Heidi Splete

Rates of chlamydia, gonorrhea, and syphilis increased in the United States during the past year and continued recent upward trends, according to a report from the Centers for Disease Control and Prevention

“Young women, racial and ethnic populations, and men who have sex with men are particularly hard hit by these diseases,” Dr. John M. Douglas Jr., director of the CDC's Division of Sexually Transmitted Disease Prevention, said in a teleconference sponsored by the CDC.

The report emphasizes both the magnitude of the diseases and the persistent racial disparity, Dr. Douglas said.

All three diseases are treatable, especially when they are diagnosed early. If left untreated, however, the severe health consequences include pelvic inflammatory disease, infertility, increased risk for HIV infection, organ damage, and death. The direct medical costs associated with STDs in the United States were estimated at nearly $15 billion in 2006, the researchers stated in the report, “Sexually Transmitted Disease Surveillance 2006,” which was presented in a telebriefing.

Of the three diseases, the increased chlamydia rates represent the greatest public health impact, said Dr. Douglas.

In 2006, the national rate of reported cases of chlamydia increased by 5.6% from 2005 to 2006. Specifically, the reported rate was 347.8 cases per 100,000 persons in 2006, compared with 329.4 cases per 100,000 persons in 2005. The increase may reflect increased screening for chlamydia and improved diagnostic tests, but it likely also reflects an increase in the number of infections, the researchers said.

Chlamydia hits hardest among adolescent girls and young women—the highest chlamydia rate was reported in young women aged 15–19 years (2,863 cases per 100,000 persons) followed by women aged 20–24 years (2,797 cases per 100,000 persons). And racial disparity is high: The chlamydia rate was highest among black women, whose rate was more than seven times higher than that of white women and more than twice as high as that of Hispanic women.

Because of the high rate of chlamydia in young women, the CDC recommends screening sexually active women younger than 26 years for the disease. Chlamydia screening is also recommended for older women with new or multiple sex partners, because these women are also at increased risk. Based on recent studies showing that chlamydia reinfection can occur in women whose partners remain untreated, the CDC's treatment guidelines include retesting patients 3 months after treatment.

Screening is one of the most effective and underutilized tools to prevent and treat chlamydia in all populations, Dr. Douglas emphasized. “Providers know the recommendations but don't assume that it applies to the population that they are dealing with,” he said.

“If there are providers who don't think the young women in their practice don't have chlamydia, they should think again,” noted Dr. Stuart Berman, chief epidemiologist at the Division of Sexually Transmitted Disease Prevention.

Gonorrhea rates increased for the second consecutive year, following a plateau in reported disease rates from 1997 to 2005. “The racial disparities are stark,” in reported gonorrhea cases, Dr. Douglas said. Overall, the rate among blacks is 18 times higher than in whites, he said.

Gonorrhea rates also continue to vary by region. As in previous years, the southern region of the United States had the highest overall gonorrhea rate in 2006, at 159 cases per 100,000 persons. But rates in the South rose by 12.3% in 2006, representing the first notable increase in 8 years.

“We are also concerned about increases in the West,” Dr. Douglas said. Gonorrhea cases in the West increased by 2.9% between 2005 and 2006, contributing to a 32% increase between 2002 and 2006. “We will need to monitor the data to determine whether this is an emerging trend.”

Untreated gonorrhea can, among other complications, increase a person's risk for HIV if he or she is exposed. But gonorrhea treatment has become more challenging, because evidence of fluoroquinolone resistance—especially among men who have sex with men—prompted the CDC in April 2007 to stop recommending fluoroquinolones as treatment for any gonorrhea cases. As an alternative, the CDC recommends cephalosporins to treat gonorrhea.

Rates of primary and secondary syphilis rate in the United States increased by nearly 14% from 2005 to 2006, but the most notable increase has occurred among men who have sex with men. Syphilis rates among that group increased by 54% from 2002 to 2006, Dr. Douglas said.

Although syphilis has the least impact on the population as a whole, the rise in reported cases for the sixth consecutive year in women and men is cause for concern, Dr. Douglas said, given a steady decrease during the 1990s.

Overall, the recent rises in reportable STD rates speak to the need for more awareness among the public and health care providers about screening and prevention, said Dr. Douglas.

The report's data provide an incomplete picture of sexually transmitted diseases in the United States, the researchers cautioned, because many cases of chlamydia, gonorrhea, and syphilis are not reported. In addition, some types of STDs, including genital herpes and human papillomavirus, are not tracked by the CDC but contribute to the overall disease burden of STDs, he noted. “These are large numbers of infections, and this is a hidden epidemic that people are not aware of,” added Dr. Berman.

To view the complete report, visit www.cdc.gov/std/stats

Rates of chlamydia, gonorrhea, and syphilis increased in the United States during the past year and continued recent upward trends, according to a report from the Centers for Disease Control and Prevention

“Young women, racial and ethnic populations, and men who have sex with men are particularly hard hit by these diseases,” Dr. John M. Douglas Jr., director of the CDC's Division of Sexually Transmitted Disease Prevention, said in a teleconference sponsored by the CDC.

The report emphasizes both the magnitude of the diseases and the persistent racial disparity, Dr. Douglas said.

All three diseases are treatable, especially when they are diagnosed early. If left untreated, however, the severe health consequences include pelvic inflammatory disease, infertility, increased risk for HIV infection, organ damage, and death. The direct medical costs associated with STDs in the United States were estimated at nearly $15 billion in 2006, the researchers stated in the report, “Sexually Transmitted Disease Surveillance 2006,” which was presented in a telebriefing.

Of the three diseases, the increased chlamydia rates represent the greatest public health impact, said Dr. Douglas.

In 2006, the national rate of reported cases of chlamydia increased by 5.6% from 2005 to 2006. Specifically, the reported rate was 347.8 cases per 100,000 persons in 2006, compared with 329.4 cases per 100,000 persons in 2005. The increase may reflect increased screening for chlamydia and improved diagnostic tests, but it likely also reflects an increase in the number of infections, the researchers said.

Chlamydia hits hardest among adolescent girls and young women—the highest chlamydia rate was reported in young women aged 15–19 years (2,863 cases per 100,000 persons) followed by women aged 20–24 years (2,797 cases per 100,000 persons). And racial disparity is high: The chlamydia rate was highest among black women, whose rate was more than seven times higher than that of white women and more than twice as high as that of Hispanic women.

Because of the high rate of chlamydia in young women, the CDC recommends screening sexually active women younger than 26 years for the disease. Chlamydia screening is also recommended for older women with new or multiple sex partners, because these women are also at increased risk. Based on recent studies showing that chlamydia reinfection can occur in women whose partners remain untreated, the CDC's treatment guidelines include retesting patients 3 months after treatment.

Screening is one of the most effective and underutilized tools to prevent and treat chlamydia in all populations, Dr. Douglas emphasized. “Providers know the recommendations but don't assume that it applies to the population that they are dealing with,” he said.

“If there are providers who don't think the young women in their practice don't have chlamydia, they should think again,” noted Dr. Stuart Berman, chief epidemiologist at the Division of Sexually Transmitted Disease Prevention.

Gonorrhea rates increased for the second consecutive year, following a plateau in reported disease rates from 1997 to 2005. “The racial disparities are stark,” in reported gonorrhea cases, Dr. Douglas said. Overall, the rate among blacks is 18 times higher than in whites, he said.

Gonorrhea rates also continue to vary by region. As in previous years, the southern region of the United States had the highest overall gonorrhea rate in 2006, at 159 cases per 100,000 persons. But rates in the South rose by 12.3% in 2006, representing the first notable increase in 8 years.

“We are also concerned about increases in the West,” Dr. Douglas said. Gonorrhea cases in the West increased by 2.9% between 2005 and 2006, contributing to a 32% increase between 2002 and 2006. “We will need to monitor the data to determine whether this is an emerging trend.”

Untreated gonorrhea can, among other complications, increase a person's risk for HIV if he or she is exposed. But gonorrhea treatment has become more challenging, because evidence of fluoroquinolone resistance—especially among men who have sex with men—prompted the CDC in April 2007 to stop recommending fluoroquinolones as treatment for any gonorrhea cases. As an alternative, the CDC recommends cephalosporins to treat gonorrhea.

Rates of primary and secondary syphilis rate in the United States increased by nearly 14% from 2005 to 2006, but the most notable increase has occurred among men who have sex with men. Syphilis rates among that group increased by 54% from 2002 to 2006, Dr. Douglas said.

Although syphilis has the least impact on the population as a whole, the rise in reported cases for the sixth consecutive year in women and men is cause for concern, Dr. Douglas said, given a steady decrease during the 1990s.

Overall, the recent rises in reportable STD rates speak to the need for more awareness among the public and health care providers about screening and prevention, said Dr. Douglas.

The report's data provide an incomplete picture of sexually transmitted diseases in the United States, the researchers cautioned, because many cases of chlamydia, gonorrhea, and syphilis are not reported. In addition, some types of STDs, including genital herpes and human papillomavirus, are not tracked by the CDC but contribute to the overall disease burden of STDs, he noted. “These are large numbers of infections, and this is a hidden epidemic that people are not aware of,” added Dr. Berman.

To view the complete report, visit www.cdc.gov/std/stats

Rates of chlamydia, gonorrhea, and syphilis increased in the United States during the past year and continued recent upward trends, according to a report from the Centers for Disease Control and Prevention

“Young women, racial and ethnic populations, and men who have sex with men are particularly hard hit by these diseases,” Dr. John M. Douglas Jr., director of the CDC's Division of Sexually Transmitted Disease Prevention, said in a teleconference sponsored by the CDC.

The report emphasizes both the magnitude of the diseases and the persistent racial disparity, Dr. Douglas said.

All three diseases are treatable, especially when they are diagnosed early. If left untreated, however, the severe health consequences include pelvic inflammatory disease, infertility, increased risk for HIV infection, organ damage, and death. The direct medical costs associated with STDs in the United States were estimated at nearly $15 billion in 2006, the researchers stated in the report, “Sexually Transmitted Disease Surveillance 2006,” which was presented in a telebriefing.

Of the three diseases, the increased chlamydia rates represent the greatest public health impact, said Dr. Douglas.

In 2006, the national rate of reported cases of chlamydia increased by 5.6% from 2005 to 2006. Specifically, the reported rate was 347.8 cases per 100,000 persons in 2006, compared with 329.4 cases per 100,000 persons in 2005. The increase may reflect increased screening for chlamydia and improved diagnostic tests, but it likely also reflects an increase in the number of infections, the researchers said.

Chlamydia hits hardest among adolescent girls and young women—the highest chlamydia rate was reported in young women aged 15–19 years (2,863 cases per 100,000 persons) followed by women aged 20–24 years (2,797 cases per 100,000 persons). And racial disparity is high: The chlamydia rate was highest among black women, whose rate was more than seven times higher than that of white women and more than twice as high as that of Hispanic women.

Because of the high rate of chlamydia in young women, the CDC recommends screening sexually active women younger than 26 years for the disease. Chlamydia screening is also recommended for older women with new or multiple sex partners, because these women are also at increased risk. Based on recent studies showing that chlamydia reinfection can occur in women whose partners remain untreated, the CDC's treatment guidelines include retesting patients 3 months after treatment.

Screening is one of the most effective and underutilized tools to prevent and treat chlamydia in all populations, Dr. Douglas emphasized. “Providers know the recommendations but don't assume that it applies to the population that they are dealing with,” he said.

“If there are providers who don't think the young women in their practice don't have chlamydia, they should think again,” noted Dr. Stuart Berman, chief epidemiologist at the Division of Sexually Transmitted Disease Prevention.

Gonorrhea rates increased for the second consecutive year, following a plateau in reported disease rates from 1997 to 2005. “The racial disparities are stark,” in reported gonorrhea cases, Dr. Douglas said. Overall, the rate among blacks is 18 times higher than in whites, he said.

Gonorrhea rates also continue to vary by region. As in previous years, the southern region of the United States had the highest overall gonorrhea rate in 2006, at 159 cases per 100,000 persons. But rates in the South rose by 12.3% in 2006, representing the first notable increase in 8 years.

“We are also concerned about increases in the West,” Dr. Douglas said. Gonorrhea cases in the West increased by 2.9% between 2005 and 2006, contributing to a 32% increase between 2002 and 2006. “We will need to monitor the data to determine whether this is an emerging trend.”

Untreated gonorrhea can, among other complications, increase a person's risk for HIV if he or she is exposed. But gonorrhea treatment has become more challenging, because evidence of fluoroquinolone resistance—especially among men who have sex with men—prompted the CDC in April 2007 to stop recommending fluoroquinolones as treatment for any gonorrhea cases. As an alternative, the CDC recommends cephalosporins to treat gonorrhea.

Rates of primary and secondary syphilis rate in the United States increased by nearly 14% from 2005 to 2006, but the most notable increase has occurred among men who have sex with men. Syphilis rates among that group increased by 54% from 2002 to 2006, Dr. Douglas said.

Although syphilis has the least impact on the population as a whole, the rise in reported cases for the sixth consecutive year in women and men is cause for concern, Dr. Douglas said, given a steady decrease during the 1990s.

Overall, the recent rises in reportable STD rates speak to the need for more awareness among the public and health care providers about screening and prevention, said Dr. Douglas.

The report's data provide an incomplete picture of sexually transmitted diseases in the United States, the researchers cautioned, because many cases of chlamydia, gonorrhea, and syphilis are not reported. In addition, some types of STDs, including genital herpes and human papillomavirus, are not tracked by the CDC but contribute to the overall disease burden of STDs, he noted. “These are large numbers of infections, and this is a hidden epidemic that people are not aware of,” added Dr. Berman.

To view the complete report, visit www.cdc.gov/std/stats

Rates of chlamydia, gonorrhea, and syphilis increased in the United States during the past year and continued recent upward trends, according to a report from the Centers for Disease Control and Prevention.

"Young women, racial and ethnic populations, and men who have sex with men are particularly hard hit by these diseases," said Dr. John M. Douglas Jr., director of the CDC's Division of Sexually Transmitted Disease Prevention.

The direct medical costs associated with STDs in the United States were estimated at nearly $15 billion in 2006, the researchers stated in the report, "Sexually Transmitted Disease Surveillance 2006," which was presented in a telebriefing.

In 2006, the national rate of reported cases of chlamydia increased by 5.6% from 2005 to 2006. Specifically, the reported rate was 347.8 cases per 100,000 persons in 2006, compared with 329.4 cases per 100,000 persons in 2005.

Chlamydia hits hardest among adolescent girls and young women—the highest chlamydia rate was reported in young women aged 15-19 years followed by women aged 20-24 years. And racial disparity is high: The chlamydia rate was highest among black women, whose rate was more than seven times higher than that of white women and more than twice as high as that of Hispanic women.

Because of the high rate of chlamydia in young women, the CDC recommends screening sexually active women younger than 26 years for the disease. Chlamydia screening also is recommended for older women with new or multiple sex partners, because these women are also at increased risk. Based on recent studies showing that chlamydia reinfection can occur in women whose partners remain untreated, the CDC's treatment guidelines include retesting patients 3 months after treatment.

"If there are providers who don't think the young women in their practice don't have chlamydia, they should think again," noted Dr. Stuart Berman, chief epidemiologist at the Division of Sexually Transmitted Disease Prevention.

Gonorrhea rates increased for the second consecutive year, following a plateau in reported disease rates from 1997 to 2005. "The racial disparities are stark," in reported gonorrhea cases, Dr. Douglas said. Overall, the rate among blacks is 18 times higher than in whites, he said.

Gonorrhea rates also continue to vary by region. As in previous years, the southern region of the United States had the highest overall gonorrhea rate in 2006, at 159 cases per 100,000 persons.

"We are also concerned about increases in the West," Dr. Douglas said. Gonorrhea cases in the West increased by 2.9% between 2005 and 2006, contributing to a 32% increase between 2002 and 2006.

Untreated gonorrhea can, among other complications, increase a person's risk for HIV if he or she is exposed. But gonorrhea treatment has become more challenging, because evidence of fluoroquinolone resistance—especially among men who have sex with men—prompted the CDC in April 2007 to stop recommending fluoroquinolones as treatment for any gonorrhea cases. As an alternative, the CDC recommends cephalosporins to treat gonorrhea.

Rates of primary and secondary syphilis in the United States increased by nearly 14% from 2005 to 2006, but the most notable increase has occurred among men who have sex with men. Syphilis rates among that group increased by 54% from 2002 to 2006, Dr. Douglas said.

The report's data provide an incomplete picture of sexually transmitted diseases in the United States, the researchers cautioned, because many cases are not reported. To view the complete report, visit www.cdc.gov/std/stats

Rates of chlamydia, gonorrhea, and syphilis increased in the United States during the past year and continued recent upward trends, according to a report from the Centers for Disease Control and Prevention.

"Young women, racial and ethnic populations, and men who have sex with men are particularly hard hit by these diseases," said Dr. John M. Douglas Jr., director of the CDC's Division of Sexually Transmitted Disease Prevention.

The direct medical costs associated with STDs in the United States were estimated at nearly $15 billion in 2006, the researchers stated in the report, "Sexually Transmitted Disease Surveillance 2006," which was presented in a telebriefing.

In 2006, the national rate of reported cases of chlamydia increased by 5.6% from 2005 to 2006. Specifically, the reported rate was 347.8 cases per 100,000 persons in 2006, compared with 329.4 cases per 100,000 persons in 2005.

Chlamydia hits hardest among adolescent girls and young women—the highest chlamydia rate was reported in young women aged 15-19 years followed by women aged 20-24 years. And racial disparity is high: The chlamydia rate was highest among black women, whose rate was more than seven times higher than that of white women and more than twice as high as that of Hispanic women.

Because of the high rate of chlamydia in young women, the CDC recommends screening sexually active women younger than 26 years for the disease. Chlamydia screening also is recommended for older women with new or multiple sex partners, because these women are also at increased risk. Based on recent studies showing that chlamydia reinfection can occur in women whose partners remain untreated, the CDC's treatment guidelines include retesting patients 3 months after treatment.

"If there are providers who don't think the young women in their practice don't have chlamydia, they should think again," noted Dr. Stuart Berman, chief epidemiologist at the Division of Sexually Transmitted Disease Prevention.

Gonorrhea rates increased for the second consecutive year, following a plateau in reported disease rates from 1997 to 2005. "The racial disparities are stark," in reported gonorrhea cases, Dr. Douglas said. Overall, the rate among blacks is 18 times higher than in whites, he said.

Gonorrhea rates also continue to vary by region. As in previous years, the southern region of the United States had the highest overall gonorrhea rate in 2006, at 159 cases per 100,000 persons.

"We are also concerned about increases in the West," Dr. Douglas said. Gonorrhea cases in the West increased by 2.9% between 2005 and 2006, contributing to a 32% increase between 2002 and 2006.

Untreated gonorrhea can, among other complications, increase a person's risk for HIV if he or she is exposed. But gonorrhea treatment has become more challenging, because evidence of fluoroquinolone resistance—especially among men who have sex with men—prompted the CDC in April 2007 to stop recommending fluoroquinolones as treatment for any gonorrhea cases. As an alternative, the CDC recommends cephalosporins to treat gonorrhea.

Rates of primary and secondary syphilis in the United States increased by nearly 14% from 2005 to 2006, but the most notable increase has occurred among men who have sex with men. Syphilis rates among that group increased by 54% from 2002 to 2006, Dr. Douglas said.

The report's data provide an incomplete picture of sexually transmitted diseases in the United States, the researchers cautioned, because many cases are not reported. To view the complete report, visit www.cdc.gov/std/stats

Rates of chlamydia, gonorrhea, and syphilis increased in the United States during the past year and continued recent upward trends, according to a report from the Centers for Disease Control and Prevention.

"Young women, racial and ethnic populations, and men who have sex with men are particularly hard hit by these diseases," said Dr. John M. Douglas Jr., director of the CDC's Division of Sexually Transmitted Disease Prevention.

The direct medical costs associated with STDs in the United States were estimated at nearly $15 billion in 2006, the researchers stated in the report, "Sexually Transmitted Disease Surveillance 2006," which was presented in a telebriefing.

In 2006, the national rate of reported cases of chlamydia increased by 5.6% from 2005 to 2006. Specifically, the reported rate was 347.8 cases per 100,000 persons in 2006, compared with 329.4 cases per 100,000 persons in 2005.

Chlamydia hits hardest among adolescent girls and young women—the highest chlamydia rate was reported in young women aged 15-19 years followed by women aged 20-24 years. And racial disparity is high: The chlamydia rate was highest among black women, whose rate was more than seven times higher than that of white women and more than twice as high as that of Hispanic women.

Because of the high rate of chlamydia in young women, the CDC recommends screening sexually active women younger than 26 years for the disease. Chlamydia screening also is recommended for older women with new or multiple sex partners, because these women are also at increased risk. Based on recent studies showing that chlamydia reinfection can occur in women whose partners remain untreated, the CDC's treatment guidelines include retesting patients 3 months after treatment.

"If there are providers who don't think the young women in their practice don't have chlamydia, they should think again," noted Dr. Stuart Berman, chief epidemiologist at the Division of Sexually Transmitted Disease Prevention.

Gonorrhea rates increased for the second consecutive year, following a plateau in reported disease rates from 1997 to 2005. "The racial disparities are stark," in reported gonorrhea cases, Dr. Douglas said. Overall, the rate among blacks is 18 times higher than in whites, he said.

Gonorrhea rates also continue to vary by region. As in previous years, the southern region of the United States had the highest overall gonorrhea rate in 2006, at 159 cases per 100,000 persons.

"We are also concerned about increases in the West," Dr. Douglas said. Gonorrhea cases in the West increased by 2.9% between 2005 and 2006, contributing to a 32% increase between 2002 and 2006.

Untreated gonorrhea can, among other complications, increase a person's risk for HIV if he or she is exposed. But gonorrhea treatment has become more challenging, because evidence of fluoroquinolone resistance—especially among men who have sex with men—prompted the CDC in April 2007 to stop recommending fluoroquinolones as treatment for any gonorrhea cases. As an alternative, the CDC recommends cephalosporins to treat gonorrhea.

Rates of primary and secondary syphilis in the United States increased by nearly 14% from 2005 to 2006, but the most notable increase has occurred among men who have sex with men. Syphilis rates among that group increased by 54% from 2002 to 2006, Dr. Douglas said.

The report's data provide an incomplete picture of sexually transmitted diseases in the United States, the researchers cautioned, because many cases are not reported. To view the complete report, visit www.cdc.gov/std/stats

Early initiation of methotrexate can postpone the development of cataracts requiring surgery in juvenile idiopathic arthritis patients who are at high risk due to posterior adhesions at diagnosis with uveitis, said Dr. Karen M. Sijssens.

Cataract surgery in eyes with inflamed uveas is difficult. The presence of posterior adhesions (synechia) at diagnosis and the treatment of uveitis with corticosteroids have been tied to an increased risk of cataracts in children with JIA who develop uveitis.

To evaluate cataract risk factors and determine effective treatments, Dr. Sijssens of the University Medical Center Utrecht (the Netherlands) and colleagues analyzed 53 children diagnosed with JIA before age 16. Fifty-one had JIA-associated uveitis; 2 had antinuclear antibody-positive uveitis (Am. J. Ophthalmol. 2007;144:574–9).

Uveitis was the first manifestation of JIA in 12 children, and arthritis was the first manifestation of JIA in 41 children.

Overall, 11 of the 12 children (92%) for whom uveitis was the first presenting symptom of JIA required cataract surgery significantly sooner after diagnosis, versus the 16 of the 41 children (39%) for whom arthritis was the first sign of JIA (3.5 years vs. 6.6 years).

Posterior synechia were present at uveitis diagnosis in 15 children. Even after controlling for the use of periocular corticosteroids, children with posterior synechia required cataract surgery significantly sooner than the 33 children without adhesions (3.0 years vs. 8.5 years).

But the need for cataract surgery was significantly delayed in the 17 children treated with methotrexate during the first year after uveitis diagnosis, versus the 25 children not treated with methotrexate (7.0 years vs. 3.5 years). The presence of adhesions was approximately the same in both the methotrexate-treated and untreated children.

The delayed development of cataracts requiring surgery in the methotrexate-treated children may be due to better inflammation control, the researchers noted. “Another explanation may be that treatment with methotrexate diminishes the need for treatment with topical or systemic corticosteroids,” they wrote.

Study limitations include its small size and the fact that no patients were studied who had methotrexate and uveitis as the first JIA symptom, the authors noted.

Early initiation of methotrexate can postpone the development of cataracts requiring surgery in juvenile idiopathic arthritis patients who are at high risk due to posterior adhesions at diagnosis with uveitis, said Dr. Karen M. Sijssens.

Cataract surgery in eyes with inflamed uveas is difficult. The presence of posterior adhesions (synechia) at diagnosis and the treatment of uveitis with corticosteroids have been tied to an increased risk of cataracts in children with JIA who develop uveitis.

To evaluate cataract risk factors and determine effective treatments, Dr. Sijssens of the University Medical Center Utrecht (the Netherlands) and colleagues analyzed 53 children diagnosed with JIA before age 16. Fifty-one had JIA-associated uveitis; 2 had antinuclear antibody-positive uveitis (Am. J. Ophthalmol. 2007;144:574–9).

Uveitis was the first manifestation of JIA in 12 children, and arthritis was the first manifestation of JIA in 41 children.

Overall, 11 of the 12 children (92%) for whom uveitis was the first presenting symptom of JIA required cataract surgery significantly sooner after diagnosis, versus the 16 of the 41 children (39%) for whom arthritis was the first sign of JIA (3.5 years vs. 6.6 years).

Posterior synechia were present at uveitis diagnosis in 15 children. Even after controlling for the use of periocular corticosteroids, children with posterior synechia required cataract surgery significantly sooner than the 33 children without adhesions (3.0 years vs. 8.5 years).

But the need for cataract surgery was significantly delayed in the 17 children treated with methotrexate during the first year after uveitis diagnosis, versus the 25 children not treated with methotrexate (7.0 years vs. 3.5 years). The presence of adhesions was approximately the same in both the methotrexate-treated and untreated children.

The delayed development of cataracts requiring surgery in the methotrexate-treated children may be due to better inflammation control, the researchers noted. “Another explanation may be that treatment with methotrexate diminishes the need for treatment with topical or systemic corticosteroids,” they wrote.

Study limitations include its small size and the fact that no patients were studied who had methotrexate and uveitis as the first JIA symptom, the authors noted.

Early initiation of methotrexate can postpone the development of cataracts requiring surgery in juvenile idiopathic arthritis patients who are at high risk due to posterior adhesions at diagnosis with uveitis, said Dr. Karen M. Sijssens.

Cataract surgery in eyes with inflamed uveas is difficult. The presence of posterior adhesions (synechia) at diagnosis and the treatment of uveitis with corticosteroids have been tied to an increased risk of cataracts in children with JIA who develop uveitis.

To evaluate cataract risk factors and determine effective treatments, Dr. Sijssens of the University Medical Center Utrecht (the Netherlands) and colleagues analyzed 53 children diagnosed with JIA before age 16. Fifty-one had JIA-associated uveitis; 2 had antinuclear antibody-positive uveitis (Am. J. Ophthalmol. 2007;144:574–9).

Uveitis was the first manifestation of JIA in 12 children, and arthritis was the first manifestation of JIA in 41 children.

Overall, 11 of the 12 children (92%) for whom uveitis was the first presenting symptom of JIA required cataract surgery significantly sooner after diagnosis, versus the 16 of the 41 children (39%) for whom arthritis was the first sign of JIA (3.5 years vs. 6.6 years).

Posterior synechia were present at uveitis diagnosis in 15 children. Even after controlling for the use of periocular corticosteroids, children with posterior synechia required cataract surgery significantly sooner than the 33 children without adhesions (3.0 years vs. 8.5 years).

But the need for cataract surgery was significantly delayed in the 17 children treated with methotrexate during the first year after uveitis diagnosis, versus the 25 children not treated with methotrexate (7.0 years vs. 3.5 years). The presence of adhesions was approximately the same in both the methotrexate-treated and untreated children.

The delayed development of cataracts requiring surgery in the methotrexate-treated children may be due to better inflammation control, the researchers noted. “Another explanation may be that treatment with methotrexate diminishes the need for treatment with topical or systemic corticosteroids,” they wrote.

Study limitations include its small size and the fact that no patients were studied who had methotrexate and uveitis as the first JIA symptom, the authors noted.

MINNEAPOLIS – Adults with Arnold-Chiari type I malformations are at greater risk for sleep-disordered breathing, compared with healthy controls, based on data presented at the annual meeting of the Associated Professional Sleep Societies.

In light of this finding, “We should be screening all Arnold-Chiari I patients for sleep-disordered breathing,” said Dr. Nate Watson, a neurologist at the University of Washington, Seattle.

The displaced brain structures that characterize Arnold-Chiari I (AC-1), a benign developmental brain anomaly, can compress the brainstem, impeding breathing, he said.

To better assess the risk of sleep-disordered breathing in AC-1 patients, Dr. Watson and his colleagues compared 18 women with AC-1 (mean age 36 years) with 35 age- and sex-matched controls.

The researchers used several subjective questionnaires including the Epworth Sleepiness Scale to assess sleep-disordered breathing and sleepiness. Based on these results, the AC-1 patients were at significantly greater risk for sleep-disordered breathing, compared with controls (69% vs. 20%). Specifically, the results from the questionnaires showed that three factors–snoring, sleepiness, and obesity/hypertension–were significantly more common among AC-1 patients vs. controls, and occurred in 44% vs. 6%, 78% vs. 46%, and 64% vs. 34%, respectively.

The AC-1 patients were significantly more likely to report other symptoms associated with sleep-disordered breathing, including nighttime choking or gasping and nighttime shortness of breath, compared with controls. And when they woke up, the AC-1 patients also reported sore throats, heartburn, and headaches significantly more often than did the control patients.

In addition, the AC-1 patients reported sleeping significantly fewer hours (6.3 hours versus 7.6 hours) and taking significantly longer to fall asleep (61.4 minutes versus 18.6 minutes), compared with controls.

Consider decompressive surgery for patients if respiration is their main complaint, but remember that they need to be followed, said Dr. Watson during the discussion after his presentation. Previous studies indicate that decompression surgery makes a difference. Data from 16 consecutive patients with AC-1 malformations showed a significant improvement in the central apnea index from 14.9 to 1.3 based on full-night polysomnography conducted approximately 200 days after decompression surgery (Neurology 2006;66:136-8).

Future studies of AC-1 patients need to continue to focus on objective measures and comparison of patients before and after they have decompressive surgery, Dr. Watson said.

MINNEAPOLIS – Adults with Arnold-Chiari type I malformations are at greater risk for sleep-disordered breathing, compared with healthy controls, based on data presented at the annual meeting of the Associated Professional Sleep Societies.

In light of this finding, “We should be screening all Arnold-Chiari I patients for sleep-disordered breathing,” said Dr. Nate Watson, a neurologist at the University of Washington, Seattle.

The displaced brain structures that characterize Arnold-Chiari I (AC-1), a benign developmental brain anomaly, can compress the brainstem, impeding breathing, he said.

To better assess the risk of sleep-disordered breathing in AC-1 patients, Dr. Watson and his colleagues compared 18 women with AC-1 (mean age 36 years) with 35 age- and sex-matched controls.

The researchers used several subjective questionnaires including the Epworth Sleepiness Scale to assess sleep-disordered breathing and sleepiness. Based on these results, the AC-1 patients were at significantly greater risk for sleep-disordered breathing, compared with controls (69% vs. 20%). Specifically, the results from the questionnaires showed that three factors–snoring, sleepiness, and obesity/hypertension–were significantly more common among AC-1 patients vs. controls, and occurred in 44% vs. 6%, 78% vs. 46%, and 64% vs. 34%, respectively.

The AC-1 patients were significantly more likely to report other symptoms associated with sleep-disordered breathing, including nighttime choking or gasping and nighttime shortness of breath, compared with controls. And when they woke up, the AC-1 patients also reported sore throats, heartburn, and headaches significantly more often than did the control patients.

In addition, the AC-1 patients reported sleeping significantly fewer hours (6.3 hours versus 7.6 hours) and taking significantly longer to fall asleep (61.4 minutes versus 18.6 minutes), compared with controls.

Consider decompressive surgery for patients if respiration is their main complaint, but remember that they need to be followed, said Dr. Watson during the discussion after his presentation. Previous studies indicate that decompression surgery makes a difference. Data from 16 consecutive patients with AC-1 malformations showed a significant improvement in the central apnea index from 14.9 to 1.3 based on full-night polysomnography conducted approximately 200 days after decompression surgery (Neurology 2006;66:136-8).

Future studies of AC-1 patients need to continue to focus on objective measures and comparison of patients before and after they have decompressive surgery, Dr. Watson said.

MINNEAPOLIS – Adults with Arnold-Chiari type I malformations are at greater risk for sleep-disordered breathing, compared with healthy controls, based on data presented at the annual meeting of the Associated Professional Sleep Societies.

In light of this finding, “We should be screening all Arnold-Chiari I patients for sleep-disordered breathing,” said Dr. Nate Watson, a neurologist at the University of Washington, Seattle.

The displaced brain structures that characterize Arnold-Chiari I (AC-1), a benign developmental brain anomaly, can compress the brainstem, impeding breathing, he said.

To better assess the risk of sleep-disordered breathing in AC-1 patients, Dr. Watson and his colleagues compared 18 women with AC-1 (mean age 36 years) with 35 age- and sex-matched controls.

The researchers used several subjective questionnaires including the Epworth Sleepiness Scale to assess sleep-disordered breathing and sleepiness. Based on these results, the AC-1 patients were at significantly greater risk for sleep-disordered breathing, compared with controls (69% vs. 20%). Specifically, the results from the questionnaires showed that three factors–snoring, sleepiness, and obesity/hypertension–were significantly more common among AC-1 patients vs. controls, and occurred in 44% vs. 6%, 78% vs. 46%, and 64% vs. 34%, respectively.

The AC-1 patients were significantly more likely to report other symptoms associated with sleep-disordered breathing, including nighttime choking or gasping and nighttime shortness of breath, compared with controls. And when they woke up, the AC-1 patients also reported sore throats, heartburn, and headaches significantly more often than did the control patients.

In addition, the AC-1 patients reported sleeping significantly fewer hours (6.3 hours versus 7.6 hours) and taking significantly longer to fall asleep (61.4 minutes versus 18.6 minutes), compared with controls.

Consider decompressive surgery for patients if respiration is their main complaint, but remember that they need to be followed, said Dr. Watson during the discussion after his presentation. Previous studies indicate that decompression surgery makes a difference. Data from 16 consecutive patients with AC-1 malformations showed a significant improvement in the central apnea index from 14.9 to 1.3 based on full-night polysomnography conducted approximately 200 days after decompression surgery (Neurology 2006;66:136-8).

Future studies of AC-1 patients need to continue to focus on objective measures and comparison of patients before and after they have decompressive surgery, Dr. Watson said.

WASHINGTON – Psychiatric comorbidities and a history of abuse are often associated with functional gastrointestinal problems, said Dr. Kevin W. Olden at the annual meeting of the American Academy of Clinical Psychiatrists.

“There is no doubt that psychiatry has a lot to offer patients with irritable bowel syndrome and the entire spectrum of gastrointestinal disorders,” said Dr. Olden, director of the division of gastroenterology and hepatology, University of Arkansas, Little Rock.

Four psychiatric diagnoses that are often present in patients with functional gastrointestinal disorders are panic disorder, generalized anxiety disorder, mood disorders (mainly depression), and somatoform disorders. As many as 44% of patients with IBS meet the diagnostic criteria for panic disorder, Dr. Olden noted (Gastroenterol. Clin. N. Am. 2003;32:477-506). In addition, Dr. Olden cited a study in which major depression was identified in 30%-90% of patients with irritable bowel syndrome. The presence of depression can influence patients' ability to seek care for IBS and their ability to cope with it, he said.

The impact of abuse on subsequent psychological problems and comorbid functional gastrointestinal disorders is an area worthy of further research, Dr. Olden said. In a survey of 206 patients who presented to a GI clinic, more than half of the patients with functional GI problems reported a history of abuse, and significantly more of these patients reported abuse, compared with those who had organic GI problems (53% vs. 37%) (Ann. Intern. Med. 1990;113:828-33).

When treatment with antidepressants relieves the gastrointestinal symptoms in some patients, they report fewer physician visits and improved ability to perform daily activities, Dr. Olden said.

WASHINGTON – Psychiatric comorbidities and a history of abuse are often associated with functional gastrointestinal problems, said Dr. Kevin W. Olden at the annual meeting of the American Academy of Clinical Psychiatrists.

“There is no doubt that psychiatry has a lot to offer patients with irritable bowel syndrome and the entire spectrum of gastrointestinal disorders,” said Dr. Olden, director of the division of gastroenterology and hepatology, University of Arkansas, Little Rock.

Four psychiatric diagnoses that are often present in patients with functional gastrointestinal disorders are panic disorder, generalized anxiety disorder, mood disorders (mainly depression), and somatoform disorders. As many as 44% of patients with IBS meet the diagnostic criteria for panic disorder, Dr. Olden noted (Gastroenterol. Clin. N. Am. 2003;32:477-506). In addition, Dr. Olden cited a study in which major depression was identified in 30%-90% of patients with irritable bowel syndrome. The presence of depression can influence patients' ability to seek care for IBS and their ability to cope with it, he said.

The impact of abuse on subsequent psychological problems and comorbid functional gastrointestinal disorders is an area worthy of further research, Dr. Olden said. In a survey of 206 patients who presented to a GI clinic, more than half of the patients with functional GI problems reported a history of abuse, and significantly more of these patients reported abuse, compared with those who had organic GI problems (53% vs. 37%) (Ann. Intern. Med. 1990;113:828-33).

When treatment with antidepressants relieves the gastrointestinal symptoms in some patients, they report fewer physician visits and improved ability to perform daily activities, Dr. Olden said.

WASHINGTON – Psychiatric comorbidities and a history of abuse are often associated with functional gastrointestinal problems, said Dr. Kevin W. Olden at the annual meeting of the American Academy of Clinical Psychiatrists.

“There is no doubt that psychiatry has a lot to offer patients with irritable bowel syndrome and the entire spectrum of gastrointestinal disorders,” said Dr. Olden, director of the division of gastroenterology and hepatology, University of Arkansas, Little Rock.

Four psychiatric diagnoses that are often present in patients with functional gastrointestinal disorders are panic disorder, generalized anxiety disorder, mood disorders (mainly depression), and somatoform disorders. As many as 44% of patients with IBS meet the diagnostic criteria for panic disorder, Dr. Olden noted (Gastroenterol. Clin. N. Am. 2003;32:477-506). In addition, Dr. Olden cited a study in which major depression was identified in 30%-90% of patients with irritable bowel syndrome. The presence of depression can influence patients' ability to seek care for IBS and their ability to cope with it, he said.

The impact of abuse on subsequent psychological problems and comorbid functional gastrointestinal disorders is an area worthy of further research, Dr. Olden said. In a survey of 206 patients who presented to a GI clinic, more than half of the patients with functional GI problems reported a history of abuse, and significantly more of these patients reported abuse, compared with those who had organic GI problems (53% vs. 37%) (Ann. Intern. Med. 1990;113:828-33).

When treatment with antidepressants relieves the gastrointestinal symptoms in some patients, they report fewer physician visits and improved ability to perform daily activities, Dr. Olden said.

The Alzheimer's Association has released new recommendations to guide end-of-life care for dementia patients in nursing homes; the recommendations focus on planning for end-of-life care as soon as possible after a dementia diagnosis is made.

The evidence-based recommendations, which were released at the Alzheimer's Association's 15th Annual Dementia Care Conference in Chicago, have been supported by more than 30 organizations, including the American Medical Directors Association, which has a clinical practice guideline on this same issue, as well as a new tool kit on palliative care/end of life. “AMDA fully supports individualized care in persons with dementia and recognizes how important end-of-life care planning is when a diagnosis of dementia is made,” said Jacqueline Vance, AMDA's director of clinical affairs.

The recommendations state that the goals of end-of-life care should include following the resident's wishes as closely as possible, which is easier if a patient-centered care plan is designed early. This includes documenting a patient's preferences for medical treatment once he or she reaches an advanced stage of dementia and designating a proxy to make decisions on the patient's behalf when he or she can no longer do so.

In addition, the care goals include supporting families, other residents, and nursing home staff when a resident is actively dying and after the person has died. And finally, end-of-life care plans must be flexible enough to accommodate changes in a resident's preferences.

The end-of-life care recommendations are the third of three phases of a document—Dementia Care Practice Recommendations for Assisted Living Residences and Nursing Homes—that was conceived as part of the Alzheimer's Association Quality Residential Care campaign. Phase 1 of the recommendations focused on basic care for dementia patients, with attention to nutrition, pain management, and social involvement. Phase 2 provided guidance for managing wandering, falling, and the need for physical restraint in dementia patients.

The phase 3 recommendations emphasize developing consistent, personalized care to the extent possible and increasing staff members' knowledge of residents' preferences. The recommendations fall into the following categories, which include guidelines for end-of-life care for dementia patients:

▸ Communications with residents and family members. Schedule regular care planning meetings that the resident, proxy decision maker, and other family members can attend (even if only by conference call). Effective communications means acknowledging the cultural and spiritual beliefs of the resident and family and taking these beliefs into account.

Be sure to allow residents and families time to respond to questions and help them understand what policies and situations would cause a resident to be moved to palliative care or a hospice.

▸ Decision making. Discuss a resident's preferences and doctor's directions, such as “comfort care only,” “do not resuscitate,” or “do not hospitalize.” Involve the resident as much as possible, because a dementia diagnosis doesn't mean that the person lacks the ability to make decisions regarding their care. But it is important to designate a proxy decision maker who can make decisions on the resident's behalf when necessary.

▸ Hospice service issues. When a resident and his or her family members opt for hospice care, establish a plan for communication about the resident's health and care issues and identify which hospice or residence staff members will be the primary contact for family members.

▸ Assessing physical symptoms. Pain-assessment guidelines are addressed in detail in phase 1 of the recommendations, but monitoring pain is just as important when a patient is actively dying. Comfort care strategies may include such things as placing a fan in the room on a low setting to move air and make breathing easier.

▸ Assessing behavioral symptoms. Behavior changes in dementia patients at the end of life may be signs of distress, so be sure that staff members know to report any differences, such as hallucinations, changes in arousal level, or mood, or striking out in discomfort or distress. Determine whether the cause of the behavior is physical or emotional and use nondrug methods to help, such as reducing environmental irritants or providing companionship for an isolated resident.

▸ Psychosocial and spiritual support. Residents with dementia can still find comfort in meaningful interactions. Staff members need to know a resident's religious or cultural outlook if possible and provide appropriate psychological and spiritual support. And don't forget the family. Grieving for a patient with dementia at the end of life can be a long, emotionally draining experience for family members. A trained nurse or staff member can help by explaining some of the signs of approaching death so that families know what to expect and by offering resources for dealing with feelings of guilt and grief.

▸ Family participation in end-of-life care. Staff members can support families who want to feel involved in the comfort of the resident at the end of life by providing pillows and blankets for overnight stays and offering comforting music, books, and anything else that might help family members spend meaningful time with loved ones.

▸ Staff training. Dementia-specific end-of-life training for nursing home residents is an important part of providing quality care. Staff members need to be able to recognize the signs that death is imminent, and they need to be trained in pain management and communication skills so that they can explain the resident's condition to family members.

▸ Death and bereavement. When one of the residents dies, encourage the staff members who were involved in caring for that person to pay tribute to them with a poem, card, or other acknowledgment. Also, consider conducting periodic in-house memorial services to bring together residents, staff, and family members to recognize the lives of residents who have died.

For a complete version of the Dementia Care Practice Recommendations for Assisted Living Residences and Nursing Homes, visit www.alz.org/documents/DCPRPhase3_.pdf

The Alzheimer's Association has released new recommendations to guide end-of-life care for dementia patients in nursing homes; the recommendations focus on planning for end-of-life care as soon as possible after a dementia diagnosis is made.

The evidence-based recommendations, which were released at the Alzheimer's Association's 15th Annual Dementia Care Conference in Chicago, have been supported by more than 30 organizations, including the American Medical Directors Association, which has a clinical practice guideline on this same issue, as well as a new tool kit on palliative care/end of life. “AMDA fully supports individualized care in persons with dementia and recognizes how important end-of-life care planning is when a diagnosis of dementia is made,” said Jacqueline Vance, AMDA's director of clinical affairs.

The recommendations state that the goals of end-of-life care should include following the resident's wishes as closely as possible, which is easier if a patient-centered care plan is designed early. This includes documenting a patient's preferences for medical treatment once he or she reaches an advanced stage of dementia and designating a proxy to make decisions on the patient's behalf when he or she can no longer do so.

In addition, the care goals include supporting families, other residents, and nursing home staff when a resident is actively dying and after the person has died. And finally, end-of-life care plans must be flexible enough to accommodate changes in a resident's preferences.

The end-of-life care recommendations are the third of three phases of a document—Dementia Care Practice Recommendations for Assisted Living Residences and Nursing Homes—that was conceived as part of the Alzheimer's Association Quality Residential Care campaign. Phase 1 of the recommendations focused on basic care for dementia patients, with attention to nutrition, pain management, and social involvement. Phase 2 provided guidance for managing wandering, falling, and the need for physical restraint in dementia patients.

The phase 3 recommendations emphasize developing consistent, personalized care to the extent possible and increasing staff members' knowledge of residents' preferences. The recommendations fall into the following categories, which include guidelines for end-of-life care for dementia patients:

▸ Communications with residents and family members. Schedule regular care planning meetings that the resident, proxy decision maker, and other family members can attend (even if only by conference call). Effective communications means acknowledging the cultural and spiritual beliefs of the resident and family and taking these beliefs into account.

Be sure to allow residents and families time to respond to questions and help them understand what policies and situations would cause a resident to be moved to palliative care or a hospice.

▸ Decision making. Discuss a resident's preferences and doctor's directions, such as “comfort care only,” “do not resuscitate,” or “do not hospitalize.” Involve the resident as much as possible, because a dementia diagnosis doesn't mean that the person lacks the ability to make decisions regarding their care. But it is important to designate a proxy decision maker who can make decisions on the resident's behalf when necessary.

▸ Hospice service issues. When a resident and his or her family members opt for hospice care, establish a plan for communication about the resident's health and care issues and identify which hospice or residence staff members will be the primary contact for family members.

▸ Assessing physical symptoms. Pain-assessment guidelines are addressed in detail in phase 1 of the recommendations, but monitoring pain is just as important when a patient is actively dying. Comfort care strategies may include such things as placing a fan in the room on a low setting to move air and make breathing easier.

▸ Assessing behavioral symptoms. Behavior changes in dementia patients at the end of life may be signs of distress, so be sure that staff members know to report any differences, such as hallucinations, changes in arousal level, or mood, or striking out in discomfort or distress. Determine whether the cause of the behavior is physical or emotional and use nondrug methods to help, such as reducing environmental irritants or providing companionship for an isolated resident.

▸ Psychosocial and spiritual support. Residents with dementia can still find comfort in meaningful interactions. Staff members need to know a resident's religious or cultural outlook if possible and provide appropriate psychological and spiritual support. And don't forget the family. Grieving for a patient with dementia at the end of life can be a long, emotionally draining experience for family members. A trained nurse or staff member can help by explaining some of the signs of approaching death so that families know what to expect and by offering resources for dealing with feelings of guilt and grief.

▸ Family participation in end-of-life care. Staff members can support families who want to feel involved in the comfort of the resident at the end of life by providing pillows and blankets for overnight stays and offering comforting music, books, and anything else that might help family members spend meaningful time with loved ones.

▸ Staff training. Dementia-specific end-of-life training for nursing home residents is an important part of providing quality care. Staff members need to be able to recognize the signs that death is imminent, and they need to be trained in pain management and communication skills so that they can explain the resident's condition to family members.

▸ Death and bereavement. When one of the residents dies, encourage the staff members who were involved in caring for that person to pay tribute to them with a poem, card, or other acknowledgment. Also, consider conducting periodic in-house memorial services to bring together residents, staff, and family members to recognize the lives of residents who have died.

For a complete version of the Dementia Care Practice Recommendations for Assisted Living Residences and Nursing Homes, visit www.alz.org/documents/DCPRPhase3_.pdf

The Alzheimer's Association has released new recommendations to guide end-of-life care for dementia patients in nursing homes; the recommendations focus on planning for end-of-life care as soon as possible after a dementia diagnosis is made.

The evidence-based recommendations, which were released at the Alzheimer's Association's 15th Annual Dementia Care Conference in Chicago, have been supported by more than 30 organizations, including the American Medical Directors Association, which has a clinical practice guideline on this same issue, as well as a new tool kit on palliative care/end of life. “AMDA fully supports individualized care in persons with dementia and recognizes how important end-of-life care planning is when a diagnosis of dementia is made,” said Jacqueline Vance, AMDA's director of clinical affairs.

The recommendations state that the goals of end-of-life care should include following the resident's wishes as closely as possible, which is easier if a patient-centered care plan is designed early. This includes documenting a patient's preferences for medical treatment once he or she reaches an advanced stage of dementia and designating a proxy to make decisions on the patient's behalf when he or she can no longer do so.

In addition, the care goals include supporting families, other residents, and nursing home staff when a resident is actively dying and after the person has died. And finally, end-of-life care plans must be flexible enough to accommodate changes in a resident's preferences.

The end-of-life care recommendations are the third of three phases of a document—Dementia Care Practice Recommendations for Assisted Living Residences and Nursing Homes—that was conceived as part of the Alzheimer's Association Quality Residential Care campaign. Phase 1 of the recommendations focused on basic care for dementia patients, with attention to nutrition, pain management, and social involvement. Phase 2 provided guidance for managing wandering, falling, and the need for physical restraint in dementia patients.

The phase 3 recommendations emphasize developing consistent, personalized care to the extent possible and increasing staff members' knowledge of residents' preferences. The recommendations fall into the following categories, which include guidelines for end-of-life care for dementia patients:

▸ Communications with residents and family members. Schedule regular care planning meetings that the resident, proxy decision maker, and other family members can attend (even if only by conference call). Effective communications means acknowledging the cultural and spiritual beliefs of the resident and family and taking these beliefs into account.

Be sure to allow residents and families time to respond to questions and help them understand what policies and situations would cause a resident to be moved to palliative care or a hospice.

▸ Decision making. Discuss a resident's preferences and doctor's directions, such as “comfort care only,” “do not resuscitate,” or “do not hospitalize.” Involve the resident as much as possible, because a dementia diagnosis doesn't mean that the person lacks the ability to make decisions regarding their care. But it is important to designate a proxy decision maker who can make decisions on the resident's behalf when necessary.

▸ Hospice service issues. When a resident and his or her family members opt for hospice care, establish a plan for communication about the resident's health and care issues and identify which hospice or residence staff members will be the primary contact for family members.

▸ Assessing physical symptoms. Pain-assessment guidelines are addressed in detail in phase 1 of the recommendations, but monitoring pain is just as important when a patient is actively dying. Comfort care strategies may include such things as placing a fan in the room on a low setting to move air and make breathing easier.

▸ Assessing behavioral symptoms. Behavior changes in dementia patients at the end of life may be signs of distress, so be sure that staff members know to report any differences, such as hallucinations, changes in arousal level, or mood, or striking out in discomfort or distress. Determine whether the cause of the behavior is physical or emotional and use nondrug methods to help, such as reducing environmental irritants or providing companionship for an isolated resident.

▸ Psychosocial and spiritual support. Residents with dementia can still find comfort in meaningful interactions. Staff members need to know a resident's religious or cultural outlook if possible and provide appropriate psychological and spiritual support. And don't forget the family. Grieving for a patient with dementia at the end of life can be a long, emotionally draining experience for family members. A trained nurse or staff member can help by explaining some of the signs of approaching death so that families know what to expect and by offering resources for dealing with feelings of guilt and grief.

▸ Family participation in end-of-life care. Staff members can support families who want to feel involved in the comfort of the resident at the end of life by providing pillows and blankets for overnight stays and offering comforting music, books, and anything else that might help family members spend meaningful time with loved ones.

▸ Staff training. Dementia-specific end-of-life training for nursing home residents is an important part of providing quality care. Staff members need to be able to recognize the signs that death is imminent, and they need to be trained in pain management and communication skills so that they can explain the resident's condition to family members.

▸ Death and bereavement. When one of the residents dies, encourage the staff members who were involved in caring for that person to pay tribute to them with a poem, card, or other acknowledgment. Also, consider conducting periodic in-house memorial services to bring together residents, staff, and family members to recognize the lives of residents who have died.

For a complete version of the Dementia Care Practice Recommendations for Assisted Living Residences and Nursing Homes, visit www.alz.org/documents/DCPRPhase3_.pdf

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]).