Jane Salodof MacNeil

PARK CITY, UTAH — Patients with immunobullous disease who are on systemic glucocorticoids require monitoring for bone loss and supportive interventions to prevent drug-induced osteoporosis, Dr. Kim B. Yancey told physicians at a clinical dermatology seminar sponsored by Medicis.

Glucocorticoid-induced osteoporosis primarily affects trabecular bone, he said, labeling the problem as “especially prominent” in children, adolescents, and postmenopausal women. Other adverse effects include osteonecrosis, primarily in the hip, and impairment in bone growth. He described the underlying mechanism as biologic.

The standard glucocorticoid therapy for patients with autoimmune blistering diseases starts at 1 mg/kg per day of oral prednisone. For patients requiring more aggressive treatment, Dr. Yancy, chairman of dermatology and codirector of the cutaneous immunopathology laboratory at the Medical College of Wisconsin in Milwaukee, recommended higher doses of oral prednisone plus 1 g/day of pulse methylprednisolone for 3–5 days.

Pemphigus and pemphigoid patients starting on long-term steroids should also be instructed to take 1,200–1,500 mg of elemental calcium daily and 400 IU of vitamin D twice a day. He recommended a low-sodium diet as well.

Later, after patients have started to benefit from the regimen, he advocated prescribing bisphosphonates and encouraging patients to do simple weight-bearing exercises.

“The main thing is to try to get patients to walk,” which is easier when they are not in severe pain, he said.

Dr. Yancey noted that taking medications associated with low bone mass or bone loss is an indication for bone mineral absorptiometry. He recommended ordering this test of bone density at baseline and 1 year.

For patients who have a notable history of renal stones or otherwise need to have urinary calcium levels monitored, he advocated calling in a consultant. He also suggested requesting a consultation in decisions regarding sex hormone replacement therapy (HRT) for men or women, thiazide diuretics, and calcitonin in patients who do not tolerate bisphosphonates or who have pain from compression fractures. When prescribing corticosteroids, physicians should also consider drug interactions. Some agents, such as azole antifungals and macrolide antibiotics, increase corticosteroid levels and toxicity.

PARK CITY, UTAH — Patients with immunobullous disease who are on systemic glucocorticoids require monitoring for bone loss and supportive interventions to prevent drug-induced osteoporosis, Dr. Kim B. Yancey told physicians at a clinical dermatology seminar sponsored by Medicis.

Glucocorticoid-induced osteoporosis primarily affects trabecular bone, he said, labeling the problem as “especially prominent” in children, adolescents, and postmenopausal women. Other adverse effects include osteonecrosis, primarily in the hip, and impairment in bone growth. He described the underlying mechanism as biologic.

The standard glucocorticoid therapy for patients with autoimmune blistering diseases starts at 1 mg/kg per day of oral prednisone. For patients requiring more aggressive treatment, Dr. Yancy, chairman of dermatology and codirector of the cutaneous immunopathology laboratory at the Medical College of Wisconsin in Milwaukee, recommended higher doses of oral prednisone plus 1 g/day of pulse methylprednisolone for 3–5 days.

Pemphigus and pemphigoid patients starting on long-term steroids should also be instructed to take 1,200–1,500 mg of elemental calcium daily and 400 IU of vitamin D twice a day. He recommended a low-sodium diet as well.

Later, after patients have started to benefit from the regimen, he advocated prescribing bisphosphonates and encouraging patients to do simple weight-bearing exercises.

“The main thing is to try to get patients to walk,” which is easier when they are not in severe pain, he said.

Dr. Yancey noted that taking medications associated with low bone mass or bone loss is an indication for bone mineral absorptiometry. He recommended ordering this test of bone density at baseline and 1 year.

For patients who have a notable history of renal stones or otherwise need to have urinary calcium levels monitored, he advocated calling in a consultant. He also suggested requesting a consultation in decisions regarding sex hormone replacement therapy (HRT) for men or women, thiazide diuretics, and calcitonin in patients who do not tolerate bisphosphonates or who have pain from compression fractures. When prescribing corticosteroids, physicians should also consider drug interactions. Some agents, such as azole antifungals and macrolide antibiotics, increase corticosteroid levels and toxicity.

PARK CITY, UTAH — Patients with immunobullous disease who are on systemic glucocorticoids require monitoring for bone loss and supportive interventions to prevent drug-induced osteoporosis, Dr. Kim B. Yancey told physicians at a clinical dermatology seminar sponsored by Medicis.

Glucocorticoid-induced osteoporosis primarily affects trabecular bone, he said, labeling the problem as “especially prominent” in children, adolescents, and postmenopausal women. Other adverse effects include osteonecrosis, primarily in the hip, and impairment in bone growth. He described the underlying mechanism as biologic.

The standard glucocorticoid therapy for patients with autoimmune blistering diseases starts at 1 mg/kg per day of oral prednisone. For patients requiring more aggressive treatment, Dr. Yancy, chairman of dermatology and codirector of the cutaneous immunopathology laboratory at the Medical College of Wisconsin in Milwaukee, recommended higher doses of oral prednisone plus 1 g/day of pulse methylprednisolone for 3–5 days.

Pemphigus and pemphigoid patients starting on long-term steroids should also be instructed to take 1,200–1,500 mg of elemental calcium daily and 400 IU of vitamin D twice a day. He recommended a low-sodium diet as well.

Later, after patients have started to benefit from the regimen, he advocated prescribing bisphosphonates and encouraging patients to do simple weight-bearing exercises.

“The main thing is to try to get patients to walk,” which is easier when they are not in severe pain, he said.

Dr. Yancey noted that taking medications associated with low bone mass or bone loss is an indication for bone mineral absorptiometry. He recommended ordering this test of bone density at baseline and 1 year.

For patients who have a notable history of renal stones or otherwise need to have urinary calcium levels monitored, he advocated calling in a consultant. He also suggested requesting a consultation in decisions regarding sex hormone replacement therapy (HRT) for men or women, thiazide diuretics, and calcitonin in patients who do not tolerate bisphosphonates or who have pain from compression fractures. When prescribing corticosteroids, physicians should also consider drug interactions. Some agents, such as azole antifungals and macrolide antibiotics, increase corticosteroid levels and toxicity.

PARK CITY, UTAH — If a leg ulcer worsens after debridement, the patient may have pyoderma gangrenosum, Dr. John Zone told physicians at a clinical dermatology seminar sponsored by Medicis.

“When a surgeon calls to say, 'we debrided, and it got bigger,' that is a hallmark of PG [pyoderma gangrenosum],” said Dr. Zone, chairman of the dermatology department at the University of Utah in Salt Lake City.

A rare skin disease caused by an intense, uncontrolled inflammatory response, PG presents with pathergy in about 20%–30% of patients, according to Dr. Zone. They develop PG at the site of a trauma, such as a needle stick, and the resulting ulcer worsens after debridement.

PG is one of a group of conditions (vasculitis, neoplastic disease, drug-induced hydroxyurea, necrobiosis lipoidica, panniculitis, and hypercoagulable state) that may cause a leg ulcer to not heal within 3 months of first-line treatment. “The most important thing in leg ulcers is keeping a differential diagnosis in place,” he said.

“These people won't get better until you figure out what they have,” he advised.

About 75% of PG cases are classic or ulcerative. In 50%–70% of these cases, he said PG is associated with an underlying systemic disease. Inflammatory bowel disease is the most common, followed by arthritis, hematologic disorders, hepatitis C, lupus, and sarcoidosis.

“The development of PG does not parallel systemic disease activity,” he said. PG can present in a patient who has not yet developed inflammatory bowel disease, as well as in a patient who has been cured of bowel disease.

About half of PG patients have multiple lesions, and a similar proportion have multiple episodes, according to Dr. Zone.

The morphology of ulcerative PG is distinct, a tender papulopustule ulcerating within days to a week, he said, noting that it may be associated with a fever. In classic cases with acute lesions, the ulcers are purulent, painful, and violaceous with black borders that may appear necrotic, he said. They are surrounded by erythema. The ulcer may extend beneath the skin edges with tissue destruction by intense inflammatory response.

Dr. Zone recommended gastrointestinal studies in symptomatic patients. He also advised doing the following laboratory tests: a complete blood count with differential, a chemistry panel, rheumatoid factor, serum protein electrophoresis (SPEP), hepatitis B and C antibodies, and antinuclear antibody, antineutrophil cytoplasmic antibodies, and antiphospholipid antibodies.

Treatment needs to suppress the inflammatory tissue response locally or systematically, Dr. Zone said, recommending aggressive treatments of secondary bacterial infections.

Local wound care should be nonaggressive, however. Only gentle debridement should be used, he said. He suggested silver dressings to suppress bacterial infection and allografts or xenografts to encourage granulation tissue.

There are no controlled studies of PG therapies, according to Dr. Zone. For mild disease, he suggested superpotent topical steroids, intralesional steroids, and topical tacrolimus or pimecrolimus.

In severe cases, he said prednisone is a standard initial therapy but with substantial side effects. He said he prefers to “pulse” steroids, giving 1 g intravenous methylprednisolone once a day for 5 days. “I'm 100% sure what they got, how much they got, and when they got it,” he said.

Additional options mentioned by Dr. Zone included calcineurin inhibitors, anti-inflammatory/immunosuppressive agents, tumor necrosis factor-α inhibitors, and steroid-sparing agents, in particular, cyclosporine. He cited a retrospective study in which 13 patients had complete healing with infliximab, (Am. J. Gastroenterology 2003;98:1821–6). Dr. Zone said his department also had good results but has tried the agent in only four patients.

Surgery is also an option, once the patient is immunosuppressed and inflammation is resolved, but Dr. Zone warned that there could still be a pathergic response.

PARK CITY, UTAH — If a leg ulcer worsens after debridement, the patient may have pyoderma gangrenosum, Dr. John Zone told physicians at a clinical dermatology seminar sponsored by Medicis.

“When a surgeon calls to say, 'we debrided, and it got bigger,' that is a hallmark of PG [pyoderma gangrenosum],” said Dr. Zone, chairman of the dermatology department at the University of Utah in Salt Lake City.

A rare skin disease caused by an intense, uncontrolled inflammatory response, PG presents with pathergy in about 20%–30% of patients, according to Dr. Zone. They develop PG at the site of a trauma, such as a needle stick, and the resulting ulcer worsens after debridement.

PG is one of a group of conditions (vasculitis, neoplastic disease, drug-induced hydroxyurea, necrobiosis lipoidica, panniculitis, and hypercoagulable state) that may cause a leg ulcer to not heal within 3 months of first-line treatment. “The most important thing in leg ulcers is keeping a differential diagnosis in place,” he said.

“These people won't get better until you figure out what they have,” he advised.

About 75% of PG cases are classic or ulcerative. In 50%–70% of these cases, he said PG is associated with an underlying systemic disease. Inflammatory bowel disease is the most common, followed by arthritis, hematologic disorders, hepatitis C, lupus, and sarcoidosis.

“The development of PG does not parallel systemic disease activity,” he said. PG can present in a patient who has not yet developed inflammatory bowel disease, as well as in a patient who has been cured of bowel disease.

About half of PG patients have multiple lesions, and a similar proportion have multiple episodes, according to Dr. Zone.

The morphology of ulcerative PG is distinct, a tender papulopustule ulcerating within days to a week, he said, noting that it may be associated with a fever. In classic cases with acute lesions, the ulcers are purulent, painful, and violaceous with black borders that may appear necrotic, he said. They are surrounded by erythema. The ulcer may extend beneath the skin edges with tissue destruction by intense inflammatory response.

Dr. Zone recommended gastrointestinal studies in symptomatic patients. He also advised doing the following laboratory tests: a complete blood count with differential, a chemistry panel, rheumatoid factor, serum protein electrophoresis (SPEP), hepatitis B and C antibodies, and antinuclear antibody, antineutrophil cytoplasmic antibodies, and antiphospholipid antibodies.

Treatment needs to suppress the inflammatory tissue response locally or systematically, Dr. Zone said, recommending aggressive treatments of secondary bacterial infections.

Local wound care should be nonaggressive, however. Only gentle debridement should be used, he said. He suggested silver dressings to suppress bacterial infection and allografts or xenografts to encourage granulation tissue.

There are no controlled studies of PG therapies, according to Dr. Zone. For mild disease, he suggested superpotent topical steroids, intralesional steroids, and topical tacrolimus or pimecrolimus.

In severe cases, he said prednisone is a standard initial therapy but with substantial side effects. He said he prefers to “pulse” steroids, giving 1 g intravenous methylprednisolone once a day for 5 days. “I'm 100% sure what they got, how much they got, and when they got it,” he said.

Additional options mentioned by Dr. Zone included calcineurin inhibitors, anti-inflammatory/immunosuppressive agents, tumor necrosis factor-α inhibitors, and steroid-sparing agents, in particular, cyclosporine. He cited a retrospective study in which 13 patients had complete healing with infliximab, (Am. J. Gastroenterology 2003;98:1821–6). Dr. Zone said his department also had good results but has tried the agent in only four patients.

Surgery is also an option, once the patient is immunosuppressed and inflammation is resolved, but Dr. Zone warned that there could still be a pathergic response.

PARK CITY, UTAH — If a leg ulcer worsens after debridement, the patient may have pyoderma gangrenosum, Dr. John Zone told physicians at a clinical dermatology seminar sponsored by Medicis.

“When a surgeon calls to say, 'we debrided, and it got bigger,' that is a hallmark of PG [pyoderma gangrenosum],” said Dr. Zone, chairman of the dermatology department at the University of Utah in Salt Lake City.

A rare skin disease caused by an intense, uncontrolled inflammatory response, PG presents with pathergy in about 20%–30% of patients, according to Dr. Zone. They develop PG at the site of a trauma, such as a needle stick, and the resulting ulcer worsens after debridement.

PG is one of a group of conditions (vasculitis, neoplastic disease, drug-induced hydroxyurea, necrobiosis lipoidica, panniculitis, and hypercoagulable state) that may cause a leg ulcer to not heal within 3 months of first-line treatment. “The most important thing in leg ulcers is keeping a differential diagnosis in place,” he said.

“These people won't get better until you figure out what they have,” he advised.

About 75% of PG cases are classic or ulcerative. In 50%–70% of these cases, he said PG is associated with an underlying systemic disease. Inflammatory bowel disease is the most common, followed by arthritis, hematologic disorders, hepatitis C, lupus, and sarcoidosis.

“The development of PG does not parallel systemic disease activity,” he said. PG can present in a patient who has not yet developed inflammatory bowel disease, as well as in a patient who has been cured of bowel disease.

About half of PG patients have multiple lesions, and a similar proportion have multiple episodes, according to Dr. Zone.

The morphology of ulcerative PG is distinct, a tender papulopustule ulcerating within days to a week, he said, noting that it may be associated with a fever. In classic cases with acute lesions, the ulcers are purulent, painful, and violaceous with black borders that may appear necrotic, he said. They are surrounded by erythema. The ulcer may extend beneath the skin edges with tissue destruction by intense inflammatory response.

Dr. Zone recommended gastrointestinal studies in symptomatic patients. He also advised doing the following laboratory tests: a complete blood count with differential, a chemistry panel, rheumatoid factor, serum protein electrophoresis (SPEP), hepatitis B and C antibodies, and antinuclear antibody, antineutrophil cytoplasmic antibodies, and antiphospholipid antibodies.

Treatment needs to suppress the inflammatory tissue response locally or systematically, Dr. Zone said, recommending aggressive treatments of secondary bacterial infections.

Local wound care should be nonaggressive, however. Only gentle debridement should be used, he said. He suggested silver dressings to suppress bacterial infection and allografts or xenografts to encourage granulation tissue.

There are no controlled studies of PG therapies, according to Dr. Zone. For mild disease, he suggested superpotent topical steroids, intralesional steroids, and topical tacrolimus or pimecrolimus.

In severe cases, he said prednisone is a standard initial therapy but with substantial side effects. He said he prefers to “pulse” steroids, giving 1 g intravenous methylprednisolone once a day for 5 days. “I'm 100% sure what they got, how much they got, and when they got it,” he said.

Additional options mentioned by Dr. Zone included calcineurin inhibitors, anti-inflammatory/immunosuppressive agents, tumor necrosis factor-α inhibitors, and steroid-sparing agents, in particular, cyclosporine. He cited a retrospective study in which 13 patients had complete healing with infliximab, (Am. J. Gastroenterology 2003;98:1821–6). Dr. Zone said his department also had good results but has tried the agent in only four patients.

Surgery is also an option, once the patient is immunosuppressed and inflammation is resolved, but Dr. Zone warned that there could still be a pathergic response.

SAN FRANCISCO — A new parvovirus linked to respiratory tract infections in young children is circulating in the New Haven area of Connecticut, an infectious disease laboratory at Yale University has reported.

Dr. Deniz Kesebir said the laboratory found the pathogen, human bocavirus (HBoV), in respiratory specimens from 22 (5.2%) of 426 children under the age of 2 years who presented with respiratory symptoms at hospitals and clinics associated with the university.

“To our knowledge, this is the first description of human bocavirus in the United States,” Dr. Kesebir, of Yale University, New Haven, said at the annual meeting of the Pediatric Academic Societies.

Canine and bovine forms of the virus are known to infect animals of all ages, but cause illness primarily in infants of those species, according to Dr. Kesebir.

Investigators at Karolinska University Hospital, Huddinge, Sweden, published the first report of a bocavirus infecting a human in September of last year (Proc. Natl. Acad. Sci. U S A 2005;102:12891–6). They identified the virus in 17 (3.1%) of 540 children less than 3 years old who were hospitalized for respiratory disease.

A month later, an Australian group reported finding the new pathogen in 18 (5.6%) of 324 children in the same age group who had respiratory tract infections (J. Clin. Virol. 2006;35:99–102).

Japanese investigators published a third report this March (J. Clin. Microbiol. 2006;44:1132–4). They found HBoV in 18 (5.7%) of 318 nasal swabs from children under the age of 3 years who were treated for respiratory tract infections.

Dr. Kesebir said the Yale infectious diseases laboratory headed by Dr. Jeffrey S. Kahn did a retrospective search for HBoV in children less than 2 years of age who presented with respiratory symptoms but screened negative on a direct immunofluorescence assay (DFA) for adenovirus, respiratory syncytial virus, and various influenza viruses.

All the positive samples were taken from children who presented with symptoms from October through April. Specimens collected from May through September were negative for HBoV.

The group also screened specimens from a matched control group of 96 children in an ongoing epidemiologic study of respiratory viruses in children. None of the asymptomatic children were positive for HBoV.

Rare polymorphisms in the positive samples established that the New Haven virus is identical to two HBoV genotypes identified in Sweden. Asked in an interview how the same virus got from Sweden to Yale, or vice versa, Dr. Kesebir said the question was on a long list of questions the investigators are trying to answer about the new pathogen.

“That's interesting. I don't know. It's exactly the same,” she said.

Dr. Kesebir reported on 20 of the 22 positive cases at the meeting, which is sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics. Her presentation excluded data on one child whose chart was unavailable for review and another who was coinfected with an adenovirus.

She said 15 (75%) of the remaining 20 infected children were hospitalized for up to 18 days. Nine children were hospitalized for 1–3 days and three for 4–18 days. Another three developed nosocomial infections. The other five children were seen in an emergency department or clinic. Seventeen children (85%) had a comorbidity, which she defined as asthma, eczema, bronchopulmonary dysplasia, or seizures.

For signs and symptoms, she reported that 19 children presented with rhinorrhea, 15 with fever, and 14 with cough. Ten children presented with wheezing, and six had oxygen saturation levels below 87%.

Abnormal chest x-rays were seen in 13 (72.2%) of 18 children for whom chest x-rays were available. Dr. Kesebir cited peribronchial cuffing, infiltrates, and hyperinflation.

Of particular interest were eight children who presented with gastrointestinal symptoms. Dr. Kesebir and her colleagues concluded that HBoV is associated with upper and lower respiratory tract disease in children, and speculated that it also may be the cause of gastrointestinal symptoms.

Among the future studies planned are screening of children up to age 5 for HBoV, DFA screening of positive specimens for coinfection with other viruses, and a search for the cause of gastrointestinal symptoms.

In the interview, Dr. Kesebir said the researchers do not know whether the virus jumped species or just had not been detected in humans before. “It is in adults as well, but most of the findings of symptoms are in children. … Probably the adults are carriers and less symptomatic or immune,” she said.

SAN FRANCISCO — A new parvovirus linked to respiratory tract infections in young children is circulating in the New Haven area of Connecticut, an infectious disease laboratory at Yale University has reported.

Dr. Deniz Kesebir said the laboratory found the pathogen, human bocavirus (HBoV), in respiratory specimens from 22 (5.2%) of 426 children under the age of 2 years who presented with respiratory symptoms at hospitals and clinics associated with the university.

“To our knowledge, this is the first description of human bocavirus in the United States,” Dr. Kesebir, of Yale University, New Haven, said at the annual meeting of the Pediatric Academic Societies.

Canine and bovine forms of the virus are known to infect animals of all ages, but cause illness primarily in infants of those species, according to Dr. Kesebir.

Investigators at Karolinska University Hospital, Huddinge, Sweden, published the first report of a bocavirus infecting a human in September of last year (Proc. Natl. Acad. Sci. U S A 2005;102:12891–6). They identified the virus in 17 (3.1%) of 540 children less than 3 years old who were hospitalized for respiratory disease.

A month later, an Australian group reported finding the new pathogen in 18 (5.6%) of 324 children in the same age group who had respiratory tract infections (J. Clin. Virol. 2006;35:99–102).

Japanese investigators published a third report this March (J. Clin. Microbiol. 2006;44:1132–4). They found HBoV in 18 (5.7%) of 318 nasal swabs from children under the age of 3 years who were treated for respiratory tract infections.

Dr. Kesebir said the Yale infectious diseases laboratory headed by Dr. Jeffrey S. Kahn did a retrospective search for HBoV in children less than 2 years of age who presented with respiratory symptoms but screened negative on a direct immunofluorescence assay (DFA) for adenovirus, respiratory syncytial virus, and various influenza viruses.

All the positive samples were taken from children who presented with symptoms from October through April. Specimens collected from May through September were negative for HBoV.

The group also screened specimens from a matched control group of 96 children in an ongoing epidemiologic study of respiratory viruses in children. None of the asymptomatic children were positive for HBoV.

Rare polymorphisms in the positive samples established that the New Haven virus is identical to two HBoV genotypes identified in Sweden. Asked in an interview how the same virus got from Sweden to Yale, or vice versa, Dr. Kesebir said the question was on a long list of questions the investigators are trying to answer about the new pathogen.

“That's interesting. I don't know. It's exactly the same,” she said.

Dr. Kesebir reported on 20 of the 22 positive cases at the meeting, which is sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics. Her presentation excluded data on one child whose chart was unavailable for review and another who was coinfected with an adenovirus.

She said 15 (75%) of the remaining 20 infected children were hospitalized for up to 18 days. Nine children were hospitalized for 1–3 days and three for 4–18 days. Another three developed nosocomial infections. The other five children were seen in an emergency department or clinic. Seventeen children (85%) had a comorbidity, which she defined as asthma, eczema, bronchopulmonary dysplasia, or seizures.

For signs and symptoms, she reported that 19 children presented with rhinorrhea, 15 with fever, and 14 with cough. Ten children presented with wheezing, and six had oxygen saturation levels below 87%.

Abnormal chest x-rays were seen in 13 (72.2%) of 18 children for whom chest x-rays were available. Dr. Kesebir cited peribronchial cuffing, infiltrates, and hyperinflation.

Of particular interest were eight children who presented with gastrointestinal symptoms. Dr. Kesebir and her colleagues concluded that HBoV is associated with upper and lower respiratory tract disease in children, and speculated that it also may be the cause of gastrointestinal symptoms.

Among the future studies planned are screening of children up to age 5 for HBoV, DFA screening of positive specimens for coinfection with other viruses, and a search for the cause of gastrointestinal symptoms.

In the interview, Dr. Kesebir said the researchers do not know whether the virus jumped species or just had not been detected in humans before. “It is in adults as well, but most of the findings of symptoms are in children. … Probably the adults are carriers and less symptomatic or immune,” she said.

SAN FRANCISCO — A new parvovirus linked to respiratory tract infections in young children is circulating in the New Haven area of Connecticut, an infectious disease laboratory at Yale University has reported.

Dr. Deniz Kesebir said the laboratory found the pathogen, human bocavirus (HBoV), in respiratory specimens from 22 (5.2%) of 426 children under the age of 2 years who presented with respiratory symptoms at hospitals and clinics associated with the university.

“To our knowledge, this is the first description of human bocavirus in the United States,” Dr. Kesebir, of Yale University, New Haven, said at the annual meeting of the Pediatric Academic Societies.

Canine and bovine forms of the virus are known to infect animals of all ages, but cause illness primarily in infants of those species, according to Dr. Kesebir.

Investigators at Karolinska University Hospital, Huddinge, Sweden, published the first report of a bocavirus infecting a human in September of last year (Proc. Natl. Acad. Sci. U S A 2005;102:12891–6). They identified the virus in 17 (3.1%) of 540 children less than 3 years old who were hospitalized for respiratory disease.

A month later, an Australian group reported finding the new pathogen in 18 (5.6%) of 324 children in the same age group who had respiratory tract infections (J. Clin. Virol. 2006;35:99–102).

Japanese investigators published a third report this March (J. Clin. Microbiol. 2006;44:1132–4). They found HBoV in 18 (5.7%) of 318 nasal swabs from children under the age of 3 years who were treated for respiratory tract infections.

Dr. Kesebir said the Yale infectious diseases laboratory headed by Dr. Jeffrey S. Kahn did a retrospective search for HBoV in children less than 2 years of age who presented with respiratory symptoms but screened negative on a direct immunofluorescence assay (DFA) for adenovirus, respiratory syncytial virus, and various influenza viruses.

All the positive samples were taken from children who presented with symptoms from October through April. Specimens collected from May through September were negative for HBoV.

The group also screened specimens from a matched control group of 96 children in an ongoing epidemiologic study of respiratory viruses in children. None of the asymptomatic children were positive for HBoV.

Rare polymorphisms in the positive samples established that the New Haven virus is identical to two HBoV genotypes identified in Sweden. Asked in an interview how the same virus got from Sweden to Yale, or vice versa, Dr. Kesebir said the question was on a long list of questions the investigators are trying to answer about the new pathogen.

“That's interesting. I don't know. It's exactly the same,” she said.

Dr. Kesebir reported on 20 of the 22 positive cases at the meeting, which is sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics. Her presentation excluded data on one child whose chart was unavailable for review and another who was coinfected with an adenovirus.

She said 15 (75%) of the remaining 20 infected children were hospitalized for up to 18 days. Nine children were hospitalized for 1–3 days and three for 4–18 days. Another three developed nosocomial infections. The other five children were seen in an emergency department or clinic. Seventeen children (85%) had a comorbidity, which she defined as asthma, eczema, bronchopulmonary dysplasia, or seizures.

For signs and symptoms, she reported that 19 children presented with rhinorrhea, 15 with fever, and 14 with cough. Ten children presented with wheezing, and six had oxygen saturation levels below 87%.

Abnormal chest x-rays were seen in 13 (72.2%) of 18 children for whom chest x-rays were available. Dr. Kesebir cited peribronchial cuffing, infiltrates, and hyperinflation.

Of particular interest were eight children who presented with gastrointestinal symptoms. Dr. Kesebir and her colleagues concluded that HBoV is associated with upper and lower respiratory tract disease in children, and speculated that it also may be the cause of gastrointestinal symptoms.

Among the future studies planned are screening of children up to age 5 for HBoV, DFA screening of positive specimens for coinfection with other viruses, and a search for the cause of gastrointestinal symptoms.

In the interview, Dr. Kesebir said the researchers do not know whether the virus jumped species or just had not been detected in humans before. “It is in adults as well, but most of the findings of symptoms are in children. … Probably the adults are carriers and less symptomatic or immune,” she said.

SCOTTSDALE, ARIZ. — Despite the first known survival of an unvaccinated rabies patient, prophylaxis still is the only proven defense after rabies exposure, Dr. L. Barry Seltz told physicians at a pediatric update sponsored by Phoenix Children's Hospital.

“There is no established, effective treatment,” Dr. Seltz of the University of Arizona in Tucson warned in a talk that addressed misconceptions about human rabies risk and why current thinking discourages vaccination in the gluteal area.

The treatment that saved the Wisconsin teenager (N. Engl. J. Med. 2005;352:2508–14) needs to be duplicated, according to Dr. Seltz. Vaccination can be before or after exposure, he said, but it must be done whenever there is reason to suspect exposure to the rabies virus.

Exposure is not always easy to document, however. For Dr. Seltz, a key lesson from the survival of the 15-year-old girl is the importance of taking a good patient history. “She said she had been bitten by a bat. She didn't think anything of it,” he said, crediting careful questioning by the teenager's primary care physician with unearthing this crucial piece of information after the patient became ill. She had not previously reported the bite.

Despite public fear of rabid dogs and widespread rabies in wild raccoons on the Eastern seaboard, Dr. Seltz said that most human rabies cases in the United States involve bats.

From 1990 to 2004, he said there were 47 total U.S. cases, including 10 cases acquired abroad. Of the 37 infections that originated within this country, 34 were determined to involve a bat variant of the rabies virus. Only one came from a raccoon.

“Bat bites are not dramatic. You may not recognize them when they occur,” Dr. Seltz said, warning that bat bites also can be difficult to verify. As examples of patients he would vaccinate in the absence of certain exposure, Dr. Seltz cited the person who was asleep when a bat flew into a room or a young child who cannot give a reliable history.

Other than a bite from a rabid animal, he said virus transmission can occur via “contamination of nonintact skin or mucous membranes with saliva from a rabid animal.” Cornea transplantation or solid organ transplantation from an infected donor also can transmit the virus.

“Petting a rabid animal is not an exposure. Contact with blood, urine, or feces of an infected animal is not exposure,” Dr. Seltz said.

The virus has a 20 to 60-day incubation period, but Dr. Seltz said one long-term case has been reported. That involved a boy who became ill 6 years after he emigrated from the Philippines. The rabies strain came from a dog native to the Philippines.

Ten days is adequate for observation of a dog that appears healthy after it has bitten someone in the United States, according to Dr. Seltz. If the dog has been infected, the virus will present itself quickly.

All told, six patients have survived after the onset of rabies worldwide, he said. Five had been vaccinated.

To control rabies in humans, he urged preexposure vaccination of veterinarians, animal handlers, laboratory workers, people moving to areas where dog rabies is common, and those who engage in activities that bring them in frequent contact with wildlife.

The postexposure protocol is three-pronged, he said: local wound care, active immunization, and passive immunization with immune globulin. “Cleaning [the wound] is critically important,” he said. “Animal studies show that wound cleaning can reduce the risk of rabies by 50%.”

The three vaccines currently available in the United States are all inactivated viruses. Dr. Seltz advised that they should be given in five doses on days 0, 3, 7, 14, and 28. These should not be injected in the gluteal area, he warned, as this method has been associated with lower response and prophylaxis failure.

Exposed patients should receive a 20- IU/kg dose—no more, no less—of immune globulin prepared from the plasma of immunized human donors, Dr. Seltz added. “Do not give more,” he said. “It will inhibit antibody response.”

In five cases of children who died despite receiving the full postexposure protocol for multiple bites, their wounds were not sufficiently infiltrated with immune globulin, according to Dr. Seltz. If a child has multiple wounds, he said to dilute the 20-IU/kg dose in normal saline solution and use the extra volume to make sure all the wounds are infiltrated.

“You spread it around,” he said. “Do as much as you can.”

U.S. Dogs Eclipsed As a Rabies Source

Dogs are the first animal that comes to mind when most people think about rabies, but Dr. Seltz said they are not much of a threat in the United States.

In 2004, only 94 rabid dogs were reported in this country, according to Dr. Seltz. Among domestic animals, there were more cases of rabid cats and rabid cattle: 281 and 115 animals, respectively.

Dog bites do account for most of the 50,000 human rabies cases worldwide each year, he said. In the United States, however, 92%–94% of animal rabies comes from wild animals.

The largest concentration of infected animals has been identified to date on the East Coast, Dr. Seltz reported. Nationwide, in 2004, there were 2,400 rabid raccoons, 1,800 skunks, and 1,300 bats.

Although rabid bats are far fewer than rabid raccoons, Dr. Seltz said they are more dispersed and more likely to come in contract with people. Hence, they are most often implicated in human infections. Squirrels are rarely found to be rabid, he said, as they generally do not survive the initial attack of a rabid animal.

In Arizona, where Dr. Seltz practices and the meeting took place, he said there were 169 cases of animal rabies in 2005—the most ever recorded.

These rabid animals included 84 bats, 67 skunks, 12 foxes, 2 bobcats, and 1 raccoon.

SCOTTSDALE, ARIZ. — Despite the first known survival of an unvaccinated rabies patient, prophylaxis still is the only proven defense after rabies exposure, Dr. L. Barry Seltz told physicians at a pediatric update sponsored by Phoenix Children's Hospital.

“There is no established, effective treatment,” Dr. Seltz of the University of Arizona in Tucson warned in a talk that addressed misconceptions about human rabies risk and why current thinking discourages vaccination in the gluteal area.

The treatment that saved the Wisconsin teenager (N. Engl. J. Med. 2005;352:2508–14) needs to be duplicated, according to Dr. Seltz. Vaccination can be before or after exposure, he said, but it must be done whenever there is reason to suspect exposure to the rabies virus.

Exposure is not always easy to document, however. For Dr. Seltz, a key lesson from the survival of the 15-year-old girl is the importance of taking a good patient history. “She said she had been bitten by a bat. She didn't think anything of it,” he said, crediting careful questioning by the teenager's primary care physician with unearthing this crucial piece of information after the patient became ill. She had not previously reported the bite.

Despite public fear of rabid dogs and widespread rabies in wild raccoons on the Eastern seaboard, Dr. Seltz said that most human rabies cases in the United States involve bats.

From 1990 to 2004, he said there were 47 total U.S. cases, including 10 cases acquired abroad. Of the 37 infections that originated within this country, 34 were determined to involve a bat variant of the rabies virus. Only one came from a raccoon.

“Bat bites are not dramatic. You may not recognize them when they occur,” Dr. Seltz said, warning that bat bites also can be difficult to verify. As examples of patients he would vaccinate in the absence of certain exposure, Dr. Seltz cited the person who was asleep when a bat flew into a room or a young child who cannot give a reliable history.

Other than a bite from a rabid animal, he said virus transmission can occur via “contamination of nonintact skin or mucous membranes with saliva from a rabid animal.” Cornea transplantation or solid organ transplantation from an infected donor also can transmit the virus.

“Petting a rabid animal is not an exposure. Contact with blood, urine, or feces of an infected animal is not exposure,” Dr. Seltz said.

The virus has a 20 to 60-day incubation period, but Dr. Seltz said one long-term case has been reported. That involved a boy who became ill 6 years after he emigrated from the Philippines. The rabies strain came from a dog native to the Philippines.

Ten days is adequate for observation of a dog that appears healthy after it has bitten someone in the United States, according to Dr. Seltz. If the dog has been infected, the virus will present itself quickly.

All told, six patients have survived after the onset of rabies worldwide, he said. Five had been vaccinated.

To control rabies in humans, he urged preexposure vaccination of veterinarians, animal handlers, laboratory workers, people moving to areas where dog rabies is common, and those who engage in activities that bring them in frequent contact with wildlife.

The postexposure protocol is three-pronged, he said: local wound care, active immunization, and passive immunization with immune globulin. “Cleaning [the wound] is critically important,” he said. “Animal studies show that wound cleaning can reduce the risk of rabies by 50%.”

The three vaccines currently available in the United States are all inactivated viruses. Dr. Seltz advised that they should be given in five doses on days 0, 3, 7, 14, and 28. These should not be injected in the gluteal area, he warned, as this method has been associated with lower response and prophylaxis failure.

Exposed patients should receive a 20- IU/kg dose—no more, no less—of immune globulin prepared from the plasma of immunized human donors, Dr. Seltz added. “Do not give more,” he said. “It will inhibit antibody response.”

In five cases of children who died despite receiving the full postexposure protocol for multiple bites, their wounds were not sufficiently infiltrated with immune globulin, according to Dr. Seltz. If a child has multiple wounds, he said to dilute the 20-IU/kg dose in normal saline solution and use the extra volume to make sure all the wounds are infiltrated.

“You spread it around,” he said. “Do as much as you can.”

U.S. Dogs Eclipsed As a Rabies Source

Dogs are the first animal that comes to mind when most people think about rabies, but Dr. Seltz said they are not much of a threat in the United States.

In 2004, only 94 rabid dogs were reported in this country, according to Dr. Seltz. Among domestic animals, there were more cases of rabid cats and rabid cattle: 281 and 115 animals, respectively.

Dog bites do account for most of the 50,000 human rabies cases worldwide each year, he said. In the United States, however, 92%–94% of animal rabies comes from wild animals.

The largest concentration of infected animals has been identified to date on the East Coast, Dr. Seltz reported. Nationwide, in 2004, there were 2,400 rabid raccoons, 1,800 skunks, and 1,300 bats.

Although rabid bats are far fewer than rabid raccoons, Dr. Seltz said they are more dispersed and more likely to come in contract with people. Hence, they are most often implicated in human infections. Squirrels are rarely found to be rabid, he said, as they generally do not survive the initial attack of a rabid animal.

In Arizona, where Dr. Seltz practices and the meeting took place, he said there were 169 cases of animal rabies in 2005—the most ever recorded.

These rabid animals included 84 bats, 67 skunks, 12 foxes, 2 bobcats, and 1 raccoon.

SCOTTSDALE, ARIZ. — Despite the first known survival of an unvaccinated rabies patient, prophylaxis still is the only proven defense after rabies exposure, Dr. L. Barry Seltz told physicians at a pediatric update sponsored by Phoenix Children's Hospital.

“There is no established, effective treatment,” Dr. Seltz of the University of Arizona in Tucson warned in a talk that addressed misconceptions about human rabies risk and why current thinking discourages vaccination in the gluteal area.

The treatment that saved the Wisconsin teenager (N. Engl. J. Med. 2005;352:2508–14) needs to be duplicated, according to Dr. Seltz. Vaccination can be before or after exposure, he said, but it must be done whenever there is reason to suspect exposure to the rabies virus.

Exposure is not always easy to document, however. For Dr. Seltz, a key lesson from the survival of the 15-year-old girl is the importance of taking a good patient history. “She said she had been bitten by a bat. She didn't think anything of it,” he said, crediting careful questioning by the teenager's primary care physician with unearthing this crucial piece of information after the patient became ill. She had not previously reported the bite.

Despite public fear of rabid dogs and widespread rabies in wild raccoons on the Eastern seaboard, Dr. Seltz said that most human rabies cases in the United States involve bats.

From 1990 to 2004, he said there were 47 total U.S. cases, including 10 cases acquired abroad. Of the 37 infections that originated within this country, 34 were determined to involve a bat variant of the rabies virus. Only one came from a raccoon.

“Bat bites are not dramatic. You may not recognize them when they occur,” Dr. Seltz said, warning that bat bites also can be difficult to verify. As examples of patients he would vaccinate in the absence of certain exposure, Dr. Seltz cited the person who was asleep when a bat flew into a room or a young child who cannot give a reliable history.

Other than a bite from a rabid animal, he said virus transmission can occur via “contamination of nonintact skin or mucous membranes with saliva from a rabid animal.” Cornea transplantation or solid organ transplantation from an infected donor also can transmit the virus.

“Petting a rabid animal is not an exposure. Contact with blood, urine, or feces of an infected animal is not exposure,” Dr. Seltz said.

The virus has a 20 to 60-day incubation period, but Dr. Seltz said one long-term case has been reported. That involved a boy who became ill 6 years after he emigrated from the Philippines. The rabies strain came from a dog native to the Philippines.

Ten days is adequate for observation of a dog that appears healthy after it has bitten someone in the United States, according to Dr. Seltz. If the dog has been infected, the virus will present itself quickly.

All told, six patients have survived after the onset of rabies worldwide, he said. Five had been vaccinated.

To control rabies in humans, he urged preexposure vaccination of veterinarians, animal handlers, laboratory workers, people moving to areas where dog rabies is common, and those who engage in activities that bring them in frequent contact with wildlife.

The postexposure protocol is three-pronged, he said: local wound care, active immunization, and passive immunization with immune globulin. “Cleaning [the wound] is critically important,” he said. “Animal studies show that wound cleaning can reduce the risk of rabies by 50%.”

The three vaccines currently available in the United States are all inactivated viruses. Dr. Seltz advised that they should be given in five doses on days 0, 3, 7, 14, and 28. These should not be injected in the gluteal area, he warned, as this method has been associated with lower response and prophylaxis failure.

Exposed patients should receive a 20- IU/kg dose—no more, no less—of immune globulin prepared from the plasma of immunized human donors, Dr. Seltz added. “Do not give more,” he said. “It will inhibit antibody response.”

In five cases of children who died despite receiving the full postexposure protocol for multiple bites, their wounds were not sufficiently infiltrated with immune globulin, according to Dr. Seltz. If a child has multiple wounds, he said to dilute the 20-IU/kg dose in normal saline solution and use the extra volume to make sure all the wounds are infiltrated.

“You spread it around,” he said. “Do as much as you can.”

U.S. Dogs Eclipsed As a Rabies Source

Dogs are the first animal that comes to mind when most people think about rabies, but Dr. Seltz said they are not much of a threat in the United States.

In 2004, only 94 rabid dogs were reported in this country, according to Dr. Seltz. Among domestic animals, there were more cases of rabid cats and rabid cattle: 281 and 115 animals, respectively.

Dog bites do account for most of the 50,000 human rabies cases worldwide each year, he said. In the United States, however, 92%–94% of animal rabies comes from wild animals.

The largest concentration of infected animals has been identified to date on the East Coast, Dr. Seltz reported. Nationwide, in 2004, there were 2,400 rabid raccoons, 1,800 skunks, and 1,300 bats.

Although rabid bats are far fewer than rabid raccoons, Dr. Seltz said they are more dispersed and more likely to come in contract with people. Hence, they are most often implicated in human infections. Squirrels are rarely found to be rabid, he said, as they generally do not survive the initial attack of a rabid animal.

In Arizona, where Dr. Seltz practices and the meeting took place, he said there were 169 cases of animal rabies in 2005—the most ever recorded.

These rabid animals included 84 bats, 67 skunks, 12 foxes, 2 bobcats, and 1 raccoon.

SAN DIEGO — Tumor thickness correlates with sentinel lymph node status in Merkel cell carcinoma and merits further investigation as a prognostic factor, Dr. Michael D. Alvarado reported in a poster at a symposium sponsored by the Society of Surgical Oncology.

Dr. Alvarado, of the H. Lee Moffitt Cancer Center & Research Institute in Tampa, Fla., presented a retrospective study of 62 Merkel cell carcinoma patients who underwent sentinel lymph node (SLN) biopsies at the center.

Investigators confirmed low recurrence rates in patients with negative SLN status, but found that patients with thicker tumors were more likely to have positive nodes.

Dr. Alvarado said that physicians at the cancer center began documenting thickness in 1998 to see whether it could be used to help stage patients, as is done in melanoma. “For Merkel cell carcinoma, no one really measures thickness,” he said. “The staging system is based on the diameter of the tumor and whether or not the nodes are positive.”

The study reviewed 62 patients who underwent SLN biopsies between 1994 and 2004. Among them, 41 patients had tumor thickness measurements available for review. Investigators found that 18 of the 41 patients (44%) had positive SLN. These patients also had thicker tumors. The average thickness was 8.9 mm in patients with positive nodes vs. 5.5 mm in those with negative nodes.

No positive nodes were found in five patients with tumors 2 mm or less in thickness, but “as you increase the thickness, the rate of positive sentinel lymph node goes up,” Dr. Alvarado said. (See box.)

He reported two nodal recurrences in the group of patients with tumors 2.1–4.9 mm in thickness and one regional recurrence in a patient whose tumor was in the 5–10 mm group.

One patient with a tumor thicker than 10 mm had a local recurrence. A third nodal recurrence occurred in a patient for whom tumor thickness had not been recorded.

All three patients with nodal recurrences had negative SLN status. The two local/regional recurrences were in SLN-positive patients, one of whom had radiation to both the primary and nodal basins and one of whom did not receive radiation therapy.

In an interview at the meeting, Dr. Alvarado said that further investigation is needed to determine which patients need SLN biopsy. Although Merkel cell carcinoma is often deadly if it recurs, Dr. Alvarado said that physicians must also be concerned about morbidity from the SLN procedure and the overtreatment of patients who are not likely to have a recurrence.

ELSEVIER GLOBAL MEDICAL NEWS

SAN DIEGO — Tumor thickness correlates with sentinel lymph node status in Merkel cell carcinoma and merits further investigation as a prognostic factor, Dr. Michael D. Alvarado reported in a poster at a symposium sponsored by the Society of Surgical Oncology.

Dr. Alvarado, of the H. Lee Moffitt Cancer Center & Research Institute in Tampa, Fla., presented a retrospective study of 62 Merkel cell carcinoma patients who underwent sentinel lymph node (SLN) biopsies at the center.

Investigators confirmed low recurrence rates in patients with negative SLN status, but found that patients with thicker tumors were more likely to have positive nodes.

Dr. Alvarado said that physicians at the cancer center began documenting thickness in 1998 to see whether it could be used to help stage patients, as is done in melanoma. “For Merkel cell carcinoma, no one really measures thickness,” he said. “The staging system is based on the diameter of the tumor and whether or not the nodes are positive.”

The study reviewed 62 patients who underwent SLN biopsies between 1994 and 2004. Among them, 41 patients had tumor thickness measurements available for review. Investigators found that 18 of the 41 patients (44%) had positive SLN. These patients also had thicker tumors. The average thickness was 8.9 mm in patients with positive nodes vs. 5.5 mm in those with negative nodes.

No positive nodes were found in five patients with tumors 2 mm or less in thickness, but “as you increase the thickness, the rate of positive sentinel lymph node goes up,” Dr. Alvarado said. (See box.)

He reported two nodal recurrences in the group of patients with tumors 2.1–4.9 mm in thickness and one regional recurrence in a patient whose tumor was in the 5–10 mm group.

One patient with a tumor thicker than 10 mm had a local recurrence. A third nodal recurrence occurred in a patient for whom tumor thickness had not been recorded.

All three patients with nodal recurrences had negative SLN status. The two local/regional recurrences were in SLN-positive patients, one of whom had radiation to both the primary and nodal basins and one of whom did not receive radiation therapy.

In an interview at the meeting, Dr. Alvarado said that further investigation is needed to determine which patients need SLN biopsy. Although Merkel cell carcinoma is often deadly if it recurs, Dr. Alvarado said that physicians must also be concerned about morbidity from the SLN procedure and the overtreatment of patients who are not likely to have a recurrence.

ELSEVIER GLOBAL MEDICAL NEWS

SAN DIEGO — Tumor thickness correlates with sentinel lymph node status in Merkel cell carcinoma and merits further investigation as a prognostic factor, Dr. Michael D. Alvarado reported in a poster at a symposium sponsored by the Society of Surgical Oncology.

Dr. Alvarado, of the H. Lee Moffitt Cancer Center & Research Institute in Tampa, Fla., presented a retrospective study of 62 Merkel cell carcinoma patients who underwent sentinel lymph node (SLN) biopsies at the center.

Investigators confirmed low recurrence rates in patients with negative SLN status, but found that patients with thicker tumors were more likely to have positive nodes.

Dr. Alvarado said that physicians at the cancer center began documenting thickness in 1998 to see whether it could be used to help stage patients, as is done in melanoma. “For Merkel cell carcinoma, no one really measures thickness,” he said. “The staging system is based on the diameter of the tumor and whether or not the nodes are positive.”

The study reviewed 62 patients who underwent SLN biopsies between 1994 and 2004. Among them, 41 patients had tumor thickness measurements available for review. Investigators found that 18 of the 41 patients (44%) had positive SLN. These patients also had thicker tumors. The average thickness was 8.9 mm in patients with positive nodes vs. 5.5 mm in those with negative nodes.

No positive nodes were found in five patients with tumors 2 mm or less in thickness, but “as you increase the thickness, the rate of positive sentinel lymph node goes up,” Dr. Alvarado said. (See box.)

He reported two nodal recurrences in the group of patients with tumors 2.1–4.9 mm in thickness and one regional recurrence in a patient whose tumor was in the 5–10 mm group.

One patient with a tumor thicker than 10 mm had a local recurrence. A third nodal recurrence occurred in a patient for whom tumor thickness had not been recorded.

All three patients with nodal recurrences had negative SLN status. The two local/regional recurrences were in SLN-positive patients, one of whom had radiation to both the primary and nodal basins and one of whom did not receive radiation therapy.

In an interview at the meeting, Dr. Alvarado said that further investigation is needed to determine which patients need SLN biopsy. Although Merkel cell carcinoma is often deadly if it recurs, Dr. Alvarado said that physicians must also be concerned about morbidity from the SLN procedure and the overtreatment of patients who are not likely to have a recurrence.

ELSEVIER GLOBAL MEDICAL NEWS

SANTA ANA PUEBLO, N.M. – Different populations may require different screening instruments for depression, according to investigators who compared the accuracy of methods for detecting depression in 209 terminally ill cancer patients in Japan.

The patients' total score on the Hospital Anxiety and Depression Scale (HADS), the most indirect tool in the study, was the most accurate indicator, Dr. Tatsuo Akechi reported in a poster at the annual meeting of the Academy of Psychosomatic Medicine.

Direct questions such as “Are you depressed?” and “Have you lost interest or pleasure?” were the least effective, identifying fewer than half the patients who were diagnosed with depression or an adjustment disorder.

“This is a very interesting and important finding because most Japanese people are not likely to express their emotion,” Dr. Akechi of Nagoya City University, Honshu, Japan, said in an interview at the meeting. “We can obtain much more information if we use [HADS] than just screening positive and negative,” he said.

Dr. Akechi and his colleagues conducted the study because similar ones had shown different results in North America and Britain. The North American study found asking “Are you depressed?” to be the best method for screening the terminally ill (Am. J. Psychiatry 1997;154:674–6), while British investigators found that method to be less effective (Palliat. Med. 2003;17:40–3; Gen. Hosp. Psychiatry 2004;26:384–9).

The HADS questionnaire asks indirect questions, such as whether patients feel tense or wound up, enjoy the things they used to enjoy, or can sit at ease and feel relaxed.

Dr. Akechi reported the total HADS score had a sensitivity of 80% and a specificity of 67% in the Japanese patients. The HADS depression subscale was nearly as accurate, with a sensitivity of 78% and specificity of 58%.

Though highly specific, the direct questions each had a sensitivity of only 47% when considered alone. Asking a Japanese patient both questions and considering both answers raised the sensitivity only to 68%.

“When the screening target includes both an adjustment disorder and major depression, the HADS is a more useful screening method than the single-item interviews,” the investigators concluded.

Two-thirds of the patients were men. Their mean age was 61. Dr. Akechi reported that 22% were diagnosed with depression: 33 patients with an adjustment disorder and 14 with major depression.

SANTA ANA PUEBLO, N.M. – Different populations may require different screening instruments for depression, according to investigators who compared the accuracy of methods for detecting depression in 209 terminally ill cancer patients in Japan.

The patients' total score on the Hospital Anxiety and Depression Scale (HADS), the most indirect tool in the study, was the most accurate indicator, Dr. Tatsuo Akechi reported in a poster at the annual meeting of the Academy of Psychosomatic Medicine.

Direct questions such as “Are you depressed?” and “Have you lost interest or pleasure?” were the least effective, identifying fewer than half the patients who were diagnosed with depression or an adjustment disorder.

“This is a very interesting and important finding because most Japanese people are not likely to express their emotion,” Dr. Akechi of Nagoya City University, Honshu, Japan, said in an interview at the meeting. “We can obtain much more information if we use [HADS] than just screening positive and negative,” he said.

Dr. Akechi and his colleagues conducted the study because similar ones had shown different results in North America and Britain. The North American study found asking “Are you depressed?” to be the best method for screening the terminally ill (Am. J. Psychiatry 1997;154:674–6), while British investigators found that method to be less effective (Palliat. Med. 2003;17:40–3; Gen. Hosp. Psychiatry 2004;26:384–9).

The HADS questionnaire asks indirect questions, such as whether patients feel tense or wound up, enjoy the things they used to enjoy, or can sit at ease and feel relaxed.

Dr. Akechi reported the total HADS score had a sensitivity of 80% and a specificity of 67% in the Japanese patients. The HADS depression subscale was nearly as accurate, with a sensitivity of 78% and specificity of 58%.

Though highly specific, the direct questions each had a sensitivity of only 47% when considered alone. Asking a Japanese patient both questions and considering both answers raised the sensitivity only to 68%.

“When the screening target includes both an adjustment disorder and major depression, the HADS is a more useful screening method than the single-item interviews,” the investigators concluded.

Two-thirds of the patients were men. Their mean age was 61. Dr. Akechi reported that 22% were diagnosed with depression: 33 patients with an adjustment disorder and 14 with major depression.

SANTA ANA PUEBLO, N.M. – Different populations may require different screening instruments for depression, according to investigators who compared the accuracy of methods for detecting depression in 209 terminally ill cancer patients in Japan.

The patients' total score on the Hospital Anxiety and Depression Scale (HADS), the most indirect tool in the study, was the most accurate indicator, Dr. Tatsuo Akechi reported in a poster at the annual meeting of the Academy of Psychosomatic Medicine.

Direct questions such as “Are you depressed?” and “Have you lost interest or pleasure?” were the least effective, identifying fewer than half the patients who were diagnosed with depression or an adjustment disorder.

“This is a very interesting and important finding because most Japanese people are not likely to express their emotion,” Dr. Akechi of Nagoya City University, Honshu, Japan, said in an interview at the meeting. “We can obtain much more information if we use [HADS] than just screening positive and negative,” he said.

Dr. Akechi and his colleagues conducted the study because similar ones had shown different results in North America and Britain. The North American study found asking “Are you depressed?” to be the best method for screening the terminally ill (Am. J. Psychiatry 1997;154:674–6), while British investigators found that method to be less effective (Palliat. Med. 2003;17:40–3; Gen. Hosp. Psychiatry 2004;26:384–9).

The HADS questionnaire asks indirect questions, such as whether patients feel tense or wound up, enjoy the things they used to enjoy, or can sit at ease and feel relaxed.

Dr. Akechi reported the total HADS score had a sensitivity of 80% and a specificity of 67% in the Japanese patients. The HADS depression subscale was nearly as accurate, with a sensitivity of 78% and specificity of 58%.

Though highly specific, the direct questions each had a sensitivity of only 47% when considered alone. Asking a Japanese patient both questions and considering both answers raised the sensitivity only to 68%.

“When the screening target includes both an adjustment disorder and major depression, the HADS is a more useful screening method than the single-item interviews,” the investigators concluded.

Two-thirds of the patients were men. Their mean age was 61. Dr. Akechi reported that 22% were diagnosed with depression: 33 patients with an adjustment disorder and 14 with major depression.

PARK CITY, UTAH — Facial reconstruction after tumor removal should be guided by the surgical defect rather than presurgical clinical appearance, Dr. Andrew J. Kaufman advised at a symposium sponsored by the American Society of Ophthalmic Plastic and Reconstructive Surgery.

Reconstruction is successful "when the aesthetic and functional goals are met," said Dr. Kaufman, a Mohs surgeon in Thousand Oaks, Calif.

Before proceeding, the surgeon should set functional goals for the patient, said Dr. Kaufman, also of the University of California, Los Angeles. To choose the "correct" repair for meeting those goals, he recommended doing a thorough preoperative evaluation.

This would include consideration of patient characteristics such as age, anxiety level, concurrent medical problems, and type of cancer. Older patients, for example, generally have more loose skin available for repairs.

Other factors to consider beyond size, depth, and location of the wound are whether the function, surface, and structure are intact, Dr. Kaufman said.

The surgeon should determine whether the wound is concave or convex and whether the skin is sebaceous or thin. Concave areas heal well with a graft, and convex areas do better with a flap. Sebaceous skin does not hide a scar as well as thin skin, he said at the meeting, which also was sponsored by the American Society for Dermatologic Surgery and the American Academy of Facial Plastic and Reconstructive Surgery.

Adjacent loose tissue also should be taken into account. "Adjacent tissue is the bank or reserve from which to borrow for repairs," he said, adding that surgeons should "avoid distortion or deviation of free margins and anatomic margins at all costs."

Dr. Kaufman recommended trying to reconstruct within cosmetic units or subunits. "Consider closing multiunit defects in individual defects," he said, suggesting that incision lines be placed at junctions between units/subunits or rhytids/furrows.

When it is appropriate, the wound should be allowed to heal by secondary intention. For big defects, consider three options: secondary intention, graft, or making the defect smaller (closing it in subunits or using combination repairs).

Consider all options for repair. "A lot of time people get locked into an idea," he said, warning that the first choice may not be the best. Assess what is missing and where its replacement is going to come from. "Look to see: Where is the loose skin, and where are the relaxed skin tension lines?" said Dr. Kaufman.

"Don't get in over your head," he cautioned. Each surgeon should build on experience, starting with complex repairs, going on to small flaps and grafts, and later attempting more advanced flaps. If uncomfortable with a reconstruction, refer it to another surgeon.

He went on to offer the following advice:

▸ Distorting an anatomic landmark is worse than having a longer scar.

▸ Keeping incision lines between cosmetic units or subunits wherever possible will help, he said, "to hide scar in shadows caused by concavities and convexities."

▸ Flaps usually are better than grafts for matching color, texture, and thickness, but grafts "work well in thin, shiny skin and in reconstruction of complete units or subunits," he noted.

▸ When doing a repair, always make sure the margins are clean before starting.

Surgeons can enhance patients' experience by playing classical music, sending them home with wound supplies, and calling to see how they are recovering. "Patients love it. They don't expect doctors to call them at home," he said. "By doing those kinds of things, you put in their mind that they are going to have good results."

'Don't get in over your head.' If you're uncomfortable with a reconstruction, refer it to another surgeon. DR. KAUFMAN

PARK CITY, UTAH — Facial reconstruction after tumor removal should be guided by the surgical defect rather than presurgical clinical appearance, Dr. Andrew J. Kaufman advised at a symposium sponsored by the American Society of Ophthalmic Plastic and Reconstructive Surgery.

Reconstruction is successful "when the aesthetic and functional goals are met," said Dr. Kaufman, a Mohs surgeon in Thousand Oaks, Calif.

Before proceeding, the surgeon should set functional goals for the patient, said Dr. Kaufman, also of the University of California, Los Angeles. To choose the "correct" repair for meeting those goals, he recommended doing a thorough preoperative evaluation.

This would include consideration of patient characteristics such as age, anxiety level, concurrent medical problems, and type of cancer. Older patients, for example, generally have more loose skin available for repairs.

Other factors to consider beyond size, depth, and location of the wound are whether the function, surface, and structure are intact, Dr. Kaufman said.

The surgeon should determine whether the wound is concave or convex and whether the skin is sebaceous or thin. Concave areas heal well with a graft, and convex areas do better with a flap. Sebaceous skin does not hide a scar as well as thin skin, he said at the meeting, which also was sponsored by the American Society for Dermatologic Surgery and the American Academy of Facial Plastic and Reconstructive Surgery.

Adjacent loose tissue also should be taken into account. "Adjacent tissue is the bank or reserve from which to borrow for repairs," he said, adding that surgeons should "avoid distortion or deviation of free margins and anatomic margins at all costs."

Dr. Kaufman recommended trying to reconstruct within cosmetic units or subunits. "Consider closing multiunit defects in individual defects," he said, suggesting that incision lines be placed at junctions between units/subunits or rhytids/furrows.

When it is appropriate, the wound should be allowed to heal by secondary intention. For big defects, consider three options: secondary intention, graft, or making the defect smaller (closing it in subunits or using combination repairs).

Consider all options for repair. "A lot of time people get locked into an idea," he said, warning that the first choice may not be the best. Assess what is missing and where its replacement is going to come from. "Look to see: Where is the loose skin, and where are the relaxed skin tension lines?" said Dr. Kaufman.

"Don't get in over your head," he cautioned. Each surgeon should build on experience, starting with complex repairs, going on to small flaps and grafts, and later attempting more advanced flaps. If uncomfortable with a reconstruction, refer it to another surgeon.

He went on to offer the following advice:

▸ Distorting an anatomic landmark is worse than having a longer scar.

▸ Keeping incision lines between cosmetic units or subunits wherever possible will help, he said, "to hide scar in shadows caused by concavities and convexities."

▸ Flaps usually are better than grafts for matching color, texture, and thickness, but grafts "work well in thin, shiny skin and in reconstruction of complete units or subunits," he noted.

▸ When doing a repair, always make sure the margins are clean before starting.

Surgeons can enhance patients' experience by playing classical music, sending them home with wound supplies, and calling to see how they are recovering. "Patients love it. They don't expect doctors to call them at home," he said. "By doing those kinds of things, you put in their mind that they are going to have good results."

'Don't get in over your head.' If you're uncomfortable with a reconstruction, refer it to another surgeon. DR. KAUFMAN

PARK CITY, UTAH — Facial reconstruction after tumor removal should be guided by the surgical defect rather than presurgical clinical appearance, Dr. Andrew J. Kaufman advised at a symposium sponsored by the American Society of Ophthalmic Plastic and Reconstructive Surgery.

Reconstruction is successful "when the aesthetic and functional goals are met," said Dr. Kaufman, a Mohs surgeon in Thousand Oaks, Calif.

Before proceeding, the surgeon should set functional goals for the patient, said Dr. Kaufman, also of the University of California, Los Angeles. To choose the "correct" repair for meeting those goals, he recommended doing a thorough preoperative evaluation.

This would include consideration of patient characteristics such as age, anxiety level, concurrent medical problems, and type of cancer. Older patients, for example, generally have more loose skin available for repairs.

Other factors to consider beyond size, depth, and location of the wound are whether the function, surface, and structure are intact, Dr. Kaufman said.

The surgeon should determine whether the wound is concave or convex and whether the skin is sebaceous or thin. Concave areas heal well with a graft, and convex areas do better with a flap. Sebaceous skin does not hide a scar as well as thin skin, he said at the meeting, which also was sponsored by the American Society for Dermatologic Surgery and the American Academy of Facial Plastic and Reconstructive Surgery.

Adjacent loose tissue also should be taken into account. "Adjacent tissue is the bank or reserve from which to borrow for repairs," he said, adding that surgeons should "avoid distortion or deviation of free margins and anatomic margins at all costs."

Dr. Kaufman recommended trying to reconstruct within cosmetic units or subunits. "Consider closing multiunit defects in individual defects," he said, suggesting that incision lines be placed at junctions between units/subunits or rhytids/furrows.

When it is appropriate, the wound should be allowed to heal by secondary intention. For big defects, consider three options: secondary intention, graft, or making the defect smaller (closing it in subunits or using combination repairs).

Consider all options for repair. "A lot of time people get locked into an idea," he said, warning that the first choice may not be the best. Assess what is missing and where its replacement is going to come from. "Look to see: Where is the loose skin, and where are the relaxed skin tension lines?" said Dr. Kaufman.

"Don't get in over your head," he cautioned. Each surgeon should build on experience, starting with complex repairs, going on to small flaps and grafts, and later attempting more advanced flaps. If uncomfortable with a reconstruction, refer it to another surgeon.

He went on to offer the following advice:

▸ Distorting an anatomic landmark is worse than having a longer scar.

▸ Keeping incision lines between cosmetic units or subunits wherever possible will help, he said, "to hide scar in shadows caused by concavities and convexities."

▸ Flaps usually are better than grafts for matching color, texture, and thickness, but grafts "work well in thin, shiny skin and in reconstruction of complete units or subunits," he noted.

▸ When doing a repair, always make sure the margins are clean before starting.

Surgeons can enhance patients' experience by playing classical music, sending them home with wound supplies, and calling to see how they are recovering. "Patients love it. They don't expect doctors to call them at home," he said. "By doing those kinds of things, you put in their mind that they are going to have good results."

'Don't get in over your head.' If you're uncomfortable with a reconstruction, refer it to another surgeon. DR. KAUFMAN

PARK CITY, UTAH — Treat Merkel cell carcinoma aggressively—recurrences are always fatal, Dr. Mary E. Maloney told physicians at a clinical dermatology seminar sponsored by Medicis.

"You have one chance to cure this disease. When treating a primary tumor, you use whatever you can to get a cure," counseled Dr. Maloney, director of dermatologic surgery at the University of Massachusetts, Worcester.

While stage I disease has a 100% survival rate, she said mortality is 11% for stage II disease. Should there be distant metastasis, the hallmark of stage III disease, mortality climbs to 100% (J. Clin. Oncol. 1988;6:1863–73).

By the time a recurrence is diagnosed, the disease has already spread, according to Dr. Maloney. "We don't have the luxury of recurrence," she said, describing this rare skin cancer as "a very difficult tumor to diagnose and to cure."

Merkel cell carcinoma strikes men and women equally, she said, putting the incidence at 500 cases per year. Though the age range is 15–97 years, the average is 69 years, as most patients are older.

Most tumors occur in sun-exposed areas, according to Dr. Maloney. Immunosuppression also appears to play a role, as Merkel cell carcinoma is more common in transplant patients and people with chronic lymphocytic leukemia than in the general population.

Because they can appear benign when small, these rare tumors are often 2 cm at presentation, said Dr. Maloney. They range from pink to red, and 20% have palpable nodes at presentation.

Ruling out other carcinomas is the clinician's first step, she said, recommending that the physical examination include a lymph node exam with careful palpitation of the entire area for deep nodules and a careful exam for satellitosis.

Electron microscopy and immunohistochemistry are important in making the diagnosis, she added. Positive staining for cytokeratins 8, 18, 19, and 20 would be a key marker, along with neuron-specific enolase, synaptophysin, chromogranin, and neurofilaments.

Neither size nor duration is a prognostic factor, according to Dr. Maloney, but lymph node involvement and tumor location are predictive. She estimated survival as 70%–80% for those with lymph node-negative tumors and less than 48% for those that are lymph node-positive. Survival is higher for lesions on a limb than on the trunk.

Increasingly, Mohs surgery is being used for Merkel cell carcinoma, according to Dr. Maloney. She said the standard Mohs technique allows for true margin control and removal of all inflammation. She advocated removing an additional margin, usually about 1 cm, after all clear sections are obtained.

Dr. Maloney also recommended adjunctive radiation treatment to improve local and regional control. Retrospective studies have not shown it to reduce mortality, but she predicted that when prospective studies are done, they will show improved survival.

With truncal lesions, she advocated adjunctive radiation therapy whether a sentinel node biopsy shows the patient's lymph nodes to be positive or negative. If the nodes are positive, she said to do full node dissection as well.

When lesions are not on the trunk, her advice is the same. She disagreed with physicians who advocate no further therapy if biopsy shows sentinel nodes to be negative. "We have one chance to cure this disease," she reiterated. "Therefore, I believe radiating … is the best shot at curing the patient."

Chemotherapy is also an option, but she cautioned that it is not life-saving. Dr. Maloney said 42 different regimens have been tried, with response rates ranging from 50% to 65%. Yet survival with chemotherapy is only 9 months for patients with metastatic disease.

"While Merkel cell appears chemosensitive, it is seldom cured with chemotherapy," she said.

PARK CITY, UTAH — Treat Merkel cell carcinoma aggressively—recurrences are always fatal, Dr. Mary E. Maloney told physicians at a clinical dermatology seminar sponsored by Medicis.

"You have one chance to cure this disease. When treating a primary tumor, you use whatever you can to get a cure," counseled Dr. Maloney, director of dermatologic surgery at the University of Massachusetts, Worcester.

While stage I disease has a 100% survival rate, she said mortality is 11% for stage II disease. Should there be distant metastasis, the hallmark of stage III disease, mortality climbs to 100% (J. Clin. Oncol. 1988;6:1863–73).

By the time a recurrence is diagnosed, the disease has already spread, according to Dr. Maloney. "We don't have the luxury of recurrence," she said, describing this rare skin cancer as "a very difficult tumor to diagnose and to cure."

Merkel cell carcinoma strikes men and women equally, she said, putting the incidence at 500 cases per year. Though the age range is 15–97 years, the average is 69 years, as most patients are older.

Most tumors occur in sun-exposed areas, according to Dr. Maloney. Immunosuppression also appears to play a role, as Merkel cell carcinoma is more common in transplant patients and people with chronic lymphocytic leukemia than in the general population.

Because they can appear benign when small, these rare tumors are often 2 cm at presentation, said Dr. Maloney. They range from pink to red, and 20% have palpable nodes at presentation.

Ruling out other carcinomas is the clinician's first step, she said, recommending that the physical examination include a lymph node exam with careful palpitation of the entire area for deep nodules and a careful exam for satellitosis.

Electron microscopy and immunohistochemistry are important in making the diagnosis, she added. Positive staining for cytokeratins 8, 18, 19, and 20 would be a key marker, along with neuron-specific enolase, synaptophysin, chromogranin, and neurofilaments.

Neither size nor duration is a prognostic factor, according to Dr. Maloney, but lymph node involvement and tumor location are predictive. She estimated survival as 70%–80% for those with lymph node-negative tumors and less than 48% for those that are lymph node-positive. Survival is higher for lesions on a limb than on the trunk.

Increasingly, Mohs surgery is being used for Merkel cell carcinoma, according to Dr. Maloney. She said the standard Mohs technique allows for true margin control and removal of all inflammation. She advocated removing an additional margin, usually about 1 cm, after all clear sections are obtained.

Dr. Maloney also recommended adjunctive radiation treatment to improve local and regional control. Retrospective studies have not shown it to reduce mortality, but she predicted that when prospective studies are done, they will show improved survival.

With truncal lesions, she advocated adjunctive radiation therapy whether a sentinel node biopsy shows the patient's lymph nodes to be positive or negative. If the nodes are positive, she said to do full node dissection as well.

When lesions are not on the trunk, her advice is the same. She disagreed with physicians who advocate no further therapy if biopsy shows sentinel nodes to be negative. "We have one chance to cure this disease," she reiterated. "Therefore, I believe radiating … is the best shot at curing the patient."

Chemotherapy is also an option, but she cautioned that it is not life-saving. Dr. Maloney said 42 different regimens have been tried, with response rates ranging from 50% to 65%. Yet survival with chemotherapy is only 9 months for patients with metastatic disease.

"While Merkel cell appears chemosensitive, it is seldom cured with chemotherapy," she said.

PARK CITY, UTAH — Treat Merkel cell carcinoma aggressively—recurrences are always fatal, Dr. Mary E. Maloney told physicians at a clinical dermatology seminar sponsored by Medicis.

"You have one chance to cure this disease. When treating a primary tumor, you use whatever you can to get a cure," counseled Dr. Maloney, director of dermatologic surgery at the University of Massachusetts, Worcester.

While stage I disease has a 100% survival rate, she said mortality is 11% for stage II disease. Should there be distant metastasis, the hallmark of stage III disease, mortality climbs to 100% (J. Clin. Oncol. 1988;6:1863–73).

By the time a recurrence is diagnosed, the disease has already spread, according to Dr. Maloney. "We don't have the luxury of recurrence," she said, describing this rare skin cancer as "a very difficult tumor to diagnose and to cure."

Merkel cell carcinoma strikes men and women equally, she said, putting the incidence at 500 cases per year. Though the age range is 15–97 years, the average is 69 years, as most patients are older.

Most tumors occur in sun-exposed areas, according to Dr. Maloney. Immunosuppression also appears to play a role, as Merkel cell carcinoma is more common in transplant patients and people with chronic lymphocytic leukemia than in the general population.

Because they can appear benign when small, these rare tumors are often 2 cm at presentation, said Dr. Maloney. They range from pink to red, and 20% have palpable nodes at presentation.

Ruling out other carcinomas is the clinician's first step, she said, recommending that the physical examination include a lymph node exam with careful palpitation of the entire area for deep nodules and a careful exam for satellitosis.

Electron microscopy and immunohistochemistry are important in making the diagnosis, she added. Positive staining for cytokeratins 8, 18, 19, and 20 would be a key marker, along with neuron-specific enolase, synaptophysin, chromogranin, and neurofilaments.

Neither size nor duration is a prognostic factor, according to Dr. Maloney, but lymph node involvement and tumor location are predictive. She estimated survival as 70%–80% for those with lymph node-negative tumors and less than 48% for those that are lymph node-positive. Survival is higher for lesions on a limb than on the trunk.

Increasingly, Mohs surgery is being used for Merkel cell carcinoma, according to Dr. Maloney. She said the standard Mohs technique allows for true margin control and removal of all inflammation. She advocated removing an additional margin, usually about 1 cm, after all clear sections are obtained.

Dr. Maloney also recommended adjunctive radiation treatment to improve local and regional control. Retrospective studies have not shown it to reduce mortality, but she predicted that when prospective studies are done, they will show improved survival.

With truncal lesions, she advocated adjunctive radiation therapy whether a sentinel node biopsy shows the patient's lymph nodes to be positive or negative. If the nodes are positive, she said to do full node dissection as well.

When lesions are not on the trunk, her advice is the same. She disagreed with physicians who advocate no further therapy if biopsy shows sentinel nodes to be negative. "We have one chance to cure this disease," she reiterated. "Therefore, I believe radiating … is the best shot at curing the patient."

Chemotherapy is also an option, but she cautioned that it is not life-saving. Dr. Maloney said 42 different regimens have been tried, with response rates ranging from 50% to 65%. Yet survival with chemotherapy is only 9 months for patients with metastatic disease.

"While Merkel cell appears chemosensitive, it is seldom cured with chemotherapy," she said.

PARK CITY, UTAH — Contour threads offer a minimally invasive alternative to plastic surgery for patients who cannot opt for a full facelift, Dr. William H. Truswell said at a symposium sponsored by the American Society of Ophthalmic Plastic and Reconstructive Surgery.

Surgery is the standard "to rejuvenate the face, but there are people who, for money or time restraints, can't have a facelift. This is an alternative I can offer them," said Dr. Truswell, a facial plastic surgeon in Northampton, Mass.

The Food and Drug Administration approved the barbed sutures for midface, brow, and neck suspension in September 2004.

Dr. Truswell estimated the subjective improvement as 60%–70% of that provided by a facelift. He suggested that the threads are well suited for minimal repairs on the "early" aging face and for a postfacelift "tune-up."

"Virtually anybody with an aging face is a candidate," he said, adding that the widely publicized procedure has drawn patients to his practice. "I have gotten more facelifts out of advertising this," he said at the meeting, which also was sponsored by the American Society for Dermatologic Surgery and the American Academy of Facial Plastic and Reconstructive Surgery.

Dr. Truswell described his first 2 months' experience with the patented, trademarked product, which is made of polypropylene. He said that he found the thread lift procedure easy to learn, and that he could do an entire face in 40 minutes.

How long the improvements will last is an open question, he noted, as the procedure is too new for him to say with certainty. The process causes some patient discomfort and requires about a week of downtime.

Two weeks before the thread lift, Dr. Truswell advises patients to stop nonsteroidal anti-inflammatory drugs. For preoperative medications, he suggests prescribing diazepam (Valium) 5 mg, oxycodone/acetaminophen (Percocet), and dimenhydrinate (Dramamine) 25 mg.

"With oral medications they tolerate it very well," he said, noting that patients must be driven to and from the office.

For 2 weeks following the procedure, patients are told not to pull down on the skin, drink from straws, strain, talk a lot, or touch the face (splashing with water is okay, but the face should be patted dry). If patients cry, cough, or sneeze, they should hold the brow area up, added Dr. Truswell.

"Men should shave upward only," he said.

All patients are told to use cold compresses to reduce swelling and to keep the head elevated above the heart for the first 48 hours. Dr. Truswell also tells them to use two pillows when resting, and he recommends that they use a donut or travel pillow at night to keep the face straight up—a precaution against pressing on the threads.

Dr. Truswell warns patients that they will look "overcorrected" for 7–14 days, but advises that most of this will resolve in the first week. "There will be some "bunching" near the incision site that usually resolves in 1 week," he said, adding that he schedules follow-up appointments 2, 7, and 14 days post procedure.

As for possible complications, Dr. Truswell listed thread failure, migration, exposure, and palpable threads. Abrupt changes in suture depth will appear as lumps and depressions once the tissue has been telescoped during contouring, he said.

"The skin should progress from smooth and tight where the suture exits to corrugated and lax at the hairline," he said.

He warned against placing a suture too deep in the forehead; gathering of the skin will be inhibited. "Avoid 'V' placement of sutures, as 'U' placement distributes the tension more broadly," he said.

Dr. Truswell said that his talk was supported by Surgical Specialties Corp., the manufacturer of Contour Threads.

PARK CITY, UTAH — Contour threads offer a minimally invasive alternative to plastic surgery for patients who cannot opt for a full facelift, Dr. William H. Truswell said at a symposium sponsored by the American Society of Ophthalmic Plastic and Reconstructive Surgery.

Surgery is the standard "to rejuvenate the face, but there are people who, for money or time restraints, can't have a facelift. This is an alternative I can offer them," said Dr. Truswell, a facial plastic surgeon in Northampton, Mass.

The Food and Drug Administration approved the barbed sutures for midface, brow, and neck suspension in September 2004.

Dr. Truswell estimated the subjective improvement as 60%–70% of that provided by a facelift. He suggested that the threads are well suited for minimal repairs on the "early" aging face and for a postfacelift "tune-up."

"Virtually anybody with an aging face is a candidate," he said, adding that the widely publicized procedure has drawn patients to his practice. "I have gotten more facelifts out of advertising this," he said at the meeting, which also was sponsored by the American Society for Dermatologic Surgery and the American Academy of Facial Plastic and Reconstructive Surgery.

Dr. Truswell described his first 2 months' experience with the patented, trademarked product, which is made of polypropylene. He said that he found the thread lift procedure easy to learn, and that he could do an entire face in 40 minutes.

How long the improvements will last is an open question, he noted, as the procedure is too new for him to say with certainty. The process causes some patient discomfort and requires about a week of downtime.

Two weeks before the thread lift, Dr. Truswell advises patients to stop nonsteroidal anti-inflammatory drugs. For preoperative medications, he suggests prescribing diazepam (Valium) 5 mg, oxycodone/acetaminophen (Percocet), and dimenhydrinate (Dramamine) 25 mg.

"With oral medications they tolerate it very well," he said, noting that patients must be driven to and from the office.

For 2 weeks following the procedure, patients are told not to pull down on the skin, drink from straws, strain, talk a lot, or touch the face (splashing with water is okay, but the face should be patted dry). If patients cry, cough, or sneeze, they should hold the brow area up, added Dr. Truswell.

"Men should shave upward only," he said.

All patients are told to use cold compresses to reduce swelling and to keep the head elevated above the heart for the first 48 hours. Dr. Truswell also tells them to use two pillows when resting, and he recommends that they use a donut or travel pillow at night to keep the face straight up—a precaution against pressing on the threads.

Dr. Truswell warns patients that they will look "overcorrected" for 7–14 days, but advises that most of this will resolve in the first week. "There will be some "bunching" near the incision site that usually resolves in 1 week," he said, adding that he schedules follow-up appointments 2, 7, and 14 days post procedure.

As for possible complications, Dr. Truswell listed thread failure, migration, exposure, and palpable threads. Abrupt changes in suture depth will appear as lumps and depressions once the tissue has been telescoped during contouring, he said.

"The skin should progress from smooth and tight where the suture exits to corrugated and lax at the hairline," he said.

He warned against placing a suture too deep in the forehead; gathering of the skin will be inhibited. "Avoid 'V' placement of sutures, as 'U' placement distributes the tension more broadly," he said.

Dr. Truswell said that his talk was supported by Surgical Specialties Corp., the manufacturer of Contour Threads.

PARK CITY, UTAH — Contour threads offer a minimally invasive alternative to plastic surgery for patients who cannot opt for a full facelift, Dr. William H. Truswell said at a symposium sponsored by the American Society of Ophthalmic Plastic and Reconstructive Surgery.

Surgery is the standard "to rejuvenate the face, but there are people who, for money or time restraints, can't have a facelift. This is an alternative I can offer them," said Dr. Truswell, a facial plastic surgeon in Northampton, Mass.

The Food and Drug Administration approved the barbed sutures for midface, brow, and neck suspension in September 2004.

Dr. Truswell estimated the subjective improvement as 60%–70% of that provided by a facelift. He suggested that the threads are well suited for minimal repairs on the "early" aging face and for a postfacelift "tune-up."

"Virtually anybody with an aging face is a candidate," he said, adding that the widely publicized procedure has drawn patients to his practice. "I have gotten more facelifts out of advertising this," he said at the meeting, which also was sponsored by the American Society for Dermatologic Surgery and the American Academy of Facial Plastic and Reconstructive Surgery.

Dr. Truswell described his first 2 months' experience with the patented, trademarked product, which is made of polypropylene. He said that he found the thread lift procedure easy to learn, and that he could do an entire face in 40 minutes.

How long the improvements will last is an open question, he noted, as the procedure is too new for him to say with certainty. The process causes some patient discomfort and requires about a week of downtime.

Two weeks before the thread lift, Dr. Truswell advises patients to stop nonsteroidal anti-inflammatory drugs. For preoperative medications, he suggests prescribing diazepam (Valium) 5 mg, oxycodone/acetaminophen (Percocet), and dimenhydrinate (Dramamine) 25 mg.

"With oral medications they tolerate it very well," he said, noting that patients must be driven to and from the office.

For 2 weeks following the procedure, patients are told not to pull down on the skin, drink from straws, strain, talk a lot, or touch the face (splashing with water is okay, but the face should be patted dry). If patients cry, cough, or sneeze, they should hold the brow area up, added Dr. Truswell.

"Men should shave upward only," he said.

All patients are told to use cold compresses to reduce swelling and to keep the head elevated above the heart for the first 48 hours. Dr. Truswell also tells them to use two pillows when resting, and he recommends that they use a donut or travel pillow at night to keep the face straight up—a precaution against pressing on the threads.

Dr. Truswell warns patients that they will look "overcorrected" for 7–14 days, but advises that most of this will resolve in the first week. "There will be some "bunching" near the incision site that usually resolves in 1 week," he said, adding that he schedules follow-up appointments 2, 7, and 14 days post procedure.

As for possible complications, Dr. Truswell listed thread failure, migration, exposure, and palpable threads. Abrupt changes in suture depth will appear as lumps and depressions once the tissue has been telescoped during contouring, he said.

"The skin should progress from smooth and tight where the suture exits to corrugated and lax at the hairline," he said.

He warned against placing a suture too deep in the forehead; gathering of the skin will be inhibited. "Avoid 'V' placement of sutures, as 'U' placement distributes the tension more broadly," he said.

Dr. Truswell said that his talk was supported by Surgical Specialties Corp., the manufacturer of Contour Threads.

SAN DIEGO — Pharmacologic prophylaxis can sharply reduce the risk of deep venous thrombosis when cancer patients undergo surgery, Dr. Michael J. Leonardi said at a symposium sponsored by the Society of Surgical Oncology.

The deep venous thrombosis (DVT) rate falls from 35% without prophylaxis to 12% when surgical oncology patients are given heparin, according to Dr. Leonardi of the University of California, Los Angeles. A combination of mechanical prophylaxis with heparin further reduces the DVT rate to just 5%.

“Cancer patients need some form of prophylaxis,” Dr. Leonardi said in an interview after his review of data from dozens of randomized, controlled trials. “If bleeding risk is not a concern,” he added, “pharmacological prophylaxis is better than mechanical prophylaxis, and combination therapy has been shown to be even more effective.”

Dr. Leonardi and his colleagues in the UCLA surgery department searched the Medline database for English-language trials and found 55 randomized controlled trials published from 1966 to 2005 on DVT prophylaxis in general surgery. Among these, 26 trials reported outcomes for 7,639 cancer patients, Dr. Leonardi said.

Colorectal and major abdominal surgical procedures accounted for 39% and 38% of cases, respectively. Upper gastrointestinal and small bowel operations were the next most common at 11%, followed by gynecologic surgery at 3%. Biliary, pancreatic, urologic, and noncardiac thoracic cancers each accounted for just 1% of the surgical procedures in Dr. Leonardi's presentation.

After a review of the wide variety of patients and surgeons in these trials, he said the best prophylaxis for individual cancers is still not known. For example, not even one randomized controlled trial was found that evaluated DVT prophylaxis in breast cancer patients. The incidence of DVT in breast cancer “is probably not as high as in some other cancers, but because breast cancer is so common a lot of DVTs are associated with it,” he said.

Among the findings from the analysis, Dr. Leonardi reported that:

▸ DVT rates vary with the detection method used. Venography was the most sensitive method, and ultrasound the least sensitive.

▸ Higher heparin doses are more effective than lower doses. DVT rates were 8% for higher doses and 14% for lower doses of the forms of heparin in 17 trials with a total of 4,005 patients.

▸ Low-molecular-weight heparin and low-weight unfractionated heparin are equally effective. Both cut DVT rates to 8% at high doses in the 17 trials just cited. At low doses, the rate was 14% for low-molecular-weight heparin and 13% for low-weight unfractionated heparin.

▸ Heparin reduces the rate of proximal DVTs. The rate went from 41% to 13% in nine trials reporting on 284 patients with DVTs. Location was unaffected by the use of low-molecular-weight heparin vs. low-weight unfractionated heparin.

▸ Major complications occur in only 1% of cases with pharmacologic prophylaxis. Based on seven trials, minor complications occurred in 10% of patients and major complications in 1%, he reported. There was no difference between low-molecular-weight heparin and low-weight unfractionated heparin. In four trials, 3% of patients discontinued prophylaxis.

SAN DIEGO — Pharmacologic prophylaxis can sharply reduce the risk of deep venous thrombosis when cancer patients undergo surgery, Dr. Michael J. Leonardi said at a symposium sponsored by the Society of Surgical Oncology.

The deep venous thrombosis (DVT) rate falls from 35% without prophylaxis to 12% when surgical oncology patients are given heparin, according to Dr. Leonardi of the University of California, Los Angeles. A combination of mechanical prophylaxis with heparin further reduces the DVT rate to just 5%.

“Cancer patients need some form of prophylaxis,” Dr. Leonardi said in an interview after his review of data from dozens of randomized, controlled trials. “If bleeding risk is not a concern,” he added, “pharmacological prophylaxis is better than mechanical prophylaxis, and combination therapy has been shown to be even more effective.”

Dr. Leonardi and his colleagues in the UCLA surgery department searched the Medline database for English-language trials and found 55 randomized controlled trials published from 1966 to 2005 on DVT prophylaxis in general surgery. Among these, 26 trials reported outcomes for 7,639 cancer patients, Dr. Leonardi said.

Colorectal and major abdominal surgical procedures accounted for 39% and 38% of cases, respectively. Upper gastrointestinal and small bowel operations were the next most common at 11%, followed by gynecologic surgery at 3%. Biliary, pancreatic, urologic, and noncardiac thoracic cancers each accounted for just 1% of the surgical procedures in Dr. Leonardi's presentation.

After a review of the wide variety of patients and surgeons in these trials, he said the best prophylaxis for individual cancers is still not known. For example, not even one randomized controlled trial was found that evaluated DVT prophylaxis in breast cancer patients. The incidence of DVT in breast cancer “is probably not as high as in some other cancers, but because breast cancer is so common a lot of DVTs are associated with it,” he said.

Among the findings from the analysis, Dr. Leonardi reported that:

▸ DVT rates vary with the detection method used. Venography was the most sensitive method, and ultrasound the least sensitive.

▸ Higher heparin doses are more effective than lower doses. DVT rates were 8% for higher doses and 14% for lower doses of the forms of heparin in 17 trials with a total of 4,005 patients.

▸ Low-molecular-weight heparin and low-weight unfractionated heparin are equally effective. Both cut DVT rates to 8% at high doses in the 17 trials just cited. At low doses, the rate was 14% for low-molecular-weight heparin and 13% for low-weight unfractionated heparin.

▸ Heparin reduces the rate of proximal DVTs. The rate went from 41% to 13% in nine trials reporting on 284 patients with DVTs. Location was unaffected by the use of low-molecular-weight heparin vs. low-weight unfractionated heparin.

▸ Major complications occur in only 1% of cases with pharmacologic prophylaxis. Based on seven trials, minor complications occurred in 10% of patients and major complications in 1%, he reported. There was no difference between low-molecular-weight heparin and low-weight unfractionated heparin. In four trials, 3% of patients discontinued prophylaxis.

SAN DIEGO — Pharmacologic prophylaxis can sharply reduce the risk of deep venous thrombosis when cancer patients undergo surgery, Dr. Michael J. Leonardi said at a symposium sponsored by the Society of Surgical Oncology.

The deep venous thrombosis (DVT) rate falls from 35% without prophylaxis to 12% when surgical oncology patients are given heparin, according to Dr. Leonardi of the University of California, Los Angeles. A combination of mechanical prophylaxis with heparin further reduces the DVT rate to just 5%.

“Cancer patients need some form of prophylaxis,” Dr. Leonardi said in an interview after his review of data from dozens of randomized, controlled trials. “If bleeding risk is not a concern,” he added, “pharmacological prophylaxis is better than mechanical prophylaxis, and combination therapy has been shown to be even more effective.”

Dr. Leonardi and his colleagues in the UCLA surgery department searched the Medline database for English-language trials and found 55 randomized controlled trials published from 1966 to 2005 on DVT prophylaxis in general surgery. Among these, 26 trials reported outcomes for 7,639 cancer patients, Dr. Leonardi said.

Colorectal and major abdominal surgical procedures accounted for 39% and 38% of cases, respectively. Upper gastrointestinal and small bowel operations were the next most common at 11%, followed by gynecologic surgery at 3%. Biliary, pancreatic, urologic, and noncardiac thoracic cancers each accounted for just 1% of the surgical procedures in Dr. Leonardi's presentation.

After a review of the wide variety of patients and surgeons in these trials, he said the best prophylaxis for individual cancers is still not known. For example, not even one randomized controlled trial was found that evaluated DVT prophylaxis in breast cancer patients. The incidence of DVT in breast cancer “is probably not as high as in some other cancers, but because breast cancer is so common a lot of DVTs are associated with it,” he said.

Among the findings from the analysis, Dr. Leonardi reported that:

▸ DVT rates vary with the detection method used. Venography was the most sensitive method, and ultrasound the least sensitive.

▸ Higher heparin doses are more effective than lower doses. DVT rates were 8% for higher doses and 14% for lower doses of the forms of heparin in 17 trials with a total of 4,005 patients.

▸ Low-molecular-weight heparin and low-weight unfractionated heparin are equally effective. Both cut DVT rates to 8% at high doses in the 17 trials just cited. At low doses, the rate was 14% for low-molecular-weight heparin and 13% for low-weight unfractionated heparin.

▸ Heparin reduces the rate of proximal DVTs. The rate went from 41% to 13% in nine trials reporting on 284 patients with DVTs. Location was unaffected by the use of low-molecular-weight heparin vs. low-weight unfractionated heparin.

▸ Major complications occur in only 1% of cases with pharmacologic prophylaxis. Based on seven trials, minor complications occurred in 10% of patients and major complications in 1%, he reported. There was no difference between low-molecular-weight heparin and low-weight unfractionated heparin. In four trials, 3% of patients discontinued prophylaxis.