Jane Salodof MacNeil

SAN DIEGO — Limiting sentinel lymph node biopsy to removal of three nodes might cut costs without sacrificing the accuracy of the procedure in breast cancer patients, Dr. Michael S. Sabel said at a symposium sponsored by the Society of Surgical Oncology.

Dr. Sabel and his colleagues reviewed SLN biopsies performed in 729 patients at the University of Michigan, Ann Arbor, from October 1998 to December 2004. The investigators included only patients who underwent biopsies using a combination of Tc-99 isotope and blue dye. Patients were excluded if no sentinel nodes were detected or only blue dye was used, said Dr. Sabel of the surgery department at the university.

Surgeons defined a sentinel node as “any node that was clinically suspicious, was blue, had blue afferent, or had 10% of the counts per minute of the highest node removed ex vivo,” said Dr. Sabel. The surgeons also recorded the order in which the nodes were removed. Patients had 2.5 lymph nodes removed on average. Nearly half the patients had three or more lymph nodes removed, and a quarter had four or more removed.

Most patients had ductal carcinomas. All told, 596 patients (82%) were node negative. The investigators determined that only one positive node had been discovered after removal of three nodes showed no disease. It was the fourth node taken from one patient. Two-thirds of positive nodes were the first nodes examined. Another 21% of positive nodes were the second node taken, and 12% of positive nodes were the third node. If the procedures had been stopped at three nodes, 99% of positive nodes would have been examined and identified. “There was only one case where going past the third lymph node had any significant impact on the accuracy of the procedure,” Dr. Sabel said.

Using the Medicare reimbursement figure of $178.06 for CPT 88307 in Michigan outside of Detroit, Dr. Sabel estimated that limiting lymph node removal to a three-node threshold would have saved about $51,000 at bare minimum for 729 patients—or $7,000 annually if extrapolated to 100 cases per year.

The actual savings would be higher, he added, because the reimbursement did not take into account operating room costs of $600 per hour or the cost of immunohistochemistry staining. “And it doesn't reflect the surgeon's time and effort, the impact on OR scheduling, the time the pathologist takes to examine slides, or the pathology tests to prepare the slides,” said Dr. Sabel.

He suggested that reducing the number of nodes also might reduce morbidity associated with the procedure. He cited lymphedema, seroma, infection, and paresthesias as adverse events associated with node removal.

The presentation generated considerable discussion about SLN biopsy procedures used at the University of Michigan Health System and elsewhere. One surgeon objected to the emphasis on cutting costs in a life-threatening disease.

Dr. Sobel disagreed, citing escalating health costs and calling on physicians to make the most productive use of new technology. “It is up to us to be responsible in bringing down health care costs,” he said.

In an interview, Dr. Sabel said he was not suggesting that hospitals drop their thresholds on the basis of the Michigan experience.

“Technique varies,” he noted. “Other institutions should take a look and see if there is a need to do so much,” he said. “You can never base wide-world practices on a single institution's retrospective experience.”

Physicians should think about cost-effectiveness, he repeated, arguing for the best use of resources. “If you save a million dollars, will one more person die from cancer?” he asked, phrasing the issue rhetorically. “If you are a patient you know the answer, and if you are an accountant you know the answer. We as oncologists are in the middle,” he said.

SAN DIEGO — Limiting sentinel lymph node biopsy to removal of three nodes might cut costs without sacrificing the accuracy of the procedure in breast cancer patients, Dr. Michael S. Sabel said at a symposium sponsored by the Society of Surgical Oncology.

Dr. Sabel and his colleagues reviewed SLN biopsies performed in 729 patients at the University of Michigan, Ann Arbor, from October 1998 to December 2004. The investigators included only patients who underwent biopsies using a combination of Tc-99 isotope and blue dye. Patients were excluded if no sentinel nodes were detected or only blue dye was used, said Dr. Sabel of the surgery department at the university.

Surgeons defined a sentinel node as “any node that was clinically suspicious, was blue, had blue afferent, or had 10% of the counts per minute of the highest node removed ex vivo,” said Dr. Sabel. The surgeons also recorded the order in which the nodes were removed. Patients had 2.5 lymph nodes removed on average. Nearly half the patients had three or more lymph nodes removed, and a quarter had four or more removed.

Most patients had ductal carcinomas. All told, 596 patients (82%) were node negative. The investigators determined that only one positive node had been discovered after removal of three nodes showed no disease. It was the fourth node taken from one patient. Two-thirds of positive nodes were the first nodes examined. Another 21% of positive nodes were the second node taken, and 12% of positive nodes were the third node. If the procedures had been stopped at three nodes, 99% of positive nodes would have been examined and identified. “There was only one case where going past the third lymph node had any significant impact on the accuracy of the procedure,” Dr. Sabel said.

Using the Medicare reimbursement figure of $178.06 for CPT 88307 in Michigan outside of Detroit, Dr. Sabel estimated that limiting lymph node removal to a three-node threshold would have saved about $51,000 at bare minimum for 729 patients—or $7,000 annually if extrapolated to 100 cases per year.

The actual savings would be higher, he added, because the reimbursement did not take into account operating room costs of $600 per hour or the cost of immunohistochemistry staining. “And it doesn't reflect the surgeon's time and effort, the impact on OR scheduling, the time the pathologist takes to examine slides, or the pathology tests to prepare the slides,” said Dr. Sabel.

He suggested that reducing the number of nodes also might reduce morbidity associated with the procedure. He cited lymphedema, seroma, infection, and paresthesias as adverse events associated with node removal.

The presentation generated considerable discussion about SLN biopsy procedures used at the University of Michigan Health System and elsewhere. One surgeon objected to the emphasis on cutting costs in a life-threatening disease.

Dr. Sobel disagreed, citing escalating health costs and calling on physicians to make the most productive use of new technology. “It is up to us to be responsible in bringing down health care costs,” he said.

In an interview, Dr. Sabel said he was not suggesting that hospitals drop their thresholds on the basis of the Michigan experience.

“Technique varies,” he noted. “Other institutions should take a look and see if there is a need to do so much,” he said. “You can never base wide-world practices on a single institution's retrospective experience.”

Physicians should think about cost-effectiveness, he repeated, arguing for the best use of resources. “If you save a million dollars, will one more person die from cancer?” he asked, phrasing the issue rhetorically. “If you are a patient you know the answer, and if you are an accountant you know the answer. We as oncologists are in the middle,” he said.

SAN DIEGO — Limiting sentinel lymph node biopsy to removal of three nodes might cut costs without sacrificing the accuracy of the procedure in breast cancer patients, Dr. Michael S. Sabel said at a symposium sponsored by the Society of Surgical Oncology.

Dr. Sabel and his colleagues reviewed SLN biopsies performed in 729 patients at the University of Michigan, Ann Arbor, from October 1998 to December 2004. The investigators included only patients who underwent biopsies using a combination of Tc-99 isotope and blue dye. Patients were excluded if no sentinel nodes were detected or only blue dye was used, said Dr. Sabel of the surgery department at the university.

Surgeons defined a sentinel node as “any node that was clinically suspicious, was blue, had blue afferent, or had 10% of the counts per minute of the highest node removed ex vivo,” said Dr. Sabel. The surgeons also recorded the order in which the nodes were removed. Patients had 2.5 lymph nodes removed on average. Nearly half the patients had three or more lymph nodes removed, and a quarter had four or more removed.

Most patients had ductal carcinomas. All told, 596 patients (82%) were node negative. The investigators determined that only one positive node had been discovered after removal of three nodes showed no disease. It was the fourth node taken from one patient. Two-thirds of positive nodes were the first nodes examined. Another 21% of positive nodes were the second node taken, and 12% of positive nodes were the third node. If the procedures had been stopped at three nodes, 99% of positive nodes would have been examined and identified. “There was only one case where going past the third lymph node had any significant impact on the accuracy of the procedure,” Dr. Sabel said.

Using the Medicare reimbursement figure of $178.06 for CPT 88307 in Michigan outside of Detroit, Dr. Sabel estimated that limiting lymph node removal to a three-node threshold would have saved about $51,000 at bare minimum for 729 patients—or $7,000 annually if extrapolated to 100 cases per year.

The actual savings would be higher, he added, because the reimbursement did not take into account operating room costs of $600 per hour or the cost of immunohistochemistry staining. “And it doesn't reflect the surgeon's time and effort, the impact on OR scheduling, the time the pathologist takes to examine slides, or the pathology tests to prepare the slides,” said Dr. Sabel.

He suggested that reducing the number of nodes also might reduce morbidity associated with the procedure. He cited lymphedema, seroma, infection, and paresthesias as adverse events associated with node removal.

The presentation generated considerable discussion about SLN biopsy procedures used at the University of Michigan Health System and elsewhere. One surgeon objected to the emphasis on cutting costs in a life-threatening disease.

Dr. Sobel disagreed, citing escalating health costs and calling on physicians to make the most productive use of new technology. “It is up to us to be responsible in bringing down health care costs,” he said.

In an interview, Dr. Sabel said he was not suggesting that hospitals drop their thresholds on the basis of the Michigan experience.

“Technique varies,” he noted. “Other institutions should take a look and see if there is a need to do so much,” he said. “You can never base wide-world practices on a single institution's retrospective experience.”

Physicians should think about cost-effectiveness, he repeated, arguing for the best use of resources. “If you save a million dollars, will one more person die from cancer?” he asked, phrasing the issue rhetorically. “If you are a patient you know the answer, and if you are an accountant you know the answer. We as oncologists are in the middle,” he said.

KAPALUA, HAWAII — A formulation of doxycycline that is anti-inflammatory without being antibiotic significantly reduced rosacea lesions in two phase III trials, according to Dr. James Q. Del Rosso, the principal investigator.

Dr. Del Rosso, a dermatologist in Las Vegas, reported that CollaGenex Pharmaceuticals Inc., in Newtown, Pa., for which he works in several roles, has applied to the Food and Drug Administration for an indication in rosacea based on the outcomes.

He gave a general description of the findings at the Winter Clinical Dermatology Conference, Hawaii, and said that data from the trials would be presented at the American Academy of Dermatology meeting this month. “This therapy provides the anti-inflammatory effect but does not predispose patients to development of antibiotic resistance. That is significant,” he said in an interview.

In his presentation, he suggested that antibiotic resistance was a concern because rosacea is a chronic disease for which patients are often treated for long periods. All tetracyclines have anti-inflammatory activity, he said, but doxycycline is the only one for which investigators have separated anti-inflammatory from antibiotic dosing.

Anti-inflammatory-dose doxycycline is a 40-mg, controlled-release doxycycline monohydrate capsule that is administered once a day, said Dr. Del Rosso. “The advantage of once-daily dosing is obviously better patient compliance,” he added.

All told, 537 patients at 28 sites were enrolled in the two randomized, double-blind, placebo-controlled studies. The investigator said that patients in both trials achieved significant improvements in inflammatory lesion counts and in Investigator's Global Assessment of Improvement scores with anti-inflammatory-dose doxycycline.

“In the two studies, patients receiving anti-inflammatory-dose doxycycline experienced a 61% and 46% mean reduction in inflammatory lesions, compared to 29% and 20%, respectively, in those receiving placebo,” Dr. Del Rosso said. Lesion-count drops in the doxycycline group became statistically significant as early as 3 weeks after treatment began.

Erythema also improved progressively in both trials, with one trial demonstrating a statistically significant difference from placebo, he said at the conference, which was sponsored by the Center for Bio-Medical Communication Inc.

Adverse reactions were similar in the placebo and active groups in both studies.

Neither trial reported phototoxicity or photosensitivity, and no female patients developed oral or vaginal candidiasis during treatment with anti-inflammatory-dose doxycycline, he emphasized.

This therapy is anti-inflammatory but does not predispose patients to antibiotic resistance. DR. DEL ROSSO

ELSEVIER GLOBAL MEDICAL NEWS

KAPALUA, HAWAII — A formulation of doxycycline that is anti-inflammatory without being antibiotic significantly reduced rosacea lesions in two phase III trials, according to Dr. James Q. Del Rosso, the principal investigator.

Dr. Del Rosso, a dermatologist in Las Vegas, reported that CollaGenex Pharmaceuticals Inc., in Newtown, Pa., for which he works in several roles, has applied to the Food and Drug Administration for an indication in rosacea based on the outcomes.

He gave a general description of the findings at the Winter Clinical Dermatology Conference, Hawaii, and said that data from the trials would be presented at the American Academy of Dermatology meeting this month. “This therapy provides the anti-inflammatory effect but does not predispose patients to development of antibiotic resistance. That is significant,” he said in an interview.

In his presentation, he suggested that antibiotic resistance was a concern because rosacea is a chronic disease for which patients are often treated for long periods. All tetracyclines have anti-inflammatory activity, he said, but doxycycline is the only one for which investigators have separated anti-inflammatory from antibiotic dosing.

Anti-inflammatory-dose doxycycline is a 40-mg, controlled-release doxycycline monohydrate capsule that is administered once a day, said Dr. Del Rosso. “The advantage of once-daily dosing is obviously better patient compliance,” he added.

All told, 537 patients at 28 sites were enrolled in the two randomized, double-blind, placebo-controlled studies. The investigator said that patients in both trials achieved significant improvements in inflammatory lesion counts and in Investigator's Global Assessment of Improvement scores with anti-inflammatory-dose doxycycline.

“In the two studies, patients receiving anti-inflammatory-dose doxycycline experienced a 61% and 46% mean reduction in inflammatory lesions, compared to 29% and 20%, respectively, in those receiving placebo,” Dr. Del Rosso said. Lesion-count drops in the doxycycline group became statistically significant as early as 3 weeks after treatment began.

Erythema also improved progressively in both trials, with one trial demonstrating a statistically significant difference from placebo, he said at the conference, which was sponsored by the Center for Bio-Medical Communication Inc.

Adverse reactions were similar in the placebo and active groups in both studies.

Neither trial reported phototoxicity or photosensitivity, and no female patients developed oral or vaginal candidiasis during treatment with anti-inflammatory-dose doxycycline, he emphasized.

This therapy is anti-inflammatory but does not predispose patients to antibiotic resistance. DR. DEL ROSSO

ELSEVIER GLOBAL MEDICAL NEWS

KAPALUA, HAWAII — A formulation of doxycycline that is anti-inflammatory without being antibiotic significantly reduced rosacea lesions in two phase III trials, according to Dr. James Q. Del Rosso, the principal investigator.

Dr. Del Rosso, a dermatologist in Las Vegas, reported that CollaGenex Pharmaceuticals Inc., in Newtown, Pa., for which he works in several roles, has applied to the Food and Drug Administration for an indication in rosacea based on the outcomes.

He gave a general description of the findings at the Winter Clinical Dermatology Conference, Hawaii, and said that data from the trials would be presented at the American Academy of Dermatology meeting this month. “This therapy provides the anti-inflammatory effect but does not predispose patients to development of antibiotic resistance. That is significant,” he said in an interview.

In his presentation, he suggested that antibiotic resistance was a concern because rosacea is a chronic disease for which patients are often treated for long periods. All tetracyclines have anti-inflammatory activity, he said, but doxycycline is the only one for which investigators have separated anti-inflammatory from antibiotic dosing.

Anti-inflammatory-dose doxycycline is a 40-mg, controlled-release doxycycline monohydrate capsule that is administered once a day, said Dr. Del Rosso. “The advantage of once-daily dosing is obviously better patient compliance,” he added.

All told, 537 patients at 28 sites were enrolled in the two randomized, double-blind, placebo-controlled studies. The investigator said that patients in both trials achieved significant improvements in inflammatory lesion counts and in Investigator's Global Assessment of Improvement scores with anti-inflammatory-dose doxycycline.

“In the two studies, patients receiving anti-inflammatory-dose doxycycline experienced a 61% and 46% mean reduction in inflammatory lesions, compared to 29% and 20%, respectively, in those receiving placebo,” Dr. Del Rosso said. Lesion-count drops in the doxycycline group became statistically significant as early as 3 weeks after treatment began.

Erythema also improved progressively in both trials, with one trial demonstrating a statistically significant difference from placebo, he said at the conference, which was sponsored by the Center for Bio-Medical Communication Inc.

Adverse reactions were similar in the placebo and active groups in both studies.

Neither trial reported phototoxicity or photosensitivity, and no female patients developed oral or vaginal candidiasis during treatment with anti-inflammatory-dose doxycycline, he emphasized.

This therapy is anti-inflammatory but does not predispose patients to antibiotic resistance. DR. DEL ROSSO

ELSEVIER GLOBAL MEDICAL NEWS

PARIS — Erectile dysfunction may be an independent risk factor for heart disease, according to investigators from two studies who gave poster presentations at the annual meeting of the European Association of Urology.

Dr. Francis Dubosq reported that myocardial scintography revealed coronary artery disease in 9 (29%) of 31 men who sought treatment for erectile dysfunction (ED) from urologists at Hôpital Foch in Suresnes, France. The investigators excluded patients with known coronary artery disease (CAD) or two or more cardiovascular risk factors from the population referred to cardiology for screening.

Dr. Arthur Bohnen reported that ED was an independent risk factor for acute myocardial infarction and stroke in a longitudinal, population-based study that followed 1,248 men for an average of 6.5 years in Krimpen, Netherlands.

His group found that older men with severe ED were 2.5 times more likely to have a cardiovascular event than men with no ED; the odds were 1.5 times higher for those with moderate ED.

Both investigators said the results from the ongoing studies were preliminary. Although they stopped short of drawing definitive conclusions, each saw immediate implications for physicians.

Dr. Dubosq, a urologist at Hôpital Foch, said physicians should view men with ED as being at high risk for coronary artery disease. “You have to be very careful because these patients are going to be candidates for artery involvements,” he said, emphasizing that the patients screened had no symptoms of coronary artery disease.

Dr. Bohnen, a general practitioner at Erasmus Medical Center, Rotterdam, Netherlands, said physicians should consider ED when estimating a patient's cardiovascular risk. “They should ask a question about ED and not only ask about smoking,” he said. “It shows here [ED] is an independent risk factor, independent of the other risk factors.”

The French study looked at a younger population, aged 45–70 years, chosen from 153 men seeking treatment for ED. The 20% sample selected for cardiology screening had a median age of 58 years. Scores on the International Index of Erectile Dysfunction showed that 2 of the men had severe ED, 10 had moderate ED, and 19 had mild ED.

Blood tests showed no evidence of diabetes, dyslipidemia, or androgen deficiency, and Doppler ultrasound did not detect peripheral artery disease in any of the subjects screened for heart disease in the French study. Using Laurier scores, described as “an estimation adapted to [the] European population of the 10-year risk for 'hard' CAD,” the investigators found that the median score was significantly different from “the ideal index of people the same age without CAD risk factors”: 6.84 for the ED population vs. 5.32.

The Dutch study enrolled men aged 50–78 years at baseline without regard to whether they presented with ED. Patients with a radical prostatectomy, prostate or bladder cancer, or neurogenic disease were excluded.

Of 1,248 men enrolled, 856 had no erectile disfunction, 284 had moderate ED, and 108 had severe ED based on responses to the International Continence Society male sex questionnaire. During the follow-up period, 4.6% of the men had cardiovascular events. Within the population of men who had a cardiovascular event, 20% had severe ED and 31% had moderate ED.

The investigators defined cardiovascular disease as “acute myocardial infarction, stroke, or sudden death determined by an expert panel based on general practitioner data and hospital discharge letters.”

Risk associated with ED was independent of cardiovascular risk factors such as cholesterol, blood pressure, body mass index, Framingham risk scores, family history, and smoking status.

'You have to be very careful because these patients are going to be candidates for artery involvements.' DR. DUBOSQ

Physicians 'should ask a question about ED and not only ask about smoking.' DR. BOHNEN

PARIS — Erectile dysfunction may be an independent risk factor for heart disease, according to investigators from two studies who gave poster presentations at the annual meeting of the European Association of Urology.

Dr. Francis Dubosq reported that myocardial scintography revealed coronary artery disease in 9 (29%) of 31 men who sought treatment for erectile dysfunction (ED) from urologists at Hôpital Foch in Suresnes, France. The investigators excluded patients with known coronary artery disease (CAD) or two or more cardiovascular risk factors from the population referred to cardiology for screening.

Dr. Arthur Bohnen reported that ED was an independent risk factor for acute myocardial infarction and stroke in a longitudinal, population-based study that followed 1,248 men for an average of 6.5 years in Krimpen, Netherlands.

His group found that older men with severe ED were 2.5 times more likely to have a cardiovascular event than men with no ED; the odds were 1.5 times higher for those with moderate ED.

Both investigators said the results from the ongoing studies were preliminary. Although they stopped short of drawing definitive conclusions, each saw immediate implications for physicians.

Dr. Dubosq, a urologist at Hôpital Foch, said physicians should view men with ED as being at high risk for coronary artery disease. “You have to be very careful because these patients are going to be candidates for artery involvements,” he said, emphasizing that the patients screened had no symptoms of coronary artery disease.

Dr. Bohnen, a general practitioner at Erasmus Medical Center, Rotterdam, Netherlands, said physicians should consider ED when estimating a patient's cardiovascular risk. “They should ask a question about ED and not only ask about smoking,” he said. “It shows here [ED] is an independent risk factor, independent of the other risk factors.”

The French study looked at a younger population, aged 45–70 years, chosen from 153 men seeking treatment for ED. The 20% sample selected for cardiology screening had a median age of 58 years. Scores on the International Index of Erectile Dysfunction showed that 2 of the men had severe ED, 10 had moderate ED, and 19 had mild ED.

Blood tests showed no evidence of diabetes, dyslipidemia, or androgen deficiency, and Doppler ultrasound did not detect peripheral artery disease in any of the subjects screened for heart disease in the French study. Using Laurier scores, described as “an estimation adapted to [the] European population of the 10-year risk for 'hard' CAD,” the investigators found that the median score was significantly different from “the ideal index of people the same age without CAD risk factors”: 6.84 for the ED population vs. 5.32.

The Dutch study enrolled men aged 50–78 years at baseline without regard to whether they presented with ED. Patients with a radical prostatectomy, prostate or bladder cancer, or neurogenic disease were excluded.

Of 1,248 men enrolled, 856 had no erectile disfunction, 284 had moderate ED, and 108 had severe ED based on responses to the International Continence Society male sex questionnaire. During the follow-up period, 4.6% of the men had cardiovascular events. Within the population of men who had a cardiovascular event, 20% had severe ED and 31% had moderate ED.

The investigators defined cardiovascular disease as “acute myocardial infarction, stroke, or sudden death determined by an expert panel based on general practitioner data and hospital discharge letters.”

Risk associated with ED was independent of cardiovascular risk factors such as cholesterol, blood pressure, body mass index, Framingham risk scores, family history, and smoking status.

'You have to be very careful because these patients are going to be candidates for artery involvements.' DR. DUBOSQ

Physicians 'should ask a question about ED and not only ask about smoking.' DR. BOHNEN

PARIS — Erectile dysfunction may be an independent risk factor for heart disease, according to investigators from two studies who gave poster presentations at the annual meeting of the European Association of Urology.

Dr. Francis Dubosq reported that myocardial scintography revealed coronary artery disease in 9 (29%) of 31 men who sought treatment for erectile dysfunction (ED) from urologists at Hôpital Foch in Suresnes, France. The investigators excluded patients with known coronary artery disease (CAD) or two or more cardiovascular risk factors from the population referred to cardiology for screening.

Dr. Arthur Bohnen reported that ED was an independent risk factor for acute myocardial infarction and stroke in a longitudinal, population-based study that followed 1,248 men for an average of 6.5 years in Krimpen, Netherlands.

His group found that older men with severe ED were 2.5 times more likely to have a cardiovascular event than men with no ED; the odds were 1.5 times higher for those with moderate ED.

Both investigators said the results from the ongoing studies were preliminary. Although they stopped short of drawing definitive conclusions, each saw immediate implications for physicians.

Dr. Dubosq, a urologist at Hôpital Foch, said physicians should view men with ED as being at high risk for coronary artery disease. “You have to be very careful because these patients are going to be candidates for artery involvements,” he said, emphasizing that the patients screened had no symptoms of coronary artery disease.

Dr. Bohnen, a general practitioner at Erasmus Medical Center, Rotterdam, Netherlands, said physicians should consider ED when estimating a patient's cardiovascular risk. “They should ask a question about ED and not only ask about smoking,” he said. “It shows here [ED] is an independent risk factor, independent of the other risk factors.”

The French study looked at a younger population, aged 45–70 years, chosen from 153 men seeking treatment for ED. The 20% sample selected for cardiology screening had a median age of 58 years. Scores on the International Index of Erectile Dysfunction showed that 2 of the men had severe ED, 10 had moderate ED, and 19 had mild ED.

Blood tests showed no evidence of diabetes, dyslipidemia, or androgen deficiency, and Doppler ultrasound did not detect peripheral artery disease in any of the subjects screened for heart disease in the French study. Using Laurier scores, described as “an estimation adapted to [the] European population of the 10-year risk for 'hard' CAD,” the investigators found that the median score was significantly different from “the ideal index of people the same age without CAD risk factors”: 6.84 for the ED population vs. 5.32.

The Dutch study enrolled men aged 50–78 years at baseline without regard to whether they presented with ED. Patients with a radical prostatectomy, prostate or bladder cancer, or neurogenic disease were excluded.

Of 1,248 men enrolled, 856 had no erectile disfunction, 284 had moderate ED, and 108 had severe ED based on responses to the International Continence Society male sex questionnaire. During the follow-up period, 4.6% of the men had cardiovascular events. Within the population of men who had a cardiovascular event, 20% had severe ED and 31% had moderate ED.

The investigators defined cardiovascular disease as “acute myocardial infarction, stroke, or sudden death determined by an expert panel based on general practitioner data and hospital discharge letters.”

Risk associated with ED was independent of cardiovascular risk factors such as cholesterol, blood pressure, body mass index, Framingham risk scores, family history, and smoking status.

'You have to be very careful because these patients are going to be candidates for artery involvements.' DR. DUBOSQ

Physicians 'should ask a question about ED and not only ask about smoking.' DR. BOHNEN

SAN DIEGO — A 15-year study of pancreatic cancer trends in the United States found more patients are receiving potentially curative surgery, but only those with node-positive disease benefit from adjuvant radiation, Dr. Nancy N. Baxter reported at a symposium sponsored by the Society of Surgical Oncology.

Although cancer-directed surgery improved survival for patients with localized disease, median and long-term outcomes remained dismal, she said.

“Pancreatic cancer has the worst survival rate of any malignancy,” said Dr. Baxter of the department of surgery at the University of Minnesota in Minneapolis.

She and her colleagues used the Surveillance, Epidemiology, and End Results (SEER) database to track 48,658 patients over age 18 who were diagnosed with pancreatic cancer between 1988 and 2002. The age-adjusted incidence of pancreatic cancer did not change over this period, she said. While 17.5% of patients were not staged, she reported that staging improved significantly over time. About a third of all patients had nonmetastatic disease.

The data showed that median survival was 4 months overall, but 9 months for patients with nonmetastatic disease, Dr. Baxter said. Disease-specific survival for all patients was 4.8% at 5 years. Patients with nonmetastatic disease did better—at 8.8%—than did patients with metastases, at 1.5%.

A total of 12% of all patients underwent cancer-directed surgery. Among 15,031 patients with nonmetastatic disease, 4,462 (30%) had surgery. The proportion of patients with nonmetastatic cancer who received surgery increased from 19% in 1988 to 34% in 2002.

Two subgroups were much less likely to be operated on, however: the elderly and African Americans. A person under age 50 was more than 11 times as likely to have surgery as someone over age 80. Compared with white patients, the odds ratio predicting surgery for African Americans was 0.85.

“There is no rationale for disparities in rate,” Dr. Baxter said, in answer to an audience question about the age differential. “We need to think about treating patients who are older more aggressively.”

For patients with nonmetastatic disease, median survival was longer for those who had surgery than for those who did not: 16 months vs. 7 months, respectively. Those who had surgery also had better 5-year disease-free survival (19.7% vs. 3.8%) and better 5-year overall survival (14.9% vs. 2%).

About 42% of patients who had surgery also were irradiated. The SEER database does not include chemotherapy data, Dr. Baxter said. But because radiochemotherapy is standard for pancreatic cancer, most patients receiving radiation probably had radiochemotherapy, she acknowledged.

Patients with localized disease were less likely to have radiation therapy after surgery (odds ratio 0.78). Among those operated on, radiation was more likely in patients under age 50 than among those over age 80 (odds ratio 5.7) and was less likely in African Americans than in whites (odds ratio 0.74).

To evaluate the effects of radiation, the investigators considered only those patients who survived long enough for radiation to be an option. They assessed 3,756 patients who were irradiated and lived at least 3 months after diagnosis.

If patients had radiation therapy, 5-year disease-specific survival was slightly worse with node-negative localized disease and about the same with node-negative extensive disease, but was better with node-positive disease (hazard ratio 0.73), she said.

“The effect of adjuvant radiation is dependent on the extent of disease,” she said. “For patients with limited disease, there is no apparent benefit. For patients with node-positive disease, there is benefit.”

Dr. Baxter added that the analysis supports the results of the adjuvant European Study Group for Pancreatic Cancer-1 (ESPAC-1) study, which found benefits for surgery and chemotherapy but not for chemoradiation (Ann Surg. 2001;234:758–68). Radiation's apparent lack of efficacy in patients with limited disease may explain the difference between the ESPAC-1 results and results of single-institution series, she said, in that the latter typically enroll sicker patients.

SAN DIEGO — A 15-year study of pancreatic cancer trends in the United States found more patients are receiving potentially curative surgery, but only those with node-positive disease benefit from adjuvant radiation, Dr. Nancy N. Baxter reported at a symposium sponsored by the Society of Surgical Oncology.

Although cancer-directed surgery improved survival for patients with localized disease, median and long-term outcomes remained dismal, she said.

“Pancreatic cancer has the worst survival rate of any malignancy,” said Dr. Baxter of the department of surgery at the University of Minnesota in Minneapolis.

She and her colleagues used the Surveillance, Epidemiology, and End Results (SEER) database to track 48,658 patients over age 18 who were diagnosed with pancreatic cancer between 1988 and 2002. The age-adjusted incidence of pancreatic cancer did not change over this period, she said. While 17.5% of patients were not staged, she reported that staging improved significantly over time. About a third of all patients had nonmetastatic disease.

The data showed that median survival was 4 months overall, but 9 months for patients with nonmetastatic disease, Dr. Baxter said. Disease-specific survival for all patients was 4.8% at 5 years. Patients with nonmetastatic disease did better—at 8.8%—than did patients with metastases, at 1.5%.

A total of 12% of all patients underwent cancer-directed surgery. Among 15,031 patients with nonmetastatic disease, 4,462 (30%) had surgery. The proportion of patients with nonmetastatic cancer who received surgery increased from 19% in 1988 to 34% in 2002.

Two subgroups were much less likely to be operated on, however: the elderly and African Americans. A person under age 50 was more than 11 times as likely to have surgery as someone over age 80. Compared with white patients, the odds ratio predicting surgery for African Americans was 0.85.

“There is no rationale for disparities in rate,” Dr. Baxter said, in answer to an audience question about the age differential. “We need to think about treating patients who are older more aggressively.”

For patients with nonmetastatic disease, median survival was longer for those who had surgery than for those who did not: 16 months vs. 7 months, respectively. Those who had surgery also had better 5-year disease-free survival (19.7% vs. 3.8%) and better 5-year overall survival (14.9% vs. 2%).

About 42% of patients who had surgery also were irradiated. The SEER database does not include chemotherapy data, Dr. Baxter said. But because radiochemotherapy is standard for pancreatic cancer, most patients receiving radiation probably had radiochemotherapy, she acknowledged.

Patients with localized disease were less likely to have radiation therapy after surgery (odds ratio 0.78). Among those operated on, radiation was more likely in patients under age 50 than among those over age 80 (odds ratio 5.7) and was less likely in African Americans than in whites (odds ratio 0.74).

To evaluate the effects of radiation, the investigators considered only those patients who survived long enough for radiation to be an option. They assessed 3,756 patients who were irradiated and lived at least 3 months after diagnosis.

If patients had radiation therapy, 5-year disease-specific survival was slightly worse with node-negative localized disease and about the same with node-negative extensive disease, but was better with node-positive disease (hazard ratio 0.73), she said.

“The effect of adjuvant radiation is dependent on the extent of disease,” she said. “For patients with limited disease, there is no apparent benefit. For patients with node-positive disease, there is benefit.”

Dr. Baxter added that the analysis supports the results of the adjuvant European Study Group for Pancreatic Cancer-1 (ESPAC-1) study, which found benefits for surgery and chemotherapy but not for chemoradiation (Ann Surg. 2001;234:758–68). Radiation's apparent lack of efficacy in patients with limited disease may explain the difference between the ESPAC-1 results and results of single-institution series, she said, in that the latter typically enroll sicker patients.

SAN DIEGO — A 15-year study of pancreatic cancer trends in the United States found more patients are receiving potentially curative surgery, but only those with node-positive disease benefit from adjuvant radiation, Dr. Nancy N. Baxter reported at a symposium sponsored by the Society of Surgical Oncology.

Although cancer-directed surgery improved survival for patients with localized disease, median and long-term outcomes remained dismal, she said.

“Pancreatic cancer has the worst survival rate of any malignancy,” said Dr. Baxter of the department of surgery at the University of Minnesota in Minneapolis.

She and her colleagues used the Surveillance, Epidemiology, and End Results (SEER) database to track 48,658 patients over age 18 who were diagnosed with pancreatic cancer between 1988 and 2002. The age-adjusted incidence of pancreatic cancer did not change over this period, she said. While 17.5% of patients were not staged, she reported that staging improved significantly over time. About a third of all patients had nonmetastatic disease.

The data showed that median survival was 4 months overall, but 9 months for patients with nonmetastatic disease, Dr. Baxter said. Disease-specific survival for all patients was 4.8% at 5 years. Patients with nonmetastatic disease did better—at 8.8%—than did patients with metastases, at 1.5%.

A total of 12% of all patients underwent cancer-directed surgery. Among 15,031 patients with nonmetastatic disease, 4,462 (30%) had surgery. The proportion of patients with nonmetastatic cancer who received surgery increased from 19% in 1988 to 34% in 2002.

Two subgroups were much less likely to be operated on, however: the elderly and African Americans. A person under age 50 was more than 11 times as likely to have surgery as someone over age 80. Compared with white patients, the odds ratio predicting surgery for African Americans was 0.85.

“There is no rationale for disparities in rate,” Dr. Baxter said, in answer to an audience question about the age differential. “We need to think about treating patients who are older more aggressively.”

For patients with nonmetastatic disease, median survival was longer for those who had surgery than for those who did not: 16 months vs. 7 months, respectively. Those who had surgery also had better 5-year disease-free survival (19.7% vs. 3.8%) and better 5-year overall survival (14.9% vs. 2%).

About 42% of patients who had surgery also were irradiated. The SEER database does not include chemotherapy data, Dr. Baxter said. But because radiochemotherapy is standard for pancreatic cancer, most patients receiving radiation probably had radiochemotherapy, she acknowledged.

Patients with localized disease were less likely to have radiation therapy after surgery (odds ratio 0.78). Among those operated on, radiation was more likely in patients under age 50 than among those over age 80 (odds ratio 5.7) and was less likely in African Americans than in whites (odds ratio 0.74).

To evaluate the effects of radiation, the investigators considered only those patients who survived long enough for radiation to be an option. They assessed 3,756 patients who were irradiated and lived at least 3 months after diagnosis.

If patients had radiation therapy, 5-year disease-specific survival was slightly worse with node-negative localized disease and about the same with node-negative extensive disease, but was better with node-positive disease (hazard ratio 0.73), she said.

“The effect of adjuvant radiation is dependent on the extent of disease,” she said. “For patients with limited disease, there is no apparent benefit. For patients with node-positive disease, there is benefit.”

Dr. Baxter added that the analysis supports the results of the adjuvant European Study Group for Pancreatic Cancer-1 (ESPAC-1) study, which found benefits for surgery and chemotherapy but not for chemoradiation (Ann Surg. 2001;234:758–68). Radiation's apparent lack of efficacy in patients with limited disease may explain the difference between the ESPAC-1 results and results of single-institution series, she said, in that the latter typically enroll sicker patients.

SAN DIEGO — A new study has found that foregut cancer patients are significantly more likely to live 5 years after surgery if their operations are performed in hospitals doing a large number of procedures annually, Dr. John D. Birkmeyer said at a symposium sponsored by the Society of Surgical Oncology.

To determine the association between hospital volume of surgical procedures and long-term surgical mortality, Dr. Birkmeyer and his coinvestigators analyzed 10 years of information (1992–2002) in a linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database.

The researchers divided hospitals into high-, medium-, and low-volume terciles based on the number of procedures performed each year. They adjusted data for patient age, acuity, comorbidities, income, stage, and adjuvant therapy to ensure they were not making unfair comparisons.

The greatest differences in the data were produced by esophageal resections, Dr. Birkmeyer reported. Five-year survival was twice as high for high-volume hospitals as for low-volume centers: 34% vs. 17%.

For gastric surgery, the survival curves were similar but showed a smaller difference at 5 years: 32% vs. 26%.

For pancreatic cancer, high-volume hospitals started out with a large advantage in postoperative survival that lasted for about 2 years. Although the difference was still significant at 5 years, it was narrower: 16% vs. 11%. “Quality in this particular cancer may help you run, but it won't help you hide,” Dr. Birkmeyer said at the meeting, where he presented results for three of six cancers in the new study.

“For foregut cancer, hospital volume has a huge effect in terms of hospital mortality, bigger than on almost any other operation,” he said. “High-volume hospitals have better outcomes largely because they have higher-volume surgeons,” he added.

An earlier study by his group and others established that high-volume centers had lower short-term surgical mortality (in hospital or within 30 days) than did hospitals doing relatively few procedures (N. Engl. J. Med. 2002;346:1128–37). When his group compared highest- and lowest-volume hospitals in that study, pancreatic resection and esophagectomy produced the greatest differences in absolute risk of mortality, at 12.5% and 11.9%, respectively. Pneumonectomy had a 5.4% difference in risk. Gastric cancer operations shared fourth place with cystectomy; both had a difference of 2.9%.

The new work shows that the benefit of high volume persists over time, said Dr. Birkmeyer, the George D. Zuidema professor of surgery at the University of Michigan, Ann Arbor. Relatively few previous studies have compared long-term survival, and most studies were small or dated, he said.

Dr. Birkmeyer suggested two strategies—selective referral and quality improvement—to address the disparities revealed by his work. He was not optimistic that either could achieve results any time soon, however.

Selective referral would focus on directing patients to the best hospitals. The media's publication of best hospital lists, the posting of comparative information on Internet databases, and payer efforts to steer patients to selected centers of excellence provide information that can enable selective referral, Dr. Birkmeyer said.

Part of this effort could include closing low-volume centers, he added. “The problem of low-volume surgery is in population-dense areas,” he said, citing previous research showing that patients would not have to travel long distances for care if low-volume centers were closed.

But pushback from angry providers and the lack of an authority to enforce such changes are greater obstacles to such plans, according to Dr. Birkmeyer. “Private payers have the will. They don't have the leverage,” he said. “Medicare has the leverage. It doesn't have the will.”

The second strategy—quality improvement—would “raise the tide” so that all hospitals performed optimally. Proponents would “systematically track surgical outcomes, identify practices associated with optimal outcomes, and assure those practices are implemented as broadly as possible.”

This might not be possible for cancer surgery, however, Dr. Birkmeyer said. First there is the challenge of identifying processes that matter, and then of finding a way to broadly implement them. For example, he cited findings that patients at high-volume hospitals get a wider variety of preoperative tests, are likelier to see a specialist before surgery, and tend to have slower operations. They also receive more invasive monitoring, and for some cancers are more likely to receive adjuvant therapy.

These processes have not been identified as important mediators, according to Dr. Birkmeyer, and he questioned whether they might simply reflect stylistic differences.

SAN DIEGO — A new study has found that foregut cancer patients are significantly more likely to live 5 years after surgery if their operations are performed in hospitals doing a large number of procedures annually, Dr. John D. Birkmeyer said at a symposium sponsored by the Society of Surgical Oncology.

To determine the association between hospital volume of surgical procedures and long-term surgical mortality, Dr. Birkmeyer and his coinvestigators analyzed 10 years of information (1992–2002) in a linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database.

The researchers divided hospitals into high-, medium-, and low-volume terciles based on the number of procedures performed each year. They adjusted data for patient age, acuity, comorbidities, income, stage, and adjuvant therapy to ensure they were not making unfair comparisons.

The greatest differences in the data were produced by esophageal resections, Dr. Birkmeyer reported. Five-year survival was twice as high for high-volume hospitals as for low-volume centers: 34% vs. 17%.

For gastric surgery, the survival curves were similar but showed a smaller difference at 5 years: 32% vs. 26%.

For pancreatic cancer, high-volume hospitals started out with a large advantage in postoperative survival that lasted for about 2 years. Although the difference was still significant at 5 years, it was narrower: 16% vs. 11%. “Quality in this particular cancer may help you run, but it won't help you hide,” Dr. Birkmeyer said at the meeting, where he presented results for three of six cancers in the new study.

“For foregut cancer, hospital volume has a huge effect in terms of hospital mortality, bigger than on almost any other operation,” he said. “High-volume hospitals have better outcomes largely because they have higher-volume surgeons,” he added.

An earlier study by his group and others established that high-volume centers had lower short-term surgical mortality (in hospital or within 30 days) than did hospitals doing relatively few procedures (N. Engl. J. Med. 2002;346:1128–37). When his group compared highest- and lowest-volume hospitals in that study, pancreatic resection and esophagectomy produced the greatest differences in absolute risk of mortality, at 12.5% and 11.9%, respectively. Pneumonectomy had a 5.4% difference in risk. Gastric cancer operations shared fourth place with cystectomy; both had a difference of 2.9%.

The new work shows that the benefit of high volume persists over time, said Dr. Birkmeyer, the George D. Zuidema professor of surgery at the University of Michigan, Ann Arbor. Relatively few previous studies have compared long-term survival, and most studies were small or dated, he said.

Dr. Birkmeyer suggested two strategies—selective referral and quality improvement—to address the disparities revealed by his work. He was not optimistic that either could achieve results any time soon, however.

Selective referral would focus on directing patients to the best hospitals. The media's publication of best hospital lists, the posting of comparative information on Internet databases, and payer efforts to steer patients to selected centers of excellence provide information that can enable selective referral, Dr. Birkmeyer said.

Part of this effort could include closing low-volume centers, he added. “The problem of low-volume surgery is in population-dense areas,” he said, citing previous research showing that patients would not have to travel long distances for care if low-volume centers were closed.

But pushback from angry providers and the lack of an authority to enforce such changes are greater obstacles to such plans, according to Dr. Birkmeyer. “Private payers have the will. They don't have the leverage,” he said. “Medicare has the leverage. It doesn't have the will.”

The second strategy—quality improvement—would “raise the tide” so that all hospitals performed optimally. Proponents would “systematically track surgical outcomes, identify practices associated with optimal outcomes, and assure those practices are implemented as broadly as possible.”

This might not be possible for cancer surgery, however, Dr. Birkmeyer said. First there is the challenge of identifying processes that matter, and then of finding a way to broadly implement them. For example, he cited findings that patients at high-volume hospitals get a wider variety of preoperative tests, are likelier to see a specialist before surgery, and tend to have slower operations. They also receive more invasive monitoring, and for some cancers are more likely to receive adjuvant therapy.

These processes have not been identified as important mediators, according to Dr. Birkmeyer, and he questioned whether they might simply reflect stylistic differences.

SAN DIEGO — A new study has found that foregut cancer patients are significantly more likely to live 5 years after surgery if their operations are performed in hospitals doing a large number of procedures annually, Dr. John D. Birkmeyer said at a symposium sponsored by the Society of Surgical Oncology.

To determine the association between hospital volume of surgical procedures and long-term surgical mortality, Dr. Birkmeyer and his coinvestigators analyzed 10 years of information (1992–2002) in a linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database.

The researchers divided hospitals into high-, medium-, and low-volume terciles based on the number of procedures performed each year. They adjusted data for patient age, acuity, comorbidities, income, stage, and adjuvant therapy to ensure they were not making unfair comparisons.

The greatest differences in the data were produced by esophageal resections, Dr. Birkmeyer reported. Five-year survival was twice as high for high-volume hospitals as for low-volume centers: 34% vs. 17%.

For gastric surgery, the survival curves were similar but showed a smaller difference at 5 years: 32% vs. 26%.

For pancreatic cancer, high-volume hospitals started out with a large advantage in postoperative survival that lasted for about 2 years. Although the difference was still significant at 5 years, it was narrower: 16% vs. 11%. “Quality in this particular cancer may help you run, but it won't help you hide,” Dr. Birkmeyer said at the meeting, where he presented results for three of six cancers in the new study.

“For foregut cancer, hospital volume has a huge effect in terms of hospital mortality, bigger than on almost any other operation,” he said. “High-volume hospitals have better outcomes largely because they have higher-volume surgeons,” he added.

An earlier study by his group and others established that high-volume centers had lower short-term surgical mortality (in hospital or within 30 days) than did hospitals doing relatively few procedures (N. Engl. J. Med. 2002;346:1128–37). When his group compared highest- and lowest-volume hospitals in that study, pancreatic resection and esophagectomy produced the greatest differences in absolute risk of mortality, at 12.5% and 11.9%, respectively. Pneumonectomy had a 5.4% difference in risk. Gastric cancer operations shared fourth place with cystectomy; both had a difference of 2.9%.

The new work shows that the benefit of high volume persists over time, said Dr. Birkmeyer, the George D. Zuidema professor of surgery at the University of Michigan, Ann Arbor. Relatively few previous studies have compared long-term survival, and most studies were small or dated, he said.

Dr. Birkmeyer suggested two strategies—selective referral and quality improvement—to address the disparities revealed by his work. He was not optimistic that either could achieve results any time soon, however.

Selective referral would focus on directing patients to the best hospitals. The media's publication of best hospital lists, the posting of comparative information on Internet databases, and payer efforts to steer patients to selected centers of excellence provide information that can enable selective referral, Dr. Birkmeyer said.

Part of this effort could include closing low-volume centers, he added. “The problem of low-volume surgery is in population-dense areas,” he said, citing previous research showing that patients would not have to travel long distances for care if low-volume centers were closed.

But pushback from angry providers and the lack of an authority to enforce such changes are greater obstacles to such plans, according to Dr. Birkmeyer. “Private payers have the will. They don't have the leverage,” he said. “Medicare has the leverage. It doesn't have the will.”

The second strategy—quality improvement—would “raise the tide” so that all hospitals performed optimally. Proponents would “systematically track surgical outcomes, identify practices associated with optimal outcomes, and assure those practices are implemented as broadly as possible.”

This might not be possible for cancer surgery, however, Dr. Birkmeyer said. First there is the challenge of identifying processes that matter, and then of finding a way to broadly implement them. For example, he cited findings that patients at high-volume hospitals get a wider variety of preoperative tests, are likelier to see a specialist before surgery, and tend to have slower operations. They also receive more invasive monitoring, and for some cancers are more likely to receive adjuvant therapy.

These processes have not been identified as important mediators, according to Dr. Birkmeyer, and he questioned whether they might simply reflect stylistic differences.

KAPALUA, HAWAII — Oral cefdinir is safe for the treatment of skin and soft-tissue infections in people who are allergic to penicillin, Dr. James Q. Del Rosso said in a poster presentation at the Winter Clinical Dermatology Conference, Hawaii.

He reported that a literature review found virtually no cross-reactivity between cefdinir (Omnicef) and penicillin, despite concerns about the use of cephalosporins in patients with a history of penicillin allergy.

“All cephalosporin antibiotics are not created equal,” said Dr. Del Rosso, who has a private dermatology practice in Las Vegas.

He maintained that differences in the seven-position side chain structure of selected cephalosporins make cross-reactivity with penicillin less likely in second- and third-generation cephalosporins such as cefdinir.

“A thorough review of available data indicates that the frequently cited risk of 8%–18% cross-reactivity to cephalosporins among penicillin-allergic patients is not accurate, is misleading, and requires revision,” Dr. Del Rosso said in his poster.

The increased risk of allergic reactions in penicillin-allergic patients is only 0.4% for first-generation cephalosporins and “nearly nil” for certain later-generation agents, which he defined as cefdinir, cefpodoxime, and cefuroxime.

“The one we use in dermatology [cefdinir] appears to have essentially no cross-reactivity with penicillin,” he said in an interview at the conference, which was sponsored by the Center for Bio-Medical Communications Inc.

Dr. Del Rosso noted that the American Academy of Pediatrics has endorsed the use of cefdinir, cefpodoxime, and cefuroxime in penicillin-allergic children, excluding those who have had life-threatening reactions such as anaphylaxis or toxic epidermal necrolysis. He also said that the American Academy of Family Physicians has taken a similar position regarding use of these agents.

“The risk of anaphylaxis associated with cephalosporin use has been cited to range from 0.1% to 0.0001%, with no cases of fatal anaphylaxis reported in children,” according to the poster.

Medicis, The Dermatology Company provided support for production of the poster.

Dr. Del Rosso is a consultant to, and serves on the speakers' bureau of, Abbott Laboratories, which is the manufacturer of Omnicef.

KAPALUA, HAWAII — Oral cefdinir is safe for the treatment of skin and soft-tissue infections in people who are allergic to penicillin, Dr. James Q. Del Rosso said in a poster presentation at the Winter Clinical Dermatology Conference, Hawaii.

He reported that a literature review found virtually no cross-reactivity between cefdinir (Omnicef) and penicillin, despite concerns about the use of cephalosporins in patients with a history of penicillin allergy.

“All cephalosporin antibiotics are not created equal,” said Dr. Del Rosso, who has a private dermatology practice in Las Vegas.

He maintained that differences in the seven-position side chain structure of selected cephalosporins make cross-reactivity with penicillin less likely in second- and third-generation cephalosporins such as cefdinir.

“A thorough review of available data indicates that the frequently cited risk of 8%–18% cross-reactivity to cephalosporins among penicillin-allergic patients is not accurate, is misleading, and requires revision,” Dr. Del Rosso said in his poster.

The increased risk of allergic reactions in penicillin-allergic patients is only 0.4% for first-generation cephalosporins and “nearly nil” for certain later-generation agents, which he defined as cefdinir, cefpodoxime, and cefuroxime.

“The one we use in dermatology [cefdinir] appears to have essentially no cross-reactivity with penicillin,” he said in an interview at the conference, which was sponsored by the Center for Bio-Medical Communications Inc.

Dr. Del Rosso noted that the American Academy of Pediatrics has endorsed the use of cefdinir, cefpodoxime, and cefuroxime in penicillin-allergic children, excluding those who have had life-threatening reactions such as anaphylaxis or toxic epidermal necrolysis. He also said that the American Academy of Family Physicians has taken a similar position regarding use of these agents.

“The risk of anaphylaxis associated with cephalosporin use has been cited to range from 0.1% to 0.0001%, with no cases of fatal anaphylaxis reported in children,” according to the poster.

Medicis, The Dermatology Company provided support for production of the poster.

Dr. Del Rosso is a consultant to, and serves on the speakers' bureau of, Abbott Laboratories, which is the manufacturer of Omnicef.

KAPALUA, HAWAII — Oral cefdinir is safe for the treatment of skin and soft-tissue infections in people who are allergic to penicillin, Dr. James Q. Del Rosso said in a poster presentation at the Winter Clinical Dermatology Conference, Hawaii.

He reported that a literature review found virtually no cross-reactivity between cefdinir (Omnicef) and penicillin, despite concerns about the use of cephalosporins in patients with a history of penicillin allergy.

“All cephalosporin antibiotics are not created equal,” said Dr. Del Rosso, who has a private dermatology practice in Las Vegas.

He maintained that differences in the seven-position side chain structure of selected cephalosporins make cross-reactivity with penicillin less likely in second- and third-generation cephalosporins such as cefdinir.

“A thorough review of available data indicates that the frequently cited risk of 8%–18% cross-reactivity to cephalosporins among penicillin-allergic patients is not accurate, is misleading, and requires revision,” Dr. Del Rosso said in his poster.

The increased risk of allergic reactions in penicillin-allergic patients is only 0.4% for first-generation cephalosporins and “nearly nil” for certain later-generation agents, which he defined as cefdinir, cefpodoxime, and cefuroxime.

“The one we use in dermatology [cefdinir] appears to have essentially no cross-reactivity with penicillin,” he said in an interview at the conference, which was sponsored by the Center for Bio-Medical Communications Inc.

Dr. Del Rosso noted that the American Academy of Pediatrics has endorsed the use of cefdinir, cefpodoxime, and cefuroxime in penicillin-allergic children, excluding those who have had life-threatening reactions such as anaphylaxis or toxic epidermal necrolysis. He also said that the American Academy of Family Physicians has taken a similar position regarding use of these agents.

“The risk of anaphylaxis associated with cephalosporin use has been cited to range from 0.1% to 0.0001%, with no cases of fatal anaphylaxis reported in children,” according to the poster.

Medicis, The Dermatology Company provided support for production of the poster.

Dr. Del Rosso is a consultant to, and serves on the speakers' bureau of, Abbott Laboratories, which is the manufacturer of Omnicef.

PARIS — The noninvasive NMP22 BladderChek assay gives general practitioners a way to screen asymptomatic patients with hematuria for bladder cancer during office visits, Dr. H. Barton Grossman said at the annual congress of the European Association of Urology.

“At least in the United States, most of these patients are not being tested at all, not being referred to urologists, until they have several episodes of significant blood in their urine,” said Dr. Grossman, professor and chairman of urology at the M.D. Anderson Cancer Center in Houston.

“I think the best use of this test is actually going to be in the initial diagnosis of people with hematuria in general practice offices,” he told European urologists who questioned whether the NMP22 protein assay yields too many false-positive results for urologists to find it clinically useful.

Dr. Grossman presented updated results from a large study that found that the NMP22 protein assay can increase the accuracy of screening when used in combination with cystoscopy (JAMA 2005;293:810–6).

The investigators compared the NMP22 test results with cytology results, with cystoscopy as the reference standard. Patients provided a voided urine sample before undergoing cystoscopy. The urine sample was divided into two parts: One portion was tested for NMP22 in the office, and the other was sent for routine cytology.

If a tumor was found and removed during cystoscopy, diagnosis was based on pathology of the tumor.

A total of 23 academic, private practice, and veterans' facilities in 10 states recruited high-risk patients from September 2001 to February 2002. Of 1,331 patients enrolled, 79 patients (6%) were found to have bladder cancers.

In the data Dr. Grossman reported at the meeting, the NMP22 test was significantly more sensitive than cytology for detecting every stage of bladder cancer, including low-, mid-, and high-grade tumors. Overall, its sensitivity was 57%, compared with 18% for cytology.

Dr. Grossman said the NMP22 test picked up six bladder cancers that were missed by cystoscopy. Used together, the noninvasive protein assay and the endoscopic procedure detected 94% of cancers (74/79) in the study population. Only 86% (68/79) were found by cystoscopy alone.

Eleven patients had muscle invasive cancers. Dr. Grossman said 10 (91%) were identified by the combination of cystoscopy and NMP22, compared with six (55%) found with cystoscopy alone.

Though less sensitive, cytology was more specific than the NMP22 assay: 99% vs. 86% in patients who did not have cancer.

Taking questions from the audience at the conclusion of his talk, Dr. Grossman debated estimates of the protein test's false-positive rate with European urologists who have argued that it is as high as 80%.

Dr. Grossman rejected the critics' estimates as too high, and said that in any case the test was not considered an alternative to cystoscopy.

“The more tumors you pick up, the fewer tumors you are going to miss, and that results in a greater negative predictive value,” he said.

In an interview, he said the NMP22 test is ideal for general practitioners because they can pretty well rule out bladder cancer if it is negative. If it is positive, he said, they should refer the patient to a urologist for further screening.

“It is fast, and it is cheap,” he said. “We have a lot of patients we follow with a history of bladder cancer. If you do this test and it is negative … you can stop right there because it has very good negative prediction. But the positive prediction is not so high, and we would follow that up.”

The test uses four drops of urine and gives results in 30 minutes at a cost of $25-$50 per patient, according to Dr. Grossman. A positive finding is based on an NMP22 antigen level of 10 U/mL or greater.

Malignant cancer cells have been found with concentrations up to 80 times greater than those found in normal cells, he said.

The assay is approved for use in the United States and Europe. Its manufacturer, Matritech Inc., financed the study. Dr. Grossman said that he has no financial disclosures.

PARIS — The noninvasive NMP22 BladderChek assay gives general practitioners a way to screen asymptomatic patients with hematuria for bladder cancer during office visits, Dr. H. Barton Grossman said at the annual congress of the European Association of Urology.

“At least in the United States, most of these patients are not being tested at all, not being referred to urologists, until they have several episodes of significant blood in their urine,” said Dr. Grossman, professor and chairman of urology at the M.D. Anderson Cancer Center in Houston.

“I think the best use of this test is actually going to be in the initial diagnosis of people with hematuria in general practice offices,” he told European urologists who questioned whether the NMP22 protein assay yields too many false-positive results for urologists to find it clinically useful.

Dr. Grossman presented updated results from a large study that found that the NMP22 protein assay can increase the accuracy of screening when used in combination with cystoscopy (JAMA 2005;293:810–6).

The investigators compared the NMP22 test results with cytology results, with cystoscopy as the reference standard. Patients provided a voided urine sample before undergoing cystoscopy. The urine sample was divided into two parts: One portion was tested for NMP22 in the office, and the other was sent for routine cytology.

If a tumor was found and removed during cystoscopy, diagnosis was based on pathology of the tumor.

A total of 23 academic, private practice, and veterans' facilities in 10 states recruited high-risk patients from September 2001 to February 2002. Of 1,331 patients enrolled, 79 patients (6%) were found to have bladder cancers.

In the data Dr. Grossman reported at the meeting, the NMP22 test was significantly more sensitive than cytology for detecting every stage of bladder cancer, including low-, mid-, and high-grade tumors. Overall, its sensitivity was 57%, compared with 18% for cytology.

Dr. Grossman said the NMP22 test picked up six bladder cancers that were missed by cystoscopy. Used together, the noninvasive protein assay and the endoscopic procedure detected 94% of cancers (74/79) in the study population. Only 86% (68/79) were found by cystoscopy alone.

Eleven patients had muscle invasive cancers. Dr. Grossman said 10 (91%) were identified by the combination of cystoscopy and NMP22, compared with six (55%) found with cystoscopy alone.

Though less sensitive, cytology was more specific than the NMP22 assay: 99% vs. 86% in patients who did not have cancer.

Taking questions from the audience at the conclusion of his talk, Dr. Grossman debated estimates of the protein test's false-positive rate with European urologists who have argued that it is as high as 80%.

Dr. Grossman rejected the critics' estimates as too high, and said that in any case the test was not considered an alternative to cystoscopy.

“The more tumors you pick up, the fewer tumors you are going to miss, and that results in a greater negative predictive value,” he said.

In an interview, he said the NMP22 test is ideal for general practitioners because they can pretty well rule out bladder cancer if it is negative. If it is positive, he said, they should refer the patient to a urologist for further screening.

“It is fast, and it is cheap,” he said. “We have a lot of patients we follow with a history of bladder cancer. If you do this test and it is negative … you can stop right there because it has very good negative prediction. But the positive prediction is not so high, and we would follow that up.”

The test uses four drops of urine and gives results in 30 minutes at a cost of $25-$50 per patient, according to Dr. Grossman. A positive finding is based on an NMP22 antigen level of 10 U/mL or greater.

Malignant cancer cells have been found with concentrations up to 80 times greater than those found in normal cells, he said.

The assay is approved for use in the United States and Europe. Its manufacturer, Matritech Inc., financed the study. Dr. Grossman said that he has no financial disclosures.

PARIS — The noninvasive NMP22 BladderChek assay gives general practitioners a way to screen asymptomatic patients with hematuria for bladder cancer during office visits, Dr. H. Barton Grossman said at the annual congress of the European Association of Urology.

“At least in the United States, most of these patients are not being tested at all, not being referred to urologists, until they have several episodes of significant blood in their urine,” said Dr. Grossman, professor and chairman of urology at the M.D. Anderson Cancer Center in Houston.

“I think the best use of this test is actually going to be in the initial diagnosis of people with hematuria in general practice offices,” he told European urologists who questioned whether the NMP22 protein assay yields too many false-positive results for urologists to find it clinically useful.

Dr. Grossman presented updated results from a large study that found that the NMP22 protein assay can increase the accuracy of screening when used in combination with cystoscopy (JAMA 2005;293:810–6).

The investigators compared the NMP22 test results with cytology results, with cystoscopy as the reference standard. Patients provided a voided urine sample before undergoing cystoscopy. The urine sample was divided into two parts: One portion was tested for NMP22 in the office, and the other was sent for routine cytology.

If a tumor was found and removed during cystoscopy, diagnosis was based on pathology of the tumor.

A total of 23 academic, private practice, and veterans' facilities in 10 states recruited high-risk patients from September 2001 to February 2002. Of 1,331 patients enrolled, 79 patients (6%) were found to have bladder cancers.

In the data Dr. Grossman reported at the meeting, the NMP22 test was significantly more sensitive than cytology for detecting every stage of bladder cancer, including low-, mid-, and high-grade tumors. Overall, its sensitivity was 57%, compared with 18% for cytology.

Dr. Grossman said the NMP22 test picked up six bladder cancers that were missed by cystoscopy. Used together, the noninvasive protein assay and the endoscopic procedure detected 94% of cancers (74/79) in the study population. Only 86% (68/79) were found by cystoscopy alone.

Eleven patients had muscle invasive cancers. Dr. Grossman said 10 (91%) were identified by the combination of cystoscopy and NMP22, compared with six (55%) found with cystoscopy alone.

Though less sensitive, cytology was more specific than the NMP22 assay: 99% vs. 86% in patients who did not have cancer.

Taking questions from the audience at the conclusion of his talk, Dr. Grossman debated estimates of the protein test's false-positive rate with European urologists who have argued that it is as high as 80%.

Dr. Grossman rejected the critics' estimates as too high, and said that in any case the test was not considered an alternative to cystoscopy.

“The more tumors you pick up, the fewer tumors you are going to miss, and that results in a greater negative predictive value,” he said.

In an interview, he said the NMP22 test is ideal for general practitioners because they can pretty well rule out bladder cancer if it is negative. If it is positive, he said, they should refer the patient to a urologist for further screening.

“It is fast, and it is cheap,” he said. “We have a lot of patients we follow with a history of bladder cancer. If you do this test and it is negative … you can stop right there because it has very good negative prediction. But the positive prediction is not so high, and we would follow that up.”

The test uses four drops of urine and gives results in 30 minutes at a cost of $25-$50 per patient, according to Dr. Grossman. A positive finding is based on an NMP22 antigen level of 10 U/mL or greater.

Malignant cancer cells have been found with concentrations up to 80 times greater than those found in normal cells, he said.

The assay is approved for use in the United States and Europe. Its manufacturer, Matritech Inc., financed the study. Dr. Grossman said that he has no financial disclosures.

PARIS — Erectile dysfunction may be an independent risk factor for heart disease, according to investigators from two studies who gave poster presentations at the annual meeting of the European Association of Urology.

Dr. Francis Dubosq reported that myocardial scintography revealed coronary artery disease in 9 (29%) of 31 men who sought treatment for erectile dysfunction (ED) from urologists at Hôpital Foch in Suresnes, France. The investigators excluded patients with known coronary artery disease or two or more cardiovascular risk factors from the population referred to cardiology for screening.

Dr. Arthur Bohnen reported that ED was an independent risk factor for acute myocardial infarction and stroke in a longitudinal, population-based study that followed 1,248 men for an average of 6.5 years in Krimpen, Netherlands.

His group found that older men with severe ED were 2.5 times more likely to have a cardiovascular event than men with no ED; the odds were 1.5 times higher for those with moderate ED. Both investigators said the results from the ongoing studies were preliminary. Although they stopped short of drawing definitive conclusions, each saw immediate implications for physicians.

Dr. Dubosq, a urologist at Hôpital Foch, said physicians should view men with ED as being at high risk for coronary artery disease. “You have to be very careful because these patients are going to be candidates for artery involvements,” he said, emphasizing that the patients screened had no symptoms of coronary artery disease.

Dr. Bohnen, a general practitioner at Erasmus Medical Center, Rotterdam, Netherlands, said physicians should consider ED when estimating a patient's cardiovascular risk. “They should ask a question about ED and not only ask about smoking,” he said. “It shows here [ED] is an independent risk factor, independent of the other risk factors.”

The French study looked at a younger population, aged 45–70 years, chosen from 153 men seeking treatment for ED. The 20% sample selected for cardiology screening had a median age of 58 years.

Scores on the International Index of Erectile Dysfunction showed that 2 of the men had severe ED, 10 had moderate ED, and 19 had mild ED.

Blood tests showed no evidence of diabetes, dyslipidemia, or androgen deficiency, and Doppler ultrasound did not detect peripheral artery disease in any of the subjects screened for heart disease in the French study. Using Laurier scores, described as “an estimation adapted to [the] European population of the 10-year risk for 'hard' CAD,” the investigators found that the median score was significantly different from “the ideal index of people the same age without CAD risk factors”: 6.84 for the ED population vs. 5.32.

The Dutch study enrolled men aged 50–78 years at baseline without regard to whether they presented with ED.

Patients with a radical prostatectomy, prostate or bladder cancer, or neurogenic disease were excluded.

Of 1,248 men enrolled, 856 had no ED, 284 had moderate ED, and 108 had severe ED based on responses to the International Continence Society male sex questionnaire. During the follow-up period, 4.6% of the men had cardiovascular events. Within the population of men who had a cardiovascular event, 20% had severe ED and 31% had moderate ED.

The investigators defined cardiovascular disease as “acute myocardial infarction, stroke, or sudden death determined by an expert panel based on general practitioner data and hospital discharge letters.”

Risk associated with ED was independent of cardiovascular risk factors such as cholesterol, blood pressure, body mass index, Framingham risk scores, family history, and smoking status.

PARIS — Erectile dysfunction may be an independent risk factor for heart disease, according to investigators from two studies who gave poster presentations at the annual meeting of the European Association of Urology.

Dr. Francis Dubosq reported that myocardial scintography revealed coronary artery disease in 9 (29%) of 31 men who sought treatment for erectile dysfunction (ED) from urologists at Hôpital Foch in Suresnes, France. The investigators excluded patients with known coronary artery disease or two or more cardiovascular risk factors from the population referred to cardiology for screening.

Dr. Arthur Bohnen reported that ED was an independent risk factor for acute myocardial infarction and stroke in a longitudinal, population-based study that followed 1,248 men for an average of 6.5 years in Krimpen, Netherlands.

His group found that older men with severe ED were 2.5 times more likely to have a cardiovascular event than men with no ED; the odds were 1.5 times higher for those with moderate ED. Both investigators said the results from the ongoing studies were preliminary. Although they stopped short of drawing definitive conclusions, each saw immediate implications for physicians.

Dr. Dubosq, a urologist at Hôpital Foch, said physicians should view men with ED as being at high risk for coronary artery disease. “You have to be very careful because these patients are going to be candidates for artery involvements,” he said, emphasizing that the patients screened had no symptoms of coronary artery disease.

Dr. Bohnen, a general practitioner at Erasmus Medical Center, Rotterdam, Netherlands, said physicians should consider ED when estimating a patient's cardiovascular risk. “They should ask a question about ED and not only ask about smoking,” he said. “It shows here [ED] is an independent risk factor, independent of the other risk factors.”

The French study looked at a younger population, aged 45–70 years, chosen from 153 men seeking treatment for ED. The 20% sample selected for cardiology screening had a median age of 58 years.

Scores on the International Index of Erectile Dysfunction showed that 2 of the men had severe ED, 10 had moderate ED, and 19 had mild ED.

Blood tests showed no evidence of diabetes, dyslipidemia, or androgen deficiency, and Doppler ultrasound did not detect peripheral artery disease in any of the subjects screened for heart disease in the French study. Using Laurier scores, described as “an estimation adapted to [the] European population of the 10-year risk for 'hard' CAD,” the investigators found that the median score was significantly different from “the ideal index of people the same age without CAD risk factors”: 6.84 for the ED population vs. 5.32.

The Dutch study enrolled men aged 50–78 years at baseline without regard to whether they presented with ED.

Patients with a radical prostatectomy, prostate or bladder cancer, or neurogenic disease were excluded.

Of 1,248 men enrolled, 856 had no ED, 284 had moderate ED, and 108 had severe ED based on responses to the International Continence Society male sex questionnaire. During the follow-up period, 4.6% of the men had cardiovascular events. Within the population of men who had a cardiovascular event, 20% had severe ED and 31% had moderate ED.

The investigators defined cardiovascular disease as “acute myocardial infarction, stroke, or sudden death determined by an expert panel based on general practitioner data and hospital discharge letters.”

Risk associated with ED was independent of cardiovascular risk factors such as cholesterol, blood pressure, body mass index, Framingham risk scores, family history, and smoking status.

PARIS — Erectile dysfunction may be an independent risk factor for heart disease, according to investigators from two studies who gave poster presentations at the annual meeting of the European Association of Urology.

Dr. Francis Dubosq reported that myocardial scintography revealed coronary artery disease in 9 (29%) of 31 men who sought treatment for erectile dysfunction (ED) from urologists at Hôpital Foch in Suresnes, France. The investigators excluded patients with known coronary artery disease or two or more cardiovascular risk factors from the population referred to cardiology for screening.

Dr. Arthur Bohnen reported that ED was an independent risk factor for acute myocardial infarction and stroke in a longitudinal, population-based study that followed 1,248 men for an average of 6.5 years in Krimpen, Netherlands.

His group found that older men with severe ED were 2.5 times more likely to have a cardiovascular event than men with no ED; the odds were 1.5 times higher for those with moderate ED. Both investigators said the results from the ongoing studies were preliminary. Although they stopped short of drawing definitive conclusions, each saw immediate implications for physicians.

Dr. Dubosq, a urologist at Hôpital Foch, said physicians should view men with ED as being at high risk for coronary artery disease. “You have to be very careful because these patients are going to be candidates for artery involvements,” he said, emphasizing that the patients screened had no symptoms of coronary artery disease.

Dr. Bohnen, a general practitioner at Erasmus Medical Center, Rotterdam, Netherlands, said physicians should consider ED when estimating a patient's cardiovascular risk. “They should ask a question about ED and not only ask about smoking,” he said. “It shows here [ED] is an independent risk factor, independent of the other risk factors.”

The French study looked at a younger population, aged 45–70 years, chosen from 153 men seeking treatment for ED. The 20% sample selected for cardiology screening had a median age of 58 years.

Scores on the International Index of Erectile Dysfunction showed that 2 of the men had severe ED, 10 had moderate ED, and 19 had mild ED.

Blood tests showed no evidence of diabetes, dyslipidemia, or androgen deficiency, and Doppler ultrasound did not detect peripheral artery disease in any of the subjects screened for heart disease in the French study. Using Laurier scores, described as “an estimation adapted to [the] European population of the 10-year risk for 'hard' CAD,” the investigators found that the median score was significantly different from “the ideal index of people the same age without CAD risk factors”: 6.84 for the ED population vs. 5.32.

The Dutch study enrolled men aged 50–78 years at baseline without regard to whether they presented with ED.

Patients with a radical prostatectomy, prostate or bladder cancer, or neurogenic disease were excluded.

Of 1,248 men enrolled, 856 had no ED, 284 had moderate ED, and 108 had severe ED based on responses to the International Continence Society male sex questionnaire. During the follow-up period, 4.6% of the men had cardiovascular events. Within the population of men who had a cardiovascular event, 20% had severe ED and 31% had moderate ED.

The investigators defined cardiovascular disease as “acute myocardial infarction, stroke, or sudden death determined by an expert panel based on general practitioner data and hospital discharge letters.”

Risk associated with ED was independent of cardiovascular risk factors such as cholesterol, blood pressure, body mass index, Framingham risk scores, family history, and smoking status.

PARK CITY, UTAH — Physicians should consider nutritional deficiencies when diagnosing facial eruptions in infants and children, according to Dr. Beth Drolet.

One of the more perplexing cases she described at a clinical dermatology seminar sponsored by Medicis was a 21/2-year-old child referred by emergency physicians for suspected Stevens-Johnson syndrome.

Dr. Drolet, medical director for dermatology at Children's Hospital of Wisconsin, Milwaukee, said the child had no history of health care or immunizations. He was brought to the hospital because of a severe rash and was found to have multiple deficiencies, including severe sensory polyneuropathy, photophobia, muscular atrophy, osteopenia, and speech and language defects.

“The child was only eating large french fries from McDonald's. He was getting enough calories, but not enough vitamins,” she said, reporting the parents said that was all he would eat. Although the boy's diet has been corrected, she reported he still has severe neuropathy and mental delay.

In another pediatric case, Dr. Drolet said that toxic epidermal necrolysis was suspected in a child with an “extremely smelly, flaky eruption.” It turned out the child had been diagnosed with a milk allergy and his diet was almost entirely Rice Dream, a nondairy beverage touted as a substitute for dairy milk.

Although Rice Dream is enriched with vitamins A, D, and B₁₂ and has comparable calcium to dairy milk, it provides little protein. Indeed, its label warns that it should not be used for infant formula or in children under 5 years of age without consulting a physician.

“This [Rice Dream] is not a bad thing if the child is getting other nutrition,” said Dr. Drolet, also of the Medical College of Wisconsin, Milwaukee.

Dr. Mark Davis of the Mayo Clinic in Rochester, Minn., described a similar case in a separate presentation on hospital dermatology at the meeting. In that case, a 2-year-old boy with rash and hair loss was diagnosed with kwashiorkor. This child also was on a Rice Dream diet, according to Dr. Davis, who emphasized the importance of history in making a diagnosis.

If a child has a nutritional deficiency, Dr. Drolet said, the facial eruption could be described by the following morphology: large plaques; large, thin scales; sharply demarcated, irregular, driplike borders; and superficial erosions.

The eruption is not itchy, she said, and it does not respond to topical steroids. The distribution is periorificial and widespread.

In addition, the child may have lackluster, hypopigmented hair with the “flag sign”—a band of lighter hair associated with nutritional deficiency.

“How does this happen in developed countries in 2006?” Dr. Drolet asked rhetorically, answering her own question with “real/perceived milk allergy, fad diets, behavioral problems, food preferences, [and] nutritional ignorance.”

Among the other nondermatologic causes of facial eruptions that could be considered when making a diagnosis, Dr. Drolet cited herpes, pediatric Horner syndrome, staphylococcus infection, juvenile idiopathic arthritis, neonatal lupus, irritable bowel disease, Crohn's disease, Henoch-Schönlein purpura, drug-induced hypersensitivity syndrome, dermoid cyst, and PHACE (posterior fossa brain malformations, hemangiomas of the face, arterial anomalies, cardiac anomalies, and eye abnormalities) syndrome.

PARK CITY, UTAH — Physicians should consider nutritional deficiencies when diagnosing facial eruptions in infants and children, according to Dr. Beth Drolet.

One of the more perplexing cases she described at a clinical dermatology seminar sponsored by Medicis was a 21/2-year-old child referred by emergency physicians for suspected Stevens-Johnson syndrome.

Dr. Drolet, medical director for dermatology at Children's Hospital of Wisconsin, Milwaukee, said the child had no history of health care or immunizations. He was brought to the hospital because of a severe rash and was found to have multiple deficiencies, including severe sensory polyneuropathy, photophobia, muscular atrophy, osteopenia, and speech and language defects.

“The child was only eating large french fries from McDonald's. He was getting enough calories, but not enough vitamins,” she said, reporting the parents said that was all he would eat. Although the boy's diet has been corrected, she reported he still has severe neuropathy and mental delay.

In another pediatric case, Dr. Drolet said that toxic epidermal necrolysis was suspected in a child with an “extremely smelly, flaky eruption.” It turned out the child had been diagnosed with a milk allergy and his diet was almost entirely Rice Dream, a nondairy beverage touted as a substitute for dairy milk.

Although Rice Dream is enriched with vitamins A, D, and B₁₂ and has comparable calcium to dairy milk, it provides little protein. Indeed, its label warns that it should not be used for infant formula or in children under 5 years of age without consulting a physician.

“This [Rice Dream] is not a bad thing if the child is getting other nutrition,” said Dr. Drolet, also of the Medical College of Wisconsin, Milwaukee.

Dr. Mark Davis of the Mayo Clinic in Rochester, Minn., described a similar case in a separate presentation on hospital dermatology at the meeting. In that case, a 2-year-old boy with rash and hair loss was diagnosed with kwashiorkor. This child also was on a Rice Dream diet, according to Dr. Davis, who emphasized the importance of history in making a diagnosis.

If a child has a nutritional deficiency, Dr. Drolet said, the facial eruption could be described by the following morphology: large plaques; large, thin scales; sharply demarcated, irregular, driplike borders; and superficial erosions.

The eruption is not itchy, she said, and it does not respond to topical steroids. The distribution is periorificial and widespread.

In addition, the child may have lackluster, hypopigmented hair with the “flag sign”—a band of lighter hair associated with nutritional deficiency.

“How does this happen in developed countries in 2006?” Dr. Drolet asked rhetorically, answering her own question with “real/perceived milk allergy, fad diets, behavioral problems, food preferences, [and] nutritional ignorance.”

Among the other nondermatologic causes of facial eruptions that could be considered when making a diagnosis, Dr. Drolet cited herpes, pediatric Horner syndrome, staphylococcus infection, juvenile idiopathic arthritis, neonatal lupus, irritable bowel disease, Crohn's disease, Henoch-Schönlein purpura, drug-induced hypersensitivity syndrome, dermoid cyst, and PHACE (posterior fossa brain malformations, hemangiomas of the face, arterial anomalies, cardiac anomalies, and eye abnormalities) syndrome.

PARK CITY, UTAH — Physicians should consider nutritional deficiencies when diagnosing facial eruptions in infants and children, according to Dr. Beth Drolet.

One of the more perplexing cases she described at a clinical dermatology seminar sponsored by Medicis was a 21/2-year-old child referred by emergency physicians for suspected Stevens-Johnson syndrome.

Dr. Drolet, medical director for dermatology at Children's Hospital of Wisconsin, Milwaukee, said the child had no history of health care or immunizations. He was brought to the hospital because of a severe rash and was found to have multiple deficiencies, including severe sensory polyneuropathy, photophobia, muscular atrophy, osteopenia, and speech and language defects.

“The child was only eating large french fries from McDonald's. He was getting enough calories, but not enough vitamins,” she said, reporting the parents said that was all he would eat. Although the boy's diet has been corrected, she reported he still has severe neuropathy and mental delay.

In another pediatric case, Dr. Drolet said that toxic epidermal necrolysis was suspected in a child with an “extremely smelly, flaky eruption.” It turned out the child had been diagnosed with a milk allergy and his diet was almost entirely Rice Dream, a nondairy beverage touted as a substitute for dairy milk.

Although Rice Dream is enriched with vitamins A, D, and B₁₂ and has comparable calcium to dairy milk, it provides little protein. Indeed, its label warns that it should not be used for infant formula or in children under 5 years of age without consulting a physician.

“This [Rice Dream] is not a bad thing if the child is getting other nutrition,” said Dr. Drolet, also of the Medical College of Wisconsin, Milwaukee.

Dr. Mark Davis of the Mayo Clinic in Rochester, Minn., described a similar case in a separate presentation on hospital dermatology at the meeting. In that case, a 2-year-old boy with rash and hair loss was diagnosed with kwashiorkor. This child also was on a Rice Dream diet, according to Dr. Davis, who emphasized the importance of history in making a diagnosis.

If a child has a nutritional deficiency, Dr. Drolet said, the facial eruption could be described by the following morphology: large plaques; large, thin scales; sharply demarcated, irregular, driplike borders; and superficial erosions.

The eruption is not itchy, she said, and it does not respond to topical steroids. The distribution is periorificial and widespread.

In addition, the child may have lackluster, hypopigmented hair with the “flag sign”—a band of lighter hair associated with nutritional deficiency.

“How does this happen in developed countries in 2006?” Dr. Drolet asked rhetorically, answering her own question with “real/perceived milk allergy, fad diets, behavioral problems, food preferences, [and] nutritional ignorance.”

Among the other nondermatologic causes of facial eruptions that could be considered when making a diagnosis, Dr. Drolet cited herpes, pediatric Horner syndrome, staphylococcus infection, juvenile idiopathic arthritis, neonatal lupus, irritable bowel disease, Crohn's disease, Henoch-Schönlein purpura, drug-induced hypersensitivity syndrome, dermoid cyst, and PHACE (posterior fossa brain malformations, hemangiomas of the face, arterial anomalies, cardiac anomalies, and eye abnormalities) syndrome.

KAPALUA, HAWAII — Since 1999, almost 13,000 Major League Baseball (MLB)players, coaches, staff, and family members have been screened for skin cancer under a program with the trademarked name of “Play Smart When It Comes to the Sun.”

Physicians from the American Academy of Dermatology (AAD) found more than 490 suspicious lesions on the “boys of summer” and those who stay out in the sun with them. Those 490 lesions included 319 suspected basal cell carcinomas, 37 suspected squamous cell carcinomas, and 43 suspected melanomas.

“Our players … no longer ask for baby oil and iodine. They know SPF numbers as well as they know the grams of protein in the shakes they are drinking,” Stephen Donohue, assistant trainer of the New York Yankees, said at the Winter Clinical Dermatology Conference, Hawaii.

“The beauty of this program is educating the public,” Mr. Donohue added. “High school kids—they see Derek Jeter or one of the public service announcements [and they think], 'If these guys are using sunblock, it must be good for me, too.'”

Public service advertisements from the program have led to more than 96 million media impressions, as well as scoreboard admonishments to put on sunscreen, Dr. Darrell Rigel told physicians at the conference, which was sponsored by the Center for Bio-Medical Communication Inc.

Dr. Rigel said the program was the idea of dermatologist Kenneth Wasserman of Drexel University, Philadelphia. Dr. Wasserman and Dr. Rigel proposed it to MLB and the MLB Players Association, and the AAD implemented the program when Rigel was president of the academy. “An important part of skin cancer prevention is in sports per se,” he said. “We know in many sports we get significant sun exposure.”

The typical player participated in Little League ball or its equivalent and has been spending time in the sun ever since, noted Dr. Rigel of New York University Medical Center. Even after they come up to the big leagues and play more games at night, the players take to the field for practice during the day.

“It's not just the players, but also their families and the people who work at the stadium each year who get lots of sun,” he added. One police officer wanted to go on television to promote sun protection after a Play Smart screening detected basal cell carcinoma. He was an undercover cop, however, and had to stay anonymous.

Two years ago, at a Play Smart screening of the San Diego Padres, a dermatologist found a suspicious mole on second baseman Mark Loretta's chest. A biopsy revealed melanoma. A California native with a family history of skin cancer, Loretta (now with the Boston Red Sox) has since joined AAD efforts to promote sun safe behavior to fans.

A diagnosis of squamous cell carcinoma helped to make pitcher Derek Lowe a sunscreen advocate, according to Dr. Mary E. Maloney, an AAD officer who screened his former team, the Boston Red Sox, for the Play Smart program. In December 2002, Lowe underwent surgery on a large growth detected on his nose in the off-season.

Dr. Maloney, director of dermatologic surgery at the University of Massachusetts, Worcester, recalled in an interview how Lowe (since traded to the Los Angeles Dodgers) would issue warnings to other players if he saw them leaving the dugout without sunscreen.

Red Sox pitcher Curt Schilling also has been supportive, Dr. Maloney added. He and his wife, Shonda, started their own foundation to promote sun protection and screening after Mrs. Schilling was treated for melanoma.

KAPALUA, HAWAII — Since 1999, almost 13,000 Major League Baseball (MLB)players, coaches, staff, and family members have been screened for skin cancer under a program with the trademarked name of “Play Smart When It Comes to the Sun.”

Physicians from the American Academy of Dermatology (AAD) found more than 490 suspicious lesions on the “boys of summer” and those who stay out in the sun with them. Those 490 lesions included 319 suspected basal cell carcinomas, 37 suspected squamous cell carcinomas, and 43 suspected melanomas.

“Our players … no longer ask for baby oil and iodine. They know SPF numbers as well as they know the grams of protein in the shakes they are drinking,” Stephen Donohue, assistant trainer of the New York Yankees, said at the Winter Clinical Dermatology Conference, Hawaii.

“The beauty of this program is educating the public,” Mr. Donohue added. “High school kids—they see Derek Jeter or one of the public service announcements [and they think], 'If these guys are using sunblock, it must be good for me, too.'”

Public service advertisements from the program have led to more than 96 million media impressions, as well as scoreboard admonishments to put on sunscreen, Dr. Darrell Rigel told physicians at the conference, which was sponsored by the Center for Bio-Medical Communication Inc.

Dr. Rigel said the program was the idea of dermatologist Kenneth Wasserman of Drexel University, Philadelphia. Dr. Wasserman and Dr. Rigel proposed it to MLB and the MLB Players Association, and the AAD implemented the program when Rigel was president of the academy. “An important part of skin cancer prevention is in sports per se,” he said. “We know in many sports we get significant sun exposure.”

The typical player participated in Little League ball or its equivalent and has been spending time in the sun ever since, noted Dr. Rigel of New York University Medical Center. Even after they come up to the big leagues and play more games at night, the players take to the field for practice during the day.

“It's not just the players, but also their families and the people who work at the stadium each year who get lots of sun,” he added. One police officer wanted to go on television to promote sun protection after a Play Smart screening detected basal cell carcinoma. He was an undercover cop, however, and had to stay anonymous.

Two years ago, at a Play Smart screening of the San Diego Padres, a dermatologist found a suspicious mole on second baseman Mark Loretta's chest. A biopsy revealed melanoma. A California native with a family history of skin cancer, Loretta (now with the Boston Red Sox) has since joined AAD efforts to promote sun safe behavior to fans.

A diagnosis of squamous cell carcinoma helped to make pitcher Derek Lowe a sunscreen advocate, according to Dr. Mary E. Maloney, an AAD officer who screened his former team, the Boston Red Sox, for the Play Smart program. In December 2002, Lowe underwent surgery on a large growth detected on his nose in the off-season.

Dr. Maloney, director of dermatologic surgery at the University of Massachusetts, Worcester, recalled in an interview how Lowe (since traded to the Los Angeles Dodgers) would issue warnings to other players if he saw them leaving the dugout without sunscreen.

Red Sox pitcher Curt Schilling also has been supportive, Dr. Maloney added. He and his wife, Shonda, started their own foundation to promote sun protection and screening after Mrs. Schilling was treated for melanoma.

KAPALUA, HAWAII — Since 1999, almost 13,000 Major League Baseball (MLB)players, coaches, staff, and family members have been screened for skin cancer under a program with the trademarked name of “Play Smart When It Comes to the Sun.”

Physicians from the American Academy of Dermatology (AAD) found more than 490 suspicious lesions on the “boys of summer” and those who stay out in the sun with them. Those 490 lesions included 319 suspected basal cell carcinomas, 37 suspected squamous cell carcinomas, and 43 suspected melanomas.

“Our players … no longer ask for baby oil and iodine. They know SPF numbers as well as they know the grams of protein in the shakes they are drinking,” Stephen Donohue, assistant trainer of the New York Yankees, said at the Winter Clinical Dermatology Conference, Hawaii.

“The beauty of this program is educating the public,” Mr. Donohue added. “High school kids—they see Derek Jeter or one of the public service announcements [and they think], 'If these guys are using sunblock, it must be good for me, too.'”

Public service advertisements from the program have led to more than 96 million media impressions, as well as scoreboard admonishments to put on sunscreen, Dr. Darrell Rigel told physicians at the conference, which was sponsored by the Center for Bio-Medical Communication Inc.

Dr. Rigel said the program was the idea of dermatologist Kenneth Wasserman of Drexel University, Philadelphia. Dr. Wasserman and Dr. Rigel proposed it to MLB and the MLB Players Association, and the AAD implemented the program when Rigel was president of the academy. “An important part of skin cancer prevention is in sports per se,” he said. “We know in many sports we get significant sun exposure.”

The typical player participated in Little League ball or its equivalent and has been spending time in the sun ever since, noted Dr. Rigel of New York University Medical Center. Even after they come up to the big leagues and play more games at night, the players take to the field for practice during the day.

“It's not just the players, but also their families and the people who work at the stadium each year who get lots of sun,” he added. One police officer wanted to go on television to promote sun protection after a Play Smart screening detected basal cell carcinoma. He was an undercover cop, however, and had to stay anonymous.

Two years ago, at a Play Smart screening of the San Diego Padres, a dermatologist found a suspicious mole on second baseman Mark Loretta's chest. A biopsy revealed melanoma. A California native with a family history of skin cancer, Loretta (now with the Boston Red Sox) has since joined AAD efforts to promote sun safe behavior to fans.

A diagnosis of squamous cell carcinoma helped to make pitcher Derek Lowe a sunscreen advocate, according to Dr. Mary E. Maloney, an AAD officer who screened his former team, the Boston Red Sox, for the Play Smart program. In December 2002, Lowe underwent surgery on a large growth detected on his nose in the off-season.

Dr. Maloney, director of dermatologic surgery at the University of Massachusetts, Worcester, recalled in an interview how Lowe (since traded to the Los Angeles Dodgers) would issue warnings to other players if he saw them leaving the dugout without sunscreen.

Red Sox pitcher Curt Schilling also has been supportive, Dr. Maloney added. He and his wife, Shonda, started their own foundation to promote sun protection and screening after Mrs. Schilling was treated for melanoma.