, as well as anyone regardless of age who has hypertension, diabetes, or chronic kidney disease. Other recommended reductions include having saturated fats comprise less that 10% of daily calories, and consuming less than 300 mg of cholesterol daily.

• Increasing certain foods and nutrients: The recommendations repeat previous dietary guidelines that call for whole-grain foods to comprise half of Americans’ grain intake. Other recommendations include replacing solid fats , eating more seafood in favor of some red meat and poultry, replacing full-fat dairy products with low-fat or fat-free options, and consuming a variety of protein-rich foods including eggs, beans, nuts, and soy.

• Building healthy eating patterns and behaviors: In addition to 20 recommendations relating to diet and exercise, the new guidelines include 3 recommendations that are less food specific: Select an eating pattern that "meets nutrient needs over time at an appropriate calorie level;" and keep a food journal to assess how food and beverage choices fit into a healthy eating pattern; follow food safety recommendations when cooking and eating to reduce the risk of foodborne illness.

Women of child-bearing age should boost iron intake by eating foods with easily absorbed heme iron and vitamin C–rich foods that enhance iron absorption. Additional recommendations include adding 400 mcg of folic acid daily for women, in addition to the folate found in a healthy diet. Recommendations for women who are pregnant or breast-feeding include eating 8-12 ounces of seafood per week, but limiting tuna consumption to 6 ounces per week and avoiding tilefish, shark, swordfish, and king mackerel because of their high mercury content. Pregnant women also are advised to take an iron supplement as recommended by their health care providers.

One additional recommendation for individuals aged 50 years and older: Consume vitamin B12-fortified foods as part of a daily diet or as supplements. However, the guidelines did not recommend a specific amount of daily B12 for this population.

Over the next few months, USDA and HHS will release consumer tips and tools to help Americans follow the guidelines, including a revised food pyramid. The complete guidelines are available online at www.dietaryguidelines.gov.

ORLANDO - Limiting treatment of actinic keratoses to cryosurgery is a disservice to patients, according to Dr. Neil A. Fenske.

Every patient with AKs deserves consideration for field therapy, he said at the Orlando Dermatology Aesthetic and Clinical Conference. Mutated cells occur not only within the visible AKs, but also in the surrounding, normal-looking skin.

"Most patients don't have one AK," said Dr. Fenske of the Moffitt Cancer Center at the University of South Florida in Tampa. Data based on mathematical models suggest that 6%-10% of typical patients with an average of eight AKs will develop at least one squamous cell carcinoma over a 10-year period.

For more complete treatment, following cryosurgery with field therapy a week later. Field therapy using methyl aminolevulinate (MAL) plus a red light–emitting diode (LED) is an up-and-coming option.

MAL has a higher relative porphyrin enrichment in AKs than in normal skin, and is able to penetrate deeply compared with 5-aminolevulinic acid, Dr. Fenske explained. In addition, the red LED at 630 nm requires a lower light dose than other light options, so there is less heating of the skin.

Dr. Fenske cited a study of MAL-PDT plus red LED at 630 nm in which 14 patients with a total of 223 AKs on the scalp and face underwent two treatments. The total number of AKs decreased by 55% after the first treatment and by 62% after the second treatment. Although global photodamage scores improved, pain was an issue (J. Dermatolog. Treat. 2010;21:252-7).

Dr. Fenske said he often uses aminolevulinic acid plus blue light, but to treat and kill bacteria deep in the sebaceous glands, "I would use red light and [MAL]," he said.

Dr. Fenske disclosed serving as a consultant and speaker for Graceway Pharmaceuticals, and serving as a speaker for Sanofi-Aventis.

ORLANDO - Limiting treatment of actinic keratoses to cryosurgery is a disservice to patients, according to Dr. Neil A. Fenske.

Every patient with AKs deserves consideration for field therapy, he said at the Orlando Dermatology Aesthetic and Clinical Conference. Mutated cells occur not only within the visible AKs, but also in the surrounding, normal-looking skin.

"Most patients don't have one AK," said Dr. Fenske of the Moffitt Cancer Center at the University of South Florida in Tampa. Data based on mathematical models suggest that 6%-10% of typical patients with an average of eight AKs will develop at least one squamous cell carcinoma over a 10-year period.

For more complete treatment, following cryosurgery with field therapy a week later. Field therapy using methyl aminolevulinate (MAL) plus a red light–emitting diode (LED) is an up-and-coming option.

MAL has a higher relative porphyrin enrichment in AKs than in normal skin, and is able to penetrate deeply compared with 5-aminolevulinic acid, Dr. Fenske explained. In addition, the red LED at 630 nm requires a lower light dose than other light options, so there is less heating of the skin.

Dr. Fenske cited a study of MAL-PDT plus red LED at 630 nm in which 14 patients with a total of 223 AKs on the scalp and face underwent two treatments. The total number of AKs decreased by 55% after the first treatment and by 62% after the second treatment. Although global photodamage scores improved, pain was an issue (J. Dermatolog. Treat. 2010;21:252-7).

Dr. Fenske said he often uses aminolevulinic acid plus blue light, but to treat and kill bacteria deep in the sebaceous glands, "I would use red light and [MAL]," he said.

Dr. Fenske disclosed serving as a consultant and speaker for Graceway Pharmaceuticals, and serving as a speaker for Sanofi-Aventis.

ORLANDO - Limiting treatment of actinic keratoses to cryosurgery is a disservice to patients, according to Dr. Neil A. Fenske.

Every patient with AKs deserves consideration for field therapy, he said at the Orlando Dermatology Aesthetic and Clinical Conference. Mutated cells occur not only within the visible AKs, but also in the surrounding, normal-looking skin.

"Most patients don't have one AK," said Dr. Fenske of the Moffitt Cancer Center at the University of South Florida in Tampa. Data based on mathematical models suggest that 6%-10% of typical patients with an average of eight AKs will develop at least one squamous cell carcinoma over a 10-year period.

For more complete treatment, following cryosurgery with field therapy a week later. Field therapy using methyl aminolevulinate (MAL) plus a red light–emitting diode (LED) is an up-and-coming option.

MAL has a higher relative porphyrin enrichment in AKs than in normal skin, and is able to penetrate deeply compared with 5-aminolevulinic acid, Dr. Fenske explained. In addition, the red LED at 630 nm requires a lower light dose than other light options, so there is less heating of the skin.

Dr. Fenske cited a study of MAL-PDT plus red LED at 630 nm in which 14 patients with a total of 223 AKs on the scalp and face underwent two treatments. The total number of AKs decreased by 55% after the first treatment and by 62% after the second treatment. Although global photodamage scores improved, pain was an issue (J. Dermatolog. Treat. 2010;21:252-7).

Dr. Fenske said he often uses aminolevulinic acid plus blue light, but to treat and kill bacteria deep in the sebaceous glands, "I would use red light and [MAL]," he said.

Dr. Fenske disclosed serving as a consultant and speaker for Graceway Pharmaceuticals, and serving as a speaker for Sanofi-Aventis.

ORLANDO - Limiting treatment of actinic keratoses to cryosurgery is a disservice to patients, according to Dr. Neil A. Fenske.

Every patient with AKs deserves consideration for field therapy, he said at the Orlando Dermatology Aesthetic and Clinical Conference. Mutated cells occur not only within the visible AKs, but also in the surrounding, normal-looking skin.

"Most patients don't have one AK," said Dr. Fenske of the Moffitt Cancer Center at the University of South Florida in Tampa. Data based on mathematical models suggest that 6%-10% of typical patients with an average of eight AKs will develop at least one squamous cell carcinoma over a 10-year period.

For more complete treatment, following cryosurgery with field therapy a week later. Field therapy using methyl aminolevulinate (MAL) plus a red light–emitting diode (LED) is an up-and-coming option.

MAL has a higher relative porphyrin enrichment in AKs than in normal skin, and is able to penetrate deeply compared with 5-aminolevulinic acid, Dr. Fenske explained. In addition, the red LED at 630 nm requires a lower light dose than other light options, so there is less heating of the skin.

Dr. Fenske cited a study of MAL-PDT plus red LED at 630 nm in which 14 patients with a total of 223 AKs on the scalp and face underwent two treatments. The total number of AKs decreased by 55% after the first treatment and by 62% after the second treatment. Although global photodamage scores improved, pain was an issue (J. Dermatolog. Treat. 2010;21:252-7).

Dr. Fenske said he often uses aminolevulinic acid plus blue light, but to treat and kill bacteria deep in the sebaceous glands, "I would use red light and [MAL]," he said.

Dr. Fenske disclosed serving as a consultant and speaker for Graceway Pharmaceuticals, and serving as a speaker for Sanofi-Aventis.

ORLANDO - Limiting treatment of actinic keratoses to cryosurgery is a disservice to patients, according to Dr. Neil A. Fenske.

Every patient with AKs deserves consideration for field therapy, he said at the Orlando Dermatology Aesthetic and Clinical Conference. Mutated cells occur not only within the visible AKs, but also in the surrounding, normal-looking skin.

"Most patients don't have one AK," said Dr. Fenske of the Moffitt Cancer Center at the University of South Florida in Tampa. Data based on mathematical models suggest that 6%-10% of typical patients with an average of eight AKs will develop at least one squamous cell carcinoma over a 10-year period.

For more complete treatment, following cryosurgery with field therapy a week later. Field therapy using methyl aminolevulinate (MAL) plus a red light–emitting diode (LED) is an up-and-coming option.

MAL has a higher relative porphyrin enrichment in AKs than in normal skin, and is able to penetrate deeply compared with 5-aminolevulinic acid, Dr. Fenske explained. In addition, the red LED at 630 nm requires a lower light dose than other light options, so there is less heating of the skin.

Dr. Fenske cited a study of MAL-PDT plus red LED at 630 nm in which 14 patients with a total of 223 AKs on the scalp and face underwent two treatments. The total number of AKs decreased by 55% after the first treatment and by 62% after the second treatment. Although global photodamage scores improved, pain was an issue (J. Dermatolog. Treat. 2010;21:252-7).

Dr. Fenske said he often uses aminolevulinic acid plus blue light, but to treat and kill bacteria deep in the sebaceous glands, "I would use red light and [MAL]," he said.

Dr. Fenske disclosed serving as a consultant and speaker for Graceway Pharmaceuticals, and serving as a speaker for Sanofi-Aventis.

ORLANDO - Limiting treatment of actinic keratoses to cryosurgery is a disservice to patients, according to Dr. Neil A. Fenske.

Every patient with AKs deserves consideration for field therapy, he said at the Orlando Dermatology Aesthetic and Clinical Conference. Mutated cells occur not only within the visible AKs, but also in the surrounding, normal-looking skin.

"Most patients don't have one AK," said Dr. Fenske of the Moffitt Cancer Center at the University of South Florida in Tampa. Data based on mathematical models suggest that 6%-10% of typical patients with an average of eight AKs will develop at least one squamous cell carcinoma over a 10-year period.

For more complete treatment, following cryosurgery with field therapy a week later. Field therapy using methyl aminolevulinate (MAL) plus a red light–emitting diode (LED) is an up-and-coming option.

MAL has a higher relative porphyrin enrichment in AKs than in normal skin, and is able to penetrate deeply compared with 5-aminolevulinic acid, Dr. Fenske explained. In addition, the red LED at 630 nm requires a lower light dose than other light options, so there is less heating of the skin.

Dr. Fenske cited a study of MAL-PDT plus red LED at 630 nm in which 14 patients with a total of 223 AKs on the scalp and face underwent two treatments. The total number of AKs decreased by 55% after the first treatment and by 62% after the second treatment. Although global photodamage scores improved, pain was an issue (J. Dermatolog. Treat. 2010;21:252-7).

Dr. Fenske said he often uses aminolevulinic acid plus blue light, but to treat and kill bacteria deep in the sebaceous glands, "I would use red light and [MAL]," he said.

Dr. Fenske disclosed serving as a consultant and speaker for Graceway Pharmaceuticals, and serving as a speaker for Sanofi-Aventis.

A 9-year-old girl presented with classic signs of sexual abuse, including vulvovaginal maceration and perianal skin tags. She also had gum hypertrophy, hand eczema, a mild degree of clubbing of the fingers, and diffuse hair loss, as well as depression and apathy. What’s your diagnosis?

Diagnosis: Crohn’s Disease

Crohn’s disease patients often present with abdominal pain and diarrhea as the first symptoms, said Dr. Sarah Al-Breiki and Dr. Nadya Al-Faraidy of King Fahd Hospital in al-Khobar, Saudi Arabia. The dermatologists presented the case at the Orlando Dermatology Aesthetic and Clinical Conference.

Previous studies have shown that perineal and anal lesions are common in Crohn’s disease, and often they appear before a diagnosis of gastrointestinal CD is made, the doctors noted. Their differential diagnosis included sexual abuse, plasma cell orificial and vulval mucositis, connective tissue disease, malignancy associated disease, congenital malabsorption disease, severe infections (including mycobacteria or parasites), and Crohn’s disease.

The doctors found no abdominal symptoms on systemic review. But vaginal swabs grew a culture of group B streptococcus and Staphylococcus aureus. In addition, biopsies from skin tags and the labia majora showed "hyperplastic keratinized stratified squamous epithelium, with a heavy infiltrate consisting mainly of plasmacytic mononuclear cells and thick-walled blood vessels."

In this case, the doctors suspected Crohn’s disease after thoroughly evaluating the patient. The diagnosis was confirmed by colonoscopy, despite the lack of abdominal symptoms. "There was a low-lying fistula that opened from the lower part of the rectum into the vagina," Dr. Al-Breiki said in an interview. The fistula was causing the maceration and erosions in the vaginal area, she said.

Laboratory results also showed iron deficiency anemia, hypoalbuminuria, and plasma cells in the skin tags. Polyclonal gammopathy ruled out multiple myeloma. Relevant lab tests that came up negative included sexually transmitted diseases, antinuclear antibodies, antineutrophil cytoplasmic antibodies, thyroid-stimulation hormone, and occult blood in the stool.

"In our case, the anemia was due to iron deficiency, and iron supplementation was initiated," the doctors noted. Psychological intervention is as important as nutritional intervention in managing a chronic illness such as Crohn’s, and symptoms such as depression and apathy can result from nutritional deficiency or from feelings of self-consciousness or poor body image, they noted.

Because children with CD can present with skin lesions prior to systemic complaints, "a dermatologist can play a crucial role in early diagnosis and referral of Crohn’s disease," the doctors noted.

The doctors had no financial conflicts to disclose.

A 9-year-old girl presented with classic signs of sexual abuse, including vulvovaginal maceration and perianal skin tags. She also had gum hypertrophy, hand eczema, a mild degree of clubbing of the fingers, and diffuse hair loss, as well as depression and apathy. What’s your diagnosis?

Diagnosis: Crohn’s Disease

Crohn’s disease patients often present with abdominal pain and diarrhea as the first symptoms, said Dr. Sarah Al-Breiki and Dr. Nadya Al-Faraidy of King Fahd Hospital in al-Khobar, Saudi Arabia. The dermatologists presented the case at the Orlando Dermatology Aesthetic and Clinical Conference.

Previous studies have shown that perineal and anal lesions are common in Crohn’s disease, and often they appear before a diagnosis of gastrointestinal CD is made, the doctors noted. Their differential diagnosis included sexual abuse, plasma cell orificial and vulval mucositis, connective tissue disease, malignancy associated disease, congenital malabsorption disease, severe infections (including mycobacteria or parasites), and Crohn’s disease.

The doctors found no abdominal symptoms on systemic review. But vaginal swabs grew a culture of group B streptococcus and Staphylococcus aureus. In addition, biopsies from skin tags and the labia majora showed "hyperplastic keratinized stratified squamous epithelium, with a heavy infiltrate consisting mainly of plasmacytic mononuclear cells and thick-walled blood vessels."

In this case, the doctors suspected Crohn’s disease after thoroughly evaluating the patient. The diagnosis was confirmed by colonoscopy, despite the lack of abdominal symptoms. "There was a low-lying fistula that opened from the lower part of the rectum into the vagina," Dr. Al-Breiki said in an interview. The fistula was causing the maceration and erosions in the vaginal area, she said.

Laboratory results also showed iron deficiency anemia, hypoalbuminuria, and plasma cells in the skin tags. Polyclonal gammopathy ruled out multiple myeloma. Relevant lab tests that came up negative included sexually transmitted diseases, antinuclear antibodies, antineutrophil cytoplasmic antibodies, thyroid-stimulation hormone, and occult blood in the stool.

"In our case, the anemia was due to iron deficiency, and iron supplementation was initiated," the doctors noted. Psychological intervention is as important as nutritional intervention in managing a chronic illness such as Crohn’s, and symptoms such as depression and apathy can result from nutritional deficiency or from feelings of self-consciousness or poor body image, they noted.

Because children with CD can present with skin lesions prior to systemic complaints, "a dermatologist can play a crucial role in early diagnosis and referral of Crohn’s disease," the doctors noted.

The doctors had no financial conflicts to disclose.

A 9-year-old girl presented with classic signs of sexual abuse, including vulvovaginal maceration and perianal skin tags. She also had gum hypertrophy, hand eczema, a mild degree of clubbing of the fingers, and diffuse hair loss, as well as depression and apathy. What’s your diagnosis?

Diagnosis: Crohn’s Disease

Crohn’s disease patients often present with abdominal pain and diarrhea as the first symptoms, said Dr. Sarah Al-Breiki and Dr. Nadya Al-Faraidy of King Fahd Hospital in al-Khobar, Saudi Arabia. The dermatologists presented the case at the Orlando Dermatology Aesthetic and Clinical Conference.

Previous studies have shown that perineal and anal lesions are common in Crohn’s disease, and often they appear before a diagnosis of gastrointestinal CD is made, the doctors noted. Their differential diagnosis included sexual abuse, plasma cell orificial and vulval mucositis, connective tissue disease, malignancy associated disease, congenital malabsorption disease, severe infections (including mycobacteria or parasites), and Crohn’s disease.

The doctors found no abdominal symptoms on systemic review. But vaginal swabs grew a culture of group B streptococcus and Staphylococcus aureus. In addition, biopsies from skin tags and the labia majora showed "hyperplastic keratinized stratified squamous epithelium, with a heavy infiltrate consisting mainly of plasmacytic mononuclear cells and thick-walled blood vessels."

In this case, the doctors suspected Crohn’s disease after thoroughly evaluating the patient. The diagnosis was confirmed by colonoscopy, despite the lack of abdominal symptoms. "There was a low-lying fistula that opened from the lower part of the rectum into the vagina," Dr. Al-Breiki said in an interview. The fistula was causing the maceration and erosions in the vaginal area, she said.

Laboratory results also showed iron deficiency anemia, hypoalbuminuria, and plasma cells in the skin tags. Polyclonal gammopathy ruled out multiple myeloma. Relevant lab tests that came up negative included sexually transmitted diseases, antinuclear antibodies, antineutrophil cytoplasmic antibodies, thyroid-stimulation hormone, and occult blood in the stool.

"In our case, the anemia was due to iron deficiency, and iron supplementation was initiated," the doctors noted. Psychological intervention is as important as nutritional intervention in managing a chronic illness such as Crohn’s, and symptoms such as depression and apathy can result from nutritional deficiency or from feelings of self-consciousness or poor body image, they noted.

Because children with CD can present with skin lesions prior to systemic complaints, "a dermatologist can play a crucial role in early diagnosis and referral of Crohn’s disease," the doctors noted.

The doctors had no financial conflicts to disclose.

A 9-year-old girl presented with classic signs of sexual abuse, including vulvovaginal maceration and perianal skin tags. She also had gum hypertrophy, hand eczema, a mild degree of clubbing of the fingers, and diffuse hair loss, as well as depression and apathy. What’s your diagnosis?

Diagnosis: Crohn’s Disease

Crohn’s disease patients often present with abdominal pain and diarrhea as the first symptoms, said Dr. Sarah Al-Breiki and Dr. Nadya Al-Faraidy of King Fahd Hospital in al-Khobar, Saudi Arabia. The dermatologists presented the case at the Orlando Dermatology Aesthetic and Clinical Conference.

Previous studies have shown that perineal and anal lesions are common in Crohn’s disease, and often they appear before a diagnosis of gastrointestinal CD is made, the doctors noted. Their differential diagnosis included sexual abuse, plasma cell orificial and vulval mucositis, connective tissue disease, malignancy associated disease, congenital malabsorption disease, severe infections (including mycobacteria or parasites), and Crohn’s disease.

The doctors found no abdominal symptoms on systemic review. But vaginal swabs grew a culture of group B streptococcus and Staphylococcus aureus. In addition, biopsies from skin tags and the labia majora showed "hyperplastic keratinized stratified squamous epithelium, with a heavy infiltrate consisting mainly of plasmacytic mononuclear cells and thick-walled blood vessels."

In this case, the doctors suspected Crohn’s disease after thoroughly evaluating the patient. The diagnosis was confirmed by colonoscopy, despite the lack of abdominal symptoms. "There was a low-lying fistula that opened from the lower part of the rectum into the vagina," Dr. Al-Breiki said in an interview. The fistula was causing the maceration and erosions in the vaginal area, she said.

Laboratory results also showed iron deficiency anemia, hypoalbuminuria, and plasma cells in the skin tags. Polyclonal gammopathy ruled out multiple myeloma. Relevant lab tests that came up negative included sexually transmitted diseases, antinuclear antibodies, antineutrophil cytoplasmic antibodies, thyroid-stimulation hormone, and occult blood in the stool.

"In our case, the anemia was due to iron deficiency, and iron supplementation was initiated," the doctors noted. Psychological intervention is as important as nutritional intervention in managing a chronic illness such as Crohn’s, and symptoms such as depression and apathy can result from nutritional deficiency or from feelings of self-consciousness or poor body image, they noted.

Because children with CD can present with skin lesions prior to systemic complaints, "a dermatologist can play a crucial role in early diagnosis and referral of Crohn’s disease," the doctors noted.

The doctors had no financial conflicts to disclose.

A 9-year-old girl presented with classic signs of sexual abuse, including vulvovaginal maceration and perianal skin tags. She also had gum hypertrophy, hand eczema, a mild degree of clubbing of the fingers, and diffuse hair loss, as well as depression and apathy. What’s your diagnosis?

Diagnosis: Crohn’s Disease

Crohn’s disease patients often present with abdominal pain and diarrhea as the first symptoms, said Dr. Sarah Al-Breiki and Dr. Nadya Al-Faraidy of King Fahd Hospital in al-Khobar, Saudi Arabia. The dermatologists presented the case at the Orlando Dermatology Aesthetic and Clinical Conference.

Previous studies have shown that perineal and anal lesions are common in Crohn’s disease, and often they appear before a diagnosis of gastrointestinal CD is made, the doctors noted. Their differential diagnosis included sexual abuse, plasma cell orificial and vulval mucositis, connective tissue disease, malignancy associated disease, congenital malabsorption disease, severe infections (including mycobacteria or parasites), and Crohn’s disease.

The doctors found no abdominal symptoms on systemic review. But vaginal swabs grew a culture of group B streptococcus and Staphylococcus aureus. In addition, biopsies from skin tags and the labia majora showed "hyperplastic keratinized stratified squamous epithelium, with a heavy infiltrate consisting mainly of plasmacytic mononuclear cells and thick-walled blood vessels."

In this case, the doctors suspected Crohn’s disease after thoroughly evaluating the patient. The diagnosis was confirmed by colonoscopy, despite the lack of abdominal symptoms. "There was a low-lying fistula that opened from the lower part of the rectum into the vagina," Dr. Al-Breiki said in an interview. The fistula was causing the maceration and erosions in the vaginal area, she said.

Laboratory results also showed iron deficiency anemia, hypoalbuminuria, and plasma cells in the skin tags. Polyclonal gammopathy ruled out multiple myeloma. Relevant lab tests that came up negative included sexually transmitted diseases, antinuclear antibodies, antineutrophil cytoplasmic antibodies, thyroid-stimulation hormone, and occult blood in the stool.

"In our case, the anemia was due to iron deficiency, and iron supplementation was initiated," the doctors noted. Psychological intervention is as important as nutritional intervention in managing a chronic illness such as Crohn’s, and symptoms such as depression and apathy can result from nutritional deficiency or from feelings of self-consciousness or poor body image, they noted.

Because children with CD can present with skin lesions prior to systemic complaints, "a dermatologist can play a crucial role in early diagnosis and referral of Crohn’s disease," the doctors noted.

The doctors had no financial conflicts to disclose.

A 9-year-old girl presented with classic signs of sexual abuse, including vulvovaginal maceration and perianal skin tags. She also had gum hypertrophy, hand eczema, a mild degree of clubbing of the fingers, and diffuse hair loss, as well as depression and apathy. What’s your diagnosis?

Diagnosis: Crohn’s Disease

Crohn’s disease patients often present with abdominal pain and diarrhea as the first symptoms, said Dr. Sarah Al-Breiki and Dr. Nadya Al-Faraidy of King Fahd Hospital in al-Khobar, Saudi Arabia. The dermatologists presented the case at the Orlando Dermatology Aesthetic and Clinical Conference.

Previous studies have shown that perineal and anal lesions are common in Crohn’s disease, and often they appear before a diagnosis of gastrointestinal CD is made, the doctors noted. Their differential diagnosis included sexual abuse, plasma cell orificial and vulval mucositis, connective tissue disease, malignancy associated disease, congenital malabsorption disease, severe infections (including mycobacteria or parasites), and Crohn’s disease.

The doctors found no abdominal symptoms on systemic review. But vaginal swabs grew a culture of group B streptococcus and Staphylococcus aureus. In addition, biopsies from skin tags and the labia majora showed "hyperplastic keratinized stratified squamous epithelium, with a heavy infiltrate consisting mainly of plasmacytic mononuclear cells and thick-walled blood vessels."

In this case, the doctors suspected Crohn’s disease after thoroughly evaluating the patient. The diagnosis was confirmed by colonoscopy, despite the lack of abdominal symptoms. "There was a low-lying fistula that opened from the lower part of the rectum into the vagina," Dr. Al-Breiki said in an interview. The fistula was causing the maceration and erosions in the vaginal area, she said.

Laboratory results also showed iron deficiency anemia, hypoalbuminuria, and plasma cells in the skin tags. Polyclonal gammopathy ruled out multiple myeloma. Relevant lab tests that came up negative included sexually transmitted diseases, antinuclear antibodies, antineutrophil cytoplasmic antibodies, thyroid-stimulation hormone, and occult blood in the stool.

"In our case, the anemia was due to iron deficiency, and iron supplementation was initiated," the doctors noted. Psychological intervention is as important as nutritional intervention in managing a chronic illness such as Crohn’s, and symptoms such as depression and apathy can result from nutritional deficiency or from feelings of self-consciousness or poor body image, they noted.

Because children with CD can present with skin lesions prior to systemic complaints, "a dermatologist can play a crucial role in early diagnosis and referral of Crohn’s disease," the doctors noted.

The doctors had no financial conflicts to disclose.

ORLANDO – "The diameter of a single hair shaft is tens of thousands of nanometers," said Dr. Adam Friedman. Nanotechnology is the branch of technology related to dimensions and tolerances ranging from 0.1 to 100 nanometers.

"At this size, matter behaves somewhat differently," Dr. Friedman, of Albert Einstein College of Medicine in New York, said. As the size of material decreases, the surface area relative to volume decreases. There is more surface to interact with the environment.

"The three properties of matter – chemical, optical, and physical – can be manipulated and exploited at the nano scale," Dr. Friedman said. For example, something that is too bulky at the macro level to go into an aqueous vehicle can be distributed more easily in nano form. And "if something is smaller than the wavelength of visible light, guess what? It is going to be invisible," he said at the Orlando Dermatology Aesthetic and Clinical Conference.

By the year 2012, nanotechnology is predicted to be a $12 billion industry in the United States, and the cosmetic and cosmeceutical industries are leading the way, Dr. Friedman noted. He discussed several nanomaterials with diagnostic and therapeutic applications for dermatologists:

• Nanoparticles. The term nanoparticle is somewhat generic, Dr. Friedman said. The term refers to a small object that behaves as a whole unit in terms of its transport and properties. Nanoparticles can be derived from organic and nonorganic materials. For example, gold nanoparticles can be used to introduce an antibody or targeting molecule into the body to target tumors. Once the tumors are bound to the gold, they can be treated using selective photolysis, in which radiation is used to heat the gold enough to kill the tumor cells. In one study of mice, hollow gold nanoparticles were used to successfully treat melanoma, said Dr. Friedman. Silver nanoparticles are already in products ranging from clothing to plastic food storage containers, to take advantage of their antimicrobial properties, he said.

• Nanoemulsions. Nanoemulsions are already widely used in dermatology, in emollients, and as delivery vehicles for antiaging products. Nanoemulsions have an appealing nongreasy texture, are invisible, and penetrate the skin rapidly, Dr. Friedman said. Nanoemulsion products currently on the market include L’Oréal Plenitude Revitalift and Caudalie Vinosun Anti-Aging Suncare.

• Quantum dots. "These highly fluorescent nanoscale crystals absorb a broad range of wavelengths; however, they only re-emit one color," said Dr. Friedman. In dermatology, quantum dots are being used to identify sentinel lymph nodes in patients with melanoma and Merkel cell carcinoma.

• Nanomagnets. Nanosized magnetic materials "no longer exhibit a net magnetic force," Dr. Friedman said. These materials could be used to create magnetic field–directed imaging or therapy.

• Nanopigments. Many currently available sunblocks include nanoparticles of titanium or zinc oxide, such as SunVex Dailywear lotions and ZinClear Nano Zinc Oxide.

About safety: "From a purely theoretical standpoint, nanoparticles should be harmful," said Dr. Friedman. The same properties that make nanoparticles useful could come with side effects. Improved skin penetration can be beneficial for dermatology, but factors that determine the potential toxicity of nanoparticles include size, chemical purity, and the activity of the surface.

The current international stance on nanoparticle safety is that it is unlikely that significant amounts of the zinc or titanium used in sunblock products will result in local or systemic toxicity. However, "the safety of nanoscale zinc and titanium in sunscreen must be fully addressed," Dr. Friedman said. In 2009, the American Academy of Dermatology established a task force to study nanotechnology and educate the dermatology community, the public, and policy makers.

Dermatologists who are intrigued by the potential of nanotechnology can join the fledgling Nanodermatology Society, which had its first meeting for the 2011 AAD annual meeting in New Orleans. For more information, visit the society's Web site at www.nanodermsociety.org.

Dr. Friedman serves on the advisory board of Makefield Therapeutics.

ORLANDO – "The diameter of a single hair shaft is tens of thousands of nanometers," said Dr. Adam Friedman. Nanotechnology is the branch of technology related to dimensions and tolerances ranging from 0.1 to 100 nanometers.

"At this size, matter behaves somewhat differently," Dr. Friedman, of Albert Einstein College of Medicine in New York, said. As the size of material decreases, the surface area relative to volume decreases. There is more surface to interact with the environment.

"The three properties of matter – chemical, optical, and physical – can be manipulated and exploited at the nano scale," Dr. Friedman said. For example, something that is too bulky at the macro level to go into an aqueous vehicle can be distributed more easily in nano form. And "if something is smaller than the wavelength of visible light, guess what? It is going to be invisible," he said at the Orlando Dermatology Aesthetic and Clinical Conference.

By the year 2012, nanotechnology is predicted to be a $12 billion industry in the United States, and the cosmetic and cosmeceutical industries are leading the way, Dr. Friedman noted. He discussed several nanomaterials with diagnostic and therapeutic applications for dermatologists:

• Nanoparticles. The term nanoparticle is somewhat generic, Dr. Friedman said. The term refers to a small object that behaves as a whole unit in terms of its transport and properties. Nanoparticles can be derived from organic and nonorganic materials. For example, gold nanoparticles can be used to introduce an antibody or targeting molecule into the body to target tumors. Once the tumors are bound to the gold, they can be treated using selective photolysis, in which radiation is used to heat the gold enough to kill the tumor cells. In one study of mice, hollow gold nanoparticles were used to successfully treat melanoma, said Dr. Friedman. Silver nanoparticles are already in products ranging from clothing to plastic food storage containers, to take advantage of their antimicrobial properties, he said.

• Nanoemulsions. Nanoemulsions are already widely used in dermatology, in emollients, and as delivery vehicles for antiaging products. Nanoemulsions have an appealing nongreasy texture, are invisible, and penetrate the skin rapidly, Dr. Friedman said. Nanoemulsion products currently on the market include L’Oréal Plenitude Revitalift and Caudalie Vinosun Anti-Aging Suncare.

• Quantum dots. "These highly fluorescent nanoscale crystals absorb a broad range of wavelengths; however, they only re-emit one color," said Dr. Friedman. In dermatology, quantum dots are being used to identify sentinel lymph nodes in patients with melanoma and Merkel cell carcinoma.

• Nanomagnets. Nanosized magnetic materials "no longer exhibit a net magnetic force," Dr. Friedman said. These materials could be used to create magnetic field–directed imaging or therapy.

• Nanopigments. Many currently available sunblocks include nanoparticles of titanium or zinc oxide, such as SunVex Dailywear lotions and ZinClear Nano Zinc Oxide.

About safety: "From a purely theoretical standpoint, nanoparticles should be harmful," said Dr. Friedman. The same properties that make nanoparticles useful could come with side effects. Improved skin penetration can be beneficial for dermatology, but factors that determine the potential toxicity of nanoparticles include size, chemical purity, and the activity of the surface.

The current international stance on nanoparticle safety is that it is unlikely that significant amounts of the zinc or titanium used in sunblock products will result in local or systemic toxicity. However, "the safety of nanoscale zinc and titanium in sunscreen must be fully addressed," Dr. Friedman said. In 2009, the American Academy of Dermatology established a task force to study nanotechnology and educate the dermatology community, the public, and policy makers.

Dermatologists who are intrigued by the potential of nanotechnology can join the fledgling Nanodermatology Society, which had its first meeting for the 2011 AAD annual meeting in New Orleans. For more information, visit the society's Web site at www.nanodermsociety.org.

Dr. Friedman serves on the advisory board of Makefield Therapeutics.

ORLANDO – "The diameter of a single hair shaft is tens of thousands of nanometers," said Dr. Adam Friedman. Nanotechnology is the branch of technology related to dimensions and tolerances ranging from 0.1 to 100 nanometers.

"At this size, matter behaves somewhat differently," Dr. Friedman, of Albert Einstein College of Medicine in New York, said. As the size of material decreases, the surface area relative to volume decreases. There is more surface to interact with the environment.

"The three properties of matter – chemical, optical, and physical – can be manipulated and exploited at the nano scale," Dr. Friedman said. For example, something that is too bulky at the macro level to go into an aqueous vehicle can be distributed more easily in nano form. And "if something is smaller than the wavelength of visible light, guess what? It is going to be invisible," he said at the Orlando Dermatology Aesthetic and Clinical Conference.

By the year 2012, nanotechnology is predicted to be a $12 billion industry in the United States, and the cosmetic and cosmeceutical industries are leading the way, Dr. Friedman noted. He discussed several nanomaterials with diagnostic and therapeutic applications for dermatologists:

• Nanoparticles. The term nanoparticle is somewhat generic, Dr. Friedman said. The term refers to a small object that behaves as a whole unit in terms of its transport and properties. Nanoparticles can be derived from organic and nonorganic materials. For example, gold nanoparticles can be used to introduce an antibody or targeting molecule into the body to target tumors. Once the tumors are bound to the gold, they can be treated using selective photolysis, in which radiation is used to heat the gold enough to kill the tumor cells. In one study of mice, hollow gold nanoparticles were used to successfully treat melanoma, said Dr. Friedman. Silver nanoparticles are already in products ranging from clothing to plastic food storage containers, to take advantage of their antimicrobial properties, he said.

• Nanoemulsions. Nanoemulsions are already widely used in dermatology, in emollients, and as delivery vehicles for antiaging products. Nanoemulsions have an appealing nongreasy texture, are invisible, and penetrate the skin rapidly, Dr. Friedman said. Nanoemulsion products currently on the market include L’Oréal Plenitude Revitalift and Caudalie Vinosun Anti-Aging Suncare.

• Quantum dots. "These highly fluorescent nanoscale crystals absorb a broad range of wavelengths; however, they only re-emit one color," said Dr. Friedman. In dermatology, quantum dots are being used to identify sentinel lymph nodes in patients with melanoma and Merkel cell carcinoma.

• Nanomagnets. Nanosized magnetic materials "no longer exhibit a net magnetic force," Dr. Friedman said. These materials could be used to create magnetic field–directed imaging or therapy.

• Nanopigments. Many currently available sunblocks include nanoparticles of titanium or zinc oxide, such as SunVex Dailywear lotions and ZinClear Nano Zinc Oxide.

About safety: "From a purely theoretical standpoint, nanoparticles should be harmful," said Dr. Friedman. The same properties that make nanoparticles useful could come with side effects. Improved skin penetration can be beneficial for dermatology, but factors that determine the potential toxicity of nanoparticles include size, chemical purity, and the activity of the surface.

The current international stance on nanoparticle safety is that it is unlikely that significant amounts of the zinc or titanium used in sunblock products will result in local or systemic toxicity. However, "the safety of nanoscale zinc and titanium in sunscreen must be fully addressed," Dr. Friedman said. In 2009, the American Academy of Dermatology established a task force to study nanotechnology and educate the dermatology community, the public, and policy makers.

Dermatologists who are intrigued by the potential of nanotechnology can join the fledgling Nanodermatology Society, which had its first meeting for the 2011 AAD annual meeting in New Orleans. For more information, visit the society's Web site at www.nanodermsociety.org.

Dr. Friedman serves on the advisory board of Makefield Therapeutics.

Prenatal surgery to repair myelomeningoceles significantly reduced the need for shunts at 1 year of age and improved children’s motor function at age 30 months, compared with children who had surgery after birth, based on data from a randomized trial of 183 pregnant women.

The results, published online Feb. 9 in the New England Journal of Medicine, reflect data from 158 children who were evaluated at 12 months of age and 134 children evaluated at 30 months. Data collection is ongoing.

The surgery to repair the opening in the spine is usually performed after birth, but data from animal studies suggest that prenatal surgery could result in fewer complications, said Dr. N. Scott Adzick of the Children’s Hospital of Philadelphia and his colleagues.

In the Management of Myelomeningocele Study (MOMS), 183 volunteer women with singleton pregnancies were randomized to prenatal surgery before the 26th week of pregnancy or surgery for their infants after birth (N. Engl. J. Med. 2011 Feb. 9 [doi:10.1056/NEJMoa1014379]).

The children were examined for two primary outcomes. The first outcome, at age 12 months, was patient death or the need for a shunt. The second outcome, at age 30 months, was a composite score of motor function and brain development. The score was based on the Bayley Scales of Infant Development II (BSID-II) Mental Development Index and the difference between each child’s actual ability and their expected motor function based on the severity of their spinal defects.

Death or the need for a shunt was significantly less likely in the prenatal surgery group, compared with the postnatal surgery group (68% vs. 98%). The rates of shunt placement were significantly lower in the prenatal surgery group, compared with the postnatal surgery group (40% vs. 82%).

All the fetuses in the study suffered from hindbrain herniation, in which the base of the brain is pulled into the spinal canal. But at 12 months, 36% of the children in the prenatal surgery group had no evidence of hindbrain herniation, compared with 4% in the postnatal surgery group. In addition, infants in the prenatal surgery group had lower rates of moderate or severe hindbrain herniation than the postnatal surgery group (25% vs. 67%).

In addition, infants in the prenatal surgery group scored an average of 21% higher on measures of mental and motor function, compared with the postnatal surgery group, with primary outcome scores of 149 vs. 123, respectively.

Infants who underwent prenatal surgery were born at a mean 34.1 weeks of pregnancy, compared with a mean 37.3 weeks of pregnancy for the postnatal surgery group. Significantly more infants in the prenatal surgery group had respiratory distress syndrome, compared with the postnatal surgery group (21% vs. 6%).

In terms of secondary outcomes, children in the prenatal surgery group were more likely to be able to walk without crutches or other orthotic devices, compared with the postnatal surgery group (21% vs. 42%).

The mean age of the pregnant women was 29 years. Each fetus had a myelomeningocele located between the T1 and S1 vertebrae, evidence of hindbrain herniation, and a gestational age of 19.0-25.9 weeks. Exclusion criteria included body mass index of 35 kg/m2 or higher, increased risk for preterm birth, and fetal anomalies unrelated to the myelomeningocele.

Approximately one-third of the women in the prenatal surgery group showed uterine thinning or an area of dehiscence at the time of delivery. Women undergoing prenatal surgery must understand that they will require a cesarean delivery for the current pregnancy and any future pregnancies, they added.

Myelomeningocele, a severe form of spina bifida in which the backbone and spinal canal do not close completely before birth, occurs in approximately 4 of every 10,000 births in the United States, Dr. Diana L. Farmer, division chief of pediatric surgery at the University of California, San Francisco, said in a teleconference. Dr. Farmer was one of several researchers on the study who took part in a teleconference to present the study findings.

The study was not large enough to show an impact of gestational age on the results, but data collection is ongoing. "This is a priceless cohort of patients that we will follow for a longer period of time," Dr. Farmer said. She noted that the National Institutes of Health has agreed to fund follow-up of the patients until age 6-9 years. Future studies will include whether the children in the prenatal surgery group remain free of shunts, maintain improved motor function, and require fewer procedures compared with the postnatal group, she said.

Although the surgery is highly specialized and more research is needed, the results suggest that ob.gyns. can recommend the procedure to appropriate patients at this time, Dr. Farmer said.

"At the present time, it would be responsible to inform families that this represents an additional option in care that they could consider," she said. "The decision to undergo fetal surgery is quite individual and different for every patient, but I think families need to know that this is one option in the armamentarium."

The study was sponsored by the National Institutes of Health.

Prenatal surgery to repair myelomeningoceles significantly reduced the need for shunts at 1 year of age and improved children’s motor function at age 30 months, compared with children who had surgery after birth, based on data from a randomized trial of 183 pregnant women.

The results, published online Feb. 9 in the New England Journal of Medicine, reflect data from 158 children who were evaluated at 12 months of age and 134 children evaluated at 30 months. Data collection is ongoing.

The surgery to repair the opening in the spine is usually performed after birth, but data from animal studies suggest that prenatal surgery could result in fewer complications, said Dr. N. Scott Adzick of the Children’s Hospital of Philadelphia and his colleagues.

In the Management of Myelomeningocele Study (MOMS), 183 volunteer women with singleton pregnancies were randomized to prenatal surgery before the 26th week of pregnancy or surgery for their infants after birth (N. Engl. J. Med. 2011 Feb. 9 [doi:10.1056/NEJMoa1014379]).

The children were examined for two primary outcomes. The first outcome, at age 12 months, was patient death or the need for a shunt. The second outcome, at age 30 months, was a composite score of motor function and brain development. The score was based on the Bayley Scales of Infant Development II (BSID-II) Mental Development Index and the difference between each child’s actual ability and their expected motor function based on the severity of their spinal defects.

Death or the need for a shunt was significantly less likely in the prenatal surgery group, compared with the postnatal surgery group (68% vs. 98%). The rates of shunt placement were significantly lower in the prenatal surgery group, compared with the postnatal surgery group (40% vs. 82%).

All the fetuses in the study suffered from hindbrain herniation, in which the base of the brain is pulled into the spinal canal. But at 12 months, 36% of the children in the prenatal surgery group had no evidence of hindbrain herniation, compared with 4% in the postnatal surgery group. In addition, infants in the prenatal surgery group had lower rates of moderate or severe hindbrain herniation than the postnatal surgery group (25% vs. 67%).

In addition, infants in the prenatal surgery group scored an average of 21% higher on measures of mental and motor function, compared with the postnatal surgery group, with primary outcome scores of 149 vs. 123, respectively.

Infants who underwent prenatal surgery were born at a mean 34.1 weeks of pregnancy, compared with a mean 37.3 weeks of pregnancy for the postnatal surgery group. Significantly more infants in the prenatal surgery group had respiratory distress syndrome, compared with the postnatal surgery group (21% vs. 6%).

In terms of secondary outcomes, children in the prenatal surgery group were more likely to be able to walk without crutches or other orthotic devices, compared with the postnatal surgery group (21% vs. 42%).

The mean age of the pregnant women was 29 years. Each fetus had a myelomeningocele located between the T1 and S1 vertebrae, evidence of hindbrain herniation, and a gestational age of 19.0-25.9 weeks. Exclusion criteria included body mass index of 35 kg/m2 or higher, increased risk for preterm birth, and fetal anomalies unrelated to the myelomeningocele.

Approximately one-third of the women in the prenatal surgery group showed uterine thinning or an area of dehiscence at the time of delivery. Women undergoing prenatal surgery must understand that they will require a cesarean delivery for the current pregnancy and any future pregnancies, they added.

Myelomeningocele, a severe form of spina bifida in which the backbone and spinal canal do not close completely before birth, occurs in approximately 4 of every 10,000 births in the United States, Dr. Diana L. Farmer, division chief of pediatric surgery at the University of California, San Francisco, said in a teleconference. Dr. Farmer was one of several researchers on the study who took part in a teleconference to present the study findings.

The study was not large enough to show an impact of gestational age on the results, but data collection is ongoing. "This is a priceless cohort of patients that we will follow for a longer period of time," Dr. Farmer said. She noted that the National Institutes of Health has agreed to fund follow-up of the patients until age 6-9 years. Future studies will include whether the children in the prenatal surgery group remain free of shunts, maintain improved motor function, and require fewer procedures compared with the postnatal group, she said.

Although the surgery is highly specialized and more research is needed, the results suggest that ob.gyns. can recommend the procedure to appropriate patients at this time, Dr. Farmer said.

"At the present time, it would be responsible to inform families that this represents an additional option in care that they could consider," she said. "The decision to undergo fetal surgery is quite individual and different for every patient, but I think families need to know that this is one option in the armamentarium."

The study was sponsored by the National Institutes of Health.

Prenatal surgery to repair myelomeningoceles significantly reduced the need for shunts at 1 year of age and improved children’s motor function at age 30 months, compared with children who had surgery after birth, based on data from a randomized trial of 183 pregnant women.

The results, published online Feb. 9 in the New England Journal of Medicine, reflect data from 158 children who were evaluated at 12 months of age and 134 children evaluated at 30 months. Data collection is ongoing.

The surgery to repair the opening in the spine is usually performed after birth, but data from animal studies suggest that prenatal surgery could result in fewer complications, said Dr. N. Scott Adzick of the Children’s Hospital of Philadelphia and his colleagues.

In the Management of Myelomeningocele Study (MOMS), 183 volunteer women with singleton pregnancies were randomized to prenatal surgery before the 26th week of pregnancy or surgery for their infants after birth (N. Engl. J. Med. 2011 Feb. 9 [doi:10.1056/NEJMoa1014379]).

The children were examined for two primary outcomes. The first outcome, at age 12 months, was patient death or the need for a shunt. The second outcome, at age 30 months, was a composite score of motor function and brain development. The score was based on the Bayley Scales of Infant Development II (BSID-II) Mental Development Index and the difference between each child’s actual ability and their expected motor function based on the severity of their spinal defects.

Death or the need for a shunt was significantly less likely in the prenatal surgery group, compared with the postnatal surgery group (68% vs. 98%). The rates of shunt placement were significantly lower in the prenatal surgery group, compared with the postnatal surgery group (40% vs. 82%).

All the fetuses in the study suffered from hindbrain herniation, in which the base of the brain is pulled into the spinal canal. But at 12 months, 36% of the children in the prenatal surgery group had no evidence of hindbrain herniation, compared with 4% in the postnatal surgery group. In addition, infants in the prenatal surgery group had lower rates of moderate or severe hindbrain herniation than the postnatal surgery group (25% vs. 67%).

In addition, infants in the prenatal surgery group scored an average of 21% higher on measures of mental and motor function, compared with the postnatal surgery group, with primary outcome scores of 149 vs. 123, respectively.

Infants who underwent prenatal surgery were born at a mean 34.1 weeks of pregnancy, compared with a mean 37.3 weeks of pregnancy for the postnatal surgery group. Significantly more infants in the prenatal surgery group had respiratory distress syndrome, compared with the postnatal surgery group (21% vs. 6%).

In terms of secondary outcomes, children in the prenatal surgery group were more likely to be able to walk without crutches or other orthotic devices, compared with the postnatal surgery group (21% vs. 42%).

The mean age of the pregnant women was 29 years. Each fetus had a myelomeningocele located between the T1 and S1 vertebrae, evidence of hindbrain herniation, and a gestational age of 19.0-25.9 weeks. Exclusion criteria included body mass index of 35 kg/m2 or higher, increased risk for preterm birth, and fetal anomalies unrelated to the myelomeningocele.

Approximately one-third of the women in the prenatal surgery group showed uterine thinning or an area of dehiscence at the time of delivery. Women undergoing prenatal surgery must understand that they will require a cesarean delivery for the current pregnancy and any future pregnancies, they added.

Myelomeningocele, a severe form of spina bifida in which the backbone and spinal canal do not close completely before birth, occurs in approximately 4 of every 10,000 births in the United States, Dr. Diana L. Farmer, division chief of pediatric surgery at the University of California, San Francisco, said in a teleconference. Dr. Farmer was one of several researchers on the study who took part in a teleconference to present the study findings.

The study was not large enough to show an impact of gestational age on the results, but data collection is ongoing. "This is a priceless cohort of patients that we will follow for a longer period of time," Dr. Farmer said. She noted that the National Institutes of Health has agreed to fund follow-up of the patients until age 6-9 years. Future studies will include whether the children in the prenatal surgery group remain free of shunts, maintain improved motor function, and require fewer procedures compared with the postnatal group, she said.

Although the surgery is highly specialized and more research is needed, the results suggest that ob.gyns. can recommend the procedure to appropriate patients at this time, Dr. Farmer said.

"At the present time, it would be responsible to inform families that this represents an additional option in care that they could consider," she said. "The decision to undergo fetal surgery is quite individual and different for every patient, but I think families need to know that this is one option in the armamentarium."

The study was sponsored by the National Institutes of Health.