Heidi Splete

GRAND CAYMAN, CAYMAN ISLANDS — Consider the possibility of acquired zinc deficiency in patients with persistent red, scaly skin on the hands and feet, Dr. Christopher O'Connell proposed at the Caribbean Dermatology Symposium.

Dr. O'Connell, a dermatology resident at St. Luke's-Roosevelt Hospital Center in New York, described the case of a 49-year-old black woman who presented with severe erythema, edema, and scaling on her palms and soles, as well as scaly patches and fissures on the backs of her hands. In addition, she had edema and erythema on her lower legs, as well as nonblanchable brown and red patches on her upper thighs. At follow-up exams, some of the nonblanchable patches had become scaly, and some of the scaly patches had progressed to form bullae and erosions.

The patient's medical history included type 2 diabetes, end-stage renal disease, hypertension, and alcohol abuse. She had completed a 2-week course of vancomycin and gentamycin for Staphylococcus aureus bacteremia one week prior to her evaluation in the dermatology department.

“This patient's alcohol abuse and renal disease were the likely causes of her acquired zinc deficiency and consequent acrodermatitis,” Dr. O'Connell said.

The initial laboratory tests revealed chronic anemia. All other blood work was normal, and blood cultures were negative. The initial differential diagnosis included staphylococcal scalded skin syndrome, a drug reaction, and vasculitis.

“A skin biopsy was performed and the histopathology was consistent with nutritional deficiency,” he said. Histologic findings that supported the final diagnosis included compact parakeratosis, pallor of the upper epidermis, hypogranulosis, intraepidermal vesiculation, keratinocyte necrosis, and architectural disarray.

Based in part on the histology findings, the differential diagnosis was expanded to include necrolytic migratory erythema, pellagra, and zinc deficiency.

Necrolytic migratory erythema was unlikely because the patient's glucose levels were well controlled on low-dose insulin glargine and a CT scan of the abdomen showed no signs of pancreatic neoplasm. Pellagra was ruled out because the rash was not photodistributed.

On further testing, the patient's zinc level was 615 mcg/L, compared with the normal, healthy range of 670–1,240 mcg/L. The diagnosis of zinc deficiency was confirmed when the patient's skin improved after zinc supplementation. The patient died, however, of complications from her renal disease.

“The skin contains 6% of the body's supply of zinc and it is the most common organ to demonstrate clinical signs of zinc deficiency,” Dr. O'Connell noted.

Acquired zinc deficiency has been reported in association with many medical disorders, including alcoholism, renal disease, gastrointestinal malabsorption syndromes, food allergies, anorexia, and severe burns. Research has shown that more than 300 enzymes require zinc in order to function. Zinc is essential for protein, carbohydrate, and fat metabolism, as well as for healthy immune system function, cell growth, and wound healing.

Hereditary zinc deficiency presents with a clinical picture similar to acquired zinc deficiency; however, it is an autosomal recessive disorder that usually presents within the first 4–10 weeks of life, he said.

The presentation of acquired zinc deficiency included non-blanchable brown and red patches on the upper thighs. Courtesy Dr. Christopher O'Connell

GRAND CAYMAN, CAYMAN ISLANDS — Consider the possibility of acquired zinc deficiency in patients with persistent red, scaly skin on the hands and feet, Dr. Christopher O'Connell proposed at the Caribbean Dermatology Symposium.

Dr. O'Connell, a dermatology resident at St. Luke's-Roosevelt Hospital Center in New York, described the case of a 49-year-old black woman who presented with severe erythema, edema, and scaling on her palms and soles, as well as scaly patches and fissures on the backs of her hands. In addition, she had edema and erythema on her lower legs, as well as nonblanchable brown and red patches on her upper thighs. At follow-up exams, some of the nonblanchable patches had become scaly, and some of the scaly patches had progressed to form bullae and erosions.

The patient's medical history included type 2 diabetes, end-stage renal disease, hypertension, and alcohol abuse. She had completed a 2-week course of vancomycin and gentamycin for Staphylococcus aureus bacteremia one week prior to her evaluation in the dermatology department.

“This patient's alcohol abuse and renal disease were the likely causes of her acquired zinc deficiency and consequent acrodermatitis,” Dr. O'Connell said.

The initial laboratory tests revealed chronic anemia. All other blood work was normal, and blood cultures were negative. The initial differential diagnosis included staphylococcal scalded skin syndrome, a drug reaction, and vasculitis.

“A skin biopsy was performed and the histopathology was consistent with nutritional deficiency,” he said. Histologic findings that supported the final diagnosis included compact parakeratosis, pallor of the upper epidermis, hypogranulosis, intraepidermal vesiculation, keratinocyte necrosis, and architectural disarray.

Based in part on the histology findings, the differential diagnosis was expanded to include necrolytic migratory erythema, pellagra, and zinc deficiency.

Necrolytic migratory erythema was unlikely because the patient's glucose levels were well controlled on low-dose insulin glargine and a CT scan of the abdomen showed no signs of pancreatic neoplasm. Pellagra was ruled out because the rash was not photodistributed.

On further testing, the patient's zinc level was 615 mcg/L, compared with the normal, healthy range of 670–1,240 mcg/L. The diagnosis of zinc deficiency was confirmed when the patient's skin improved after zinc supplementation. The patient died, however, of complications from her renal disease.

“The skin contains 6% of the body's supply of zinc and it is the most common organ to demonstrate clinical signs of zinc deficiency,” Dr. O'Connell noted.

Acquired zinc deficiency has been reported in association with many medical disorders, including alcoholism, renal disease, gastrointestinal malabsorption syndromes, food allergies, anorexia, and severe burns. Research has shown that more than 300 enzymes require zinc in order to function. Zinc is essential for protein, carbohydrate, and fat metabolism, as well as for healthy immune system function, cell growth, and wound healing.

Hereditary zinc deficiency presents with a clinical picture similar to acquired zinc deficiency; however, it is an autosomal recessive disorder that usually presents within the first 4–10 weeks of life, he said.

The presentation of acquired zinc deficiency included non-blanchable brown and red patches on the upper thighs. Courtesy Dr. Christopher O'Connell

GRAND CAYMAN, CAYMAN ISLANDS — Consider the possibility of acquired zinc deficiency in patients with persistent red, scaly skin on the hands and feet, Dr. Christopher O'Connell proposed at the Caribbean Dermatology Symposium.

Dr. O'Connell, a dermatology resident at St. Luke's-Roosevelt Hospital Center in New York, described the case of a 49-year-old black woman who presented with severe erythema, edema, and scaling on her palms and soles, as well as scaly patches and fissures on the backs of her hands. In addition, she had edema and erythema on her lower legs, as well as nonblanchable brown and red patches on her upper thighs. At follow-up exams, some of the nonblanchable patches had become scaly, and some of the scaly patches had progressed to form bullae and erosions.

The patient's medical history included type 2 diabetes, end-stage renal disease, hypertension, and alcohol abuse. She had completed a 2-week course of vancomycin and gentamycin for Staphylococcus aureus bacteremia one week prior to her evaluation in the dermatology department.

“This patient's alcohol abuse and renal disease were the likely causes of her acquired zinc deficiency and consequent acrodermatitis,” Dr. O'Connell said.

The initial laboratory tests revealed chronic anemia. All other blood work was normal, and blood cultures were negative. The initial differential diagnosis included staphylococcal scalded skin syndrome, a drug reaction, and vasculitis.

“A skin biopsy was performed and the histopathology was consistent with nutritional deficiency,” he said. Histologic findings that supported the final diagnosis included compact parakeratosis, pallor of the upper epidermis, hypogranulosis, intraepidermal vesiculation, keratinocyte necrosis, and architectural disarray.

Based in part on the histology findings, the differential diagnosis was expanded to include necrolytic migratory erythema, pellagra, and zinc deficiency.

Necrolytic migratory erythema was unlikely because the patient's glucose levels were well controlled on low-dose insulin glargine and a CT scan of the abdomen showed no signs of pancreatic neoplasm. Pellagra was ruled out because the rash was not photodistributed.

On further testing, the patient's zinc level was 615 mcg/L, compared with the normal, healthy range of 670–1,240 mcg/L. The diagnosis of zinc deficiency was confirmed when the patient's skin improved after zinc supplementation. The patient died, however, of complications from her renal disease.

“The skin contains 6% of the body's supply of zinc and it is the most common organ to demonstrate clinical signs of zinc deficiency,” Dr. O'Connell noted.

Acquired zinc deficiency has been reported in association with many medical disorders, including alcoholism, renal disease, gastrointestinal malabsorption syndromes, food allergies, anorexia, and severe burns. Research has shown that more than 300 enzymes require zinc in order to function. Zinc is essential for protein, carbohydrate, and fat metabolism, as well as for healthy immune system function, cell growth, and wound healing.

Hereditary zinc deficiency presents with a clinical picture similar to acquired zinc deficiency; however, it is an autosomal recessive disorder that usually presents within the first 4–10 weeks of life, he said.

The presentation of acquired zinc deficiency included non-blanchable brown and red patches on the upper thighs. Courtesy Dr. Christopher O'Connell

MIAMI — At-home tests that involve self-collected vaginal samples that are sent to a lab for analysis are effective at identifying women with sexually transmitted diseases, suggest findings from a pilot study presented at the annual meeting of the American College of Preventive Medicine.

“We thought maybe we could reach out and get out of the clinic and encourage asymptomatic women to collect samples at home,” said Charlotte A. Gaydos, Dr.P.H., a microbiologist in the division of infectious diseases at Johns Hopkins University, Baltimore.

Surmising that the Internet might be an effective way to promote such at-home tests, the researchers established a Web site (www.iwantthekit.org

Data from 778 samples that had been analyzed as of Jan. 31, 2007, show 71 samples (9%) were positive for Chlamydia trachomatis and 12 (1%) were positive for Neisseria gonorrhoeae. Four samples showed coinfection with chlamydia and gonorrhea. Samples collected since September 2006 were tested for Trichomonas vaginalis, and 13 of 115 samples (11%) tested positive.

The test kit includes sterile swabs for collecting vaginal samples and a questionnaire soliciting information on demographics, sexual history, and the participants' opinions about at-home testing and their preferences for methods to receive test results.

“We require two positive assays for a positive diagnosis,” Dr. Gaydos said. Samples are analyzed using nucleic acid amplification tests (NAATs), which are more than 90% sensitive, compared with the 85% sensitivity associated with cultures. “The NAATs are the best tests there are today; they are very powerful,” Dr. Gaydos said.

Participants received their test results via a toll-free number. A study coordinator arranged treatment appointments at a free local clinic for those women with positive test results.

So far, most of the women who tested positive have been treated, Dr. Gaydos noted. All 11 patients with gonorrhea were treated, as were 66 of 69 (96%) chlamydia cases.

Of the 760 participants who identified their race, 70% were black, 22% were white, and the remainder were another race or mixed race. Chlamydia rates were significantly higher among black women, compared with white women (12% vs. 2%).

The participants ranged from 14 to 63 years of age, with an average age of 23 years, but those who tested positive tended to be younger, and the average age at first sex was 15 years, Dr. Gaydos noted.

Positive tests were most common in the 15− to 19-year-olds (16%), followed by 20− to 24-year-olds (8.5%) and 25− to 29-year-olds (8%).

After the researchers controlled for multiple factors including age and race, the strongest risk factors for positive test results were use of birth control, nonconsensual sex, and multiple partners.

In addition, more than 50% of the participants reported a history of STDs; 40% reported a history of chlamydia, and 15% reported a history of gonorrhea.

Results of the questionnaires that accompanied the kits suggest participants were receptive to the idea of at-home STD testing. On a Likert scale of 1 to 5, 96% said that the sampling process was “easy” or “very easy” and 93% said that they would use it again.

Nearly 25% said they preferred to receive results by e-mail, but a secure Web site to provide results is too expensive at this time, Dr. Gaydos said. Under the current protocol, participants calling the toll-free number give the kit number and a password that they chose to ensure confidentiality.

Even with the current phone-in method of requesting results, the success of the Web site in recruiting patients for home sampling and in treating those who test positive is encouraging, she added. “This may be another tool that we can use to reach out of the clinic and to save money. You can save a lot of money if you don't have to pay clinicians to collect the samples.”

A test kit for men was recently developed, and it is promoted on www.iwantthekit.org

MIAMI — At-home tests that involve self-collected vaginal samples that are sent to a lab for analysis are effective at identifying women with sexually transmitted diseases, suggest findings from a pilot study presented at the annual meeting of the American College of Preventive Medicine.

“We thought maybe we could reach out and get out of the clinic and encourage asymptomatic women to collect samples at home,” said Charlotte A. Gaydos, Dr.P.H., a microbiologist in the division of infectious diseases at Johns Hopkins University, Baltimore.

Surmising that the Internet might be an effective way to promote such at-home tests, the researchers established a Web site (www.iwantthekit.org

Data from 778 samples that had been analyzed as of Jan. 31, 2007, show 71 samples (9%) were positive for Chlamydia trachomatis and 12 (1%) were positive for Neisseria gonorrhoeae. Four samples showed coinfection with chlamydia and gonorrhea. Samples collected since September 2006 were tested for Trichomonas vaginalis, and 13 of 115 samples (11%) tested positive.

The test kit includes sterile swabs for collecting vaginal samples and a questionnaire soliciting information on demographics, sexual history, and the participants' opinions about at-home testing and their preferences for methods to receive test results.

“We require two positive assays for a positive diagnosis,” Dr. Gaydos said. Samples are analyzed using nucleic acid amplification tests (NAATs), which are more than 90% sensitive, compared with the 85% sensitivity associated with cultures. “The NAATs are the best tests there are today; they are very powerful,” Dr. Gaydos said.

Participants received their test results via a toll-free number. A study coordinator arranged treatment appointments at a free local clinic for those women with positive test results.

So far, most of the women who tested positive have been treated, Dr. Gaydos noted. All 11 patients with gonorrhea were treated, as were 66 of 69 (96%) chlamydia cases.

Of the 760 participants who identified their race, 70% were black, 22% were white, and the remainder were another race or mixed race. Chlamydia rates were significantly higher among black women, compared with white women (12% vs. 2%).

The participants ranged from 14 to 63 years of age, with an average age of 23 years, but those who tested positive tended to be younger, and the average age at first sex was 15 years, Dr. Gaydos noted.

Positive tests were most common in the 15− to 19-year-olds (16%), followed by 20− to 24-year-olds (8.5%) and 25− to 29-year-olds (8%).

After the researchers controlled for multiple factors including age and race, the strongest risk factors for positive test results were use of birth control, nonconsensual sex, and multiple partners.

In addition, more than 50% of the participants reported a history of STDs; 40% reported a history of chlamydia, and 15% reported a history of gonorrhea.

Results of the questionnaires that accompanied the kits suggest participants were receptive to the idea of at-home STD testing. On a Likert scale of 1 to 5, 96% said that the sampling process was “easy” or “very easy” and 93% said that they would use it again.

Nearly 25% said they preferred to receive results by e-mail, but a secure Web site to provide results is too expensive at this time, Dr. Gaydos said. Under the current protocol, participants calling the toll-free number give the kit number and a password that they chose to ensure confidentiality.

Even with the current phone-in method of requesting results, the success of the Web site in recruiting patients for home sampling and in treating those who test positive is encouraging, she added. “This may be another tool that we can use to reach out of the clinic and to save money. You can save a lot of money if you don't have to pay clinicians to collect the samples.”

A test kit for men was recently developed, and it is promoted on www.iwantthekit.org

MIAMI — At-home tests that involve self-collected vaginal samples that are sent to a lab for analysis are effective at identifying women with sexually transmitted diseases, suggest findings from a pilot study presented at the annual meeting of the American College of Preventive Medicine.

“We thought maybe we could reach out and get out of the clinic and encourage asymptomatic women to collect samples at home,” said Charlotte A. Gaydos, Dr.P.H., a microbiologist in the division of infectious diseases at Johns Hopkins University, Baltimore.

Surmising that the Internet might be an effective way to promote such at-home tests, the researchers established a Web site (www.iwantthekit.org

Data from 778 samples that had been analyzed as of Jan. 31, 2007, show 71 samples (9%) were positive for Chlamydia trachomatis and 12 (1%) were positive for Neisseria gonorrhoeae. Four samples showed coinfection with chlamydia and gonorrhea. Samples collected since September 2006 were tested for Trichomonas vaginalis, and 13 of 115 samples (11%) tested positive.

The test kit includes sterile swabs for collecting vaginal samples and a questionnaire soliciting information on demographics, sexual history, and the participants' opinions about at-home testing and their preferences for methods to receive test results.

“We require two positive assays for a positive diagnosis,” Dr. Gaydos said. Samples are analyzed using nucleic acid amplification tests (NAATs), which are more than 90% sensitive, compared with the 85% sensitivity associated with cultures. “The NAATs are the best tests there are today; they are very powerful,” Dr. Gaydos said.

Participants received their test results via a toll-free number. A study coordinator arranged treatment appointments at a free local clinic for those women with positive test results.

So far, most of the women who tested positive have been treated, Dr. Gaydos noted. All 11 patients with gonorrhea were treated, as were 66 of 69 (96%) chlamydia cases.

Of the 760 participants who identified their race, 70% were black, 22% were white, and the remainder were another race or mixed race. Chlamydia rates were significantly higher among black women, compared with white women (12% vs. 2%).

The participants ranged from 14 to 63 years of age, with an average age of 23 years, but those who tested positive tended to be younger, and the average age at first sex was 15 years, Dr. Gaydos noted.

Positive tests were most common in the 15− to 19-year-olds (16%), followed by 20− to 24-year-olds (8.5%) and 25− to 29-year-olds (8%).

After the researchers controlled for multiple factors including age and race, the strongest risk factors for positive test results were use of birth control, nonconsensual sex, and multiple partners.

In addition, more than 50% of the participants reported a history of STDs; 40% reported a history of chlamydia, and 15% reported a history of gonorrhea.

Results of the questionnaires that accompanied the kits suggest participants were receptive to the idea of at-home STD testing. On a Likert scale of 1 to 5, 96% said that the sampling process was “easy” or “very easy” and 93% said that they would use it again.

Nearly 25% said they preferred to receive results by e-mail, but a secure Web site to provide results is too expensive at this time, Dr. Gaydos said. Under the current protocol, participants calling the toll-free number give the kit number and a password that they chose to ensure confidentiality.

Even with the current phone-in method of requesting results, the success of the Web site in recruiting patients for home sampling and in treating those who test positive is encouraging, she added. “This may be another tool that we can use to reach out of the clinic and to save money. You can save a lot of money if you don't have to pay clinicians to collect the samples.”

A test kit for men was recently developed, and it is promoted on www.iwantthekit.org

Cannabis Use May Predict Later Anxiety

Young people who use cannabis at 15 years of age are significantly more likely to show symptoms of anxiety and depression in young adulthood, compared with non-cannabis users, data show.

From a clinical standpoint, reducing cannabis use in adolescents could reduce anxiety and depression in young adulthood, wrote Dr. Mohammad R. Hayatbakhsh and his colleagues at the University of Queensland in Brisbane, Australia.

To assess the relationships among cannabis use and anxiety and depression, the researchers reviewed data on 3,239 Australian young people from birth to age 21 and measured confounding factors at birth, age 14, and age 21 (J. Am. Acad. Child Adolesc. Psychiatry 2007;46:408–17).

A total of 1,586 youth (49%) reported ever using cannabis; 36.8% were occasional users (an average of one use per month) and 12.2% were frequent users (an average of one use every few days). Symptoms of anxiety and depression were assessed using the Youth Self-Report questionnaire.

After the researchers controlled for multiple factors, including gender, mother's mental health, family income, and smoking and alcohol consumption, young people who were frequent cannabis users before 15 years of age were more than twice as likely to show signs of anxiety and depression as young adults than were non-cannabis users. The association persisted, whether or not the young people used other illicit drugs in addition to cannabis.

Conversely, the presence of anxiety and depression before age 15 was not significantly associated with cannabis use in young adulthood. However, the findings suggest that cannabis use in adolescence may predict mental health problems later in life, the researchers noted.

Risky Sex Linked to Sensation-Seeking

Black adolescent girls who reported risky sexual activities scored significantly higher on tests of sexual sensation-seeking traits than did those who didn't report risky sex, based on data from 1,245 sexually active females aged 15–21 years.

To examine the relationship between sexual sensation seeking and sexual risk taking in adolescents, Joshua Spitalnick, Ph.D., of Emory University, Atlanta, and his colleagues surveyed black girls who were seeking sexual health services at community health clinics (J. Adolescence 2007;30:165–73).

Most (84%) of these adolescents reported that they were involved in a sexual relationship. The average length of that relationship was 15 months, and the respondents reported an average of nine lifetime partners. The average age of the participants was 18 years.

They were evaluated using the Sexual Sensation Seeking for Adolescents (SSSA) scale, which included statements such as, “I enjoy the thrill of having sex in public places,” with answer choices ranging from 1 (strongly disagree) to 4 (strongly agree). Scores ranged from 9 to 36, with an average score of 17.53.

Overall, respondents with high SSSA scores were significantly more likely to report risky sexual behavior including more-frequent vaginal intercourse, more sexual partners, and inconsistent use of condoms or other protection than were girls who scored lower on the SSSA.

Delinquent Teens at Risk for Suicide

Teenage delinquency was significantly associated with an increased risk for suicidal behavior in girls, according to data from a nationally representative sample of American teens.

To prospectively examine the association between delinquency and suicide in teens, Martie P. Thompson, Ph.D., and her colleagues at Clemson (S.C.) University reviewed data on 15,034 teens aged 12–17 years from the National Longitudinal Study of Adolescent Health, a survey of factors that affect teens' health and behavior (J. Adolesc. Health 2007;40:232–7).

Delinquency was assessed using a 15-item survey of behaviors in the previous 12 months, with questions such as, “How often did you deliberately damage property that didn't belong to you?”

After the researchers controlled for age, race, gender, and urban dwelling status, delinquent teens were significantly more likely than their nondelinquent peers to report suicidal ideation, suicide attempts, and treatment for suicide attempts at both 1 and 7 years' follow-up. When the researchers controlled for behavioral risk factors such as depression, impulsivity, religiosity, and problem drinking, delinquency remained significantly associated with suicidal ideation 1 year later and with suicide attempts 1 and 7 years later among girls. The association for boys remained but was not statistically significant.

Minority teens were less likely than were white teens to report suicidal ideation after 1 year, but there were no significant racial differences in those who attempted suicide or who required medical treatment after attempting suicide, Dr. Thompson and her associates noted.

Cannabis Use May Predict Later Anxiety

Young people who use cannabis at 15 years of age are significantly more likely to show symptoms of anxiety and depression in young adulthood, compared with non-cannabis users, data show.

From a clinical standpoint, reducing cannabis use in adolescents could reduce anxiety and depression in young adulthood, wrote Dr. Mohammad R. Hayatbakhsh and his colleagues at the University of Queensland in Brisbane, Australia.

To assess the relationships among cannabis use and anxiety and depression, the researchers reviewed data on 3,239 Australian young people from birth to age 21 and measured confounding factors at birth, age 14, and age 21 (J. Am. Acad. Child Adolesc. Psychiatry 2007;46:408–17).

A total of 1,586 youth (49%) reported ever using cannabis; 36.8% were occasional users (an average of one use per month) and 12.2% were frequent users (an average of one use every few days). Symptoms of anxiety and depression were assessed using the Youth Self-Report questionnaire.

After the researchers controlled for multiple factors, including gender, mother's mental health, family income, and smoking and alcohol consumption, young people who were frequent cannabis users before 15 years of age were more than twice as likely to show signs of anxiety and depression as young adults than were non-cannabis users. The association persisted, whether or not the young people used other illicit drugs in addition to cannabis.

Conversely, the presence of anxiety and depression before age 15 was not significantly associated with cannabis use in young adulthood. However, the findings suggest that cannabis use in adolescence may predict mental health problems later in life, the researchers noted.

Risky Sex Linked to Sensation-Seeking

Black adolescent girls who reported risky sexual activities scored significantly higher on tests of sexual sensation-seeking traits than did those who didn't report risky sex, based on data from 1,245 sexually active females aged 15–21 years.

To examine the relationship between sexual sensation seeking and sexual risk taking in adolescents, Joshua Spitalnick, Ph.D., of Emory University, Atlanta, and his colleagues surveyed black girls who were seeking sexual health services at community health clinics (J. Adolescence 2007;30:165–73).

Most (84%) of these adolescents reported that they were involved in a sexual relationship. The average length of that relationship was 15 months, and the respondents reported an average of nine lifetime partners. The average age of the participants was 18 years.

They were evaluated using the Sexual Sensation Seeking for Adolescents (SSSA) scale, which included statements such as, “I enjoy the thrill of having sex in public places,” with answer choices ranging from 1 (strongly disagree) to 4 (strongly agree). Scores ranged from 9 to 36, with an average score of 17.53.

Overall, respondents with high SSSA scores were significantly more likely to report risky sexual behavior including more-frequent vaginal intercourse, more sexual partners, and inconsistent use of condoms or other protection than were girls who scored lower on the SSSA.

Delinquent Teens at Risk for Suicide

Teenage delinquency was significantly associated with an increased risk for suicidal behavior in girls, according to data from a nationally representative sample of American teens.

To prospectively examine the association between delinquency and suicide in teens, Martie P. Thompson, Ph.D., and her colleagues at Clemson (S.C.) University reviewed data on 15,034 teens aged 12–17 years from the National Longitudinal Study of Adolescent Health, a survey of factors that affect teens' health and behavior (J. Adolesc. Health 2007;40:232–7).

Delinquency was assessed using a 15-item survey of behaviors in the previous 12 months, with questions such as, “How often did you deliberately damage property that didn't belong to you?”

After the researchers controlled for age, race, gender, and urban dwelling status, delinquent teens were significantly more likely than their nondelinquent peers to report suicidal ideation, suicide attempts, and treatment for suicide attempts at both 1 and 7 years' follow-up. When the researchers controlled for behavioral risk factors such as depression, impulsivity, religiosity, and problem drinking, delinquency remained significantly associated with suicidal ideation 1 year later and with suicide attempts 1 and 7 years later among girls. The association for boys remained but was not statistically significant.

Minority teens were less likely than were white teens to report suicidal ideation after 1 year, but there were no significant racial differences in those who attempted suicide or who required medical treatment after attempting suicide, Dr. Thompson and her associates noted.

Cannabis Use May Predict Later Anxiety

Young people who use cannabis at 15 years of age are significantly more likely to show symptoms of anxiety and depression in young adulthood, compared with non-cannabis users, data show.

From a clinical standpoint, reducing cannabis use in adolescents could reduce anxiety and depression in young adulthood, wrote Dr. Mohammad R. Hayatbakhsh and his colleagues at the University of Queensland in Brisbane, Australia.

To assess the relationships among cannabis use and anxiety and depression, the researchers reviewed data on 3,239 Australian young people from birth to age 21 and measured confounding factors at birth, age 14, and age 21 (J. Am. Acad. Child Adolesc. Psychiatry 2007;46:408–17).

A total of 1,586 youth (49%) reported ever using cannabis; 36.8% were occasional users (an average of one use per month) and 12.2% were frequent users (an average of one use every few days). Symptoms of anxiety and depression were assessed using the Youth Self-Report questionnaire.

After the researchers controlled for multiple factors, including gender, mother's mental health, family income, and smoking and alcohol consumption, young people who were frequent cannabis users before 15 years of age were more than twice as likely to show signs of anxiety and depression as young adults than were non-cannabis users. The association persisted, whether or not the young people used other illicit drugs in addition to cannabis.

Conversely, the presence of anxiety and depression before age 15 was not significantly associated with cannabis use in young adulthood. However, the findings suggest that cannabis use in adolescence may predict mental health problems later in life, the researchers noted.

Risky Sex Linked to Sensation-Seeking

Black adolescent girls who reported risky sexual activities scored significantly higher on tests of sexual sensation-seeking traits than did those who didn't report risky sex, based on data from 1,245 sexually active females aged 15–21 years.

To examine the relationship between sexual sensation seeking and sexual risk taking in adolescents, Joshua Spitalnick, Ph.D., of Emory University, Atlanta, and his colleagues surveyed black girls who were seeking sexual health services at community health clinics (J. Adolescence 2007;30:165–73).

Most (84%) of these adolescents reported that they were involved in a sexual relationship. The average length of that relationship was 15 months, and the respondents reported an average of nine lifetime partners. The average age of the participants was 18 years.

They were evaluated using the Sexual Sensation Seeking for Adolescents (SSSA) scale, which included statements such as, “I enjoy the thrill of having sex in public places,” with answer choices ranging from 1 (strongly disagree) to 4 (strongly agree). Scores ranged from 9 to 36, with an average score of 17.53.

Overall, respondents with high SSSA scores were significantly more likely to report risky sexual behavior including more-frequent vaginal intercourse, more sexual partners, and inconsistent use of condoms or other protection than were girls who scored lower on the SSSA.

Delinquent Teens at Risk for Suicide

Teenage delinquency was significantly associated with an increased risk for suicidal behavior in girls, according to data from a nationally representative sample of American teens.

To prospectively examine the association between delinquency and suicide in teens, Martie P. Thompson, Ph.D., and her colleagues at Clemson (S.C.) University reviewed data on 15,034 teens aged 12–17 years from the National Longitudinal Study of Adolescent Health, a survey of factors that affect teens' health and behavior (J. Adolesc. Health 2007;40:232–7).

Delinquency was assessed using a 15-item survey of behaviors in the previous 12 months, with questions such as, “How often did you deliberately damage property that didn't belong to you?”

After the researchers controlled for age, race, gender, and urban dwelling status, delinquent teens were significantly more likely than their nondelinquent peers to report suicidal ideation, suicide attempts, and treatment for suicide attempts at both 1 and 7 years' follow-up. When the researchers controlled for behavioral risk factors such as depression, impulsivity, religiosity, and problem drinking, delinquency remained significantly associated with suicidal ideation 1 year later and with suicide attempts 1 and 7 years later among girls. The association for boys remained but was not statistically significant.

Minority teens were less likely than were white teens to report suicidal ideation after 1 year, but there were no significant racial differences in those who attempted suicide or who required medical treatment after attempting suicide, Dr. Thompson and her associates noted.

GRAND CAYMAN, CAYMAN ISLANDS — "Read clinical research studies carefully and thoughtfully, and don't rely on anyone to think for you," Dr. Lee Zane advised at the Caribbean Dermatology Symposium.

An important skill to master is the ability to summarize a study in a single sentence that describes the study design, primary predictors, primary outcomes, and study population, said Dr. Zane, a dermatologist at the University of California, San Francisco.

Readers who adroitly summarize a study can communicate its essential elements to others and create a framework for evaluating the study's results. To that end, Dr. Zane offered several points to consider when reading a study.

All studies have limitations, such as bias or confounders, that may compromise the interpretation of the results. Such factors do not generally invalidate the results, but they invite readers to consider the results in the context of the limitations, Dr. Zane explained. "In fact, sometimes conclusions may be strengthened by the presence of a confounder," he said.

Randomized clinical trials are considered to provide some of the strongest clinical evidence, but even they have vulnerabilities that can compromise their interpretation.

Randomization itself is one such limitation. If not done properly, randomization can introduce bias into a study. For example, randomization by whether a patient comes in on Monday or Wednesday versus Tuesday or Thursday is not true randomization, Dr. Zane said. In addition, traits such as age and sex can confound the results if they aren't distributed equally among randomized groups.

"Always scrutinize Table 1," he advised. Table 1 shows the features of the randomized groups. "If there are differences among groups, you have to decide whether they may have had a significant effect on the outcome."

Don't confuse clinical significance with statistical significance. "Just because a result has a low P value doesn't mean it is an important or useful clinical finding," he said at the meeting.

"There is a general overreliance on P values in our literature," Dr. Zane said. He cited the historical origin of P greater than .05 as an indicator of statistical significance. The value was arbitrarily chosen by statistician Ronald Fisher in 1926 in a paper assessing the effectiveness of manure on crop growth.

"Investigators should report the actual P value rather than simply saying whether it is greater or less than .05," he said. "Knowing whether a P value is .06 or .98 provides much more information about how likely the result may have been simply due to chance."

Confidence intervals may be a preferable alternative to P values, Dr. Zane said. These intervals are a measure of precision, not the result of a statistical test, and they provide a range of values around an estimate that may be considered statistically similar to that estimate.

Don't forget to consider such methodologic factors as the size and composition of the sample population—as well as the level of blinding—when reading and evaluating a study, he said. "Are the subjects in the study similar to those that you see in your clinic? Could the lack of blinding in an open-label study have contributed to the observed results?"

All studies provide evidence of some sort. "The key is being able to determine the strength of that evidence," he said.

GRAND CAYMAN, CAYMAN ISLANDS — "Read clinical research studies carefully and thoughtfully, and don't rely on anyone to think for you," Dr. Lee Zane advised at the Caribbean Dermatology Symposium.

An important skill to master is the ability to summarize a study in a single sentence that describes the study design, primary predictors, primary outcomes, and study population, said Dr. Zane, a dermatologist at the University of California, San Francisco.

Readers who adroitly summarize a study can communicate its essential elements to others and create a framework for evaluating the study's results. To that end, Dr. Zane offered several points to consider when reading a study.

All studies have limitations, such as bias or confounders, that may compromise the interpretation of the results. Such factors do not generally invalidate the results, but they invite readers to consider the results in the context of the limitations, Dr. Zane explained. "In fact, sometimes conclusions may be strengthened by the presence of a confounder," he said.

Randomized clinical trials are considered to provide some of the strongest clinical evidence, but even they have vulnerabilities that can compromise their interpretation.

Randomization itself is one such limitation. If not done properly, randomization can introduce bias into a study. For example, randomization by whether a patient comes in on Monday or Wednesday versus Tuesday or Thursday is not true randomization, Dr. Zane said. In addition, traits such as age and sex can confound the results if they aren't distributed equally among randomized groups.

"Always scrutinize Table 1," he advised. Table 1 shows the features of the randomized groups. "If there are differences among groups, you have to decide whether they may have had a significant effect on the outcome."

Don't confuse clinical significance with statistical significance. "Just because a result has a low P value doesn't mean it is an important or useful clinical finding," he said at the meeting.

"There is a general overreliance on P values in our literature," Dr. Zane said. He cited the historical origin of P greater than .05 as an indicator of statistical significance. The value was arbitrarily chosen by statistician Ronald Fisher in 1926 in a paper assessing the effectiveness of manure on crop growth.

"Investigators should report the actual P value rather than simply saying whether it is greater or less than .05," he said. "Knowing whether a P value is .06 or .98 provides much more information about how likely the result may have been simply due to chance."

Confidence intervals may be a preferable alternative to P values, Dr. Zane said. These intervals are a measure of precision, not the result of a statistical test, and they provide a range of values around an estimate that may be considered statistically similar to that estimate.

Don't forget to consider such methodologic factors as the size and composition of the sample population—as well as the level of blinding—when reading and evaluating a study, he said. "Are the subjects in the study similar to those that you see in your clinic? Could the lack of blinding in an open-label study have contributed to the observed results?"

All studies provide evidence of some sort. "The key is being able to determine the strength of that evidence," he said.

GRAND CAYMAN, CAYMAN ISLANDS — "Read clinical research studies carefully and thoughtfully, and don't rely on anyone to think for you," Dr. Lee Zane advised at the Caribbean Dermatology Symposium.

An important skill to master is the ability to summarize a study in a single sentence that describes the study design, primary predictors, primary outcomes, and study population, said Dr. Zane, a dermatologist at the University of California, San Francisco.

Readers who adroitly summarize a study can communicate its essential elements to others and create a framework for evaluating the study's results. To that end, Dr. Zane offered several points to consider when reading a study.

All studies have limitations, such as bias or confounders, that may compromise the interpretation of the results. Such factors do not generally invalidate the results, but they invite readers to consider the results in the context of the limitations, Dr. Zane explained. "In fact, sometimes conclusions may be strengthened by the presence of a confounder," he said.

Randomized clinical trials are considered to provide some of the strongest clinical evidence, but even they have vulnerabilities that can compromise their interpretation.

Randomization itself is one such limitation. If not done properly, randomization can introduce bias into a study. For example, randomization by whether a patient comes in on Monday or Wednesday versus Tuesday or Thursday is not true randomization, Dr. Zane said. In addition, traits such as age and sex can confound the results if they aren't distributed equally among randomized groups.

"Always scrutinize Table 1," he advised. Table 1 shows the features of the randomized groups. "If there are differences among groups, you have to decide whether they may have had a significant effect on the outcome."

Don't confuse clinical significance with statistical significance. "Just because a result has a low P value doesn't mean it is an important or useful clinical finding," he said at the meeting.

"There is a general overreliance on P values in our literature," Dr. Zane said. He cited the historical origin of P greater than .05 as an indicator of statistical significance. The value was arbitrarily chosen by statistician Ronald Fisher in 1926 in a paper assessing the effectiveness of manure on crop growth.

"Investigators should report the actual P value rather than simply saying whether it is greater or less than .05," he said. "Knowing whether a P value is .06 or .98 provides much more information about how likely the result may have been simply due to chance."

Confidence intervals may be a preferable alternative to P values, Dr. Zane said. These intervals are a measure of precision, not the result of a statistical test, and they provide a range of values around an estimate that may be considered statistically similar to that estimate.

Don't forget to consider such methodologic factors as the size and composition of the sample population—as well as the level of blinding—when reading and evaluating a study, he said. "Are the subjects in the study similar to those that you see in your clinic? Could the lack of blinding in an open-label study have contributed to the observed results?"

All studies provide evidence of some sort. "The key is being able to determine the strength of that evidence," he said.

GRAND CAYMAN, CAYMAN ISLANDS — Lid and ocular surface lesions are signs of conditions where the eye and the skin overlap, Dr. Catherine Newton said at the Caribbean Dermatology Symposium.

Dr. Newton, a professor of ophthalmology at the University of Louisville (Ky.), presented examples of cases with skin and eye involvement that are not inflammatory diseases, including benign conditions (neoplasms) and potentially serious infections such as herpes.

Dr. Newton presented a case of an 82-year-old man who reported "something blocking his view" during a visit for corneal care. It was a bumpy mass that was diagnosed as a verrucous papilloma.

Cysts and benign neoplasms near the eye are common, Dr. Newton said.

An ophthalmologist performed a surgical resection of the verrucous papilloma, and the patient has had no recurrence, she said in an interview.

Another case of a benign neoplasm involved a woman with a bump on the lower left lid (acanthoma). Dr. Newton treated this patient with lidocaine ointment, and she was later able to use a jeweler's forceps and remove the sac, which spared the patient an excision.

Dr. Newton presented a case of an 11-year-old girl with molluscum contagiosum as an example of an infectious disease that can involve the eyes and skin. Molluscum contagiosum lesions often occur on the faces in children who acquire the infection by nonsexual transmission. The lesions can be mistaken for pustules, but histology data confirm the infection.

She treated the girl by curetting the lesions using local anesthesia, and the lesions have resolved completely. Cryotherapy and a peeling agent such as salicylic acid may also be used to treat molluscum contagiosum lesions.

GRAND CAYMAN, CAYMAN ISLANDS — Lid and ocular surface lesions are signs of conditions where the eye and the skin overlap, Dr. Catherine Newton said at the Caribbean Dermatology Symposium.

Dr. Newton, a professor of ophthalmology at the University of Louisville (Ky.), presented examples of cases with skin and eye involvement that are not inflammatory diseases, including benign conditions (neoplasms) and potentially serious infections such as herpes.

Dr. Newton presented a case of an 82-year-old man who reported "something blocking his view" during a visit for corneal care. It was a bumpy mass that was diagnosed as a verrucous papilloma.

Cysts and benign neoplasms near the eye are common, Dr. Newton said.

An ophthalmologist performed a surgical resection of the verrucous papilloma, and the patient has had no recurrence, she said in an interview.

Another case of a benign neoplasm involved a woman with a bump on the lower left lid (acanthoma). Dr. Newton treated this patient with lidocaine ointment, and she was later able to use a jeweler's forceps and remove the sac, which spared the patient an excision.

Dr. Newton presented a case of an 11-year-old girl with molluscum contagiosum as an example of an infectious disease that can involve the eyes and skin. Molluscum contagiosum lesions often occur on the faces in children who acquire the infection by nonsexual transmission. The lesions can be mistaken for pustules, but histology data confirm the infection.

She treated the girl by curetting the lesions using local anesthesia, and the lesions have resolved completely. Cryotherapy and a peeling agent such as salicylic acid may also be used to treat molluscum contagiosum lesions.

GRAND CAYMAN, CAYMAN ISLANDS — Lid and ocular surface lesions are signs of conditions where the eye and the skin overlap, Dr. Catherine Newton said at the Caribbean Dermatology Symposium.

Dr. Newton, a professor of ophthalmology at the University of Louisville (Ky.), presented examples of cases with skin and eye involvement that are not inflammatory diseases, including benign conditions (neoplasms) and potentially serious infections such as herpes.

Dr. Newton presented a case of an 82-year-old man who reported "something blocking his view" during a visit for corneal care. It was a bumpy mass that was diagnosed as a verrucous papilloma.

Cysts and benign neoplasms near the eye are common, Dr. Newton said.

An ophthalmologist performed a surgical resection of the verrucous papilloma, and the patient has had no recurrence, she said in an interview.

Another case of a benign neoplasm involved a woman with a bump on the lower left lid (acanthoma). Dr. Newton treated this patient with lidocaine ointment, and she was later able to use a jeweler's forceps and remove the sac, which spared the patient an excision.

Dr. Newton presented a case of an 11-year-old girl with molluscum contagiosum as an example of an infectious disease that can involve the eyes and skin. Molluscum contagiosum lesions often occur on the faces in children who acquire the infection by nonsexual transmission. The lesions can be mistaken for pustules, but histology data confirm the infection.

She treated the girl by curetting the lesions using local anesthesia, and the lesions have resolved completely. Cryotherapy and a peeling agent such as salicylic acid may also be used to treat molluscum contagiosum lesions.

MIAMI — At-home tests involving self-collected vaginal samples that are sent to a lab for analysis are effective at identifying women with sexually transmitted diseases, suggests a pilot study presented at the annual meeting of the American College of Preventive Medicine.

“This may be another tool that we can use to reach out of the clinic and to save money. You can save a lot of money if you don't have to pay clinicians to collect the samples,” said Charlotte A. Gaydos, Dr.P.H., a microbiologist in the division of infectious diseases at Johns Hopkins University, Baltimore.

The researchers established a Web site (www.iwantthekit.org

Data from 778 samples that had been analyzed as of Jan. 31, 2007, show 71 samples (9%) were positive for Chlamydia trachomatis and 12 (1%) were positive for Neisseria gonorrhoeae. Four samples showed coinfection with chlamydia and gonorrhea. Samples collected since September 2006 were tested for Trichomonas vaginalis, and 13 of 115 samples (11%) tested positive.

The kit includes swabs for collecting vaginal samples and a questionnaire on demographics, sexual history, and the participants' opinions about at-home testing.

“We require two positive assays for a positive diagnosis,” Dr. Gaydos said. Samples are analyzed using nucleic acid amplification tests (NAATs), which are more than 90% sensitive, compared with the 85% sensitivity associated with cultures. Participants received their test results via a toll-free number. A study coordinator arranged treatment appointments at a free local clinic for women with positive results.

So far, most women who tested positive have been treated, Dr. Gaydos noted. All 11 patients with gonorrhea were treated, as were 66 of 69 (96%) chlamydia cases.

Of 760 participants who identified their race, 70% were black, 22% were white, and the remainder were another race or mixed race. Chlamydia rates were significantly higher among black women, compared with white women (12% vs. 2%).

The participants ranged from 14 to 63 years of age, with an average age of 23, but those who tested positive tended to be younger. Average age at first sex was 15 years, Dr. Gaydos noted.

Positive tests were most common in the 15- to 19-year-olds (16%), followed by 20- to 24-year-olds (8.5%) and 25- to 29-year-olds (8%).

After controlling for multiple factors including age and race, the strongest risk factors for positive test results were use of birth control, nonconsensual sex, and multiple partners.

More than half of the participants reported a history of STDs; 40% had a history of chlamydia and 15% reported a history of gonorrhea.

Results of the questionnaires showed that on a Likert scale of 1 to 5, 96% said the sampling process was “easy” or “very easy” and 93% said they would use it again.

Nearly 25% said they preferred to receive results by e-mail, but a secure Web site to provide results is too expensive at this time, Dr. Gaydos said.

Under current protocol, participants calling the toll-free number give the kit number and a password that they chose to ensure confidentiality.

Even with the phone-in method of requesting results, the success in recruiting patients for home sampling and treating those who test positive is encouraging, Dr. Gaydos added.

A test kit for men is also promoted on www.iwantthekit.org

MIAMI — At-home tests involving self-collected vaginal samples that are sent to a lab for analysis are effective at identifying women with sexually transmitted diseases, suggests a pilot study presented at the annual meeting of the American College of Preventive Medicine.

“This may be another tool that we can use to reach out of the clinic and to save money. You can save a lot of money if you don't have to pay clinicians to collect the samples,” said Charlotte A. Gaydos, Dr.P.H., a microbiologist in the division of infectious diseases at Johns Hopkins University, Baltimore.

The researchers established a Web site (www.iwantthekit.org

Data from 778 samples that had been analyzed as of Jan. 31, 2007, show 71 samples (9%) were positive for Chlamydia trachomatis and 12 (1%) were positive for Neisseria gonorrhoeae. Four samples showed coinfection with chlamydia and gonorrhea. Samples collected since September 2006 were tested for Trichomonas vaginalis, and 13 of 115 samples (11%) tested positive.

The kit includes swabs for collecting vaginal samples and a questionnaire on demographics, sexual history, and the participants' opinions about at-home testing.

“We require two positive assays for a positive diagnosis,” Dr. Gaydos said. Samples are analyzed using nucleic acid amplification tests (NAATs), which are more than 90% sensitive, compared with the 85% sensitivity associated with cultures. Participants received their test results via a toll-free number. A study coordinator arranged treatment appointments at a free local clinic for women with positive results.

So far, most women who tested positive have been treated, Dr. Gaydos noted. All 11 patients with gonorrhea were treated, as were 66 of 69 (96%) chlamydia cases.

Of 760 participants who identified their race, 70% were black, 22% were white, and the remainder were another race or mixed race. Chlamydia rates were significantly higher among black women, compared with white women (12% vs. 2%).

The participants ranged from 14 to 63 years of age, with an average age of 23, but those who tested positive tended to be younger. Average age at first sex was 15 years, Dr. Gaydos noted.

Positive tests were most common in the 15- to 19-year-olds (16%), followed by 20- to 24-year-olds (8.5%) and 25- to 29-year-olds (8%).

After controlling for multiple factors including age and race, the strongest risk factors for positive test results were use of birth control, nonconsensual sex, and multiple partners.

More than half of the participants reported a history of STDs; 40% had a history of chlamydia and 15% reported a history of gonorrhea.

Results of the questionnaires showed that on a Likert scale of 1 to 5, 96% said the sampling process was “easy” or “very easy” and 93% said they would use it again.

Nearly 25% said they preferred to receive results by e-mail, but a secure Web site to provide results is too expensive at this time, Dr. Gaydos said.

Under current protocol, participants calling the toll-free number give the kit number and a password that they chose to ensure confidentiality.

Even with the phone-in method of requesting results, the success in recruiting patients for home sampling and treating those who test positive is encouraging, Dr. Gaydos added.

A test kit for men is also promoted on www.iwantthekit.org

MIAMI — At-home tests involving self-collected vaginal samples that are sent to a lab for analysis are effective at identifying women with sexually transmitted diseases, suggests a pilot study presented at the annual meeting of the American College of Preventive Medicine.

“This may be another tool that we can use to reach out of the clinic and to save money. You can save a lot of money if you don't have to pay clinicians to collect the samples,” said Charlotte A. Gaydos, Dr.P.H., a microbiologist in the division of infectious diseases at Johns Hopkins University, Baltimore.

The researchers established a Web site (www.iwantthekit.org

Data from 778 samples that had been analyzed as of Jan. 31, 2007, show 71 samples (9%) were positive for Chlamydia trachomatis and 12 (1%) were positive for Neisseria gonorrhoeae. Four samples showed coinfection with chlamydia and gonorrhea. Samples collected since September 2006 were tested for Trichomonas vaginalis, and 13 of 115 samples (11%) tested positive.

The kit includes swabs for collecting vaginal samples and a questionnaire on demographics, sexual history, and the participants' opinions about at-home testing.

“We require two positive assays for a positive diagnosis,” Dr. Gaydos said. Samples are analyzed using nucleic acid amplification tests (NAATs), which are more than 90% sensitive, compared with the 85% sensitivity associated with cultures. Participants received their test results via a toll-free number. A study coordinator arranged treatment appointments at a free local clinic for women with positive results.

So far, most women who tested positive have been treated, Dr. Gaydos noted. All 11 patients with gonorrhea were treated, as were 66 of 69 (96%) chlamydia cases.

Of 760 participants who identified their race, 70% were black, 22% were white, and the remainder were another race or mixed race. Chlamydia rates were significantly higher among black women, compared with white women (12% vs. 2%).

The participants ranged from 14 to 63 years of age, with an average age of 23, but those who tested positive tended to be younger. Average age at first sex was 15 years, Dr. Gaydos noted.

Positive tests were most common in the 15- to 19-year-olds (16%), followed by 20- to 24-year-olds (8.5%) and 25- to 29-year-olds (8%).

After controlling for multiple factors including age and race, the strongest risk factors for positive test results were use of birth control, nonconsensual sex, and multiple partners.

More than half of the participants reported a history of STDs; 40% had a history of chlamydia and 15% reported a history of gonorrhea.

Results of the questionnaires showed that on a Likert scale of 1 to 5, 96% said the sampling process was “easy” or “very easy” and 93% said they would use it again.

Nearly 25% said they preferred to receive results by e-mail, but a secure Web site to provide results is too expensive at this time, Dr. Gaydos said.

Under current protocol, participants calling the toll-free number give the kit number and a password that they chose to ensure confidentiality.

Even with the phone-in method of requesting results, the success in recruiting patients for home sampling and treating those who test positive is encouraging, Dr. Gaydos added.

A test kit for men is also promoted on www.iwantthekit.org

Nine influenza-related deaths have been reported in children in six states during the 2006–2007 flu season as of Feb. 3, based on a report issued Feb. 16 by the Centers for Disease Control and Prevention.

Five children were boys; four were girls. The children ranged in age from 3 months to 14 years (average age 7.5 years).

All nine children tested positive for the influenza A virus, and two specimens were identified as the influenza A (H1) virus (MMWR 2007;56:118–21).

The preliminary rate of laboratory-confirmed flu hospitalizations among children aged 0–17 years was 0.13 per 10,000 children based on the Emerging Infections Program database for the period from Oct. 1, 2006, through Jan. 20, 2007.

When the children were divided by age group, the rates were 0.13 per 10,000 children aged 0–4 years, and 0.05 per 10,000 children aged 5–17 years.

In addition, the preliminary rate of laboratory-confirmed flu hospitalizations among children aged 0–4 years was 0.63 per 10,000 children, based on the New Vaccine Surveillance Network database for the period from Nov. 5, 2006, through Jan. 20, 2007.

Influenza A (H1) has been the most often reported virus in flu patients overall this year. The weekly percentage of deaths in patients of any age from pneumonia and influenza has ranged from 5.6% to 7.5% this year, but as of Feb. 3, these rates had not passed the epidemic threshold as defined by the CDC at any point during the 2006–2007 flu season.

Nine influenza-related deaths have been reported in children in six states during the 2006–2007 flu season as of Feb. 3, based on a report issued Feb. 16 by the Centers for Disease Control and Prevention.

Five children were boys; four were girls. The children ranged in age from 3 months to 14 years (average age 7.5 years).

All nine children tested positive for the influenza A virus, and two specimens were identified as the influenza A (H1) virus (MMWR 2007;56:118–21).

The preliminary rate of laboratory-confirmed flu hospitalizations among children aged 0–17 years was 0.13 per 10,000 children based on the Emerging Infections Program database for the period from Oct. 1, 2006, through Jan. 20, 2007.

When the children were divided by age group, the rates were 0.13 per 10,000 children aged 0–4 years, and 0.05 per 10,000 children aged 5–17 years.

In addition, the preliminary rate of laboratory-confirmed flu hospitalizations among children aged 0–4 years was 0.63 per 10,000 children, based on the New Vaccine Surveillance Network database for the period from Nov. 5, 2006, through Jan. 20, 2007.

Influenza A (H1) has been the most often reported virus in flu patients overall this year. The weekly percentage of deaths in patients of any age from pneumonia and influenza has ranged from 5.6% to 7.5% this year, but as of Feb. 3, these rates had not passed the epidemic threshold as defined by the CDC at any point during the 2006–2007 flu season.

Nine influenza-related deaths have been reported in children in six states during the 2006–2007 flu season as of Feb. 3, based on a report issued Feb. 16 by the Centers for Disease Control and Prevention.

Five children were boys; four were girls. The children ranged in age from 3 months to 14 years (average age 7.5 years).

All nine children tested positive for the influenza A virus, and two specimens were identified as the influenza A (H1) virus (MMWR 2007;56:118–21).

The preliminary rate of laboratory-confirmed flu hospitalizations among children aged 0–17 years was 0.13 per 10,000 children based on the Emerging Infections Program database for the period from Oct. 1, 2006, through Jan. 20, 2007.

When the children were divided by age group, the rates were 0.13 per 10,000 children aged 0–4 years, and 0.05 per 10,000 children aged 5–17 years.

In addition, the preliminary rate of laboratory-confirmed flu hospitalizations among children aged 0–4 years was 0.63 per 10,000 children, based on the New Vaccine Surveillance Network database for the period from Nov. 5, 2006, through Jan. 20, 2007.

Influenza A (H1) has been the most often reported virus in flu patients overall this year. The weekly percentage of deaths in patients of any age from pneumonia and influenza has ranged from 5.6% to 7.5% this year, but as of Feb. 3, these rates had not passed the epidemic threshold as defined by the CDC at any point during the 2006–2007 flu season.

Cranial ultrasound scanning significantly predicted developmental outcomes in symptomatic newborns with cytomegalovirus, based on a study of 57 infants reported in the February issue of the Journal of Pediatrics.

To determine how well cranial ultrasound predicted clinical outcomes, two of the researchers reviewed the scans of the infants while blinded to the results (J. Pediatr. 2007;150:157–61). The ultrasound scans were taken during the first week of life and repeated weekly for the first month in cases of abnormal findings, and then repeated monthly until the infants were 6 months old.

Overall, 18 newborns had clinical and laboratory signs of cytomegalovirus (CMV) at birth, and 39 had no observable symptoms at birth. A total of 12 of the 57 (21%) infants had brain abnormalities that were visible on an ultrasound image. Ultrasound lesions were found in 10 of 18 (56%) newborns with clinical and laboratory symptoms, compared with 2 of 39 (5%) asymptomatic newborns.

None of the infants with normal ultrasound findings at birth had developed lesions at follow-up evaluations, and the negative predictive value of the ultrasound was 100% for motor delay and low developmental quotient and 93.3% for sensorineural hearing loss, Dr. Gina Ancora of the University of Bologna (Italy) and her colleagues wrote.

Data from evaluations at 12 months of age were available for 56 of 57 patients; one infant with visible ultrasound lesions had died of aortic thrombosis. Ten of the 11 remaining symptomatic newborns with abnormal ultrasound findings at birth developed at least one sequela, whereas none of the 8 newborns who were symptomatic but had normal ultrasound findings developed sequelae.

Similarly, only 3 of the 37 asymptomatic infants with no ultrasound abnormalities had poor outcomes at 12 months (sensorineural hearing loss), and 1 of 2 asymptomatic infants with abnormal ultrasound findings developed severe sequelae.

The presence of CMV symptoms at birth may not be enough to differentiate between children who will and will not develop lesions later, and ultrasound is a safe and easy diagnostic tool in this population, even for children in critical condition, the researchers wrote.

But the data were insufficient to make recommendations for ultrasound imaging in asymptomatic children, they said.

Cranial ultrasound scanning significantly predicted developmental outcomes in symptomatic newborns with cytomegalovirus, based on a study of 57 infants reported in the February issue of the Journal of Pediatrics.

To determine how well cranial ultrasound predicted clinical outcomes, two of the researchers reviewed the scans of the infants while blinded to the results (J. Pediatr. 2007;150:157–61). The ultrasound scans were taken during the first week of life and repeated weekly for the first month in cases of abnormal findings, and then repeated monthly until the infants were 6 months old.

Overall, 18 newborns had clinical and laboratory signs of cytomegalovirus (CMV) at birth, and 39 had no observable symptoms at birth. A total of 12 of the 57 (21%) infants had brain abnormalities that were visible on an ultrasound image. Ultrasound lesions were found in 10 of 18 (56%) newborns with clinical and laboratory symptoms, compared with 2 of 39 (5%) asymptomatic newborns.

None of the infants with normal ultrasound findings at birth had developed lesions at follow-up evaluations, and the negative predictive value of the ultrasound was 100% for motor delay and low developmental quotient and 93.3% for sensorineural hearing loss, Dr. Gina Ancora of the University of Bologna (Italy) and her colleagues wrote.

Data from evaluations at 12 months of age were available for 56 of 57 patients; one infant with visible ultrasound lesions had died of aortic thrombosis. Ten of the 11 remaining symptomatic newborns with abnormal ultrasound findings at birth developed at least one sequela, whereas none of the 8 newborns who were symptomatic but had normal ultrasound findings developed sequelae.

Similarly, only 3 of the 37 asymptomatic infants with no ultrasound abnormalities had poor outcomes at 12 months (sensorineural hearing loss), and 1 of 2 asymptomatic infants with abnormal ultrasound findings developed severe sequelae.

The presence of CMV symptoms at birth may not be enough to differentiate between children who will and will not develop lesions later, and ultrasound is a safe and easy diagnostic tool in this population, even for children in critical condition, the researchers wrote.

But the data were insufficient to make recommendations for ultrasound imaging in asymptomatic children, they said.

Cranial ultrasound scanning significantly predicted developmental outcomes in symptomatic newborns with cytomegalovirus, based on a study of 57 infants reported in the February issue of the Journal of Pediatrics.

To determine how well cranial ultrasound predicted clinical outcomes, two of the researchers reviewed the scans of the infants while blinded to the results (J. Pediatr. 2007;150:157–61). The ultrasound scans were taken during the first week of life and repeated weekly for the first month in cases of abnormal findings, and then repeated monthly until the infants were 6 months old.

Overall, 18 newborns had clinical and laboratory signs of cytomegalovirus (CMV) at birth, and 39 had no observable symptoms at birth. A total of 12 of the 57 (21%) infants had brain abnormalities that were visible on an ultrasound image. Ultrasound lesions were found in 10 of 18 (56%) newborns with clinical and laboratory symptoms, compared with 2 of 39 (5%) asymptomatic newborns.

None of the infants with normal ultrasound findings at birth had developed lesions at follow-up evaluations, and the negative predictive value of the ultrasound was 100% for motor delay and low developmental quotient and 93.3% for sensorineural hearing loss, Dr. Gina Ancora of the University of Bologna (Italy) and her colleagues wrote.

Data from evaluations at 12 months of age were available for 56 of 57 patients; one infant with visible ultrasound lesions had died of aortic thrombosis. Ten of the 11 remaining symptomatic newborns with abnormal ultrasound findings at birth developed at least one sequela, whereas none of the 8 newborns who were symptomatic but had normal ultrasound findings developed sequelae.

Similarly, only 3 of the 37 asymptomatic infants with no ultrasound abnormalities had poor outcomes at 12 months (sensorineural hearing loss), and 1 of 2 asymptomatic infants with abnormal ultrasound findings developed severe sequelae.

The presence of CMV symptoms at birth may not be enough to differentiate between children who will and will not develop lesions later, and ultrasound is a safe and easy diagnostic tool in this population, even for children in critical condition, the researchers wrote.

But the data were insufficient to make recommendations for ultrasound imaging in asymptomatic children, they said.

PHOENIX — Neonatal thyroid-stimulating hormone data can be used to detect epidemiologic trends in iodine sufficiency in pregnant women, even in countries where iodine intake is usually adequate, based on a study of 54,400 neonates presented at the annual meeting of the American Thyroid Association.

“Readily available neonatal TSH can be used to track the effects of altered trends in maternal iodine nutrition,” said Dr. Peter Smyth of the Conway Institute of Biomolecular and Biomedical Research at the University College Dublin.

Steps can be taken to increase iodine intake in pregnant women (which is important for proper fetal cognitive development) if the neonatal TSH in a population suggests low levels of maternal dietary iodine. The fetus depends on maternal thyroid hormones for normal development during the first 13–15 weeks of pregnancy, Dr. Smyth noted.

To assess the potential role of neonatal TSH as an indicator of a mother's iodine status, researchers screened a birth cohort of babies born in Ireland between 1988 and 2006.

Overall, TSH levels in newborns increased slightly but steadily during the study period, although the proportion of infants with severe iodine deficiency (TSH less than 5 mU/L) remained constant and stayed in a range of 2.35%–2.83%.

Notably, data from routine neonatal TSH screening showed a seasonal variation: Infants born in August had consistently higher TSH levels than infants born in January. Most dietary iodine in Ireland comes from milk and dairy products, and dietary iodine intake is disproportionately lower during the summer because the herd animals are out grazing and not receiving any nutritional supplements, Dr. Smyth explained.

Iodine levels in pregnant women were assessed using urinary iodine (UI) excretion values, and the decline in these values during the study period confirmed that the pregnant female population was borderline iodine deficient but relatively stable, although the UI values reflected the seasonal variation in dietary iodine intake.

From 1988 to 2003, the mean maternal UI values ranged from 70 to 83 mcg/L during the summer months and from 82 to 137 mcg/L during the winter months.

But findings from 2004 and 2005 showed a significant drop in maternal UI levels, which fell to a mean of 45 mcg/L in 2004 and 42.5 mcg/L in 2005. That trend has raised concerns about the need for dietary iodine supplementation in pregnant women in Ireland, said Dr. Smyth.

The study results support the link between declining urinary iodine levels in pregnant women and fetal thyroid function, and the trend data for maternal UI can be used to decide whether to initiate thyroid screening programs during pregnancy.

PHOENIX — Neonatal thyroid-stimulating hormone data can be used to detect epidemiologic trends in iodine sufficiency in pregnant women, even in countries where iodine intake is usually adequate, based on a study of 54,400 neonates presented at the annual meeting of the American Thyroid Association.

“Readily available neonatal TSH can be used to track the effects of altered trends in maternal iodine nutrition,” said Dr. Peter Smyth of the Conway Institute of Biomolecular and Biomedical Research at the University College Dublin.

Steps can be taken to increase iodine intake in pregnant women (which is important for proper fetal cognitive development) if the neonatal TSH in a population suggests low levels of maternal dietary iodine. The fetus depends on maternal thyroid hormones for normal development during the first 13–15 weeks of pregnancy, Dr. Smyth noted.

To assess the potential role of neonatal TSH as an indicator of a mother's iodine status, researchers screened a birth cohort of babies born in Ireland between 1988 and 2006.

Overall, TSH levels in newborns increased slightly but steadily during the study period, although the proportion of infants with severe iodine deficiency (TSH less than 5 mU/L) remained constant and stayed in a range of 2.35%–2.83%.

Notably, data from routine neonatal TSH screening showed a seasonal variation: Infants born in August had consistently higher TSH levels than infants born in January. Most dietary iodine in Ireland comes from milk and dairy products, and dietary iodine intake is disproportionately lower during the summer because the herd animals are out grazing and not receiving any nutritional supplements, Dr. Smyth explained.

Iodine levels in pregnant women were assessed using urinary iodine (UI) excretion values, and the decline in these values during the study period confirmed that the pregnant female population was borderline iodine deficient but relatively stable, although the UI values reflected the seasonal variation in dietary iodine intake.

From 1988 to 2003, the mean maternal UI values ranged from 70 to 83 mcg/L during the summer months and from 82 to 137 mcg/L during the winter months.

But findings from 2004 and 2005 showed a significant drop in maternal UI levels, which fell to a mean of 45 mcg/L in 2004 and 42.5 mcg/L in 2005. That trend has raised concerns about the need for dietary iodine supplementation in pregnant women in Ireland, said Dr. Smyth.

The study results support the link between declining urinary iodine levels in pregnant women and fetal thyroid function, and the trend data for maternal UI can be used to decide whether to initiate thyroid screening programs during pregnancy.

PHOENIX — Neonatal thyroid-stimulating hormone data can be used to detect epidemiologic trends in iodine sufficiency in pregnant women, even in countries where iodine intake is usually adequate, based on a study of 54,400 neonates presented at the annual meeting of the American Thyroid Association.

“Readily available neonatal TSH can be used to track the effects of altered trends in maternal iodine nutrition,” said Dr. Peter Smyth of the Conway Institute of Biomolecular and Biomedical Research at the University College Dublin.

Steps can be taken to increase iodine intake in pregnant women (which is important for proper fetal cognitive development) if the neonatal TSH in a population suggests low levels of maternal dietary iodine. The fetus depends on maternal thyroid hormones for normal development during the first 13–15 weeks of pregnancy, Dr. Smyth noted.

To assess the potential role of neonatal TSH as an indicator of a mother's iodine status, researchers screened a birth cohort of babies born in Ireland between 1988 and 2006.

Overall, TSH levels in newborns increased slightly but steadily during the study period, although the proportion of infants with severe iodine deficiency (TSH less than 5 mU/L) remained constant and stayed in a range of 2.35%–2.83%.

Notably, data from routine neonatal TSH screening showed a seasonal variation: Infants born in August had consistently higher TSH levels than infants born in January. Most dietary iodine in Ireland comes from milk and dairy products, and dietary iodine intake is disproportionately lower during the summer because the herd animals are out grazing and not receiving any nutritional supplements, Dr. Smyth explained.

Iodine levels in pregnant women were assessed using urinary iodine (UI) excretion values, and the decline in these values during the study period confirmed that the pregnant female population was borderline iodine deficient but relatively stable, although the UI values reflected the seasonal variation in dietary iodine intake.

From 1988 to 2003, the mean maternal UI values ranged from 70 to 83 mcg/L during the summer months and from 82 to 137 mcg/L during the winter months.

But findings from 2004 and 2005 showed a significant drop in maternal UI levels, which fell to a mean of 45 mcg/L in 2004 and 42.5 mcg/L in 2005. That trend has raised concerns about the need for dietary iodine supplementation in pregnant women in Ireland, said Dr. Smyth.

The study results support the link between declining urinary iodine levels in pregnant women and fetal thyroid function, and the trend data for maternal UI can be used to decide whether to initiate thyroid screening programs during pregnancy.

OTTAWA — Determine the vascular supply to a limb as the first step in the treatment of a lower extremity wound, Dr. Stephan Mostowy said at the annual conference of the Canadian Association of Wound Care.

Early identification of a wound's etiology and assessment of a patient's risk factors can give the patient the best chance to heal, he said. “The overall incidence of vascular disease is growing as our population ages,” but only 10% of patients are symptomatic, said Dr. Mostowy, a vascular surgeon at Credit Valley Hospital in Mississauga, Ont.

Smoking, hypertension, and hyperlipidemia are common culprits in peripheral vascular disease, so physicians should consider arterial insufficiency in patients with these risk factors who present with leg wounds, he said.

In addition to a physical exam and checking pulses, an ankle brachial index (ABI) of less than 0.9 mm Hg can indicate peripheral vascular disease because it demonstrates decreased blood flow to the legs. In some cases, a vascular surgeon can improve the blood flow to the wounded area and improve the patient's chances for healing.

“Working in a multidisciplinary team is crucial to improving rates of healing in our patients,” emphasized Dr. Mostowy and Laurie Goodman, a clinical wound care specialist at the hospital. Dr. Mostowy and Ms. Goodman copresented three cases that are typical of wounds with three different etiologies: arterial, venous, and diabetic.

Surgery Needed

Dr. Mostowy began with the case of a 74-year-old male smoker who had diabetes, hypertension, and hypercholesterolemia. The patient presented with a painful, pale, and punched-out ulcer on the back of his calf. He had no discernible pulses in the lower leg, which was cool to the touch, and he had a reduced ABI of 0.3 mm Hg, which suggested arterial insufficiency.

By contrast, venous ulcers are usually shallower than arterial wounds, and they are often located on the lower leg just above the ankle and below the calf (the “gaiter” area), Dr. Mostowy said. Venous ulcers also are more likely to be associated with varicose veins, he added.

Surgery (femoral-distal bypass) was the appropriate choice for this patient to improve his blood supply and heal the lesion. The procedure involved making two incisions in the patient's leg and harvesting an arm vein to use as a conduit.

The result was a well-healed ulcer that was completely closed and pain free after a few weeks. The patient also quit smoking, which will help the long-term durability of the bypass, Dr. Mostowy noted.

A Very Venous Problem

The next case involved a 39-year-old male with a recurrent venous ulcer on his left leg. The patient was a professional cook and a single father, and was standing all day. He had a history of varicose veins and deep venous insufficiency from a similar ulcer 2 years ago that had healed, but he was nonadherent about wearing the compression stocking that was necessary to keep his leg healthy, Dr. Mostowy said.

The patient presented with a new ulcer that was so infected and advanced that he was hospitalized for wound management and pain relief. He had strong digital pulses suggestive of a normal arterial supply, indicating a venous etiology rather than arterial, Dr. Mostowy explained.

The patient underwent surgical wound debridement, received intravenous antibiotics, and had dressing changes. Once the ulcer was under control, he was treated as an outpatient with a four-layer compression system of dressing, which addressed his venous hypertension. The use of analgesia and an airbed made a significant difference in his comfort at home and reduced his pain to a 5 on a 10-point scale.

When the ulcer was nearly healed, the patient was matched with a compression stocking supplier to help him transition to a stocking with better compliance. This case is an example of a successful team effort to heal the ulcer. “Hopefully, this patient is better educated and will wear the compression stocking to prevent future recurrences,” Dr. Mostowy said.

Diabetic Foot Fix-Up

The third case involved a 63-year-old woman who “arrived at the emergency department with a terrible diabetic foot infection,” Dr. Mostowy said.

The patient had pus draining from the bottom of her foot, and she had a fever and chills. The wound required surgical draining of the plantar space and amputation of the fourth and fifth toes to control the infection. After the area was drained, the wound was stabilized with antibiotics and a local dressing and the wound care team assessed the vascularity of the wound to determine the potential for healing.

Because the patient's blood supply was adequate (ABI greater than 0.9 mm Hg), the defect had the potential to heal. Vacuum-assisted closure therapy was instituted to accelerate healing, and the wound care team saved the patient's foot.

During the wound care process, the patient learned how to improve control of her diabetes, and she learned the importance of using moisturizer and orthotics and protective footwear to better care for her feet, he said.

An arterial ulcer on the calf of this patient has a “punched out” appearance.

A superinfected venous ulcer became circumferential with the infection.

A diabetic infection requires amputation of two toes, leaving a large cavity. Photos courtesy Dr. Stephan Mostowy

OTTAWA — Determine the vascular supply to a limb as the first step in the treatment of a lower extremity wound, Dr. Stephan Mostowy said at the annual conference of the Canadian Association of Wound Care.

Early identification of a wound's etiology and assessment of a patient's risk factors can give the patient the best chance to heal, he said. “The overall incidence of vascular disease is growing as our population ages,” but only 10% of patients are symptomatic, said Dr. Mostowy, a vascular surgeon at Credit Valley Hospital in Mississauga, Ont.

Smoking, hypertension, and hyperlipidemia are common culprits in peripheral vascular disease, so physicians should consider arterial insufficiency in patients with these risk factors who present with leg wounds, he said.

In addition to a physical exam and checking pulses, an ankle brachial index (ABI) of less than 0.9 mm Hg can indicate peripheral vascular disease because it demonstrates decreased blood flow to the legs. In some cases, a vascular surgeon can improve the blood flow to the wounded area and improve the patient's chances for healing.

“Working in a multidisciplinary team is crucial to improving rates of healing in our patients,” emphasized Dr. Mostowy and Laurie Goodman, a clinical wound care specialist at the hospital. Dr. Mostowy and Ms. Goodman copresented three cases that are typical of wounds with three different etiologies: arterial, venous, and diabetic.

Surgery Needed

Dr. Mostowy began with the case of a 74-year-old male smoker who had diabetes, hypertension, and hypercholesterolemia. The patient presented with a painful, pale, and punched-out ulcer on the back of his calf. He had no discernible pulses in the lower leg, which was cool to the touch, and he had a reduced ABI of 0.3 mm Hg, which suggested arterial insufficiency.

By contrast, venous ulcers are usually shallower than arterial wounds, and they are often located on the lower leg just above the ankle and below the calf (the “gaiter” area), Dr. Mostowy said. Venous ulcers also are more likely to be associated with varicose veins, he added.

Surgery (femoral-distal bypass) was the appropriate choice for this patient to improve his blood supply and heal the lesion. The procedure involved making two incisions in the patient's leg and harvesting an arm vein to use as a conduit.

The result was a well-healed ulcer that was completely closed and pain free after a few weeks. The patient also quit smoking, which will help the long-term durability of the bypass, Dr. Mostowy noted.

A Very Venous Problem

The next case involved a 39-year-old male with a recurrent venous ulcer on his left leg. The patient was a professional cook and a single father, and was standing all day. He had a history of varicose veins and deep venous insufficiency from a similar ulcer 2 years ago that had healed, but he was nonadherent about wearing the compression stocking that was necessary to keep his leg healthy, Dr. Mostowy said.

The patient presented with a new ulcer that was so infected and advanced that he was hospitalized for wound management and pain relief. He had strong digital pulses suggestive of a normal arterial supply, indicating a venous etiology rather than arterial, Dr. Mostowy explained.

The patient underwent surgical wound debridement, received intravenous antibiotics, and had dressing changes. Once the ulcer was under control, he was treated as an outpatient with a four-layer compression system of dressing, which addressed his venous hypertension. The use of analgesia and an airbed made a significant difference in his comfort at home and reduced his pain to a 5 on a 10-point scale.

When the ulcer was nearly healed, the patient was matched with a compression stocking supplier to help him transition to a stocking with better compliance. This case is an example of a successful team effort to heal the ulcer. “Hopefully, this patient is better educated and will wear the compression stocking to prevent future recurrences,” Dr. Mostowy said.

Diabetic Foot Fix-Up

The third case involved a 63-year-old woman who “arrived at the emergency department with a terrible diabetic foot infection,” Dr. Mostowy said.

The patient had pus draining from the bottom of her foot, and she had a fever and chills. The wound required surgical draining of the plantar space and amputation of the fourth and fifth toes to control the infection. After the area was drained, the wound was stabilized with antibiotics and a local dressing and the wound care team assessed the vascularity of the wound to determine the potential for healing.

Because the patient's blood supply was adequate (ABI greater than 0.9 mm Hg), the defect had the potential to heal. Vacuum-assisted closure therapy was instituted to accelerate healing, and the wound care team saved the patient's foot.

During the wound care process, the patient learned how to improve control of her diabetes, and she learned the importance of using moisturizer and orthotics and protective footwear to better care for her feet, he said.

An arterial ulcer on the calf of this patient has a “punched out” appearance.

A superinfected venous ulcer became circumferential with the infection.

A diabetic infection requires amputation of two toes, leaving a large cavity. Photos courtesy Dr. Stephan Mostowy

OTTAWA — Determine the vascular supply to a limb as the first step in the treatment of a lower extremity wound, Dr. Stephan Mostowy said at the annual conference of the Canadian Association of Wound Care.

Early identification of a wound's etiology and assessment of a patient's risk factors can give the patient the best chance to heal, he said. “The overall incidence of vascular disease is growing as our population ages,” but only 10% of patients are symptomatic, said Dr. Mostowy, a vascular surgeon at Credit Valley Hospital in Mississauga, Ont.

Smoking, hypertension, and hyperlipidemia are common culprits in peripheral vascular disease, so physicians should consider arterial insufficiency in patients with these risk factors who present with leg wounds, he said.

In addition to a physical exam and checking pulses, an ankle brachial index (ABI) of less than 0.9 mm Hg can indicate peripheral vascular disease because it demonstrates decreased blood flow to the legs. In some cases, a vascular surgeon can improve the blood flow to the wounded area and improve the patient's chances for healing.

“Working in a multidisciplinary team is crucial to improving rates of healing in our patients,” emphasized Dr. Mostowy and Laurie Goodman, a clinical wound care specialist at the hospital. Dr. Mostowy and Ms. Goodman copresented three cases that are typical of wounds with three different etiologies: arterial, venous, and diabetic.

Surgery Needed

Dr. Mostowy began with the case of a 74-year-old male smoker who had diabetes, hypertension, and hypercholesterolemia. The patient presented with a painful, pale, and punched-out ulcer on the back of his calf. He had no discernible pulses in the lower leg, which was cool to the touch, and he had a reduced ABI of 0.3 mm Hg, which suggested arterial insufficiency.

By contrast, venous ulcers are usually shallower than arterial wounds, and they are often located on the lower leg just above the ankle and below the calf (the “gaiter” area), Dr. Mostowy said. Venous ulcers also are more likely to be associated with varicose veins, he added.

Surgery (femoral-distal bypass) was the appropriate choice for this patient to improve his blood supply and heal the lesion. The procedure involved making two incisions in the patient's leg and harvesting an arm vein to use as a conduit.

The result was a well-healed ulcer that was completely closed and pain free after a few weeks. The patient also quit smoking, which will help the long-term durability of the bypass, Dr. Mostowy noted.

A Very Venous Problem

The next case involved a 39-year-old male with a recurrent venous ulcer on his left leg. The patient was a professional cook and a single father, and was standing all day. He had a history of varicose veins and deep venous insufficiency from a similar ulcer 2 years ago that had healed, but he was nonadherent about wearing the compression stocking that was necessary to keep his leg healthy, Dr. Mostowy said.

The patient presented with a new ulcer that was so infected and advanced that he was hospitalized for wound management and pain relief. He had strong digital pulses suggestive of a normal arterial supply, indicating a venous etiology rather than arterial, Dr. Mostowy explained.

The patient underwent surgical wound debridement, received intravenous antibiotics, and had dressing changes. Once the ulcer was under control, he was treated as an outpatient with a four-layer compression system of dressing, which addressed his venous hypertension. The use of analgesia and an airbed made a significant difference in his comfort at home and reduced his pain to a 5 on a 10-point scale.

When the ulcer was nearly healed, the patient was matched with a compression stocking supplier to help him transition to a stocking with better compliance. This case is an example of a successful team effort to heal the ulcer. “Hopefully, this patient is better educated and will wear the compression stocking to prevent future recurrences,” Dr. Mostowy said.

Diabetic Foot Fix-Up

The third case involved a 63-year-old woman who “arrived at the emergency department with a terrible diabetic foot infection,” Dr. Mostowy said.

The patient had pus draining from the bottom of her foot, and she had a fever and chills. The wound required surgical draining of the plantar space and amputation of the fourth and fifth toes to control the infection. After the area was drained, the wound was stabilized with antibiotics and a local dressing and the wound care team assessed the vascularity of the wound to determine the potential for healing.

Because the patient's blood supply was adequate (ABI greater than 0.9 mm Hg), the defect had the potential to heal. Vacuum-assisted closure therapy was instituted to accelerate healing, and the wound care team saved the patient's foot.

During the wound care process, the patient learned how to improve control of her diabetes, and she learned the importance of using moisturizer and orthotics and protective footwear to better care for her feet, he said.

An arterial ulcer on the calf of this patient has a “punched out” appearance.

A superinfected venous ulcer became circumferential with the infection.

A diabetic infection requires amputation of two toes, leaving a large cavity. Photos courtesy Dr. Stephan Mostowy