Heidi Splete

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.

ORLANDO – The photodynamic therapy protocol that works best on the face is not necessarily the best protocol for the scalp, according to Dr. Amy Forman Taub of Northwestern University in Chicago.

The main indications for PDT are actinic keratoses, acne, and photorejuvenation, but other indications include psoriasis, vulvar neoplasia, methicillin-resistant Staphylococcus aureus, and onychomycosis.

"For long-term cosmesis, nothing stands up like PDT," said Dr. Taub at the Orlando Dermatology Aesthetic and Clinical Conference. She explained her protocols for using PDT for actinic keratoses on different parts of the body.

• Scalp. To treat actinic keratoses on the scalp, Dr. Taub recommended incubation for 60-90 minutes with 5-aminolevulinic acid (5-ALA), followed by exposure to blue light at 2-4 inches for 20 minutes. Next, prescribe emollients for morning use and fluticasone for nighttime use. Check the scalp at 4 weeks. Repeat the PDT protocol after 8 weeks. Check the patient again in 12-16 weeks and biopsy any residual lesions, Dr. Taub said.

• Face. For severe actinic keratoses on the face, Dr. Taub recommended incubation with 5-ALA for 1 hour, followed by exposure to blue light for 16 minutes. Next, instruct the patient to apply zinc oxide sunscreen on top of topical emollients in the morning, and to use topical emollients at night. If 20% or fewer lesions remain at a 4-week follow-up visit, use an alternate therapy. But if more than 20% of the lesions remain, repeat the PDT with 90 minutes of incubation and 1 minute of blue light, Dr. Taub advised.

• Arms and hands. Be sure to elevate the arms so they are 2-4 inches from the light source, Dr. Taub said. She recommended using the push-up handles sold at sporting goods stores to elevate a patient’s arms for more effective PDT. Her preferred protocol for treatment of the arms and hands is to incubate with 5-ALA for 2 hours using Saran Wrap and gloves for occlusion, followed by exposure to blue light for 20 minutes. Repeat the procedure in 4-8 weeks, then examine the patient 12 weeks later and biopsy any residual lesions.

• Legs and feet. When planning PDT for the legs, remove or biopsy any lesions 4 weeks before PDT, said Dr. Taub. She recommended dividing the legs into four quadrants that each take one stick of ALA: upper, lower, anterior, and posterior. Perform the PDT on each quadrant separately, she said. Incubate the area for 2-3 hours, ideally after 1 week of 5-fluorouracil treatment. Next, expose the quadrant to blue light for 20 minutes. Repeat the protocol 8 weeks later, and re-evaluate the patient 12 weeks after the second treatment, she said.

Tricky areas such as the arms, legs, and chest can respond especially well to intense pulsed light (IPL)-PDT, Dr. Taub noted. The cost to the patient is higher, but she has seen dramatic improvements. Another option is to do one IPL-PDT treatment and follow with a blue light treatment if necessary, she said.

Dr. Taub disclosed serving as a consultant and speaker for, and receiving research funding from, DUSA Pharmaceuticals and Syneron.

ORLANDO – The photodynamic therapy protocol that works best on the face is not necessarily the best protocol for the scalp, according to Dr. Amy Forman Taub of Northwestern University in Chicago.

The main indications for PDT are actinic keratoses, acne, and photorejuvenation, but other indications include psoriasis, vulvar neoplasia, methicillin-resistant Staphylococcus aureus, and onychomycosis.

"For long-term cosmesis, nothing stands up like PDT," said Dr. Taub at the Orlando Dermatology Aesthetic and Clinical Conference. She explained her protocols for using PDT for actinic keratoses on different parts of the body.

• Scalp. To treat actinic keratoses on the scalp, Dr. Taub recommended incubation for 60-90 minutes with 5-aminolevulinic acid (5-ALA), followed by exposure to blue light at 2-4 inches for 20 minutes. Next, prescribe emollients for morning use and fluticasone for nighttime use. Check the scalp at 4 weeks. Repeat the PDT protocol after 8 weeks. Check the patient again in 12-16 weeks and biopsy any residual lesions, Dr. Taub said.

• Face. For severe actinic keratoses on the face, Dr. Taub recommended incubation with 5-ALA for 1 hour, followed by exposure to blue light for 16 minutes. Next, instruct the patient to apply zinc oxide sunscreen on top of topical emollients in the morning, and to use topical emollients at night. If 20% or fewer lesions remain at a 4-week follow-up visit, use an alternate therapy. But if more than 20% of the lesions remain, repeat the PDT with 90 minutes of incubation and 1 minute of blue light, Dr. Taub advised.

• Arms and hands. Be sure to elevate the arms so they are 2-4 inches from the light source, Dr. Taub said. She recommended using the push-up handles sold at sporting goods stores to elevate a patient’s arms for more effective PDT. Her preferred protocol for treatment of the arms and hands is to incubate with 5-ALA for 2 hours using Saran Wrap and gloves for occlusion, followed by exposure to blue light for 20 minutes. Repeat the procedure in 4-8 weeks, then examine the patient 12 weeks later and biopsy any residual lesions.

• Legs and feet. When planning PDT for the legs, remove or biopsy any lesions 4 weeks before PDT, said Dr. Taub. She recommended dividing the legs into four quadrants that each take one stick of ALA: upper, lower, anterior, and posterior. Perform the PDT on each quadrant separately, she said. Incubate the area for 2-3 hours, ideally after 1 week of 5-fluorouracil treatment. Next, expose the quadrant to blue light for 20 minutes. Repeat the protocol 8 weeks later, and re-evaluate the patient 12 weeks after the second treatment, she said.

Tricky areas such as the arms, legs, and chest can respond especially well to intense pulsed light (IPL)-PDT, Dr. Taub noted. The cost to the patient is higher, but she has seen dramatic improvements. Another option is to do one IPL-PDT treatment and follow with a blue light treatment if necessary, she said.

Dr. Taub disclosed serving as a consultant and speaker for, and receiving research funding from, DUSA Pharmaceuticals and Syneron.

ORLANDO – The photodynamic therapy protocol that works best on the face is not necessarily the best protocol for the scalp, according to Dr. Amy Forman Taub of Northwestern University in Chicago.

The main indications for PDT are actinic keratoses, acne, and photorejuvenation, but other indications include psoriasis, vulvar neoplasia, methicillin-resistant Staphylococcus aureus, and onychomycosis.

"For long-term cosmesis, nothing stands up like PDT," said Dr. Taub at the Orlando Dermatology Aesthetic and Clinical Conference. She explained her protocols for using PDT for actinic keratoses on different parts of the body.

• Scalp. To treat actinic keratoses on the scalp, Dr. Taub recommended incubation for 60-90 minutes with 5-aminolevulinic acid (5-ALA), followed by exposure to blue light at 2-4 inches for 20 minutes. Next, prescribe emollients for morning use and fluticasone for nighttime use. Check the scalp at 4 weeks. Repeat the PDT protocol after 8 weeks. Check the patient again in 12-16 weeks and biopsy any residual lesions, Dr. Taub said.

• Face. For severe actinic keratoses on the face, Dr. Taub recommended incubation with 5-ALA for 1 hour, followed by exposure to blue light for 16 minutes. Next, instruct the patient to apply zinc oxide sunscreen on top of topical emollients in the morning, and to use topical emollients at night. If 20% or fewer lesions remain at a 4-week follow-up visit, use an alternate therapy. But if more than 20% of the lesions remain, repeat the PDT with 90 minutes of incubation and 1 minute of blue light, Dr. Taub advised.

• Arms and hands. Be sure to elevate the arms so they are 2-4 inches from the light source, Dr. Taub said. She recommended using the push-up handles sold at sporting goods stores to elevate a patient’s arms for more effective PDT. Her preferred protocol for treatment of the arms and hands is to incubate with 5-ALA for 2 hours using Saran Wrap and gloves for occlusion, followed by exposure to blue light for 20 minutes. Repeat the procedure in 4-8 weeks, then examine the patient 12 weeks later and biopsy any residual lesions.

• Legs and feet. When planning PDT for the legs, remove or biopsy any lesions 4 weeks before PDT, said Dr. Taub. She recommended dividing the legs into four quadrants that each take one stick of ALA: upper, lower, anterior, and posterior. Perform the PDT on each quadrant separately, she said. Incubate the area for 2-3 hours, ideally after 1 week of 5-fluorouracil treatment. Next, expose the quadrant to blue light for 20 minutes. Repeat the protocol 8 weeks later, and re-evaluate the patient 12 weeks after the second treatment, she said.

Tricky areas such as the arms, legs, and chest can respond especially well to intense pulsed light (IPL)-PDT, Dr. Taub noted. The cost to the patient is higher, but she has seen dramatic improvements. Another option is to do one IPL-PDT treatment and follow with a blue light treatment if necessary, she said.

Dr. Taub disclosed serving as a consultant and speaker for, and receiving research funding from, DUSA Pharmaceuticals and Syneron.

In October 2010, when a cholera outbreak erupted in Haiti, doctors from around the world responded to the outbreak, including Dr. Kwan Kew Lai. In December, she spent a week in the island nation, sponsored by Medical Teams International Disaster Response, treating cholera patients of all ages at the Northwest Haiti Christian Mission in St. Louis du Nord.

Photo credit: Dr. Kwan Kew Lai

Dr. Lai is no novice to providing medical relief services overseas. In 2009, she worked treating HIV/AIDS patients as part of the Global Medic Force. Here, Dr. Lai discusses her experience in Haiti.

How did you learn about Medical Teams International Disaster Response?

I found out about the group immediately after the earthquake last year, when I searched the Internet for a team to go to Haiti to help care for patients there. I was asked to go with Partners in Development (PID) as a physician for their response team. MTI required me to formally apply to be on their team, which I did. They asked for descriptions of my previous experience with international work, as well as letters of recommendation. Last April, I was interviewed by phone, and later I was accepted to join their disaster response team.

In October, when the cholera epidemic began in Haiti, MTI contacted team members to go. But I was in West Africa at the time, completing HIV/AIDS mentoring work for the Institute of Human Virology, Nigeria, and Global Medic Force, Abuja, Nigeria, so I could not respond immediately. In December, I heard from MTI again, and they asked me to be ready to go in a few days. Our team included six doctors and a nurse.

Did you have any previous experience in treating cholera?

I had no previous experience in treating cholera patients, except that when I was in South Africa in 2009, near the border of Zimbabwe, I arrived at the end of a cholera outbreak among the refugees. So I did see a few cases in the hospital then.

What steps did the medical team take to avoid becoming ill themselves?

We used a lot of hand sanitizer; there were no sinks at St. Louis du Nord. We were vigilant about cleaning our hands between patients and before meals. MTI provided gloves, but they were used only for starting IVs and in cases when there might be possible contact with body fluids. No masks were required because cholera is spread via the fecal-oral route through contaminated food or water.

What were some of the challenges of treating cholera in Haiti?

There seemed to be a difference in opinion between Haitian doctors and visiting doctors as to how vigorously a dehydrated patient should be resuscitated. The World Health Organization guidelines were posted on the walls and I believe in giving fluids aggressively, but our Haitian counterparts seemed to be more conservative and tended to turn the fluids down. So there was an ongoing battle. Our team would turn up the fluids only to find the fluids turned down shortly thereafter.

The language barrier is an issue, because we did not have an interpreter with us all the time. It was especially difficult to communicate with the Haitian nurses.

The lack of accessibility to clean water continues to be a concern, especially when patients are sent home to unsanitary conditions.

There were also cultural differences. Some Haitians believe in fate. If a patient seemed to them to be dying, they accepted it and thought that it was time for him to go, so there should not be any heroic measures. However, to us cholera is an extremely treatable condition. Vigorous hydration can generally save a life.

What was your basic treatment strategy for most patients?

Our standard treatment strategy was to do a quick assessment of the patient’s state of hydration. Patients with severe hydration generally received an IV immediately. Patients who were moderately or slightly dehydrated, with no persistent vomiting, were generally encouraged to drink oral rehydration solution (ORS).

The elderly and very young cholera patients are at the greatest risk of dying from extreme dehydration. Patients who arrived at the clinic from long distances, and those who had been ill for several days, were also at increased risk of dying. Lack of clean water plays a major role in the spread of cholera. Malnutrition, which is common in Haiti, certainly does not help the immune system to fight infections. Near Port-au-Prince, we saw people washing their clothes and bathing in dirty river water; we were not at all sure where their drinking water came from.

At St. Louis du Nord, we were lucky to have ample supplies of intravenous fluids provided by MTI and delivered by the United Nations Humanitarian Services. We also had a good supply of clean water. Space was limited, and patients were put on cots and even on the floor. The floor and the cots were constantly being washed with bleach. Patients were provided with basins to use as toilets for their diarrhea, since cholera cots were in short supply and constantly soiled.

What was the setup at the hospital where you worked?

From Dr. Lai’s blog: The cholera treatment area was divided into three areas: the so-called ICU, which held the sickest patients, all of whom were on IVs and encouraged to take ORS; the step-down unit (where patients were taking ORS and had been discharged from the ICU, but who still had diarrhea and some vomiting); and the ready-to-discharge unit (patients on ORS who were ready to be discharged).

In the units with the less severe cases, patients and their relatives slept on mats on the floor. After the first few days, we were told that the patient count had decreased by half. There were 20 or so patients in this area. In the ICU there were about 25 patients lying on cots, some of which were diarrheal cots, with holes in the center. The ward was surprisingly free from strong stench. Many of the patients had the classic glazed look, with sunken and listless eyes, and were either restless or motionless.

What were some of the specific cases that you managed?

From Dr. Lai’s blog: One day, two men carried a sick woman in on a bed-frame. She had been sick for 5 days with vomiting and diarrhea, and it was rumored that they had to travel for 2 hours to come to the mission. The woman was not able to answer questions; her eyes were glazed and she was dehydrated. I examined her and felt her belly and asked if she was pregnant. She turned out to be 7 months pregnant. I told my interpreter that we would need to put two IVs in her. She asked me why. I replied that she was very dry, having been sick for 5 days and that she was pregnant. My interpreter looked at me and said, "Is the second IV for the baby?" Her face brightened up at the idea. The woman improved within 2 hours, after initially only being able to whisper to us.

Another case was a baby being breast-fed by her mother. One of the doctors placed an intraosseous line in the tibia, but it wasn’t working, so we used a nasogastric tube. After 100 to 200 cc of fluids were pushed into her, she became quite feisty. IVs and ORS made a huge difference for so many of these patients.

Interview by Heidi Splete. Blog excerpts are from haiticholeraoutbreakkwankew.blogspot.com.

Think globally. Practice locally.

U.S.-trained internists who have practiced abroad will receive a $100 stipend for contributing to this column. For details, send an e-mail to [email protected].

In October 2010, when a cholera outbreak erupted in Haiti, doctors from around the world responded to the outbreak, including Dr. Kwan Kew Lai. In December, she spent a week in the island nation, sponsored by Medical Teams International Disaster Response, treating cholera patients of all ages at the Northwest Haiti Christian Mission in St. Louis du Nord.

Photo credit: Dr. Kwan Kew Lai

Dr. Lai is no novice to providing medical relief services overseas. In 2009, she worked treating HIV/AIDS patients as part of the Global Medic Force. Here, Dr. Lai discusses her experience in Haiti.

How did you learn about Medical Teams International Disaster Response?

I found out about the group immediately after the earthquake last year, when I searched the Internet for a team to go to Haiti to help care for patients there. I was asked to go with Partners in Development (PID) as a physician for their response team. MTI required me to formally apply to be on their team, which I did. They asked for descriptions of my previous experience with international work, as well as letters of recommendation. Last April, I was interviewed by phone, and later I was accepted to join their disaster response team.

In October, when the cholera epidemic began in Haiti, MTI contacted team members to go. But I was in West Africa at the time, completing HIV/AIDS mentoring work for the Institute of Human Virology, Nigeria, and Global Medic Force, Abuja, Nigeria, so I could not respond immediately. In December, I heard from MTI again, and they asked me to be ready to go in a few days. Our team included six doctors and a nurse.

Did you have any previous experience in treating cholera?

I had no previous experience in treating cholera patients, except that when I was in South Africa in 2009, near the border of Zimbabwe, I arrived at the end of a cholera outbreak among the refugees. So I did see a few cases in the hospital then.

What steps did the medical team take to avoid becoming ill themselves?

We used a lot of hand sanitizer; there were no sinks at St. Louis du Nord. We were vigilant about cleaning our hands between patients and before meals. MTI provided gloves, but they were used only for starting IVs and in cases when there might be possible contact with body fluids. No masks were required because cholera is spread via the fecal-oral route through contaminated food or water.

What were some of the challenges of treating cholera in Haiti?

There seemed to be a difference in opinion between Haitian doctors and visiting doctors as to how vigorously a dehydrated patient should be resuscitated. The World Health Organization guidelines were posted on the walls and I believe in giving fluids aggressively, but our Haitian counterparts seemed to be more conservative and tended to turn the fluids down. So there was an ongoing battle. Our team would turn up the fluids only to find the fluids turned down shortly thereafter.

The language barrier is an issue, because we did not have an interpreter with us all the time. It was especially difficult to communicate with the Haitian nurses.

The lack of accessibility to clean water continues to be a concern, especially when patients are sent home to unsanitary conditions.

There were also cultural differences. Some Haitians believe in fate. If a patient seemed to them to be dying, they accepted it and thought that it was time for him to go, so there should not be any heroic measures. However, to us cholera is an extremely treatable condition. Vigorous hydration can generally save a life.

What was your basic treatment strategy for most patients?

Our standard treatment strategy was to do a quick assessment of the patient’s state of hydration. Patients with severe hydration generally received an IV immediately. Patients who were moderately or slightly dehydrated, with no persistent vomiting, were generally encouraged to drink oral rehydration solution (ORS).

The elderly and very young cholera patients are at the greatest risk of dying from extreme dehydration. Patients who arrived at the clinic from long distances, and those who had been ill for several days, were also at increased risk of dying. Lack of clean water plays a major role in the spread of cholera. Malnutrition, which is common in Haiti, certainly does not help the immune system to fight infections. Near Port-au-Prince, we saw people washing their clothes and bathing in dirty river water; we were not at all sure where their drinking water came from.

At St. Louis du Nord, we were lucky to have ample supplies of intravenous fluids provided by MTI and delivered by the United Nations Humanitarian Services. We also had a good supply of clean water. Space was limited, and patients were put on cots and even on the floor. The floor and the cots were constantly being washed with bleach. Patients were provided with basins to use as toilets for their diarrhea, since cholera cots were in short supply and constantly soiled.

What was the setup at the hospital where you worked?

From Dr. Lai’s blog: The cholera treatment area was divided into three areas: the so-called ICU, which held the sickest patients, all of whom were on IVs and encouraged to take ORS; the step-down unit (where patients were taking ORS and had been discharged from the ICU, but who still had diarrhea and some vomiting); and the ready-to-discharge unit (patients on ORS who were ready to be discharged).

In the units with the less severe cases, patients and their relatives slept on mats on the floor. After the first few days, we were told that the patient count had decreased by half. There were 20 or so patients in this area. In the ICU there were about 25 patients lying on cots, some of which were diarrheal cots, with holes in the center. The ward was surprisingly free from strong stench. Many of the patients had the classic glazed look, with sunken and listless eyes, and were either restless or motionless.

What were some of the specific cases that you managed?

From Dr. Lai’s blog: One day, two men carried a sick woman in on a bed-frame. She had been sick for 5 days with vomiting and diarrhea, and it was rumored that they had to travel for 2 hours to come to the mission. The woman was not able to answer questions; her eyes were glazed and she was dehydrated. I examined her and felt her belly and asked if she was pregnant. She turned out to be 7 months pregnant. I told my interpreter that we would need to put two IVs in her. She asked me why. I replied that she was very dry, having been sick for 5 days and that she was pregnant. My interpreter looked at me and said, "Is the second IV for the baby?" Her face brightened up at the idea. The woman improved within 2 hours, after initially only being able to whisper to us.

Another case was a baby being breast-fed by her mother. One of the doctors placed an intraosseous line in the tibia, but it wasn’t working, so we used a nasogastric tube. After 100 to 200 cc of fluids were pushed into her, she became quite feisty. IVs and ORS made a huge difference for so many of these patients.

Interview by Heidi Splete. Blog excerpts are from haiticholeraoutbreakkwankew.blogspot.com.

Think globally. Practice locally.

U.S.-trained internists who have practiced abroad will receive a $100 stipend for contributing to this column. For details, send an e-mail to [email protected].

In October 2010, when a cholera outbreak erupted in Haiti, doctors from around the world responded to the outbreak, including Dr. Kwan Kew Lai. In December, she spent a week in the island nation, sponsored by Medical Teams International Disaster Response, treating cholera patients of all ages at the Northwest Haiti Christian Mission in St. Louis du Nord.

Photo credit: Dr. Kwan Kew Lai

Dr. Lai is no novice to providing medical relief services overseas. In 2009, she worked treating HIV/AIDS patients as part of the Global Medic Force. Here, Dr. Lai discusses her experience in Haiti.

How did you learn about Medical Teams International Disaster Response?

I found out about the group immediately after the earthquake last year, when I searched the Internet for a team to go to Haiti to help care for patients there. I was asked to go with Partners in Development (PID) as a physician for their response team. MTI required me to formally apply to be on their team, which I did. They asked for descriptions of my previous experience with international work, as well as letters of recommendation. Last April, I was interviewed by phone, and later I was accepted to join their disaster response team.

In October, when the cholera epidemic began in Haiti, MTI contacted team members to go. But I was in West Africa at the time, completing HIV/AIDS mentoring work for the Institute of Human Virology, Nigeria, and Global Medic Force, Abuja, Nigeria, so I could not respond immediately. In December, I heard from MTI again, and they asked me to be ready to go in a few days. Our team included six doctors and a nurse.

Did you have any previous experience in treating cholera?

I had no previous experience in treating cholera patients, except that when I was in South Africa in 2009, near the border of Zimbabwe, I arrived at the end of a cholera outbreak among the refugees. So I did see a few cases in the hospital then.

What steps did the medical team take to avoid becoming ill themselves?

We used a lot of hand sanitizer; there were no sinks at St. Louis du Nord. We were vigilant about cleaning our hands between patients and before meals. MTI provided gloves, but they were used only for starting IVs and in cases when there might be possible contact with body fluids. No masks were required because cholera is spread via the fecal-oral route through contaminated food or water.

What were some of the challenges of treating cholera in Haiti?

There seemed to be a difference in opinion between Haitian doctors and visiting doctors as to how vigorously a dehydrated patient should be resuscitated. The World Health Organization guidelines were posted on the walls and I believe in giving fluids aggressively, but our Haitian counterparts seemed to be more conservative and tended to turn the fluids down. So there was an ongoing battle. Our team would turn up the fluids only to find the fluids turned down shortly thereafter.

The language barrier is an issue, because we did not have an interpreter with us all the time. It was especially difficult to communicate with the Haitian nurses.

The lack of accessibility to clean water continues to be a concern, especially when patients are sent home to unsanitary conditions.

There were also cultural differences. Some Haitians believe in fate. If a patient seemed to them to be dying, they accepted it and thought that it was time for him to go, so there should not be any heroic measures. However, to us cholera is an extremely treatable condition. Vigorous hydration can generally save a life.

What was your basic treatment strategy for most patients?

Our standard treatment strategy was to do a quick assessment of the patient’s state of hydration. Patients with severe hydration generally received an IV immediately. Patients who were moderately or slightly dehydrated, with no persistent vomiting, were generally encouraged to drink oral rehydration solution (ORS).

The elderly and very young cholera patients are at the greatest risk of dying from extreme dehydration. Patients who arrived at the clinic from long distances, and those who had been ill for several days, were also at increased risk of dying. Lack of clean water plays a major role in the spread of cholera. Malnutrition, which is common in Haiti, certainly does not help the immune system to fight infections. Near Port-au-Prince, we saw people washing their clothes and bathing in dirty river water; we were not at all sure where their drinking water came from.

At St. Louis du Nord, we were lucky to have ample supplies of intravenous fluids provided by MTI and delivered by the United Nations Humanitarian Services. We also had a good supply of clean water. Space was limited, and patients were put on cots and even on the floor. The floor and the cots were constantly being washed with bleach. Patients were provided with basins to use as toilets for their diarrhea, since cholera cots were in short supply and constantly soiled.

What was the setup at the hospital where you worked?

From Dr. Lai’s blog: The cholera treatment area was divided into three areas: the so-called ICU, which held the sickest patients, all of whom were on IVs and encouraged to take ORS; the step-down unit (where patients were taking ORS and had been discharged from the ICU, but who still had diarrhea and some vomiting); and the ready-to-discharge unit (patients on ORS who were ready to be discharged).

In the units with the less severe cases, patients and their relatives slept on mats on the floor. After the first few days, we were told that the patient count had decreased by half. There were 20 or so patients in this area. In the ICU there were about 25 patients lying on cots, some of which were diarrheal cots, with holes in the center. The ward was surprisingly free from strong stench. Many of the patients had the classic glazed look, with sunken and listless eyes, and were either restless or motionless.

What were some of the specific cases that you managed?

From Dr. Lai’s blog: One day, two men carried a sick woman in on a bed-frame. She had been sick for 5 days with vomiting and diarrhea, and it was rumored that they had to travel for 2 hours to come to the mission. The woman was not able to answer questions; her eyes were glazed and she was dehydrated. I examined her and felt her belly and asked if she was pregnant. She turned out to be 7 months pregnant. I told my interpreter that we would need to put two IVs in her. She asked me why. I replied that she was very dry, having been sick for 5 days and that she was pregnant. My interpreter looked at me and said, "Is the second IV for the baby?" Her face brightened up at the idea. The woman improved within 2 hours, after initially only being able to whisper to us.

Another case was a baby being breast-fed by her mother. One of the doctors placed an intraosseous line in the tibia, but it wasn’t working, so we used a nasogastric tube. After 100 to 200 cc of fluids were pushed into her, she became quite feisty. IVs and ORS made a huge difference for so many of these patients.

Interview by Heidi Splete. Blog excerpts are from haiticholeraoutbreakkwankew.blogspot.com.

Think globally. Practice locally.

U.S.-trained internists who have practiced abroad will receive a $100 stipend for contributing to this column. For details, send an e-mail to [email protected].

ORLANDO – Foam sclerotherapy can be an effective treatment for varicose veins ranging from 1 mm to more than 5 mm in diameter, said Dr. Hema Sundaram, medical director of Sundaram Dermatology, Cosmetic & Laser Surgery in Rockville, Md.

As many as 20% of adults in the United States and Western Europe have varicose veins, and many of them can be successfully treated in a dermatology practice, Dr. Sundaram said at the Orlando Dermatology Aesthetic and Clinical Conference.

Her treatment of choice for sclerotherapy is polidocanol, which was approved by the Food and Drug Administration last year for treating varicose veins. Polidocanol has been studied more extensively than any other sclerosant, noted Dr. Sundaram, who is in private practice in Rockville. The adverse events are low, allergic reactions are rare, and patients report less pain compared with other sclerosants.

She said that she successfully uses polidocanol for foam sclerotherapy. The best candidates for this off-label use are patients who have veins with varicosities from 1 mm to greater than 5 mm in diameter. For telangiectatic veins up to 1 mm in diameter, she prefers liquid polidocanol. "The foam can be a bit traumatic for the smaller veins," she said.

To treat varicose veins with foam, mix air with the sclerosant in a sclerosant:air ratio of 1:3 or 1:4, said Dr. Sundaram. She uses a three-way stopcock and a double syringe to combine the air and sclerosant. The foam in the syringe should resemble shaving foam.

Maintain a maximum foam volume of 10 mL per leg per session to minimize the risk of deep vein thrombosis, she noted.

"The important thing is to use the foam quickly, because the air will dissipate," Dr. Sundaram said. Stop injecting the foam when the flow of sclerosant into superficial veins is no longer visible.

For the right-sized veins, foam sclerotherapy can displace the blood more efficiently and put more of the sclerosant in contact with the vascular endothelial wall, Dr. Sundaram said.

Foam sclerotherapy has demonstrated safety and efficacy. In a review of data from 325 patients who were treated at a single center over 7 years, patients rated improvement as 1.94 on a scale of 3, while rating pain at 0.22, ulceration at 0.06, and hyperpigmentation at 0.35 (Dermatol. Surg. 2010;36[suppl. 2]:1026-33).

Dr. Sundaram’s foam sclerotherapy procedure is as follows:

• Inject while the patient is lying down.

• Start proximally and move distally; some smaller veins can be filled through larger ones.

• Start with the largest veins and work down.

• After injecting the sclerosant and removing the needle, compress the entire vein.

• Direct the patient to used graduated leg compression with bandages or stockings for 3 days to 3 weeks after the procedure.

Because foam sclerotherapy is an off-label use, be sure to include this fact in the informed consent form that patients sign, Dr. Sundaram noted.

Pretreatment evaluation is as important for a sclerotherapy patient as it is for a patient undergoing any other type of aesthetic procedure. "The assessment determines how successful we are going to be," she said.

She recommended an ultrasound evaluation prior to sclerotherapy in order to locate the reflux areas and to identify any insufficiency in the greater saphenous vein. Patients with greater saphenous vein insufficiency tend not to respond well to sclerotherapy and are more likely to experience recurrence of varicosities, she explained. In addition, these patients are at increased risk of superficial thrombophlebitis. Dr. Sundaram refers these patients to a vascular surgeon for evaluation and treatment.

Contraindications for sclerotherapy include allergy to the sclerosing agent, acute deep vein thrombosis, infection, and significant leg swelling, as well as pregnancy, polyneuropathy, severe asthma, and hypercoagulability.

Dr. Sundaram serves as an advisor, consultant, and/or clinical investigator for the following companies: Johnson & Johnson, Merz Aesthetics, Biopelle, Colorescience, Medicis, Merz, SkinMedica, Suneva Medical, Syneron/Candela, and Ulthera.

ORLANDO – Foam sclerotherapy can be an effective treatment for varicose veins ranging from 1 mm to more than 5 mm in diameter, said Dr. Hema Sundaram, medical director of Sundaram Dermatology, Cosmetic & Laser Surgery in Rockville, Md.

As many as 20% of adults in the United States and Western Europe have varicose veins, and many of them can be successfully treated in a dermatology practice, Dr. Sundaram said at the Orlando Dermatology Aesthetic and Clinical Conference.

Her treatment of choice for sclerotherapy is polidocanol, which was approved by the Food and Drug Administration last year for treating varicose veins. Polidocanol has been studied more extensively than any other sclerosant, noted Dr. Sundaram, who is in private practice in Rockville. The adverse events are low, allergic reactions are rare, and patients report less pain compared with other sclerosants.

She said that she successfully uses polidocanol for foam sclerotherapy. The best candidates for this off-label use are patients who have veins with varicosities from 1 mm to greater than 5 mm in diameter. For telangiectatic veins up to 1 mm in diameter, she prefers liquid polidocanol. "The foam can be a bit traumatic for the smaller veins," she said.

To treat varicose veins with foam, mix air with the sclerosant in a sclerosant:air ratio of 1:3 or 1:4, said Dr. Sundaram. She uses a three-way stopcock and a double syringe to combine the air and sclerosant. The foam in the syringe should resemble shaving foam.

Maintain a maximum foam volume of 10 mL per leg per session to minimize the risk of deep vein thrombosis, she noted.

"The important thing is to use the foam quickly, because the air will dissipate," Dr. Sundaram said. Stop injecting the foam when the flow of sclerosant into superficial veins is no longer visible.

For the right-sized veins, foam sclerotherapy can displace the blood more efficiently and put more of the sclerosant in contact with the vascular endothelial wall, Dr. Sundaram said.

Foam sclerotherapy has demonstrated safety and efficacy. In a review of data from 325 patients who were treated at a single center over 7 years, patients rated improvement as 1.94 on a scale of 3, while rating pain at 0.22, ulceration at 0.06, and hyperpigmentation at 0.35 (Dermatol. Surg. 2010;36[suppl. 2]:1026-33).

Dr. Sundaram’s foam sclerotherapy procedure is as follows:

• Inject while the patient is lying down.

• Start proximally and move distally; some smaller veins can be filled through larger ones.

• Start with the largest veins and work down.

• After injecting the sclerosant and removing the needle, compress the entire vein.

• Direct the patient to used graduated leg compression with bandages or stockings for 3 days to 3 weeks after the procedure.

Because foam sclerotherapy is an off-label use, be sure to include this fact in the informed consent form that patients sign, Dr. Sundaram noted.

Pretreatment evaluation is as important for a sclerotherapy patient as it is for a patient undergoing any other type of aesthetic procedure. "The assessment determines how successful we are going to be," she said.

She recommended an ultrasound evaluation prior to sclerotherapy in order to locate the reflux areas and to identify any insufficiency in the greater saphenous vein. Patients with greater saphenous vein insufficiency tend not to respond well to sclerotherapy and are more likely to experience recurrence of varicosities, she explained. In addition, these patients are at increased risk of superficial thrombophlebitis. Dr. Sundaram refers these patients to a vascular surgeon for evaluation and treatment.

Contraindications for sclerotherapy include allergy to the sclerosing agent, acute deep vein thrombosis, infection, and significant leg swelling, as well as pregnancy, polyneuropathy, severe asthma, and hypercoagulability.

Dr. Sundaram serves as an advisor, consultant, and/or clinical investigator for the following companies: Johnson & Johnson, Merz Aesthetics, Biopelle, Colorescience, Medicis, Merz, SkinMedica, Suneva Medical, Syneron/Candela, and Ulthera.

ORLANDO – Foam sclerotherapy can be an effective treatment for varicose veins ranging from 1 mm to more than 5 mm in diameter, said Dr. Hema Sundaram, medical director of Sundaram Dermatology, Cosmetic & Laser Surgery in Rockville, Md.

As many as 20% of adults in the United States and Western Europe have varicose veins, and many of them can be successfully treated in a dermatology practice, Dr. Sundaram said at the Orlando Dermatology Aesthetic and Clinical Conference.

Her treatment of choice for sclerotherapy is polidocanol, which was approved by the Food and Drug Administration last year for treating varicose veins. Polidocanol has been studied more extensively than any other sclerosant, noted Dr. Sundaram, who is in private practice in Rockville. The adverse events are low, allergic reactions are rare, and patients report less pain compared with other sclerosants.

She said that she successfully uses polidocanol for foam sclerotherapy. The best candidates for this off-label use are patients who have veins with varicosities from 1 mm to greater than 5 mm in diameter. For telangiectatic veins up to 1 mm in diameter, she prefers liquid polidocanol. "The foam can be a bit traumatic for the smaller veins," she said.

To treat varicose veins with foam, mix air with the sclerosant in a sclerosant:air ratio of 1:3 or 1:4, said Dr. Sundaram. She uses a three-way stopcock and a double syringe to combine the air and sclerosant. The foam in the syringe should resemble shaving foam.

Maintain a maximum foam volume of 10 mL per leg per session to minimize the risk of deep vein thrombosis, she noted.

"The important thing is to use the foam quickly, because the air will dissipate," Dr. Sundaram said. Stop injecting the foam when the flow of sclerosant into superficial veins is no longer visible.

For the right-sized veins, foam sclerotherapy can displace the blood more efficiently and put more of the sclerosant in contact with the vascular endothelial wall, Dr. Sundaram said.

Foam sclerotherapy has demonstrated safety and efficacy. In a review of data from 325 patients who were treated at a single center over 7 years, patients rated improvement as 1.94 on a scale of 3, while rating pain at 0.22, ulceration at 0.06, and hyperpigmentation at 0.35 (Dermatol. Surg. 2010;36[suppl. 2]:1026-33).

Dr. Sundaram’s foam sclerotherapy procedure is as follows:

• Inject while the patient is lying down.

• Start proximally and move distally; some smaller veins can be filled through larger ones.

• Start with the largest veins and work down.

• After injecting the sclerosant and removing the needle, compress the entire vein.

• Direct the patient to used graduated leg compression with bandages or stockings for 3 days to 3 weeks after the procedure.

Because foam sclerotherapy is an off-label use, be sure to include this fact in the informed consent form that patients sign, Dr. Sundaram noted.

Pretreatment evaluation is as important for a sclerotherapy patient as it is for a patient undergoing any other type of aesthetic procedure. "The assessment determines how successful we are going to be," she said.

She recommended an ultrasound evaluation prior to sclerotherapy in order to locate the reflux areas and to identify any insufficiency in the greater saphenous vein. Patients with greater saphenous vein insufficiency tend not to respond well to sclerotherapy and are more likely to experience recurrence of varicosities, she explained. In addition, these patients are at increased risk of superficial thrombophlebitis. Dr. Sundaram refers these patients to a vascular surgeon for evaluation and treatment.

Contraindications for sclerotherapy include allergy to the sclerosing agent, acute deep vein thrombosis, infection, and significant leg swelling, as well as pregnancy, polyneuropathy, severe asthma, and hypercoagulability.

Dr. Sundaram serves as an advisor, consultant, and/or clinical investigator for the following companies: Johnson & Johnson, Merz Aesthetics, Biopelle, Colorescience, Medicis, Merz, SkinMedica, Suneva Medical, Syneron/Candela, and Ulthera.

ORLANDO - Foam sclerotherapy can be an effective treatment for varicose veins ranging from 1 mm to more than 5 mm in diameter, said Dr. Hema Sundaram, medical director of Sundaram Dermatology, Cosmetic & Laser Surgery in Rockville, Md.

As many as 20% of adults in the United States and Western Europe have varicose veins, and many of them can be successfully treated in a dermatology practice. Her treatment of choice for sclerotherapy is polidocanol, which was approved by the Food and Drug Administration last year for treating varicose veins. Polidocanol has been studied more extensively than any other sclerosant, noted Dr. Sundaram, who is in private practice in Rockville. The adverse events are low, allergic reactions are rare, and patients report less pain compared with other sclerosants.

She said that she successfully uses polidocanol for foam sclerotherapy. The best candidates for this off-label use are patients who have veins with varicosities from 1 mm to greater than 5 mm in diameter. For telangiectatic veins up to 1 mm in diameter, she prefers liquid polidocanol. "The foam can be a bit traumatic for the smaller veins," she said.

To treat varicose veins with foam, mix air with the sclerosant in a sclerosant:air ratio of 1:3 or 1:4, said Dr. Sundaram. She uses a three-way stopcock and a double syringe to combine the air and sclerosant. The foam in the syringe should resemble shaving foam.

Maintain a maximum foam volume of 10 mL per leg per session to minimize the risk of deep vein thrombosis, she noted.

"The important thing is to use the foam quickly, because the air will dissipate," Dr. Sundaram said. Stop injecting the foam when the flow of sclerosant into superficial veins is no longer visible.

For the right-sized veins, foam sclerotherapy can displace the blood more efficiently and put more of the sclerosant in contact with the vascular endothelial wall, Dr. Sundaram said.

Foam sclerotherapy has demonstrated safety and efficacy. In a review of data from 325 patients who were treated at a single center over 7 years, patients rated improvement as 1.94 on a scale of 3, while rating pain at 0.22, ulceration at 0.06, and hyperpigmentation at 0.35 (Dermatol. Surg. 2010;36[suppl. 2]:1026-33).

Dr. Sundaram’s foam sclerotherapy procedure is as follows:

• Inject while the patient is lying down.

• Start proximally and move distally; some smaller veins can be filled through larger ones.

• Start with the largest veins and work down.

• After injecting the sclerosant and removing the needle, compress the entire vein.

• Direct the patient to used graduated leg compression with bandages or stockings for 3 days to 3 weeks after the procedure.

Because foam sclerotherapy is an off-label use, be sure to include this fact in the informed consent form that patients sign, Dr. Sundaram noted.

Pretreatment evaluation is as important for a sclerotherapy patient as it is for a patient undergoing any other type of aesthetic procedure. "The assessment determines how successful we are going to be," she said.

She recommended an ultrasound evaluation prior to sclerotherapy in order to locate the reflux areas and to identify any insufficiency in the greater saphenous vein. Patients with greater saphenous vein insufficiency tend not to respond well to sclerotherapy and are more likely to experience recurrence of varicosities, she explained. In addition, these patients are at increased risk of superficial thrombophlebitis. Dr. Sundaram refers these patients to a vascular surgeon for evaluation and treatment.

Contraindications for sclerotherapy include allergy to the sclerosing agent, acute deep vein thrombosis, infection, and significant leg swelling, as well as pregnancy, polyneuropathy, severe asthma, and hypercoagulability.

Dr. Sundaram serves as an advisor, consultant, and/or clinical investigator for the following companies: Johnson & Johnson, Merz Aesthetics, Biopelle, Colorescience, Medicis, Merz, SkinMedica, Suneva Medical, Syneron/Candela, and Ulthera.

ORLANDO - Foam sclerotherapy can be an effective treatment for varicose veins ranging from 1 mm to more than 5 mm in diameter, said Dr. Hema Sundaram, medical director of Sundaram Dermatology, Cosmetic & Laser Surgery in Rockville, Md.

As many as 20% of adults in the United States and Western Europe have varicose veins, and many of them can be successfully treated in a dermatology practice. Her treatment of choice for sclerotherapy is polidocanol, which was approved by the Food and Drug Administration last year for treating varicose veins. Polidocanol has been studied more extensively than any other sclerosant, noted Dr. Sundaram, who is in private practice in Rockville. The adverse events are low, allergic reactions are rare, and patients report less pain compared with other sclerosants.

She said that she successfully uses polidocanol for foam sclerotherapy. The best candidates for this off-label use are patients who have veins with varicosities from 1 mm to greater than 5 mm in diameter. For telangiectatic veins up to 1 mm in diameter, she prefers liquid polidocanol. "The foam can be a bit traumatic for the smaller veins," she said.

To treat varicose veins with foam, mix air with the sclerosant in a sclerosant:air ratio of 1:3 or 1:4, said Dr. Sundaram. She uses a three-way stopcock and a double syringe to combine the air and sclerosant. The foam in the syringe should resemble shaving foam.

Maintain a maximum foam volume of 10 mL per leg per session to minimize the risk of deep vein thrombosis, she noted.

"The important thing is to use the foam quickly, because the air will dissipate," Dr. Sundaram said. Stop injecting the foam when the flow of sclerosant into superficial veins is no longer visible.

For the right-sized veins, foam sclerotherapy can displace the blood more efficiently and put more of the sclerosant in contact with the vascular endothelial wall, Dr. Sundaram said.

Foam sclerotherapy has demonstrated safety and efficacy. In a review of data from 325 patients who were treated at a single center over 7 years, patients rated improvement as 1.94 on a scale of 3, while rating pain at 0.22, ulceration at 0.06, and hyperpigmentation at 0.35 (Dermatol. Surg. 2010;36[suppl. 2]:1026-33).

Dr. Sundaram’s foam sclerotherapy procedure is as follows:

• Inject while the patient is lying down.

• Start proximally and move distally; some smaller veins can be filled through larger ones.

• Start with the largest veins and work down.

• After injecting the sclerosant and removing the needle, compress the entire vein.

• Direct the patient to used graduated leg compression with bandages or stockings for 3 days to 3 weeks after the procedure.

Because foam sclerotherapy is an off-label use, be sure to include this fact in the informed consent form that patients sign, Dr. Sundaram noted.

Pretreatment evaluation is as important for a sclerotherapy patient as it is for a patient undergoing any other type of aesthetic procedure. "The assessment determines how successful we are going to be," she said.

She recommended an ultrasound evaluation prior to sclerotherapy in order to locate the reflux areas and to identify any insufficiency in the greater saphenous vein. Patients with greater saphenous vein insufficiency tend not to respond well to sclerotherapy and are more likely to experience recurrence of varicosities, she explained. In addition, these patients are at increased risk of superficial thrombophlebitis. Dr. Sundaram refers these patients to a vascular surgeon for evaluation and treatment.

Contraindications for sclerotherapy include allergy to the sclerosing agent, acute deep vein thrombosis, infection, and significant leg swelling, as well as pregnancy, polyneuropathy, severe asthma, and hypercoagulability.

Dr. Sundaram serves as an advisor, consultant, and/or clinical investigator for the following companies: Johnson & Johnson, Merz Aesthetics, Biopelle, Colorescience, Medicis, Merz, SkinMedica, Suneva Medical, Syneron/Candela, and Ulthera.

ORLANDO - Foam sclerotherapy can be an effective treatment for varicose veins ranging from 1 mm to more than 5 mm in diameter, said Dr. Hema Sundaram, medical director of Sundaram Dermatology, Cosmetic & Laser Surgery in Rockville, Md.

As many as 20% of adults in the United States and Western Europe have varicose veins, and many of them can be successfully treated in a dermatology practice. Her treatment of choice for sclerotherapy is polidocanol, which was approved by the Food and Drug Administration last year for treating varicose veins. Polidocanol has been studied more extensively than any other sclerosant, noted Dr. Sundaram, who is in private practice in Rockville. The adverse events are low, allergic reactions are rare, and patients report less pain compared with other sclerosants.

She said that she successfully uses polidocanol for foam sclerotherapy. The best candidates for this off-label use are patients who have veins with varicosities from 1 mm to greater than 5 mm in diameter. For telangiectatic veins up to 1 mm in diameter, she prefers liquid polidocanol. "The foam can be a bit traumatic for the smaller veins," she said.

To treat varicose veins with foam, mix air with the sclerosant in a sclerosant:air ratio of 1:3 or 1:4, said Dr. Sundaram. She uses a three-way stopcock and a double syringe to combine the air and sclerosant. The foam in the syringe should resemble shaving foam.

Maintain a maximum foam volume of 10 mL per leg per session to minimize the risk of deep vein thrombosis, she noted.

"The important thing is to use the foam quickly, because the air will dissipate," Dr. Sundaram said. Stop injecting the foam when the flow of sclerosant into superficial veins is no longer visible.

For the right-sized veins, foam sclerotherapy can displace the blood more efficiently and put more of the sclerosant in contact with the vascular endothelial wall, Dr. Sundaram said.

Foam sclerotherapy has demonstrated safety and efficacy. In a review of data from 325 patients who were treated at a single center over 7 years, patients rated improvement as 1.94 on a scale of 3, while rating pain at 0.22, ulceration at 0.06, and hyperpigmentation at 0.35 (Dermatol. Surg. 2010;36[suppl. 2]:1026-33).

Dr. Sundaram’s foam sclerotherapy procedure is as follows:

• Inject while the patient is lying down.

• Start proximally and move distally; some smaller veins can be filled through larger ones.

• Start with the largest veins and work down.

• After injecting the sclerosant and removing the needle, compress the entire vein.

• Direct the patient to used graduated leg compression with bandages or stockings for 3 days to 3 weeks after the procedure.

Because foam sclerotherapy is an off-label use, be sure to include this fact in the informed consent form that patients sign, Dr. Sundaram noted.

Pretreatment evaluation is as important for a sclerotherapy patient as it is for a patient undergoing any other type of aesthetic procedure. "The assessment determines how successful we are going to be," she said.

She recommended an ultrasound evaluation prior to sclerotherapy in order to locate the reflux areas and to identify any insufficiency in the greater saphenous vein. Patients with greater saphenous vein insufficiency tend not to respond well to sclerotherapy and are more likely to experience recurrence of varicosities, she explained. In addition, these patients are at increased risk of superficial thrombophlebitis. Dr. Sundaram refers these patients to a vascular surgeon for evaluation and treatment.

Contraindications for sclerotherapy include allergy to the sclerosing agent, acute deep vein thrombosis, infection, and significant leg swelling, as well as pregnancy, polyneuropathy, severe asthma, and hypercoagulability.

Dr. Sundaram serves as an advisor, consultant, and/or clinical investigator for the following companies: Johnson & Johnson, Merz Aesthetics, Biopelle, Colorescience, Medicis, Merz, SkinMedica, Suneva Medical, Syneron/Candela, and Ulthera.

ORLANDO - A 0.04% tretinoin microsphere gel pump significantly reduced the number of acne lesions in preteens, based on data from a small pilot study of children aged 9-11 years. The findings were presented in a poster at the Orlando Dermatology Aesthetic & Clinical Conference.

Currently, no drug is approved in the United States for treating acne in children younger than 10 years, noted Dr. Lawrence Eichenfield, chief of pediatric dermatology at the University of California, San Diego, and his colleagues. However, identification and treatment of acne in younger children might prevent more severe acne in adolescence, thus reducing the physical and emotional scars of acne, as well as the financial cost to patients, the researchers wrote.

Dr. Eichenfield and his colleagues randomized 55 children to use either a 0.04% tretinoin microsphere gel (TMG) pump or a placebo pump. Two pumps of the medication or placebo were applied to the face after washing each evening for 12 weeks.

The children had moderate acne (grade III or higher) and a minimum of 30 facial lesions (including a minimum of 20 inflammatory lesions) at baseline, based on the IGA (Investigator's Global Assessment) scale of acne severity. The patients were assessed at baseline and weeks 2, 4, 6, 8, 10, and 12.

At week 12, TMG patients had lesion counts reduced by an average of 44%, compared with 31% in the placebo group. This difference was statistically significant.

In addition, significantly more TMG patients than placebo patients achieved "excellent" results, (26% vs. 13%). More TMG patients than placebo patients achieved "clear" or "almost clear" status based on other scales, but these differences were not significant.

No significant differences in erythema, dryness, peeling, itching, or burning/stinging were observed between the two groups at any of the study visits.

A total of nine children discontinued the study. Of these, four TMG patients and one placebo patient discontinued because of adverse events, two TMG patients were lost to follow-up, and two TMG patients discontinued for personal reasons. The per-protocol study population excluded these 9 patients and 2 additional patients, for a total of 46 patients in the TMG group and 53 in the placebo group.

The findings were limited by the small size of the study. But the results suggest that TMG 0.04% was safe and well tolerated in preteen children with acne, and larger studies are warranted, the researchers said.

The study was sponsored by Johnson & Johnson. Dr. Eichenfield disclosed that he has served as an investigator without personal compensation, a consultant, or an adviser for the following companies: Astellas Pharma, Coria Laboratories, Galderma, Ortho Dermatologics, GlaxoSmithKline (Stiefel), Sanofi-Aventis, and Johnson & Johnson.

ORLANDO - A 0.04% tretinoin microsphere gel pump significantly reduced the number of acne lesions in preteens, based on data from a small pilot study of children aged 9-11 years. The findings were presented in a poster at the Orlando Dermatology Aesthetic & Clinical Conference.

Currently, no drug is approved in the United States for treating acne in children younger than 10 years, noted Dr. Lawrence Eichenfield, chief of pediatric dermatology at the University of California, San Diego, and his colleagues. However, identification and treatment of acne in younger children might prevent more severe acne in adolescence, thus reducing the physical and emotional scars of acne, as well as the financial cost to patients, the researchers wrote.

Dr. Eichenfield and his colleagues randomized 55 children to use either a 0.04% tretinoin microsphere gel (TMG) pump or a placebo pump. Two pumps of the medication or placebo were applied to the face after washing each evening for 12 weeks.

The children had moderate acne (grade III or higher) and a minimum of 30 facial lesions (including a minimum of 20 inflammatory lesions) at baseline, based on the IGA (Investigator's Global Assessment) scale of acne severity. The patients were assessed at baseline and weeks 2, 4, 6, 8, 10, and 12.

At week 12, TMG patients had lesion counts reduced by an average of 44%, compared with 31% in the placebo group. This difference was statistically significant.

In addition, significantly more TMG patients than placebo patients achieved "excellent" results, (26% vs. 13%). More TMG patients than placebo patients achieved "clear" or "almost clear" status based on other scales, but these differences were not significant.

No significant differences in erythema, dryness, peeling, itching, or burning/stinging were observed between the two groups at any of the study visits.

A total of nine children discontinued the study. Of these, four TMG patients and one placebo patient discontinued because of adverse events, two TMG patients were lost to follow-up, and two TMG patients discontinued for personal reasons. The per-protocol study population excluded these 9 patients and 2 additional patients, for a total of 46 patients in the TMG group and 53 in the placebo group.

The findings were limited by the small size of the study. But the results suggest that TMG 0.04% was safe and well tolerated in preteen children with acne, and larger studies are warranted, the researchers said.

The study was sponsored by Johnson & Johnson. Dr. Eichenfield disclosed that he has served as an investigator without personal compensation, a consultant, or an adviser for the following companies: Astellas Pharma, Coria Laboratories, Galderma, Ortho Dermatologics, GlaxoSmithKline (Stiefel), Sanofi-Aventis, and Johnson & Johnson.

ORLANDO - A 0.04% tretinoin microsphere gel pump significantly reduced the number of acne lesions in preteens, based on data from a small pilot study of children aged 9-11 years. The findings were presented in a poster at the Orlando Dermatology Aesthetic & Clinical Conference.

Currently, no drug is approved in the United States for treating acne in children younger than 10 years, noted Dr. Lawrence Eichenfield, chief of pediatric dermatology at the University of California, San Diego, and his colleagues. However, identification and treatment of acne in younger children might prevent more severe acne in adolescence, thus reducing the physical and emotional scars of acne, as well as the financial cost to patients, the researchers wrote.

Dr. Eichenfield and his colleagues randomized 55 children to use either a 0.04% tretinoin microsphere gel (TMG) pump or a placebo pump. Two pumps of the medication or placebo were applied to the face after washing each evening for 12 weeks.

The children had moderate acne (grade III or higher) and a minimum of 30 facial lesions (including a minimum of 20 inflammatory lesions) at baseline, based on the IGA (Investigator's Global Assessment) scale of acne severity. The patients were assessed at baseline and weeks 2, 4, 6, 8, 10, and 12.

At week 12, TMG patients had lesion counts reduced by an average of 44%, compared with 31% in the placebo group. This difference was statistically significant.

In addition, significantly more TMG patients than placebo patients achieved "excellent" results, (26% vs. 13%). More TMG patients than placebo patients achieved "clear" or "almost clear" status based on other scales, but these differences were not significant.

No significant differences in erythema, dryness, peeling, itching, or burning/stinging were observed between the two groups at any of the study visits.

A total of nine children discontinued the study. Of these, four TMG patients and one placebo patient discontinued because of adverse events, two TMG patients were lost to follow-up, and two TMG patients discontinued for personal reasons. The per-protocol study population excluded these 9 patients and 2 additional patients, for a total of 46 patients in the TMG group and 53 in the placebo group.

The findings were limited by the small size of the study. But the results suggest that TMG 0.04% was safe and well tolerated in preteen children with acne, and larger studies are warranted, the researchers said.

The study was sponsored by Johnson & Johnson. Dr. Eichenfield disclosed that he has served as an investigator without personal compensation, a consultant, or an adviser for the following companies: Astellas Pharma, Coria Laboratories, Galderma, Ortho Dermatologics, GlaxoSmithKline (Stiefel), Sanofi-Aventis, and Johnson & Johnson.

ORLANDO – A 0.04% tretinoin microsphere gel pump significantly reduced the number of acne lesions in preteens, based on data from a small pilot study of children aged 9-11 years. The findings were presented in a poster at the Orlando Dermatology Aesthetic & Clinical Conference.

Currently, no drug is approved in the United States for treating acne in children younger than 10 years, noted Dr. Lawrence Eichenfield, chief of pediatric dermatology at the University of California, San Diego, and his colleagues. However, identification and treatment of acne in younger children might prevent more severe acne in adolescence, thus reducing the physical and emotional scars of acne, as well as the financial cost to patients, the researchers wrote.

Dr. Eichenfield and his colleagues randomized 55 children to use either a 0.04% tretinoin microsphere gel (TMG) pump or a placebo pump. Two pumps of the medication or placebo were applied to the face after washing each evening for 12 weeks.

The children had moderate acne (grade III or higher) and a minimum of 30 facial lesions (including a minimum of 20 inflammatory lesions) at baseline, based on the IGA (Investigator’s Global Assessment) scale of acne severity. The patients were assessed at baseline and weeks 2, 4, 6, 8, 10, and 12.

At week 12, TMG patients had lesion counts reduced by an average of 44%, compared with 31% in the placebo group. This difference was statistically significant.

In addition, significantly more TMG patients than placebo patients achieved "excellent" results, (26% vs. 13%). More TMG patients than placebo patients achieved "clear" or "almost clear" status based on other scales, but these differences were not significant.

No significant differences in erythema, dryness, peeling, itching, or burning/stinging were observed between the two groups at any of the study visits.

A total of nine children discontinued the study. Of these, four TMG patients and one placebo patient discontinued because of adverse events, two TMG patients were lost to follow-up, and two TMG patients discontinued for personal reasons. The per-protocol study population excluded these 9 patients and 2 additional patients, for a total of 46 patients in the TMG group and 53 in the placebo group.

The findings were limited by the small size of the study. But the results suggest that TMG 0.04% was safe and well tolerated in preteen children with acne, and larger studies are warranted, the researchers said.

The study was sponsored by Johnson & Johnson. Dr. Eichenfield disclosed that he has served as an investigator without personal compensation, a consultant, or an adviser for the following companies: Astellas Pharma, Coria Laboratories, Galderma, Ortho Dermatologics, GlaxoSmithKline (Stiefel), Sanofi-Aventis, and Johnson & Johnson.

ORLANDO – A 0.04% tretinoin microsphere gel pump significantly reduced the number of acne lesions in preteens, based on data from a small pilot study of children aged 9-11 years. The findings were presented in a poster at the Orlando Dermatology Aesthetic & Clinical Conference.

Currently, no drug is approved in the United States for treating acne in children younger than 10 years, noted Dr. Lawrence Eichenfield, chief of pediatric dermatology at the University of California, San Diego, and his colleagues. However, identification and treatment of acne in younger children might prevent more severe acne in adolescence, thus reducing the physical and emotional scars of acne, as well as the financial cost to patients, the researchers wrote.

Dr. Eichenfield and his colleagues randomized 55 children to use either a 0.04% tretinoin microsphere gel (TMG) pump or a placebo pump. Two pumps of the medication or placebo were applied to the face after washing each evening for 12 weeks.

The children had moderate acne (grade III or higher) and a minimum of 30 facial lesions (including a minimum of 20 inflammatory lesions) at baseline, based on the IGA (Investigator’s Global Assessment) scale of acne severity. The patients were assessed at baseline and weeks 2, 4, 6, 8, 10, and 12.

At week 12, TMG patients had lesion counts reduced by an average of 44%, compared with 31% in the placebo group. This difference was statistically significant.

In addition, significantly more TMG patients than placebo patients achieved "excellent" results, (26% vs. 13%). More TMG patients than placebo patients achieved "clear" or "almost clear" status based on other scales, but these differences were not significant.

No significant differences in erythema, dryness, peeling, itching, or burning/stinging were observed between the two groups at any of the study visits.

A total of nine children discontinued the study. Of these, four TMG patients and one placebo patient discontinued because of adverse events, two TMG patients were lost to follow-up, and two TMG patients discontinued for personal reasons. The per-protocol study population excluded these 9 patients and 2 additional patients, for a total of 46 patients in the TMG group and 53 in the placebo group.

The findings were limited by the small size of the study. But the results suggest that TMG 0.04% was safe and well tolerated in preteen children with acne, and larger studies are warranted, the researchers said.

The study was sponsored by Johnson & Johnson. Dr. Eichenfield disclosed that he has served as an investigator without personal compensation, a consultant, or an adviser for the following companies: Astellas Pharma, Coria Laboratories, Galderma, Ortho Dermatologics, GlaxoSmithKline (Stiefel), Sanofi-Aventis, and Johnson & Johnson.

ORLANDO – A 0.04% tretinoin microsphere gel pump significantly reduced the number of acne lesions in preteens, based on data from a small pilot study of children aged 9-11 years. The findings were presented in a poster at the Orlando Dermatology Aesthetic & Clinical Conference.

Currently, no drug is approved in the United States for treating acne in children younger than 10 years, noted Dr. Lawrence Eichenfield, chief of pediatric dermatology at the University of California, San Diego, and his colleagues. However, identification and treatment of acne in younger children might prevent more severe acne in adolescence, thus reducing the physical and emotional scars of acne, as well as the financial cost to patients, the researchers wrote.

Dr. Eichenfield and his colleagues randomized 55 children to use either a 0.04% tretinoin microsphere gel (TMG) pump or a placebo pump. Two pumps of the medication or placebo were applied to the face after washing each evening for 12 weeks.

The children had moderate acne (grade III or higher) and a minimum of 30 facial lesions (including a minimum of 20 inflammatory lesions) at baseline, based on the IGA (Investigator’s Global Assessment) scale of acne severity. The patients were assessed at baseline and weeks 2, 4, 6, 8, 10, and 12.

At week 12, TMG patients had lesion counts reduced by an average of 44%, compared with 31% in the placebo group. This difference was statistically significant.

In addition, significantly more TMG patients than placebo patients achieved "excellent" results, (26% vs. 13%). More TMG patients than placebo patients achieved "clear" or "almost clear" status based on other scales, but these differences were not significant.

No significant differences in erythema, dryness, peeling, itching, or burning/stinging were observed between the two groups at any of the study visits.

A total of nine children discontinued the study. Of these, four TMG patients and one placebo patient discontinued because of adverse events, two TMG patients were lost to follow-up, and two TMG patients discontinued for personal reasons. The per-protocol study population excluded these 9 patients and 2 additional patients, for a total of 46 patients in the TMG group and 53 in the placebo group.

The findings were limited by the small size of the study. But the results suggest that TMG 0.04% was safe and well tolerated in preteen children with acne, and larger studies are warranted, the researchers said.

The study was sponsored by Johnson & Johnson. Dr. Eichenfield disclosed that he has served as an investigator without personal compensation, a consultant, or an adviser for the following companies: Astellas Pharma, Coria Laboratories, Galderma, Ortho Dermatologics, GlaxoSmithKline (Stiefel), Sanofi-Aventis, and Johnson & Johnson.

ORLANDO – Mohs surgery is an appropriate choice for lentigo maligna patients because advances in immunostaining allow easier and more efficient identification of melanocytes on frozen sections, said Dr. Basil S. Cherpelis.

Recent literature shows the recommended 5-mm margin for melanoma is often inadequate, Dr. Cherpelis said at the Orlando Dermatology Aesthetic and Clinical conference.

The margins needed for successful treatment of lentigo maligna vary – 5 mm is enough for some melanomas, while others might need a 1-cm margin.

"It makes sense to use a method of intraoperative margin control," said Dr. Cherpelis, of the Moffitt Cancer Center at the University of South Florida in Tampa. "That’s what gives you the flexibility to adjust your margins based on the melanoma that you happen to be treating."

One option for intraoperative margin control is traditional frozen sections, Dr. Cherpelis said. But frozen sections offer a limited view of the margin, and they pose the problem of freeze artifacts, which can make the distinction between melanocytes and keratinocytes difficult. A second option is the square or perimeter method, but this method involves a 1-2 week wait for complete results, which is inconvenient for doctors and patients.

A third option is Mohs surgery. Literature shows that Mohs is effective for melanoma, with the benefits of entire visualization and same-day reconstruction, but it is not widely used, Dr. Cherpelis said. One reason: Melanomas on permanent sections have halos around them, making identification easy, but frozen sections have similar halos around keratinocytes and melanocytes.

Using immunostaining as part of Mohs surgery can solve the identification problem, but until recently immunostain protocols could take at least an hour.

Dr. Cherpelis and his colleagues have streamlined the process.

"We have been able to shorten our protocols down to 19 minutes for MART-1 [melanoma-associated antigen recognized by T cells] and 35 minutes for MITF [microphthalmia-associated transcription factor]," Dr. Cherpelis said (Derm. Surg. 2009;35:207-13; Am. J. Dermatopath. 2010; 32:319-25, respectively). The protocols make Mohs surgery easier because the immunostain helps clinicians easily identify melanocytes.

MART-1 (a cytoplasmic stain) is the most common immunostain, but some data suggest it can falsely label keratinocytes in inflamed skin or in pigmented actinic keratoses, Dr. Cherpelis said. It also can cause pseudo-confluence (the appearance of touching melanocytes). By contrast, MITF is a nuclear stain, so it does not have the problem of pseudo-confluence.

Dr. Cherpelis said he had no relevant financial disclosures.

ORLANDO – Mohs surgery is an appropriate choice for lentigo maligna patients because advances in immunostaining allow easier and more efficient identification of melanocytes on frozen sections, said Dr. Basil S. Cherpelis.

Recent literature shows the recommended 5-mm margin for melanoma is often inadequate, Dr. Cherpelis said at the Orlando Dermatology Aesthetic and Clinical conference.

The margins needed for successful treatment of lentigo maligna vary – 5 mm is enough for some melanomas, while others might need a 1-cm margin.

"It makes sense to use a method of intraoperative margin control," said Dr. Cherpelis, of the Moffitt Cancer Center at the University of South Florida in Tampa. "That’s what gives you the flexibility to adjust your margins based on the melanoma that you happen to be treating."

One option for intraoperative margin control is traditional frozen sections, Dr. Cherpelis said. But frozen sections offer a limited view of the margin, and they pose the problem of freeze artifacts, which can make the distinction between melanocytes and keratinocytes difficult. A second option is the square or perimeter method, but this method involves a 1-2 week wait for complete results, which is inconvenient for doctors and patients.

A third option is Mohs surgery. Literature shows that Mohs is effective for melanoma, with the benefits of entire visualization and same-day reconstruction, but it is not widely used, Dr. Cherpelis said. One reason: Melanomas on permanent sections have halos around them, making identification easy, but frozen sections have similar halos around keratinocytes and melanocytes.

Using immunostaining as part of Mohs surgery can solve the identification problem, but until recently immunostain protocols could take at least an hour.

Dr. Cherpelis and his colleagues have streamlined the process.

"We have been able to shorten our protocols down to 19 minutes for MART-1 [melanoma-associated antigen recognized by T cells] and 35 minutes for MITF [microphthalmia-associated transcription factor]," Dr. Cherpelis said (Derm. Surg. 2009;35:207-13; Am. J. Dermatopath. 2010; 32:319-25, respectively). The protocols make Mohs surgery easier because the immunostain helps clinicians easily identify melanocytes.

MART-1 (a cytoplasmic stain) is the most common immunostain, but some data suggest it can falsely label keratinocytes in inflamed skin or in pigmented actinic keratoses, Dr. Cherpelis said. It also can cause pseudo-confluence (the appearance of touching melanocytes). By contrast, MITF is a nuclear stain, so it does not have the problem of pseudo-confluence.

Dr. Cherpelis said he had no relevant financial disclosures.

ORLANDO – Mohs surgery is an appropriate choice for lentigo maligna patients because advances in immunostaining allow easier and more efficient identification of melanocytes on frozen sections, said Dr. Basil S. Cherpelis.

Recent literature shows the recommended 5-mm margin for melanoma is often inadequate, Dr. Cherpelis said at the Orlando Dermatology Aesthetic and Clinical conference.

The margins needed for successful treatment of lentigo maligna vary – 5 mm is enough for some melanomas, while others might need a 1-cm margin.

"It makes sense to use a method of intraoperative margin control," said Dr. Cherpelis, of the Moffitt Cancer Center at the University of South Florida in Tampa. "That’s what gives you the flexibility to adjust your margins based on the melanoma that you happen to be treating."

One option for intraoperative margin control is traditional frozen sections, Dr. Cherpelis said. But frozen sections offer a limited view of the margin, and they pose the problem of freeze artifacts, which can make the distinction between melanocytes and keratinocytes difficult. A second option is the square or perimeter method, but this method involves a 1-2 week wait for complete results, which is inconvenient for doctors and patients.

A third option is Mohs surgery. Literature shows that Mohs is effective for melanoma, with the benefits of entire visualization and same-day reconstruction, but it is not widely used, Dr. Cherpelis said. One reason: Melanomas on permanent sections have halos around them, making identification easy, but frozen sections have similar halos around keratinocytes and melanocytes.

Using immunostaining as part of Mohs surgery can solve the identification problem, but until recently immunostain protocols could take at least an hour.

Dr. Cherpelis and his colleagues have streamlined the process.

"We have been able to shorten our protocols down to 19 minutes for MART-1 [melanoma-associated antigen recognized by T cells] and 35 minutes for MITF [microphthalmia-associated transcription factor]," Dr. Cherpelis said (Derm. Surg. 2009;35:207-13; Am. J. Dermatopath. 2010; 32:319-25, respectively). The protocols make Mohs surgery easier because the immunostain helps clinicians easily identify melanocytes.

MART-1 (a cytoplasmic stain) is the most common immunostain, but some data suggest it can falsely label keratinocytes in inflamed skin or in pigmented actinic keratoses, Dr. Cherpelis said. It also can cause pseudo-confluence (the appearance of touching melanocytes). By contrast, MITF is a nuclear stain, so it does not have the problem of pseudo-confluence.

Dr. Cherpelis said he had no relevant financial disclosures.

ORLANDO – Mohs surgery is an appropriate choice for lentigo maligna patients because advances in immunostaining allow easier and more efficient identification of melanocytes on frozen sections, said Dr. Basil S. Cherpelis.

Recent literature shows the recommended 5-mm margin for melanoma is often inadequate, Dr. Cherpelis said at the Orlando Dermatology Aesthetic and Clinical conference.

The margins needed for successful treatment of lentigo maligna vary – 5 mm is enough for some melanomas, while others might need a 1-cm margin.

"It makes sense to use a method of intraoperative margin control," said Dr. Cherpelis, of the Moffitt Cancer Center at the University of South Florida in Tampa. "That’s what gives you the flexibility to adjust your margins based on the melanoma that you happen to be treating."

One option for intraoperative margin control is traditional frozen sections, Dr. Cherpelis said. But frozen sections offer a limited view of the margin, and they pose the problem of freeze artifacts, which can make the distinction between melanocytes and keratinocytes difficult. A second option is the square or perimeter method, but this method involves a 1-2 week wait for complete results, which is inconvenient for doctors and patients.

A third option is Mohs surgery. Literature shows that Mohs is effective for melanoma, with the benefits of entire visualization and same-day reconstruction, but it is not widely used, Dr. Cherpelis said. One reason: Melanomas on permanent sections have halos around them, making identification easy, but frozen sections have similar halos around keratinocytes and melanocytes.

Using immunostaining as part of Mohs surgery can solve the identification problem, but until recently immunostain protocols could take at least an hour.

Dr. Cherpelis and his colleagues have streamlined the process.

"We have been able to shorten our protocols down to 19 minutes for MART-1 [melanoma-associated antigen recognized by T cells] and 35 minutes for MITF [microphthalmia-associated transcription factor]," Dr. Cherpelis said (Derm. Surg. 2009;35:207-13; Am. J. Dermatopath. 2010; 32:319-25, respectively). The protocols make Mohs surgery easier because the immunostain helps clinicians easily identify melanocytes.

MART-1 (a cytoplasmic stain) is the most common immunostain, but some data suggest it can falsely label keratinocytes in inflamed skin or in pigmented actinic keratoses, Dr. Cherpelis said. It also can cause pseudo-confluence (the appearance of touching melanocytes). By contrast, MITF is a nuclear stain, so it does not have the problem of pseudo-confluence.

Dr. Cherpelis said he had no relevant financial disclosures.

ORLANDO – Mohs surgery is an appropriate choice for lentigo maligna patients because advances in immunostaining allow easier and more efficient identification of melanocytes on frozen sections, said Dr. Basil S. Cherpelis.

Recent literature shows the recommended 5-mm margin for melanoma is often inadequate, Dr. Cherpelis said at the Orlando Dermatology Aesthetic and Clinical conference.

The margins needed for successful treatment of lentigo maligna vary – 5 mm is enough for some melanomas, while others might need a 1-cm margin.

"It makes sense to use a method of intraoperative margin control," said Dr. Cherpelis, of the Moffitt Cancer Center at the University of South Florida in Tampa. "That’s what gives you the flexibility to adjust your margins based on the melanoma that you happen to be treating."

One option for intraoperative margin control is traditional frozen sections, Dr. Cherpelis said. But frozen sections offer a limited view of the margin, and they pose the problem of freeze artifacts, which can make the distinction between melanocytes and keratinocytes difficult. A second option is the square or perimeter method, but this method involves a 1-2 week wait for complete results, which is inconvenient for doctors and patients.

A third option is Mohs surgery. Literature shows that Mohs is effective for melanoma, with the benefits of entire visualization and same-day reconstruction, but it is not widely used, Dr. Cherpelis said. One reason: Melanomas on permanent sections have halos around them, making identification easy, but frozen sections have similar halos around keratinocytes and melanocytes.

Using immunostaining as part of Mohs surgery can solve the identification problem, but until recently immunostain protocols could take at least an hour.

Dr. Cherpelis and his colleagues have streamlined the process.

"We have been able to shorten our protocols down to 19 minutes for MART-1 [melanoma-associated antigen recognized by T cells] and 35 minutes for MITF [microphthalmia-associated transcription factor]," Dr. Cherpelis said (Derm. Surg. 2009;35:207-13; Am. J. Dermatopath. 2010; 32:319-25, respectively). The protocols make Mohs surgery easier because the immunostain helps clinicians easily identify melanocytes.

MART-1 (a cytoplasmic stain) is the most common immunostain, but some data suggest it can falsely label keratinocytes in inflamed skin or in pigmented actinic keratoses, Dr. Cherpelis said. It also can cause pseudo-confluence (the appearance of touching melanocytes). By contrast, MITF is a nuclear stain, so it does not have the problem of pseudo-confluence.

Dr. Cherpelis said he had no relevant financial disclosures.

ORLANDO – Mohs surgery is an appropriate choice for lentigo maligna patients because advances in immunostaining allow easier and more efficient identification of melanocytes on frozen sections, said Dr. Basil S. Cherpelis.

Recent literature shows the recommended 5-mm margin for melanoma is often inadequate, Dr. Cherpelis said at the Orlando Dermatology Aesthetic and Clinical conference.

The margins needed for successful treatment of lentigo maligna vary – 5 mm is enough for some melanomas, while others might need a 1-cm margin.

"It makes sense to use a method of intraoperative margin control," said Dr. Cherpelis, of the Moffitt Cancer Center at the University of South Florida in Tampa. "That’s what gives you the flexibility to adjust your margins based on the melanoma that you happen to be treating."

One option for intraoperative margin control is traditional frozen sections, Dr. Cherpelis said. But frozen sections offer a limited view of the margin, and they pose the problem of freeze artifacts, which can make the distinction between melanocytes and keratinocytes difficult. A second option is the square or perimeter method, but this method involves a 1-2 week wait for complete results, which is inconvenient for doctors and patients.

A third option is Mohs surgery. Literature shows that Mohs is effective for melanoma, with the benefits of entire visualization and same-day reconstruction, but it is not widely used, Dr. Cherpelis said. One reason: Melanomas on permanent sections have halos around them, making identification easy, but frozen sections have similar halos around keratinocytes and melanocytes.

Using immunostaining as part of Mohs surgery can solve the identification problem, but until recently immunostain protocols could take at least an hour.

Dr. Cherpelis and his colleagues have streamlined the process.

"We have been able to shorten our protocols down to 19 minutes for MART-1 [melanoma-associated antigen recognized by T cells] and 35 minutes for MITF [microphthalmia-associated transcription factor]," Dr. Cherpelis said (Derm. Surg. 2009;35:207-13; Am. J. Dermatopath. 2010; 32:319-25, respectively). The protocols make Mohs surgery easier because the immunostain helps clinicians easily identify melanocytes.

MART-1 (a cytoplasmic stain) is the most common immunostain, but some data suggest it can falsely label keratinocytes in inflamed skin or in pigmented actinic keratoses, Dr. Cherpelis said. It also can cause pseudo-confluence (the appearance of touching melanocytes). By contrast, MITF is a nuclear stain, so it does not have the problem of pseudo-confluence.

Dr. Cherpelis said he had no relevant financial disclosures.

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 on Feb. 1.

"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 the 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 on Feb. 1.

"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 the 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 on Feb. 1.

"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 the 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).