Kerri Wachter

PHILADELPHIA — When it comes to the management of epidermolysis bullosa, patient preference for bathing and dressings is important, follow-up is key to the treatment of associated anemia, and lesions suspicious for squamous cell carcinoma should undergo early biopsy and be treated aggressively, according to Dr. Dedee F. Murrell, an expert in the care of patients with this painful condition.

Dr. Murrell focused on these areas during her presentation on the management of epidermolysis bullosa (EB) at the annual meeting of the Society for Pediatric Dermatology. In Australia, she is the chair of the dermatology department at St. George Hospital in Kogarah, New South Wales, and a consultant dermatologist for EB at Sydney Children's Hospital in Randwick, New South Wales.

Dressings and Bathing

There is no consensus on how to bathe infants with EB. "There's still debate about whether you should immerse the baby completely in the bath or change the dressings limb by limb," she said. Although the limb-by-limb method may be easier to teach parents, one drawback is that the baby never learns to be comfortable with the bath setting.

"We've found it very useful in Sydney to use heated-up normal saline baths for these newborns. It makes [the water] comfortable and doesn't sting their skin when they go in the bath," she said. Some older children move on to showering, but most do not like the feeling of water splashing on their skin and prefer bathing.

"We tend to recommend saline baths for bigger patients," she noted. Patients are advised to add 1 kg of swimming pool salts to the bath water. Swimming pool salts are cheaper to use than table salt. Sometimes patients are advised to add a half cup of bleach to reduce colonization of the skin.

When their dressings are changed, it is important for patients or their caretakers to pop the EB blisters to reduce the extension of the blisters. Dr. Murrell and her colleagues usually recommend using a large-bore (such as a 19-gauge) sterile needle, which is inserted parallel to the skin surface so that it doesn't hurt the underlying skin. It's better to rupture the blister in the lowest part, so that it does not reaccumulate fluid when the patient stands. Next, press gauze over the blister to drain and collect the fluid. "Some patients prefer scissors and others even use scalpels, but I think there are [fewer accidents] with the needles," she said.

As for the optimal dressing, "I believe, personally, that the ideal dressings for EB are still to be found," said Dr. Murrell.

For now, nonstick, silicone-based dressings appear to be the best option. However, most of these require secondary dressings of variable thickness to absorb the exudate, depending on the wound. Some products are available with combined primary and secondary dressings.

Most dressings need bandages to hold them in place. "You need special training and experience not to wrap them too tightly and cause new blistering by too much pressure at the edge of these dressings," she said. For children—especially those with recessive dystrophic EB (RDEB), whose fingers are eroded—parents need to be taught how to wrap the fingers individually. Parents also need to be taught how to lift children with EB to avoid causing more blisters.

Silver-impregnated dressings are also an option, particularly the newer ones that are silicone based. However, these cannot be used continuously for a long period of time because of the possibility of argyria.

Anemia

"It turns out that it's not just iron-deficiency anemia these patients have, but anemia of chronic disease as well," said Dr. Murrell. Patients with EB have persistently open wounds and repeated infections. As a defense mechanism, cytokines reduce the availability of iron so that infectious organisms cannot use it. Reduced iron availability, coupled with loss of iron through the skin, leads to low serum iron and altered iron metabolism. The inflammatory response in these patients also leads to blunted erythropoietin response. Cytokines, such as interferon-gamma and tumor necrosis factor–alpha, interfere with bone marrow response to erythropoietin.

"Malnutrition doesn't assist us in the management of anemia either. That's another problem these patients face," said Dr. Murrell. Patients with EB have low protein and albumin levels, and may also have low vitamin C levels. Protein has been shown in animals to lower the body's production of erythropoietin. In addition, iron deficiency can cause mucosal changes that reduce the intestine's ability to absorb iron. As a result, patients with EB need parenteral iron. Intravenous parenteral iron is preferable because intramuscular injection is painful and these patients often have low muscle mass.

Anemia treatments include combinations of oral iron supplements, blood transfusions, parenteral iron infusions, and erythropoietin. Patients taking oral iron supplements should be advised to take them between meals and without milk to improve absorption. The ferrous form is more soluble and better absorbed; however, this advantage comes at the cost of more side effects (such as constipation). The ferric form is less soluble and has fewer side effects, but leads to a slower response.

Poor compliance rates with oral iron supplements often result from dysphagia and constipation. However, poor gastrointestinal absorption and lack of bone marrow response may also contribute to poor results. Adequate vitamin C levels can improve iron absorption, she said.

Blood transfusions are reserved for patients with low hemoglobin (less than 7 g/dL). Use of transfusions tends to be restricted because of adverse events, said Dr. Murrell. These adverse events include the potential risk of infection (for example, from hepatitis). In addition, transfusions may require time off from work for family members, and may result in psychological costs as well.

Iron transfusions had fallen out of favor because of reactions to intravenous iron-dextran and intramuscular iron-sorbitol-citric acid. However, ferric hydroxide–sucrose mixtures are safer to use. "We're now using these iron infusions many times as an alternative to blood transfusions," she said.

Iron deficiencies need to be corrected for erythropoietin to increase erythropoiesis and raise hemoglobin levels. Studies of erythropoietin that was given to improve chronic anemia in children with inflammatory arthritis have shown improvements in quality of life, energy levels, appetite, and mental functioning. However, the drug did not work without adequate iron levels.

At the EB clinic in Sydney, patients have blood work done 3 weeks prior to a visit. Physicians look at patient levels of hemoglobin, mean corpuscular volume, reticulocyte count, and soluble transferring receptor levels. If iron levels are low, they will start the patient on oral iron and vitamin C supplements, along with nutritional support.

However, if a patient fails to respond, erythropoietin levels are checked. Iron infusions are then given every 3 months. If iron levels increase, the patient is started on erythropoietin every 2 weeks. Blood parameters are monitored every 3 months.

Squamous Cell Carcinoma in EB

SCC in patients with EB is more aggressive than other cutaneous SCCs and occurs at a much younger age, Dr. Murrell noted. "These tumors behave in a highly anaplastic way, despite looking well differentiated on pathology." SCC is the No. 1 cause of death in patients with recessive dystrophic EB, she said.

Most SCCs arise on the hands and feet. "However, [these SCCs] are often multifocal, so you can't just examine the hands and feet of these patients. SCCs arise in wound margins at the sites of chronic blistering and scarring," Dr. Murrell said. The appearance of these lesions can be highly variable. "They may look hyperkeratotic and exophytic, but sometimes they just look like ulcers that haven't been healing," she said. Typically, several biopsies are necessary to exclude SCC.

SCCs in patients with EB appear to be associated with chronic wounds. "One of the theories is that there are mutations arising during wound repair [that] are not being recognized and being fixed," said Dr. Murrell.

"The early recognition of SCC is really important. In my mind, it's like early recognition of melanoma," she said.

Dr. Murrell and her colleagues have been following 16 RDEB patients since 1999. They perform biopsies on any nodules or ulcers that persist for more than 3 months, or any nodules that become enlarged or are painful. Photographic monitoring provides documentation of erosion size and location. This is very helpful in identifying and performing biopsies on lesions that persist.

One of the keys to this approach is patient participation. Dr. Murrell told of a 20-year-old patient who did not regularly attend these sessions, and ultimately had to have her hand amputated. In contrast, a 60-year-old patient has had more than 50 early SCC excisions and is still doing well. "She jumps at getting the biopsies done as soon as she realizes there is anything unusual or untoward about any of her wounds," said Dr. Murrell.

Patients with EB need vigilant monitoring for SCCs. Treating physicians should have a low threshold for biopsy. If an SCC is identified, a wide excision should be performed, said Dr. Murrell.

In terms of treatment, Mohs surgery has been used for SCCs in patients with RDEB. However, "I'd be hesitant to use that because the margins are not very big," she said.

Retinoids have been proved to reduce SCCs in immunosuppressed patients. "We use them a lot in Australia in elderly people with multiple SCCs," said Dr. Murrell. In particular, isotretinoin and acitretin are both well tolerated.

One area of active research is the use of epidermal growth factor receptor (EGFR) inhibitors. EGFR is strongly expressed in metastatic SCCs of the skin. Cetuximab is indicated in the United States for the treatment of locally or regionally advanced SCC of the head and neck in combination with radiation therapy, and in recurrent or metastatic SCC of the head and neck that progresses after platinum-based therapy.

Dr. Murrell reported that she has received financial support from Mölnlycke Health Care, which makes wound dressings.

This patient with recessive dystrophic EB and pseudosyndactyly did not attend regular follow-ups. She developed SCC on the right hand (above), and it had to be amputated.

Source ©Dr. Dedee F. Murrell

PHILADELPHIA — When it comes to the management of epidermolysis bullosa, patient preference for bathing and dressings is important, follow-up is key to the treatment of associated anemia, and lesions suspicious for squamous cell carcinoma should undergo early biopsy and be treated aggressively, according to Dr. Dedee F. Murrell, an expert in the care of patients with this painful condition.

Dr. Murrell focused on these areas during her presentation on the management of epidermolysis bullosa (EB) at the annual meeting of the Society for Pediatric Dermatology. In Australia, she is the chair of the dermatology department at St. George Hospital in Kogarah, New South Wales, and a consultant dermatologist for EB at Sydney Children's Hospital in Randwick, New South Wales.

Dressings and Bathing

There is no consensus on how to bathe infants with EB. "There's still debate about whether you should immerse the baby completely in the bath or change the dressings limb by limb," she said. Although the limb-by-limb method may be easier to teach parents, one drawback is that the baby never learns to be comfortable with the bath setting.

"We've found it very useful in Sydney to use heated-up normal saline baths for these newborns. It makes [the water] comfortable and doesn't sting their skin when they go in the bath," she said. Some older children move on to showering, but most do not like the feeling of water splashing on their skin and prefer bathing.

"We tend to recommend saline baths for bigger patients," she noted. Patients are advised to add 1 kg of swimming pool salts to the bath water. Swimming pool salts are cheaper to use than table salt. Sometimes patients are advised to add a half cup of bleach to reduce colonization of the skin.

When their dressings are changed, it is important for patients or their caretakers to pop the EB blisters to reduce the extension of the blisters. Dr. Murrell and her colleagues usually recommend using a large-bore (such as a 19-gauge) sterile needle, which is inserted parallel to the skin surface so that it doesn't hurt the underlying skin. It's better to rupture the blister in the lowest part, so that it does not reaccumulate fluid when the patient stands. Next, press gauze over the blister to drain and collect the fluid. "Some patients prefer scissors and others even use scalpels, but I think there are [fewer accidents] with the needles," she said.

As for the optimal dressing, "I believe, personally, that the ideal dressings for EB are still to be found," said Dr. Murrell.

For now, nonstick, silicone-based dressings appear to be the best option. However, most of these require secondary dressings of variable thickness to absorb the exudate, depending on the wound. Some products are available with combined primary and secondary dressings.

Most dressings need bandages to hold them in place. "You need special training and experience not to wrap them too tightly and cause new blistering by too much pressure at the edge of these dressings," she said. For children—especially those with recessive dystrophic EB (RDEB), whose fingers are eroded—parents need to be taught how to wrap the fingers individually. Parents also need to be taught how to lift children with EB to avoid causing more blisters.

Silver-impregnated dressings are also an option, particularly the newer ones that are silicone based. However, these cannot be used continuously for a long period of time because of the possibility of argyria.

Anemia

"It turns out that it's not just iron-deficiency anemia these patients have, but anemia of chronic disease as well," said Dr. Murrell. Patients with EB have persistently open wounds and repeated infections. As a defense mechanism, cytokines reduce the availability of iron so that infectious organisms cannot use it. Reduced iron availability, coupled with loss of iron through the skin, leads to low serum iron and altered iron metabolism. The inflammatory response in these patients also leads to blunted erythropoietin response. Cytokines, such as interferon-gamma and tumor necrosis factor–alpha, interfere with bone marrow response to erythropoietin.

"Malnutrition doesn't assist us in the management of anemia either. That's another problem these patients face," said Dr. Murrell. Patients with EB have low protein and albumin levels, and may also have low vitamin C levels. Protein has been shown in animals to lower the body's production of erythropoietin. In addition, iron deficiency can cause mucosal changes that reduce the intestine's ability to absorb iron. As a result, patients with EB need parenteral iron. Intravenous parenteral iron is preferable because intramuscular injection is painful and these patients often have low muscle mass.

Anemia treatments include combinations of oral iron supplements, blood transfusions, parenteral iron infusions, and erythropoietin. Patients taking oral iron supplements should be advised to take them between meals and without milk to improve absorption. The ferrous form is more soluble and better absorbed; however, this advantage comes at the cost of more side effects (such as constipation). The ferric form is less soluble and has fewer side effects, but leads to a slower response.

Poor compliance rates with oral iron supplements often result from dysphagia and constipation. However, poor gastrointestinal absorption and lack of bone marrow response may also contribute to poor results. Adequate vitamin C levels can improve iron absorption, she said.

Blood transfusions are reserved for patients with low hemoglobin (less than 7 g/dL). Use of transfusions tends to be restricted because of adverse events, said Dr. Murrell. These adverse events include the potential risk of infection (for example, from hepatitis). In addition, transfusions may require time off from work for family members, and may result in psychological costs as well.

Iron transfusions had fallen out of favor because of reactions to intravenous iron-dextran and intramuscular iron-sorbitol-citric acid. However, ferric hydroxide–sucrose mixtures are safer to use. "We're now using these iron infusions many times as an alternative to blood transfusions," she said.

Iron deficiencies need to be corrected for erythropoietin to increase erythropoiesis and raise hemoglobin levels. Studies of erythropoietin that was given to improve chronic anemia in children with inflammatory arthritis have shown improvements in quality of life, energy levels, appetite, and mental functioning. However, the drug did not work without adequate iron levels.

At the EB clinic in Sydney, patients have blood work done 3 weeks prior to a visit. Physicians look at patient levels of hemoglobin, mean corpuscular volume, reticulocyte count, and soluble transferring receptor levels. If iron levels are low, they will start the patient on oral iron and vitamin C supplements, along with nutritional support.

However, if a patient fails to respond, erythropoietin levels are checked. Iron infusions are then given every 3 months. If iron levels increase, the patient is started on erythropoietin every 2 weeks. Blood parameters are monitored every 3 months.

Squamous Cell Carcinoma in EB

SCC in patients with EB is more aggressive than other cutaneous SCCs and occurs at a much younger age, Dr. Murrell noted. "These tumors behave in a highly anaplastic way, despite looking well differentiated on pathology." SCC is the No. 1 cause of death in patients with recessive dystrophic EB, she said.

Most SCCs arise on the hands and feet. "However, [these SCCs] are often multifocal, so you can't just examine the hands and feet of these patients. SCCs arise in wound margins at the sites of chronic blistering and scarring," Dr. Murrell said. The appearance of these lesions can be highly variable. "They may look hyperkeratotic and exophytic, but sometimes they just look like ulcers that haven't been healing," she said. Typically, several biopsies are necessary to exclude SCC.

SCCs in patients with EB appear to be associated with chronic wounds. "One of the theories is that there are mutations arising during wound repair [that] are not being recognized and being fixed," said Dr. Murrell.

"The early recognition of SCC is really important. In my mind, it's like early recognition of melanoma," she said.

Dr. Murrell and her colleagues have been following 16 RDEB patients since 1999. They perform biopsies on any nodules or ulcers that persist for more than 3 months, or any nodules that become enlarged or are painful. Photographic monitoring provides documentation of erosion size and location. This is very helpful in identifying and performing biopsies on lesions that persist.

One of the keys to this approach is patient participation. Dr. Murrell told of a 20-year-old patient who did not regularly attend these sessions, and ultimately had to have her hand amputated. In contrast, a 60-year-old patient has had more than 50 early SCC excisions and is still doing well. "She jumps at getting the biopsies done as soon as she realizes there is anything unusual or untoward about any of her wounds," said Dr. Murrell.

Patients with EB need vigilant monitoring for SCCs. Treating physicians should have a low threshold for biopsy. If an SCC is identified, a wide excision should be performed, said Dr. Murrell.

In terms of treatment, Mohs surgery has been used for SCCs in patients with RDEB. However, "I'd be hesitant to use that because the margins are not very big," she said.

Retinoids have been proved to reduce SCCs in immunosuppressed patients. "We use them a lot in Australia in elderly people with multiple SCCs," said Dr. Murrell. In particular, isotretinoin and acitretin are both well tolerated.

One area of active research is the use of epidermal growth factor receptor (EGFR) inhibitors. EGFR is strongly expressed in metastatic SCCs of the skin. Cetuximab is indicated in the United States for the treatment of locally or regionally advanced SCC of the head and neck in combination with radiation therapy, and in recurrent or metastatic SCC of the head and neck that progresses after platinum-based therapy.

Dr. Murrell reported that she has received financial support from Mölnlycke Health Care, which makes wound dressings.

This patient with recessive dystrophic EB and pseudosyndactyly did not attend regular follow-ups. She developed SCC on the right hand (above), and it had to be amputated.

Source ©Dr. Dedee F. Murrell

PHILADELPHIA — When it comes to the management of epidermolysis bullosa, patient preference for bathing and dressings is important, follow-up is key to the treatment of associated anemia, and lesions suspicious for squamous cell carcinoma should undergo early biopsy and be treated aggressively, according to Dr. Dedee F. Murrell, an expert in the care of patients with this painful condition.

Dr. Murrell focused on these areas during her presentation on the management of epidermolysis bullosa (EB) at the annual meeting of the Society for Pediatric Dermatology. In Australia, she is the chair of the dermatology department at St. George Hospital in Kogarah, New South Wales, and a consultant dermatologist for EB at Sydney Children's Hospital in Randwick, New South Wales.

Dressings and Bathing

There is no consensus on how to bathe infants with EB. "There's still debate about whether you should immerse the baby completely in the bath or change the dressings limb by limb," she said. Although the limb-by-limb method may be easier to teach parents, one drawback is that the baby never learns to be comfortable with the bath setting.

"We've found it very useful in Sydney to use heated-up normal saline baths for these newborns. It makes [the water] comfortable and doesn't sting their skin when they go in the bath," she said. Some older children move on to showering, but most do not like the feeling of water splashing on their skin and prefer bathing.

"We tend to recommend saline baths for bigger patients," she noted. Patients are advised to add 1 kg of swimming pool salts to the bath water. Swimming pool salts are cheaper to use than table salt. Sometimes patients are advised to add a half cup of bleach to reduce colonization of the skin.

When their dressings are changed, it is important for patients or their caretakers to pop the EB blisters to reduce the extension of the blisters. Dr. Murrell and her colleagues usually recommend using a large-bore (such as a 19-gauge) sterile needle, which is inserted parallel to the skin surface so that it doesn't hurt the underlying skin. It's better to rupture the blister in the lowest part, so that it does not reaccumulate fluid when the patient stands. Next, press gauze over the blister to drain and collect the fluid. "Some patients prefer scissors and others even use scalpels, but I think there are [fewer accidents] with the needles," she said.

As for the optimal dressing, "I believe, personally, that the ideal dressings for EB are still to be found," said Dr. Murrell.

For now, nonstick, silicone-based dressings appear to be the best option. However, most of these require secondary dressings of variable thickness to absorb the exudate, depending on the wound. Some products are available with combined primary and secondary dressings.

Most dressings need bandages to hold them in place. "You need special training and experience not to wrap them too tightly and cause new blistering by too much pressure at the edge of these dressings," she said. For children—especially those with recessive dystrophic EB (RDEB), whose fingers are eroded—parents need to be taught how to wrap the fingers individually. Parents also need to be taught how to lift children with EB to avoid causing more blisters.

Silver-impregnated dressings are also an option, particularly the newer ones that are silicone based. However, these cannot be used continuously for a long period of time because of the possibility of argyria.

Anemia

"It turns out that it's not just iron-deficiency anemia these patients have, but anemia of chronic disease as well," said Dr. Murrell. Patients with EB have persistently open wounds and repeated infections. As a defense mechanism, cytokines reduce the availability of iron so that infectious organisms cannot use it. Reduced iron availability, coupled with loss of iron through the skin, leads to low serum iron and altered iron metabolism. The inflammatory response in these patients also leads to blunted erythropoietin response. Cytokines, such as interferon-gamma and tumor necrosis factor–alpha, interfere with bone marrow response to erythropoietin.

"Malnutrition doesn't assist us in the management of anemia either. That's another problem these patients face," said Dr. Murrell. Patients with EB have low protein and albumin levels, and may also have low vitamin C levels. Protein has been shown in animals to lower the body's production of erythropoietin. In addition, iron deficiency can cause mucosal changes that reduce the intestine's ability to absorb iron. As a result, patients with EB need parenteral iron. Intravenous parenteral iron is preferable because intramuscular injection is painful and these patients often have low muscle mass.

Anemia treatments include combinations of oral iron supplements, blood transfusions, parenteral iron infusions, and erythropoietin. Patients taking oral iron supplements should be advised to take them between meals and without milk to improve absorption. The ferrous form is more soluble and better absorbed; however, this advantage comes at the cost of more side effects (such as constipation). The ferric form is less soluble and has fewer side effects, but leads to a slower response.

Poor compliance rates with oral iron supplements often result from dysphagia and constipation. However, poor gastrointestinal absorption and lack of bone marrow response may also contribute to poor results. Adequate vitamin C levels can improve iron absorption, she said.

Blood transfusions are reserved for patients with low hemoglobin (less than 7 g/dL). Use of transfusions tends to be restricted because of adverse events, said Dr. Murrell. These adverse events include the potential risk of infection (for example, from hepatitis). In addition, transfusions may require time off from work for family members, and may result in psychological costs as well.

Iron transfusions had fallen out of favor because of reactions to intravenous iron-dextran and intramuscular iron-sorbitol-citric acid. However, ferric hydroxide–sucrose mixtures are safer to use. "We're now using these iron infusions many times as an alternative to blood transfusions," she said.

Iron deficiencies need to be corrected for erythropoietin to increase erythropoiesis and raise hemoglobin levels. Studies of erythropoietin that was given to improve chronic anemia in children with inflammatory arthritis have shown improvements in quality of life, energy levels, appetite, and mental functioning. However, the drug did not work without adequate iron levels.

At the EB clinic in Sydney, patients have blood work done 3 weeks prior to a visit. Physicians look at patient levels of hemoglobin, mean corpuscular volume, reticulocyte count, and soluble transferring receptor levels. If iron levels are low, they will start the patient on oral iron and vitamin C supplements, along with nutritional support.

However, if a patient fails to respond, erythropoietin levels are checked. Iron infusions are then given every 3 months. If iron levels increase, the patient is started on erythropoietin every 2 weeks. Blood parameters are monitored every 3 months.

Squamous Cell Carcinoma in EB

SCC in patients with EB is more aggressive than other cutaneous SCCs and occurs at a much younger age, Dr. Murrell noted. "These tumors behave in a highly anaplastic way, despite looking well differentiated on pathology." SCC is the No. 1 cause of death in patients with recessive dystrophic EB, she said.

Most SCCs arise on the hands and feet. "However, [these SCCs] are often multifocal, so you can't just examine the hands and feet of these patients. SCCs arise in wound margins at the sites of chronic blistering and scarring," Dr. Murrell said. The appearance of these lesions can be highly variable. "They may look hyperkeratotic and exophytic, but sometimes they just look like ulcers that haven't been healing," she said. Typically, several biopsies are necessary to exclude SCC.

SCCs in patients with EB appear to be associated with chronic wounds. "One of the theories is that there are mutations arising during wound repair [that] are not being recognized and being fixed," said Dr. Murrell.

"The early recognition of SCC is really important. In my mind, it's like early recognition of melanoma," she said.

Dr. Murrell and her colleagues have been following 16 RDEB patients since 1999. They perform biopsies on any nodules or ulcers that persist for more than 3 months, or any nodules that become enlarged or are painful. Photographic monitoring provides documentation of erosion size and location. This is very helpful in identifying and performing biopsies on lesions that persist.

One of the keys to this approach is patient participation. Dr. Murrell told of a 20-year-old patient who did not regularly attend these sessions, and ultimately had to have her hand amputated. In contrast, a 60-year-old patient has had more than 50 early SCC excisions and is still doing well. "She jumps at getting the biopsies done as soon as she realizes there is anything unusual or untoward about any of her wounds," said Dr. Murrell.

Patients with EB need vigilant monitoring for SCCs. Treating physicians should have a low threshold for biopsy. If an SCC is identified, a wide excision should be performed, said Dr. Murrell.

In terms of treatment, Mohs surgery has been used for SCCs in patients with RDEB. However, "I'd be hesitant to use that because the margins are not very big," she said.

Retinoids have been proved to reduce SCCs in immunosuppressed patients. "We use them a lot in Australia in elderly people with multiple SCCs," said Dr. Murrell. In particular, isotretinoin and acitretin are both well tolerated.

One area of active research is the use of epidermal growth factor receptor (EGFR) inhibitors. EGFR is strongly expressed in metastatic SCCs of the skin. Cetuximab is indicated in the United States for the treatment of locally or regionally advanced SCC of the head and neck in combination with radiation therapy, and in recurrent or metastatic SCC of the head and neck that progresses after platinum-based therapy.

Dr. Murrell reported that she has received financial support from Mölnlycke Health Care, which makes wound dressings.

This patient with recessive dystrophic EB and pseudosyndactyly did not attend regular follow-ups. She developed SCC on the right hand (above), and it had to be amputated.

Source ©Dr. Dedee F. Murrell

BOSTON — Cosmetic dermatologists have the knowledge and training to choose the right fillers that will garner the best results, according to Dr. Mary Lupo.

"Every FDA-approved filler, in my opinion, has an appropriate indication. You just need to know the relative strengths and weaknesses," said Dr. Lupo, at the American Academy of Dermatology's Academy 2009 meeting.

Optimal results require an appropriate candidate, the choice of an appropriate product based on the patient's presentation, injection of a sufficient amount of product, the right complementing procedures, and maintenance of the effect with touch-ups, said Dr. Lupo, professor of dermatology at Tulane University in New Orleans.

Treating Older Patients

In general, older patients need more volume restoration, because their immune response is decreased. "So when one has an active filler, such as poly-L-lactic acid, the older patient may have less of an immune response to give you a final result," she said. However, the corollary is that the older patient may require so much volume with other fillers that it becomes financially unfeasible.

"Older patients always need complementing procedures to get a good result," she said.

When examining the defect being considered for correction, decide whether it is a line or a fold. Lines require less viscous fillers to avoid lumpiness. "When a skin fold is more redundant, however, you need a thicker, more structural filler in order to lift the fold." When working with folds, Dr. Lupo recommends improving the area superior to the fold in addition to filling the fold.

When talking with the patient, "it's important to point out that it really doesn't do much good to fill a line if the overall photoaging is so severe and the 'canvas of the skin' is so mottled and deformed that it will not give an overall improvement," she said. Fillers can be used adjunctively with other methods to achieve better results.

Filler Contraindications

Many of the hyaluronic acid (HA) fillers are manufactured from a streptococcal fermentation process, so ask about hypersensitivity to strep, she said. Some patients have sensitivity to lidocaine. If this is the case, avoid using Prevelle Silk, CosmoDerm, and CosmoPlast. Poly-L-lactic acid is a component of Vicryl sutures, so if a patient has a history of allergic reaction to these sutures, avoid using Sculptra.

The use of anticoagulants by a patient is not necessarily a contraindication, "but it certainly behooves you to discuss the incidence of bruising that might be significant in these patients," Dr. Lupo said. For smokers wanting fillers, she uses a consent form to make these patients aware of the increased risk of necrosis.

Managing Expectations

The issue of cost also should be part of the discussion. Older patients will need more filler, meaning that temporary fillers may not be as cost effective over time. Semipermanent fillers may offer more benefit and it might be worth considering permanent.

To get the most out of a filler, complementing procedures should be considered. Such procedures can include onabotulinumtoxinA (Botox), intense pulsed light, chemical peel, nonablative laser, and ablative laser. "At the end of the day, the more procedures that a patient can afford, the better they will look," Dr. Lupo noted.

The Fillers

▸ CosmoDerm and CosmoPlast (human collagen). These products are the best choice for immediate results. They are great for lining the lips and for fine perioral lines, and both are fairly painless. They have a short duration, however, and both will be discontinued in 2010, according to Dr. Lupo.

▸ Restylane (HA gel). The filler is versatile and can be reversed by using hyaluronidase. It also can be injected with a finer-gauge needle, which reduces pain and allows treatment of finer lines. One injection lasts about 6 months, but it can last longer with touch-ups. Swelling and bruising should be considered, she said.

▸ Perlane (HA gel). This filler is a larger-particle gel suspension of HA. It is typically used for nasolabial folds and cheeks, and it can be used for lips with good technique to avoid lumping. "I have not found that the duration is any better than with Restylane," said Dr. Lupo.

▸ Juvéderm Ultra and Juvéderm Ultra Plus (cross-linked HA). This product is malleable and soft. It is also great for lips; however, because it is so malleable, it is not the best choice for defining the lip border. This filler is also reversible. "It is a little bit harder to get through a 1-inch needle," she said. Duration is 7-9 months without touch-ups.

Juvéderm Ultra Plus is the same as Juvéderm Ultra, although increased crosslinking of HA results in improved longevity—up to 1 year without touch-ups. "It's never to be used in fine lines, in my opinion," Dr. Lupo said. It is best injected with a 30-gauge needle. This filler is extremely good in skin of color.

▸ Prevelle Silk (cross-linked HA and lidocaine). The added lidocaine decreases patient discomfort. There is very little swelling because of the low HA concentration, but as a result it does not last as long—3 months or less. "It's inexpensive, and it's a good introductory filler for the hesitant patient," she said.

▸ Elevess (cross-linked HA and lidocaine). Elevess has the highest concentration of HA available on the market. "My personal opinion, based on my limited experience with it, is that it tends to be highly inflammatory as a result of this high concentration of HA," she said.

▸ Radiesse (calcium hydroxylapatite). This structural filler is great for men. It does cause a lot of same-day redness. "I do routinely mix it with lidocaine, and that is now FDA approved and has been found not to decrease its longevity," she said. It's a good choice for marionette lines and the pre-jowl sulcus, but avoid using it for the lips, she said.

▸ Sculptra (poly-L-lactic acid). The FDA cleared Sculptra this year for cosmetic purposes—correction of mild-to-severe nasolabial folds and wrinkles and contour irregularities. "The optimal patient for this is a younger lipoatrophy patient, because these patients still have enough of an immune response to actually get a good bang for the buck," she said. This filler is not reversible. The most common problem with Sculptra is the presence of nodules if it is injected too superficially, said Dr. Lupo.

▸ Evolence (porcine collagen). "In my opinion, it's a stiffer, more structural filler," she said. It works well in the nasolabial folds. Dr. Lupo always mixes it with lidocaine, though this makes it flow more quickly, so she uses a 30-gauge needle. It is a good choice for men with thick skin. Evolence has a low incidence of bruising and swelling.

Dr. Lupo reported significant financial relationships with a number of pharmaceutical and skin care companies.

A patient is shown before treatment with one syringe of Restylane.

The effect was prolonged for 3.5 years by performing periodic touch-ups.

Source Photos courtesy Dr. Mary Lupo

BOSTON — Cosmetic dermatologists have the knowledge and training to choose the right fillers that will garner the best results, according to Dr. Mary Lupo.

"Every FDA-approved filler, in my opinion, has an appropriate indication. You just need to know the relative strengths and weaknesses," said Dr. Lupo, at the American Academy of Dermatology's Academy 2009 meeting.

Optimal results require an appropriate candidate, the choice of an appropriate product based on the patient's presentation, injection of a sufficient amount of product, the right complementing procedures, and maintenance of the effect with touch-ups, said Dr. Lupo, professor of dermatology at Tulane University in New Orleans.

Treating Older Patients

In general, older patients need more volume restoration, because their immune response is decreased. "So when one has an active filler, such as poly-L-lactic acid, the older patient may have less of an immune response to give you a final result," she said. However, the corollary is that the older patient may require so much volume with other fillers that it becomes financially unfeasible.

"Older patients always need complementing procedures to get a good result," she said.

When examining the defect being considered for correction, decide whether it is a line or a fold. Lines require less viscous fillers to avoid lumpiness. "When a skin fold is more redundant, however, you need a thicker, more structural filler in order to lift the fold." When working with folds, Dr. Lupo recommends improving the area superior to the fold in addition to filling the fold.

When talking with the patient, "it's important to point out that it really doesn't do much good to fill a line if the overall photoaging is so severe and the 'canvas of the skin' is so mottled and deformed that it will not give an overall improvement," she said. Fillers can be used adjunctively with other methods to achieve better results.

Filler Contraindications

Many of the hyaluronic acid (HA) fillers are manufactured from a streptococcal fermentation process, so ask about hypersensitivity to strep, she said. Some patients have sensitivity to lidocaine. If this is the case, avoid using Prevelle Silk, CosmoDerm, and CosmoPlast. Poly-L-lactic acid is a component of Vicryl sutures, so if a patient has a history of allergic reaction to these sutures, avoid using Sculptra.

The use of anticoagulants by a patient is not necessarily a contraindication, "but it certainly behooves you to discuss the incidence of bruising that might be significant in these patients," Dr. Lupo said. For smokers wanting fillers, she uses a consent form to make these patients aware of the increased risk of necrosis.

Managing Expectations

The issue of cost also should be part of the discussion. Older patients will need more filler, meaning that temporary fillers may not be as cost effective over time. Semipermanent fillers may offer more benefit and it might be worth considering permanent.

To get the most out of a filler, complementing procedures should be considered. Such procedures can include onabotulinumtoxinA (Botox), intense pulsed light, chemical peel, nonablative laser, and ablative laser. "At the end of the day, the more procedures that a patient can afford, the better they will look," Dr. Lupo noted.

The Fillers

▸ CosmoDerm and CosmoPlast (human collagen). These products are the best choice for immediate results. They are great for lining the lips and for fine perioral lines, and both are fairly painless. They have a short duration, however, and both will be discontinued in 2010, according to Dr. Lupo.

▸ Restylane (HA gel). The filler is versatile and can be reversed by using hyaluronidase. It also can be injected with a finer-gauge needle, which reduces pain and allows treatment of finer lines. One injection lasts about 6 months, but it can last longer with touch-ups. Swelling and bruising should be considered, she said.

▸ Perlane (HA gel). This filler is a larger-particle gel suspension of HA. It is typically used for nasolabial folds and cheeks, and it can be used for lips with good technique to avoid lumping. "I have not found that the duration is any better than with Restylane," said Dr. Lupo.

▸ Juvéderm Ultra and Juvéderm Ultra Plus (cross-linked HA). This product is malleable and soft. It is also great for lips; however, because it is so malleable, it is not the best choice for defining the lip border. This filler is also reversible. "It is a little bit harder to get through a 1-inch needle," she said. Duration is 7-9 months without touch-ups.

Juvéderm Ultra Plus is the same as Juvéderm Ultra, although increased crosslinking of HA results in improved longevity—up to 1 year without touch-ups. "It's never to be used in fine lines, in my opinion," Dr. Lupo said. It is best injected with a 30-gauge needle. This filler is extremely good in skin of color.

▸ Prevelle Silk (cross-linked HA and lidocaine). The added lidocaine decreases patient discomfort. There is very little swelling because of the low HA concentration, but as a result it does not last as long—3 months or less. "It's inexpensive, and it's a good introductory filler for the hesitant patient," she said.

▸ Elevess (cross-linked HA and lidocaine). Elevess has the highest concentration of HA available on the market. "My personal opinion, based on my limited experience with it, is that it tends to be highly inflammatory as a result of this high concentration of HA," she said.

▸ Radiesse (calcium hydroxylapatite). This structural filler is great for men. It does cause a lot of same-day redness. "I do routinely mix it with lidocaine, and that is now FDA approved and has been found not to decrease its longevity," she said. It's a good choice for marionette lines and the pre-jowl sulcus, but avoid using it for the lips, she said.

▸ Sculptra (poly-L-lactic acid). The FDA cleared Sculptra this year for cosmetic purposes—correction of mild-to-severe nasolabial folds and wrinkles and contour irregularities. "The optimal patient for this is a younger lipoatrophy patient, because these patients still have enough of an immune response to actually get a good bang for the buck," she said. This filler is not reversible. The most common problem with Sculptra is the presence of nodules if it is injected too superficially, said Dr. Lupo.

▸ Evolence (porcine collagen). "In my opinion, it's a stiffer, more structural filler," she said. It works well in the nasolabial folds. Dr. Lupo always mixes it with lidocaine, though this makes it flow more quickly, so she uses a 30-gauge needle. It is a good choice for men with thick skin. Evolence has a low incidence of bruising and swelling.

Dr. Lupo reported significant financial relationships with a number of pharmaceutical and skin care companies.

A patient is shown before treatment with one syringe of Restylane.

The effect was prolonged for 3.5 years by performing periodic touch-ups.

Source Photos courtesy Dr. Mary Lupo

BOSTON — Cosmetic dermatologists have the knowledge and training to choose the right fillers that will garner the best results, according to Dr. Mary Lupo.

"Every FDA-approved filler, in my opinion, has an appropriate indication. You just need to know the relative strengths and weaknesses," said Dr. Lupo, at the American Academy of Dermatology's Academy 2009 meeting.

Optimal results require an appropriate candidate, the choice of an appropriate product based on the patient's presentation, injection of a sufficient amount of product, the right complementing procedures, and maintenance of the effect with touch-ups, said Dr. Lupo, professor of dermatology at Tulane University in New Orleans.

Treating Older Patients

In general, older patients need more volume restoration, because their immune response is decreased. "So when one has an active filler, such as poly-L-lactic acid, the older patient may have less of an immune response to give you a final result," she said. However, the corollary is that the older patient may require so much volume with other fillers that it becomes financially unfeasible.

"Older patients always need complementing procedures to get a good result," she said.

When examining the defect being considered for correction, decide whether it is a line or a fold. Lines require less viscous fillers to avoid lumpiness. "When a skin fold is more redundant, however, you need a thicker, more structural filler in order to lift the fold." When working with folds, Dr. Lupo recommends improving the area superior to the fold in addition to filling the fold.

When talking with the patient, "it's important to point out that it really doesn't do much good to fill a line if the overall photoaging is so severe and the 'canvas of the skin' is so mottled and deformed that it will not give an overall improvement," she said. Fillers can be used adjunctively with other methods to achieve better results.

Filler Contraindications

Many of the hyaluronic acid (HA) fillers are manufactured from a streptococcal fermentation process, so ask about hypersensitivity to strep, she said. Some patients have sensitivity to lidocaine. If this is the case, avoid using Prevelle Silk, CosmoDerm, and CosmoPlast. Poly-L-lactic acid is a component of Vicryl sutures, so if a patient has a history of allergic reaction to these sutures, avoid using Sculptra.

The use of anticoagulants by a patient is not necessarily a contraindication, "but it certainly behooves you to discuss the incidence of bruising that might be significant in these patients," Dr. Lupo said. For smokers wanting fillers, she uses a consent form to make these patients aware of the increased risk of necrosis.

Managing Expectations

The issue of cost also should be part of the discussion. Older patients will need more filler, meaning that temporary fillers may not be as cost effective over time. Semipermanent fillers may offer more benefit and it might be worth considering permanent.

To get the most out of a filler, complementing procedures should be considered. Such procedures can include onabotulinumtoxinA (Botox), intense pulsed light, chemical peel, nonablative laser, and ablative laser. "At the end of the day, the more procedures that a patient can afford, the better they will look," Dr. Lupo noted.

The Fillers

▸ CosmoDerm and CosmoPlast (human collagen). These products are the best choice for immediate results. They are great for lining the lips and for fine perioral lines, and both are fairly painless. They have a short duration, however, and both will be discontinued in 2010, according to Dr. Lupo.

▸ Restylane (HA gel). The filler is versatile and can be reversed by using hyaluronidase. It also can be injected with a finer-gauge needle, which reduces pain and allows treatment of finer lines. One injection lasts about 6 months, but it can last longer with touch-ups. Swelling and bruising should be considered, she said.

▸ Perlane (HA gel). This filler is a larger-particle gel suspension of HA. It is typically used for nasolabial folds and cheeks, and it can be used for lips with good technique to avoid lumping. "I have not found that the duration is any better than with Restylane," said Dr. Lupo.

▸ Juvéderm Ultra and Juvéderm Ultra Plus (cross-linked HA). This product is malleable and soft. It is also great for lips; however, because it is so malleable, it is not the best choice for defining the lip border. This filler is also reversible. "It is a little bit harder to get through a 1-inch needle," she said. Duration is 7-9 months without touch-ups.

Juvéderm Ultra Plus is the same as Juvéderm Ultra, although increased crosslinking of HA results in improved longevity—up to 1 year without touch-ups. "It's never to be used in fine lines, in my opinion," Dr. Lupo said. It is best injected with a 30-gauge needle. This filler is extremely good in skin of color.

▸ Prevelle Silk (cross-linked HA and lidocaine). The added lidocaine decreases patient discomfort. There is very little swelling because of the low HA concentration, but as a result it does not last as long—3 months or less. "It's inexpensive, and it's a good introductory filler for the hesitant patient," she said.

▸ Elevess (cross-linked HA and lidocaine). Elevess has the highest concentration of HA available on the market. "My personal opinion, based on my limited experience with it, is that it tends to be highly inflammatory as a result of this high concentration of HA," she said.

▸ Radiesse (calcium hydroxylapatite). This structural filler is great for men. It does cause a lot of same-day redness. "I do routinely mix it with lidocaine, and that is now FDA approved and has been found not to decrease its longevity," she said. It's a good choice for marionette lines and the pre-jowl sulcus, but avoid using it for the lips, she said.

▸ Sculptra (poly-L-lactic acid). The FDA cleared Sculptra this year for cosmetic purposes—correction of mild-to-severe nasolabial folds and wrinkles and contour irregularities. "The optimal patient for this is a younger lipoatrophy patient, because these patients still have enough of an immune response to actually get a good bang for the buck," she said. This filler is not reversible. The most common problem with Sculptra is the presence of nodules if it is injected too superficially, said Dr. Lupo.

▸ Evolence (porcine collagen). "In my opinion, it's a stiffer, more structural filler," she said. It works well in the nasolabial folds. Dr. Lupo always mixes it with lidocaine, though this makes it flow more quickly, so she uses a 30-gauge needle. It is a good choice for men with thick skin. Evolence has a low incidence of bruising and swelling.

Dr. Lupo reported significant financial relationships with a number of pharmaceutical and skin care companies.

A patient is shown before treatment with one syringe of Restylane.

The effect was prolonged for 3.5 years by performing periodic touch-ups.

Source Photos courtesy Dr. Mary Lupo

Medical imaging exposes a significant portion of patients to various doses of ionizing radiation, and in some cases, to substantial doses, potentially increasing the associated risk of cancer, according to findings of a retrospective cohort study.

The results are based on an analysis of 952,420 nonelderly adults who were enrolled in United Healthcare's database between Jan. 1, 2005, and Dec. 31, 2007, and living in Arizona, Dallas, Orlando, South Florida, or Wisconsin.

Roughly 70% of the study population underwent at least one imaging exam during the 3-year study period, “resulting in mean effective doses that almost doubled what would be expected from natural sources alone,” wrote Dr. Reza Fazel, assistant professor of cardiology at Emory University, Atlanta, and her coinvestigators.

Most patients received less than 3 millisievert (mSv) per year—considered low exposure—but a sizable minority of patients who received moderate, high, or very high radiation doses, they wrote.

CPT codes for imaging procedures involving radiation were used to identify claims from hospitals, outpatient facilities, and physicians' offices. They excluded procedures in which radiation was specifically delivered for therapeutic purposes, such as high-dose radiation for cancer.

Estimates of typical effective doses from published literature were used to approximate radiation exposure for each imaging procedure. The effective dose is an inexact measure of the overall detrimental biologic effect from radiation exposure.

Patients were stratified by gender and age: 18–34, 35–39, 40–44, 45–49, 50–54, 55–59, and 60–64; 52% were women. The researchers calculated effective doses for the population overall and for each age-based and sex-based group and categorized them by dose: low (no more than 3 mSv/year year, the background level of radiation from natural sources in the United States), moderate (3–20 mSv/year, the upper annual limit for occupational exposure for at-risk workers, averaged over 5 years), high (20–50 mSv/year, the upper annual limit for occupational exposure for at-risk workers in any given year, and very high (greater than 50 mSv/year).

A total of 3,442,111 imaging procedures associated with 655,613 patients were identified in the 3-year period. The average number of procedures per person per year was 1.2 and median number was 0.7/person per year. The mean effective dose was 2.4 mSv/person per year with a median effective dose of 0.1 mSv/year.

The proportion of patients undergoing at least one procedure during the study period increased with age—from 50% in those aged 18–34 years to 86% in those aged 60–64 years. A total of 79% of women underwent at least one procedure during the study period, compared with 60% for men (N. Engl. J. Med. 2009;361:849–57).

Moderate doses occurred at an annual rate of 199 per 1,000 patients. High and very high doses occurred at annual rates of 19 and 2 per 1,000 patients, respectively. Each rate “rose with advancing age,” noted Dr. Fazel.

“Generalization of our findings to the United States suggests that these procedures lead to cumulative effective doses that exceed 20 mSv per year in approximately 4 million Americans,” the researchers wrote.

Myocardial perfusion imaging accounted for almost a quarter of the total effective dose (22%). CT of the abdomen, pelvis, and chest accounted for 38% of the total effective dose.

“CT and nuclear imaging accounted for 21% of the total number of procedures and 71.4% of the total effective dose,” the researchers reported. By anatomical site, chest procedures accounted for 45% of the total effective dose. Lastly, the bulk of the total effective dose—82%—was delivered in outpatient settings, primarily physicians' offices.

The findings are concerning, particularly for patients who undergo several imaging tests in a short period of time, Dr. Michael S. Lauer wrote in an accompanying editorial (N. Engl. J. Med. 2009;361;841–3).

“Irradiation represents a direct danger imposed by a physician's decision to refer a patient for imaging. Though the danger may be small, it is cumulative and hence of particular relevance to the small but substantial minority of patients, who … undergo clusters of tests,” he said.

Despite the cumulative risk associated with radiation exposure, it's generally not something that is discussed with patients undergoing an imaging procedure, noted Dr. Lauer, who is director of the prevention and population sciences division of the National Heart, Lung, and Blood Institute in Bethesda, Md.

Dr. Fazel reported that she has no relevant conflicts of interest, though several of her coauthors reported significant relationships with pharmaceutical and medical imaging companies. Dr. Lauer reported that he has no relevant conflicts of interest.

NIH's Clinical Center to Track Radiation Exposure

The National Institutes of Health will require new CT and PET equipment purchased by the agency's clinical center to routinely record the patient's radiation dose in their hospital-based electronic medical record.

“The [NIH] Clinical Center's approach is an important first step in making it possible to more easily document and track information about a patient's exposure to radiation,” Dr. John I. Gallin, director of the center, said in a statement.

The risks associated with exposure to low doses of radiation from medical imaging tests are unknown. The ability to track a person's radiation exposure will help researchers evaluate the health risks of these procedures. The center plans to work with its vendors to develop software tools to extract the type of examination, the date, and the radiation dose for uploading to an EHR.

Medical imaging exposes a significant portion of patients to various doses of ionizing radiation, and in some cases, to substantial doses, potentially increasing the associated risk of cancer, according to findings of a retrospective cohort study.

The results are based on an analysis of 952,420 nonelderly adults who were enrolled in United Healthcare's database between Jan. 1, 2005, and Dec. 31, 2007, and living in Arizona, Dallas, Orlando, South Florida, or Wisconsin.

Roughly 70% of the study population underwent at least one imaging exam during the 3-year study period, “resulting in mean effective doses that almost doubled what would be expected from natural sources alone,” wrote Dr. Reza Fazel, assistant professor of cardiology at Emory University, Atlanta, and her coinvestigators.

Most patients received less than 3 millisievert (mSv) per year—considered low exposure—but a sizable minority of patients who received moderate, high, or very high radiation doses, they wrote.

CPT codes for imaging procedures involving radiation were used to identify claims from hospitals, outpatient facilities, and physicians' offices. They excluded procedures in which radiation was specifically delivered for therapeutic purposes, such as high-dose radiation for cancer.

Estimates of typical effective doses from published literature were used to approximate radiation exposure for each imaging procedure. The effective dose is an inexact measure of the overall detrimental biologic effect from radiation exposure.

Patients were stratified by gender and age: 18–34, 35–39, 40–44, 45–49, 50–54, 55–59, and 60–64; 52% were women. The researchers calculated effective doses for the population overall and for each age-based and sex-based group and categorized them by dose: low (no more than 3 mSv/year year, the background level of radiation from natural sources in the United States), moderate (3–20 mSv/year, the upper annual limit for occupational exposure for at-risk workers, averaged over 5 years), high (20–50 mSv/year, the upper annual limit for occupational exposure for at-risk workers in any given year, and very high (greater than 50 mSv/year).

A total of 3,442,111 imaging procedures associated with 655,613 patients were identified in the 3-year period. The average number of procedures per person per year was 1.2 and median number was 0.7/person per year. The mean effective dose was 2.4 mSv/person per year with a median effective dose of 0.1 mSv/year.

The proportion of patients undergoing at least one procedure during the study period increased with age—from 50% in those aged 18–34 years to 86% in those aged 60–64 years. A total of 79% of women underwent at least one procedure during the study period, compared with 60% for men (N. Engl. J. Med. 2009;361:849–57).

Moderate doses occurred at an annual rate of 199 per 1,000 patients. High and very high doses occurred at annual rates of 19 and 2 per 1,000 patients, respectively. Each rate “rose with advancing age,” noted Dr. Fazel.

“Generalization of our findings to the United States suggests that these procedures lead to cumulative effective doses that exceed 20 mSv per year in approximately 4 million Americans,” the researchers wrote.

Myocardial perfusion imaging accounted for almost a quarter of the total effective dose (22%). CT of the abdomen, pelvis, and chest accounted for 38% of the total effective dose.

“CT and nuclear imaging accounted for 21% of the total number of procedures and 71.4% of the total effective dose,” the researchers reported. By anatomical site, chest procedures accounted for 45% of the total effective dose. Lastly, the bulk of the total effective dose—82%—was delivered in outpatient settings, primarily physicians' offices.

The findings are concerning, particularly for patients who undergo several imaging tests in a short period of time, Dr. Michael S. Lauer wrote in an accompanying editorial (N. Engl. J. Med. 2009;361;841–3).

“Irradiation represents a direct danger imposed by a physician's decision to refer a patient for imaging. Though the danger may be small, it is cumulative and hence of particular relevance to the small but substantial minority of patients, who … undergo clusters of tests,” he said.

Despite the cumulative risk associated with radiation exposure, it's generally not something that is discussed with patients undergoing an imaging procedure, noted Dr. Lauer, who is director of the prevention and population sciences division of the National Heart, Lung, and Blood Institute in Bethesda, Md.

Dr. Fazel reported that she has no relevant conflicts of interest, though several of her coauthors reported significant relationships with pharmaceutical and medical imaging companies. Dr. Lauer reported that he has no relevant conflicts of interest.

NIH's Clinical Center to Track Radiation Exposure

The National Institutes of Health will require new CT and PET equipment purchased by the agency's clinical center to routinely record the patient's radiation dose in their hospital-based electronic medical record.

“The [NIH] Clinical Center's approach is an important first step in making it possible to more easily document and track information about a patient's exposure to radiation,” Dr. John I. Gallin, director of the center, said in a statement.

The risks associated with exposure to low doses of radiation from medical imaging tests are unknown. The ability to track a person's radiation exposure will help researchers evaluate the health risks of these procedures. The center plans to work with its vendors to develop software tools to extract the type of examination, the date, and the radiation dose for uploading to an EHR.

Medical imaging exposes a significant portion of patients to various doses of ionizing radiation, and in some cases, to substantial doses, potentially increasing the associated risk of cancer, according to findings of a retrospective cohort study.

The results are based on an analysis of 952,420 nonelderly adults who were enrolled in United Healthcare's database between Jan. 1, 2005, and Dec. 31, 2007, and living in Arizona, Dallas, Orlando, South Florida, or Wisconsin.

Roughly 70% of the study population underwent at least one imaging exam during the 3-year study period, “resulting in mean effective doses that almost doubled what would be expected from natural sources alone,” wrote Dr. Reza Fazel, assistant professor of cardiology at Emory University, Atlanta, and her coinvestigators.

Most patients received less than 3 millisievert (mSv) per year—considered low exposure—but a sizable minority of patients who received moderate, high, or very high radiation doses, they wrote.

CPT codes for imaging procedures involving radiation were used to identify claims from hospitals, outpatient facilities, and physicians' offices. They excluded procedures in which radiation was specifically delivered for therapeutic purposes, such as high-dose radiation for cancer.

Estimates of typical effective doses from published literature were used to approximate radiation exposure for each imaging procedure. The effective dose is an inexact measure of the overall detrimental biologic effect from radiation exposure.

Patients were stratified by gender and age: 18–34, 35–39, 40–44, 45–49, 50–54, 55–59, and 60–64; 52% were women. The researchers calculated effective doses for the population overall and for each age-based and sex-based group and categorized them by dose: low (no more than 3 mSv/year year, the background level of radiation from natural sources in the United States), moderate (3–20 mSv/year, the upper annual limit for occupational exposure for at-risk workers, averaged over 5 years), high (20–50 mSv/year, the upper annual limit for occupational exposure for at-risk workers in any given year, and very high (greater than 50 mSv/year).

A total of 3,442,111 imaging procedures associated with 655,613 patients were identified in the 3-year period. The average number of procedures per person per year was 1.2 and median number was 0.7/person per year. The mean effective dose was 2.4 mSv/person per year with a median effective dose of 0.1 mSv/year.

The proportion of patients undergoing at least one procedure during the study period increased with age—from 50% in those aged 18–34 years to 86% in those aged 60–64 years. A total of 79% of women underwent at least one procedure during the study period, compared with 60% for men (N. Engl. J. Med. 2009;361:849–57).

Moderate doses occurred at an annual rate of 199 per 1,000 patients. High and very high doses occurred at annual rates of 19 and 2 per 1,000 patients, respectively. Each rate “rose with advancing age,” noted Dr. Fazel.

“Generalization of our findings to the United States suggests that these procedures lead to cumulative effective doses that exceed 20 mSv per year in approximately 4 million Americans,” the researchers wrote.

Myocardial perfusion imaging accounted for almost a quarter of the total effective dose (22%). CT of the abdomen, pelvis, and chest accounted for 38% of the total effective dose.

“CT and nuclear imaging accounted for 21% of the total number of procedures and 71.4% of the total effective dose,” the researchers reported. By anatomical site, chest procedures accounted for 45% of the total effective dose. Lastly, the bulk of the total effective dose—82%—was delivered in outpatient settings, primarily physicians' offices.

The findings are concerning, particularly for patients who undergo several imaging tests in a short period of time, Dr. Michael S. Lauer wrote in an accompanying editorial (N. Engl. J. Med. 2009;361;841–3).

“Irradiation represents a direct danger imposed by a physician's decision to refer a patient for imaging. Though the danger may be small, it is cumulative and hence of particular relevance to the small but substantial minority of patients, who … undergo clusters of tests,” he said.

Despite the cumulative risk associated with radiation exposure, it's generally not something that is discussed with patients undergoing an imaging procedure, noted Dr. Lauer, who is director of the prevention and population sciences division of the National Heart, Lung, and Blood Institute in Bethesda, Md.

Dr. Fazel reported that she has no relevant conflicts of interest, though several of her coauthors reported significant relationships with pharmaceutical and medical imaging companies. Dr. Lauer reported that he has no relevant conflicts of interest.

NIH's Clinical Center to Track Radiation Exposure

The National Institutes of Health will require new CT and PET equipment purchased by the agency's clinical center to routinely record the patient's radiation dose in their hospital-based electronic medical record.

“The [NIH] Clinical Center's approach is an important first step in making it possible to more easily document and track information about a patient's exposure to radiation,” Dr. John I. Gallin, director of the center, said in a statement.

The risks associated with exposure to low doses of radiation from medical imaging tests are unknown. The ability to track a person's radiation exposure will help researchers evaluate the health risks of these procedures. The center plans to work with its vendors to develop software tools to extract the type of examination, the date, and the radiation dose for uploading to an EHR.

Adolescent abuse of prescription stimulant attention-deficit/hyperactivity disorder medications increased far more rapidly than general and adolescent substance abuse for the years of 1998–2005, according to Dr. Jennifer Setlik and her associates.

Stimulant abuse–related calls to poison control centers rose 76%, general substance abuse calls rose 59%, and adolescent substance abuse calls increased 55% over the 8-year period.

The findings come from a study of data from poison control calls collected in the National Poison Data System (NPDS) (Pediatrics 2009;124:875–80; doi:10.1542/peds.2008-0931

“The sharp increase in calls related to teen ADHD medication abuse, out of proportion to other poison center calls, suggests a rising problem with abuse of these medications,” wrote Dr. Setlik and her coinvestigators. Dr. Setlik is an emergency physician at Cincinnati Children's Hospital Medical Center.

The researchers searched the NPDS database for cases of adolescent exposure to prescription ADHD medications for 1998–2005. The NPDS contains data on every human exposure report received by a member poison control center. The database includes 41.1 million cases from 1983 to 2005.

The cases had to meet specified criteria: age 13–19 years with intentional abuse/misuse as the reason for exposure. All product codes for generic and brand name stimulant ADHD medications were identified and used in the search. Stimulant medications were broken down to amphetamine/dextroamphetamine or methylphenidate.

The centers classify medical outcomes as no effect, minor effect (minimally bothersome/resolves quickly), moderate effect (more pronounced/prolonged/systemic), major effect (life-threatening or resulted in significant residual disability/disfigurement), and death. The American Association of Poison Control Centers defines misuse as improper or incorrect use of a substance; abuse is defined as improper or incorrect use of a substance with the intent to get high or achieve some other psychotropic effect.

In addition, the researchers used the National Disease and Therapeutic Index database to assess ADHD prescription medication rates for those aged 10–19 and those aged 3–9 between 1998–2005. The database (IMS Health Inc.) collects the data from ongoing surveys using quarterly sampling of more than 4,000 physicians who record all drugs recommended (prescription and over-the-counter) for 2 consecutive days.

During the study period, calls for adolescent abuse of ADHD prescription drugs rose 76% from 330 to 581 per year. However, the number of prescriptions written for these medications for 10- to 19-year-olds rose 86% during the same period, from 4.2 million to 7.8 million.

“The 76% rise in the number of calls for teen abuse of ADHD medications is significant and is faster than the also significant rise in the number of calls for victims of substance abuse generally (59%) and teen substance abuse specifically (55%),” the researchers wrote. In contrast, the annual rate of total and teen exposures was unchanged.

Amphetamine/dextroamphetamine calls increased 476%, from 71 to 409 per year, while prescriptions for amphetamine/dextroamphetamine increased 141%, from 1.5 million to 3.6 million per year for 10- to 19-year-olds. The number of amphetamine-dextroamphetamine abuse calls per million prescriptions for 10- to 19-year-olds increased 140%.

Methylphenidate calls decreased 30% during the same period, from 246 to 172 per year, while prescriptions increased 57%, from 2.7 million to 4.3 million for 10- to 19-year-olds. The number of methylphenidate abuse calls per million prescriptions for 10- to 19-year-olds increased 55%.

Prescription data in the study was acquired through funding from the RADARS System, a governmental non-profit operation of the Rocky Mountain Poison and Drug Center. The authors reported that they have no financial relationships relevant to this article.

Adolescent abuse of prescription stimulant attention-deficit/hyperactivity disorder medications increased far more rapidly than general and adolescent substance abuse for the years of 1998–2005, according to Dr. Jennifer Setlik and her associates.

Stimulant abuse–related calls to poison control centers rose 76%, general substance abuse calls rose 59%, and adolescent substance abuse calls increased 55% over the 8-year period.

The findings come from a study of data from poison control calls collected in the National Poison Data System (NPDS) (Pediatrics 2009;124:875–80; doi:10.1542/peds.2008-0931

“The sharp increase in calls related to teen ADHD medication abuse, out of proportion to other poison center calls, suggests a rising problem with abuse of these medications,” wrote Dr. Setlik and her coinvestigators. Dr. Setlik is an emergency physician at Cincinnati Children's Hospital Medical Center.

The researchers searched the NPDS database for cases of adolescent exposure to prescription ADHD medications for 1998–2005. The NPDS contains data on every human exposure report received by a member poison control center. The database includes 41.1 million cases from 1983 to 2005.

The cases had to meet specified criteria: age 13–19 years with intentional abuse/misuse as the reason for exposure. All product codes for generic and brand name stimulant ADHD medications were identified and used in the search. Stimulant medications were broken down to amphetamine/dextroamphetamine or methylphenidate.

The centers classify medical outcomes as no effect, minor effect (minimally bothersome/resolves quickly), moderate effect (more pronounced/prolonged/systemic), major effect (life-threatening or resulted in significant residual disability/disfigurement), and death. The American Association of Poison Control Centers defines misuse as improper or incorrect use of a substance; abuse is defined as improper or incorrect use of a substance with the intent to get high or achieve some other psychotropic effect.

In addition, the researchers used the National Disease and Therapeutic Index database to assess ADHD prescription medication rates for those aged 10–19 and those aged 3–9 between 1998–2005. The database (IMS Health Inc.) collects the data from ongoing surveys using quarterly sampling of more than 4,000 physicians who record all drugs recommended (prescription and over-the-counter) for 2 consecutive days.

During the study period, calls for adolescent abuse of ADHD prescription drugs rose 76% from 330 to 581 per year. However, the number of prescriptions written for these medications for 10- to 19-year-olds rose 86% during the same period, from 4.2 million to 7.8 million.

“The 76% rise in the number of calls for teen abuse of ADHD medications is significant and is faster than the also significant rise in the number of calls for victims of substance abuse generally (59%) and teen substance abuse specifically (55%),” the researchers wrote. In contrast, the annual rate of total and teen exposures was unchanged.

Amphetamine/dextroamphetamine calls increased 476%, from 71 to 409 per year, while prescriptions for amphetamine/dextroamphetamine increased 141%, from 1.5 million to 3.6 million per year for 10- to 19-year-olds. The number of amphetamine-dextroamphetamine abuse calls per million prescriptions for 10- to 19-year-olds increased 140%.

Methylphenidate calls decreased 30% during the same period, from 246 to 172 per year, while prescriptions increased 57%, from 2.7 million to 4.3 million for 10- to 19-year-olds. The number of methylphenidate abuse calls per million prescriptions for 10- to 19-year-olds increased 55%.

Prescription data in the study was acquired through funding from the RADARS System, a governmental non-profit operation of the Rocky Mountain Poison and Drug Center. The authors reported that they have no financial relationships relevant to this article.

Adolescent abuse of prescription stimulant attention-deficit/hyperactivity disorder medications increased far more rapidly than general and adolescent substance abuse for the years of 1998–2005, according to Dr. Jennifer Setlik and her associates.

Stimulant abuse–related calls to poison control centers rose 76%, general substance abuse calls rose 59%, and adolescent substance abuse calls increased 55% over the 8-year period.

The findings come from a study of data from poison control calls collected in the National Poison Data System (NPDS) (Pediatrics 2009;124:875–80; doi:10.1542/peds.2008-0931

“The sharp increase in calls related to teen ADHD medication abuse, out of proportion to other poison center calls, suggests a rising problem with abuse of these medications,” wrote Dr. Setlik and her coinvestigators. Dr. Setlik is an emergency physician at Cincinnati Children's Hospital Medical Center.

The researchers searched the NPDS database for cases of adolescent exposure to prescription ADHD medications for 1998–2005. The NPDS contains data on every human exposure report received by a member poison control center. The database includes 41.1 million cases from 1983 to 2005.

The cases had to meet specified criteria: age 13–19 years with intentional abuse/misuse as the reason for exposure. All product codes for generic and brand name stimulant ADHD medications were identified and used in the search. Stimulant medications were broken down to amphetamine/dextroamphetamine or methylphenidate.

The centers classify medical outcomes as no effect, minor effect (minimally bothersome/resolves quickly), moderate effect (more pronounced/prolonged/systemic), major effect (life-threatening or resulted in significant residual disability/disfigurement), and death. The American Association of Poison Control Centers defines misuse as improper or incorrect use of a substance; abuse is defined as improper or incorrect use of a substance with the intent to get high or achieve some other psychotropic effect.

In addition, the researchers used the National Disease and Therapeutic Index database to assess ADHD prescription medication rates for those aged 10–19 and those aged 3–9 between 1998–2005. The database (IMS Health Inc.) collects the data from ongoing surveys using quarterly sampling of more than 4,000 physicians who record all drugs recommended (prescription and over-the-counter) for 2 consecutive days.

During the study period, calls for adolescent abuse of ADHD prescription drugs rose 76% from 330 to 581 per year. However, the number of prescriptions written for these medications for 10- to 19-year-olds rose 86% during the same period, from 4.2 million to 7.8 million.

“The 76% rise in the number of calls for teen abuse of ADHD medications is significant and is faster than the also significant rise in the number of calls for victims of substance abuse generally (59%) and teen substance abuse specifically (55%),” the researchers wrote. In contrast, the annual rate of total and teen exposures was unchanged.

Amphetamine/dextroamphetamine calls increased 476%, from 71 to 409 per year, while prescriptions for amphetamine/dextroamphetamine increased 141%, from 1.5 million to 3.6 million per year for 10- to 19-year-olds. The number of amphetamine-dextroamphetamine abuse calls per million prescriptions for 10- to 19-year-olds increased 140%.

Methylphenidate calls decreased 30% during the same period, from 246 to 172 per year, while prescriptions increased 57%, from 2.7 million to 4.3 million for 10- to 19-year-olds. The number of methylphenidate abuse calls per million prescriptions for 10- to 19-year-olds increased 55%.

Prescription data in the study was acquired through funding from the RADARS System, a governmental non-profit operation of the Rocky Mountain Poison and Drug Center. The authors reported that they have no financial relationships relevant to this article.

BOSTON — Lesion darkness would make a better criterion for identifying early melanomas than the 6-mm diameter cutoff in the ABCDE criteria currently used by dermatologists and patients, according to Dr. Stuart Goldsmith.

“It's recognized that all melanomas start as a single cell or a few cells. So microscopically, they're already cancer, but we're not even telling patients to look for small lesions,” he said.

“If we were doing okay [in terms of mortality], then it wouldn't matter. The fact is that we are not doing as well as we want to for our patients,” Dr. Goldsmith said at the American Academy of Dermatology's Academy 2009 meeting. “More than 8,000 Americans die every year of melanoma—most from cutaneous lesions, lesions on the skin that could have been removed when smaller than 6 mm and in time to save the patient's life.

“Dermatology is simply not on the same page as other specialties in terms of cancer surveillance by the very existence of the diameter criterion,” he said. Specialties that have had more success than dermatology in decreasing cancer mortality rates are looking for smaller, earlier lesions, Dr. Goldsmith noted. The European Society for Medical Oncology has already eliminated the diameter criterion for melanoma detection (Ann. Oncol. 2009;20[suppl. 4]:129-31).

Although the ABCDE criteria are intended to enhance the diagnosis of early melanoma, Dr. Goldsmith related that some dermatologists suggest that elimination of the diameter criterion would lead to too many biopsies. “In other words, it's become a cost issue,” he said.

“I'm not saying that saving money shouldn't be a priority. It just shouldn't be a priority of these criteria,” he said.

Dr. Goldsmith contends that the concerns about cost are unjustified. He used Medicare rates for 2009 in Albany, Ga., where he practices dermatology, to develop a specific cost model to assess the argument that excision and pathology for smaller suspect lesions would increase costs. He used a cost of $94 for excisions 1-5 mm in diameter and a cost of $116.54 for excisions 6-10 mm in diameter. Pathologic evaluation (at Emory University in Atlanta) cost $66, yielding a total cost of $160 for lesions 1-5 mm and $182.54 for lesions 6-10 mm.

“Assuming our society's accepted cost of $50,000 per quality-adjusted life-year saved, and rounding up to $200 per excision, if 1 in 250 excisions saved 1 year of one person's life, the cost would be justified,” he said. Given that the average life-years lost per fatal melanoma is 18.6 (based on the Surveillance, Epidemiology, and End Results database), the cost would be justified if 1 in every 4,650 small-diameter lesions excised would have prevented a death from melanoma. “This cost justification is valid even if there would be no cost savings,” he said.

Models to decrease the cost of melanoma have emphasized the need to diagnose earlier invasive and in situ disease. The estimated treatment of stage III and IV disease accounted for 90% of costs from melanoma. Disease caught earlier could avoid much of this cost (J. Am. Acad. Dermatol. 1998;38:669-80).

Therefore, an increase in small-diameter biopsies would not lead to unacceptable costs and may even result in cost savings, he said.

A cost analysis must also include a discussion of the number of lesions needed to excise (NNE), or biopsy, to diagnose one melanoma. NNE should be discussed only in the context of sensitivity of melanoma diagnosis.

Dr. Goldsmith highlighted two articles from 2008. In the first study, the NNE for small-diameter lesions (6 mm and smaller) was 1 in 24, while the NNE for larger lesions was approximately 1 in 8 (Arch. Dermatol. 2008;144:469-74). The authors concluded that the 6-mm criterion remains useful and that their biopsy rate for smaller lesions was appropriate.

In the second article, however, the study's group of expert dermoscopists would not only have misdiagnosed but would have totally missed—would not have biopsied—29% of small-diameter melanomas. Lesions were evaluated using dermoscopic images with information given about the patient's age, sex, and lesion location (Arch. Dermatol. 2008;144:476-82).

Many patients express the preference to be safe rather than sorry if there is any risk of a lesion being a melanoma. “That desire should be considered when evaluating the results of the two studies just discussed. Would a patient who would rather be safe than sorry think that a risk of 1 in 24 for the excision of a small-diameter lesion was appropriate if he or she was also given the information that the diagnosis of more than 1 in 4 small-diameter melanomas may be missed?” he asked.

Studies show that patients find their melanomas more often than physicians do. Unfortunately, the lesions found by patients are likely to be deeper or more advanced than those that physicians find. “The fact that patients would monitor for smaller lesions and start the process of getting in to see the doctor to get a lesion checked as early as possible could hopefully avoid what could end up being a critical delay in the recognition of a melanoma,” he said.

Dr. Goldsmith also addressed lesion darkness. “The single criterion that seems to have the most impact on recognition of the smallest melanomas is the criterion of darkness,” he said.

The singular importance of darkness for the diagnosis of small-diameter melanomas has been described in several series (Tumori 2004;90:128-31; J. Eur. Acad. Dermatol. Venereol. 2007;21:929-34; Arch. Dermatol. 1998;134:103-4). These reports suggest that, “when evaluating a lesion of unknown history, an 8-mm lightly pigmented macule with symmetric variation in pigmentation—two of the four current ABCD features—is of less concern than a 3-mm, circular, evenly pigmented black macule or papule with none of the four current ABCD criteria,” Dr. Goldsmith said.

In other words, the criterion of darkness is a stand-alone, nonredundant feature to help recognize melanomas. “It just doesn't make sense that darkness is currently not even one of four objective criteria used in educational strategies related to melanoma recognition,” he said.

Dr. Goldsmith also provided evidence that increased emphasis on the criterion of darkness enhances other strategies to diagnose melanomas, including early recognition of asymmetry in melanomas (Arch. Dermatol. 1994;130:1013-7), recognition of change in melanomas, (Br. J. Dermatol. 1999;141:783-7), and identifying small “ugly ducklings” that are melanomas (Arch. Dermatol. 1998;134:103-4).

“Changing the D from diameter to dark would accomplish two goals: We would not deter the recognition of smaller melanomas, and we would educate patients and the public about how to recognize many smaller lesions of concern,” he said. This change would represent a true evolution of the ABCDE criteria, he added.

A related video is at www.youtube.com/InternalMedicineNews

Darkness is the criterion that 'seems to have the most impact on recognition of the smallest melanomas.'

Source Dr. Goldsmith

More biopsies of smaller lesions may avoid the possibility of “a critical delay in the recognition of a melanoma.”

Source Courtesy kimggraphics

BOSTON — Lesion darkness would make a better criterion for identifying early melanomas than the 6-mm diameter cutoff in the ABCDE criteria currently used by dermatologists and patients, according to Dr. Stuart Goldsmith.

“It's recognized that all melanomas start as a single cell or a few cells. So microscopically, they're already cancer, but we're not even telling patients to look for small lesions,” he said.

“If we were doing okay [in terms of mortality], then it wouldn't matter. The fact is that we are not doing as well as we want to for our patients,” Dr. Goldsmith said at the American Academy of Dermatology's Academy 2009 meeting. “More than 8,000 Americans die every year of melanoma—most from cutaneous lesions, lesions on the skin that could have been removed when smaller than 6 mm and in time to save the patient's life.

“Dermatology is simply not on the same page as other specialties in terms of cancer surveillance by the very existence of the diameter criterion,” he said. Specialties that have had more success than dermatology in decreasing cancer mortality rates are looking for smaller, earlier lesions, Dr. Goldsmith noted. The European Society for Medical Oncology has already eliminated the diameter criterion for melanoma detection (Ann. Oncol. 2009;20[suppl. 4]:129-31).

Although the ABCDE criteria are intended to enhance the diagnosis of early melanoma, Dr. Goldsmith related that some dermatologists suggest that elimination of the diameter criterion would lead to too many biopsies. “In other words, it's become a cost issue,” he said.

“I'm not saying that saving money shouldn't be a priority. It just shouldn't be a priority of these criteria,” he said.

Dr. Goldsmith contends that the concerns about cost are unjustified. He used Medicare rates for 2009 in Albany, Ga., where he practices dermatology, to develop a specific cost model to assess the argument that excision and pathology for smaller suspect lesions would increase costs. He used a cost of $94 for excisions 1-5 mm in diameter and a cost of $116.54 for excisions 6-10 mm in diameter. Pathologic evaluation (at Emory University in Atlanta) cost $66, yielding a total cost of $160 for lesions 1-5 mm and $182.54 for lesions 6-10 mm.

“Assuming our society's accepted cost of $50,000 per quality-adjusted life-year saved, and rounding up to $200 per excision, if 1 in 250 excisions saved 1 year of one person's life, the cost would be justified,” he said. Given that the average life-years lost per fatal melanoma is 18.6 (based on the Surveillance, Epidemiology, and End Results database), the cost would be justified if 1 in every 4,650 small-diameter lesions excised would have prevented a death from melanoma. “This cost justification is valid even if there would be no cost savings,” he said.

Models to decrease the cost of melanoma have emphasized the need to diagnose earlier invasive and in situ disease. The estimated treatment of stage III and IV disease accounted for 90% of costs from melanoma. Disease caught earlier could avoid much of this cost (J. Am. Acad. Dermatol. 1998;38:669-80).

Therefore, an increase in small-diameter biopsies would not lead to unacceptable costs and may even result in cost savings, he said.

A cost analysis must also include a discussion of the number of lesions needed to excise (NNE), or biopsy, to diagnose one melanoma. NNE should be discussed only in the context of sensitivity of melanoma diagnosis.

Dr. Goldsmith highlighted two articles from 2008. In the first study, the NNE for small-diameter lesions (6 mm and smaller) was 1 in 24, while the NNE for larger lesions was approximately 1 in 8 (Arch. Dermatol. 2008;144:469-74). The authors concluded that the 6-mm criterion remains useful and that their biopsy rate for smaller lesions was appropriate.

In the second article, however, the study's group of expert dermoscopists would not only have misdiagnosed but would have totally missed—would not have biopsied—29% of small-diameter melanomas. Lesions were evaluated using dermoscopic images with information given about the patient's age, sex, and lesion location (Arch. Dermatol. 2008;144:476-82).

Many patients express the preference to be safe rather than sorry if there is any risk of a lesion being a melanoma. “That desire should be considered when evaluating the results of the two studies just discussed. Would a patient who would rather be safe than sorry think that a risk of 1 in 24 for the excision of a small-diameter lesion was appropriate if he or she was also given the information that the diagnosis of more than 1 in 4 small-diameter melanomas may be missed?” he asked.

Studies show that patients find their melanomas more often than physicians do. Unfortunately, the lesions found by patients are likely to be deeper or more advanced than those that physicians find. “The fact that patients would monitor for smaller lesions and start the process of getting in to see the doctor to get a lesion checked as early as possible could hopefully avoid what could end up being a critical delay in the recognition of a melanoma,” he said.

Dr. Goldsmith also addressed lesion darkness. “The single criterion that seems to have the most impact on recognition of the smallest melanomas is the criterion of darkness,” he said.

The singular importance of darkness for the diagnosis of small-diameter melanomas has been described in several series (Tumori 2004;90:128-31; J. Eur. Acad. Dermatol. Venereol. 2007;21:929-34; Arch. Dermatol. 1998;134:103-4). These reports suggest that, “when evaluating a lesion of unknown history, an 8-mm lightly pigmented macule with symmetric variation in pigmentation—two of the four current ABCD features—is of less concern than a 3-mm, circular, evenly pigmented black macule or papule with none of the four current ABCD criteria,” Dr. Goldsmith said.

In other words, the criterion of darkness is a stand-alone, nonredundant feature to help recognize melanomas. “It just doesn't make sense that darkness is currently not even one of four objective criteria used in educational strategies related to melanoma recognition,” he said.

Dr. Goldsmith also provided evidence that increased emphasis on the criterion of darkness enhances other strategies to diagnose melanomas, including early recognition of asymmetry in melanomas (Arch. Dermatol. 1994;130:1013-7), recognition of change in melanomas, (Br. J. Dermatol. 1999;141:783-7), and identifying small “ugly ducklings” that are melanomas (Arch. Dermatol. 1998;134:103-4).

“Changing the D from diameter to dark would accomplish two goals: We would not deter the recognition of smaller melanomas, and we would educate patients and the public about how to recognize many smaller lesions of concern,” he said. This change would represent a true evolution of the ABCDE criteria, he added.

A related video is at www.youtube.com/InternalMedicineNews

Darkness is the criterion that 'seems to have the most impact on recognition of the smallest melanomas.'

Source Dr. Goldsmith

More biopsies of smaller lesions may avoid the possibility of “a critical delay in the recognition of a melanoma.”

Source Courtesy kimggraphics

BOSTON — Lesion darkness would make a better criterion for identifying early melanomas than the 6-mm diameter cutoff in the ABCDE criteria currently used by dermatologists and patients, according to Dr. Stuart Goldsmith.

“It's recognized that all melanomas start as a single cell or a few cells. So microscopically, they're already cancer, but we're not even telling patients to look for small lesions,” he said.

“If we were doing okay [in terms of mortality], then it wouldn't matter. The fact is that we are not doing as well as we want to for our patients,” Dr. Goldsmith said at the American Academy of Dermatology's Academy 2009 meeting. “More than 8,000 Americans die every year of melanoma—most from cutaneous lesions, lesions on the skin that could have been removed when smaller than 6 mm and in time to save the patient's life.

“Dermatology is simply not on the same page as other specialties in terms of cancer surveillance by the very existence of the diameter criterion,” he said. Specialties that have had more success than dermatology in decreasing cancer mortality rates are looking for smaller, earlier lesions, Dr. Goldsmith noted. The European Society for Medical Oncology has already eliminated the diameter criterion for melanoma detection (Ann. Oncol. 2009;20[suppl. 4]:129-31).

Although the ABCDE criteria are intended to enhance the diagnosis of early melanoma, Dr. Goldsmith related that some dermatologists suggest that elimination of the diameter criterion would lead to too many biopsies. “In other words, it's become a cost issue,” he said.

“I'm not saying that saving money shouldn't be a priority. It just shouldn't be a priority of these criteria,” he said.

Dr. Goldsmith contends that the concerns about cost are unjustified. He used Medicare rates for 2009 in Albany, Ga., where he practices dermatology, to develop a specific cost model to assess the argument that excision and pathology for smaller suspect lesions would increase costs. He used a cost of $94 for excisions 1-5 mm in diameter and a cost of $116.54 for excisions 6-10 mm in diameter. Pathologic evaluation (at Emory University in Atlanta) cost $66, yielding a total cost of $160 for lesions 1-5 mm and $182.54 for lesions 6-10 mm.

“Assuming our society's accepted cost of $50,000 per quality-adjusted life-year saved, and rounding up to $200 per excision, if 1 in 250 excisions saved 1 year of one person's life, the cost would be justified,” he said. Given that the average life-years lost per fatal melanoma is 18.6 (based on the Surveillance, Epidemiology, and End Results database), the cost would be justified if 1 in every 4,650 small-diameter lesions excised would have prevented a death from melanoma. “This cost justification is valid even if there would be no cost savings,” he said.

Models to decrease the cost of melanoma have emphasized the need to diagnose earlier invasive and in situ disease. The estimated treatment of stage III and IV disease accounted for 90% of costs from melanoma. Disease caught earlier could avoid much of this cost (J. Am. Acad. Dermatol. 1998;38:669-80).

Therefore, an increase in small-diameter biopsies would not lead to unacceptable costs and may even result in cost savings, he said.

A cost analysis must also include a discussion of the number of lesions needed to excise (NNE), or biopsy, to diagnose one melanoma. NNE should be discussed only in the context of sensitivity of melanoma diagnosis.

Dr. Goldsmith highlighted two articles from 2008. In the first study, the NNE for small-diameter lesions (6 mm and smaller) was 1 in 24, while the NNE for larger lesions was approximately 1 in 8 (Arch. Dermatol. 2008;144:469-74). The authors concluded that the 6-mm criterion remains useful and that their biopsy rate for smaller lesions was appropriate.

In the second article, however, the study's group of expert dermoscopists would not only have misdiagnosed but would have totally missed—would not have biopsied—29% of small-diameter melanomas. Lesions were evaluated using dermoscopic images with information given about the patient's age, sex, and lesion location (Arch. Dermatol. 2008;144:476-82).

Many patients express the preference to be safe rather than sorry if there is any risk of a lesion being a melanoma. “That desire should be considered when evaluating the results of the two studies just discussed. Would a patient who would rather be safe than sorry think that a risk of 1 in 24 for the excision of a small-diameter lesion was appropriate if he or she was also given the information that the diagnosis of more than 1 in 4 small-diameter melanomas may be missed?” he asked.

Studies show that patients find their melanomas more often than physicians do. Unfortunately, the lesions found by patients are likely to be deeper or more advanced than those that physicians find. “The fact that patients would monitor for smaller lesions and start the process of getting in to see the doctor to get a lesion checked as early as possible could hopefully avoid what could end up being a critical delay in the recognition of a melanoma,” he said.

Dr. Goldsmith also addressed lesion darkness. “The single criterion that seems to have the most impact on recognition of the smallest melanomas is the criterion of darkness,” he said.

The singular importance of darkness for the diagnosis of small-diameter melanomas has been described in several series (Tumori 2004;90:128-31; J. Eur. Acad. Dermatol. Venereol. 2007;21:929-34; Arch. Dermatol. 1998;134:103-4). These reports suggest that, “when evaluating a lesion of unknown history, an 8-mm lightly pigmented macule with symmetric variation in pigmentation—two of the four current ABCD features—is of less concern than a 3-mm, circular, evenly pigmented black macule or papule with none of the four current ABCD criteria,” Dr. Goldsmith said.

In other words, the criterion of darkness is a stand-alone, nonredundant feature to help recognize melanomas. “It just doesn't make sense that darkness is currently not even one of four objective criteria used in educational strategies related to melanoma recognition,” he said.

Dr. Goldsmith also provided evidence that increased emphasis on the criterion of darkness enhances other strategies to diagnose melanomas, including early recognition of asymmetry in melanomas (Arch. Dermatol. 1994;130:1013-7), recognition of change in melanomas, (Br. J. Dermatol. 1999;141:783-7), and identifying small “ugly ducklings” that are melanomas (Arch. Dermatol. 1998;134:103-4).

“Changing the D from diameter to dark would accomplish two goals: We would not deter the recognition of smaller melanomas, and we would educate patients and the public about how to recognize many smaller lesions of concern,” he said. This change would represent a true evolution of the ABCDE criteria, he added.

A related video is at www.youtube.com/InternalMedicineNews

Darkness is the criterion that 'seems to have the most impact on recognition of the smallest melanomas.'

Source Dr. Goldsmith

More biopsies of smaller lesions may avoid the possibility of “a critical delay in the recognition of a melanoma.”

Source Courtesy kimggraphics

BALTIMORE — Empiric treatment for sexually transmitted infections among adolescent girls presenting to a pediatric emergency department is high, but many patients are unreachable for follow-up and some remain unaware that they are infected, according to a 3-month baseline study.

In all, 120 young women aged 14–21 years who were seen at the Cincinnati Children's Hospital pediatric emergency department (PED) tested positive for Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis between July 1 and Sept. 23, 2008, reported Dr. Jennifer Reed, an attending physician in the division of emergency medicine.

More than two-thirds of adolescents (69%) who tested positive for sexually transmitted infections (STIs) were treated empirically in the PED. The researchers were able to contact almost half of STI-positive patients (46%) within 7 days and were able to contact only 60% within 30 days, according to data presented as a poster at the annual meeting of the Pediatric Academic Societies.

“The most prevalent reasons for the unreachable patients included phones being disconnected, no answer, and full voice mailboxes,” Dr. Reed said in an interview.

However, she noted that these data have not been analyzed yet.

The researchers tracked adolescent patients who tested positive for any STI. The usual clinical protocol involved contacting only those patients who tested positive for an STI but who were not treated empirically in the PED.

During the study period, a nurse practitioner attempted to contact all patients who tested positive for an STI, as soon as test results were available, regardless of documentation of PED treatment. Patients contacted at home were notified of their results and offered treatment if needed.

After three unsuccessful phone attempts to contact the patient, a registered letter was sent to the patient with the STI test results and a request to return to the PED. Those without treatment and no telephone contact or follow-up in the PED were classified as lost to follow-up.

The researchers recorded the date of contact and calculated the proportion of patients successfully contacted, the mean and median days to treatment/notification, and the proportions notified within 7 days and within 30 days.

For the 36 patients untreated at the initial PED visit but who tested positive and were successfully contacted, the median number of days to treatment was 8. In all, 9% of girls were lost to follow-up.

A total of 33 (28%) patients were empirically treated for STIs but remained unaware of their infections, putting their partners at risk and themselves at risk for reinfection from positive untreated partners.

A total of 11 (9%) patients were untreated and unaware of their infections, putting themselves at risk for complications from STIs, as well as for spreading infection.

This study is phase I of a quality improvement project designed to improve the STI reporting system in the PED.

The study was supported by a grant from the Cincinnati Hospital Research Foundation Outcomes award, as well as a K23 award from the National Institute of Allergy and Infectious Disease.

BALTIMORE — Empiric treatment for sexually transmitted infections among adolescent girls presenting to a pediatric emergency department is high, but many patients are unreachable for follow-up and some remain unaware that they are infected, according to a 3-month baseline study.

In all, 120 young women aged 14–21 years who were seen at the Cincinnati Children's Hospital pediatric emergency department (PED) tested positive for Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis between July 1 and Sept. 23, 2008, reported Dr. Jennifer Reed, an attending physician in the division of emergency medicine.

More than two-thirds of adolescents (69%) who tested positive for sexually transmitted infections (STIs) were treated empirically in the PED. The researchers were able to contact almost half of STI-positive patients (46%) within 7 days and were able to contact only 60% within 30 days, according to data presented as a poster at the annual meeting of the Pediatric Academic Societies.

“The most prevalent reasons for the unreachable patients included phones being disconnected, no answer, and full voice mailboxes,” Dr. Reed said in an interview.

However, she noted that these data have not been analyzed yet.

The researchers tracked adolescent patients who tested positive for any STI. The usual clinical protocol involved contacting only those patients who tested positive for an STI but who were not treated empirically in the PED.

During the study period, a nurse practitioner attempted to contact all patients who tested positive for an STI, as soon as test results were available, regardless of documentation of PED treatment. Patients contacted at home were notified of their results and offered treatment if needed.

After three unsuccessful phone attempts to contact the patient, a registered letter was sent to the patient with the STI test results and a request to return to the PED. Those without treatment and no telephone contact or follow-up in the PED were classified as lost to follow-up.

The researchers recorded the date of contact and calculated the proportion of patients successfully contacted, the mean and median days to treatment/notification, and the proportions notified within 7 days and within 30 days.

For the 36 patients untreated at the initial PED visit but who tested positive and were successfully contacted, the median number of days to treatment was 8. In all, 9% of girls were lost to follow-up.

A total of 33 (28%) patients were empirically treated for STIs but remained unaware of their infections, putting their partners at risk and themselves at risk for reinfection from positive untreated partners.

A total of 11 (9%) patients were untreated and unaware of their infections, putting themselves at risk for complications from STIs, as well as for spreading infection.

This study is phase I of a quality improvement project designed to improve the STI reporting system in the PED.

The study was supported by a grant from the Cincinnati Hospital Research Foundation Outcomes award, as well as a K23 award from the National Institute of Allergy and Infectious Disease.

BALTIMORE — Empiric treatment for sexually transmitted infections among adolescent girls presenting to a pediatric emergency department is high, but many patients are unreachable for follow-up and some remain unaware that they are infected, according to a 3-month baseline study.

In all, 120 young women aged 14–21 years who were seen at the Cincinnati Children's Hospital pediatric emergency department (PED) tested positive for Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis between July 1 and Sept. 23, 2008, reported Dr. Jennifer Reed, an attending physician in the division of emergency medicine.

More than two-thirds of adolescents (69%) who tested positive for sexually transmitted infections (STIs) were treated empirically in the PED. The researchers were able to contact almost half of STI-positive patients (46%) within 7 days and were able to contact only 60% within 30 days, according to data presented as a poster at the annual meeting of the Pediatric Academic Societies.

“The most prevalent reasons for the unreachable patients included phones being disconnected, no answer, and full voice mailboxes,” Dr. Reed said in an interview.

However, she noted that these data have not been analyzed yet.

The researchers tracked adolescent patients who tested positive for any STI. The usual clinical protocol involved contacting only those patients who tested positive for an STI but who were not treated empirically in the PED.

During the study period, a nurse practitioner attempted to contact all patients who tested positive for an STI, as soon as test results were available, regardless of documentation of PED treatment. Patients contacted at home were notified of their results and offered treatment if needed.

After three unsuccessful phone attempts to contact the patient, a registered letter was sent to the patient with the STI test results and a request to return to the PED. Those without treatment and no telephone contact or follow-up in the PED were classified as lost to follow-up.

The researchers recorded the date of contact and calculated the proportion of patients successfully contacted, the mean and median days to treatment/notification, and the proportions notified within 7 days and within 30 days.

For the 36 patients untreated at the initial PED visit but who tested positive and were successfully contacted, the median number of days to treatment was 8. In all, 9% of girls were lost to follow-up.

A total of 33 (28%) patients were empirically treated for STIs but remained unaware of their infections, putting their partners at risk and themselves at risk for reinfection from positive untreated partners.

A total of 11 (9%) patients were untreated and unaware of their infections, putting themselves at risk for complications from STIs, as well as for spreading infection.

This study is phase I of a quality improvement project designed to improve the STI reporting system in the PED.

The study was supported by a grant from the Cincinnati Hospital Research Foundation Outcomes award, as well as a K23 award from the National Institute of Allergy and Infectious Disease.

Medical imaging exposes a significant portion of patients to various doses of ionizing radiation, and in some cases, to substantial doses, potentially increasing the associated risk of cancer, according to findings of a retrospective cohort study.

The results are based on an analysis of 952,420 nonelderly adults who were enrolled in United Healthcare's database between 2005 and 2007, and living in one of five U.S. markets: Arizona, Dallas, Orlando, South Florida, and Wisconsin.

Roughly 70% of the study population underwent at least one imaging exam during the 3-year study period, “resulting in mean effective doses that almost doubled what would be expected from natural sources alone,” wrote Dr. Reza Fazel of the division of cardiology at Emory University, Atlanta, and her coinvestigators.

Although most patients received less than 3 millisievert (mSv) per year—which was considered low exposure—there was a sizable minority of patients who received moderate, high, or very high radiation doses, they wrote.

CPT codes for imaging procedures involving radiation were used to identify claims from hospitals, outpatient facilities, and physicians' offices. They excluded procedures in which radiation was specifically delivered for therapeutic purposes, such as high-dose radiation for cancer.

Procedures were categorized by technique: plain radiography, CT, fluoroscopy (including angiography), and nuclear imaging. They also categorized the procedures by area of focus: chest (including cardiac imaging), abdomen, pelvis, arm or leg, head and neck (including brain), multiple areas (including whole-body scanning), and unspecified.

In all, 3,442,111 imaging procedures associated with 655,613 patients were identified in the 3-year period. The average number of procedures per person per year was 1.2 and median number was 0.7 per person per year. The mean effective dose was 2.4 mSv/person per year with a median effective dose of 0.1 mSv/year.

The proportion of patients undergoing at least one procedure during the study period increased with age, from 50% in those aged 18-34 years to 86% in those aged 60-64 years. A total of 79% of women underwent at least one procedure during the study period, compared with 60% for men (N. Engl. J. Med. 2009;361:849-57).

Moderate doses (3-20 mSv/year, the upper annual limit for occupational exposure for at-risk workers, averaged over 5 years) occurred at an annual rate of 199 per 1,000 patients. High (20-50 mSv/year, the upper annual limit for occupational exposure for at-risk workers in any given year) and very high (greater than 50 mSv/year) doses occurred at annual rates of 19 and 2 per 1,000 patients, respectively. “Each of these rates rose with advancing age,” noted Dr. Fazel.

“Generalization of our findings to the United States suggests that these procedures lead to cumulative effective doses that exceed 20 mSv per year in approximately 4 million Americans,” the researchers wrote.

By anatomical site, chest procedures accounted for 45% of the total effective dose. Lastly, the bulk of the total effective dose—82%—was delivered in outpatient settings, primarily physicians' offices.

The findings are concerning, particularly for patients who undergo several imaging tests in a short period of time, Dr. Michael S. Lauer wrote in an accompanying editorial (N. Engl. J. Med. 2009;361;841-3).

Despite the cumulative risk associated with radiation exposure, it's generally not something that is discussed with patients undergoing an imaging procedure, noted Dr. Lauer, who is director of the Prevention and Population Sciences Division of the National Heart, Lung, and Blood Institute. “The issue of radiation exposure is unlikely to come up because each procedure is considered in isolation, the risks posed by each procedure are low and seemingly unmeasurable, and any radiation-induced cancer won't appear for years and cannot easily be linked to past imaging procedures.”

“The exposure of patients cannot be restricted, largely because of the inherent difficulty in balancing the immediate clinical need for these procedures, which is frequently substantial, against stochastic risks of cancer that would not be evident for years, if at all.”

Dr. Fazel reported that she has no relevant conflicts of interest, although several of her coauthors reported significant relationships with pharmaceutical and medical imaging companies. Dr. Lauer reported that he has no relevant conflicts of interest.

Medical imaging exposes a significant portion of patients to various doses of ionizing radiation, and in some cases, to substantial doses, potentially increasing the associated risk of cancer, according to findings of a retrospective cohort study.

The results are based on an analysis of 952,420 nonelderly adults who were enrolled in United Healthcare's database between 2005 and 2007, and living in one of five U.S. markets: Arizona, Dallas, Orlando, South Florida, and Wisconsin.

Roughly 70% of the study population underwent at least one imaging exam during the 3-year study period, “resulting in mean effective doses that almost doubled what would be expected from natural sources alone,” wrote Dr. Reza Fazel of the division of cardiology at Emory University, Atlanta, and her coinvestigators.

Although most patients received less than 3 millisievert (mSv) per year—which was considered low exposure—there was a sizable minority of patients who received moderate, high, or very high radiation doses, they wrote.

CPT codes for imaging procedures involving radiation were used to identify claims from hospitals, outpatient facilities, and physicians' offices. They excluded procedures in which radiation was specifically delivered for therapeutic purposes, such as high-dose radiation for cancer.

Procedures were categorized by technique: plain radiography, CT, fluoroscopy (including angiography), and nuclear imaging. They also categorized the procedures by area of focus: chest (including cardiac imaging), abdomen, pelvis, arm or leg, head and neck (including brain), multiple areas (including whole-body scanning), and unspecified.

In all, 3,442,111 imaging procedures associated with 655,613 patients were identified in the 3-year period. The average number of procedures per person per year was 1.2 and median number was 0.7 per person per year. The mean effective dose was 2.4 mSv/person per year with a median effective dose of 0.1 mSv/year.

The proportion of patients undergoing at least one procedure during the study period increased with age, from 50% in those aged 18-34 years to 86% in those aged 60-64 years. A total of 79% of women underwent at least one procedure during the study period, compared with 60% for men (N. Engl. J. Med. 2009;361:849-57).

Moderate doses (3-20 mSv/year, the upper annual limit for occupational exposure for at-risk workers, averaged over 5 years) occurred at an annual rate of 199 per 1,000 patients. High (20-50 mSv/year, the upper annual limit for occupational exposure for at-risk workers in any given year) and very high (greater than 50 mSv/year) doses occurred at annual rates of 19 and 2 per 1,000 patients, respectively. “Each of these rates rose with advancing age,” noted Dr. Fazel.

“Generalization of our findings to the United States suggests that these procedures lead to cumulative effective doses that exceed 20 mSv per year in approximately 4 million Americans,” the researchers wrote.

By anatomical site, chest procedures accounted for 45% of the total effective dose. Lastly, the bulk of the total effective dose—82%—was delivered in outpatient settings, primarily physicians' offices.

The findings are concerning, particularly for patients who undergo several imaging tests in a short period of time, Dr. Michael S. Lauer wrote in an accompanying editorial (N. Engl. J. Med. 2009;361;841-3).

Despite the cumulative risk associated with radiation exposure, it's generally not something that is discussed with patients undergoing an imaging procedure, noted Dr. Lauer, who is director of the Prevention and Population Sciences Division of the National Heart, Lung, and Blood Institute. “The issue of radiation exposure is unlikely to come up because each procedure is considered in isolation, the risks posed by each procedure are low and seemingly unmeasurable, and any radiation-induced cancer won't appear for years and cannot easily be linked to past imaging procedures.”

“The exposure of patients cannot be restricted, largely because of the inherent difficulty in balancing the immediate clinical need for these procedures, which is frequently substantial, against stochastic risks of cancer that would not be evident for years, if at all.”

Dr. Fazel reported that she has no relevant conflicts of interest, although several of her coauthors reported significant relationships with pharmaceutical and medical imaging companies. Dr. Lauer reported that he has no relevant conflicts of interest.

Medical imaging exposes a significant portion of patients to various doses of ionizing radiation, and in some cases, to substantial doses, potentially increasing the associated risk of cancer, according to findings of a retrospective cohort study.

The results are based on an analysis of 952,420 nonelderly adults who were enrolled in United Healthcare's database between 2005 and 2007, and living in one of five U.S. markets: Arizona, Dallas, Orlando, South Florida, and Wisconsin.

Roughly 70% of the study population underwent at least one imaging exam during the 3-year study period, “resulting in mean effective doses that almost doubled what would be expected from natural sources alone,” wrote Dr. Reza Fazel of the division of cardiology at Emory University, Atlanta, and her coinvestigators.

Although most patients received less than 3 millisievert (mSv) per year—which was considered low exposure—there was a sizable minority of patients who received moderate, high, or very high radiation doses, they wrote.

CPT codes for imaging procedures involving radiation were used to identify claims from hospitals, outpatient facilities, and physicians' offices. They excluded procedures in which radiation was specifically delivered for therapeutic purposes, such as high-dose radiation for cancer.

Procedures were categorized by technique: plain radiography, CT, fluoroscopy (including angiography), and nuclear imaging. They also categorized the procedures by area of focus: chest (including cardiac imaging), abdomen, pelvis, arm or leg, head and neck (including brain), multiple areas (including whole-body scanning), and unspecified.

In all, 3,442,111 imaging procedures associated with 655,613 patients were identified in the 3-year period. The average number of procedures per person per year was 1.2 and median number was 0.7 per person per year. The mean effective dose was 2.4 mSv/person per year with a median effective dose of 0.1 mSv/year.

The proportion of patients undergoing at least one procedure during the study period increased with age, from 50% in those aged 18-34 years to 86% in those aged 60-64 years. A total of 79% of women underwent at least one procedure during the study period, compared with 60% for men (N. Engl. J. Med. 2009;361:849-57).

Moderate doses (3-20 mSv/year, the upper annual limit for occupational exposure for at-risk workers, averaged over 5 years) occurred at an annual rate of 199 per 1,000 patients. High (20-50 mSv/year, the upper annual limit for occupational exposure for at-risk workers in any given year) and very high (greater than 50 mSv/year) doses occurred at annual rates of 19 and 2 per 1,000 patients, respectively. “Each of these rates rose with advancing age,” noted Dr. Fazel.

“Generalization of our findings to the United States suggests that these procedures lead to cumulative effective doses that exceed 20 mSv per year in approximately 4 million Americans,” the researchers wrote.

By anatomical site, chest procedures accounted for 45% of the total effective dose. Lastly, the bulk of the total effective dose—82%—was delivered in outpatient settings, primarily physicians' offices.

The findings are concerning, particularly for patients who undergo several imaging tests in a short period of time, Dr. Michael S. Lauer wrote in an accompanying editorial (N. Engl. J. Med. 2009;361;841-3).

Despite the cumulative risk associated with radiation exposure, it's generally not something that is discussed with patients undergoing an imaging procedure, noted Dr. Lauer, who is director of the Prevention and Population Sciences Division of the National Heart, Lung, and Blood Institute. “The issue of radiation exposure is unlikely to come up because each procedure is considered in isolation, the risks posed by each procedure are low and seemingly unmeasurable, and any radiation-induced cancer won't appear for years and cannot easily be linked to past imaging procedures.”

“The exposure of patients cannot be restricted, largely because of the inherent difficulty in balancing the immediate clinical need for these procedures, which is frequently substantial, against stochastic risks of cancer that would not be evident for years, if at all.”

Dr. Fazel reported that she has no relevant conflicts of interest, although several of her coauthors reported significant relationships with pharmaceutical and medical imaging companies. Dr. Lauer reported that he has no relevant conflicts of interest.

BOSTON — Lesion darkness would make a better criterion for identifying early melanomas than the 6-mm diameter cutoff in the ABCDE criteria currently used by physicians and patients, said Dr. Stuart Goldsmith.

“It's recognized that all melanomas start as a single cell or a few cells. So microscopically, they're already cancer, but we're not even telling patients to look for small lesions,” he said.

“If we were doing okay [in terms of mortality], then it wouldn't matter. The fact is that we are not doing as well as we want to for our patients,” said Dr. Goldsmith, a practicing dermatologist in Albany, Ga. “More than 8,000 Americans die every year of melanoma—most from cutaneous lesions, lesions on the skin that could have been removed when smaller than 6 mm and in time to save the patient's life,” Dr. Goldsmith noted at the American Academy of Dermatology's Academy 2009 meeting.

Although the ABCDE criteria are intended to enhance the diagnosis of early melanoma, Dr. Goldsmith related that some dermatologists suggest that elimination of the diameter criterion would lead to too many biopsies. “In other words, it's become a cost issue,” he said.

“I'm not saying that saving money shouldn't be a priority. It just shouldn't be a priority of these criteria,” he said.

Dr. Goldsmith contends that the concerns about cost are unjustified. He used data from his own practice (Medicare rates for 2009, Albany, Ga.) to develop a specific cost model to assess the argument that excision and pathology for smaller suspect lesions would increase costs. “Assuming our society's accepted cost of $50,000 per quality-adjusted life-year saved, and rounding up to $200 per excision, if 1 in 250 excisions saved 1 year of one person's life, the cost would be justified,” he said. Given that the average life-years lost per fatal melanoma is 18.6 (based on Surveillance, Epidemiology and End Results data), the cost would be justified if 1 in every 4,650 small-diameter lesions excised would have prevented a death from melanoma. “This cost justification is valid even if there would be no costs savings,” he said.

Models to decrease the cost of melanoma have emphasized the need to diagnose earlier invasive and in situ disease. The estimated treatment of stage III and IV disease accounted for 90% of costs from melanoma. Disease caught earlier could avoid much of this cost (J. Am. Acad. Dermatol. 1998;38:669-80).

In terms of cost alone, an increase in small-diameter biopsies would not lead to unacceptable costs and may even result in cost savings, he said.

A cost analysis must also include a discussion of the number of lesions needed to excise, or biopsy, (NNE) to diagnose one melanoma. NNE should only be discussed in the context of sensitivity of melanoma diagnosis.

Dr. Goldsmith highlighted two articles from 2008. In the first study, the NNE for small-diameter lesions (those 6 mm and smaller) was 1 in 24, while the NNE for larger lesions was approximately 1 in 8 (Arch. Dermatol. 2008;144:469-74). The authors concluded that the 6-mm criterion remains useful and that their biopsy rate for smaller lesions was appropriate.

In the second article, however, the study's group of expert dermoscopists would not only have misdiagnosed but would have totally missed—would not have biopsied—29% of small-diameter melanomas. Lesions were evaluated using dermoscopic images with information given about the patient's age, sex, and lesion location (Arch. Dermatol. 2008;144:476-82).

Studies show that patients find their melanomas more often than physicians do. Unfortunately, the lesions found by patients are likely to be deeper or more advanced than those that physicians find. “The fact that patients would monitor for smaller lesions and start the process of getting in to see the doctor to get a lesion checked as early as possible could hopefully avoid what could end up being a critical delay in the recognition of a melanoma,” he said.

“The single criterion that seems to have the most impact on recognition of the smallest melanomas is the criterion of darkness,” he said.

The singular importance of darkness for the diagnosis of small-diameter melanomas has been described in several series (Tumori 2004;90:128-31; J. Eur. Acad. Dermatol. Venereol. 2007;21:929-34; and Arch. Dermatol. 1998;134:103-4). These reports suggest that, “when evaluating a lesion of unknown history, an 8-mm lightly pigmented macule with symmetric variation in pigmentation—two of the four current ABCD features—is of less concern than a 3-mm, circular, evenly pigmented black macule or papule with none of the four current ABCD criteria,” he said.

In other words, the criterion of darkness is a stand-alone, nonredundant feature to help recognize melanomas. “It just doesn't make sense that darkness is currently not even one of four objective criteria used in educational strategies related to melanoma recognition,” he said.

Increased emphasis on the criterion of darkness enhances other strategies to diagnose melanomas, he said, including early recognition of asymmetry in melanomas (Arch. Dermatol. 1994;130:1013-7), recognition of change in melanomas (Br. J. Dermatol. 1999;141:783-7), and identifying small “ugly ducklings” that are melanomas (Arch. Dermatol. 1998;134:103-4).

This patient has melanoma in-situ, mixed pattern, with regression.

Source Courtesy kimggraphics

BOSTON — Lesion darkness would make a better criterion for identifying early melanomas than the 6-mm diameter cutoff in the ABCDE criteria currently used by physicians and patients, said Dr. Stuart Goldsmith.

“It's recognized that all melanomas start as a single cell or a few cells. So microscopically, they're already cancer, but we're not even telling patients to look for small lesions,” he said.

“If we were doing okay [in terms of mortality], then it wouldn't matter. The fact is that we are not doing as well as we want to for our patients,” said Dr. Goldsmith, a practicing dermatologist in Albany, Ga. “More than 8,000 Americans die every year of melanoma—most from cutaneous lesions, lesions on the skin that could have been removed when smaller than 6 mm and in time to save the patient's life,” Dr. Goldsmith noted at the American Academy of Dermatology's Academy 2009 meeting.

Although the ABCDE criteria are intended to enhance the diagnosis of early melanoma, Dr. Goldsmith related that some dermatologists suggest that elimination of the diameter criterion would lead to too many biopsies. “In other words, it's become a cost issue,” he said.

“I'm not saying that saving money shouldn't be a priority. It just shouldn't be a priority of these criteria,” he said.

Dr. Goldsmith contends that the concerns about cost are unjustified. He used data from his own practice (Medicare rates for 2009, Albany, Ga.) to develop a specific cost model to assess the argument that excision and pathology for smaller suspect lesions would increase costs. “Assuming our society's accepted cost of $50,000 per quality-adjusted life-year saved, and rounding up to $200 per excision, if 1 in 250 excisions saved 1 year of one person's life, the cost would be justified,” he said. Given that the average life-years lost per fatal melanoma is 18.6 (based on Surveillance, Epidemiology and End Results data), the cost would be justified if 1 in every 4,650 small-diameter lesions excised would have prevented a death from melanoma. “This cost justification is valid even if there would be no costs savings,” he said.

Models to decrease the cost of melanoma have emphasized the need to diagnose earlier invasive and in situ disease. The estimated treatment of stage III and IV disease accounted for 90% of costs from melanoma. Disease caught earlier could avoid much of this cost (J. Am. Acad. Dermatol. 1998;38:669-80).

In terms of cost alone, an increase in small-diameter biopsies would not lead to unacceptable costs and may even result in cost savings, he said.

A cost analysis must also include a discussion of the number of lesions needed to excise, or biopsy, (NNE) to diagnose one melanoma. NNE should only be discussed in the context of sensitivity of melanoma diagnosis.

Dr. Goldsmith highlighted two articles from 2008. In the first study, the NNE for small-diameter lesions (those 6 mm and smaller) was 1 in 24, while the NNE for larger lesions was approximately 1 in 8 (Arch. Dermatol. 2008;144:469-74). The authors concluded that the 6-mm criterion remains useful and that their biopsy rate for smaller lesions was appropriate.

In the second article, however, the study's group of expert dermoscopists would not only have misdiagnosed but would have totally missed—would not have biopsied—29% of small-diameter melanomas. Lesions were evaluated using dermoscopic images with information given about the patient's age, sex, and lesion location (Arch. Dermatol. 2008;144:476-82).

Studies show that patients find their melanomas more often than physicians do. Unfortunately, the lesions found by patients are likely to be deeper or more advanced than those that physicians find. “The fact that patients would monitor for smaller lesions and start the process of getting in to see the doctor to get a lesion checked as early as possible could hopefully avoid what could end up being a critical delay in the recognition of a melanoma,” he said.

“The single criterion that seems to have the most impact on recognition of the smallest melanomas is the criterion of darkness,” he said.

The singular importance of darkness for the diagnosis of small-diameter melanomas has been described in several series (Tumori 2004;90:128-31; J. Eur. Acad. Dermatol. Venereol. 2007;21:929-34; and Arch. Dermatol. 1998;134:103-4). These reports suggest that, “when evaluating a lesion of unknown history, an 8-mm lightly pigmented macule with symmetric variation in pigmentation—two of the four current ABCD features—is of less concern than a 3-mm, circular, evenly pigmented black macule or papule with none of the four current ABCD criteria,” he said.

In other words, the criterion of darkness is a stand-alone, nonredundant feature to help recognize melanomas. “It just doesn't make sense that darkness is currently not even one of four objective criteria used in educational strategies related to melanoma recognition,” he said.

Increased emphasis on the criterion of darkness enhances other strategies to diagnose melanomas, he said, including early recognition of asymmetry in melanomas (Arch. Dermatol. 1994;130:1013-7), recognition of change in melanomas (Br. J. Dermatol. 1999;141:783-7), and identifying small “ugly ducklings” that are melanomas (Arch. Dermatol. 1998;134:103-4).

This patient has melanoma in-situ, mixed pattern, with regression.

Source Courtesy kimggraphics

BOSTON — Lesion darkness would make a better criterion for identifying early melanomas than the 6-mm diameter cutoff in the ABCDE criteria currently used by physicians and patients, said Dr. Stuart Goldsmith.

“It's recognized that all melanomas start as a single cell or a few cells. So microscopically, they're already cancer, but we're not even telling patients to look for small lesions,” he said.

“If we were doing okay [in terms of mortality], then it wouldn't matter. The fact is that we are not doing as well as we want to for our patients,” said Dr. Goldsmith, a practicing dermatologist in Albany, Ga. “More than 8,000 Americans die every year of melanoma—most from cutaneous lesions, lesions on the skin that could have been removed when smaller than 6 mm and in time to save the patient's life,” Dr. Goldsmith noted at the American Academy of Dermatology's Academy 2009 meeting.

Although the ABCDE criteria are intended to enhance the diagnosis of early melanoma, Dr. Goldsmith related that some dermatologists suggest that elimination of the diameter criterion would lead to too many biopsies. “In other words, it's become a cost issue,” he said.

“I'm not saying that saving money shouldn't be a priority. It just shouldn't be a priority of these criteria,” he said.

Dr. Goldsmith contends that the concerns about cost are unjustified. He used data from his own practice (Medicare rates for 2009, Albany, Ga.) to develop a specific cost model to assess the argument that excision and pathology for smaller suspect lesions would increase costs. “Assuming our society's accepted cost of $50,000 per quality-adjusted life-year saved, and rounding up to $200 per excision, if 1 in 250 excisions saved 1 year of one person's life, the cost would be justified,” he said. Given that the average life-years lost per fatal melanoma is 18.6 (based on Surveillance, Epidemiology and End Results data), the cost would be justified if 1 in every 4,650 small-diameter lesions excised would have prevented a death from melanoma. “This cost justification is valid even if there would be no costs savings,” he said.

Models to decrease the cost of melanoma have emphasized the need to diagnose earlier invasive and in situ disease. The estimated treatment of stage III and IV disease accounted for 90% of costs from melanoma. Disease caught earlier could avoid much of this cost (J. Am. Acad. Dermatol. 1998;38:669-80).

In terms of cost alone, an increase in small-diameter biopsies would not lead to unacceptable costs and may even result in cost savings, he said.

A cost analysis must also include a discussion of the number of lesions needed to excise, or biopsy, (NNE) to diagnose one melanoma. NNE should only be discussed in the context of sensitivity of melanoma diagnosis.

Dr. Goldsmith highlighted two articles from 2008. In the first study, the NNE for small-diameter lesions (those 6 mm and smaller) was 1 in 24, while the NNE for larger lesions was approximately 1 in 8 (Arch. Dermatol. 2008;144:469-74). The authors concluded that the 6-mm criterion remains useful and that their biopsy rate for smaller lesions was appropriate.

In the second article, however, the study's group of expert dermoscopists would not only have misdiagnosed but would have totally missed—would not have biopsied—29% of small-diameter melanomas. Lesions were evaluated using dermoscopic images with information given about the patient's age, sex, and lesion location (Arch. Dermatol. 2008;144:476-82).

Studies show that patients find their melanomas more often than physicians do. Unfortunately, the lesions found by patients are likely to be deeper or more advanced than those that physicians find. “The fact that patients would monitor for smaller lesions and start the process of getting in to see the doctor to get a lesion checked as early as possible could hopefully avoid what could end up being a critical delay in the recognition of a melanoma,” he said.

“The single criterion that seems to have the most impact on recognition of the smallest melanomas is the criterion of darkness,” he said.

The singular importance of darkness for the diagnosis of small-diameter melanomas has been described in several series (Tumori 2004;90:128-31; J. Eur. Acad. Dermatol. Venereol. 2007;21:929-34; and Arch. Dermatol. 1998;134:103-4). These reports suggest that, “when evaluating a lesion of unknown history, an 8-mm lightly pigmented macule with symmetric variation in pigmentation—two of the four current ABCD features—is of less concern than a 3-mm, circular, evenly pigmented black macule or papule with none of the four current ABCD criteria,” he said.

In other words, the criterion of darkness is a stand-alone, nonredundant feature to help recognize melanomas. “It just doesn't make sense that darkness is currently not even one of four objective criteria used in educational strategies related to melanoma recognition,” he said.

Increased emphasis on the criterion of darkness enhances other strategies to diagnose melanomas, he said, including early recognition of asymmetry in melanomas (Arch. Dermatol. 1994;130:1013-7), recognition of change in melanomas (Br. J. Dermatol. 1999;141:783-7), and identifying small “ugly ducklings” that are melanomas (Arch. Dermatol. 1998;134:103-4).

This patient has melanoma in-situ, mixed pattern, with regression.

Source Courtesy kimggraphics

Adolescent abuse of prescription stimulant attention-deficit/hyperactivity disorder medications increased far more rapidly than general and adolescent substance abuse for the years of 1998-2005, a study recently published online shows.

Stimulant abuse–elated calls to poison control centers rose 76%, general substance abuse calls rose 59%, and adolescent substance abuse calls increased 55% over the 8-year period.

The findings, which come from a study of data from poison control calls collected in the National Poison Data System (NPDS), are published in the September issue of Pediatrics (2009;124:875-80; doi:10.1542/peds.2008-0931

“The sharp increase in calls related to teen ADHD medication abuse, out of proportion to other poison center calls, suggests a rising problem with abuse of these medications,” wrote Dr. Jennifer Setlik and her coinvestigators. Dr. Setlik is an emergency physician at Cincinnati Children's Hospital Medical Center.

Dr. Mark S. Gold, chairman of the department of psychiatry at the University of Florida, Gainesville, has written about the increasing use of prescription medications. Prescription medications (psychostimulants) are used for performance-enhancing effects and ADHD stimulant medications are sometimes used to reverse the effects of marijuana and alcohol, improving concentration and the ability to study.

“From our experience, these medications are given or traded and used for studying, alertness, or other drug-effect reversals. When these medications are snorted or injected or mixed with other prescriptions, they are used for abuse and by abusers,” he said in an interview.

For this study, the researchers searched the database NPDS for cases of adolescent exposure to prescription ADHD medications for 1998-2005. The NPDS contains data on every human exposure report received by a member poison control center. The database includes 41.1 million cases from 1983 to 2005. Information collected includes patient and caller demographics, exposure scenario, symptoms/signs of clinical toxicity, treatment, and medical outcome.

The cases had to meet specified criteria: age 13-19 years with intentional abuse/misuse as the reason for exposure. All product codes for generic and brand name stimulant ADHD medications were identified and used in the search. Stimulant medications were broken down to amphetamine/dextroamphetamine or methylphenidate.

The centers classify medical outcomes as no effect, minor effect (minimally bothersome/resolves quickly), moderate effect (more pronounced/prolonged/systemic), major effect (life-threatening or resulted in significant residual disability/disfigurement), and death. The American Association of Poison Control Centers defines misuse as improper or incorrect use of a substance; abuse is defined as improper or incorrect use of a substance with the intent to get high or achieve some other psychotropic effect.

For context, the researchers also assessed the total number of human exposure calls for the same period. They also looked at total population served, total number of calls coded as intentional abuse (and within the subset aged 13-19 years), and the total number of acetaminophen product exposures coded as suicide (all ages and 13-19 years).

During the study period, calls for adolescent abuse of ADHD prescription drugs rose 76% from 330 to 581 per year. However, the number of prescriptions written for these medications for 10- to 19-year-olds rose 86% during the same period, from 4.2 million to 7.8 million.

“The 76% rise in the number of calls for teen abuse of ADHD medications is significant,” the researchers wrote. In contrast, the annual rate of total and teen exposures was unchanged. “This demonstrates a significant independent rise in reports of adolescent abuse of ADHD medications.”

The authors reported that they have no financial relationships relevant to this article.

Adolescent abuse of prescription stimulant attention-deficit/hyperactivity disorder medications increased far more rapidly than general and adolescent substance abuse for the years of 1998-2005, a study recently published online shows.

Stimulant abuse–elated calls to poison control centers rose 76%, general substance abuse calls rose 59%, and adolescent substance abuse calls increased 55% over the 8-year period.

The findings, which come from a study of data from poison control calls collected in the National Poison Data System (NPDS), are published in the September issue of Pediatrics (2009;124:875-80; doi:10.1542/peds.2008-0931

“The sharp increase in calls related to teen ADHD medication abuse, out of proportion to other poison center calls, suggests a rising problem with abuse of these medications,” wrote Dr. Jennifer Setlik and her coinvestigators. Dr. Setlik is an emergency physician at Cincinnati Children's Hospital Medical Center.

Dr. Mark S. Gold, chairman of the department of psychiatry at the University of Florida, Gainesville, has written about the increasing use of prescription medications. Prescription medications (psychostimulants) are used for performance-enhancing effects and ADHD stimulant medications are sometimes used to reverse the effects of marijuana and alcohol, improving concentration and the ability to study.

“From our experience, these medications are given or traded and used for studying, alertness, or other drug-effect reversals. When these medications are snorted or injected or mixed with other prescriptions, they are used for abuse and by abusers,” he said in an interview.

For this study, the researchers searched the database NPDS for cases of adolescent exposure to prescription ADHD medications for 1998-2005. The NPDS contains data on every human exposure report received by a member poison control center. The database includes 41.1 million cases from 1983 to 2005. Information collected includes patient and caller demographics, exposure scenario, symptoms/signs of clinical toxicity, treatment, and medical outcome.

The cases had to meet specified criteria: age 13-19 years with intentional abuse/misuse as the reason for exposure. All product codes for generic and brand name stimulant ADHD medications were identified and used in the search. Stimulant medications were broken down to amphetamine/dextroamphetamine or methylphenidate.

The centers classify medical outcomes as no effect, minor effect (minimally bothersome/resolves quickly), moderate effect (more pronounced/prolonged/systemic), major effect (life-threatening or resulted in significant residual disability/disfigurement), and death. The American Association of Poison Control Centers defines misuse as improper or incorrect use of a substance; abuse is defined as improper or incorrect use of a substance with the intent to get high or achieve some other psychotropic effect.

For context, the researchers also assessed the total number of human exposure calls for the same period. They also looked at total population served, total number of calls coded as intentional abuse (and within the subset aged 13-19 years), and the total number of acetaminophen product exposures coded as suicide (all ages and 13-19 years).

During the study period, calls for adolescent abuse of ADHD prescription drugs rose 76% from 330 to 581 per year. However, the number of prescriptions written for these medications for 10- to 19-year-olds rose 86% during the same period, from 4.2 million to 7.8 million.

“The 76% rise in the number of calls for teen abuse of ADHD medications is significant,” the researchers wrote. In contrast, the annual rate of total and teen exposures was unchanged. “This demonstrates a significant independent rise in reports of adolescent abuse of ADHD medications.”

The authors reported that they have no financial relationships relevant to this article.

Adolescent abuse of prescription stimulant attention-deficit/hyperactivity disorder medications increased far more rapidly than general and adolescent substance abuse for the years of 1998-2005, a study recently published online shows.

Stimulant abuse–elated calls to poison control centers rose 76%, general substance abuse calls rose 59%, and adolescent substance abuse calls increased 55% over the 8-year period.

The findings, which come from a study of data from poison control calls collected in the National Poison Data System (NPDS), are published in the September issue of Pediatrics (2009;124:875-80; doi:10.1542/peds.2008-0931

“The sharp increase in calls related to teen ADHD medication abuse, out of proportion to other poison center calls, suggests a rising problem with abuse of these medications,” wrote Dr. Jennifer Setlik and her coinvestigators. Dr. Setlik is an emergency physician at Cincinnati Children's Hospital Medical Center.

Dr. Mark S. Gold, chairman of the department of psychiatry at the University of Florida, Gainesville, has written about the increasing use of prescription medications. Prescription medications (psychostimulants) are used for performance-enhancing effects and ADHD stimulant medications are sometimes used to reverse the effects of marijuana and alcohol, improving concentration and the ability to study.

“From our experience, these medications are given or traded and used for studying, alertness, or other drug-effect reversals. When these medications are snorted or injected or mixed with other prescriptions, they are used for abuse and by abusers,” he said in an interview.

For this study, the researchers searched the database NPDS for cases of adolescent exposure to prescription ADHD medications for 1998-2005. The NPDS contains data on every human exposure report received by a member poison control center. The database includes 41.1 million cases from 1983 to 2005. Information collected includes patient and caller demographics, exposure scenario, symptoms/signs of clinical toxicity, treatment, and medical outcome.

The cases had to meet specified criteria: age 13-19 years with intentional abuse/misuse as the reason for exposure. All product codes for generic and brand name stimulant ADHD medications were identified and used in the search. Stimulant medications were broken down to amphetamine/dextroamphetamine or methylphenidate.

The centers classify medical outcomes as no effect, minor effect (minimally bothersome/resolves quickly), moderate effect (more pronounced/prolonged/systemic), major effect (life-threatening or resulted in significant residual disability/disfigurement), and death. The American Association of Poison Control Centers defines misuse as improper or incorrect use of a substance; abuse is defined as improper or incorrect use of a substance with the intent to get high or achieve some other psychotropic effect.

For context, the researchers also assessed the total number of human exposure calls for the same period. They also looked at total population served, total number of calls coded as intentional abuse (and within the subset aged 13-19 years), and the total number of acetaminophen product exposures coded as suicide (all ages and 13-19 years).

During the study period, calls for adolescent abuse of ADHD prescription drugs rose 76% from 330 to 581 per year. However, the number of prescriptions written for these medications for 10- to 19-year-olds rose 86% during the same period, from 4.2 million to 7.8 million.

“The 76% rise in the number of calls for teen abuse of ADHD medications is significant,” the researchers wrote. In contrast, the annual rate of total and teen exposures was unchanged. “This demonstrates a significant independent rise in reports of adolescent abuse of ADHD medications.”

The authors reported that they have no financial relationships relevant to this article.

PHILADELPHIA — An expert group has proposed consensus diagnostic criteria for PHACES syndrome that call for full neurologic and cerebrovascular, ophthalmologic, and cardiologic work-ups to be performed on infants with hemangiomas who are at risk for the syndrome.

“Basically we're recommending a work-up of all three organ systems for any patient who has large facial hemangioma, no matter where it's located,” said Dr. Denise Metry, first author of a poster on the criteria presented at the annual meeting of the Society for Pediatric Dermatology.

The neurocutaneous PHACES—posterior fossa anomalies, hemangioma, arterial abnormalities, cardiac and aortic arch defects, eye abnormalities, and sternal cleft anomalies—syndrome affects a subgroup of patients with infantile hemangiomas.

The syndrome involves structural anomalies of the brain, cerebral vasculature, aorta, eyes, and the chest wall. The most common features are brain and cerebral vasculature abnormalities, so neurologic and cognitive impairments are among the most common morbidities.

Often, patients with hemangiomas on the upper part of the face tend to be more at risk for brain and eye abnormalities, while infants with hemangiomas on the lower part of the face are more likely to be at risk for cardiac issues or airway involvement. These are not, however, hard and fast rules. “I had a patient [with] a mandibular segment hemangioma, who had brain involvement,” said Dr. Metry, highlighting the need for the criteria.

The proposed criteria for PHACES syndrome include a facial hemangioma larger than 5 cm in diameter plus one major criterion or two minor criteria. The major and minor criteria are categorized by organ system: cerebrovascular, structural brain, cardiovascular, ocular, and ventral or midline. (See table.)

Possible PHACES syndrome criteria include a facial hemangioma larger than 5 cm in diameter and one minor criterion, a hemangioma of the neck or upper torso plus one major or two minor criteria, or no hemangioma plus two major criteria.

“We're hoping that the criteria gain widespread acceptance,” said Dr. Metry, who is chief of the Texas Children's Dermatology Clinic in Houston.

Formal guidelines have been lacking for the care of infants with this disorder, though it is generally recommended that infants with large hemangiomas of the face or scalp undergo head, neck, and chest imaging, along with ophthalmologic and skin examinations.

Likewise, there have been no standardized criteria for the diagnosis of PHACES syndrome.

The development of these criteria followed standard consensus methodology, based on a review of published clinical data and the combined experience of a multidisciplinary expert panel that included pediatric dermatologists, neuroradiologists, pediatric oncologists, geneticists, pediatric cardiologists, ophthalmologists, and representatives from patient support groups.

The expert panel reviewed published, peer-reviewed medical literature obtained by querying the Medline and PubMed databases.

After the panel put together and reviewed an initial draft, key features were discussed and a basic consensus statement was drafted during an executive session at the PHACE syndrome research conference and workshop in 2008.

During the conference, diagnostic criteria were circulated to the attendees for discussion and revision. After the conference, the expert panel resolved all conflicting recommendations via e-mail and teleconferencing.

In creating the major and minor criteria, the panel members determined the relative frequencies of each criterion in the literature and existing registries.

“While these diagnostic criteria will continue to evolve as new research findings are incorporated, the establishment of guidelines will enhance clinical care by improving screening, detection, and awareness of this neurocutaneous disorder,” Dr. Metry and her associates wrote.

Major and Minor Criteria for PHACES Syndrome

Source ELSEVIER GLOBAL MEDICAL NEWS

PHILADELPHIA — An expert group has proposed consensus diagnostic criteria for PHACES syndrome that call for full neurologic and cerebrovascular, ophthalmologic, and cardiologic work-ups to be performed on infants with hemangiomas who are at risk for the syndrome.

“Basically we're recommending a work-up of all three organ systems for any patient who has large facial hemangioma, no matter where it's located,” said Dr. Denise Metry, first author of a poster on the criteria presented at the annual meeting of the Society for Pediatric Dermatology.

The neurocutaneous PHACES—posterior fossa anomalies, hemangioma, arterial abnormalities, cardiac and aortic arch defects, eye abnormalities, and sternal cleft anomalies—syndrome affects a subgroup of patients with infantile hemangiomas.

The syndrome involves structural anomalies of the brain, cerebral vasculature, aorta, eyes, and the chest wall. The most common features are brain and cerebral vasculature abnormalities, so neurologic and cognitive impairments are among the most common morbidities.

Often, patients with hemangiomas on the upper part of the face tend to be more at risk for brain and eye abnormalities, while infants with hemangiomas on the lower part of the face are more likely to be at risk for cardiac issues or airway involvement. These are not, however, hard and fast rules. “I had a patient [with] a mandibular segment hemangioma, who had brain involvement,” said Dr. Metry, highlighting the need for the criteria.

The proposed criteria for PHACES syndrome include a facial hemangioma larger than 5 cm in diameter plus one major criterion or two minor criteria. The major and minor criteria are categorized by organ system: cerebrovascular, structural brain, cardiovascular, ocular, and ventral or midline. (See table.)

Possible PHACES syndrome criteria include a facial hemangioma larger than 5 cm in diameter and one minor criterion, a hemangioma of the neck or upper torso plus one major or two minor criteria, or no hemangioma plus two major criteria.

“We're hoping that the criteria gain widespread acceptance,” said Dr. Metry, who is chief of the Texas Children's Dermatology Clinic in Houston.

Formal guidelines have been lacking for the care of infants with this disorder, though it is generally recommended that infants with large hemangiomas of the face or scalp undergo head, neck, and chest imaging, along with ophthalmologic and skin examinations.

Likewise, there have been no standardized criteria for the diagnosis of PHACES syndrome.

The development of these criteria followed standard consensus methodology, based on a review of published clinical data and the combined experience of a multidisciplinary expert panel that included pediatric dermatologists, neuroradiologists, pediatric oncologists, geneticists, pediatric cardiologists, ophthalmologists, and representatives from patient support groups.

The expert panel reviewed published, peer-reviewed medical literature obtained by querying the Medline and PubMed databases.

After the panel put together and reviewed an initial draft, key features were discussed and a basic consensus statement was drafted during an executive session at the PHACE syndrome research conference and workshop in 2008.

During the conference, diagnostic criteria were circulated to the attendees for discussion and revision. After the conference, the expert panel resolved all conflicting recommendations via e-mail and teleconferencing.

In creating the major and minor criteria, the panel members determined the relative frequencies of each criterion in the literature and existing registries.

“While these diagnostic criteria will continue to evolve as new research findings are incorporated, the establishment of guidelines will enhance clinical care by improving screening, detection, and awareness of this neurocutaneous disorder,” Dr. Metry and her associates wrote.

Major and Minor Criteria for PHACES Syndrome

Source ELSEVIER GLOBAL MEDICAL NEWS

PHILADELPHIA — An expert group has proposed consensus diagnostic criteria for PHACES syndrome that call for full neurologic and cerebrovascular, ophthalmologic, and cardiologic work-ups to be performed on infants with hemangiomas who are at risk for the syndrome.

“Basically we're recommending a work-up of all three organ systems for any patient who has large facial hemangioma, no matter where it's located,” said Dr. Denise Metry, first author of a poster on the criteria presented at the annual meeting of the Society for Pediatric Dermatology.

The neurocutaneous PHACES—posterior fossa anomalies, hemangioma, arterial abnormalities, cardiac and aortic arch defects, eye abnormalities, and sternal cleft anomalies—syndrome affects a subgroup of patients with infantile hemangiomas.

The syndrome involves structural anomalies of the brain, cerebral vasculature, aorta, eyes, and the chest wall. The most common features are brain and cerebral vasculature abnormalities, so neurologic and cognitive impairments are among the most common morbidities.

Often, patients with hemangiomas on the upper part of the face tend to be more at risk for brain and eye abnormalities, while infants with hemangiomas on the lower part of the face are more likely to be at risk for cardiac issues or airway involvement. These are not, however, hard and fast rules. “I had a patient [with] a mandibular segment hemangioma, who had brain involvement,” said Dr. Metry, highlighting the need for the criteria.

The proposed criteria for PHACES syndrome include a facial hemangioma larger than 5 cm in diameter plus one major criterion or two minor criteria. The major and minor criteria are categorized by organ system: cerebrovascular, structural brain, cardiovascular, ocular, and ventral or midline. (See table.)

Possible PHACES syndrome criteria include a facial hemangioma larger than 5 cm in diameter and one minor criterion, a hemangioma of the neck or upper torso plus one major or two minor criteria, or no hemangioma plus two major criteria.

“We're hoping that the criteria gain widespread acceptance,” said Dr. Metry, who is chief of the Texas Children's Dermatology Clinic in Houston.

Formal guidelines have been lacking for the care of infants with this disorder, though it is generally recommended that infants with large hemangiomas of the face or scalp undergo head, neck, and chest imaging, along with ophthalmologic and skin examinations.

Likewise, there have been no standardized criteria for the diagnosis of PHACES syndrome.

The development of these criteria followed standard consensus methodology, based on a review of published clinical data and the combined experience of a multidisciplinary expert panel that included pediatric dermatologists, neuroradiologists, pediatric oncologists, geneticists, pediatric cardiologists, ophthalmologists, and representatives from patient support groups.

The expert panel reviewed published, peer-reviewed medical literature obtained by querying the Medline and PubMed databases.

After the panel put together and reviewed an initial draft, key features were discussed and a basic consensus statement was drafted during an executive session at the PHACE syndrome research conference and workshop in 2008.

During the conference, diagnostic criteria were circulated to the attendees for discussion and revision. After the conference, the expert panel resolved all conflicting recommendations via e-mail and teleconferencing.

In creating the major and minor criteria, the panel members determined the relative frequencies of each criterion in the literature and existing registries.

“While these diagnostic criteria will continue to evolve as new research findings are incorporated, the establishment of guidelines will enhance clinical care by improving screening, detection, and awareness of this neurocutaneous disorder,” Dr. Metry and her associates wrote.

Major and Minor Criteria for PHACES Syndrome

Source ELSEVIER GLOBAL MEDICAL NEWS