Heidi Splete

PTSD and Asthma

Adolescents with asthma who have experienced a life-threatening event–as well as their parents–are significantly more likely to experience posttraumatic stress symptoms than are adolescents with less severe asthma or healthy controls, reported Emily Millikan Kean, Ph.D., of the Children's Hospital, Denver, and her associates.

Events related to severe asthma attacks–such as ambulance rides and invasive procedures, as well as lingering feelings about the possibility of death even after the events resolve–may make children and adolescents with asthma, and their parents, vulnerable to posttraumatic stress disorder (PTSD), the researchers noted.

Their study of three groups of adolescents aged 12–18 years included 49 adolescents who had experienced a life-threatening episode, 71 who had asthma but had not experienced a severe episode, and 80 healthy controls (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:78–86).

Overall, 20% of the adolescents with life-threatening events met the criteria for PTSD, compared with 11% of those with mild asthma and 8% of controls.

The adolescents completed three measures: the UCLA PTSD Reaction Index for DSM-IV, the Multidimensional Anxiety Scale for Children, and the Reynolds Depression Inventory-2. Parents also completed several measures, including the Brief Symptom Inventory.

Predictably, the parents of children who had experienced life-threatening events were significantly more likely to meet criteria for PTSD (29%), compared with the parents of adolescents with nonsevere asthma (14%) and the parents of controls (2%).

Substance Abuse and Suicide

Substance abuse within 48 hours of suicide was far more common among white adolescents than African American adolescents in an investigation of 75 cases, wrote Dr. Steven J. Garlow of Emory University, Atlanta, and his colleagues.

The researchers reviewed the medical examiner's records for 49 African American and 26 white adolescents aged 19 years and younger in Fulton County, Ga., from January 1989 to December 2003 (J. Psychiatr. Res. 2005[Epub doi:10.1016/j.jpsychires.08.008]).

About 82% of the African American teens tested negative for cocaine and alcohol, compared with 58% of the white teens. Only 9% of African American teens had used cocaine prior to death, compared with 28% of the white teens, and 9% of African American teens had used alcohol prior to death, compared with 21% of white teens.

When the data were analyzed along gender lines, white males had the highest detectable levels of alcohol use (22%), which was more than double the incidence among African American males (10%). Only one of the white females and none of the African American females showed signs of alcohol use prior to death.

Whites had higher rates of alcohol and cocaine use, but African American adolescents had slightly higher rates of completed suicides than did white adolescents (5.5 vs. 4.2 per 100,000 teens per year). In addition, African American teens had a significantly higher rate of firearm use in suicides, compared with white teens.

OCD Often Cormorbid With ADHD

More than 25% of children and adolescents with obsessive-compulsive disorder had comorbid attention-deficit hyperactivity disorder in a consecutive study of 94 patients, reported Dr. Gabriele Masi and her associates at the Scientific Institute of Child Neurology and Psychiatry in Calambrone, Pisa (Italy).

Overall, 88% of the 24 comorbid patients were male, and the average age of onset of obsessive-compulsive disorder (OCD) was slightly higher among patients with comorbid attention-deficit hyperactivity disorder (ADHD). Several disruptive behavior disorders–oppositional defiant disorder, bipolar disorder, and tic disorder–were significantly more common among comorbid patients.

The 3-year study included 65 males and 29 females aged 8–18 years. All of the patients were undergoing treatment for OCD with serotonin reuptake inhibitors, such as fluoxetine and sertraline (Zoloft), but none was being treated for ADHD with psychostimulants (Compr. Psychiatry 2006;47:42–7). In patients with comorbid ADHD, functional baseline impairment was higher, and improvement in symptoms after 6 months of follow-up was lower. Patients with co-occurring OCD-ADHD were more frequently male (88% vs. 62%). No significant differences were seen between patients with and without comorbid ADHD with regard to OCD behaviors involving ordering, aggression, contamination, and hoarding. The study results suggest a need for ADHD screening in all children and adolescents with OCD, the investigators wrote.

PTSD and Asthma

Adolescents with asthma who have experienced a life-threatening event–as well as their parents–are significantly more likely to experience posttraumatic stress symptoms than are adolescents with less severe asthma or healthy controls, reported Emily Millikan Kean, Ph.D., of the Children's Hospital, Denver, and her associates.

Events related to severe asthma attacks–such as ambulance rides and invasive procedures, as well as lingering feelings about the possibility of death even after the events resolve–may make children and adolescents with asthma, and their parents, vulnerable to posttraumatic stress disorder (PTSD), the researchers noted.

Their study of three groups of adolescents aged 12–18 years included 49 adolescents who had experienced a life-threatening episode, 71 who had asthma but had not experienced a severe episode, and 80 healthy controls (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:78–86).

Overall, 20% of the adolescents with life-threatening events met the criteria for PTSD, compared with 11% of those with mild asthma and 8% of controls.

The adolescents completed three measures: the UCLA PTSD Reaction Index for DSM-IV, the Multidimensional Anxiety Scale for Children, and the Reynolds Depression Inventory-2. Parents also completed several measures, including the Brief Symptom Inventory.

Predictably, the parents of children who had experienced life-threatening events were significantly more likely to meet criteria for PTSD (29%), compared with the parents of adolescents with nonsevere asthma (14%) and the parents of controls (2%).

Substance Abuse and Suicide

Substance abuse within 48 hours of suicide was far more common among white adolescents than African American adolescents in an investigation of 75 cases, wrote Dr. Steven J. Garlow of Emory University, Atlanta, and his colleagues.

The researchers reviewed the medical examiner's records for 49 African American and 26 white adolescents aged 19 years and younger in Fulton County, Ga., from January 1989 to December 2003 (J. Psychiatr. Res. 2005[Epub doi:10.1016/j.jpsychires.08.008]).

About 82% of the African American teens tested negative for cocaine and alcohol, compared with 58% of the white teens. Only 9% of African American teens had used cocaine prior to death, compared with 28% of the white teens, and 9% of African American teens had used alcohol prior to death, compared with 21% of white teens.

When the data were analyzed along gender lines, white males had the highest detectable levels of alcohol use (22%), which was more than double the incidence among African American males (10%). Only one of the white females and none of the African American females showed signs of alcohol use prior to death.

Whites had higher rates of alcohol and cocaine use, but African American adolescents had slightly higher rates of completed suicides than did white adolescents (5.5 vs. 4.2 per 100,000 teens per year). In addition, African American teens had a significantly higher rate of firearm use in suicides, compared with white teens.

OCD Often Cormorbid With ADHD

More than 25% of children and adolescents with obsessive-compulsive disorder had comorbid attention-deficit hyperactivity disorder in a consecutive study of 94 patients, reported Dr. Gabriele Masi and her associates at the Scientific Institute of Child Neurology and Psychiatry in Calambrone, Pisa (Italy).

Overall, 88% of the 24 comorbid patients were male, and the average age of onset of obsessive-compulsive disorder (OCD) was slightly higher among patients with comorbid attention-deficit hyperactivity disorder (ADHD). Several disruptive behavior disorders–oppositional defiant disorder, bipolar disorder, and tic disorder–were significantly more common among comorbid patients.

The 3-year study included 65 males and 29 females aged 8–18 years. All of the patients were undergoing treatment for OCD with serotonin reuptake inhibitors, such as fluoxetine and sertraline (Zoloft), but none was being treated for ADHD with psychostimulants (Compr. Psychiatry 2006;47:42–7). In patients with comorbid ADHD, functional baseline impairment was higher, and improvement in symptoms after 6 months of follow-up was lower. Patients with co-occurring OCD-ADHD were more frequently male (88% vs. 62%). No significant differences were seen between patients with and without comorbid ADHD with regard to OCD behaviors involving ordering, aggression, contamination, and hoarding. The study results suggest a need for ADHD screening in all children and adolescents with OCD, the investigators wrote.

PTSD and Asthma

Adolescents with asthma who have experienced a life-threatening event–as well as their parents–are significantly more likely to experience posttraumatic stress symptoms than are adolescents with less severe asthma or healthy controls, reported Emily Millikan Kean, Ph.D., of the Children's Hospital, Denver, and her associates.

Events related to severe asthma attacks–such as ambulance rides and invasive procedures, as well as lingering feelings about the possibility of death even after the events resolve–may make children and adolescents with asthma, and their parents, vulnerable to posttraumatic stress disorder (PTSD), the researchers noted.

Their study of three groups of adolescents aged 12–18 years included 49 adolescents who had experienced a life-threatening episode, 71 who had asthma but had not experienced a severe episode, and 80 healthy controls (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:78–86).

Overall, 20% of the adolescents with life-threatening events met the criteria for PTSD, compared with 11% of those with mild asthma and 8% of controls.

The adolescents completed three measures: the UCLA PTSD Reaction Index for DSM-IV, the Multidimensional Anxiety Scale for Children, and the Reynolds Depression Inventory-2. Parents also completed several measures, including the Brief Symptom Inventory.

Predictably, the parents of children who had experienced life-threatening events were significantly more likely to meet criteria for PTSD (29%), compared with the parents of adolescents with nonsevere asthma (14%) and the parents of controls (2%).

Substance Abuse and Suicide

Substance abuse within 48 hours of suicide was far more common among white adolescents than African American adolescents in an investigation of 75 cases, wrote Dr. Steven J. Garlow of Emory University, Atlanta, and his colleagues.

The researchers reviewed the medical examiner's records for 49 African American and 26 white adolescents aged 19 years and younger in Fulton County, Ga., from January 1989 to December 2003 (J. Psychiatr. Res. 2005[Epub doi:10.1016/j.jpsychires.08.008]).

About 82% of the African American teens tested negative for cocaine and alcohol, compared with 58% of the white teens. Only 9% of African American teens had used cocaine prior to death, compared with 28% of the white teens, and 9% of African American teens had used alcohol prior to death, compared with 21% of white teens.

When the data were analyzed along gender lines, white males had the highest detectable levels of alcohol use (22%), which was more than double the incidence among African American males (10%). Only one of the white females and none of the African American females showed signs of alcohol use prior to death.

Whites had higher rates of alcohol and cocaine use, but African American adolescents had slightly higher rates of completed suicides than did white adolescents (5.5 vs. 4.2 per 100,000 teens per year). In addition, African American teens had a significantly higher rate of firearm use in suicides, compared with white teens.

OCD Often Cormorbid With ADHD

More than 25% of children and adolescents with obsessive-compulsive disorder had comorbid attention-deficit hyperactivity disorder in a consecutive study of 94 patients, reported Dr. Gabriele Masi and her associates at the Scientific Institute of Child Neurology and Psychiatry in Calambrone, Pisa (Italy).

Overall, 88% of the 24 comorbid patients were male, and the average age of onset of obsessive-compulsive disorder (OCD) was slightly higher among patients with comorbid attention-deficit hyperactivity disorder (ADHD). Several disruptive behavior disorders–oppositional defiant disorder, bipolar disorder, and tic disorder–were significantly more common among comorbid patients.

The 3-year study included 65 males and 29 females aged 8–18 years. All of the patients were undergoing treatment for OCD with serotonin reuptake inhibitors, such as fluoxetine and sertraline (Zoloft), but none was being treated for ADHD with psychostimulants (Compr. Psychiatry 2006;47:42–7). In patients with comorbid ADHD, functional baseline impairment was higher, and improvement in symptoms after 6 months of follow-up was lower. Patients with co-occurring OCD-ADHD were more frequently male (88% vs. 62%). No significant differences were seen between patients with and without comorbid ADHD with regard to OCD behaviors involving ordering, aggression, contamination, and hoarding. The study results suggest a need for ADHD screening in all children and adolescents with OCD, the investigators wrote.

WASHINGTON – Pubertal changes were more likely to trigger body dissatisfaction in white girls than in African American girls in a study of 331 girls, reported Tiffany Floyd, Ph.D., in a poster presented at the annual meeting of the Association for Behavioral and Cognitive Therapies.

Previous studies have shown that body dissatisfaction during puberty is more common among girls than among boys–because pubertal changes conflict with the idealized image of the thin female–and that this increase in body dissatisfaction may promote depression. However, additional research has shown that larger female body types are more desirable and acceptable among African Americans than they are among whites, wrote Dr. Floyd, of City College, New York, and her colleagues.

The study included girls in grades 4 through 9, with an average age of 12 years. Approximately 50% of the girls were African American.

Overall, white girls reported significantly more body dissatisfaction than did African American girls. Although pubertal status did not directly predict depression in either group, pubertal status significantly predicted body dissatisfaction among white girls in a linear regression analysis, which in turn predicted depressive symptoms.

Pubertal status failed to predict body dissatisfaction among African American girls, but body dissatisfaction significantly predicted depressive symptoms independently of pubertal status.

WASHINGTON – Pubertal changes were more likely to trigger body dissatisfaction in white girls than in African American girls in a study of 331 girls, reported Tiffany Floyd, Ph.D., in a poster presented at the annual meeting of the Association for Behavioral and Cognitive Therapies.

Previous studies have shown that body dissatisfaction during puberty is more common among girls than among boys–because pubertal changes conflict with the idealized image of the thin female–and that this increase in body dissatisfaction may promote depression. However, additional research has shown that larger female body types are more desirable and acceptable among African Americans than they are among whites, wrote Dr. Floyd, of City College, New York, and her colleagues.

The study included girls in grades 4 through 9, with an average age of 12 years. Approximately 50% of the girls were African American.

Overall, white girls reported significantly more body dissatisfaction than did African American girls. Although pubertal status did not directly predict depression in either group, pubertal status significantly predicted body dissatisfaction among white girls in a linear regression analysis, which in turn predicted depressive symptoms.

Pubertal status failed to predict body dissatisfaction among African American girls, but body dissatisfaction significantly predicted depressive symptoms independently of pubertal status.

WASHINGTON – Pubertal changes were more likely to trigger body dissatisfaction in white girls than in African American girls in a study of 331 girls, reported Tiffany Floyd, Ph.D., in a poster presented at the annual meeting of the Association for Behavioral and Cognitive Therapies.

Previous studies have shown that body dissatisfaction during puberty is more common among girls than among boys–because pubertal changes conflict with the idealized image of the thin female–and that this increase in body dissatisfaction may promote depression. However, additional research has shown that larger female body types are more desirable and acceptable among African Americans than they are among whites, wrote Dr. Floyd, of City College, New York, and her colleagues.

The study included girls in grades 4 through 9, with an average age of 12 years. Approximately 50% of the girls were African American.

Overall, white girls reported significantly more body dissatisfaction than did African American girls. Although pubertal status did not directly predict depression in either group, pubertal status significantly predicted body dissatisfaction among white girls in a linear regression analysis, which in turn predicted depressive symptoms.

Pubertal status failed to predict body dissatisfaction among African American girls, but body dissatisfaction significantly predicted depressive symptoms independently of pubertal status.

SAN DIEGO — Organization in both record keeping and patient scheduling is essential to a successful Mohs surgery practice, Dr. Edward H. Yob said at a meeting sponsored by the American Society for Mohs Surgery.

Patient care records may include handwritten notes, dictation/transcription, and electronic medical records, although electronic records are becoming the documentation method of choice, noted Dr. Yob, a specialist in Mohs surgery and dermatologic surgery in Tulsa, Okla.

The best electronic medical records system for your office is one that is accurate, simple, and cost effective and saves you time. Ease in training is also important; a high school-educated medical assistant should be able to learn the program with minimal training, said Dr. Yob, who owns stock in Ratio Medical Software, the company that markets the Razor electronic medical records system.

Clinical records for Mohs surgery patients include the preoperative evaluation, operative consent form, operative notes, Mohs map, anesthesia record (if any), and postoperative notes.

"Not everyone has this entire set of items for each patient, but you need enough information to substantiate the indications for Mohs," Dr. Yob said.

The preoperative record establishes the patient's candidacy for Mohs, including the general state of health, any medications, or past surgical or anesthesia difficulties, he noted.

The Mohs map is an integral part of the record. "Every bit of information you could want should be on that Mohs map," Dr. Yob said. "Accuracy is the key, and the map should tell the story exactly as it is."

Document postoperative visits, even if the patient simply comes in for care and cleaning of the wound by a medical assistant. In addition, keep the referring physician in the loop. Dr. Yob always sends a simple cover letter, along with a copy of the operative notes and photos of the defect and final repair, to the referring physician.

"I want to educate the physician and let him or her know that they made the right choice in referring the patient for Mohs surgery," he said.

Clinical logs are descriptions of your practice, compared with clinical reports, which are descriptions of individual patients. Photography is a crucial time saver when it comes to keeping a clinical log. "Digital photos are accurate and easy, and there is no better way to document treatment than photography," he said.

In Dr. Yob's office, a nurse first photographs the patient's name from the chart; the succeeding photos are of that patient until the next photo of a patient's name in a chart is taken.

When staff members archive the photos, they label the computerized file with the patient's name. In some offices, the technicians set up a file for each day and download the day's files into one directory, then erase the digital card in preparation for the next day. A staff member can later sort the photos by patient.

Data storage is another important element of record keeping in a Mohs practice. "You are going to have glass slides to store, and you need an archival system," Dr. Yob said. Store all operative reports and Mohs maps and keep track of expenses.

"You are going to generate an enormous [number] of documents, photographs, and slides, and if you take some time to think it through before you start practicing Mohs surgery, you can develop a system that will be organized and not take you an enormous amount of time to process," Dr. Yob said.

He also shared tips for patient selection and scheduling.

There are two types of scheduling: integrated and exclusive, and there are advantages to both. Integrated scheduling is more efficient and more economical, but it is extremely distracting. "You could be ready to do a Mohs repair, and then you get a complicated consultation on a lupus patient," Dr. Yob said. This type of scheduling is not practical for a high-volume Mohs practice.

Exclusive scheduling means treating Mohs patients from start to finish without interruption for other types of patients. This type of scheduling is more predictable and allows more time with the patient. "I like to see patients preoperatively so I can talk to them and evaluate them. I want them to feel comfortable, and I want to take their blood pressure," Dr. Yob said. "I don't want to waste a surgical slot if the patient's blood pressure is high."

Dr. Yob's office ranks patients by three levels of complexity: quick, average, and complex. He recommends that surgeons determine how the total number of patients with varying degrees of complexity fits with what they consider their workload. "A complicated patient may be the only Mohs surgery you do in one morning," Dr. Yob said.

Regardless of scheduling type, Dr. Yob suggests starting conservatively, with small defects, and scheduling more than enough time, and not hesitating to finish a patient's procedure the next day. The volume of patients will depend on the skill and speed of the surgeon, the experience of the surgical team, and the efficiency of the office setup.

Determine how the total number of patients with varying degrees of complexity fits with the workload. DR. YOB

Building a Mohs Surgery Practice Takes Planning and Hard Work

"When you are establishing a practice, consider how and whether you are willing to commit the time and resources—and it is a considerable commitment in the beginning—to develop a Mohs practice and do it right," Dr. Yob said. "You won't make money when you start, and you must be willing to work hard and train your staff."

When starting in a Mohs surgery practice, it is best to start small, allow extra time, not treat complex cases, avoid distractions, and pay attention to details, he said.

There are several other elements to consider:

Choosing Practice Type

Group or solo? Will patients be practice generated or referred?

Scouting Geographic Area

Research the local area and learn about the population: Is there a large population of retirees and suburban moms, or a lot of college students?

Determining Community Practice Patterns

Know the size of the community and the number of dermatologists in the area. If there are other dermatologists in the area, find out how they treat skin cancer and ask about their attitudes toward Mohs surgery. Find out whether primary care physicians treat skin cancer and how they feel about Mohs surgery. "Treat the family doctors with respect," Dr. Yob said. "The more you share with them, the more they respect you."

Evaluating Your Practice

How important is Mohs to you? Is it a focal point, or is it something you do in addition to general dermatology?

Generating Referrals

Talk to ENT surgeons and plastic surgeons. "If you can convince them that you can clean out the cancer and send them a tumor-free patient, they may appreciate that," he said.

Getting the Word Out

Other ways to generate business include giving lectures to physicians and participating in CME programs at hospitals and medical meetings, as well as giving community-based talks to church or civic groups. Pamphlets and Web sites are also helpful ways for Mohs surgeons to introduce themselves to the community.

Hiring Good Help

The lab technician is "the Mohs lifeline," Dr. Yob said. You can hire a full-time staff technician or contract with one. "If you plan to do Mohs only 2 days a week, you might be able to share a technician with another surgeon who does Mohs 3 days each week," he said. The advantages of an in-house technician are convenience, availability, and consistency, as well as faster communication. However, a contract technician is often more cost effective, usually experienced, and generally has a backup on call. A contracted technician also may have helpful insights into the community and sources of patients for surgeons who are in the early stages of establishing a Mohs practice. If a nurse or another member of your staff is eager to learn, consider training them. Their personality and willingness to learn is as important as previous background, he said.

SAN DIEGO — Organization in both record keeping and patient scheduling is essential to a successful Mohs surgery practice, Dr. Edward H. Yob said at a meeting sponsored by the American Society for Mohs Surgery.

Patient care records may include handwritten notes, dictation/transcription, and electronic medical records, although electronic records are becoming the documentation method of choice, noted Dr. Yob, a specialist in Mohs surgery and dermatologic surgery in Tulsa, Okla.

The best electronic medical records system for your office is one that is accurate, simple, and cost effective and saves you time. Ease in training is also important; a high school-educated medical assistant should be able to learn the program with minimal training, said Dr. Yob, who owns stock in Ratio Medical Software, the company that markets the Razor electronic medical records system.

Clinical records for Mohs surgery patients include the preoperative evaluation, operative consent form, operative notes, Mohs map, anesthesia record (if any), and postoperative notes.

"Not everyone has this entire set of items for each patient, but you need enough information to substantiate the indications for Mohs," Dr. Yob said.

The preoperative record establishes the patient's candidacy for Mohs, including the general state of health, any medications, or past surgical or anesthesia difficulties, he noted.

The Mohs map is an integral part of the record. "Every bit of information you could want should be on that Mohs map," Dr. Yob said. "Accuracy is the key, and the map should tell the story exactly as it is."

Document postoperative visits, even if the patient simply comes in for care and cleaning of the wound by a medical assistant. In addition, keep the referring physician in the loop. Dr. Yob always sends a simple cover letter, along with a copy of the operative notes and photos of the defect and final repair, to the referring physician.

"I want to educate the physician and let him or her know that they made the right choice in referring the patient for Mohs surgery," he said.

Clinical logs are descriptions of your practice, compared with clinical reports, which are descriptions of individual patients. Photography is a crucial time saver when it comes to keeping a clinical log. "Digital photos are accurate and easy, and there is no better way to document treatment than photography," he said.

In Dr. Yob's office, a nurse first photographs the patient's name from the chart; the succeeding photos are of that patient until the next photo of a patient's name in a chart is taken.

When staff members archive the photos, they label the computerized file with the patient's name. In some offices, the technicians set up a file for each day and download the day's files into one directory, then erase the digital card in preparation for the next day. A staff member can later sort the photos by patient.

Data storage is another important element of record keeping in a Mohs practice. "You are going to have glass slides to store, and you need an archival system," Dr. Yob said. Store all operative reports and Mohs maps and keep track of expenses.

"You are going to generate an enormous [number] of documents, photographs, and slides, and if you take some time to think it through before you start practicing Mohs surgery, you can develop a system that will be organized and not take you an enormous amount of time to process," Dr. Yob said.

He also shared tips for patient selection and scheduling.

There are two types of scheduling: integrated and exclusive, and there are advantages to both. Integrated scheduling is more efficient and more economical, but it is extremely distracting. "You could be ready to do a Mohs repair, and then you get a complicated consultation on a lupus patient," Dr. Yob said. This type of scheduling is not practical for a high-volume Mohs practice.

Exclusive scheduling means treating Mohs patients from start to finish without interruption for other types of patients. This type of scheduling is more predictable and allows more time with the patient. "I like to see patients preoperatively so I can talk to them and evaluate them. I want them to feel comfortable, and I want to take their blood pressure," Dr. Yob said. "I don't want to waste a surgical slot if the patient's blood pressure is high."

Dr. Yob's office ranks patients by three levels of complexity: quick, average, and complex. He recommends that surgeons determine how the total number of patients with varying degrees of complexity fits with what they consider their workload. "A complicated patient may be the only Mohs surgery you do in one morning," Dr. Yob said.

Regardless of scheduling type, Dr. Yob suggests starting conservatively, with small defects, and scheduling more than enough time, and not hesitating to finish a patient's procedure the next day. The volume of patients will depend on the skill and speed of the surgeon, the experience of the surgical team, and the efficiency of the office setup.

Determine how the total number of patients with varying degrees of complexity fits with the workload. DR. YOB

Building a Mohs Surgery Practice Takes Planning and Hard Work

"When you are establishing a practice, consider how and whether you are willing to commit the time and resources—and it is a considerable commitment in the beginning—to develop a Mohs practice and do it right," Dr. Yob said. "You won't make money when you start, and you must be willing to work hard and train your staff."

When starting in a Mohs surgery practice, it is best to start small, allow extra time, not treat complex cases, avoid distractions, and pay attention to details, he said.

There are several other elements to consider:

Choosing Practice Type

Group or solo? Will patients be practice generated or referred?

Scouting Geographic Area

Research the local area and learn about the population: Is there a large population of retirees and suburban moms, or a lot of college students?

Determining Community Practice Patterns

Know the size of the community and the number of dermatologists in the area. If there are other dermatologists in the area, find out how they treat skin cancer and ask about their attitudes toward Mohs surgery. Find out whether primary care physicians treat skin cancer and how they feel about Mohs surgery. "Treat the family doctors with respect," Dr. Yob said. "The more you share with them, the more they respect you."

Evaluating Your Practice

How important is Mohs to you? Is it a focal point, or is it something you do in addition to general dermatology?

Generating Referrals

Talk to ENT surgeons and plastic surgeons. "If you can convince them that you can clean out the cancer and send them a tumor-free patient, they may appreciate that," he said.

Getting the Word Out

Other ways to generate business include giving lectures to physicians and participating in CME programs at hospitals and medical meetings, as well as giving community-based talks to church or civic groups. Pamphlets and Web sites are also helpful ways for Mohs surgeons to introduce themselves to the community.

Hiring Good Help

The lab technician is "the Mohs lifeline," Dr. Yob said. You can hire a full-time staff technician or contract with one. "If you plan to do Mohs only 2 days a week, you might be able to share a technician with another surgeon who does Mohs 3 days each week," he said. The advantages of an in-house technician are convenience, availability, and consistency, as well as faster communication. However, a contract technician is often more cost effective, usually experienced, and generally has a backup on call. A contracted technician also may have helpful insights into the community and sources of patients for surgeons who are in the early stages of establishing a Mohs practice. If a nurse or another member of your staff is eager to learn, consider training them. Their personality and willingness to learn is as important as previous background, he said.

SAN DIEGO — Organization in both record keeping and patient scheduling is essential to a successful Mohs surgery practice, Dr. Edward H. Yob said at a meeting sponsored by the American Society for Mohs Surgery.

Patient care records may include handwritten notes, dictation/transcription, and electronic medical records, although electronic records are becoming the documentation method of choice, noted Dr. Yob, a specialist in Mohs surgery and dermatologic surgery in Tulsa, Okla.

The best electronic medical records system for your office is one that is accurate, simple, and cost effective and saves you time. Ease in training is also important; a high school-educated medical assistant should be able to learn the program with minimal training, said Dr. Yob, who owns stock in Ratio Medical Software, the company that markets the Razor electronic medical records system.

Clinical records for Mohs surgery patients include the preoperative evaluation, operative consent form, operative notes, Mohs map, anesthesia record (if any), and postoperative notes.

"Not everyone has this entire set of items for each patient, but you need enough information to substantiate the indications for Mohs," Dr. Yob said.

The preoperative record establishes the patient's candidacy for Mohs, including the general state of health, any medications, or past surgical or anesthesia difficulties, he noted.

The Mohs map is an integral part of the record. "Every bit of information you could want should be on that Mohs map," Dr. Yob said. "Accuracy is the key, and the map should tell the story exactly as it is."

Document postoperative visits, even if the patient simply comes in for care and cleaning of the wound by a medical assistant. In addition, keep the referring physician in the loop. Dr. Yob always sends a simple cover letter, along with a copy of the operative notes and photos of the defect and final repair, to the referring physician.

"I want to educate the physician and let him or her know that they made the right choice in referring the patient for Mohs surgery," he said.

Clinical logs are descriptions of your practice, compared with clinical reports, which are descriptions of individual patients. Photography is a crucial time saver when it comes to keeping a clinical log. "Digital photos are accurate and easy, and there is no better way to document treatment than photography," he said.

In Dr. Yob's office, a nurse first photographs the patient's name from the chart; the succeeding photos are of that patient until the next photo of a patient's name in a chart is taken.

When staff members archive the photos, they label the computerized file with the patient's name. In some offices, the technicians set up a file for each day and download the day's files into one directory, then erase the digital card in preparation for the next day. A staff member can later sort the photos by patient.

Data storage is another important element of record keeping in a Mohs practice. "You are going to have glass slides to store, and you need an archival system," Dr. Yob said. Store all operative reports and Mohs maps and keep track of expenses.

"You are going to generate an enormous [number] of documents, photographs, and slides, and if you take some time to think it through before you start practicing Mohs surgery, you can develop a system that will be organized and not take you an enormous amount of time to process," Dr. Yob said.

He also shared tips for patient selection and scheduling.

There are two types of scheduling: integrated and exclusive, and there are advantages to both. Integrated scheduling is more efficient and more economical, but it is extremely distracting. "You could be ready to do a Mohs repair, and then you get a complicated consultation on a lupus patient," Dr. Yob said. This type of scheduling is not practical for a high-volume Mohs practice.

Exclusive scheduling means treating Mohs patients from start to finish without interruption for other types of patients. This type of scheduling is more predictable and allows more time with the patient. "I like to see patients preoperatively so I can talk to them and evaluate them. I want them to feel comfortable, and I want to take their blood pressure," Dr. Yob said. "I don't want to waste a surgical slot if the patient's blood pressure is high."

Dr. Yob's office ranks patients by three levels of complexity: quick, average, and complex. He recommends that surgeons determine how the total number of patients with varying degrees of complexity fits with what they consider their workload. "A complicated patient may be the only Mohs surgery you do in one morning," Dr. Yob said.

Regardless of scheduling type, Dr. Yob suggests starting conservatively, with small defects, and scheduling more than enough time, and not hesitating to finish a patient's procedure the next day. The volume of patients will depend on the skill and speed of the surgeon, the experience of the surgical team, and the efficiency of the office setup.

Determine how the total number of patients with varying degrees of complexity fits with the workload. DR. YOB

Building a Mohs Surgery Practice Takes Planning and Hard Work

"When you are establishing a practice, consider how and whether you are willing to commit the time and resources—and it is a considerable commitment in the beginning—to develop a Mohs practice and do it right," Dr. Yob said. "You won't make money when you start, and you must be willing to work hard and train your staff."

When starting in a Mohs surgery practice, it is best to start small, allow extra time, not treat complex cases, avoid distractions, and pay attention to details, he said.

There are several other elements to consider:

Choosing Practice Type

Group or solo? Will patients be practice generated or referred?

Scouting Geographic Area

Research the local area and learn about the population: Is there a large population of retirees and suburban moms, or a lot of college students?

Determining Community Practice Patterns

Know the size of the community and the number of dermatologists in the area. If there are other dermatologists in the area, find out how they treat skin cancer and ask about their attitudes toward Mohs surgery. Find out whether primary care physicians treat skin cancer and how they feel about Mohs surgery. "Treat the family doctors with respect," Dr. Yob said. "The more you share with them, the more they respect you."

Evaluating Your Practice

How important is Mohs to you? Is it a focal point, or is it something you do in addition to general dermatology?

Generating Referrals

Talk to ENT surgeons and plastic surgeons. "If you can convince them that you can clean out the cancer and send them a tumor-free patient, they may appreciate that," he said.

Getting the Word Out

Other ways to generate business include giving lectures to physicians and participating in CME programs at hospitals and medical meetings, as well as giving community-based talks to church or civic groups. Pamphlets and Web sites are also helpful ways for Mohs surgeons to introduce themselves to the community.

Hiring Good Help

The lab technician is "the Mohs lifeline," Dr. Yob said. You can hire a full-time staff technician or contract with one. "If you plan to do Mohs only 2 days a week, you might be able to share a technician with another surgeon who does Mohs 3 days each week," he said. The advantages of an in-house technician are convenience, availability, and consistency, as well as faster communication. However, a contract technician is often more cost effective, usually experienced, and generally has a backup on call. A contracted technician also may have helpful insights into the community and sources of patients for surgeons who are in the early stages of establishing a Mohs practice. If a nurse or another member of your staff is eager to learn, consider training them. Their personality and willingness to learn is as important as previous background, he said.

SAN DIEGO — When it comes to evaluating basal cell carcinomas for Mohs surgery, experience trumps criteria, Dr. Ronald P. Rapini said at a meeting sponsored by the American Society for Mohs Surgery.

The more slides that physicians review, the better they are at distinguishing basal cell carcinoma (BCC) from other conditions, said Dr. Rapini, professor and chair of dermatology at the University of Texas, Houston, and the M.D. Anderson Cancer Center.

The main problem with BCC as it relates to Mohs surgery is that the cancer tends to resemble follicles, sweat ducts, and sebaceous glands in Mohs sections, he explained.

To best evaluate histopathology slides for basal cell carcinoma, the surgeon should scan images on low power—the equivalent of flying over the tumor in a blimp and looking at it from a distance—and then zoom in for a closer look at anything that appears suspicious.

Get a special condenser for your microscope in order to have a 2x objective view, Dr. Rapini said. These condensers are more expensive but are worth it.

"You have to get in your blimp and look at the tumors from far away," he said. First find the tumor, then note the ink, then correlate it with the Mohs map of the problem area. "I prefer to look at the slide first and then look at the map. Even if the technician has flipped the sections by mistake, you can tell the orientation of the specimen from looking at the ink," Dr. Rapini said.

Looking for a BCC on a histopathology slide is sort of like finding a single black sheep in a herd of white sheep. "Look for bluish aggregates that don't look like they belong," he suggested.

Sometimes tumor cells will look like follicles, and sometimes they will clump together. When toluidine blue stain is used, purplish smudges of mucin are more apparent around tumors than around follicles, which can help distinguish between them.

"If you are unsure, scan on low power, and then get closer," Dr. Rapini said. Thick or fixed sections may have brownish areas that make tumor spotting more difficult, and these require a closer look with a higher-powered objective.

BCC often can be distinguished by looking for signs of an inflammatory reaction. Basaloid cells have the ability to differentiate toward sweat ducts, follicles, and sebaceous glands, but this rarely changes the prognosis.

The principal types of basal cell carcinoma are nodular, pigmented, superficial (also known as multicentric), and sclerosing (also known as morpheaform). The term "infiltrating BCC" is also used, but the definition depends on the user; the term has been used to describe any deeply invasive BCC and also has been used as a synonym for sclerosing or morpheaform BCC.

Micronodular BCC is a term currently in vogue in dermatology circles, even though its characteristics have been demonstrated in only one paper.

"It's supposed to be more aggressive than the average basal cell, but in my opinion, this definition is overrated," Dr. Rapini said. Any BCC can be aggressive or nonaggressive. Ordinary nodular BCC can get into bone, for instance, and sclerosing BCC can sometimes prove only a minor problem.

When the tumor does penetrate the bone, a multidisciplinary approach may be needed, including collaboration with a radiation therapist or orthopedist.

Folliculocentric basaloid proliferation is something else to consider in cases of potential BCC. Dr. Rapini cited the journal article that described funny-looking follicles (Arch. Dermatol. 1990;126:900–6). "These follicles are benign, but they just look strange," Dr. Rapini said. "There may be some sort of phenomenon where the nearby basal cell stimulates the follicular infundibulum," he added.

It's critical to remember that evidence of follicular differentiation does not rule out the possibility of BCC, Dr. Rapini noted. However, if papillary mesenchymal bodies, hair bulbs, or hair shafts are present, the area is more likely to be benign than cancerous.

Dr. Rapini recommends deeper cuts and a higher-powered examination to look for things like necrosis and stromal retraction. "The presence of lymphocytes can help distinguish BCC from follicles, but that isn't always reliable, especially in patients with rosacea," he said.

Even when there is follicular differentiation, physicians should not rule out BCC in a patient with a solitary tumor, especially in sun-damaged skin. A benign trichoepithelioma, for instance, can be confused with BCC. With regard to these tumors, Dr. Rapini said, "when in doubt, cut it out."

Dr. Rapini pointed out that breast cancer is the most common tumor to metastasize in the skin, and it can look like a basal cell or sclerosing basal cell carcinoma. A breast cancer tumor usually sits in the dermis, however, without connecting to the surface, and the patient usually mentions a history of breast cancer. Most of these metastases occur on the chest, he said.

Other conditions that simulate basal cell carcinoma include ameloblastoma (a dental tumor inside the mouth), cloacogenic carcinoma (anus), hair follicle tumors, sweat gland tumors, and sebaceous gland tumors.

The histopathology of metastatic breast cancer can resemble sclerosing or infiltrating basal cell carcinoma.

Pleomorphic basal cell carcinoma, which is essentially a BCC with giant atypical cells, behaves like any other BCC. Photos courtesy Dr. Ronald P. Rapini

SAN DIEGO — When it comes to evaluating basal cell carcinomas for Mohs surgery, experience trumps criteria, Dr. Ronald P. Rapini said at a meeting sponsored by the American Society for Mohs Surgery.

The more slides that physicians review, the better they are at distinguishing basal cell carcinoma (BCC) from other conditions, said Dr. Rapini, professor and chair of dermatology at the University of Texas, Houston, and the M.D. Anderson Cancer Center.

The main problem with BCC as it relates to Mohs surgery is that the cancer tends to resemble follicles, sweat ducts, and sebaceous glands in Mohs sections, he explained.

To best evaluate histopathology slides for basal cell carcinoma, the surgeon should scan images on low power—the equivalent of flying over the tumor in a blimp and looking at it from a distance—and then zoom in for a closer look at anything that appears suspicious.

Get a special condenser for your microscope in order to have a 2x objective view, Dr. Rapini said. These condensers are more expensive but are worth it.

"You have to get in your blimp and look at the tumors from far away," he said. First find the tumor, then note the ink, then correlate it with the Mohs map of the problem area. "I prefer to look at the slide first and then look at the map. Even if the technician has flipped the sections by mistake, you can tell the orientation of the specimen from looking at the ink," Dr. Rapini said.

Looking for a BCC on a histopathology slide is sort of like finding a single black sheep in a herd of white sheep. "Look for bluish aggregates that don't look like they belong," he suggested.

Sometimes tumor cells will look like follicles, and sometimes they will clump together. When toluidine blue stain is used, purplish smudges of mucin are more apparent around tumors than around follicles, which can help distinguish between them.

"If you are unsure, scan on low power, and then get closer," Dr. Rapini said. Thick or fixed sections may have brownish areas that make tumor spotting more difficult, and these require a closer look with a higher-powered objective.

BCC often can be distinguished by looking for signs of an inflammatory reaction. Basaloid cells have the ability to differentiate toward sweat ducts, follicles, and sebaceous glands, but this rarely changes the prognosis.

The principal types of basal cell carcinoma are nodular, pigmented, superficial (also known as multicentric), and sclerosing (also known as morpheaform). The term "infiltrating BCC" is also used, but the definition depends on the user; the term has been used to describe any deeply invasive BCC and also has been used as a synonym for sclerosing or morpheaform BCC.

Micronodular BCC is a term currently in vogue in dermatology circles, even though its characteristics have been demonstrated in only one paper.

"It's supposed to be more aggressive than the average basal cell, but in my opinion, this definition is overrated," Dr. Rapini said. Any BCC can be aggressive or nonaggressive. Ordinary nodular BCC can get into bone, for instance, and sclerosing BCC can sometimes prove only a minor problem.

When the tumor does penetrate the bone, a multidisciplinary approach may be needed, including collaboration with a radiation therapist or orthopedist.

Folliculocentric basaloid proliferation is something else to consider in cases of potential BCC. Dr. Rapini cited the journal article that described funny-looking follicles (Arch. Dermatol. 1990;126:900–6). "These follicles are benign, but they just look strange," Dr. Rapini said. "There may be some sort of phenomenon where the nearby basal cell stimulates the follicular infundibulum," he added.

It's critical to remember that evidence of follicular differentiation does not rule out the possibility of BCC, Dr. Rapini noted. However, if papillary mesenchymal bodies, hair bulbs, or hair shafts are present, the area is more likely to be benign than cancerous.

Dr. Rapini recommends deeper cuts and a higher-powered examination to look for things like necrosis and stromal retraction. "The presence of lymphocytes can help distinguish BCC from follicles, but that isn't always reliable, especially in patients with rosacea," he said.

Even when there is follicular differentiation, physicians should not rule out BCC in a patient with a solitary tumor, especially in sun-damaged skin. A benign trichoepithelioma, for instance, can be confused with BCC. With regard to these tumors, Dr. Rapini said, "when in doubt, cut it out."

Dr. Rapini pointed out that breast cancer is the most common tumor to metastasize in the skin, and it can look like a basal cell or sclerosing basal cell carcinoma. A breast cancer tumor usually sits in the dermis, however, without connecting to the surface, and the patient usually mentions a history of breast cancer. Most of these metastases occur on the chest, he said.

Other conditions that simulate basal cell carcinoma include ameloblastoma (a dental tumor inside the mouth), cloacogenic carcinoma (anus), hair follicle tumors, sweat gland tumors, and sebaceous gland tumors.

The histopathology of metastatic breast cancer can resemble sclerosing or infiltrating basal cell carcinoma.

Pleomorphic basal cell carcinoma, which is essentially a BCC with giant atypical cells, behaves like any other BCC. Photos courtesy Dr. Ronald P. Rapini

SAN DIEGO — When it comes to evaluating basal cell carcinomas for Mohs surgery, experience trumps criteria, Dr. Ronald P. Rapini said at a meeting sponsored by the American Society for Mohs Surgery.

The more slides that physicians review, the better they are at distinguishing basal cell carcinoma (BCC) from other conditions, said Dr. Rapini, professor and chair of dermatology at the University of Texas, Houston, and the M.D. Anderson Cancer Center.

The main problem with BCC as it relates to Mohs surgery is that the cancer tends to resemble follicles, sweat ducts, and sebaceous glands in Mohs sections, he explained.

To best evaluate histopathology slides for basal cell carcinoma, the surgeon should scan images on low power—the equivalent of flying over the tumor in a blimp and looking at it from a distance—and then zoom in for a closer look at anything that appears suspicious.

Get a special condenser for your microscope in order to have a 2x objective view, Dr. Rapini said. These condensers are more expensive but are worth it.

"You have to get in your blimp and look at the tumors from far away," he said. First find the tumor, then note the ink, then correlate it with the Mohs map of the problem area. "I prefer to look at the slide first and then look at the map. Even if the technician has flipped the sections by mistake, you can tell the orientation of the specimen from looking at the ink," Dr. Rapini said.

Looking for a BCC on a histopathology slide is sort of like finding a single black sheep in a herd of white sheep. "Look for bluish aggregates that don't look like they belong," he suggested.

Sometimes tumor cells will look like follicles, and sometimes they will clump together. When toluidine blue stain is used, purplish smudges of mucin are more apparent around tumors than around follicles, which can help distinguish between them.

"If you are unsure, scan on low power, and then get closer," Dr. Rapini said. Thick or fixed sections may have brownish areas that make tumor spotting more difficult, and these require a closer look with a higher-powered objective.

BCC often can be distinguished by looking for signs of an inflammatory reaction. Basaloid cells have the ability to differentiate toward sweat ducts, follicles, and sebaceous glands, but this rarely changes the prognosis.

The principal types of basal cell carcinoma are nodular, pigmented, superficial (also known as multicentric), and sclerosing (also known as morpheaform). The term "infiltrating BCC" is also used, but the definition depends on the user; the term has been used to describe any deeply invasive BCC and also has been used as a synonym for sclerosing or morpheaform BCC.

Micronodular BCC is a term currently in vogue in dermatology circles, even though its characteristics have been demonstrated in only one paper.

"It's supposed to be more aggressive than the average basal cell, but in my opinion, this definition is overrated," Dr. Rapini said. Any BCC can be aggressive or nonaggressive. Ordinary nodular BCC can get into bone, for instance, and sclerosing BCC can sometimes prove only a minor problem.

When the tumor does penetrate the bone, a multidisciplinary approach may be needed, including collaboration with a radiation therapist or orthopedist.

Folliculocentric basaloid proliferation is something else to consider in cases of potential BCC. Dr. Rapini cited the journal article that described funny-looking follicles (Arch. Dermatol. 1990;126:900–6). "These follicles are benign, but they just look strange," Dr. Rapini said. "There may be some sort of phenomenon where the nearby basal cell stimulates the follicular infundibulum," he added.

It's critical to remember that evidence of follicular differentiation does not rule out the possibility of BCC, Dr. Rapini noted. However, if papillary mesenchymal bodies, hair bulbs, or hair shafts are present, the area is more likely to be benign than cancerous.

Dr. Rapini recommends deeper cuts and a higher-powered examination to look for things like necrosis and stromal retraction. "The presence of lymphocytes can help distinguish BCC from follicles, but that isn't always reliable, especially in patients with rosacea," he said.

Even when there is follicular differentiation, physicians should not rule out BCC in a patient with a solitary tumor, especially in sun-damaged skin. A benign trichoepithelioma, for instance, can be confused with BCC. With regard to these tumors, Dr. Rapini said, "when in doubt, cut it out."

Dr. Rapini pointed out that breast cancer is the most common tumor to metastasize in the skin, and it can look like a basal cell or sclerosing basal cell carcinoma. A breast cancer tumor usually sits in the dermis, however, without connecting to the surface, and the patient usually mentions a history of breast cancer. Most of these metastases occur on the chest, he said.

Other conditions that simulate basal cell carcinoma include ameloblastoma (a dental tumor inside the mouth), cloacogenic carcinoma (anus), hair follicle tumors, sweat gland tumors, and sebaceous gland tumors.

The histopathology of metastatic breast cancer can resemble sclerosing or infiltrating basal cell carcinoma.

Pleomorphic basal cell carcinoma, which is essentially a BCC with giant atypical cells, behaves like any other BCC. Photos courtesy Dr. Ronald P. Rapini

SAN DIEGO — The art of treating skin cancer involves knowing which lesions are high risk and which are low risk, Dr. Ronald P. Rapini said at a meeting sponsored by the American Society for Mohs Surgery.

Patients with high-risk squamous cell carcinomas (SCCs) can be viable candidates for Mohs surgery. High-risk SCCs include those greater than 2 cm in size or 1 cm in depth or those in highly vascular areas such as the lips, said Dr. Rapini, professor and chairman of dermatology at the University of Texas, Houston.

"I think squamous cell is harder to see on slides than basal cell," Dr. Rapini said. When scanning with low power, remember that SCC tends to show up as the color pink, and it can be subtle within the dermis and muscle. For example, SCC often features atypical cells, but well-differentiated SCC might not show atypical cells.

Perineural invasion is present in approximately 10%–20% of SCCs and is more common when the tumor is recurrent or deeper than 2 cm, and approximately 40% of SCC patients report pain or nerve palsy.

Dr. Rapini said that "usually SCCs must be approximately 1 cm thick before they metastasize." Recurrent tumors, tumors that arise from burn scars, and postradiation tumors are additional examples of high-risk SCCs, as are poorly differentiated tumors, tumors with perineural invasion, and tumors in highly vascular locations, such as the lips or ears. SCCs in transplant patients and in those with pseudoglandular changes are also more likely to be severe.

Spindle cell tumors are a particular problem. The "big three" diagnoses on sun-fried skin are atypical fibroxanthoma, spindle cell squamous carcinoma, and spindle cell melanoma, he said.

Dr. Rapini also discussed other severe types of SCC:

▸ Keratoacanthoma. Specific criteria for a keratoacanthoma diagnosis—a central crater, lack of atypia in histology, and rapid growth—are worthless because they are so common to other cancers, he said. "The claim to fame of keratoacanthoma is spontaneous regression, but if you have a rapidly growing tumor you don't wait for it to regress," Dr. Rapini said, describing a keratoacanthoma as pale and glassy, with not a lot of atypia. "But if there are a lot of atypical cells, I'll just call it SCC," he said.

▸ Basosquamous cell carcinoma. This condition includes features of both SCC and basal cell carcinoma. Don't call it basosquamous simply because it is keratinizing under ulcers—that is just BCC, Dr. Rapini said. Some basosquamous cell carcinomas have clear cells as well, he added.

▸ Verrucous carcinoma. "I think of this as a wart that went amuck," Dr. Rapini said. This carcinoma appears pale and glassy, with minimal atypia. It does not metastasize, and it looks like a huge, nasty wart. The three most common variations occur on the sole of the foot (epithelioma cuniculatum), the genitals (Buschke-Lowenstein tumor), and mouth (oral florid papillomatosis).

Low-risk categories of SCC include actinic keratosis, Bowen's disease, and inverted follicular keratosis.

Some doctors call an actinic keratosis (AK) a superficial squamous cell carcinoma. AKs are often multifocal, and they can cause problems in the margins during Mohs surgery because they resemble SCC. Some surgeons use Mohs to get the invasive tumor out, and then treat the patient with imiquimod or freeze the edges of the wound after Mohs to treat any precancerous changes in the wound edge. On histopathology, an AK often alternates between pink and blue in the stratum corneum.

"In my opinion, Bowen's [squamous cell carcinoma in situ] is rarely an indication for Mohs surgery," Dr. Rapini said. Most states do not routinely cover Mohs surgery to treat Bowen's disease, and it is rarely necessary. He advised any surgeon who thinks that Mohs is indicated to document the reasons in the patient's chart and use code 173.8 (this depends upon the individual insurance carrier).

Inverted follicular keratosis, a downward-growing irritated seborrheic keratosis, has fewer clear cells than trichilemmoma (hair follicle tumor).

It has some AK features, but it is not as atypical as SCC.

SCC has many look-alikes, including hypertrophic lichen planus, hypertrophic lupus, prurigo nodularis, sweat duct metaplasia, and healing wounds.

Muscle degeneration also can mimic the squamous cell. "Damaged skeletal muscle may look bizarre, and it can be mistaken for SCC," Dr. Rapini said. "If you aren't sure, you can do a keratin stain."

Adnexal cell metaplasia, sweat ducts, and hair follicles can become metaplastic and strange looking, but none of these are SCC. A tangential section of epidermis—especially if it includes an AK—also can resemble a SCC if it is cut at a 45-degree angle. "A lot of people with squamous cell have AKs in the margins, and you may feel like you can't get clear because their whole face is one big AK," he noted.

When faced with a possible SCC, it's important to determine which lesions are superficial squamous cells and which ones are deep and aggressive. "I think the best skin cancer surgeon uses multiple modalities, including Mohs, radiation, and imiquimod, depending on the individual patient," Dr. Rapini said.

The patient on the left has recurrent squamous cell carcinoma with satellite nodules and would not be a good candidate for Mohs surgery. The image on the right shows pseudocarcinomatous hyperplasia in a previous biopsy site of a Spitz nevus. Photos courtesy Dr. Ronald P. Rapini

The best skin cancer surgeon uses multiple modalities, including Mohs, radiation, and imiquimod. DR. RAPINI

SAN DIEGO — The art of treating skin cancer involves knowing which lesions are high risk and which are low risk, Dr. Ronald P. Rapini said at a meeting sponsored by the American Society for Mohs Surgery.

Patients with high-risk squamous cell carcinomas (SCCs) can be viable candidates for Mohs surgery. High-risk SCCs include those greater than 2 cm in size or 1 cm in depth or those in highly vascular areas such as the lips, said Dr. Rapini, professor and chairman of dermatology at the University of Texas, Houston.

"I think squamous cell is harder to see on slides than basal cell," Dr. Rapini said. When scanning with low power, remember that SCC tends to show up as the color pink, and it can be subtle within the dermis and muscle. For example, SCC often features atypical cells, but well-differentiated SCC might not show atypical cells.

Perineural invasion is present in approximately 10%–20% of SCCs and is more common when the tumor is recurrent or deeper than 2 cm, and approximately 40% of SCC patients report pain or nerve palsy.

Dr. Rapini said that "usually SCCs must be approximately 1 cm thick before they metastasize." Recurrent tumors, tumors that arise from burn scars, and postradiation tumors are additional examples of high-risk SCCs, as are poorly differentiated tumors, tumors with perineural invasion, and tumors in highly vascular locations, such as the lips or ears. SCCs in transplant patients and in those with pseudoglandular changes are also more likely to be severe.

Spindle cell tumors are a particular problem. The "big three" diagnoses on sun-fried skin are atypical fibroxanthoma, spindle cell squamous carcinoma, and spindle cell melanoma, he said.

Dr. Rapini also discussed other severe types of SCC:

▸ Keratoacanthoma. Specific criteria for a keratoacanthoma diagnosis—a central crater, lack of atypia in histology, and rapid growth—are worthless because they are so common to other cancers, he said. "The claim to fame of keratoacanthoma is spontaneous regression, but if you have a rapidly growing tumor you don't wait for it to regress," Dr. Rapini said, describing a keratoacanthoma as pale and glassy, with not a lot of atypia. "But if there are a lot of atypical cells, I'll just call it SCC," he said.

▸ Basosquamous cell carcinoma. This condition includes features of both SCC and basal cell carcinoma. Don't call it basosquamous simply because it is keratinizing under ulcers—that is just BCC, Dr. Rapini said. Some basosquamous cell carcinomas have clear cells as well, he added.

▸ Verrucous carcinoma. "I think of this as a wart that went amuck," Dr. Rapini said. This carcinoma appears pale and glassy, with minimal atypia. It does not metastasize, and it looks like a huge, nasty wart. The three most common variations occur on the sole of the foot (epithelioma cuniculatum), the genitals (Buschke-Lowenstein tumor), and mouth (oral florid papillomatosis).

Low-risk categories of SCC include actinic keratosis, Bowen's disease, and inverted follicular keratosis.

Some doctors call an actinic keratosis (AK) a superficial squamous cell carcinoma. AKs are often multifocal, and they can cause problems in the margins during Mohs surgery because they resemble SCC. Some surgeons use Mohs to get the invasive tumor out, and then treat the patient with imiquimod or freeze the edges of the wound after Mohs to treat any precancerous changes in the wound edge. On histopathology, an AK often alternates between pink and blue in the stratum corneum.

"In my opinion, Bowen's [squamous cell carcinoma in situ] is rarely an indication for Mohs surgery," Dr. Rapini said. Most states do not routinely cover Mohs surgery to treat Bowen's disease, and it is rarely necessary. He advised any surgeon who thinks that Mohs is indicated to document the reasons in the patient's chart and use code 173.8 (this depends upon the individual insurance carrier).

Inverted follicular keratosis, a downward-growing irritated seborrheic keratosis, has fewer clear cells than trichilemmoma (hair follicle tumor).

It has some AK features, but it is not as atypical as SCC.

SCC has many look-alikes, including hypertrophic lichen planus, hypertrophic lupus, prurigo nodularis, sweat duct metaplasia, and healing wounds.

Muscle degeneration also can mimic the squamous cell. "Damaged skeletal muscle may look bizarre, and it can be mistaken for SCC," Dr. Rapini said. "If you aren't sure, you can do a keratin stain."

Adnexal cell metaplasia, sweat ducts, and hair follicles can become metaplastic and strange looking, but none of these are SCC. A tangential section of epidermis—especially if it includes an AK—also can resemble a SCC if it is cut at a 45-degree angle. "A lot of people with squamous cell have AKs in the margins, and you may feel like you can't get clear because their whole face is one big AK," he noted.

When faced with a possible SCC, it's important to determine which lesions are superficial squamous cells and which ones are deep and aggressive. "I think the best skin cancer surgeon uses multiple modalities, including Mohs, radiation, and imiquimod, depending on the individual patient," Dr. Rapini said.

The patient on the left has recurrent squamous cell carcinoma with satellite nodules and would not be a good candidate for Mohs surgery. The image on the right shows pseudocarcinomatous hyperplasia in a previous biopsy site of a Spitz nevus. Photos courtesy Dr. Ronald P. Rapini

The best skin cancer surgeon uses multiple modalities, including Mohs, radiation, and imiquimod. DR. RAPINI

SAN DIEGO — The art of treating skin cancer involves knowing which lesions are high risk and which are low risk, Dr. Ronald P. Rapini said at a meeting sponsored by the American Society for Mohs Surgery.

Patients with high-risk squamous cell carcinomas (SCCs) can be viable candidates for Mohs surgery. High-risk SCCs include those greater than 2 cm in size or 1 cm in depth or those in highly vascular areas such as the lips, said Dr. Rapini, professor and chairman of dermatology at the University of Texas, Houston.

"I think squamous cell is harder to see on slides than basal cell," Dr. Rapini said. When scanning with low power, remember that SCC tends to show up as the color pink, and it can be subtle within the dermis and muscle. For example, SCC often features atypical cells, but well-differentiated SCC might not show atypical cells.

Perineural invasion is present in approximately 10%–20% of SCCs and is more common when the tumor is recurrent or deeper than 2 cm, and approximately 40% of SCC patients report pain or nerve palsy.

Dr. Rapini said that "usually SCCs must be approximately 1 cm thick before they metastasize." Recurrent tumors, tumors that arise from burn scars, and postradiation tumors are additional examples of high-risk SCCs, as are poorly differentiated tumors, tumors with perineural invasion, and tumors in highly vascular locations, such as the lips or ears. SCCs in transplant patients and in those with pseudoglandular changes are also more likely to be severe.

Spindle cell tumors are a particular problem. The "big three" diagnoses on sun-fried skin are atypical fibroxanthoma, spindle cell squamous carcinoma, and spindle cell melanoma, he said.

Dr. Rapini also discussed other severe types of SCC:

▸ Keratoacanthoma. Specific criteria for a keratoacanthoma diagnosis—a central crater, lack of atypia in histology, and rapid growth—are worthless because they are so common to other cancers, he said. "The claim to fame of keratoacanthoma is spontaneous regression, but if you have a rapidly growing tumor you don't wait for it to regress," Dr. Rapini said, describing a keratoacanthoma as pale and glassy, with not a lot of atypia. "But if there are a lot of atypical cells, I'll just call it SCC," he said.

▸ Basosquamous cell carcinoma. This condition includes features of both SCC and basal cell carcinoma. Don't call it basosquamous simply because it is keratinizing under ulcers—that is just BCC, Dr. Rapini said. Some basosquamous cell carcinomas have clear cells as well, he added.

▸ Verrucous carcinoma. "I think of this as a wart that went amuck," Dr. Rapini said. This carcinoma appears pale and glassy, with minimal atypia. It does not metastasize, and it looks like a huge, nasty wart. The three most common variations occur on the sole of the foot (epithelioma cuniculatum), the genitals (Buschke-Lowenstein tumor), and mouth (oral florid papillomatosis).

Low-risk categories of SCC include actinic keratosis, Bowen's disease, and inverted follicular keratosis.

Some doctors call an actinic keratosis (AK) a superficial squamous cell carcinoma. AKs are often multifocal, and they can cause problems in the margins during Mohs surgery because they resemble SCC. Some surgeons use Mohs to get the invasive tumor out, and then treat the patient with imiquimod or freeze the edges of the wound after Mohs to treat any precancerous changes in the wound edge. On histopathology, an AK often alternates between pink and blue in the stratum corneum.

"In my opinion, Bowen's [squamous cell carcinoma in situ] is rarely an indication for Mohs surgery," Dr. Rapini said. Most states do not routinely cover Mohs surgery to treat Bowen's disease, and it is rarely necessary. He advised any surgeon who thinks that Mohs is indicated to document the reasons in the patient's chart and use code 173.8 (this depends upon the individual insurance carrier).

Inverted follicular keratosis, a downward-growing irritated seborrheic keratosis, has fewer clear cells than trichilemmoma (hair follicle tumor).

It has some AK features, but it is not as atypical as SCC.

SCC has many look-alikes, including hypertrophic lichen planus, hypertrophic lupus, prurigo nodularis, sweat duct metaplasia, and healing wounds.

Muscle degeneration also can mimic the squamous cell. "Damaged skeletal muscle may look bizarre, and it can be mistaken for SCC," Dr. Rapini said. "If you aren't sure, you can do a keratin stain."

Adnexal cell metaplasia, sweat ducts, and hair follicles can become metaplastic and strange looking, but none of these are SCC. A tangential section of epidermis—especially if it includes an AK—also can resemble a SCC if it is cut at a 45-degree angle. "A lot of people with squamous cell have AKs in the margins, and you may feel like you can't get clear because their whole face is one big AK," he noted.

When faced with a possible SCC, it's important to determine which lesions are superficial squamous cells and which ones are deep and aggressive. "I think the best skin cancer surgeon uses multiple modalities, including Mohs, radiation, and imiquimod, depending on the individual patient," Dr. Rapini said.

The patient on the left has recurrent squamous cell carcinoma with satellite nodules and would not be a good candidate for Mohs surgery. The image on the right shows pseudocarcinomatous hyperplasia in a previous biopsy site of a Spitz nevus. Photos courtesy Dr. Ronald P. Rapini

The best skin cancer surgeon uses multiple modalities, including Mohs, radiation, and imiquimod. DR. RAPINI

SAN DIEGO — The decision for or against Mohs surgery must be based on a combination of criteria that includes histology, anatomy, type of patient, and type of tumor, Dr. Lynn Proctor Shipman said at a meeting sponsored by the American Society for Mohs Surgery.

Recurrent basal cell or squamous cell carcinomas are among the strongest indicators for Mohs surgery, said Dr. Shipman of the University of California, San Diego.

The advantages of Mohs surgery include a high cure rate and its status as an outpatient procedure (except in very difficult cases) that often preserves more tissue than do other cancer treatments. The disadvantages include the expense of staff and equipment and the need for specialized surgical training. Mohs also can be time consuming and tedious, and the procedure can be traumatic for the patient, she said.

There are no solid recurrence data comparing tumor treatment modalities. The differences among tumors, among patients, and among surgeons do not make for effective controlled studies, Dr. Shipman noted.

However, Mohs has demonstrated higher cure rates for primary and recurrent basal cell and squamous cell carcinoma compared with other treatments, including radiation.

Not all patients make good candidates for Mohs surgery. A frail or elderly patient, or a patient who would be too traumatized by the size of the defect in a Mohs procedure, should not receive the procedure (SKIN & ALLERGY NEWS, August 2005, p. 1).

Factors that make someone a good candidate for Mohs are the presence of infiltrating or micronodular tumors, aggressive tumors, or perineural invasion.

Dr. Shipman suggested that Mohs surgeons assessing patients should remember the five Cs:

Cure. The first treatment has the highest chance of cure, and Mohs cure rates are higher than those of other modalities.

Complications. Consider the medical status of the patients. Take a patient's blood pressure before you operate, and be aware of his or her medications.

Cosmesis. Mohs is often touted as tissue sparing, although preservation of function should be the most important goal. That said, a Mohs surgeon can often satisfy patients with a functional and cosmetically acceptable outcome.

Convenience. Although some waiting time is involved, Mohs is reasonably convenient for most patients.

Cost. Mohs is expensive, but radiation can be more expensive, and the cost of treating recurrent tumors can add up. Be sure to document the reasons for Mohs surgery in the patient's records to ensure Medicare coverage.

Certain anatomic sites with high recurrence rates are also indications for Mohs surgery.

The nose, for instance, is the bread and butter of Mohs. "There's almost never a day when I don't operate on the nose, especially the nasal tip," Dr. Shipman said. Mohs also is indicated for functionally significant sites, such as the finger, and in cases when a favorable cosmetic result is desired.

Immunocompromised patients are often candidates for Mohs surgery because of their increased susceptibility to tumors. "The longer they have been on immunosuppressant drugs, the greater the risk of tumor formation," Dr. Shipman noted. Unlike other patients, immunocompromised patients have a higher risk of squamous cell carcinoma than of basal cell carcinoma, particularly among cardiac patients, she added.

It is also important to remember that Mohs is not always successful, and is not recommended for oral, pharyngeal, or laryngeal tumors.

"Remember that many tumors require adjunctive therapy and a multidisciplinary approach for successful resolution," Dr. Shipman said.

Surgeons who are just beginning to perform Mohs surgery should consult colleagues from other disciplines before tackling multifocal or aggressive tumors, she emphasized.

SAN DIEGO — The decision for or against Mohs surgery must be based on a combination of criteria that includes histology, anatomy, type of patient, and type of tumor, Dr. Lynn Proctor Shipman said at a meeting sponsored by the American Society for Mohs Surgery.

Recurrent basal cell or squamous cell carcinomas are among the strongest indicators for Mohs surgery, said Dr. Shipman of the University of California, San Diego.

The advantages of Mohs surgery include a high cure rate and its status as an outpatient procedure (except in very difficult cases) that often preserves more tissue than do other cancer treatments. The disadvantages include the expense of staff and equipment and the need for specialized surgical training. Mohs also can be time consuming and tedious, and the procedure can be traumatic for the patient, she said.

There are no solid recurrence data comparing tumor treatment modalities. The differences among tumors, among patients, and among surgeons do not make for effective controlled studies, Dr. Shipman noted.

However, Mohs has demonstrated higher cure rates for primary and recurrent basal cell and squamous cell carcinoma compared with other treatments, including radiation.

Not all patients make good candidates for Mohs surgery. A frail or elderly patient, or a patient who would be too traumatized by the size of the defect in a Mohs procedure, should not receive the procedure (SKIN & ALLERGY NEWS, August 2005, p. 1).

Factors that make someone a good candidate for Mohs are the presence of infiltrating or micronodular tumors, aggressive tumors, or perineural invasion.

Dr. Shipman suggested that Mohs surgeons assessing patients should remember the five Cs:

Cure. The first treatment has the highest chance of cure, and Mohs cure rates are higher than those of other modalities.

Complications. Consider the medical status of the patients. Take a patient's blood pressure before you operate, and be aware of his or her medications.

Cosmesis. Mohs is often touted as tissue sparing, although preservation of function should be the most important goal. That said, a Mohs surgeon can often satisfy patients with a functional and cosmetically acceptable outcome.

Convenience. Although some waiting time is involved, Mohs is reasonably convenient for most patients.

Cost. Mohs is expensive, but radiation can be more expensive, and the cost of treating recurrent tumors can add up. Be sure to document the reasons for Mohs surgery in the patient's records to ensure Medicare coverage.

Certain anatomic sites with high recurrence rates are also indications for Mohs surgery.

The nose, for instance, is the bread and butter of Mohs. "There's almost never a day when I don't operate on the nose, especially the nasal tip," Dr. Shipman said. Mohs also is indicated for functionally significant sites, such as the finger, and in cases when a favorable cosmetic result is desired.

Immunocompromised patients are often candidates for Mohs surgery because of their increased susceptibility to tumors. "The longer they have been on immunosuppressant drugs, the greater the risk of tumor formation," Dr. Shipman noted. Unlike other patients, immunocompromised patients have a higher risk of squamous cell carcinoma than of basal cell carcinoma, particularly among cardiac patients, she added.

It is also important to remember that Mohs is not always successful, and is not recommended for oral, pharyngeal, or laryngeal tumors.

"Remember that many tumors require adjunctive therapy and a multidisciplinary approach for successful resolution," Dr. Shipman said.

Surgeons who are just beginning to perform Mohs surgery should consult colleagues from other disciplines before tackling multifocal or aggressive tumors, she emphasized.

SAN DIEGO — The decision for or against Mohs surgery must be based on a combination of criteria that includes histology, anatomy, type of patient, and type of tumor, Dr. Lynn Proctor Shipman said at a meeting sponsored by the American Society for Mohs Surgery.

Recurrent basal cell or squamous cell carcinomas are among the strongest indicators for Mohs surgery, said Dr. Shipman of the University of California, San Diego.

The advantages of Mohs surgery include a high cure rate and its status as an outpatient procedure (except in very difficult cases) that often preserves more tissue than do other cancer treatments. The disadvantages include the expense of staff and equipment and the need for specialized surgical training. Mohs also can be time consuming and tedious, and the procedure can be traumatic for the patient, she said.

There are no solid recurrence data comparing tumor treatment modalities. The differences among tumors, among patients, and among surgeons do not make for effective controlled studies, Dr. Shipman noted.

However, Mohs has demonstrated higher cure rates for primary and recurrent basal cell and squamous cell carcinoma compared with other treatments, including radiation.

Not all patients make good candidates for Mohs surgery. A frail or elderly patient, or a patient who would be too traumatized by the size of the defect in a Mohs procedure, should not receive the procedure (SKIN & ALLERGY NEWS, August 2005, p. 1).

Factors that make someone a good candidate for Mohs are the presence of infiltrating or micronodular tumors, aggressive tumors, or perineural invasion.

Dr. Shipman suggested that Mohs surgeons assessing patients should remember the five Cs:

Cure. The first treatment has the highest chance of cure, and Mohs cure rates are higher than those of other modalities.

Complications. Consider the medical status of the patients. Take a patient's blood pressure before you operate, and be aware of his or her medications.

Cosmesis. Mohs is often touted as tissue sparing, although preservation of function should be the most important goal. That said, a Mohs surgeon can often satisfy patients with a functional and cosmetically acceptable outcome.

Convenience. Although some waiting time is involved, Mohs is reasonably convenient for most patients.

Cost. Mohs is expensive, but radiation can be more expensive, and the cost of treating recurrent tumors can add up. Be sure to document the reasons for Mohs surgery in the patient's records to ensure Medicare coverage.

Certain anatomic sites with high recurrence rates are also indications for Mohs surgery.

The nose, for instance, is the bread and butter of Mohs. "There's almost never a day when I don't operate on the nose, especially the nasal tip," Dr. Shipman said. Mohs also is indicated for functionally significant sites, such as the finger, and in cases when a favorable cosmetic result is desired.

Immunocompromised patients are often candidates for Mohs surgery because of their increased susceptibility to tumors. "The longer they have been on immunosuppressant drugs, the greater the risk of tumor formation," Dr. Shipman noted. Unlike other patients, immunocompromised patients have a higher risk of squamous cell carcinoma than of basal cell carcinoma, particularly among cardiac patients, she added.

It is also important to remember that Mohs is not always successful, and is not recommended for oral, pharyngeal, or laryngeal tumors.

"Remember that many tumors require adjunctive therapy and a multidisciplinary approach for successful resolution," Dr. Shipman said.

Surgeons who are just beginning to perform Mohs surgery should consult colleagues from other disciplines before tackling multifocal or aggressive tumors, she emphasized.

SAN DIEGO — Mohs surgery requires meticulous mapping.

A Mohs map preserves the integrity between the surgical wound and the histologic findings on the slides, Dr. Howard Steinman said at a meeting sponsored by the American Society for Mohs Surgery.

An accurate, readable Mohs map must show the wound shape and the location of reference marks for correct orientation. It also must depict the location of tumor and other findings in the surgical area, such as scars, unrelated tumors, and incomplete margins, he said.

The map is essential for avoiding orientation errors and serves as a pictorial representation of the pathology report. It is also a medicolegal document, and surgeons can and will rely on it to help remember what they did in any given case. The map is critical for communication with lab technicians and consulting physicians, and it serves as part of the operative report. As such, it is vital in the event of a lawsuit.

"The map is the only pathology report you have," said Dr. Steinman, a dermatologist in private practice in Chula Vista, Calif. "A good map will tell you what you did for a particular patient when you look at it years later."

In addition to tumor foci, the map must document incomplete surgical margins. "You want to be able to mark that there was an incomplete skin edge, to document why you needed to take another layer of tissue," Dr. Steinman pointed out.

Although mapping using digital photography is likely the wave of the future, it's worth developing a strategy for creating a functional Mohs map using other methods. Some surgeons use preprinted anatomic diagrams, whereas others use hand-drawn sketches or nondigital photographs. A representational shape of the wound is okay; it doesn't have to be precise. The map should be drawn larger than the actual size of the wound, however, so it will be easier to correlate findings between the microscope slides and the surgical wound, he said.

Before any tissue is processed, the Mohs map must include patient information, clinical information, the exact location of reference marks, and the wound shape. During tissue processing, the map depicts specimen subdivision patterns, tissue section-numbering schemes, and tissue inking patterns.

During the procedure, the Mohs map is essential for documenting the surgery, processing tissue, and maintaining orientation of the specimen and microscope slides to the wound. After the procedure, the map is an essential record of the work that was performed. When marking findings, most surgeons mark tumor foci in red and other findings in black on the map.

Tissue inking must be accurately drawn on the map and must appear the same both through the microscope and on the map. Inking orients and differentiates tissue specimens, and must be visible on the processed tissue wafers. Dr. Steinman recommends using a consistent drawing symbol for each color. "Pick one set of symbols and be consistent; use it for the rest of your career," he said. When subdividing large specimens, ink opposing cut edges the same color.

"I ink my specimens first and then mark the map, because if I mark the map first and do not ink the tissue accordingly, I have to go back and change the map," he said. Although Dr. Mohs used red as a tissue ink, many surgeons today favor blue, black, or green, because they are easier to see on the microscope slides.

Dr. Steinman tries to process the least number of tissue sections for each Mohs stage, processing specimens as one piece when possible. A consistent inking pattern should be developed for small, circular-shaped specimens, the most common first-stage specimen shape. Dr. Steinman uses blue ink from the 9:00–12:00 reference marks and black ink from 12:00–3:00. He places a green dot at the 6:00 mark on a specimen. Another method is to simply place ink into the four reference nicks of the specimen. "The important thing is to pick a method and be consistent," he said.

In addition, making a "Pac Man" incision to subdivide a specimen can offer an internal orientation. "When you cut a surgical specimen in half or quarters and use only two ink colors along their cut edges, you have created identically shaped pieces. You then need to place a third color on only one of each pair," Dr. Steinman said. "The third color is vital to preserve orientation."

Be aware of dense inflammation, which often masks tumor. "If you see dense inflammation on your first or second tissue wafers, tumor may be present in the wound base that requires another stage of Mohs surgery," Dr. Steinman said. Respect the dense inflammation and mark it on the Mohs map.

Establish orientation when examining slides by drawing a line radiating from the 12:00 point of the tissue wafer. Draw the line directly on the slide with a red pen. Also mark the tumor foci on appropriate wafers. This allows the slide to be held directly over the map, and findings can be oriented and drawn on the map more easily, he explained.

Subdividing a specimen with a 'Pac-Man' incision provides an internal orientation.

These images show a Mohs map and the wound that it documents. Note the complementary inking patterns between the map and wound. Photos courtesy Dr. Howard Steinman

SAN DIEGO — Mohs surgery requires meticulous mapping.

A Mohs map preserves the integrity between the surgical wound and the histologic findings on the slides, Dr. Howard Steinman said at a meeting sponsored by the American Society for Mohs Surgery.

An accurate, readable Mohs map must show the wound shape and the location of reference marks for correct orientation. It also must depict the location of tumor and other findings in the surgical area, such as scars, unrelated tumors, and incomplete margins, he said.

The map is essential for avoiding orientation errors and serves as a pictorial representation of the pathology report. It is also a medicolegal document, and surgeons can and will rely on it to help remember what they did in any given case. The map is critical for communication with lab technicians and consulting physicians, and it serves as part of the operative report. As such, it is vital in the event of a lawsuit.

"The map is the only pathology report you have," said Dr. Steinman, a dermatologist in private practice in Chula Vista, Calif. "A good map will tell you what you did for a particular patient when you look at it years later."

In addition to tumor foci, the map must document incomplete surgical margins. "You want to be able to mark that there was an incomplete skin edge, to document why you needed to take another layer of tissue," Dr. Steinman pointed out.

Although mapping using digital photography is likely the wave of the future, it's worth developing a strategy for creating a functional Mohs map using other methods. Some surgeons use preprinted anatomic diagrams, whereas others use hand-drawn sketches or nondigital photographs. A representational shape of the wound is okay; it doesn't have to be precise. The map should be drawn larger than the actual size of the wound, however, so it will be easier to correlate findings between the microscope slides and the surgical wound, he said.

Before any tissue is processed, the Mohs map must include patient information, clinical information, the exact location of reference marks, and the wound shape. During tissue processing, the map depicts specimen subdivision patterns, tissue section-numbering schemes, and tissue inking patterns.

During the procedure, the Mohs map is essential for documenting the surgery, processing tissue, and maintaining orientation of the specimen and microscope slides to the wound. After the procedure, the map is an essential record of the work that was performed. When marking findings, most surgeons mark tumor foci in red and other findings in black on the map.

Tissue inking must be accurately drawn on the map and must appear the same both through the microscope and on the map. Inking orients and differentiates tissue specimens, and must be visible on the processed tissue wafers. Dr. Steinman recommends using a consistent drawing symbol for each color. "Pick one set of symbols and be consistent; use it for the rest of your career," he said. When subdividing large specimens, ink opposing cut edges the same color.

"I ink my specimens first and then mark the map, because if I mark the map first and do not ink the tissue accordingly, I have to go back and change the map," he said. Although Dr. Mohs used red as a tissue ink, many surgeons today favor blue, black, or green, because they are easier to see on the microscope slides.

Dr. Steinman tries to process the least number of tissue sections for each Mohs stage, processing specimens as one piece when possible. A consistent inking pattern should be developed for small, circular-shaped specimens, the most common first-stage specimen shape. Dr. Steinman uses blue ink from the 9:00–12:00 reference marks and black ink from 12:00–3:00. He places a green dot at the 6:00 mark on a specimen. Another method is to simply place ink into the four reference nicks of the specimen. "The important thing is to pick a method and be consistent," he said.

In addition, making a "Pac Man" incision to subdivide a specimen can offer an internal orientation. "When you cut a surgical specimen in half or quarters and use only two ink colors along their cut edges, you have created identically shaped pieces. You then need to place a third color on only one of each pair," Dr. Steinman said. "The third color is vital to preserve orientation."

Be aware of dense inflammation, which often masks tumor. "If you see dense inflammation on your first or second tissue wafers, tumor may be present in the wound base that requires another stage of Mohs surgery," Dr. Steinman said. Respect the dense inflammation and mark it on the Mohs map.

Establish orientation when examining slides by drawing a line radiating from the 12:00 point of the tissue wafer. Draw the line directly on the slide with a red pen. Also mark the tumor foci on appropriate wafers. This allows the slide to be held directly over the map, and findings can be oriented and drawn on the map more easily, he explained.

Subdividing a specimen with a 'Pac-Man' incision provides an internal orientation.

These images show a Mohs map and the wound that it documents. Note the complementary inking patterns between the map and wound. Photos courtesy Dr. Howard Steinman

SAN DIEGO — Mohs surgery requires meticulous mapping.

A Mohs map preserves the integrity between the surgical wound and the histologic findings on the slides, Dr. Howard Steinman said at a meeting sponsored by the American Society for Mohs Surgery.

An accurate, readable Mohs map must show the wound shape and the location of reference marks for correct orientation. It also must depict the location of tumor and other findings in the surgical area, such as scars, unrelated tumors, and incomplete margins, he said.

The map is essential for avoiding orientation errors and serves as a pictorial representation of the pathology report. It is also a medicolegal document, and surgeons can and will rely on it to help remember what they did in any given case. The map is critical for communication with lab technicians and consulting physicians, and it serves as part of the operative report. As such, it is vital in the event of a lawsuit.

"The map is the only pathology report you have," said Dr. Steinman, a dermatologist in private practice in Chula Vista, Calif. "A good map will tell you what you did for a particular patient when you look at it years later."

In addition to tumor foci, the map must document incomplete surgical margins. "You want to be able to mark that there was an incomplete skin edge, to document why you needed to take another layer of tissue," Dr. Steinman pointed out.

Although mapping using digital photography is likely the wave of the future, it's worth developing a strategy for creating a functional Mohs map using other methods. Some surgeons use preprinted anatomic diagrams, whereas others use hand-drawn sketches or nondigital photographs. A representational shape of the wound is okay; it doesn't have to be precise. The map should be drawn larger than the actual size of the wound, however, so it will be easier to correlate findings between the microscope slides and the surgical wound, he said.

Before any tissue is processed, the Mohs map must include patient information, clinical information, the exact location of reference marks, and the wound shape. During tissue processing, the map depicts specimen subdivision patterns, tissue section-numbering schemes, and tissue inking patterns.

During the procedure, the Mohs map is essential for documenting the surgery, processing tissue, and maintaining orientation of the specimen and microscope slides to the wound. After the procedure, the map is an essential record of the work that was performed. When marking findings, most surgeons mark tumor foci in red and other findings in black on the map.

Tissue inking must be accurately drawn on the map and must appear the same both through the microscope and on the map. Inking orients and differentiates tissue specimens, and must be visible on the processed tissue wafers. Dr. Steinman recommends using a consistent drawing symbol for each color. "Pick one set of symbols and be consistent; use it for the rest of your career," he said. When subdividing large specimens, ink opposing cut edges the same color.

"I ink my specimens first and then mark the map, because if I mark the map first and do not ink the tissue accordingly, I have to go back and change the map," he said. Although Dr. Mohs used red as a tissue ink, many surgeons today favor blue, black, or green, because they are easier to see on the microscope slides.

Dr. Steinman tries to process the least number of tissue sections for each Mohs stage, processing specimens as one piece when possible. A consistent inking pattern should be developed for small, circular-shaped specimens, the most common first-stage specimen shape. Dr. Steinman uses blue ink from the 9:00–12:00 reference marks and black ink from 12:00–3:00. He places a green dot at the 6:00 mark on a specimen. Another method is to simply place ink into the four reference nicks of the specimen. "The important thing is to pick a method and be consistent," he said.

In addition, making a "Pac Man" incision to subdivide a specimen can offer an internal orientation. "When you cut a surgical specimen in half or quarters and use only two ink colors along their cut edges, you have created identically shaped pieces. You then need to place a third color on only one of each pair," Dr. Steinman said. "The third color is vital to preserve orientation."

Be aware of dense inflammation, which often masks tumor. "If you see dense inflammation on your first or second tissue wafers, tumor may be present in the wound base that requires another stage of Mohs surgery," Dr. Steinman said. Respect the dense inflammation and mark it on the Mohs map.

Establish orientation when examining slides by drawing a line radiating from the 12:00 point of the tissue wafer. Draw the line directly on the slide with a red pen. Also mark the tumor foci on appropriate wafers. This allows the slide to be held directly over the map, and findings can be oriented and drawn on the map more easily, he explained.

Subdividing a specimen with a 'Pac-Man' incision provides an internal orientation.

These images show a Mohs map and the wound that it documents. Note the complementary inking patterns between the map and wound. Photos courtesy Dr. Howard Steinman

Measles Outbreak in Boarding School

The largest reported school-based measles outbreak in the United States since 1998 was limited to nine cases—eight students and one adult staff member—in a boarding school of more than 600 students, said Dr. Lorraine F. Yeung of the Centers for Disease Control and Prevention, Atlanta, and her associates.

A total of 629 (95%) of the 663 students aged 13–26 years had received at least two doses of measles-containing vaccine (MCV); two of those students had accidentally received a third dose. Eight students had not received any vaccination (Pediatrics 2005;116:1287–91). The vaccine effectiveness rate was 97% among the 627 students who received two doses.

Six of the eight student cases had received two doses of vaccine, and two were unvaccinated. Of the six vaccinated patients, three had received their doses outside of the United States, including the source patient, a 17-year-old boy who had traveled to Beirut, Lebanon, and became ill upon his return.

The most severe cases occurred in the two unvaccinated students—13-year-old twins who were hospitalized for dehydration. Overall, the six vaccinated patients had significantly fewer days of rash (5 vs. 10) and fewer missed days of school or work (5 vs. 8), compared with the unvaccinated patients, the investigators said.

Hepatitis A Vaccine Cuts Outbreaks

Routine implementation of the hepatitis A vaccine contributed to historically low levels of infection in Maricopa County, Ariz., said Hesha Jani Duggirala, Ph.D., of Tulane University, New Orleans, and the Maricopa County Department of Public Health in Phoenix.

Maricopa County traditionally averaged 38 hepatitis cases per 100,000 people—more than three times the national average. In a communitywide outbreak in 1997, hepatitis patients were more than six times as likely to have a history of attending or working in a child care center, compared with healthy people, and approximately 40% of cases in 1997 were linked to direct or indirect child care contact. This finding prompted the requirement of hepatitis A vaccination for all children aged 2–5 years who attended child care centers (Pediatr. Infect. Dis. J. 2005;24:974–8).

According to data from the Arizona State Immunization Information System, 23,817 children aged 2–5 years living in Maricopa County received one dose of the hepatitis A vaccine between February 1999 and June 2000; this number represented approximately 12% of children aged 2–5 years living in the county.

During 1998–2001, the age-specific incidence declined for all age groups; the steepest declines occurred among children aged 0–4 years (−91%) and aged 5–9 years (−94%).

In contrast to the 1997 outbreak, few cases reported during 1998–2001 were associated with child care centers.

FluMist School Program Shows Benefit

Use of live, attentuated flu vaccine significantly reduced the rates of fever and respiratory illness in a pilot study of 185 school-aged children, said Dr. James C. King of the University of Maryland, Baltimore, and his associates.

Children at a designated test school received the live, attenuated vaccine (FluMist) prior to the 2003–2004 flu season, while children from two other schools in the community served as controls.

Overall, both adults and children in the test school households reported significantly fewer fever- and respiratory illness-related ambulatory physician visits, compared with controls, during a 7-day recall period near the peak influenza week in December 2003. The most significant differences between the test and control groups included the mean number of medical visits per 100 children (5.6 in the test school group, compared with 15.3 and 18.3 in the two control groups) and the number of over-the-counter medicines purchased per 100 households (25.9 in the test group vs. 51.2 and 44.5 for the two control groups).

Chlamydia Follow-Up Needs Work

The majority of adolescents received appropriate antibiotics for chlamydia an average of 6 days after testing positive, but few received other types of follow-up care, based on a study of 122 patients, said Dr. Loris Y. Hwang and colleagues at the University of California, San Francisco.

The 96 girls and 26 boys aged 14–19 years had tested positive for Chlamydia trachomatis infection during the study period, and 118 cases were treated. Although 97% of the adolescents received appropriate antibiotics, only 79% received safe sex counseling and 52% received partner management advice (Arch. Pediatr. Adolesc. Med. 2005;159:1162–6).

Significantly fewer boys than girls received either safe sex counseling (62% vs. 83%) or partner management advice (31% vs. 57%). The lack of counseling illustrates a missed opportunity to moderate high-risk behavior, the researchers noted.

Measles Outbreak in Boarding School

The largest reported school-based measles outbreak in the United States since 1998 was limited to nine cases—eight students and one adult staff member—in a boarding school of more than 600 students, said Dr. Lorraine F. Yeung of the Centers for Disease Control and Prevention, Atlanta, and her associates.

A total of 629 (95%) of the 663 students aged 13–26 years had received at least two doses of measles-containing vaccine (MCV); two of those students had accidentally received a third dose. Eight students had not received any vaccination (Pediatrics 2005;116:1287–91). The vaccine effectiveness rate was 97% among the 627 students who received two doses.

Six of the eight student cases had received two doses of vaccine, and two were unvaccinated. Of the six vaccinated patients, three had received their doses outside of the United States, including the source patient, a 17-year-old boy who had traveled to Beirut, Lebanon, and became ill upon his return.

The most severe cases occurred in the two unvaccinated students—13-year-old twins who were hospitalized for dehydration. Overall, the six vaccinated patients had significantly fewer days of rash (5 vs. 10) and fewer missed days of school or work (5 vs. 8), compared with the unvaccinated patients, the investigators said.

Hepatitis A Vaccine Cuts Outbreaks

Routine implementation of the hepatitis A vaccine contributed to historically low levels of infection in Maricopa County, Ariz., said Hesha Jani Duggirala, Ph.D., of Tulane University, New Orleans, and the Maricopa County Department of Public Health in Phoenix.

Maricopa County traditionally averaged 38 hepatitis cases per 100,000 people—more than three times the national average. In a communitywide outbreak in 1997, hepatitis patients were more than six times as likely to have a history of attending or working in a child care center, compared with healthy people, and approximately 40% of cases in 1997 were linked to direct or indirect child care contact. This finding prompted the requirement of hepatitis A vaccination for all children aged 2–5 years who attended child care centers (Pediatr. Infect. Dis. J. 2005;24:974–8).

According to data from the Arizona State Immunization Information System, 23,817 children aged 2–5 years living in Maricopa County received one dose of the hepatitis A vaccine between February 1999 and June 2000; this number represented approximately 12% of children aged 2–5 years living in the county.

During 1998–2001, the age-specific incidence declined for all age groups; the steepest declines occurred among children aged 0–4 years (−91%) and aged 5–9 years (−94%).

In contrast to the 1997 outbreak, few cases reported during 1998–2001 were associated with child care centers.

FluMist School Program Shows Benefit

Use of live, attentuated flu vaccine significantly reduced the rates of fever and respiratory illness in a pilot study of 185 school-aged children, said Dr. James C. King of the University of Maryland, Baltimore, and his associates.

Children at a designated test school received the live, attenuated vaccine (FluMist) prior to the 2003–2004 flu season, while children from two other schools in the community served as controls.

Overall, both adults and children in the test school households reported significantly fewer fever- and respiratory illness-related ambulatory physician visits, compared with controls, during a 7-day recall period near the peak influenza week in December 2003. The most significant differences between the test and control groups included the mean number of medical visits per 100 children (5.6 in the test school group, compared with 15.3 and 18.3 in the two control groups) and the number of over-the-counter medicines purchased per 100 households (25.9 in the test group vs. 51.2 and 44.5 for the two control groups).

Chlamydia Follow-Up Needs Work

The majority of adolescents received appropriate antibiotics for chlamydia an average of 6 days after testing positive, but few received other types of follow-up care, based on a study of 122 patients, said Dr. Loris Y. Hwang and colleagues at the University of California, San Francisco.

The 96 girls and 26 boys aged 14–19 years had tested positive for Chlamydia trachomatis infection during the study period, and 118 cases were treated. Although 97% of the adolescents received appropriate antibiotics, only 79% received safe sex counseling and 52% received partner management advice (Arch. Pediatr. Adolesc. Med. 2005;159:1162–6).

Significantly fewer boys than girls received either safe sex counseling (62% vs. 83%) or partner management advice (31% vs. 57%). The lack of counseling illustrates a missed opportunity to moderate high-risk behavior, the researchers noted.

Measles Outbreak in Boarding School

The largest reported school-based measles outbreak in the United States since 1998 was limited to nine cases—eight students and one adult staff member—in a boarding school of more than 600 students, said Dr. Lorraine F. Yeung of the Centers for Disease Control and Prevention, Atlanta, and her associates.

A total of 629 (95%) of the 663 students aged 13–26 years had received at least two doses of measles-containing vaccine (MCV); two of those students had accidentally received a third dose. Eight students had not received any vaccination (Pediatrics 2005;116:1287–91). The vaccine effectiveness rate was 97% among the 627 students who received two doses.

Six of the eight student cases had received two doses of vaccine, and two were unvaccinated. Of the six vaccinated patients, three had received their doses outside of the United States, including the source patient, a 17-year-old boy who had traveled to Beirut, Lebanon, and became ill upon his return.

The most severe cases occurred in the two unvaccinated students—13-year-old twins who were hospitalized for dehydration. Overall, the six vaccinated patients had significantly fewer days of rash (5 vs. 10) and fewer missed days of school or work (5 vs. 8), compared with the unvaccinated patients, the investigators said.

Hepatitis A Vaccine Cuts Outbreaks

Routine implementation of the hepatitis A vaccine contributed to historically low levels of infection in Maricopa County, Ariz., said Hesha Jani Duggirala, Ph.D., of Tulane University, New Orleans, and the Maricopa County Department of Public Health in Phoenix.

Maricopa County traditionally averaged 38 hepatitis cases per 100,000 people—more than three times the national average. In a communitywide outbreak in 1997, hepatitis patients were more than six times as likely to have a history of attending or working in a child care center, compared with healthy people, and approximately 40% of cases in 1997 were linked to direct or indirect child care contact. This finding prompted the requirement of hepatitis A vaccination for all children aged 2–5 years who attended child care centers (Pediatr. Infect. Dis. J. 2005;24:974–8).

According to data from the Arizona State Immunization Information System, 23,817 children aged 2–5 years living in Maricopa County received one dose of the hepatitis A vaccine between February 1999 and June 2000; this number represented approximately 12% of children aged 2–5 years living in the county.

During 1998–2001, the age-specific incidence declined for all age groups; the steepest declines occurred among children aged 0–4 years (−91%) and aged 5–9 years (−94%).

In contrast to the 1997 outbreak, few cases reported during 1998–2001 were associated with child care centers.

FluMist School Program Shows Benefit

Use of live, attentuated flu vaccine significantly reduced the rates of fever and respiratory illness in a pilot study of 185 school-aged children, said Dr. James C. King of the University of Maryland, Baltimore, and his associates.

Children at a designated test school received the live, attenuated vaccine (FluMist) prior to the 2003–2004 flu season, while children from two other schools in the community served as controls.

Overall, both adults and children in the test school households reported significantly fewer fever- and respiratory illness-related ambulatory physician visits, compared with controls, during a 7-day recall period near the peak influenza week in December 2003. The most significant differences between the test and control groups included the mean number of medical visits per 100 children (5.6 in the test school group, compared with 15.3 and 18.3 in the two control groups) and the number of over-the-counter medicines purchased per 100 households (25.9 in the test group vs. 51.2 and 44.5 for the two control groups).

Chlamydia Follow-Up Needs Work

The majority of adolescents received appropriate antibiotics for chlamydia an average of 6 days after testing positive, but few received other types of follow-up care, based on a study of 122 patients, said Dr. Loris Y. Hwang and colleagues at the University of California, San Francisco.

The 96 girls and 26 boys aged 14–19 years had tested positive for Chlamydia trachomatis infection during the study period, and 118 cases were treated. Although 97% of the adolescents received appropriate antibiotics, only 79% received safe sex counseling and 52% received partner management advice (Arch. Pediatr. Adolesc. Med. 2005;159:1162–6).

Significantly fewer boys than girls received either safe sex counseling (62% vs. 83%) or partner management advice (31% vs. 57%). The lack of counseling illustrates a missed opportunity to moderate high-risk behavior, the researchers noted.

Vaccine Contains Measles in School

The largest reported school-based measles outbreak in the United States since 1998 was limited to nine cases—eight students and one adult staff member—in a boarding school of more than 600 students, said Dr. Lorraine F. Yeung of the Centers for Disease Control and Prevention, Atlanta, and her associates.

A total of 629 (95%) of the 663 students aged 13–26 years had received at least two doses of measles-containing vaccine (MCV); two of those students had accidentally received a third dose. Eight students had not received any vaccination; four of these had not been vaccinated for philosophical or religious reasons (Pediatrics 2005;116:1287–91). The vaccine effectiveness rate was 97% among the 627 students who received two doses, but it was higher among those who had received both doses in the United States than among those who received both doses outside the United States (99% vs. 94%).

Six of the eight student cases had received two doses of vaccine, and two were unvaccinated. Of the six vaccinated patients, three had received their doses outside of the United States, including the source patient, a 17-year-old boy who had traveled to Beirut, Lebanon, and became ill upon his return.

Lack of Follow-Up for Chlamydia

The majority of adolescents received appropriate antibiotics for chlamydia an average of 6 days after testing positive, but few received other types of follow-up care, based on a study of 122 patients, said Dr. Loris Y. Hwang and colleagues at the University of California, San Francisco.

The 96 girls and 26 boys aged 14–19 years had tested positive for Chlamydia trachomatis infection during the study period, and 118 cases were treated. Although 97% of the adolescents received appropriate antibiotics, only 79% received safe sex counseling and 52% received partner management advice (Arch. Pediatr. Adolesc. Med. 2005;159:1162–6).

Hepatitis in Child Care Settings

Routine implementation of the hepatitis A vaccine contributed to historically low levels of infection—6/100,000 people—in Maricopa County, Ariz., said Hesha Jani Duggirala, Ph.D., of Tulane University, New Orleans, and the Maricopa County Department of Public Health, Phoenix.

Maricopa County traditionally averaged 38 hepatitis cases per 100,000 people—more than three times the national average. In a community-wide outbreak in 1997, hepatitis patients were more than six times as likely to have a history of attending or working in a child care center, compared with healthy people, and approximately 40% of cases in 1997 were linked to direct or indirect child care contact. This finding prompted the requirement of hepatitis A vaccination for all children aged 2–5 years who attended child care centers (Pediatr. Infect. Dis. J. 2005;24:974–8).

According to data from the Arizona State Immunization Information System, 23,817 children aged 2–5 years living in Maricopa County received one dose of the hepatitis A vaccine between February 1999 and June 2000; this number represented approximately 12% of children aged 2–5 years living in the county.

During 1998–2001, the age-specific incidence declined for all age groups; the steepest declines occurred among children aged 0–4 years (−91%) and aged 5–9 years (−94%).

Unlike the 1997 outbreak, few cases reported during 1998–2001 were associated with child care centers. The researchers conducted a case-control study of 72 cases and 144 age-matched controls, and found that neither direct nor indirect child care center contact was significantly associated with illness in a logistic regression analysis, although direct contact with an infected person remained a significant risk factor.

FluMist Program Cuts Illness Rates

Use of live, attentuated flu vaccine significantly reduced the rates of fever and respiratory illness in a pilot study of 185 school-aged children, said Dr. James C. King Jr. of the University of Maryland, Baltimore, and his associates.

Children at a designated test school received the live, attenuated vaccine (FluMist) prior to the 2003–2004 flu season, while children from two other schools in the community served as controls (Pediatrics 2005;116:868–73).

Overall, adults and children in the test school households reported significantly fewer fever and respiratory illness-related ambulatory physician visits, compared with controls, during a 7-day recall period near the peak influenza week in December 2003. The most significant differences between the test and control groups included the mean number of child medical visits per 100 children (5.6 in the test school group, compared with 15.3 and 18.3 in the two control groups) and the number of over-the-counter medicines purchased per 100 households (25.9 in the test group vs. 51.2 and 44.5 for the two control groups).

Vaccine Contains Measles in School

The largest reported school-based measles outbreak in the United States since 1998 was limited to nine cases—eight students and one adult staff member—in a boarding school of more than 600 students, said Dr. Lorraine F. Yeung of the Centers for Disease Control and Prevention, Atlanta, and her associates.

A total of 629 (95%) of the 663 students aged 13–26 years had received at least two doses of measles-containing vaccine (MCV); two of those students had accidentally received a third dose. Eight students had not received any vaccination; four of these had not been vaccinated for philosophical or religious reasons (Pediatrics 2005;116:1287–91). The vaccine effectiveness rate was 97% among the 627 students who received two doses, but it was higher among those who had received both doses in the United States than among those who received both doses outside the United States (99% vs. 94%).

Six of the eight student cases had received two doses of vaccine, and two were unvaccinated. Of the six vaccinated patients, three had received their doses outside of the United States, including the source patient, a 17-year-old boy who had traveled to Beirut, Lebanon, and became ill upon his return.

Lack of Follow-Up for Chlamydia

The majority of adolescents received appropriate antibiotics for chlamydia an average of 6 days after testing positive, but few received other types of follow-up care, based on a study of 122 patients, said Dr. Loris Y. Hwang and colleagues at the University of California, San Francisco.

The 96 girls and 26 boys aged 14–19 years had tested positive for Chlamydia trachomatis infection during the study period, and 118 cases were treated. Although 97% of the adolescents received appropriate antibiotics, only 79% received safe sex counseling and 52% received partner management advice (Arch. Pediatr. Adolesc. Med. 2005;159:1162–6).

Hepatitis in Child Care Settings

Routine implementation of the hepatitis A vaccine contributed to historically low levels of infection—6/100,000 people—in Maricopa County, Ariz., said Hesha Jani Duggirala, Ph.D., of Tulane University, New Orleans, and the Maricopa County Department of Public Health, Phoenix.

Maricopa County traditionally averaged 38 hepatitis cases per 100,000 people—more than three times the national average. In a community-wide outbreak in 1997, hepatitis patients were more than six times as likely to have a history of attending or working in a child care center, compared with healthy people, and approximately 40% of cases in 1997 were linked to direct or indirect child care contact. This finding prompted the requirement of hepatitis A vaccination for all children aged 2–5 years who attended child care centers (Pediatr. Infect. Dis. J. 2005;24:974–8).

According to data from the Arizona State Immunization Information System, 23,817 children aged 2–5 years living in Maricopa County received one dose of the hepatitis A vaccine between February 1999 and June 2000; this number represented approximately 12% of children aged 2–5 years living in the county.

During 1998–2001, the age-specific incidence declined for all age groups; the steepest declines occurred among children aged 0–4 years (−91%) and aged 5–9 years (−94%).

Unlike the 1997 outbreak, few cases reported during 1998–2001 were associated with child care centers. The researchers conducted a case-control study of 72 cases and 144 age-matched controls, and found that neither direct nor indirect child care center contact was significantly associated with illness in a logistic regression analysis, although direct contact with an infected person remained a significant risk factor.

FluMist Program Cuts Illness Rates

Use of live, attentuated flu vaccine significantly reduced the rates of fever and respiratory illness in a pilot study of 185 school-aged children, said Dr. James C. King Jr. of the University of Maryland, Baltimore, and his associates.

Children at a designated test school received the live, attenuated vaccine (FluMist) prior to the 2003–2004 flu season, while children from two other schools in the community served as controls (Pediatrics 2005;116:868–73).

Overall, adults and children in the test school households reported significantly fewer fever and respiratory illness-related ambulatory physician visits, compared with controls, during a 7-day recall period near the peak influenza week in December 2003. The most significant differences between the test and control groups included the mean number of child medical visits per 100 children (5.6 in the test school group, compared with 15.3 and 18.3 in the two control groups) and the number of over-the-counter medicines purchased per 100 households (25.9 in the test group vs. 51.2 and 44.5 for the two control groups).

Vaccine Contains Measles in School

The largest reported school-based measles outbreak in the United States since 1998 was limited to nine cases—eight students and one adult staff member—in a boarding school of more than 600 students, said Dr. Lorraine F. Yeung of the Centers for Disease Control and Prevention, Atlanta, and her associates.

A total of 629 (95%) of the 663 students aged 13–26 years had received at least two doses of measles-containing vaccine (MCV); two of those students had accidentally received a third dose. Eight students had not received any vaccination; four of these had not been vaccinated for philosophical or religious reasons (Pediatrics 2005;116:1287–91). The vaccine effectiveness rate was 97% among the 627 students who received two doses, but it was higher among those who had received both doses in the United States than among those who received both doses outside the United States (99% vs. 94%).

Six of the eight student cases had received two doses of vaccine, and two were unvaccinated. Of the six vaccinated patients, three had received their doses outside of the United States, including the source patient, a 17-year-old boy who had traveled to Beirut, Lebanon, and became ill upon his return.

Lack of Follow-Up for Chlamydia

The majority of adolescents received appropriate antibiotics for chlamydia an average of 6 days after testing positive, but few received other types of follow-up care, based on a study of 122 patients, said Dr. Loris Y. Hwang and colleagues at the University of California, San Francisco.

The 96 girls and 26 boys aged 14–19 years had tested positive for Chlamydia trachomatis infection during the study period, and 118 cases were treated. Although 97% of the adolescents received appropriate antibiotics, only 79% received safe sex counseling and 52% received partner management advice (Arch. Pediatr. Adolesc. Med. 2005;159:1162–6).

Hepatitis in Child Care Settings

Routine implementation of the hepatitis A vaccine contributed to historically low levels of infection—6/100,000 people—in Maricopa County, Ariz., said Hesha Jani Duggirala, Ph.D., of Tulane University, New Orleans, and the Maricopa County Department of Public Health, Phoenix.

Maricopa County traditionally averaged 38 hepatitis cases per 100,000 people—more than three times the national average. In a community-wide outbreak in 1997, hepatitis patients were more than six times as likely to have a history of attending or working in a child care center, compared with healthy people, and approximately 40% of cases in 1997 were linked to direct or indirect child care contact. This finding prompted the requirement of hepatitis A vaccination for all children aged 2–5 years who attended child care centers (Pediatr. Infect. Dis. J. 2005;24:974–8).

According to data from the Arizona State Immunization Information System, 23,817 children aged 2–5 years living in Maricopa County received one dose of the hepatitis A vaccine between February 1999 and June 2000; this number represented approximately 12% of children aged 2–5 years living in the county.

During 1998–2001, the age-specific incidence declined for all age groups; the steepest declines occurred among children aged 0–4 years (−91%) and aged 5–9 years (−94%).

Unlike the 1997 outbreak, few cases reported during 1998–2001 were associated with child care centers. The researchers conducted a case-control study of 72 cases and 144 age-matched controls, and found that neither direct nor indirect child care center contact was significantly associated with illness in a logistic regression analysis, although direct contact with an infected person remained a significant risk factor.

FluMist Program Cuts Illness Rates

Use of live, attentuated flu vaccine significantly reduced the rates of fever and respiratory illness in a pilot study of 185 school-aged children, said Dr. James C. King Jr. of the University of Maryland, Baltimore, and his associates.

Children at a designated test school received the live, attenuated vaccine (FluMist) prior to the 2003–2004 flu season, while children from two other schools in the community served as controls (Pediatrics 2005;116:868–73).

Overall, adults and children in the test school households reported significantly fewer fever and respiratory illness-related ambulatory physician visits, compared with controls, during a 7-day recall period near the peak influenza week in December 2003. The most significant differences between the test and control groups included the mean number of child medical visits per 100 children (5.6 in the test school group, compared with 15.3 and 18.3 in the two control groups) and the number of over-the-counter medicines purchased per 100 households (25.9 in the test group vs. 51.2 and 44.5 for the two control groups).

ST. LOUIS — A medical practice intervention reduced the incidence of Candida species from 36% among 45 control neonates admitted between Jan. 1, 1995, and June 30, 1996, to 6% among 69 neonates admitted between July 1, 1996, and December 31, 1998, said Dr. Maliha J. Shareef in a poster presented at the annual meeting of the Midwest Society for Pediatric Research.

The intervention included administration of oral nystatin every 6 hours for the first week of life, and as an accompaniment to each antibiotic course during the first 4 weeks, wrote Dr. Shareef of St. Francis Medical Center, Peoria, Ill. Modification of parameters for early extubation, early discontinuation of central lines, and use of parenteral nutrition and antibiotics also were part of the intervention.

The study included neonates weighing 750 g or less at birth, who were admitted to a neonatal ICU within the first week of life.

A retrospective analysis revealed that the intervention group experienced significantly fewer episodes of Candida after controlling for gestational age, model of delivery, and number of days of central vascular access. However, exposure to a high humidity environment was significantly associated with an increased risk of Candida sepsis within the intervention group (odds ratio 10.5).

Overall infection rates remained in the 0%–3% range during 1999–2004.

ST. LOUIS — A medical practice intervention reduced the incidence of Candida species from 36% among 45 control neonates admitted between Jan. 1, 1995, and June 30, 1996, to 6% among 69 neonates admitted between July 1, 1996, and December 31, 1998, said Dr. Maliha J. Shareef in a poster presented at the annual meeting of the Midwest Society for Pediatric Research.

The intervention included administration of oral nystatin every 6 hours for the first week of life, and as an accompaniment to each antibiotic course during the first 4 weeks, wrote Dr. Shareef of St. Francis Medical Center, Peoria, Ill. Modification of parameters for early extubation, early discontinuation of central lines, and use of parenteral nutrition and antibiotics also were part of the intervention.

The study included neonates weighing 750 g or less at birth, who were admitted to a neonatal ICU within the first week of life.

A retrospective analysis revealed that the intervention group experienced significantly fewer episodes of Candida after controlling for gestational age, model of delivery, and number of days of central vascular access. However, exposure to a high humidity environment was significantly associated with an increased risk of Candida sepsis within the intervention group (odds ratio 10.5).

Overall infection rates remained in the 0%–3% range during 1999–2004.

ST. LOUIS — A medical practice intervention reduced the incidence of Candida species from 36% among 45 control neonates admitted between Jan. 1, 1995, and June 30, 1996, to 6% among 69 neonates admitted between July 1, 1996, and December 31, 1998, said Dr. Maliha J. Shareef in a poster presented at the annual meeting of the Midwest Society for Pediatric Research.

The intervention included administration of oral nystatin every 6 hours for the first week of life, and as an accompaniment to each antibiotic course during the first 4 weeks, wrote Dr. Shareef of St. Francis Medical Center, Peoria, Ill. Modification of parameters for early extubation, early discontinuation of central lines, and use of parenteral nutrition and antibiotics also were part of the intervention.

The study included neonates weighing 750 g or less at birth, who were admitted to a neonatal ICU within the first week of life.

A retrospective analysis revealed that the intervention group experienced significantly fewer episodes of Candida after controlling for gestational age, model of delivery, and number of days of central vascular access. However, exposure to a high humidity environment was significantly associated with an increased risk of Candida sepsis within the intervention group (odds ratio 10.5).

Overall infection rates remained in the 0%–3% range during 1999–2004.