Heidi Splete

WASHINGTON — Develop a unique cataloging system for digital images to make tracking and retrieving patient information quicker and easier, Dr. Clinton Humphrey said at the annual fall meeting of the American Academy for Facial Plastic and Reconstructive Surgery.

A strategy to manage digital images—including video footage and illustrations—helps physicians find photos to use for preoperative planning, for reference during surgery, and for patient education, said Dr. Humphrey, an otolaryngologist at the University of Kansas Medical Center in Kansas City.

Efficient image management also makes it easier to choose photos for academic publications or presentations. And digital images can serve as legal evidence, he added.

Digital asset management involves naming files, placing them in archiving software, and categorizing them so they can be tracked and retrieved. Categorization is the most important step in the process, and the most effective way to categorize digital files is by using metadata, Dr. Humphrey said.

Metadata is information embedded in an image file or other software file. It was pioneered as a digital asset management tool by professional photographers, but it works for anyone who needs to manage a large volume of digital images.

Be sure to employ user-assigned metadata (known as IPTC), which will follow photos across different computer programs and software, Dr. Humphrey said. The IPTC metadata lets users embed information about diagnoses, procedures, and other details. IPTC stands for International Press Telecommunications Council, a European-based consortium of major news agencies that maintains technical standards for news and information exchange.

By contrast, another form of metadata, called Exif (Exchangeable Image File Format), is automatically assigned by the digital imaging software in the camera and includes the type of camera, the camera settings, and the date the photo was taken.

This information is of limited use to physicians because it doesn't allow many keywords when naming a file that has been downloaded. Also, the information may not transfer across to other software programs.

When naming a file using metadata, certain rules apply, Dr. Humphrey said.

"The file name needs to be original so you never use the same name twice," he said. In his practice, a digital image is identified by the surgeon's initials, followed by the date of the photo with the year first (to store the files sequentially), followed by text.

For an IPTC file to be universally compatible across different software platforms, it must have fewer than 36 characters. Underscores and dashes can be used to separate words, but spaces can't be used in file names. "And you want a system that makes backup automatic," he said.

"Although metadata is valuable, it is only as good as what you put in," Dr. Humphrey said. "You need to use a very closed vocabulary when you assign your keywords and use the same terms when you describe a diagnosis or procedure each time."

Scrutinize the digital imaging software. "Some of the most popular programs used in our survey don't support the IPTC standard data and so they will wipe out metadata once the files are imported," he said.

To evaluate trends in digital asset management among plastic surgeons, Dr. Humphrey and his fellow colleagues surveyed 255 practices, more than half of which were more than 10 years old. Their responses showed a steady conversion to digital photography since 1996, he said.

The results showed that the average facial plastic surgeon took more than 100 photos each week. The survey also showed that nearly one-third of respondents did not have a file management strategy or were not familiar with the file management strategies in their digital imaging software programs. No single method prevailed for archiving images, and there was no standard level of image resolution.

"The biggest problems we saw in the survey were inconsistent file-naming strategies and underutilization of metadata," Dr. Humphrey said.

Based on their conducted research, the investigators recommend a digital management strategy that includes assigning metadata in the form of keywords that provide information about diagnoses and procedures.

"We think metadata will make your images more accessible and retrievable and assure compatibility if you switch software programs," he said.

For more detailed information about digital asset management, visit www.iptc.org

Another useful resource is "The DAM Book: Digital Asset Management for Photographers" (San Francisco: O'Reilly Media, 2005) by Peter Krogh, a professional photographer and recognized expert in digital asset management, Dr. Humphrey said.

WASHINGTON — Develop a unique cataloging system for digital images to make tracking and retrieving patient information quicker and easier, Dr. Clinton Humphrey said at the annual fall meeting of the American Academy for Facial Plastic and Reconstructive Surgery.

A strategy to manage digital images—including video footage and illustrations—helps physicians find photos to use for preoperative planning, for reference during surgery, and for patient education, said Dr. Humphrey, an otolaryngologist at the University of Kansas Medical Center in Kansas City.

Efficient image management also makes it easier to choose photos for academic publications or presentations. And digital images can serve as legal evidence, he added.

Digital asset management involves naming files, placing them in archiving software, and categorizing them so they can be tracked and retrieved. Categorization is the most important step in the process, and the most effective way to categorize digital files is by using metadata, Dr. Humphrey said.

Metadata is information embedded in an image file or other software file. It was pioneered as a digital asset management tool by professional photographers, but it works for anyone who needs to manage a large volume of digital images.

Be sure to employ user-assigned metadata (known as IPTC), which will follow photos across different computer programs and software, Dr. Humphrey said. The IPTC metadata lets users embed information about diagnoses, procedures, and other details. IPTC stands for International Press Telecommunications Council, a European-based consortium of major news agencies that maintains technical standards for news and information exchange.

By contrast, another form of metadata, called Exif (Exchangeable Image File Format), is automatically assigned by the digital imaging software in the camera and includes the type of camera, the camera settings, and the date the photo was taken.

This information is of limited use to physicians because it doesn't allow many keywords when naming a file that has been downloaded. Also, the information may not transfer across to other software programs.

When naming a file using metadata, certain rules apply, Dr. Humphrey said.

"The file name needs to be original so you never use the same name twice," he said. In his practice, a digital image is identified by the surgeon's initials, followed by the date of the photo with the year first (to store the files sequentially), followed by text.

For an IPTC file to be universally compatible across different software platforms, it must have fewer than 36 characters. Underscores and dashes can be used to separate words, but spaces can't be used in file names. "And you want a system that makes backup automatic," he said.

"Although metadata is valuable, it is only as good as what you put in," Dr. Humphrey said. "You need to use a very closed vocabulary when you assign your keywords and use the same terms when you describe a diagnosis or procedure each time."

Scrutinize the digital imaging software. "Some of the most popular programs used in our survey don't support the IPTC standard data and so they will wipe out metadata once the files are imported," he said.

To evaluate trends in digital asset management among plastic surgeons, Dr. Humphrey and his fellow colleagues surveyed 255 practices, more than half of which were more than 10 years old. Their responses showed a steady conversion to digital photography since 1996, he said.

The results showed that the average facial plastic surgeon took more than 100 photos each week. The survey also showed that nearly one-third of respondents did not have a file management strategy or were not familiar with the file management strategies in their digital imaging software programs. No single method prevailed for archiving images, and there was no standard level of image resolution.

"The biggest problems we saw in the survey were inconsistent file-naming strategies and underutilization of metadata," Dr. Humphrey said.

Based on their conducted research, the investigators recommend a digital management strategy that includes assigning metadata in the form of keywords that provide information about diagnoses and procedures.

"We think metadata will make your images more accessible and retrievable and assure compatibility if you switch software programs," he said.

For more detailed information about digital asset management, visit www.iptc.org

Another useful resource is "The DAM Book: Digital Asset Management for Photographers" (San Francisco: O'Reilly Media, 2005) by Peter Krogh, a professional photographer and recognized expert in digital asset management, Dr. Humphrey said.

WASHINGTON — Develop a unique cataloging system for digital images to make tracking and retrieving patient information quicker and easier, Dr. Clinton Humphrey said at the annual fall meeting of the American Academy for Facial Plastic and Reconstructive Surgery.

A strategy to manage digital images—including video footage and illustrations—helps physicians find photos to use for preoperative planning, for reference during surgery, and for patient education, said Dr. Humphrey, an otolaryngologist at the University of Kansas Medical Center in Kansas City.

Efficient image management also makes it easier to choose photos for academic publications or presentations. And digital images can serve as legal evidence, he added.

Digital asset management involves naming files, placing them in archiving software, and categorizing them so they can be tracked and retrieved. Categorization is the most important step in the process, and the most effective way to categorize digital files is by using metadata, Dr. Humphrey said.

Metadata is information embedded in an image file or other software file. It was pioneered as a digital asset management tool by professional photographers, but it works for anyone who needs to manage a large volume of digital images.

Be sure to employ user-assigned metadata (known as IPTC), which will follow photos across different computer programs and software, Dr. Humphrey said. The IPTC metadata lets users embed information about diagnoses, procedures, and other details. IPTC stands for International Press Telecommunications Council, a European-based consortium of major news agencies that maintains technical standards for news and information exchange.

By contrast, another form of metadata, called Exif (Exchangeable Image File Format), is automatically assigned by the digital imaging software in the camera and includes the type of camera, the camera settings, and the date the photo was taken.

This information is of limited use to physicians because it doesn't allow many keywords when naming a file that has been downloaded. Also, the information may not transfer across to other software programs.

When naming a file using metadata, certain rules apply, Dr. Humphrey said.

"The file name needs to be original so you never use the same name twice," he said. In his practice, a digital image is identified by the surgeon's initials, followed by the date of the photo with the year first (to store the files sequentially), followed by text.

For an IPTC file to be universally compatible across different software platforms, it must have fewer than 36 characters. Underscores and dashes can be used to separate words, but spaces can't be used in file names. "And you want a system that makes backup automatic," he said.

"Although metadata is valuable, it is only as good as what you put in," Dr. Humphrey said. "You need to use a very closed vocabulary when you assign your keywords and use the same terms when you describe a diagnosis or procedure each time."

Scrutinize the digital imaging software. "Some of the most popular programs used in our survey don't support the IPTC standard data and so they will wipe out metadata once the files are imported," he said.

To evaluate trends in digital asset management among plastic surgeons, Dr. Humphrey and his fellow colleagues surveyed 255 practices, more than half of which were more than 10 years old. Their responses showed a steady conversion to digital photography since 1996, he said.

The results showed that the average facial plastic surgeon took more than 100 photos each week. The survey also showed that nearly one-third of respondents did not have a file management strategy or were not familiar with the file management strategies in their digital imaging software programs. No single method prevailed for archiving images, and there was no standard level of image resolution.

"The biggest problems we saw in the survey were inconsistent file-naming strategies and underutilization of metadata," Dr. Humphrey said.

Based on their conducted research, the investigators recommend a digital management strategy that includes assigning metadata in the form of keywords that provide information about diagnoses and procedures.

"We think metadata will make your images more accessible and retrievable and assure compatibility if you switch software programs," he said.

For more detailed information about digital asset management, visit www.iptc.org

Another useful resource is "The DAM Book: Digital Asset Management for Photographers" (San Francisco: O'Reilly Media, 2005) by Peter Krogh, a professional photographer and recognized expert in digital asset management, Dr. Humphrey said.

CHICAGO — Bone density was no different in children who were treated with oral glucocorticoids for hemangiomas of infancy than it was in healthy controls, based on data presented in a poster at the annual meeting of the Society for Pediatric Dermatology.

Although oral glucocorticoids are considered the first choice of medication for the treatment of infant hemangiomas, concerns persist about the risk that these children will develop osteoporosis because glucocorticoids may prevent the formation of new bone, wrote Dr. Amy J. Nopper, a dermatologist at the Children's Mercy Hospitals and Clinics in Kansas City, Mo.

To assess the possible impact of systemic glucocorticoids on the density of children's bones, Dr. Nopper and her colleagues compared 35 children (mean age 44 months) who received glucocorticoids for hemangiomas for an average of 8.5 months with 35 controls.

The average treatment dose was 2.2 mg/kg per day of prednisolone. The average body mass index was approximately 16 kg/m2 for both the treatment and control groups.

The researchers measured the children's bone density after they had been off treatment for a period of at least 1 year. The results showed that the average spinal bone mineral density was the same (0.6 g/m2) for both the treatment and control groups. The average total bone mineral density also was the same for both groups of children (0.8 g/m2), and no significant differences appeared in the tibial ultrasound measurements between the two groups.

The results complement findings from other studies that have shown that the use of corticosteroids for the treatment of hemangiomas in early childhood does not prevent children from catching up in growth and achieving normal adult height, noted Dr. Nopper.

CHICAGO — Bone density was no different in children who were treated with oral glucocorticoids for hemangiomas of infancy than it was in healthy controls, based on data presented in a poster at the annual meeting of the Society for Pediatric Dermatology.

Although oral glucocorticoids are considered the first choice of medication for the treatment of infant hemangiomas, concerns persist about the risk that these children will develop osteoporosis because glucocorticoids may prevent the formation of new bone, wrote Dr. Amy J. Nopper, a dermatologist at the Children's Mercy Hospitals and Clinics in Kansas City, Mo.

To assess the possible impact of systemic glucocorticoids on the density of children's bones, Dr. Nopper and her colleagues compared 35 children (mean age 44 months) who received glucocorticoids for hemangiomas for an average of 8.5 months with 35 controls.

The average treatment dose was 2.2 mg/kg per day of prednisolone. The average body mass index was approximately 16 kg/m2 for both the treatment and control groups.

The researchers measured the children's bone density after they had been off treatment for a period of at least 1 year. The results showed that the average spinal bone mineral density was the same (0.6 g/m2) for both the treatment and control groups. The average total bone mineral density also was the same for both groups of children (0.8 g/m2), and no significant differences appeared in the tibial ultrasound measurements between the two groups.

The results complement findings from other studies that have shown that the use of corticosteroids for the treatment of hemangiomas in early childhood does not prevent children from catching up in growth and achieving normal adult height, noted Dr. Nopper.

CHICAGO — Bone density was no different in children who were treated with oral glucocorticoids for hemangiomas of infancy than it was in healthy controls, based on data presented in a poster at the annual meeting of the Society for Pediatric Dermatology.

Although oral glucocorticoids are considered the first choice of medication for the treatment of infant hemangiomas, concerns persist about the risk that these children will develop osteoporosis because glucocorticoids may prevent the formation of new bone, wrote Dr. Amy J. Nopper, a dermatologist at the Children's Mercy Hospitals and Clinics in Kansas City, Mo.

To assess the possible impact of systemic glucocorticoids on the density of children's bones, Dr. Nopper and her colleagues compared 35 children (mean age 44 months) who received glucocorticoids for hemangiomas for an average of 8.5 months with 35 controls.

The average treatment dose was 2.2 mg/kg per day of prednisolone. The average body mass index was approximately 16 kg/m2 for both the treatment and control groups.

The researchers measured the children's bone density after they had been off treatment for a period of at least 1 year. The results showed that the average spinal bone mineral density was the same (0.6 g/m2) for both the treatment and control groups. The average total bone mineral density also was the same for both groups of children (0.8 g/m2), and no significant differences appeared in the tibial ultrasound measurements between the two groups.

The results complement findings from other studies that have shown that the use of corticosteroids for the treatment of hemangiomas in early childhood does not prevent children from catching up in growth and achieving normal adult height, noted Dr. Nopper.

CHICAGO — A treatment plan for infants and children with large and giant nevi must satisfy concerns about malignancy while optimizing aesthetic and functional outcomes for the patient, Dr. Bruce Bauer said at the annual meeting of the Society for Pediatric Dermatology.

"Conducting a critical assessment of a large or giant nevus in a child and choosing the appropriate procedures as early as possible will reduce the total number of surgeries and the need for complex surgery later on to deal with potential complications caused by scarring," noted Dr. Bauer, a pediatric plastic surgeon and chief of plastic surgery at Children's Memorial Hospital, Chicago, who specializes in the treatment of large and giant congenital nevi.

Each child and each tissue heal differently, and some surgeries are easier and more effective at earlier ages than later, he added.

Although various classifications for nevi exist in the medical literature, a nevus larger than 20 cm in a child is usually considered a giant nevus, and a nevus that is 11–20 cm is considered large. In general, patients with large or giant nevi are at the greatest risk for malignant change, but size doesn't guarantee malignancy. The overall incidence of cutaneous or extracutaneous melanoma in patients with large or giant nevi is between 4.5% and 10%, said Dr. Bauer, and controversies persist about the medical necessity of plastic surgery to manage the nevi.

"The exact risk of malignant change in congenital melanocytic nevi may never be determined," Dr. Bauer acknowledged. "The managing physician or surgeon must develop a treatment philosophy based on an understanding of pertinent studies."

The primary rationales for excision of large or giant nevi are a concern for malignancy and a desire for an improved appearance. Some patients and physicians may decide that the risk of malignancy is too small to warrant the potentially extensive scarring or unsightly skin grafts needed to excise a large or giant nevus. But for those who make the decision in favor of excision, the sooner the better, Dr. Bauer said.

If the excision is performed in infancy or early childhood, the tissue is more flexible and heals more smoothly and rapidly. The psychological benefits and generally good patient tolerance also tip the scales in favor of early excision.

Tissue expansion—in which skin adjacent to the nevus is stretched, with both stretch and new cell growth occurring—provides the added tissue needed to cover the area from which the nevus has been excised, and is now one of the most powerful tools available in the treatment of these extensive lesions. The ability to expand tissue of similar skin characteristics to the involved area allows expansion of hair-bearing scalp to replace a scalp nevus, and non-hair-bearing skin to replace nevi in all other areas.

Dr. Bauer shared some elements of his surgical approach to large and giant congenital nevi the following areas of the body:

▸ Scalp/forehead. Tissue expansion is the preferred method for treatment of large and giant nevi of the scalp and forehead, and has become the standard of care. Expansion may begin when the patient is as young as 6 months of age without long-term effects on the growing skull. In addition, the use of transposition flaps yields a more natural hairline reconstruction.

Good flap planning can reduce the need for repeated tissue expansion procedures, Dr. Bauer noted. Combined expansion of scalp and forehead for nevi that cover both areas will also reduce the number of surgical procedures needed to excise the nevus and reconstruct the defect. In rare cases in which minimal normal forehead skin is available, free tissue transfer can be considered, with expansion used at the distant donor sites to allow harvest of a large, microvascular free flap, with primary closure of the donor site, he explained.

▸ Midface/periorbital region. Tissue expansion can be used for large and giant nevi on the forehead, neck, and cheek, and large expanded full-thickness skin grafts may provide color-compatible coverage for the periorbital and nasal area in a single skin unit.

"As you get to the midface, you need to avoid distortion of the lateral canthus and the downward pull of the lower eyelid," Dr. Bauer noted. "Use of direct upward advancement of either expanded or nonexpanded flaps from the lower cheek and submental area may increase the risk of these problems," he added. Lateral movement with rotation or transposition of flaps reduces this risk.

With thoughtful flap planning, one can place scars at the borders of the natural aesthetic units of the face and minimize their visibility. With adequate time for tissue healing and changes in the reconstructed tissues with the child's growth, one can achieve a natural appearance and minimize the need for additional complex reconstruction later in life.

▸ Trunk. On the anterior trunk, abdominoplasty techniques (with or without tissue expansion) are most effective. "We try to have the challenging part of the reconstruction done while the child is still small and the tissue is more flexible," Dr. Bauer said. But when the nevus encroaches on the breast area, particularly in girls, delay surgery until the breasts have begun to develop in order to avoid an injury to the developing breast bud, he said.

On the posterior trunk, tissue expansion has provided a way to excise many giant nevi with excellent aesthetic and function outcomes, Dr. Bauer said. Transposition flaps from the lower abdomen and the back can be moved longer distances than can the traditional advancement flaps. Flaps can be transposed from the back to the buttocks and reexpanded and brought to the perineal area. And flaps from the lower abdomen can be transposed into the upper-thigh region.

"In some cases, as tissue is moved into the buttock and perineal area, the extra tissue that is gained can be used for genital reconstruction in young girls," Dr. Bauer added. But aside from rare cases, he leaves genital nevi in place in both boys and girls to avoid potential tissue scarring.

Excision of a nevus and coverage of the defect with a split-thickness skin graft are reserved for cases in which there is little, if any, uninvolved tissue available to expand. "The excision is concentrated on the back where the risk of degeneration is thought to be greater and the aesthetic and functional outcome can still be quite acceptable," Dr. Bauer said.

When there is so little uninvolved tissue that there are no acceptable skin graft donor sites, the patient should be followed by a pediatric dermatologist and areas of concern should be selectively biopsied, he said.

In some cases of patients who underwent early excision and skin graft with poor aesthetic outcomes and dense scarring, tissue expansion may be able to provide the normal tissue necessary to excise or revise the scars and provide a more acceptable outcome.

▸ Extremities. The treatment of large and giant nevi on the extremities is especially challenging because the contour from skin grafts is often poor, said Dr. Bauer. Although skin grafts can be used for large nevi on the hands, concerns about mobility and functional problems are significant, he said. "Looking for a better way, we went back to the old plastic surgery techniques and drew from the ideas of pedicle flaps, but we used tissue expansion to advantage," he explained.

For example, tissue expansion from the abdomen and flank can be used to reconstruct large nevi from the wrist to the arm proximal to the elbow. The use of staged, expanded pedicle flaps can yield excellent contour without distortion of the limb. When such flaps are combined with expansion of the scapular region, the extremity can be resurfaced with tissue of similar quality, thickness, and sensibility from the shoulder to the wrist, with the donor scars placed in acceptable positions, noted Dr. Bauer.

Microvascular transfer of expanded skin flaps—and some unique application of pedicle-flap principles—may be used for reconstruction of large and giant nevi of the lower extremity where expansion of that region is less effective. The lower extremity region remains one of the greater challenges in the treatment of large and giant nevi, Dr. Bauer said.

The search for newer approaches, or the application of older techniques in new ways, can lead to improved aesthetic and functional outcomes. But cooperation and understanding from patients and families are the true essentials for successful treatment of large and giant nevi, Dr. Bauer said.

This infant had a circumferential giant nevus—from above the wrist to the mid upper arm—that could have undergone a malignant change.

Skin of the child's abdomen and flank is expanded to create a flap through which the arm will be tunneled after the majority of the nevus is excised.

The baby's arm is shown attached to the created flap. After 3 weeks, the area of attachment can be divided.

The arm after surgery shows excellent contour and color match. Scars are positioned to avoid any late functional disturbance. PHOTOS COURTESY DR. BRUCE BAUER

CHICAGO — A treatment plan for infants and children with large and giant nevi must satisfy concerns about malignancy while optimizing aesthetic and functional outcomes for the patient, Dr. Bruce Bauer said at the annual meeting of the Society for Pediatric Dermatology.

"Conducting a critical assessment of a large or giant nevus in a child and choosing the appropriate procedures as early as possible will reduce the total number of surgeries and the need for complex surgery later on to deal with potential complications caused by scarring," noted Dr. Bauer, a pediatric plastic surgeon and chief of plastic surgery at Children's Memorial Hospital, Chicago, who specializes in the treatment of large and giant congenital nevi.

Each child and each tissue heal differently, and some surgeries are easier and more effective at earlier ages than later, he added.

Although various classifications for nevi exist in the medical literature, a nevus larger than 20 cm in a child is usually considered a giant nevus, and a nevus that is 11–20 cm is considered large. In general, patients with large or giant nevi are at the greatest risk for malignant change, but size doesn't guarantee malignancy. The overall incidence of cutaneous or extracutaneous melanoma in patients with large or giant nevi is between 4.5% and 10%, said Dr. Bauer, and controversies persist about the medical necessity of plastic surgery to manage the nevi.

"The exact risk of malignant change in congenital melanocytic nevi may never be determined," Dr. Bauer acknowledged. "The managing physician or surgeon must develop a treatment philosophy based on an understanding of pertinent studies."

The primary rationales for excision of large or giant nevi are a concern for malignancy and a desire for an improved appearance. Some patients and physicians may decide that the risk of malignancy is too small to warrant the potentially extensive scarring or unsightly skin grafts needed to excise a large or giant nevus. But for those who make the decision in favor of excision, the sooner the better, Dr. Bauer said.

If the excision is performed in infancy or early childhood, the tissue is more flexible and heals more smoothly and rapidly. The psychological benefits and generally good patient tolerance also tip the scales in favor of early excision.

Tissue expansion—in which skin adjacent to the nevus is stretched, with both stretch and new cell growth occurring—provides the added tissue needed to cover the area from which the nevus has been excised, and is now one of the most powerful tools available in the treatment of these extensive lesions. The ability to expand tissue of similar skin characteristics to the involved area allows expansion of hair-bearing scalp to replace a scalp nevus, and non-hair-bearing skin to replace nevi in all other areas.

Dr. Bauer shared some elements of his surgical approach to large and giant congenital nevi the following areas of the body:

▸ Scalp/forehead. Tissue expansion is the preferred method for treatment of large and giant nevi of the scalp and forehead, and has become the standard of care. Expansion may begin when the patient is as young as 6 months of age without long-term effects on the growing skull. In addition, the use of transposition flaps yields a more natural hairline reconstruction.

Good flap planning can reduce the need for repeated tissue expansion procedures, Dr. Bauer noted. Combined expansion of scalp and forehead for nevi that cover both areas will also reduce the number of surgical procedures needed to excise the nevus and reconstruct the defect. In rare cases in which minimal normal forehead skin is available, free tissue transfer can be considered, with expansion used at the distant donor sites to allow harvest of a large, microvascular free flap, with primary closure of the donor site, he explained.

▸ Midface/periorbital region. Tissue expansion can be used for large and giant nevi on the forehead, neck, and cheek, and large expanded full-thickness skin grafts may provide color-compatible coverage for the periorbital and nasal area in a single skin unit.

"As you get to the midface, you need to avoid distortion of the lateral canthus and the downward pull of the lower eyelid," Dr. Bauer noted. "Use of direct upward advancement of either expanded or nonexpanded flaps from the lower cheek and submental area may increase the risk of these problems," he added. Lateral movement with rotation or transposition of flaps reduces this risk.

With thoughtful flap planning, one can place scars at the borders of the natural aesthetic units of the face and minimize their visibility. With adequate time for tissue healing and changes in the reconstructed tissues with the child's growth, one can achieve a natural appearance and minimize the need for additional complex reconstruction later in life.

▸ Trunk. On the anterior trunk, abdominoplasty techniques (with or without tissue expansion) are most effective. "We try to have the challenging part of the reconstruction done while the child is still small and the tissue is more flexible," Dr. Bauer said. But when the nevus encroaches on the breast area, particularly in girls, delay surgery until the breasts have begun to develop in order to avoid an injury to the developing breast bud, he said.

On the posterior trunk, tissue expansion has provided a way to excise many giant nevi with excellent aesthetic and function outcomes, Dr. Bauer said. Transposition flaps from the lower abdomen and the back can be moved longer distances than can the traditional advancement flaps. Flaps can be transposed from the back to the buttocks and reexpanded and brought to the perineal area. And flaps from the lower abdomen can be transposed into the upper-thigh region.

"In some cases, as tissue is moved into the buttock and perineal area, the extra tissue that is gained can be used for genital reconstruction in young girls," Dr. Bauer added. But aside from rare cases, he leaves genital nevi in place in both boys and girls to avoid potential tissue scarring.

Excision of a nevus and coverage of the defect with a split-thickness skin graft are reserved for cases in which there is little, if any, uninvolved tissue available to expand. "The excision is concentrated on the back where the risk of degeneration is thought to be greater and the aesthetic and functional outcome can still be quite acceptable," Dr. Bauer said.

When there is so little uninvolved tissue that there are no acceptable skin graft donor sites, the patient should be followed by a pediatric dermatologist and areas of concern should be selectively biopsied, he said.

In some cases of patients who underwent early excision and skin graft with poor aesthetic outcomes and dense scarring, tissue expansion may be able to provide the normal tissue necessary to excise or revise the scars and provide a more acceptable outcome.

▸ Extremities. The treatment of large and giant nevi on the extremities is especially challenging because the contour from skin grafts is often poor, said Dr. Bauer. Although skin grafts can be used for large nevi on the hands, concerns about mobility and functional problems are significant, he said. "Looking for a better way, we went back to the old plastic surgery techniques and drew from the ideas of pedicle flaps, but we used tissue expansion to advantage," he explained.

For example, tissue expansion from the abdomen and flank can be used to reconstruct large nevi from the wrist to the arm proximal to the elbow. The use of staged, expanded pedicle flaps can yield excellent contour without distortion of the limb. When such flaps are combined with expansion of the scapular region, the extremity can be resurfaced with tissue of similar quality, thickness, and sensibility from the shoulder to the wrist, with the donor scars placed in acceptable positions, noted Dr. Bauer.

Microvascular transfer of expanded skin flaps—and some unique application of pedicle-flap principles—may be used for reconstruction of large and giant nevi of the lower extremity where expansion of that region is less effective. The lower extremity region remains one of the greater challenges in the treatment of large and giant nevi, Dr. Bauer said.

The search for newer approaches, or the application of older techniques in new ways, can lead to improved aesthetic and functional outcomes. But cooperation and understanding from patients and families are the true essentials for successful treatment of large and giant nevi, Dr. Bauer said.

This infant had a circumferential giant nevus—from above the wrist to the mid upper arm—that could have undergone a malignant change.

Skin of the child's abdomen and flank is expanded to create a flap through which the arm will be tunneled after the majority of the nevus is excised.

The baby's arm is shown attached to the created flap. After 3 weeks, the area of attachment can be divided.

The arm after surgery shows excellent contour and color match. Scars are positioned to avoid any late functional disturbance. PHOTOS COURTESY DR. BRUCE BAUER

CHICAGO — A treatment plan for infants and children with large and giant nevi must satisfy concerns about malignancy while optimizing aesthetic and functional outcomes for the patient, Dr. Bruce Bauer said at the annual meeting of the Society for Pediatric Dermatology.

"Conducting a critical assessment of a large or giant nevus in a child and choosing the appropriate procedures as early as possible will reduce the total number of surgeries and the need for complex surgery later on to deal with potential complications caused by scarring," noted Dr. Bauer, a pediatric plastic surgeon and chief of plastic surgery at Children's Memorial Hospital, Chicago, who specializes in the treatment of large and giant congenital nevi.

Each child and each tissue heal differently, and some surgeries are easier and more effective at earlier ages than later, he added.

Although various classifications for nevi exist in the medical literature, a nevus larger than 20 cm in a child is usually considered a giant nevus, and a nevus that is 11–20 cm is considered large. In general, patients with large or giant nevi are at the greatest risk for malignant change, but size doesn't guarantee malignancy. The overall incidence of cutaneous or extracutaneous melanoma in patients with large or giant nevi is between 4.5% and 10%, said Dr. Bauer, and controversies persist about the medical necessity of plastic surgery to manage the nevi.

"The exact risk of malignant change in congenital melanocytic nevi may never be determined," Dr. Bauer acknowledged. "The managing physician or surgeon must develop a treatment philosophy based on an understanding of pertinent studies."

The primary rationales for excision of large or giant nevi are a concern for malignancy and a desire for an improved appearance. Some patients and physicians may decide that the risk of malignancy is too small to warrant the potentially extensive scarring or unsightly skin grafts needed to excise a large or giant nevus. But for those who make the decision in favor of excision, the sooner the better, Dr. Bauer said.

If the excision is performed in infancy or early childhood, the tissue is more flexible and heals more smoothly and rapidly. The psychological benefits and generally good patient tolerance also tip the scales in favor of early excision.

Tissue expansion—in which skin adjacent to the nevus is stretched, with both stretch and new cell growth occurring—provides the added tissue needed to cover the area from which the nevus has been excised, and is now one of the most powerful tools available in the treatment of these extensive lesions. The ability to expand tissue of similar skin characteristics to the involved area allows expansion of hair-bearing scalp to replace a scalp nevus, and non-hair-bearing skin to replace nevi in all other areas.

Dr. Bauer shared some elements of his surgical approach to large and giant congenital nevi the following areas of the body:

▸ Scalp/forehead. Tissue expansion is the preferred method for treatment of large and giant nevi of the scalp and forehead, and has become the standard of care. Expansion may begin when the patient is as young as 6 months of age without long-term effects on the growing skull. In addition, the use of transposition flaps yields a more natural hairline reconstruction.

Good flap planning can reduce the need for repeated tissue expansion procedures, Dr. Bauer noted. Combined expansion of scalp and forehead for nevi that cover both areas will also reduce the number of surgical procedures needed to excise the nevus and reconstruct the defect. In rare cases in which minimal normal forehead skin is available, free tissue transfer can be considered, with expansion used at the distant donor sites to allow harvest of a large, microvascular free flap, with primary closure of the donor site, he explained.

▸ Midface/periorbital region. Tissue expansion can be used for large and giant nevi on the forehead, neck, and cheek, and large expanded full-thickness skin grafts may provide color-compatible coverage for the periorbital and nasal area in a single skin unit.

"As you get to the midface, you need to avoid distortion of the lateral canthus and the downward pull of the lower eyelid," Dr. Bauer noted. "Use of direct upward advancement of either expanded or nonexpanded flaps from the lower cheek and submental area may increase the risk of these problems," he added. Lateral movement with rotation or transposition of flaps reduces this risk.

With thoughtful flap planning, one can place scars at the borders of the natural aesthetic units of the face and minimize their visibility. With adequate time for tissue healing and changes in the reconstructed tissues with the child's growth, one can achieve a natural appearance and minimize the need for additional complex reconstruction later in life.

▸ Trunk. On the anterior trunk, abdominoplasty techniques (with or without tissue expansion) are most effective. "We try to have the challenging part of the reconstruction done while the child is still small and the tissue is more flexible," Dr. Bauer said. But when the nevus encroaches on the breast area, particularly in girls, delay surgery until the breasts have begun to develop in order to avoid an injury to the developing breast bud, he said.

On the posterior trunk, tissue expansion has provided a way to excise many giant nevi with excellent aesthetic and function outcomes, Dr. Bauer said. Transposition flaps from the lower abdomen and the back can be moved longer distances than can the traditional advancement flaps. Flaps can be transposed from the back to the buttocks and reexpanded and brought to the perineal area. And flaps from the lower abdomen can be transposed into the upper-thigh region.

"In some cases, as tissue is moved into the buttock and perineal area, the extra tissue that is gained can be used for genital reconstruction in young girls," Dr. Bauer added. But aside from rare cases, he leaves genital nevi in place in both boys and girls to avoid potential tissue scarring.

Excision of a nevus and coverage of the defect with a split-thickness skin graft are reserved for cases in which there is little, if any, uninvolved tissue available to expand. "The excision is concentrated on the back where the risk of degeneration is thought to be greater and the aesthetic and functional outcome can still be quite acceptable," Dr. Bauer said.

When there is so little uninvolved tissue that there are no acceptable skin graft donor sites, the patient should be followed by a pediatric dermatologist and areas of concern should be selectively biopsied, he said.

In some cases of patients who underwent early excision and skin graft with poor aesthetic outcomes and dense scarring, tissue expansion may be able to provide the normal tissue necessary to excise or revise the scars and provide a more acceptable outcome.

▸ Extremities. The treatment of large and giant nevi on the extremities is especially challenging because the contour from skin grafts is often poor, said Dr. Bauer. Although skin grafts can be used for large nevi on the hands, concerns about mobility and functional problems are significant, he said. "Looking for a better way, we went back to the old plastic surgery techniques and drew from the ideas of pedicle flaps, but we used tissue expansion to advantage," he explained.

For example, tissue expansion from the abdomen and flank can be used to reconstruct large nevi from the wrist to the arm proximal to the elbow. The use of staged, expanded pedicle flaps can yield excellent contour without distortion of the limb. When such flaps are combined with expansion of the scapular region, the extremity can be resurfaced with tissue of similar quality, thickness, and sensibility from the shoulder to the wrist, with the donor scars placed in acceptable positions, noted Dr. Bauer.

Microvascular transfer of expanded skin flaps—and some unique application of pedicle-flap principles—may be used for reconstruction of large and giant nevi of the lower extremity where expansion of that region is less effective. The lower extremity region remains one of the greater challenges in the treatment of large and giant nevi, Dr. Bauer said.

The search for newer approaches, or the application of older techniques in new ways, can lead to improved aesthetic and functional outcomes. But cooperation and understanding from patients and families are the true essentials for successful treatment of large and giant nevi, Dr. Bauer said.

This infant had a circumferential giant nevus—from above the wrist to the mid upper arm—that could have undergone a malignant change.

Skin of the child's abdomen and flank is expanded to create a flap through which the arm will be tunneled after the majority of the nevus is excised.

The baby's arm is shown attached to the created flap. After 3 weeks, the area of attachment can be divided.

The arm after surgery shows excellent contour and color match. Scars are positioned to avoid any late functional disturbance. PHOTOS COURTESY DR. BRUCE BAUER

Influenza vaccinations don't reduce flu-related mortality in elderly adults in the United States, and prior reports of the vaccine's efficacy in this population have been exaggerated, according to a recent report.

Although flu vaccination rates in the United States have increased from 15% to 65% since 1980, recent mortality studies cannot confirm any decrease in flu-related deaths in adults aged 70 years and older, wrote Lone Simonsen, Ph.D., of George Washington University, Washington, and colleagues (Lancet Infect. Dis. 2007;7:656–66 [Epub doi:10.1016/S1473-3099(07)70236-0]).

To assess the validity of the evidence for and against flu shots for the elderly, the researchers reviewed data from previous studies and found few randomized, controlled trials of flu vaccination effectiveness in the elderly. Most of the current evidence stems from observational studies that compared mortality in vaccinated vs. unvaccinated persons. In addition, studies of flu vaccination and flu-related mortality in the elderly likely are affected by selection bias and don't account for frailty, the researchers explained.

The review included all available clinical studies of vaccine effectiveness in elderly persons. Of note, data from the largest and most rigorous placebo-controlled randomized study (which is often cited as evidence of vaccine effectiveness) showed that the flu vaccine's effectiveness may decline with age.

The study, which included 1,838 healthy adults aged 60 and older, cites a 50% vaccine efficacy among adults aged 60 and older, the researchers noted (JAMA 1994;272:1661–5). But vaccine efficacy was only 23% among adults aged 70 years and older, compared with 57% among persons aged 60–69 years.

The decline in flu vaccine benefits is consistent with evidence of a decline in overall immune responsiveness later in life. The researchers cited data from a review of placebo-controlled antibody responses showing that responses of older persons receiving the vaccinations were one-quarter to one-half as vigorous as responses in younger adults, although data are limited for persons aged 70 years and older (Vaccine 2005;24:1159–69).

Pending further evidence, flu vaccinations for the elderly are useful because three-quarters of influenza deaths per year are in persons over age 70, and even a partly effective vaccine is better than no vaccine, they concluded.

In another report, Dr. Tom Jefferson and Dr. Carlo Di Pietrantonj wrote that data from Cochrane Reviews published in 2005 and 2006 supported the presence of a selection bias and the subsequent weak evidence for the effectiveness of flu vaccination to prevent mortality in adults aged 65 years and older. Dr. Jefferson and Dr. Di Pietrantonj, members of the Cochrane Vaccines Field in Alessandria, Italy, contributed to the 2005 and 2006 Cochrane Reviews, which showed that flu vaccines significantly reduced all-cause mortality—but not flu-specific mortality—in older people. “We concluded that the most probable explanation for such contradictory findings was selection bias, which occurred when not-so-frail elderly people were more likely to be vaccinated than their infirm peers, thus affecting the outcome,” they wrote (Lancet 2007 [Epub doi:10.1016/S0140-6736(07)61389-0]).

Influenza vaccinations don't reduce flu-related mortality in elderly adults in the United States, and prior reports of the vaccine's efficacy in this population have been exaggerated, according to a recent report.

Although flu vaccination rates in the United States have increased from 15% to 65% since 1980, recent mortality studies cannot confirm any decrease in flu-related deaths in adults aged 70 years and older, wrote Lone Simonsen, Ph.D., of George Washington University, Washington, and colleagues (Lancet Infect. Dis. 2007;7:656–66 [Epub doi:10.1016/S1473-3099(07)70236-0]).

To assess the validity of the evidence for and against flu shots for the elderly, the researchers reviewed data from previous studies and found few randomized, controlled trials of flu vaccination effectiveness in the elderly. Most of the current evidence stems from observational studies that compared mortality in vaccinated vs. unvaccinated persons. In addition, studies of flu vaccination and flu-related mortality in the elderly likely are affected by selection bias and don't account for frailty, the researchers explained.

The review included all available clinical studies of vaccine effectiveness in elderly persons. Of note, data from the largest and most rigorous placebo-controlled randomized study (which is often cited as evidence of vaccine effectiveness) showed that the flu vaccine's effectiveness may decline with age.

The study, which included 1,838 healthy adults aged 60 and older, cites a 50% vaccine efficacy among adults aged 60 and older, the researchers noted (JAMA 1994;272:1661–5). But vaccine efficacy was only 23% among adults aged 70 years and older, compared with 57% among persons aged 60–69 years.

The decline in flu vaccine benefits is consistent with evidence of a decline in overall immune responsiveness later in life. The researchers cited data from a review of placebo-controlled antibody responses showing that responses of older persons receiving the vaccinations were one-quarter to one-half as vigorous as responses in younger adults, although data are limited for persons aged 70 years and older (Vaccine 2005;24:1159–69).

Pending further evidence, flu vaccinations for the elderly are useful because three-quarters of influenza deaths per year are in persons over age 70, and even a partly effective vaccine is better than no vaccine, they concluded.

In another report, Dr. Tom Jefferson and Dr. Carlo Di Pietrantonj wrote that data from Cochrane Reviews published in 2005 and 2006 supported the presence of a selection bias and the subsequent weak evidence for the effectiveness of flu vaccination to prevent mortality in adults aged 65 years and older. Dr. Jefferson and Dr. Di Pietrantonj, members of the Cochrane Vaccines Field in Alessandria, Italy, contributed to the 2005 and 2006 Cochrane Reviews, which showed that flu vaccines significantly reduced all-cause mortality—but not flu-specific mortality—in older people. “We concluded that the most probable explanation for such contradictory findings was selection bias, which occurred when not-so-frail elderly people were more likely to be vaccinated than their infirm peers, thus affecting the outcome,” they wrote (Lancet 2007 [Epub doi:10.1016/S0140-6736(07)61389-0]).

Influenza vaccinations don't reduce flu-related mortality in elderly adults in the United States, and prior reports of the vaccine's efficacy in this population have been exaggerated, according to a recent report.

Although flu vaccination rates in the United States have increased from 15% to 65% since 1980, recent mortality studies cannot confirm any decrease in flu-related deaths in adults aged 70 years and older, wrote Lone Simonsen, Ph.D., of George Washington University, Washington, and colleagues (Lancet Infect. Dis. 2007;7:656–66 [Epub doi:10.1016/S1473-3099(07)70236-0]).

To assess the validity of the evidence for and against flu shots for the elderly, the researchers reviewed data from previous studies and found few randomized, controlled trials of flu vaccination effectiveness in the elderly. Most of the current evidence stems from observational studies that compared mortality in vaccinated vs. unvaccinated persons. In addition, studies of flu vaccination and flu-related mortality in the elderly likely are affected by selection bias and don't account for frailty, the researchers explained.

The review included all available clinical studies of vaccine effectiveness in elderly persons. Of note, data from the largest and most rigorous placebo-controlled randomized study (which is often cited as evidence of vaccine effectiveness) showed that the flu vaccine's effectiveness may decline with age.

The study, which included 1,838 healthy adults aged 60 and older, cites a 50% vaccine efficacy among adults aged 60 and older, the researchers noted (JAMA 1994;272:1661–5). But vaccine efficacy was only 23% among adults aged 70 years and older, compared with 57% among persons aged 60–69 years.

The decline in flu vaccine benefits is consistent with evidence of a decline in overall immune responsiveness later in life. The researchers cited data from a review of placebo-controlled antibody responses showing that responses of older persons receiving the vaccinations were one-quarter to one-half as vigorous as responses in younger adults, although data are limited for persons aged 70 years and older (Vaccine 2005;24:1159–69).

Pending further evidence, flu vaccinations for the elderly are useful because three-quarters of influenza deaths per year are in persons over age 70, and even a partly effective vaccine is better than no vaccine, they concluded.

In another report, Dr. Tom Jefferson and Dr. Carlo Di Pietrantonj wrote that data from Cochrane Reviews published in 2005 and 2006 supported the presence of a selection bias and the subsequent weak evidence for the effectiveness of flu vaccination to prevent mortality in adults aged 65 years and older. Dr. Jefferson and Dr. Di Pietrantonj, members of the Cochrane Vaccines Field in Alessandria, Italy, contributed to the 2005 and 2006 Cochrane Reviews, which showed that flu vaccines significantly reduced all-cause mortality—but not flu-specific mortality—in older people. “We concluded that the most probable explanation for such contradictory findings was selection bias, which occurred when not-so-frail elderly people were more likely to be vaccinated than their infirm peers, thus affecting the outcome,” they wrote (Lancet 2007 [Epub doi:10.1016/S0140-6736(07)61389-0]).

WASHINGTON — High intelligence may be protective against brain injury-associated cognitive dysfunction, judging from follow-up data on veterans injured during the war in Vietnam, Jordan Grafman, Ph.D., said at a meeting sponsored by the Institute of Medicine.

Dr. Grafman, chief of the cognitive neurosciences section of the National Institute of Neurological Disorders and Stroke, presented new data from 35 years of following Vietnam War veterans with traumatic brain injury (TBI). The study is the most recent phase in the ongoing Vietnam Head Injury Study, a long-term follow-up of veterans who suffered head injuries in combat. The cohort included 199 men with TBI and 55 controls; their average age at most recent follow up was 59 years.

Participants completed a variation of a U.S. Army classification test used to assess mental ability. The test was similar to an intelligence test that the soldiers took when they first enlisted. Overall, 4.5% of the participants scored less than 24 on the Mini-Mental State Examination, but those who scored lower also had below-average baseline intelligence scores.

The controls showed a cognitive decline with age, and the soldiers with penetrating head injuries showed a slightly greater decline, even when investigators controlled for a host of variables.

“But if you look at subgroups, those with the lowest preinjury intelligence scores had the most cognitive decline from preinjury to follow-up, and the difference was statistically significant, compared with controls,” Dr. Grafman said. He also noted that soldiers with head injuries who show exacerbated cognitive decline as they age may be mistakenly diagnosed with dementia, when in fact their increased cognitive decline results from a combination of aging and the size of their lesions.

Based in part on these findings, Dr. Grafman does not believe that TBI is always a precursor to Alzheimer's disease. But the long-term findings suggest that the location of the injury contributes to late-life cognitive decline and other symptoms.

“Lesions of the caudate nucleus of the brain significantly and consistently predicted late-life cognitive decline, and may indicate the importance of certain neurotransmitters in maintaining functions as we age,” Dr. Grafman said.

By contrast, the location of a TBI can be protective, too. Posttraumatic stress is clearly part of the experience of war, especially if someone experiences combat, Dr. Grafman said. But none the men with injuries to the amygdala showed signs of posttraumatic stress disorder, whereas 18% of those men with ventromedial prefrontal cortex lesions and more than 40% of patients with lesions elsewhere in the brain had developed PTSD over time since their injuries.

Dr. Grafman emphasized the importance of longitudinal studies for brain injury patients in general, and for veterans in particular, because baseline data are often available. “Preinjury intelligence is by far the best predictor of outcome, no matter what other variables you throw in,” Dr. Grafman said, based on the 35-year data and data from the same group of veterans at 5 and 15 years' follow-up. Data gathered on the cohort at 10 years showed individuals who scored higher on baseline intelligence tests were more likely to be working years later, and they were more able to handle daily activities, compared with those who had lower baseline intelligence scores.

Veterans are an outstanding patient group, and a systematic plan is needed to keep them from being lost in the medical system, Dr. Grafman noted, adding, “There needs to be a well-run centralized database for the registry of head-injured soldiers with a small number of manageable variables.”

WASHINGTON — High intelligence may be protective against brain injury-associated cognitive dysfunction, judging from follow-up data on veterans injured during the war in Vietnam, Jordan Grafman, Ph.D., said at a meeting sponsored by the Institute of Medicine.

Dr. Grafman, chief of the cognitive neurosciences section of the National Institute of Neurological Disorders and Stroke, presented new data from 35 years of following Vietnam War veterans with traumatic brain injury (TBI). The study is the most recent phase in the ongoing Vietnam Head Injury Study, a long-term follow-up of veterans who suffered head injuries in combat. The cohort included 199 men with TBI and 55 controls; their average age at most recent follow up was 59 years.

Participants completed a variation of a U.S. Army classification test used to assess mental ability. The test was similar to an intelligence test that the soldiers took when they first enlisted. Overall, 4.5% of the participants scored less than 24 on the Mini-Mental State Examination, but those who scored lower also had below-average baseline intelligence scores.

The controls showed a cognitive decline with age, and the soldiers with penetrating head injuries showed a slightly greater decline, even when investigators controlled for a host of variables.

“But if you look at subgroups, those with the lowest preinjury intelligence scores had the most cognitive decline from preinjury to follow-up, and the difference was statistically significant, compared with controls,” Dr. Grafman said. He also noted that soldiers with head injuries who show exacerbated cognitive decline as they age may be mistakenly diagnosed with dementia, when in fact their increased cognitive decline results from a combination of aging and the size of their lesions.

Based in part on these findings, Dr. Grafman does not believe that TBI is always a precursor to Alzheimer's disease. But the long-term findings suggest that the location of the injury contributes to late-life cognitive decline and other symptoms.

“Lesions of the caudate nucleus of the brain significantly and consistently predicted late-life cognitive decline, and may indicate the importance of certain neurotransmitters in maintaining functions as we age,” Dr. Grafman said.

By contrast, the location of a TBI can be protective, too. Posttraumatic stress is clearly part of the experience of war, especially if someone experiences combat, Dr. Grafman said. But none the men with injuries to the amygdala showed signs of posttraumatic stress disorder, whereas 18% of those men with ventromedial prefrontal cortex lesions and more than 40% of patients with lesions elsewhere in the brain had developed PTSD over time since their injuries.

Dr. Grafman emphasized the importance of longitudinal studies for brain injury patients in general, and for veterans in particular, because baseline data are often available. “Preinjury intelligence is by far the best predictor of outcome, no matter what other variables you throw in,” Dr. Grafman said, based on the 35-year data and data from the same group of veterans at 5 and 15 years' follow-up. Data gathered on the cohort at 10 years showed individuals who scored higher on baseline intelligence tests were more likely to be working years later, and they were more able to handle daily activities, compared with those who had lower baseline intelligence scores.

Veterans are an outstanding patient group, and a systematic plan is needed to keep them from being lost in the medical system, Dr. Grafman noted, adding, “There needs to be a well-run centralized database for the registry of head-injured soldiers with a small number of manageable variables.”

WASHINGTON — High intelligence may be protective against brain injury-associated cognitive dysfunction, judging from follow-up data on veterans injured during the war in Vietnam, Jordan Grafman, Ph.D., said at a meeting sponsored by the Institute of Medicine.

Dr. Grafman, chief of the cognitive neurosciences section of the National Institute of Neurological Disorders and Stroke, presented new data from 35 years of following Vietnam War veterans with traumatic brain injury (TBI). The study is the most recent phase in the ongoing Vietnam Head Injury Study, a long-term follow-up of veterans who suffered head injuries in combat. The cohort included 199 men with TBI and 55 controls; their average age at most recent follow up was 59 years.

Participants completed a variation of a U.S. Army classification test used to assess mental ability. The test was similar to an intelligence test that the soldiers took when they first enlisted. Overall, 4.5% of the participants scored less than 24 on the Mini-Mental State Examination, but those who scored lower also had below-average baseline intelligence scores.

The controls showed a cognitive decline with age, and the soldiers with penetrating head injuries showed a slightly greater decline, even when investigators controlled for a host of variables.

“But if you look at subgroups, those with the lowest preinjury intelligence scores had the most cognitive decline from preinjury to follow-up, and the difference was statistically significant, compared with controls,” Dr. Grafman said. He also noted that soldiers with head injuries who show exacerbated cognitive decline as they age may be mistakenly diagnosed with dementia, when in fact their increased cognitive decline results from a combination of aging and the size of their lesions.

Based in part on these findings, Dr. Grafman does not believe that TBI is always a precursor to Alzheimer's disease. But the long-term findings suggest that the location of the injury contributes to late-life cognitive decline and other symptoms.

“Lesions of the caudate nucleus of the brain significantly and consistently predicted late-life cognitive decline, and may indicate the importance of certain neurotransmitters in maintaining functions as we age,” Dr. Grafman said.

By contrast, the location of a TBI can be protective, too. Posttraumatic stress is clearly part of the experience of war, especially if someone experiences combat, Dr. Grafman said. But none the men with injuries to the amygdala showed signs of posttraumatic stress disorder, whereas 18% of those men with ventromedial prefrontal cortex lesions and more than 40% of patients with lesions elsewhere in the brain had developed PTSD over time since their injuries.

Dr. Grafman emphasized the importance of longitudinal studies for brain injury patients in general, and for veterans in particular, because baseline data are often available. “Preinjury intelligence is by far the best predictor of outcome, no matter what other variables you throw in,” Dr. Grafman said, based on the 35-year data and data from the same group of veterans at 5 and 15 years' follow-up. Data gathered on the cohort at 10 years showed individuals who scored higher on baseline intelligence tests were more likely to be working years later, and they were more able to handle daily activities, compared with those who had lower baseline intelligence scores.

Veterans are an outstanding patient group, and a systematic plan is needed to keep them from being lost in the medical system, Dr. Grafman noted, adding, “There needs to be a well-run centralized database for the registry of head-injured soldiers with a small number of manageable variables.”

CHICAGO — When facing a child with localized scleroderma, be wary if the scleroderma is linear, especially on the face or a limb where it crosses a joint, Dr. Amy Gilliam said at the annual meeting of the Society for Pediatric Dermatology.

Not all young people initially present with the skin hardening and atrophy that characterizes scleroderma, explained Dr. Gilliam, of the University of California, San Francisco. These patients are often misdiagnosed with vitiligo for months or years before the correct diagnosis of juvenile localized scleroderma is made.

To better characterize localized scleroderma in children, Dr. Gilliam and her colleagues reviewed data from 127 patients under 21 years evaluated at UCSF. Dr. Gilliam's research was supported in part by a grant from the Society for Pediatric Dermatology and the Dermatology Foundation, but she had no other financial disclosures. “We collected information on body surface area of involvement. And we had a dermatology perspective rather than a rheumatology perspective,” Dr. Gilliam said.

“The presenting sign in about 50% of the patients was some type of dyspigmentation, either hyper-, hypo- or depigmentation,” she said. Add the 19 patients who had what they called a “bruise,” and dyspigmentation was a presenting symptom in nearly two-thirds of the cases.

Another finding was that patients whose scleroderma involved 5% or more of total body surface area were significantly more likely to have extracutaneous symptoms—arthralgias and orthopedic, pulmonary, and gastrointestinal problems—than were patients whose scleroderma involved less than 5% of total body surface. This held in separate analyses of 89 patients whose charts were reviewed retrospectively and 38 patients studied prospectively and followed.

But neurologic problems were the notable exception in the patient population. “That sticks out like a sore thumb,” said Dr. Gilliam. Localized scleroderma on less than 5% of the body surface area was significantly associated with neurologic problems, and neurologic problems were significantly more common in patients with facial linear scleroderma.

“When we are talking about neurologic problems in the setting of localized scleroderma, we are usually talking about the face, which has at most 6% of the surface area, so these patients with neurologic problems are likely to have lower total body surface area involvement,” she said.

Apart from the relationship with body surface area, Dr. Gilliam showed neurologic problems were more common in patients with facial linear scleroderma versus other forms of localized scleroderma (33% vs. 8%). Her data showed that orthopedic problems were significantly more common in patients with nonfacial linear scleroderma, compared with those who had other forms of localized scleroderma (22% vs. 2%).

But body surface area alone isn't enough to assess localized scleroderma, Dr. Gilliam said. The patients to worry about are those with segmental or linear presentations and those with the characteristic pinkish-purple macules that indicate generalized morphea.

It's important to think about location in cases of localized scleroderma, Dr. Gilliam added. In her study, gastrointestinal problems were significantly more common in patients with generalized morphea and in patients who had scleroderma on the trunk, compared with those who had scleroderma in other locations (21% vs. 5%). But location isn't everything: Pulmonary problems were significantly more common among patients with generalized morphea, but the presence or absence of localized scleroderma on the trunk was not significant.

Dr. Gilliam did not find a significant link between positive levels of antinuclear antibodies and extracutaneous conditions, although she cited a separate study of 750 patients that did show a significant association (Arthritis Rheum. 2005;52:2873-81). She found positive antinuclear antibody levels were slightly, but not significantly, more prevalent in patients with linear scleroderma and with generalized morphea.

CHICAGO — When facing a child with localized scleroderma, be wary if the scleroderma is linear, especially on the face or a limb where it crosses a joint, Dr. Amy Gilliam said at the annual meeting of the Society for Pediatric Dermatology.

Not all young people initially present with the skin hardening and atrophy that characterizes scleroderma, explained Dr. Gilliam, of the University of California, San Francisco. These patients are often misdiagnosed with vitiligo for months or years before the correct diagnosis of juvenile localized scleroderma is made.

To better characterize localized scleroderma in children, Dr. Gilliam and her colleagues reviewed data from 127 patients under 21 years evaluated at UCSF. Dr. Gilliam's research was supported in part by a grant from the Society for Pediatric Dermatology and the Dermatology Foundation, but she had no other financial disclosures. “We collected information on body surface area of involvement. And we had a dermatology perspective rather than a rheumatology perspective,” Dr. Gilliam said.

“The presenting sign in about 50% of the patients was some type of dyspigmentation, either hyper-, hypo- or depigmentation,” she said. Add the 19 patients who had what they called a “bruise,” and dyspigmentation was a presenting symptom in nearly two-thirds of the cases.

Another finding was that patients whose scleroderma involved 5% or more of total body surface area were significantly more likely to have extracutaneous symptoms—arthralgias and orthopedic, pulmonary, and gastrointestinal problems—than were patients whose scleroderma involved less than 5% of total body surface. This held in separate analyses of 89 patients whose charts were reviewed retrospectively and 38 patients studied prospectively and followed.

But neurologic problems were the notable exception in the patient population. “That sticks out like a sore thumb,” said Dr. Gilliam. Localized scleroderma on less than 5% of the body surface area was significantly associated with neurologic problems, and neurologic problems were significantly more common in patients with facial linear scleroderma.

“When we are talking about neurologic problems in the setting of localized scleroderma, we are usually talking about the face, which has at most 6% of the surface area, so these patients with neurologic problems are likely to have lower total body surface area involvement,” she said.

Apart from the relationship with body surface area, Dr. Gilliam showed neurologic problems were more common in patients with facial linear scleroderma versus other forms of localized scleroderma (33% vs. 8%). Her data showed that orthopedic problems were significantly more common in patients with nonfacial linear scleroderma, compared with those who had other forms of localized scleroderma (22% vs. 2%).

But body surface area alone isn't enough to assess localized scleroderma, Dr. Gilliam said. The patients to worry about are those with segmental or linear presentations and those with the characteristic pinkish-purple macules that indicate generalized morphea.

It's important to think about location in cases of localized scleroderma, Dr. Gilliam added. In her study, gastrointestinal problems were significantly more common in patients with generalized morphea and in patients who had scleroderma on the trunk, compared with those who had scleroderma in other locations (21% vs. 5%). But location isn't everything: Pulmonary problems were significantly more common among patients with generalized morphea, but the presence or absence of localized scleroderma on the trunk was not significant.

Dr. Gilliam did not find a significant link between positive levels of antinuclear antibodies and extracutaneous conditions, although she cited a separate study of 750 patients that did show a significant association (Arthritis Rheum. 2005;52:2873-81). She found positive antinuclear antibody levels were slightly, but not significantly, more prevalent in patients with linear scleroderma and with generalized morphea.

CHICAGO — When facing a child with localized scleroderma, be wary if the scleroderma is linear, especially on the face or a limb where it crosses a joint, Dr. Amy Gilliam said at the annual meeting of the Society for Pediatric Dermatology.

Not all young people initially present with the skin hardening and atrophy that characterizes scleroderma, explained Dr. Gilliam, of the University of California, San Francisco. These patients are often misdiagnosed with vitiligo for months or years before the correct diagnosis of juvenile localized scleroderma is made.

To better characterize localized scleroderma in children, Dr. Gilliam and her colleagues reviewed data from 127 patients under 21 years evaluated at UCSF. Dr. Gilliam's research was supported in part by a grant from the Society for Pediatric Dermatology and the Dermatology Foundation, but she had no other financial disclosures. “We collected information on body surface area of involvement. And we had a dermatology perspective rather than a rheumatology perspective,” Dr. Gilliam said.

“The presenting sign in about 50% of the patients was some type of dyspigmentation, either hyper-, hypo- or depigmentation,” she said. Add the 19 patients who had what they called a “bruise,” and dyspigmentation was a presenting symptom in nearly two-thirds of the cases.

Another finding was that patients whose scleroderma involved 5% or more of total body surface area were significantly more likely to have extracutaneous symptoms—arthralgias and orthopedic, pulmonary, and gastrointestinal problems—than were patients whose scleroderma involved less than 5% of total body surface. This held in separate analyses of 89 patients whose charts were reviewed retrospectively and 38 patients studied prospectively and followed.

But neurologic problems were the notable exception in the patient population. “That sticks out like a sore thumb,” said Dr. Gilliam. Localized scleroderma on less than 5% of the body surface area was significantly associated with neurologic problems, and neurologic problems were significantly more common in patients with facial linear scleroderma.

“When we are talking about neurologic problems in the setting of localized scleroderma, we are usually talking about the face, which has at most 6% of the surface area, so these patients with neurologic problems are likely to have lower total body surface area involvement,” she said.

Apart from the relationship with body surface area, Dr. Gilliam showed neurologic problems were more common in patients with facial linear scleroderma versus other forms of localized scleroderma (33% vs. 8%). Her data showed that orthopedic problems were significantly more common in patients with nonfacial linear scleroderma, compared with those who had other forms of localized scleroderma (22% vs. 2%).

But body surface area alone isn't enough to assess localized scleroderma, Dr. Gilliam said. The patients to worry about are those with segmental or linear presentations and those with the characteristic pinkish-purple macules that indicate generalized morphea.

It's important to think about location in cases of localized scleroderma, Dr. Gilliam added. In her study, gastrointestinal problems were significantly more common in patients with generalized morphea and in patients who had scleroderma on the trunk, compared with those who had scleroderma in other locations (21% vs. 5%). But location isn't everything: Pulmonary problems were significantly more common among patients with generalized morphea, but the presence or absence of localized scleroderma on the trunk was not significant.

Dr. Gilliam did not find a significant link between positive levels of antinuclear antibodies and extracutaneous conditions, although she cited a separate study of 750 patients that did show a significant association (Arthritis Rheum. 2005;52:2873-81). She found positive antinuclear antibody levels were slightly, but not significantly, more prevalent in patients with linear scleroderma and with generalized morphea.

MINNEAPOLIS — Metabolic changes and comorbid conditions are just a few of the challenges involved in treating insomnia in older adults.

“The predictability of your giving drug X to patient A and knowing what is going to happen goes way down. That's the bottom line,” said Dr. Daniel Buysse, a professor of psychiatry and the director of the Clinical Neuroscience Research Center at the University of Pittsburgh.

The physiologic changes that occur with aging affect how the body absorbs medication, Dr. Buysse said at the annual meeting of the Associated Professional Sleep Societies.

“As we get older, our lean body mass decreases and our adipose tissue increases,” he noted. Because the drugs used to treat insomnia are lipid soluble, older adults who have a greater proportion of adipose tissue will store the drug longer before processing it through the body, Dr. Buysse explained. Consequently, older patients may have more residual sleepiness the next day after taking a sleep medication the previous night, and their dosages may need adjustment.

Hypnotics have shown effectiveness in treating insomnia in adults, but be aware that the measured blood concentrations of drugs are much more variable in an older population, Dr. Buysse said. In addition, some data have shown that hypnotics are associated with cognitive and psycho- motor problems in older patients.

Antidepressants such as trazodone may be helpful for some patients; but be aware of the risks of dizziness, which could lead to falls, and the risk of oversedation because of older adults' slower metabolisms.

Choosing insomnia medications for older adults is tricky, said Dr. Alon Avidan, a neurologist at the University of California, Los Angeles. Drugs have their risks, but untreated insomnia can be just as risky, because it has been linked to an increased risk of falls in older adults. Elderly people who wake up at night are likely to get out of bed, which means that they are at greater risk for falls than older adults who are able to sleep longer.

In fact, hypnotics may be protective in preventing falls in older adults with insomnia, Dr. Avidan said, based on data from his study of more than 34,000 nursing home residents with an average age of 84 years (J. Am. Geriatr. Soc. 2005;53:955–62).

The patients with untreated insomnia were 30% more likely to fall, compared with those who were treated with hypnotics. But treating insomnia had no measurable effect on the patients' risk for hip fractures, Dr. Avidan noted.

Dr. Buysse shared his top clinical considerations when choosing drug therapies for elderly patients with insomnia.

First, keep expectations realistic, he advised. “The fact that older adults have comorbidities may limit how well we can do with our treatments,” he noted. Comorbid health conditions may affect how older adults feel during the day regardless of whether they have slept well.

Second, remind patients that insomnia medication is not a general anesthesia. “Some older adults look at sleep as a behavioral alternative when they run out of things to do,” Dr. Buysse said. “Some patients take a pill at 8 p.m. and they think they will be out for the night.”

In addition, remember that no evidence-based treatment guidelines exist to direct treatment of insomnia in older adults.

“We have not the least idea how to match a particular treatment to a patient, and we don't really know what constitutes a clinically significant response,” Dr. Buysse said.

Findings from a recent meta-analysis suggest that many of the drugs currently available for treating insomnia—including the nonbenzodiazepine hypnotics zolpidem and zaleplon, some benzodiazepines, and the antidepressant drug trazodone—have not shown consistent effectiveness in improving sleep in older adults (Ann. Clin. Psychiatry 2006;18:49–56).

Dr. Buysse recommended starting with a benzodiazepine receptor agonist, and then switching to a sedating antidepressant if the benzodiazepine doesn't help.

“When people still don't improve, you could start moving to other methods such as behavioral therapy,” he said.

More research is needed to understand how to combine drug therapy with behavior therapy to treat insomnia in older adults, he added.

Keep expectations realistic. 'The fact that older adults have comorbidities may limit how well we can do with our treatments.' DR. BUYSSE

MINNEAPOLIS — Metabolic changes and comorbid conditions are just a few of the challenges involved in treating insomnia in older adults.

“The predictability of your giving drug X to patient A and knowing what is going to happen goes way down. That's the bottom line,” said Dr. Daniel Buysse, a professor of psychiatry and the director of the Clinical Neuroscience Research Center at the University of Pittsburgh.

The physiologic changes that occur with aging affect how the body absorbs medication, Dr. Buysse said at the annual meeting of the Associated Professional Sleep Societies.

“As we get older, our lean body mass decreases and our adipose tissue increases,” he noted. Because the drugs used to treat insomnia are lipid soluble, older adults who have a greater proportion of adipose tissue will store the drug longer before processing it through the body, Dr. Buysse explained. Consequently, older patients may have more residual sleepiness the next day after taking a sleep medication the previous night, and their dosages may need adjustment.

Hypnotics have shown effectiveness in treating insomnia in adults, but be aware that the measured blood concentrations of drugs are much more variable in an older population, Dr. Buysse said. In addition, some data have shown that hypnotics are associated with cognitive and psycho- motor problems in older patients.

Antidepressants such as trazodone may be helpful for some patients; but be aware of the risks of dizziness, which could lead to falls, and the risk of oversedation because of older adults' slower metabolisms.

Choosing insomnia medications for older adults is tricky, said Dr. Alon Avidan, a neurologist at the University of California, Los Angeles. Drugs have their risks, but untreated insomnia can be just as risky, because it has been linked to an increased risk of falls in older adults. Elderly people who wake up at night are likely to get out of bed, which means that they are at greater risk for falls than older adults who are able to sleep longer.

In fact, hypnotics may be protective in preventing falls in older adults with insomnia, Dr. Avidan said, based on data from his study of more than 34,000 nursing home residents with an average age of 84 years (J. Am. Geriatr. Soc. 2005;53:955–62).

The patients with untreated insomnia were 30% more likely to fall, compared with those who were treated with hypnotics. But treating insomnia had no measurable effect on the patients' risk for hip fractures, Dr. Avidan noted.

Dr. Buysse shared his top clinical considerations when choosing drug therapies for elderly patients with insomnia.

First, keep expectations realistic, he advised. “The fact that older adults have comorbidities may limit how well we can do with our treatments,” he noted. Comorbid health conditions may affect how older adults feel during the day regardless of whether they have slept well.

Second, remind patients that insomnia medication is not a general anesthesia. “Some older adults look at sleep as a behavioral alternative when they run out of things to do,” Dr. Buysse said. “Some patients take a pill at 8 p.m. and they think they will be out for the night.”

In addition, remember that no evidence-based treatment guidelines exist to direct treatment of insomnia in older adults.

“We have not the least idea how to match a particular treatment to a patient, and we don't really know what constitutes a clinically significant response,” Dr. Buysse said.

Findings from a recent meta-analysis suggest that many of the drugs currently available for treating insomnia—including the nonbenzodiazepine hypnotics zolpidem and zaleplon, some benzodiazepines, and the antidepressant drug trazodone—have not shown consistent effectiveness in improving sleep in older adults (Ann. Clin. Psychiatry 2006;18:49–56).

Dr. Buysse recommended starting with a benzodiazepine receptor agonist, and then switching to a sedating antidepressant if the benzodiazepine doesn't help.

“When people still don't improve, you could start moving to other methods such as behavioral therapy,” he said.

More research is needed to understand how to combine drug therapy with behavior therapy to treat insomnia in older adults, he added.

Keep expectations realistic. 'The fact that older adults have comorbidities may limit how well we can do with our treatments.' DR. BUYSSE

MINNEAPOLIS — Metabolic changes and comorbid conditions are just a few of the challenges involved in treating insomnia in older adults.

“The predictability of your giving drug X to patient A and knowing what is going to happen goes way down. That's the bottom line,” said Dr. Daniel Buysse, a professor of psychiatry and the director of the Clinical Neuroscience Research Center at the University of Pittsburgh.

The physiologic changes that occur with aging affect how the body absorbs medication, Dr. Buysse said at the annual meeting of the Associated Professional Sleep Societies.

“As we get older, our lean body mass decreases and our adipose tissue increases,” he noted. Because the drugs used to treat insomnia are lipid soluble, older adults who have a greater proportion of adipose tissue will store the drug longer before processing it through the body, Dr. Buysse explained. Consequently, older patients may have more residual sleepiness the next day after taking a sleep medication the previous night, and their dosages may need adjustment.

Hypnotics have shown effectiveness in treating insomnia in adults, but be aware that the measured blood concentrations of drugs are much more variable in an older population, Dr. Buysse said. In addition, some data have shown that hypnotics are associated with cognitive and psycho- motor problems in older patients.

Antidepressants such as trazodone may be helpful for some patients; but be aware of the risks of dizziness, which could lead to falls, and the risk of oversedation because of older adults' slower metabolisms.

Choosing insomnia medications for older adults is tricky, said Dr. Alon Avidan, a neurologist at the University of California, Los Angeles. Drugs have their risks, but untreated insomnia can be just as risky, because it has been linked to an increased risk of falls in older adults. Elderly people who wake up at night are likely to get out of bed, which means that they are at greater risk for falls than older adults who are able to sleep longer.

In fact, hypnotics may be protective in preventing falls in older adults with insomnia, Dr. Avidan said, based on data from his study of more than 34,000 nursing home residents with an average age of 84 years (J. Am. Geriatr. Soc. 2005;53:955–62).

The patients with untreated insomnia were 30% more likely to fall, compared with those who were treated with hypnotics. But treating insomnia had no measurable effect on the patients' risk for hip fractures, Dr. Avidan noted.

Dr. Buysse shared his top clinical considerations when choosing drug therapies for elderly patients with insomnia.

First, keep expectations realistic, he advised. “The fact that older adults have comorbidities may limit how well we can do with our treatments,” he noted. Comorbid health conditions may affect how older adults feel during the day regardless of whether they have slept well.

Second, remind patients that insomnia medication is not a general anesthesia. “Some older adults look at sleep as a behavioral alternative when they run out of things to do,” Dr. Buysse said. “Some patients take a pill at 8 p.m. and they think they will be out for the night.”

In addition, remember that no evidence-based treatment guidelines exist to direct treatment of insomnia in older adults.

“We have not the least idea how to match a particular treatment to a patient, and we don't really know what constitutes a clinically significant response,” Dr. Buysse said.

Findings from a recent meta-analysis suggest that many of the drugs currently available for treating insomnia—including the nonbenzodiazepine hypnotics zolpidem and zaleplon, some benzodiazepines, and the antidepressant drug trazodone—have not shown consistent effectiveness in improving sleep in older adults (Ann. Clin. Psychiatry 2006;18:49–56).

Dr. Buysse recommended starting with a benzodiazepine receptor agonist, and then switching to a sedating antidepressant if the benzodiazepine doesn't help.

“When people still don't improve, you could start moving to other methods such as behavioral therapy,” he said.

More research is needed to understand how to combine drug therapy with behavior therapy to treat insomnia in older adults, he added.

Keep expectations realistic. 'The fact that older adults have comorbidities may limit how well we can do with our treatments.' DR. BUYSSE

CHICAGO — Intermittent treatment with tacrolimus ointment kept atopic dermatitis under control with no need for corticosteroids in patients aged 2–15 years whose conditions had stabilized, according to a presentation at the annual meeting of the Society for Pediatric Dermatology.

Concerns persist about the long-term effects of corticosteroid use by children and teens, so safe and effective alternatives are needed for the long-term management of atopic dermatitis (AD). The black box warning attached to tacrolimus (Protopic) says that continuous use should be avoided, so Dr. Amy S. Paller of Northwestern University, Chicago, and her colleagues designed a plan that involved applying tacrolimus ointment to the affected skin three times weekly for 40 weeks.

The goal was to prevent flares in patients whose AD had stabilized. The randomized trial of the protocol's safety and effectiveness was sponsored by Astellas Pharma US Inc.

A total of 206 patients were randomized, but 54 discontinued the study. The most common reason for discontinuation was loss to follow-up (15 patients). Ten children dropped out because of uncontrolled rebound exacerbation of their AD, and five dropped out because of an adverse event.

Overall, those who received tacrolimus ointment had significantly fewer relapse days (47) than those who received a control ointment containing alclometasone (76 days). The tacrolimus patients remained stable for significantly more days before their first relapses (116 days vs. 31 days).

Only 6% of the children in the tacrolimus group relapsed for up to 3 days during the study period. In the control group, 19% of the children relapsed for up to 6 days. The most common adverse events reported by tacrolimus patients were burning and itching at the application site, which reflects results from previous safety studies.

CHICAGO — Intermittent treatment with tacrolimus ointment kept atopic dermatitis under control with no need for corticosteroids in patients aged 2–15 years whose conditions had stabilized, according to a presentation at the annual meeting of the Society for Pediatric Dermatology.

Concerns persist about the long-term effects of corticosteroid use by children and teens, so safe and effective alternatives are needed for the long-term management of atopic dermatitis (AD). The black box warning attached to tacrolimus (Protopic) says that continuous use should be avoided, so Dr. Amy S. Paller of Northwestern University, Chicago, and her colleagues designed a plan that involved applying tacrolimus ointment to the affected skin three times weekly for 40 weeks.

The goal was to prevent flares in patients whose AD had stabilized. The randomized trial of the protocol's safety and effectiveness was sponsored by Astellas Pharma US Inc.

A total of 206 patients were randomized, but 54 discontinued the study. The most common reason for discontinuation was loss to follow-up (15 patients). Ten children dropped out because of uncontrolled rebound exacerbation of their AD, and five dropped out because of an adverse event.

Overall, those who received tacrolimus ointment had significantly fewer relapse days (47) than those who received a control ointment containing alclometasone (76 days). The tacrolimus patients remained stable for significantly more days before their first relapses (116 days vs. 31 days).

Only 6% of the children in the tacrolimus group relapsed for up to 3 days during the study period. In the control group, 19% of the children relapsed for up to 6 days. The most common adverse events reported by tacrolimus patients were burning and itching at the application site, which reflects results from previous safety studies.

CHICAGO — Intermittent treatment with tacrolimus ointment kept atopic dermatitis under control with no need for corticosteroids in patients aged 2–15 years whose conditions had stabilized, according to a presentation at the annual meeting of the Society for Pediatric Dermatology.

Concerns persist about the long-term effects of corticosteroid use by children and teens, so safe and effective alternatives are needed for the long-term management of atopic dermatitis (AD). The black box warning attached to tacrolimus (Protopic) says that continuous use should be avoided, so Dr. Amy S. Paller of Northwestern University, Chicago, and her colleagues designed a plan that involved applying tacrolimus ointment to the affected skin three times weekly for 40 weeks.

The goal was to prevent flares in patients whose AD had stabilized. The randomized trial of the protocol's safety and effectiveness was sponsored by Astellas Pharma US Inc.

A total of 206 patients were randomized, but 54 discontinued the study. The most common reason for discontinuation was loss to follow-up (15 patients). Ten children dropped out because of uncontrolled rebound exacerbation of their AD, and five dropped out because of an adverse event.

Overall, those who received tacrolimus ointment had significantly fewer relapse days (47) than those who received a control ointment containing alclometasone (76 days). The tacrolimus patients remained stable for significantly more days before their first relapses (116 days vs. 31 days).

Only 6% of the children in the tacrolimus group relapsed for up to 3 days during the study period. In the control group, 19% of the children relapsed for up to 6 days. The most common adverse events reported by tacrolimus patients were burning and itching at the application site, which reflects results from previous safety studies.

CHICAGO — Many genetically based periodic fever syndromes have skin signs that may help identify the syndromes on the rare occasions when they occur, Dr. Kathryn M. Edwards said at the annual meeting of the Society for Pediatric Dermatology.

Although these syndromes, called familial periodic fever syndromes, are rare, knowing something about them will “allow you to think more about how we control fever and inflammatory processes in children,” noted Dr. Edwards, professor of pediatrics at Vanderbilt University, Nashville, Tenn.

“Periodic fever is a very specific diagnosis,” said Dr. Edwards, an expert vaccinologist who has conducted research for the National Institutes of Health. Periodic fevers are fevers that recur at intervals lasting from a few days to a few weeks separated by totally symptom-free intervals.

A periodic fever syndrome is a form of autoinflammatory disorder. “Generally periodic fevers that have been present for more than 2 years are never associated with infection or malignancy,” she explained.

In one study, 29 children with periodic fevers tended to be younger at the onset of the fever (often less than 1 year of age), had a longer duration of symptoms before they were referred for further evaluation, and had higher maximum fever temperatures, compared with 11 children with daily fevers (J. Pediatr. 1996;129:419–23).

About a quarter of the periodic fever patients had a nonspecific rash, but so did the children with daily fevers. Comorbid rash and fever isn't enough to diagnose a familial periodic fever syndrome. But pharyngitis and oral ulcers or adenopathy were seen much more often in patients with periodic fever during their intervals of fever than in those with daily fevers.

The familial syndromes are characterized by identified genetic defects that inhibit the body's ability to control inflammation, and genetic testing is needed to confirm a diagnosis of these syndromes.

There are distinct patterns of ancestry for familial periodic fever syndromes and the genes have been circulating for generations, said Dr. Edwards. “The familial febrile syndromes are not easy to diagnose, and if you have a patient who you suspect has one of these syndromes, please contact the NIH for genotyping,” she said.

Following are the familial periodic fever syndromes she described:

▸ Familial Mediterranean Fever (FMF). FMF is linked to a recessive gene known as MEFV. Many patients experience secondary amyloidosis, in which a protein buildup in various organs and tissues can impede their functions. FMF is common in Jewish families of Spanish, Portuguese, or Middle Eastern descent, but it is rare in Jewish families of European descent, Dr. Edwards noted.

Clinical features include serositis and scrotal swelling, and the periodic attacks of fever often begin in childhood. The most common dermatologic manifestation is a distinctive erysipeloid rash on the lower extremities that occurs in about 15% of children with this syndrome. Studies have shown that about half of these patients also report arthritis in one ankle, knee, or hip. The fever attacks in FMF patients occur at regular intervals, and they usually respond to treatment within 12–72 hours. Colchicine treatment has been shown to be effective in preventing the fever episodes (and the subsequent rash), although not in treating the acute attacks of fever once they occur.

“If you treat people with FMF regularly with colchicine they don't get attacks of fever and they don't get amyloidosis, so it is important that FMF is diagnosed,” Dr. Edwards said.

▸ Hyperimmunoglobulinemia D Syndrome (HIDS). HIDS has an early onset (the median age of onset is 6 months), and recurrent attacks of fever persist throughout the patient's life. Febrile attacks usually last for 3–7 days at irregular intervals ranging from 4 to 8 weeks. Clinical features include cervical adenitis, vomiting, and diarrhea. A patient with HIDS may present to a dermatologist with a maculopapular rash, with petechiae and purpura that appear during a febrile attack. Generalized lymphadenopathy and rash are very common in these patients.

Distinctive laboratory features include an elevated IgD (greater than 14.3 mg/dL), but this elevation is not present in all HIDS patients. The gene for HIDS has been mapped to chromosome 12 and at least 8 different mutations or deletions have been seen, but the syndrome is most likely to occur in people with Dutch or French ancestry, Dr. Edwards said.

▸ Tumor Necrosis Factor-Receptor Associated Periodic Syndrome (TRAPS). Children with TRAPS may have a lifelong history of febrile episodes that last 2–3 weeks at a time, but the febrile episodes only occur 2–3 times per year.

Conjunctivitis and raised red lesions distinguish TRAPS from other familial periodic fever syndromes. One study of 25 TRAPS patients showed that 21 (84%) had erythematous patches, including both wavy and circular lesions (N. Engl. J. Med. 2001;345:1748–57). Other clinical features of TRAPS include myalgia, arthralgia, and abdominal pain.

Skin manifestations are much more common with TRAPS than with the other familial periodic fever syndromes. “Almost all of these children will have skin lesions that may persist even when the fever is gone,” Dr. Edwards noted.

When a febrile episode occurs, TNF receptors are suppressed, which creates an uncontrolled inflammatory response. Consequently, TNF inhibitors can be used to treat these patients, Dr. Edwards said.

▸ Muckle-Wells Syndrome/Familial Cold Urticaria. These two syndromes are both associated with mutations of the CIAS1 gene family. Mutations in these genes lead to autoinflammatory syndromes in which large numbers of cytokines are generated, which means that amyloidosis is very frequent in these individuals.

Patients with Muckle-Wells syndrome (MWS) generally present with urticaria and progressive sensorineural loss and deafness. Because MWS is a disease of dominant genes, the parent may show signs of hearing problems, which should prompt clinicians to include MWS in the differential diagnosis of recurrent urticaria and fever.

By contrast, patients with familial cold urticaria will present not only with urticaria and wheals, but with complaints of painful joints, chills, and fever. Febrile episodes in patients with familial cold urticaria generally occur several hours after exposure to cold. Both syndromes are associated with German, English, French, and North American ancestry.

CHICAGO — Many genetically based periodic fever syndromes have skin signs that may help identify the syndromes on the rare occasions when they occur, Dr. Kathryn M. Edwards said at the annual meeting of the Society for Pediatric Dermatology.

Although these syndromes, called familial periodic fever syndromes, are rare, knowing something about them will “allow you to think more about how we control fever and inflammatory processes in children,” noted Dr. Edwards, professor of pediatrics at Vanderbilt University, Nashville, Tenn.

“Periodic fever is a very specific diagnosis,” said Dr. Edwards, an expert vaccinologist who has conducted research for the National Institutes of Health. Periodic fevers are fevers that recur at intervals lasting from a few days to a few weeks separated by totally symptom-free intervals.

A periodic fever syndrome is a form of autoinflammatory disorder. “Generally periodic fevers that have been present for more than 2 years are never associated with infection or malignancy,” she explained.

In one study, 29 children with periodic fevers tended to be younger at the onset of the fever (often less than 1 year of age), had a longer duration of symptoms before they were referred for further evaluation, and had higher maximum fever temperatures, compared with 11 children with daily fevers (J. Pediatr. 1996;129:419–23).

About a quarter of the periodic fever patients had a nonspecific rash, but so did the children with daily fevers. Comorbid rash and fever isn't enough to diagnose a familial periodic fever syndrome. But pharyngitis and oral ulcers or adenopathy were seen much more often in patients with periodic fever during their intervals of fever than in those with daily fevers.

The familial syndromes are characterized by identified genetic defects that inhibit the body's ability to control inflammation, and genetic testing is needed to confirm a diagnosis of these syndromes.

There are distinct patterns of ancestry for familial periodic fever syndromes and the genes have been circulating for generations, said Dr. Edwards. “The familial febrile syndromes are not easy to diagnose, and if you have a patient who you suspect has one of these syndromes, please contact the NIH for genotyping,” she said.

Following are the familial periodic fever syndromes she described:

▸ Familial Mediterranean Fever (FMF). FMF is linked to a recessive gene known as MEFV. Many patients experience secondary amyloidosis, in which a protein buildup in various organs and tissues can impede their functions. FMF is common in Jewish families of Spanish, Portuguese, or Middle Eastern descent, but it is rare in Jewish families of European descent, Dr. Edwards noted.

Clinical features include serositis and scrotal swelling, and the periodic attacks of fever often begin in childhood. The most common dermatologic manifestation is a distinctive erysipeloid rash on the lower extremities that occurs in about 15% of children with this syndrome. Studies have shown that about half of these patients also report arthritis in one ankle, knee, or hip. The fever attacks in FMF patients occur at regular intervals, and they usually respond to treatment within 12–72 hours. Colchicine treatment has been shown to be effective in preventing the fever episodes (and the subsequent rash), although not in treating the acute attacks of fever once they occur.

“If you treat people with FMF regularly with colchicine they don't get attacks of fever and they don't get amyloidosis, so it is important that FMF is diagnosed,” Dr. Edwards said.

▸ Hyperimmunoglobulinemia D Syndrome (HIDS). HIDS has an early onset (the median age of onset is 6 months), and recurrent attacks of fever persist throughout the patient's life. Febrile attacks usually last for 3–7 days at irregular intervals ranging from 4 to 8 weeks. Clinical features include cervical adenitis, vomiting, and diarrhea. A patient with HIDS may present to a dermatologist with a maculopapular rash, with petechiae and purpura that appear during a febrile attack. Generalized lymphadenopathy and rash are very common in these patients.

Distinctive laboratory features include an elevated IgD (greater than 14.3 mg/dL), but this elevation is not present in all HIDS patients. The gene for HIDS has been mapped to chromosome 12 and at least 8 different mutations or deletions have been seen, but the syndrome is most likely to occur in people with Dutch or French ancestry, Dr. Edwards said.

▸ Tumor Necrosis Factor-Receptor Associated Periodic Syndrome (TRAPS). Children with TRAPS may have a lifelong history of febrile episodes that last 2–3 weeks at a time, but the febrile episodes only occur 2–3 times per year.

Conjunctivitis and raised red lesions distinguish TRAPS from other familial periodic fever syndromes. One study of 25 TRAPS patients showed that 21 (84%) had erythematous patches, including both wavy and circular lesions (N. Engl. J. Med. 2001;345:1748–57). Other clinical features of TRAPS include myalgia, arthralgia, and abdominal pain.

Skin manifestations are much more common with TRAPS than with the other familial periodic fever syndromes. “Almost all of these children will have skin lesions that may persist even when the fever is gone,” Dr. Edwards noted.

When a febrile episode occurs, TNF receptors are suppressed, which creates an uncontrolled inflammatory response. Consequently, TNF inhibitors can be used to treat these patients, Dr. Edwards said.

▸ Muckle-Wells Syndrome/Familial Cold Urticaria. These two syndromes are both associated with mutations of the CIAS1 gene family. Mutations in these genes lead to autoinflammatory syndromes in which large numbers of cytokines are generated, which means that amyloidosis is very frequent in these individuals.

Patients with Muckle-Wells syndrome (MWS) generally present with urticaria and progressive sensorineural loss and deafness. Because MWS is a disease of dominant genes, the parent may show signs of hearing problems, which should prompt clinicians to include MWS in the differential diagnosis of recurrent urticaria and fever.

By contrast, patients with familial cold urticaria will present not only with urticaria and wheals, but with complaints of painful joints, chills, and fever. Febrile episodes in patients with familial cold urticaria generally occur several hours after exposure to cold. Both syndromes are associated with German, English, French, and North American ancestry.

CHICAGO — Many genetically based periodic fever syndromes have skin signs that may help identify the syndromes on the rare occasions when they occur, Dr. Kathryn M. Edwards said at the annual meeting of the Society for Pediatric Dermatology.

Although these syndromes, called familial periodic fever syndromes, are rare, knowing something about them will “allow you to think more about how we control fever and inflammatory processes in children,” noted Dr. Edwards, professor of pediatrics at Vanderbilt University, Nashville, Tenn.

“Periodic fever is a very specific diagnosis,” said Dr. Edwards, an expert vaccinologist who has conducted research for the National Institutes of Health. Periodic fevers are fevers that recur at intervals lasting from a few days to a few weeks separated by totally symptom-free intervals.

A periodic fever syndrome is a form of autoinflammatory disorder. “Generally periodic fevers that have been present for more than 2 years are never associated with infection or malignancy,” she explained.

In one study, 29 children with periodic fevers tended to be younger at the onset of the fever (often less than 1 year of age), had a longer duration of symptoms before they were referred for further evaluation, and had higher maximum fever temperatures, compared with 11 children with daily fevers (J. Pediatr. 1996;129:419–23).

About a quarter of the periodic fever patients had a nonspecific rash, but so did the children with daily fevers. Comorbid rash and fever isn't enough to diagnose a familial periodic fever syndrome. But pharyngitis and oral ulcers or adenopathy were seen much more often in patients with periodic fever during their intervals of fever than in those with daily fevers.

The familial syndromes are characterized by identified genetic defects that inhibit the body's ability to control inflammation, and genetic testing is needed to confirm a diagnosis of these syndromes.

There are distinct patterns of ancestry for familial periodic fever syndromes and the genes have been circulating for generations, said Dr. Edwards. “The familial febrile syndromes are not easy to diagnose, and if you have a patient who you suspect has one of these syndromes, please contact the NIH for genotyping,” she said.

Following are the familial periodic fever syndromes she described:

▸ Familial Mediterranean Fever (FMF). FMF is linked to a recessive gene known as MEFV. Many patients experience secondary amyloidosis, in which a protein buildup in various organs and tissues can impede their functions. FMF is common in Jewish families of Spanish, Portuguese, or Middle Eastern descent, but it is rare in Jewish families of European descent, Dr. Edwards noted.

Clinical features include serositis and scrotal swelling, and the periodic attacks of fever often begin in childhood. The most common dermatologic manifestation is a distinctive erysipeloid rash on the lower extremities that occurs in about 15% of children with this syndrome. Studies have shown that about half of these patients also report arthritis in one ankle, knee, or hip. The fever attacks in FMF patients occur at regular intervals, and they usually respond to treatment within 12–72 hours. Colchicine treatment has been shown to be effective in preventing the fever episodes (and the subsequent rash), although not in treating the acute attacks of fever once they occur.

“If you treat people with FMF regularly with colchicine they don't get attacks of fever and they don't get amyloidosis, so it is important that FMF is diagnosed,” Dr. Edwards said.

▸ Hyperimmunoglobulinemia D Syndrome (HIDS). HIDS has an early onset (the median age of onset is 6 months), and recurrent attacks of fever persist throughout the patient's life. Febrile attacks usually last for 3–7 days at irregular intervals ranging from 4 to 8 weeks. Clinical features include cervical adenitis, vomiting, and diarrhea. A patient with HIDS may present to a dermatologist with a maculopapular rash, with petechiae and purpura that appear during a febrile attack. Generalized lymphadenopathy and rash are very common in these patients.

Distinctive laboratory features include an elevated IgD (greater than 14.3 mg/dL), but this elevation is not present in all HIDS patients. The gene for HIDS has been mapped to chromosome 12 and at least 8 different mutations or deletions have been seen, but the syndrome is most likely to occur in people with Dutch or French ancestry, Dr. Edwards said.

▸ Tumor Necrosis Factor-Receptor Associated Periodic Syndrome (TRAPS). Children with TRAPS may have a lifelong history of febrile episodes that last 2–3 weeks at a time, but the febrile episodes only occur 2–3 times per year.

Conjunctivitis and raised red lesions distinguish TRAPS from other familial periodic fever syndromes. One study of 25 TRAPS patients showed that 21 (84%) had erythematous patches, including both wavy and circular lesions (N. Engl. J. Med. 2001;345:1748–57). Other clinical features of TRAPS include myalgia, arthralgia, and abdominal pain.

Skin manifestations are much more common with TRAPS than with the other familial periodic fever syndromes. “Almost all of these children will have skin lesions that may persist even when the fever is gone,” Dr. Edwards noted.

When a febrile episode occurs, TNF receptors are suppressed, which creates an uncontrolled inflammatory response. Consequently, TNF inhibitors can be used to treat these patients, Dr. Edwards said.

▸ Muckle-Wells Syndrome/Familial Cold Urticaria. These two syndromes are both associated with mutations of the CIAS1 gene family. Mutations in these genes lead to autoinflammatory syndromes in which large numbers of cytokines are generated, which means that amyloidosis is very frequent in these individuals.

Patients with Muckle-Wells syndrome (MWS) generally present with urticaria and progressive sensorineural loss and deafness. Because MWS is a disease of dominant genes, the parent may show signs of hearing problems, which should prompt clinicians to include MWS in the differential diagnosis of recurrent urticaria and fever.

By contrast, patients with familial cold urticaria will present not only with urticaria and wheals, but with complaints of painful joints, chills, and fever. Febrile episodes in patients with familial cold urticaria generally occur several hours after exposure to cold. Both syndromes are associated with German, English, French, and North American ancestry.

MINNEAPOLIS – Women with no history of sleep disorders often report sleep problems–especially difficulty falling asleep–as they undergo menopause. Their complaints were validated by a sleep study of more than 700 women presented at the annual meeting of the Associated Professional Sleep Societies.

“These data provide, for the first time, objective findings to support this common sleep complaint in postmenopausal women,” asserted Edward O. Bixler, Ph.D., who is vice chair of the sleep research division at Pennsylvania State University in Hershey.

To confirm the association between menopause and poor sleep and to seek a possible mechanism for this connection, Dr. Bixler and his colleagues conducted single-night polysomnographies on 715 women with a mean age of 49 years. Of these, 400 women were premenopausal, 120 were postmenopausal and using hormone therapy (HT), and 195 were postmenopausal but not using HT.

Women sleep as well as or better than men until they reach menopause, but sleep needs change with age, Dr. Bixler noted.

With this fact in mind, the researchers used a group of 609 men who were at least 45 years old (with an average age of 49 years) as controls for the study. The average body mass index for both genders was 26.9 kg/m

The results of the single-night sleep test showed that the postmenopausal women who were not on hormone therapy took an average of 15 minutes longer to fall asleep, compared with women who were on HT, and an average of 10 minutes longer to fall asleep compared with the men. These differences were statistically significant.

The average time it took for the male controls to fall asleep was not significantly different from that of premenopausal women (a difference of 1.6 minutes) or of postmenopausal women who were taking hormone therapy (a difference of 5.6 minutes).

“What was unexpected was that we didn't find an increase in daytime sleepiness,” Dr. Bixler noted. He proposed that the lack of daytime sleepiness might be a result of the reduced need for sleep that is a natural part of aging. “As you age, you are less likely to be sleepy during the day even though you are sleeping less at night,” he said.

When the researchers looked at slow wave sleep, which is associated with the brain's ability to recharge, think, and remember, they found no differences between premenopausal women and male controls.

Postmenopausal women who didn't use HT, however, were twice as likely to have slow wave sleep as were male controls, and postmenopausal women who used HT were four times as likely to have slow wave sleep as were male controls. Therefore, postmenopausal women who used HT were twice as likely to have slow wave sleep as were women who didn't use HT.

The data suggest that sleep latency is a valid symptom among menopausal women without a history of sleep disorders, especially among those who are not using HT. Based on these findings, menopausal women may be at increased risk for developing chronic insomnia that may require treatment, Dr. Bixler added.

“We would speculate that [menopausal changes] may be triggers for the onset of primary insomnia in vulnerable women,” he said.

MINNEAPOLIS – Women with no history of sleep disorders often report sleep problems–especially difficulty falling asleep–as they undergo menopause. Their complaints were validated by a sleep study of more than 700 women presented at the annual meeting of the Associated Professional Sleep Societies.

“These data provide, for the first time, objective findings to support this common sleep complaint in postmenopausal women,” asserted Edward O. Bixler, Ph.D., who is vice chair of the sleep research division at Pennsylvania State University in Hershey.

To confirm the association between menopause and poor sleep and to seek a possible mechanism for this connection, Dr. Bixler and his colleagues conducted single-night polysomnographies on 715 women with a mean age of 49 years. Of these, 400 women were premenopausal, 120 were postmenopausal and using hormone therapy (HT), and 195 were postmenopausal but not using HT.

Women sleep as well as or better than men until they reach menopause, but sleep needs change with age, Dr. Bixler noted.

With this fact in mind, the researchers used a group of 609 men who were at least 45 years old (with an average age of 49 years) as controls for the study. The average body mass index for both genders was 26.9 kg/m

The results of the single-night sleep test showed that the postmenopausal women who were not on hormone therapy took an average of 15 minutes longer to fall asleep, compared with women who were on HT, and an average of 10 minutes longer to fall asleep compared with the men. These differences were statistically significant.

The average time it took for the male controls to fall asleep was not significantly different from that of premenopausal women (a difference of 1.6 minutes) or of postmenopausal women who were taking hormone therapy (a difference of 5.6 minutes).

“What was unexpected was that we didn't find an increase in daytime sleepiness,” Dr. Bixler noted. He proposed that the lack of daytime sleepiness might be a result of the reduced need for sleep that is a natural part of aging. “As you age, you are less likely to be sleepy during the day even though you are sleeping less at night,” he said.

When the researchers looked at slow wave sleep, which is associated with the brain's ability to recharge, think, and remember, they found no differences between premenopausal women and male controls.

Postmenopausal women who didn't use HT, however, were twice as likely to have slow wave sleep as were male controls, and postmenopausal women who used HT were four times as likely to have slow wave sleep as were male controls. Therefore, postmenopausal women who used HT were twice as likely to have slow wave sleep as were women who didn't use HT.

The data suggest that sleep latency is a valid symptom among menopausal women without a history of sleep disorders, especially among those who are not using HT. Based on these findings, menopausal women may be at increased risk for developing chronic insomnia that may require treatment, Dr. Bixler added.

“We would speculate that [menopausal changes] may be triggers for the onset of primary insomnia in vulnerable women,” he said.

MINNEAPOLIS – Women with no history of sleep disorders often report sleep problems–especially difficulty falling asleep–as they undergo menopause. Their complaints were validated by a sleep study of more than 700 women presented at the annual meeting of the Associated Professional Sleep Societies.

“These data provide, for the first time, objective findings to support this common sleep complaint in postmenopausal women,” asserted Edward O. Bixler, Ph.D., who is vice chair of the sleep research division at Pennsylvania State University in Hershey.

To confirm the association between menopause and poor sleep and to seek a possible mechanism for this connection, Dr. Bixler and his colleagues conducted single-night polysomnographies on 715 women with a mean age of 49 years. Of these, 400 women were premenopausal, 120 were postmenopausal and using hormone therapy (HT), and 195 were postmenopausal but not using HT.

Women sleep as well as or better than men until they reach menopause, but sleep needs change with age, Dr. Bixler noted.

With this fact in mind, the researchers used a group of 609 men who were at least 45 years old (with an average age of 49 years) as controls for the study. The average body mass index for both genders was 26.9 kg/m

The results of the single-night sleep test showed that the postmenopausal women who were not on hormone therapy took an average of 15 minutes longer to fall asleep, compared with women who were on HT, and an average of 10 minutes longer to fall asleep compared with the men. These differences were statistically significant.

The average time it took for the male controls to fall asleep was not significantly different from that of premenopausal women (a difference of 1.6 minutes) or of postmenopausal women who were taking hormone therapy (a difference of 5.6 minutes).

“What was unexpected was that we didn't find an increase in daytime sleepiness,” Dr. Bixler noted. He proposed that the lack of daytime sleepiness might be a result of the reduced need for sleep that is a natural part of aging. “As you age, you are less likely to be sleepy during the day even though you are sleeping less at night,” he said.

When the researchers looked at slow wave sleep, which is associated with the brain's ability to recharge, think, and remember, they found no differences between premenopausal women and male controls.

Postmenopausal women who didn't use HT, however, were twice as likely to have slow wave sleep as were male controls, and postmenopausal women who used HT were four times as likely to have slow wave sleep as were male controls. Therefore, postmenopausal women who used HT were twice as likely to have slow wave sleep as were women who didn't use HT.

The data suggest that sleep latency is a valid symptom among menopausal women without a history of sleep disorders, especially among those who are not using HT. Based on these findings, menopausal women may be at increased risk for developing chronic insomnia that may require treatment, Dr. Bixler added.

“We would speculate that [menopausal changes] may be triggers for the onset of primary insomnia in vulnerable women,” he said.