Kerri Wachter

SAN ANTONIO — Breast cancer survivors with poor physical health, particularly those with limited physical activity, have a worse prognosis than those with adequate physical health, based on the results of a study of almost 3,000 survivors followed for 6 years.

“Approximately 40% of breast cancer survivors are at higher risk because of their poor physical health status,” Abu N. Saquib, Ph.D., wrote in a poster presented at the San Antonio Breast Cancer Symposium.

Dr. Saquib and his coinvestigators at the University of California, San Diego, assessed the effect of physical health and physical activity on additional breast cancer events and deaths among 2,967 early-stage breast cancer survivors, who were enrolled in the Women's Healthy Eating and Living study during 1995–2000.

The investigators found that both physical activity and physical health were strong predictors of breast cancer prognosis on univariate analysis. However, multivariate analysis—which adjusted for age, race, body mass index, menopausal status, tumor type, tumor grade, tumor stage, anti-estrogen use, and other factors—showed that physical health was a stronger predictor of additional breast cancer events and death from breast cancer than was physical activity. Those with low physical health had a 57% increased risk of having additional breast cancer events and a 50% increased risk of breast cancer death during follow-up than did those with adequate physical health.

SAN ANTONIO — Breast cancer survivors with poor physical health, particularly those with limited physical activity, have a worse prognosis than those with adequate physical health, based on the results of a study of almost 3,000 survivors followed for 6 years.

“Approximately 40% of breast cancer survivors are at higher risk because of their poor physical health status,” Abu N. Saquib, Ph.D., wrote in a poster presented at the San Antonio Breast Cancer Symposium.

Dr. Saquib and his coinvestigators at the University of California, San Diego, assessed the effect of physical health and physical activity on additional breast cancer events and deaths among 2,967 early-stage breast cancer survivors, who were enrolled in the Women's Healthy Eating and Living study during 1995–2000.

The investigators found that both physical activity and physical health were strong predictors of breast cancer prognosis on univariate analysis. However, multivariate analysis—which adjusted for age, race, body mass index, menopausal status, tumor type, tumor grade, tumor stage, anti-estrogen use, and other factors—showed that physical health was a stronger predictor of additional breast cancer events and death from breast cancer than was physical activity. Those with low physical health had a 57% increased risk of having additional breast cancer events and a 50% increased risk of breast cancer death during follow-up than did those with adequate physical health.

SAN ANTONIO — Breast cancer survivors with poor physical health, particularly those with limited physical activity, have a worse prognosis than those with adequate physical health, based on the results of a study of almost 3,000 survivors followed for 6 years.

“Approximately 40% of breast cancer survivors are at higher risk because of their poor physical health status,” Abu N. Saquib, Ph.D., wrote in a poster presented at the San Antonio Breast Cancer Symposium.

Dr. Saquib and his coinvestigators at the University of California, San Diego, assessed the effect of physical health and physical activity on additional breast cancer events and deaths among 2,967 early-stage breast cancer survivors, who were enrolled in the Women's Healthy Eating and Living study during 1995–2000.

The investigators found that both physical activity and physical health were strong predictors of breast cancer prognosis on univariate analysis. However, multivariate analysis—which adjusted for age, race, body mass index, menopausal status, tumor type, tumor grade, tumor stage, anti-estrogen use, and other factors—showed that physical health was a stronger predictor of additional breast cancer events and death from breast cancer than was physical activity. Those with low physical health had a 57% increased risk of having additional breast cancer events and a 50% increased risk of breast cancer death during follow-up than did those with adequate physical health.

The U.S. Preventive Services Task Force still cannot recommend for or against whole-body skin examination by a primary care physician or by patient self-examination for the early detection of cutaneous melanoma, basal cell cancer, or squamous cell skin cancer in the adult general population.

The task force concluded that there is not enough evidence to assess the benefits and harms from such examinations in its latest recommendations (Ann. Int. Med. 2009;150:188-93).

The previous recommendation came in 2001, when the group also concluded that there was insufficient evidence to recommend for or against routine whole-body skin examination for skin cancer screening.

“This is not to say that studies have shown that it's not effective; what they're saying is that there are just no studies out there,” commented Dr. Darrell S. Rigel, a clinical professor of dermatology at New York University.

“If you talk to people who have had melanomas detected during screenings, they are very happy. They think screening is great because you basically have saved their lives,” he said.

The task force did note two critical gaps in knowledge. First, there is insufficient evidence (a lack of studies) to determine whether early detection of skin cancer reduces morbidity or mortality from skin cancer. Second, there is insufficient evidence to determine the magnitude of harms from screening for skin cancer.

The task force found no randomized studies that examined whether screening by clinicians is associated with improved clinical outcomes. Screening appears to consistently identify thinner melanomas on the average than those found during usual care, the task force noted. However, it's not known whether the detection of the thinner lesions leads to decreased morbidity or mortality.

Based on the current review, the USPSTF noted that there is fair evidence that screening by clinicians is moderately accurate in detecting melanoma. They determined primary care physicians to be moderately accurate in diagnosing melanoma—with sensitivity ranging from 42% to 100% and specificity ranging from 70% to 98%.

“What I recommend to primary care physicians is to incorporate the screening as part of the full-body exam. … The marginal cost is nothing,” Dr. Rigel said.

The task force noted that the recommendation applies only to the adult general population without a history of premalignant or malignant lesions. They did not assess outcomes related to surveillance of patients at extremely high risk.

Primary care clinicians should be aware that fair-skinned men and women older than 65 years, patients with atypical moles, or those with more than 50 moles are groups that are known to be at a substantially increased risk for melanoma.

The task force urged primary care clinicians to remain alert for skin lesions with malignant features that are noted during physical examinations performed for other purposes. The ABCD criteria—asymmetry, border, color, and diameter—or rapidly changing lesions are features associated with an increased risk for cancer, they noted. Biopsy of suspected lesions is warranted.

The American Academy of Dermatology offers free skin examinations by volunteer dermatologists for the general public through its Melanoma/Skin Cancer Screening Program (www.aad.org/public/exams/screenings/index.html

“The academy has screened almost 2 million people now—this is the 25th year of the program coming up this year—and there have been tens of thousands of melanomas picked up and lots more nonmelanoma skin cancers,” he said.

The U.S. Preventive Services Task Force still cannot recommend for or against whole-body skin examination by a primary care physician or by patient self-examination for the early detection of cutaneous melanoma, basal cell cancer, or squamous cell skin cancer in the adult general population.

The task force concluded that there is not enough evidence to assess the benefits and harms from such examinations in its latest recommendations (Ann. Int. Med. 2009;150:188-93).

The previous recommendation came in 2001, when the group also concluded that there was insufficient evidence to recommend for or against routine whole-body skin examination for skin cancer screening.

“This is not to say that studies have shown that it's not effective; what they're saying is that there are just no studies out there,” commented Dr. Darrell S. Rigel, a clinical professor of dermatology at New York University.

“If you talk to people who have had melanomas detected during screenings, they are very happy. They think screening is great because you basically have saved their lives,” he said.

The task force did note two critical gaps in knowledge. First, there is insufficient evidence (a lack of studies) to determine whether early detection of skin cancer reduces morbidity or mortality from skin cancer. Second, there is insufficient evidence to determine the magnitude of harms from screening for skin cancer.

The task force found no randomized studies that examined whether screening by clinicians is associated with improved clinical outcomes. Screening appears to consistently identify thinner melanomas on the average than those found during usual care, the task force noted. However, it's not known whether the detection of the thinner lesions leads to decreased morbidity or mortality.

Based on the current review, the USPSTF noted that there is fair evidence that screening by clinicians is moderately accurate in detecting melanoma. They determined primary care physicians to be moderately accurate in diagnosing melanoma—with sensitivity ranging from 42% to 100% and specificity ranging from 70% to 98%.

“What I recommend to primary care physicians is to incorporate the screening as part of the full-body exam. … The marginal cost is nothing,” Dr. Rigel said.

The task force noted that the recommendation applies only to the adult general population without a history of premalignant or malignant lesions. They did not assess outcomes related to surveillance of patients at extremely high risk.

Primary care clinicians should be aware that fair-skinned men and women older than 65 years, patients with atypical moles, or those with more than 50 moles are groups that are known to be at a substantially increased risk for melanoma.

The task force urged primary care clinicians to remain alert for skin lesions with malignant features that are noted during physical examinations performed for other purposes. The ABCD criteria—asymmetry, border, color, and diameter—or rapidly changing lesions are features associated with an increased risk for cancer, they noted. Biopsy of suspected lesions is warranted.

The American Academy of Dermatology offers free skin examinations by volunteer dermatologists for the general public through its Melanoma/Skin Cancer Screening Program (www.aad.org/public/exams/screenings/index.html

“The academy has screened almost 2 million people now—this is the 25th year of the program coming up this year—and there have been tens of thousands of melanomas picked up and lots more nonmelanoma skin cancers,” he said.

The U.S. Preventive Services Task Force still cannot recommend for or against whole-body skin examination by a primary care physician or by patient self-examination for the early detection of cutaneous melanoma, basal cell cancer, or squamous cell skin cancer in the adult general population.

The task force concluded that there is not enough evidence to assess the benefits and harms from such examinations in its latest recommendations (Ann. Int. Med. 2009;150:188-93).

The previous recommendation came in 2001, when the group also concluded that there was insufficient evidence to recommend for or against routine whole-body skin examination for skin cancer screening.

“This is not to say that studies have shown that it's not effective; what they're saying is that there are just no studies out there,” commented Dr. Darrell S. Rigel, a clinical professor of dermatology at New York University.

“If you talk to people who have had melanomas detected during screenings, they are very happy. They think screening is great because you basically have saved their lives,” he said.

The task force did note two critical gaps in knowledge. First, there is insufficient evidence (a lack of studies) to determine whether early detection of skin cancer reduces morbidity or mortality from skin cancer. Second, there is insufficient evidence to determine the magnitude of harms from screening for skin cancer.

The task force found no randomized studies that examined whether screening by clinicians is associated with improved clinical outcomes. Screening appears to consistently identify thinner melanomas on the average than those found during usual care, the task force noted. However, it's not known whether the detection of the thinner lesions leads to decreased morbidity or mortality.

Based on the current review, the USPSTF noted that there is fair evidence that screening by clinicians is moderately accurate in detecting melanoma. They determined primary care physicians to be moderately accurate in diagnosing melanoma—with sensitivity ranging from 42% to 100% and specificity ranging from 70% to 98%.

“What I recommend to primary care physicians is to incorporate the screening as part of the full-body exam. … The marginal cost is nothing,” Dr. Rigel said.

The task force noted that the recommendation applies only to the adult general population without a history of premalignant or malignant lesions. They did not assess outcomes related to surveillance of patients at extremely high risk.

Primary care clinicians should be aware that fair-skinned men and women older than 65 years, patients with atypical moles, or those with more than 50 moles are groups that are known to be at a substantially increased risk for melanoma.

The task force urged primary care clinicians to remain alert for skin lesions with malignant features that are noted during physical examinations performed for other purposes. The ABCD criteria—asymmetry, border, color, and diameter—or rapidly changing lesions are features associated with an increased risk for cancer, they noted. Biopsy of suspected lesions is warranted.

The American Academy of Dermatology offers free skin examinations by volunteer dermatologists for the general public through its Melanoma/Skin Cancer Screening Program (www.aad.org/public/exams/screenings/index.html

“The academy has screened almost 2 million people now—this is the 25th year of the program coming up this year—and there have been tens of thousands of melanomas picked up and lots more nonmelanoma skin cancers,” he said.

PARIS — Nonbiologic systemic drugs can be effective choices for the treatment of psoriasis if they are chosen properly, according to Dr. Jonathan Barker.

Traditional systemic drugs work but are not always effective, and are often associated with considerable toxicity, he said at the annual congress of the European Academy of Dermatology and Venereology.

“To optimize systemic therapy, we're talking about maximizing efficacy and minimizing toxicity,” said Dr. Barker, head of the skin inflammation unit at St. John's Institute of Dermatology, King's College, London. He gave an overview of several standard systemic drugs:

▸ Methotrexate. The preferred drug for unrelenting disease that is likely to require long-term therapy, it also helps in psoriatic arthritis. The key to avoiding adverse events is to start with a low dose and increase it slowly. Dr. Barker said he and his colleagues begin psoriasis patients on 5 mg/week and then increase the dose by 5 mg/week up to 15 mg/week for the first 3 months. The maximum dose they use for psoriasis is 25 mg/week.

Most causes of death that are associated with methotrexate are attributable to bone marrow suppression, not hepatotoxicity. These deaths usually result from confusion over dosage, or from folic acid deficiency, he said. Bone marrow suppression is rare when patients are on folic acid supplementation.

Liver function can be monitored without routine liver biopsy by measuring serum levels of procollagen III aminopeptide (Br. J. Dermatol. 2005;152:444-50). Dr. Barker checks serum levels every 3 months for psoriasis patients on long-term methotrexate. “If this practice were to be widely adopted, then methotrexate would become a more acceptable option for many patients who are dissuaded from considering it because of the threat of repeated liver biopsy,” he said.

▸ Cyclosporine. It is a fast-acting drug that “presents a different set of problems with respect to usage,” Dr. Barker noted. “It's a very good drug for patients with intermittent disease, where they need a quick fix but you're hoping that the duration of therapy will be very short.”

Glomerular sclerosis is extremely unlikely to occur in patients who are treated with cyclosporine for less than 12 months and in whom there is an insignificant rise in creatinine levels. Glomerular sclerosis is much more likely to occur when cyclosporine is used for more than a year.

Also, long-term cyclosporine A—the main form of this drug—is associated with an increased risk of nonmelanoma skin cancer. However, this risk can be minimized by limiting both dosage and duration of use (no longer than 1-2 years), Dr. Barker said. Cyclosporine use should be minimized in patients who have had significant phototherapy.

▸ Acitretin. It can be used “occasionally in moderate chronic plaque psoriasis, more so in palmo-plantar pustulosis,” said Dr. Barker, who added that he starts with the lowest dosage (25 mg/day) and uses it with narrow-band UVB phototherapy.

But one should use extreme caution when treating women of child-bearing age with acitretin because it can cause major fetal abnormalities, he cautioned.

In addition, it is very helpful as an adjunctive treatment for patients with severe disease and multiple squamoproliferative lesions who have been on phototherapy in the past.

“This is not an immunosuppressive drug, and there is some evidence that it has chemoprotective activity for malignancy,” he said.

Dr. Barker has consulted for several pharmaceutical companies making biologics but noted that none was relevant to his presentation.

PARIS — Nonbiologic systemic drugs can be effective choices for the treatment of psoriasis if they are chosen properly, according to Dr. Jonathan Barker.

Traditional systemic drugs work but are not always effective, and are often associated with considerable toxicity, he said at the annual congress of the European Academy of Dermatology and Venereology.

“To optimize systemic therapy, we're talking about maximizing efficacy and minimizing toxicity,” said Dr. Barker, head of the skin inflammation unit at St. John's Institute of Dermatology, King's College, London. He gave an overview of several standard systemic drugs:

▸ Methotrexate. The preferred drug for unrelenting disease that is likely to require long-term therapy, it also helps in psoriatic arthritis. The key to avoiding adverse events is to start with a low dose and increase it slowly. Dr. Barker said he and his colleagues begin psoriasis patients on 5 mg/week and then increase the dose by 5 mg/week up to 15 mg/week for the first 3 months. The maximum dose they use for psoriasis is 25 mg/week.

Most causes of death that are associated with methotrexate are attributable to bone marrow suppression, not hepatotoxicity. These deaths usually result from confusion over dosage, or from folic acid deficiency, he said. Bone marrow suppression is rare when patients are on folic acid supplementation.

Liver function can be monitored without routine liver biopsy by measuring serum levels of procollagen III aminopeptide (Br. J. Dermatol. 2005;152:444-50). Dr. Barker checks serum levels every 3 months for psoriasis patients on long-term methotrexate. “If this practice were to be widely adopted, then methotrexate would become a more acceptable option for many patients who are dissuaded from considering it because of the threat of repeated liver biopsy,” he said.

▸ Cyclosporine. It is a fast-acting drug that “presents a different set of problems with respect to usage,” Dr. Barker noted. “It's a very good drug for patients with intermittent disease, where they need a quick fix but you're hoping that the duration of therapy will be very short.”

Glomerular sclerosis is extremely unlikely to occur in patients who are treated with cyclosporine for less than 12 months and in whom there is an insignificant rise in creatinine levels. Glomerular sclerosis is much more likely to occur when cyclosporine is used for more than a year.

Also, long-term cyclosporine A—the main form of this drug—is associated with an increased risk of nonmelanoma skin cancer. However, this risk can be minimized by limiting both dosage and duration of use (no longer than 1-2 years), Dr. Barker said. Cyclosporine use should be minimized in patients who have had significant phototherapy.

▸ Acitretin. It can be used “occasionally in moderate chronic plaque psoriasis, more so in palmo-plantar pustulosis,” said Dr. Barker, who added that he starts with the lowest dosage (25 mg/day) and uses it with narrow-band UVB phototherapy.

But one should use extreme caution when treating women of child-bearing age with acitretin because it can cause major fetal abnormalities, he cautioned.

In addition, it is very helpful as an adjunctive treatment for patients with severe disease and multiple squamoproliferative lesions who have been on phototherapy in the past.

“This is not an immunosuppressive drug, and there is some evidence that it has chemoprotective activity for malignancy,” he said.

Dr. Barker has consulted for several pharmaceutical companies making biologics but noted that none was relevant to his presentation.

PARIS — Nonbiologic systemic drugs can be effective choices for the treatment of psoriasis if they are chosen properly, according to Dr. Jonathan Barker.

Traditional systemic drugs work but are not always effective, and are often associated with considerable toxicity, he said at the annual congress of the European Academy of Dermatology and Venereology.

“To optimize systemic therapy, we're talking about maximizing efficacy and minimizing toxicity,” said Dr. Barker, head of the skin inflammation unit at St. John's Institute of Dermatology, King's College, London. He gave an overview of several standard systemic drugs:

▸ Methotrexate. The preferred drug for unrelenting disease that is likely to require long-term therapy, it also helps in psoriatic arthritis. The key to avoiding adverse events is to start with a low dose and increase it slowly. Dr. Barker said he and his colleagues begin psoriasis patients on 5 mg/week and then increase the dose by 5 mg/week up to 15 mg/week for the first 3 months. The maximum dose they use for psoriasis is 25 mg/week.

Most causes of death that are associated with methotrexate are attributable to bone marrow suppression, not hepatotoxicity. These deaths usually result from confusion over dosage, or from folic acid deficiency, he said. Bone marrow suppression is rare when patients are on folic acid supplementation.

Liver function can be monitored without routine liver biopsy by measuring serum levels of procollagen III aminopeptide (Br. J. Dermatol. 2005;152:444-50). Dr. Barker checks serum levels every 3 months for psoriasis patients on long-term methotrexate. “If this practice were to be widely adopted, then methotrexate would become a more acceptable option for many patients who are dissuaded from considering it because of the threat of repeated liver biopsy,” he said.

▸ Cyclosporine. It is a fast-acting drug that “presents a different set of problems with respect to usage,” Dr. Barker noted. “It's a very good drug for patients with intermittent disease, where they need a quick fix but you're hoping that the duration of therapy will be very short.”

Glomerular sclerosis is extremely unlikely to occur in patients who are treated with cyclosporine for less than 12 months and in whom there is an insignificant rise in creatinine levels. Glomerular sclerosis is much more likely to occur when cyclosporine is used for more than a year.

Also, long-term cyclosporine A—the main form of this drug—is associated with an increased risk of nonmelanoma skin cancer. However, this risk can be minimized by limiting both dosage and duration of use (no longer than 1-2 years), Dr. Barker said. Cyclosporine use should be minimized in patients who have had significant phototherapy.

▸ Acitretin. It can be used “occasionally in moderate chronic plaque psoriasis, more so in palmo-plantar pustulosis,” said Dr. Barker, who added that he starts with the lowest dosage (25 mg/day) and uses it with narrow-band UVB phototherapy.

But one should use extreme caution when treating women of child-bearing age with acitretin because it can cause major fetal abnormalities, he cautioned.

In addition, it is very helpful as an adjunctive treatment for patients with severe disease and multiple squamoproliferative lesions who have been on phototherapy in the past.

“This is not an immunosuppressive drug, and there is some evidence that it has chemoprotective activity for malignancy,” he said.

Dr. Barker has consulted for several pharmaceutical companies making biologics but noted that none was relevant to his presentation.

SAN ANTONIO — Adjuvant exemestane appears to have little effect on cognitive function in postmenopausal women with breast cancer, but women on adjuvant tamoxifen perform significantly worse than do healthy controls in several cognitive domains after 1 year of treatment, based on results of a substudy of the TEAM (Tamoxifen Exemestane Adjuvant Multicenter) trial.

After 1 year, researchers found that there were no significant differences in cognition between women who received adjuvant exemestane (Aromasin) and healthy controls after adjustment for baseline neurocognitive test scores and other covariates.

However, those women who received adjuvant tamoxifen performed significantly worse on verbal memory and executive functioning than did healthy controls. In addition, the tamoxifen groups also performed worse than exemestane users on information processing speed, Dr. Christina M. Schilder reported in a poster presentation at the San Antonio Breast Cancer Symposium.

“Our results suggest that 1 year of adjuvant exemestane treatment is advantageous, compared with 1 year of adjuvant tamoxifen treatment with respect to cognitive functioning in postmenopausal breast cancer patients,” wrote Dr. Schilder, of the Netherlands Cancer Institute in Amsterdam, and her colleagues.

Investigators in the TEAM trial compared the efficacy of 5 years of exemestane with 2.5 years of tamoxifen followed by 2.5 years of exemstane in postmenopausal women who had hormone-sensitive breast cancer. This subanalysis included Dutch patients involved in the study–80 women who were on tamoxifen and 99 who were on exemestane. They were compared with 120 healthy controls.

The study patients underwent neuropsychologic assessments at baseline and again after 1 year of adjuvant endocrine therapy. A healthy control group underwent the same assessments with a similar time interval.

The comprehensive test battery consisted of 18 test indices that were designed to assess eight cognitive domains including verbal, visual, and working memory; information processing speed; executive functioning; verbal fluency; and reaction speed.

Cognitive test scores at baseline and at 1 year were converted to standardized z scores, based on the mean and standard deviation of the healthy control group. The analyses were adjusted for anxiety, depression, fatigue, and menopausal symptoms.

Among women who were aged 65 years and younger, 30 tamoxifen users performed significantly worse on executive functioning than did 60 healthy controls.

Among women who were older than 65 years, 50 tamoxifen users performed worse on verbal memory and information processing than did than 60 healthy controls. Also in this age group, tamoxifen users performed worse on information processing speed than did exemestane users.

Further research is needed to determine cognitive effects of the drugs over a longer period of time and to establish whether exemestane's lack of an effect on cognition is a specific property of exemestane or whether it is a result of all aromatase inhibitors, the investigators noted.

Dr. Schilder reported that she has received grant support from Pfizer Inc., which manufactures Aromasin. The TEAM study is funded by Pfizer.

SAN ANTONIO — Adjuvant exemestane appears to have little effect on cognitive function in postmenopausal women with breast cancer, but women on adjuvant tamoxifen perform significantly worse than do healthy controls in several cognitive domains after 1 year of treatment, based on results of a substudy of the TEAM (Tamoxifen Exemestane Adjuvant Multicenter) trial.

After 1 year, researchers found that there were no significant differences in cognition between women who received adjuvant exemestane (Aromasin) and healthy controls after adjustment for baseline neurocognitive test scores and other covariates.

However, those women who received adjuvant tamoxifen performed significantly worse on verbal memory and executive functioning than did healthy controls. In addition, the tamoxifen groups also performed worse than exemestane users on information processing speed, Dr. Christina M. Schilder reported in a poster presentation at the San Antonio Breast Cancer Symposium.

“Our results suggest that 1 year of adjuvant exemestane treatment is advantageous, compared with 1 year of adjuvant tamoxifen treatment with respect to cognitive functioning in postmenopausal breast cancer patients,” wrote Dr. Schilder, of the Netherlands Cancer Institute in Amsterdam, and her colleagues.

Investigators in the TEAM trial compared the efficacy of 5 years of exemestane with 2.5 years of tamoxifen followed by 2.5 years of exemstane in postmenopausal women who had hormone-sensitive breast cancer. This subanalysis included Dutch patients involved in the study–80 women who were on tamoxifen and 99 who were on exemestane. They were compared with 120 healthy controls.

The study patients underwent neuropsychologic assessments at baseline and again after 1 year of adjuvant endocrine therapy. A healthy control group underwent the same assessments with a similar time interval.

The comprehensive test battery consisted of 18 test indices that were designed to assess eight cognitive domains including verbal, visual, and working memory; information processing speed; executive functioning; verbal fluency; and reaction speed.

Cognitive test scores at baseline and at 1 year were converted to standardized z scores, based on the mean and standard deviation of the healthy control group. The analyses were adjusted for anxiety, depression, fatigue, and menopausal symptoms.

Among women who were aged 65 years and younger, 30 tamoxifen users performed significantly worse on executive functioning than did 60 healthy controls.

Among women who were older than 65 years, 50 tamoxifen users performed worse on verbal memory and information processing than did than 60 healthy controls. Also in this age group, tamoxifen users performed worse on information processing speed than did exemestane users.

Further research is needed to determine cognitive effects of the drugs over a longer period of time and to establish whether exemestane's lack of an effect on cognition is a specific property of exemestane or whether it is a result of all aromatase inhibitors, the investigators noted.

Dr. Schilder reported that she has received grant support from Pfizer Inc., which manufactures Aromasin. The TEAM study is funded by Pfizer.

SAN ANTONIO — Adjuvant exemestane appears to have little effect on cognitive function in postmenopausal women with breast cancer, but women on adjuvant tamoxifen perform significantly worse than do healthy controls in several cognitive domains after 1 year of treatment, based on results of a substudy of the TEAM (Tamoxifen Exemestane Adjuvant Multicenter) trial.

After 1 year, researchers found that there were no significant differences in cognition between women who received adjuvant exemestane (Aromasin) and healthy controls after adjustment for baseline neurocognitive test scores and other covariates.

However, those women who received adjuvant tamoxifen performed significantly worse on verbal memory and executive functioning than did healthy controls. In addition, the tamoxifen groups also performed worse than exemestane users on information processing speed, Dr. Christina M. Schilder reported in a poster presentation at the San Antonio Breast Cancer Symposium.

“Our results suggest that 1 year of adjuvant exemestane treatment is advantageous, compared with 1 year of adjuvant tamoxifen treatment with respect to cognitive functioning in postmenopausal breast cancer patients,” wrote Dr. Schilder, of the Netherlands Cancer Institute in Amsterdam, and her colleagues.

Investigators in the TEAM trial compared the efficacy of 5 years of exemestane with 2.5 years of tamoxifen followed by 2.5 years of exemstane in postmenopausal women who had hormone-sensitive breast cancer. This subanalysis included Dutch patients involved in the study–80 women who were on tamoxifen and 99 who were on exemestane. They were compared with 120 healthy controls.

The study patients underwent neuropsychologic assessments at baseline and again after 1 year of adjuvant endocrine therapy. A healthy control group underwent the same assessments with a similar time interval.

The comprehensive test battery consisted of 18 test indices that were designed to assess eight cognitive domains including verbal, visual, and working memory; information processing speed; executive functioning; verbal fluency; and reaction speed.

Cognitive test scores at baseline and at 1 year were converted to standardized z scores, based on the mean and standard deviation of the healthy control group. The analyses were adjusted for anxiety, depression, fatigue, and menopausal symptoms.

Among women who were aged 65 years and younger, 30 tamoxifen users performed significantly worse on executive functioning than did 60 healthy controls.

Among women who were older than 65 years, 50 tamoxifen users performed worse on verbal memory and information processing than did than 60 healthy controls. Also in this age group, tamoxifen users performed worse on information processing speed than did exemestane users.

Further research is needed to determine cognitive effects of the drugs over a longer period of time and to establish whether exemestane's lack of an effect on cognition is a specific property of exemestane or whether it is a result of all aromatase inhibitors, the investigators noted.

Dr. Schilder reported that she has received grant support from Pfizer Inc., which manufactures Aromasin. The TEAM study is funded by Pfizer.

PARIS — Vitiligo can be a psychologically devastating disorder, but there are several effective therapies that can improve skin pigmentation and reduce the burden of this disease, according to Dr. Pearl Grimes.

“Pigmentation significantly influences the paradigm of psychosocial interactions. … Any aberration or any deviation from normal causes enormous distress for patients,” Dr. Grimes said during a plenary session at the annual congress of the European Academy of Dermatology and Venereology.

Vitiligo is associated with depression, stigmatization, low self-esteem, social embarrassment, and impaired interpersonal relationships. The disease is particularly problematic for children in their formative years, and some quality of life studies have shown that negative childhood experiences are significantly associated with impairment in early adulthood, said Dr. Grimes, who is the director of a practice that specializes in vitiligo and pigmentation in Los Angeles.

During the last 10–15 years, several studies have also shown that severity of vitiligo correlates with quality of life, that impairment is greatest in women, and that counseling may help improve body image, self-esteem, and quality of life for children and adults.

The message for physicians: “Be sensitized and aware of these issues for patients, and refer them for counseling to cope with the despair caused by this disease,” Dr. Grimes said.

She discussed recent advances in vitiligo assessment and therapy that have offered hope to these patients:

▸ Definition and assessment. Historically, there has been no common grading scale for vitiligo that could be used to compare the results of clinical studies.

In 2007, the Vitiligo European Task Force published a consensus report on the definition of vitiligo and methodologies for assessing treatments for this skin disease (Pigment Cell Res. 2007;20:27–35). The assessment is based on body surface area, disease stage, and progression.

“I think the European task force has done a wonderful job in addressing some of the issues that we face as physicians in addressing this disease,” she said.

▸ Topical calcineurin inhibitors. In recent years, multiple studies have documented the efficacy and safety of calcineurin inhibitors as repigmentation tools in the treatment of vitiligo.

These topical immunomodulators “are now the No. 1 treatment that is prescribed for patients who have limited involvement,” Dr. Grimes said.

Calcineurin inhibitors work by inhibiting T-cell activation, deactivating calcineurin, and inhibiting the formation of proinflammatory cytokines. These agents also decrease tumor necrosis factor-α levels following treatment, and stimulate melanocyte growth.

Calcineurin inhibitors offer several advantages, she continued. These agents are well tolerated. They do not cause atrophy or telangiectasia, as steroids do. Pigmentation is homogeneous. And calcineurin inhibitors work especially well for the face and neck.

They are the optimal treatment for patients with limited involvement over the body surface area, Dr. Grimes said.

However, in the United States these agents carry black box warnings regarding long-term use. Rare cases of cancer have been reported in patients who were treated with topical calcineurin inhibitors, although no causal relationship has been established. Physicians are encouraged to avoid continuous long-term use of these agents for their patients and to limit application to areas of involvement, she said.

Despite the black box warning, the evidence for an association with cancer is not clear. In a nested case-control study published in 2007, researchers looked at the possible association between topical immunosuppressives and lymphoma in more than 290,000 patients with atopic dermatitis. Based on logistic regression analysis, there was no increase in lymphomas in patients who were treated with calcineurin inhibitors (J. Invest. Dermatol. 2007;127:808–16).

“At the end of the day, as clinicians … you have to decide how you will situate these combination protocols/combination uses in your practice,” Dr. Grimes said.

She added that she relies on calcineurin inhibitors tremendously in her practice, but does not use them with ultraviolet light. Instead, she treats patients on the basis of a rotational algorithm, starting with tacrolimus/pimecrolimus, then targeted phototherapy, then steroids/calcipotriol, then steroids/tacrolimus, and back to tacrolimus/pimecrolimus.

▸ Vitamin D analogues. Another treatment that is being considered for vitiligo is vitamin D. “There are exciting new data in the literature on the role of vitamin D in the autoimmune process,” Dr. Grimes said. The immunomodulatory effects of vitamin D include suppression of T-cell activation, induction of regulatory T cells, and modulation of the production of proinflammatory cytokines from activated T cells and keratinocytes. Vitamin D also has antioxidant and photoprotective effects.

Vitamin D stimulates the differentiation of immature melanocyte precursors and plays a regulatory role in melanocyte development and melanogenesis. Vitamin D also increases tyrosinase activity.

However, in terms of using vitamin D analogues as repigmentation therapies, results have been varied. Response is poor when these agents are used as monotherapy. The best results are achieved with sunlight, phototherapy, or topical mid- to high-potency steroids.

The use of vitamin D analogues may decrease the cumulative UV dose and number of phototherapy treatments required for repigmentation. The fact that vitamin D analogues are degraded by UV light may account for some of the variability seen in the studies, Dr. Grimes said.

▸ Narrow-band UVB. Narrow-band UVB (NB-UVB) phototherapy, which affects both peripheral blood and lesional skin, has moved to the forefront as a treatment for vitiligo. In peripheral blood, narrow-band UVB decreases natural killer-cell activity, cytokine response, and lymphoproliferative responses. In lesional skin, this therapy decreases Langerhans cell activation and increases apoptosis, melanocyte proliferation, and melanogenesis.

NB-UVB has no systemic side effects, requires no posttreatment ocular protection, and has a good safety profile for adults and children. A good response can be achieved even in patients with extensive involvement. “We know that narrow-band [UVB phototherapy] is tremendously well tolerated and easier for the patient,” Dr. Grimes said.

NB-UVB appears to provide a better response than does psoralen with UVA (PUVA). In a recent study, 25 patients with vitiligo were treated with PUVA and 25 with NB-UVB (Arch. Dermatol. 2007;143:578–84). At the end of therapy, 64% of the NB-UVB patients had a greater-than-50% improvement in affected body surface area, compared with 36% of the PUVA group. The color match of the repigmented skin was excellent in all patients in the NB-UVB group, but in only 44% of those in the PUVA group.

On the down side, NB-UVB therapy may require three treatments per week for maximum efficacy. In addition, the long-term carcinogenic effects—as well as the long-term stability of NB-UVB repigmentation—are not known.

“We need more data on the stability of the treatments that we do, as well as [on] the need for maintenance treatment once you achieve repigmentation,” she said.

▸ Polypodium and phototherapy. Polypodium leucotomos (PL), a fern plant grown in Central America that was used in the 1980s as a repigmenting agent, is enjoying a resurgence in interest. The plant has been found to have antitumor and anti-inflammatory effects. It has immunosuppressive properties, reducing CD4 and CD8 levels.

In one study, researchers explored the effects of PUVA plus PL in a pilot randomized, double-blind, placebo-controlled trial with 19 patients who had generalized vitiligo. Skin repigmentation greater than 50% was achieved by a significantly higher percentage of patients in the PUVA-plus-PL arm than in the PUVA-plus-placebo arm (J. Dermatol. Sci. 2006;41:213–6).

“I think that we're going to be seeing more on this combination of Polypodium plus light in the future,” Dr. Grimes said.

▸ Targeted light therapy. Excimer laser-targeted light therapy is another effective option for treating vitiligo. This therapy targets affected skin with a high-intensity light, but avoids exposure to normal skin. Rapid therapeutic responses are seen; cumulative UV exposure is limited.

In addition, targeted light therapy can have a synergistic effect with certain topical agents. Studies suggest that the fastest repigmentation occurs with treatment two to three times per week.

This therapy is a good choice for patients with areas of depigmentation on the genitalia. “Typically in my practice, I tend to avoid treating these areas. But I do have a cohort of gentlemen who are absolutely devastated by genital depigmentation,” Dr. Grimes said. She said she has had good results using targeted light therapy in these patients.

▸ Imatinib mesylate. Imatinib mesylate (Gleevec) is a tyrosine kinase inhibitor that is used for the treatment of chronic myeloid leukemia. “One of the most common side effects is that it induces hypopigmentation and depigmentation,” Dr. Grimes said, so this may be a future depigmenting agent for vitiligo.

▸ Surgical options. Surgical therapy for vitiligo is indicated for stable disease that is focal or segmental and does not respond to medical treatment. It is contraindicated in patients with keloids and hypertrophic scars.

Available procedures include autologous suction blister grafts, autologous melanocyte transplants, autologous punch grafts, sheet grafts, and co-cultures of melanocytes and keratinocytes. “Using these grafting procedures, we actually have the ability to cure some patients who have segmental vitiligo,” Dr. Grimes said.

One new surgical option is a technology called ReCell (Avita Medical Ltd.). This is a single-use, battery-operated, autologous cell harvesting system. The cell suspension is sprayed onto the affected areas of skin.

Dr. Grimes reported that she had no relevant conflicts of interest.

Vitiligo is associated with depression, stigmatization, low self-esteem, and social embarrassment. Courtesy Dr. Steven R. Feldman

PARIS — Vitiligo can be a psychologically devastating disorder, but there are several effective therapies that can improve skin pigmentation and reduce the burden of this disease, according to Dr. Pearl Grimes.

“Pigmentation significantly influences the paradigm of psychosocial interactions. … Any aberration or any deviation from normal causes enormous distress for patients,” Dr. Grimes said during a plenary session at the annual congress of the European Academy of Dermatology and Venereology.

Vitiligo is associated with depression, stigmatization, low self-esteem, social embarrassment, and impaired interpersonal relationships. The disease is particularly problematic for children in their formative years, and some quality of life studies have shown that negative childhood experiences are significantly associated with impairment in early adulthood, said Dr. Grimes, who is the director of a practice that specializes in vitiligo and pigmentation in Los Angeles.

During the last 10–15 years, several studies have also shown that severity of vitiligo correlates with quality of life, that impairment is greatest in women, and that counseling may help improve body image, self-esteem, and quality of life for children and adults.

The message for physicians: “Be sensitized and aware of these issues for patients, and refer them for counseling to cope with the despair caused by this disease,” Dr. Grimes said.

She discussed recent advances in vitiligo assessment and therapy that have offered hope to these patients:

▸ Definition and assessment. Historically, there has been no common grading scale for vitiligo that could be used to compare the results of clinical studies.

In 2007, the Vitiligo European Task Force published a consensus report on the definition of vitiligo and methodologies for assessing treatments for this skin disease (Pigment Cell Res. 2007;20:27–35). The assessment is based on body surface area, disease stage, and progression.

“I think the European task force has done a wonderful job in addressing some of the issues that we face as physicians in addressing this disease,” she said.

▸ Topical calcineurin inhibitors. In recent years, multiple studies have documented the efficacy and safety of calcineurin inhibitors as repigmentation tools in the treatment of vitiligo.

These topical immunomodulators “are now the No. 1 treatment that is prescribed for patients who have limited involvement,” Dr. Grimes said.

Calcineurin inhibitors work by inhibiting T-cell activation, deactivating calcineurin, and inhibiting the formation of proinflammatory cytokines. These agents also decrease tumor necrosis factor-α levels following treatment, and stimulate melanocyte growth.

Calcineurin inhibitors offer several advantages, she continued. These agents are well tolerated. They do not cause atrophy or telangiectasia, as steroids do. Pigmentation is homogeneous. And calcineurin inhibitors work especially well for the face and neck.

They are the optimal treatment for patients with limited involvement over the body surface area, Dr. Grimes said.

However, in the United States these agents carry black box warnings regarding long-term use. Rare cases of cancer have been reported in patients who were treated with topical calcineurin inhibitors, although no causal relationship has been established. Physicians are encouraged to avoid continuous long-term use of these agents for their patients and to limit application to areas of involvement, she said.

Despite the black box warning, the evidence for an association with cancer is not clear. In a nested case-control study published in 2007, researchers looked at the possible association between topical immunosuppressives and lymphoma in more than 290,000 patients with atopic dermatitis. Based on logistic regression analysis, there was no increase in lymphomas in patients who were treated with calcineurin inhibitors (J. Invest. Dermatol. 2007;127:808–16).

“At the end of the day, as clinicians … you have to decide how you will situate these combination protocols/combination uses in your practice,” Dr. Grimes said.

She added that she relies on calcineurin inhibitors tremendously in her practice, but does not use them with ultraviolet light. Instead, she treats patients on the basis of a rotational algorithm, starting with tacrolimus/pimecrolimus, then targeted phototherapy, then steroids/calcipotriol, then steroids/tacrolimus, and back to tacrolimus/pimecrolimus.

▸ Vitamin D analogues. Another treatment that is being considered for vitiligo is vitamin D. “There are exciting new data in the literature on the role of vitamin D in the autoimmune process,” Dr. Grimes said. The immunomodulatory effects of vitamin D include suppression of T-cell activation, induction of regulatory T cells, and modulation of the production of proinflammatory cytokines from activated T cells and keratinocytes. Vitamin D also has antioxidant and photoprotective effects.

Vitamin D stimulates the differentiation of immature melanocyte precursors and plays a regulatory role in melanocyte development and melanogenesis. Vitamin D also increases tyrosinase activity.

However, in terms of using vitamin D analogues as repigmentation therapies, results have been varied. Response is poor when these agents are used as monotherapy. The best results are achieved with sunlight, phototherapy, or topical mid- to high-potency steroids.

The use of vitamin D analogues may decrease the cumulative UV dose and number of phototherapy treatments required for repigmentation. The fact that vitamin D analogues are degraded by UV light may account for some of the variability seen in the studies, Dr. Grimes said.

▸ Narrow-band UVB. Narrow-band UVB (NB-UVB) phototherapy, which affects both peripheral blood and lesional skin, has moved to the forefront as a treatment for vitiligo. In peripheral blood, narrow-band UVB decreases natural killer-cell activity, cytokine response, and lymphoproliferative responses. In lesional skin, this therapy decreases Langerhans cell activation and increases apoptosis, melanocyte proliferation, and melanogenesis.

NB-UVB has no systemic side effects, requires no posttreatment ocular protection, and has a good safety profile for adults and children. A good response can be achieved even in patients with extensive involvement. “We know that narrow-band [UVB phototherapy] is tremendously well tolerated and easier for the patient,” Dr. Grimes said.

NB-UVB appears to provide a better response than does psoralen with UVA (PUVA). In a recent study, 25 patients with vitiligo were treated with PUVA and 25 with NB-UVB (Arch. Dermatol. 2007;143:578–84). At the end of therapy, 64% of the NB-UVB patients had a greater-than-50% improvement in affected body surface area, compared with 36% of the PUVA group. The color match of the repigmented skin was excellent in all patients in the NB-UVB group, but in only 44% of those in the PUVA group.

On the down side, NB-UVB therapy may require three treatments per week for maximum efficacy. In addition, the long-term carcinogenic effects—as well as the long-term stability of NB-UVB repigmentation—are not known.

“We need more data on the stability of the treatments that we do, as well as [on] the need for maintenance treatment once you achieve repigmentation,” she said.

▸ Polypodium and phototherapy. Polypodium leucotomos (PL), a fern plant grown in Central America that was used in the 1980s as a repigmenting agent, is enjoying a resurgence in interest. The plant has been found to have antitumor and anti-inflammatory effects. It has immunosuppressive properties, reducing CD4 and CD8 levels.

In one study, researchers explored the effects of PUVA plus PL in a pilot randomized, double-blind, placebo-controlled trial with 19 patients who had generalized vitiligo. Skin repigmentation greater than 50% was achieved by a significantly higher percentage of patients in the PUVA-plus-PL arm than in the PUVA-plus-placebo arm (J. Dermatol. Sci. 2006;41:213–6).

“I think that we're going to be seeing more on this combination of Polypodium plus light in the future,” Dr. Grimes said.

▸ Targeted light therapy. Excimer laser-targeted light therapy is another effective option for treating vitiligo. This therapy targets affected skin with a high-intensity light, but avoids exposure to normal skin. Rapid therapeutic responses are seen; cumulative UV exposure is limited.

In addition, targeted light therapy can have a synergistic effect with certain topical agents. Studies suggest that the fastest repigmentation occurs with treatment two to three times per week.

This therapy is a good choice for patients with areas of depigmentation on the genitalia. “Typically in my practice, I tend to avoid treating these areas. But I do have a cohort of gentlemen who are absolutely devastated by genital depigmentation,” Dr. Grimes said. She said she has had good results using targeted light therapy in these patients.

▸ Imatinib mesylate. Imatinib mesylate (Gleevec) is a tyrosine kinase inhibitor that is used for the treatment of chronic myeloid leukemia. “One of the most common side effects is that it induces hypopigmentation and depigmentation,” Dr. Grimes said, so this may be a future depigmenting agent for vitiligo.

▸ Surgical options. Surgical therapy for vitiligo is indicated for stable disease that is focal or segmental and does not respond to medical treatment. It is contraindicated in patients with keloids and hypertrophic scars.

Available procedures include autologous suction blister grafts, autologous melanocyte transplants, autologous punch grafts, sheet grafts, and co-cultures of melanocytes and keratinocytes. “Using these grafting procedures, we actually have the ability to cure some patients who have segmental vitiligo,” Dr. Grimes said.

One new surgical option is a technology called ReCell (Avita Medical Ltd.). This is a single-use, battery-operated, autologous cell harvesting system. The cell suspension is sprayed onto the affected areas of skin.

Dr. Grimes reported that she had no relevant conflicts of interest.

Vitiligo is associated with depression, stigmatization, low self-esteem, and social embarrassment. Courtesy Dr. Steven R. Feldman

PARIS — Vitiligo can be a psychologically devastating disorder, but there are several effective therapies that can improve skin pigmentation and reduce the burden of this disease, according to Dr. Pearl Grimes.

“Pigmentation significantly influences the paradigm of psychosocial interactions. … Any aberration or any deviation from normal causes enormous distress for patients,” Dr. Grimes said during a plenary session at the annual congress of the European Academy of Dermatology and Venereology.

Vitiligo is associated with depression, stigmatization, low self-esteem, social embarrassment, and impaired interpersonal relationships. The disease is particularly problematic for children in their formative years, and some quality of life studies have shown that negative childhood experiences are significantly associated with impairment in early adulthood, said Dr. Grimes, who is the director of a practice that specializes in vitiligo and pigmentation in Los Angeles.

During the last 10–15 years, several studies have also shown that severity of vitiligo correlates with quality of life, that impairment is greatest in women, and that counseling may help improve body image, self-esteem, and quality of life for children and adults.

The message for physicians: “Be sensitized and aware of these issues for patients, and refer them for counseling to cope with the despair caused by this disease,” Dr. Grimes said.

She discussed recent advances in vitiligo assessment and therapy that have offered hope to these patients:

▸ Definition and assessment. Historically, there has been no common grading scale for vitiligo that could be used to compare the results of clinical studies.

In 2007, the Vitiligo European Task Force published a consensus report on the definition of vitiligo and methodologies for assessing treatments for this skin disease (Pigment Cell Res. 2007;20:27–35). The assessment is based on body surface area, disease stage, and progression.

“I think the European task force has done a wonderful job in addressing some of the issues that we face as physicians in addressing this disease,” she said.

▸ Topical calcineurin inhibitors. In recent years, multiple studies have documented the efficacy and safety of calcineurin inhibitors as repigmentation tools in the treatment of vitiligo.

These topical immunomodulators “are now the No. 1 treatment that is prescribed for patients who have limited involvement,” Dr. Grimes said.

Calcineurin inhibitors work by inhibiting T-cell activation, deactivating calcineurin, and inhibiting the formation of proinflammatory cytokines. These agents also decrease tumor necrosis factor-α levels following treatment, and stimulate melanocyte growth.

Calcineurin inhibitors offer several advantages, she continued. These agents are well tolerated. They do not cause atrophy or telangiectasia, as steroids do. Pigmentation is homogeneous. And calcineurin inhibitors work especially well for the face and neck.

They are the optimal treatment for patients with limited involvement over the body surface area, Dr. Grimes said.

However, in the United States these agents carry black box warnings regarding long-term use. Rare cases of cancer have been reported in patients who were treated with topical calcineurin inhibitors, although no causal relationship has been established. Physicians are encouraged to avoid continuous long-term use of these agents for their patients and to limit application to areas of involvement, she said.

Despite the black box warning, the evidence for an association with cancer is not clear. In a nested case-control study published in 2007, researchers looked at the possible association between topical immunosuppressives and lymphoma in more than 290,000 patients with atopic dermatitis. Based on logistic regression analysis, there was no increase in lymphomas in patients who were treated with calcineurin inhibitors (J. Invest. Dermatol. 2007;127:808–16).

“At the end of the day, as clinicians … you have to decide how you will situate these combination protocols/combination uses in your practice,” Dr. Grimes said.

She added that she relies on calcineurin inhibitors tremendously in her practice, but does not use them with ultraviolet light. Instead, she treats patients on the basis of a rotational algorithm, starting with tacrolimus/pimecrolimus, then targeted phototherapy, then steroids/calcipotriol, then steroids/tacrolimus, and back to tacrolimus/pimecrolimus.

▸ Vitamin D analogues. Another treatment that is being considered for vitiligo is vitamin D. “There are exciting new data in the literature on the role of vitamin D in the autoimmune process,” Dr. Grimes said. The immunomodulatory effects of vitamin D include suppression of T-cell activation, induction of regulatory T cells, and modulation of the production of proinflammatory cytokines from activated T cells and keratinocytes. Vitamin D also has antioxidant and photoprotective effects.

Vitamin D stimulates the differentiation of immature melanocyte precursors and plays a regulatory role in melanocyte development and melanogenesis. Vitamin D also increases tyrosinase activity.

However, in terms of using vitamin D analogues as repigmentation therapies, results have been varied. Response is poor when these agents are used as monotherapy. The best results are achieved with sunlight, phototherapy, or topical mid- to high-potency steroids.

The use of vitamin D analogues may decrease the cumulative UV dose and number of phototherapy treatments required for repigmentation. The fact that vitamin D analogues are degraded by UV light may account for some of the variability seen in the studies, Dr. Grimes said.

▸ Narrow-band UVB. Narrow-band UVB (NB-UVB) phototherapy, which affects both peripheral blood and lesional skin, has moved to the forefront as a treatment for vitiligo. In peripheral blood, narrow-band UVB decreases natural killer-cell activity, cytokine response, and lymphoproliferative responses. In lesional skin, this therapy decreases Langerhans cell activation and increases apoptosis, melanocyte proliferation, and melanogenesis.

NB-UVB has no systemic side effects, requires no posttreatment ocular protection, and has a good safety profile for adults and children. A good response can be achieved even in patients with extensive involvement. “We know that narrow-band [UVB phototherapy] is tremendously well tolerated and easier for the patient,” Dr. Grimes said.

NB-UVB appears to provide a better response than does psoralen with UVA (PUVA). In a recent study, 25 patients with vitiligo were treated with PUVA and 25 with NB-UVB (Arch. Dermatol. 2007;143:578–84). At the end of therapy, 64% of the NB-UVB patients had a greater-than-50% improvement in affected body surface area, compared with 36% of the PUVA group. The color match of the repigmented skin was excellent in all patients in the NB-UVB group, but in only 44% of those in the PUVA group.

On the down side, NB-UVB therapy may require three treatments per week for maximum efficacy. In addition, the long-term carcinogenic effects—as well as the long-term stability of NB-UVB repigmentation—are not known.

“We need more data on the stability of the treatments that we do, as well as [on] the need for maintenance treatment once you achieve repigmentation,” she said.

▸ Polypodium and phototherapy. Polypodium leucotomos (PL), a fern plant grown in Central America that was used in the 1980s as a repigmenting agent, is enjoying a resurgence in interest. The plant has been found to have antitumor and anti-inflammatory effects. It has immunosuppressive properties, reducing CD4 and CD8 levels.

In one study, researchers explored the effects of PUVA plus PL in a pilot randomized, double-blind, placebo-controlled trial with 19 patients who had generalized vitiligo. Skin repigmentation greater than 50% was achieved by a significantly higher percentage of patients in the PUVA-plus-PL arm than in the PUVA-plus-placebo arm (J. Dermatol. Sci. 2006;41:213–6).

“I think that we're going to be seeing more on this combination of Polypodium plus light in the future,” Dr. Grimes said.

▸ Targeted light therapy. Excimer laser-targeted light therapy is another effective option for treating vitiligo. This therapy targets affected skin with a high-intensity light, but avoids exposure to normal skin. Rapid therapeutic responses are seen; cumulative UV exposure is limited.

In addition, targeted light therapy can have a synergistic effect with certain topical agents. Studies suggest that the fastest repigmentation occurs with treatment two to three times per week.

This therapy is a good choice for patients with areas of depigmentation on the genitalia. “Typically in my practice, I tend to avoid treating these areas. But I do have a cohort of gentlemen who are absolutely devastated by genital depigmentation,” Dr. Grimes said. She said she has had good results using targeted light therapy in these patients.

▸ Imatinib mesylate. Imatinib mesylate (Gleevec) is a tyrosine kinase inhibitor that is used for the treatment of chronic myeloid leukemia. “One of the most common side effects is that it induces hypopigmentation and depigmentation,” Dr. Grimes said, so this may be a future depigmenting agent for vitiligo.

▸ Surgical options. Surgical therapy for vitiligo is indicated for stable disease that is focal or segmental and does not respond to medical treatment. It is contraindicated in patients with keloids and hypertrophic scars.

Available procedures include autologous suction blister grafts, autologous melanocyte transplants, autologous punch grafts, sheet grafts, and co-cultures of melanocytes and keratinocytes. “Using these grafting procedures, we actually have the ability to cure some patients who have segmental vitiligo,” Dr. Grimes said.

One new surgical option is a technology called ReCell (Avita Medical Ltd.). This is a single-use, battery-operated, autologous cell harvesting system. The cell suspension is sprayed onto the affected areas of skin.

Dr. Grimes reported that she had no relevant conflicts of interest.

Vitiligo is associated with depression, stigmatization, low self-esteem, and social embarrassment. Courtesy Dr. Steven R. Feldman

In an ongoing randomized trial, Dr. Daniel H.S. Silverman, Dr. Natalie L. Rasgon, and their colleagues are examining the effects of both endogenous and exogenous estrogen exposure on regional cerebral metabolism in women who were on hormone therapy (HT) at the time of recruitment and had an increased risk of Alzheimer's disease. These women either stopped or continued HT and then underwent fluorine-18 FDG-PET imaging at baseline and at 2 years. Dr. Silverman, head of the neuronuclear imaging section of the Ahmanson Biological Imaging Division at the University of California, Los Angeles, presented data at the San Antonio Breast Cancer Symposium on the first 25 women to complete the protocol.

Endogenous estrogen exposure was positively correlated most significantly with the metabolism of the precuneus area of the posterior medial cortex. “That's a part of the brain in which blood flow is decreased most significantly in early stages of Alzheimer's disease,” he said.

Two years after discontinuation of HT, those women exhibited a highly significant negative correlation between the duration of endogenous exposure and the metabolism of the anterior medial cortex. “That's part of the brain that we know is affected most significantly by normal aging of the brain,” he said. In contrast, women who continued on HT during the trial demonstrated a relative increase in the most anterior portion of the medial prefrontal cortex after 2 years.

In women who stopped HT, “there were two things that we saw. First of all, they didn't have that preservation of the frontal area that declines with normal aging. In addition, they experienced a significant decrease in metabolism in the inferior parietal cortex, a part of the brain that is affected very early in incipient Alzheimer's disease,” he said.

In a parallel but unrelated trial, Dr. Silverman, along with UCLA oncologist Dr. Patti Ganz and UCLA neuropsychologist Steve Castellon, Ph.D., set out to determine the cognitive effects of chemotherapy on breast cancer patients. They conducted PET scans in 16 women who had been exposed to adjuvant chemotherapy for breast cancer—and to tamoxifen in the majority of cases. The women were studied 5-10 years after their last dose of chemotherapy and were compared with age-matched controls, who had not been exposed to chemotherapy.

Controversy exists over how much of the neurocognitive impairment that follows chemotherapy exposure (chemobrain) is directly associated with chemotherapy and how much is attributable to related factors, such as the cancer itself and precipitous menopause.

“Those who had cognitive impairment after having been exposed to chemotherapy had significantly decreased metabolism [in the inferior frontal cortex] at mental rest and substantially increased activation when performing short-term memory tasks. … these are people who start off with lower metabolism or lower activity in that part of the brain, so to perform the same task, that area of the brain has to work a lot harder to get to the same level,” he said.

Women on continual hormone therapy had increased metabolism in both sides of the medial prefrontal cortex. Images courtesy Dr. Daniel Silverman

In an ongoing randomized trial, Dr. Daniel H.S. Silverman, Dr. Natalie L. Rasgon, and their colleagues are examining the effects of both endogenous and exogenous estrogen exposure on regional cerebral metabolism in women who were on hormone therapy (HT) at the time of recruitment and had an increased risk of Alzheimer's disease. These women either stopped or continued HT and then underwent fluorine-18 FDG-PET imaging at baseline and at 2 years. Dr. Silverman, head of the neuronuclear imaging section of the Ahmanson Biological Imaging Division at the University of California, Los Angeles, presented data at the San Antonio Breast Cancer Symposium on the first 25 women to complete the protocol.

Endogenous estrogen exposure was positively correlated most significantly with the metabolism of the precuneus area of the posterior medial cortex. “That's a part of the brain in which blood flow is decreased most significantly in early stages of Alzheimer's disease,” he said.

Two years after discontinuation of HT, those women exhibited a highly significant negative correlation between the duration of endogenous exposure and the metabolism of the anterior medial cortex. “That's part of the brain that we know is affected most significantly by normal aging of the brain,” he said. In contrast, women who continued on HT during the trial demonstrated a relative increase in the most anterior portion of the medial prefrontal cortex after 2 years.

In women who stopped HT, “there were two things that we saw. First of all, they didn't have that preservation of the frontal area that declines with normal aging. In addition, they experienced a significant decrease in metabolism in the inferior parietal cortex, a part of the brain that is affected very early in incipient Alzheimer's disease,” he said.

In a parallel but unrelated trial, Dr. Silverman, along with UCLA oncologist Dr. Patti Ganz and UCLA neuropsychologist Steve Castellon, Ph.D., set out to determine the cognitive effects of chemotherapy on breast cancer patients. They conducted PET scans in 16 women who had been exposed to adjuvant chemotherapy for breast cancer—and to tamoxifen in the majority of cases. The women were studied 5-10 years after their last dose of chemotherapy and were compared with age-matched controls, who had not been exposed to chemotherapy.

Controversy exists over how much of the neurocognitive impairment that follows chemotherapy exposure (chemobrain) is directly associated with chemotherapy and how much is attributable to related factors, such as the cancer itself and precipitous menopause.

“Those who had cognitive impairment after having been exposed to chemotherapy had significantly decreased metabolism [in the inferior frontal cortex] at mental rest and substantially increased activation when performing short-term memory tasks. … these are people who start off with lower metabolism or lower activity in that part of the brain, so to perform the same task, that area of the brain has to work a lot harder to get to the same level,” he said.

Women on continual hormone therapy had increased metabolism in both sides of the medial prefrontal cortex. Images courtesy Dr. Daniel Silverman

In an ongoing randomized trial, Dr. Daniel H.S. Silverman, Dr. Natalie L. Rasgon, and their colleagues are examining the effects of both endogenous and exogenous estrogen exposure on regional cerebral metabolism in women who were on hormone therapy (HT) at the time of recruitment and had an increased risk of Alzheimer's disease. These women either stopped or continued HT and then underwent fluorine-18 FDG-PET imaging at baseline and at 2 years. Dr. Silverman, head of the neuronuclear imaging section of the Ahmanson Biological Imaging Division at the University of California, Los Angeles, presented data at the San Antonio Breast Cancer Symposium on the first 25 women to complete the protocol.

Endogenous estrogen exposure was positively correlated most significantly with the metabolism of the precuneus area of the posterior medial cortex. “That's a part of the brain in which blood flow is decreased most significantly in early stages of Alzheimer's disease,” he said.

Two years after discontinuation of HT, those women exhibited a highly significant negative correlation between the duration of endogenous exposure and the metabolism of the anterior medial cortex. “That's part of the brain that we know is affected most significantly by normal aging of the brain,” he said. In contrast, women who continued on HT during the trial demonstrated a relative increase in the most anterior portion of the medial prefrontal cortex after 2 years.

In women who stopped HT, “there were two things that we saw. First of all, they didn't have that preservation of the frontal area that declines with normal aging. In addition, they experienced a significant decrease in metabolism in the inferior parietal cortex, a part of the brain that is affected very early in incipient Alzheimer's disease,” he said.

In a parallel but unrelated trial, Dr. Silverman, along with UCLA oncologist Dr. Patti Ganz and UCLA neuropsychologist Steve Castellon, Ph.D., set out to determine the cognitive effects of chemotherapy on breast cancer patients. They conducted PET scans in 16 women who had been exposed to adjuvant chemotherapy for breast cancer—and to tamoxifen in the majority of cases. The women were studied 5-10 years after their last dose of chemotherapy and were compared with age-matched controls, who had not been exposed to chemotherapy.

Controversy exists over how much of the neurocognitive impairment that follows chemotherapy exposure (chemobrain) is directly associated with chemotherapy and how much is attributable to related factors, such as the cancer itself and precipitous menopause.

“Those who had cognitive impairment after having been exposed to chemotherapy had significantly decreased metabolism [in the inferior frontal cortex] at mental rest and substantially increased activation when performing short-term memory tasks. … these are people who start off with lower metabolism or lower activity in that part of the brain, so to perform the same task, that area of the brain has to work a lot harder to get to the same level,” he said.

Women on continual hormone therapy had increased metabolism in both sides of the medial prefrontal cortex. Images courtesy Dr. Daniel Silverman

In rheumatoid arthritis, imaging often helps contribute to early diagnosis, and can assess response to treatment. But all forms of imaging are not equal in RA.

While both ultrasound and MRI can visualize synovitis and erosions, only MRI can show osteitis.

Dr. Norman B. Gaylis, a practicing rheumatologist in Aventura, Fla., and the president of International Society of Extremity MRI in Rheumatology (ISEMIR), has been using imaging in his practice for many years.

He has a small-magnet (0.27 T) MRI extremity scanner, which he uses not only to diagnose RA but also to monitor patient response to treatment.

He also uses in-office ultrasound. “I think MRI and ultrasound are very different modalities. Everyone tries to compare them … but that's not how they're meant to be used. They should complement each other, not be alternatives.”

Here are Dr. Gaylis' thoughts on how different imaging modalities can help to better manage RA.

MRI

MRI is useful for much more than simply making an early diagnosis. MRI is also a powerful tool for helping to manage, maintain, and adjust a patient's treatment regimen.

We have 10 years' experience using MRI to evaluate and monitor rheumatoid arthritis changes. The detection of erosions that are not present on x-ray is not the exclusive reason for using MRI. Visualization of bone marrow edema is equally important, Dr. Gaylis noted.

In fact, osteitis and synovitis “are almost markers for disease activity in RA,” particularly in patients who appear to be free of inflammation by other indicators (sedimentation rates, CRP levels, and subjective perception of wellness). “On MRI, the presence of synovitis or osteitis may be a reason to continue treatment,” said Dr. Gaylis.

On the other hand, when no osteitis, synovitis, or active erosions are visible using MRI, it suggests the time has come to discontinue biologic treatment. If, on repeat MRI in 6-12 months, there are no signs of active disease, the patient is in remission. On the other hand, if there are signs of disease activity on repeat MRI, biologic treatment needs to be restarted.

It's generally adequate to repeat MRI scans on a yearly basis, regardless of the treatment. However, clinical or serologic findings may prompt rescanning sooner.

Some patients who are clinically and serologically in remission with no progression on MRI for several years of observation may not require continued yearly imaging, Dr. Gaylis said.

Getting paid for performing MRI scans for RA remains a challenge, largely because of the American College of Rheumatology white paper, “Evaluation of Low Field Extremity Magnetic Resonance Imaging (MRI),” which has been used as a basis to deny reimbursement.

In May 2008, however, the ACR issued a letter (see resources box), in which the organization stated that insurance companies should not be using the white paper to deny coverage or reimbursement for MRI scans to evaluate RA. “It's clear that MRI imaging, both high field and low field, is more sensitive than plain x-ray in detection of erosions and osteitis,” the letter stated.

“One still has to recognize that this is a problem with some insurance companies. There are other insurance companies that are very up to date with the literature,” he said. For the majority of insurance companies with which Dr. Gaylis works, “once I have documented the reason why, they are actually reimbursing.”

In-office MRI can be attractive to some rheumatologists. “The bulk of [RA] patients who need an MRI in a community environment would have to be referred to an MRI center,” said Dr. Gaylis. These facilities have a number of drawbacks. The first is scheduling, because RA patients must compete with patients from a number of other specialties.

In addition, these facilities typically use large, whole-body, high-field scanners. Positioning is very uncomfortable for RA patients in these large machines, which require hands above the head.

These scans are usually read by radiologists who do not have specific musculoskeletal training. These radiologists “are never going to have the ability to interpret and understand the nuances of RA findings to the same extent as someone who is a board-certified musculoskeletal radiologist, who is reading the scans of 100 RA patients a week,” he said.

Ultrasound

Ultrasound “definitely does help us see syno-vitis,” said Dr. Gaylis. “We know that clinically there may be no evidence of synovitis and yet in many cases the Doppler ultrasound imaging is going to be positive.” Ultrasound is very helpful in following disease activity by measuring synovial inflammation.

Ultrasound is a good option when you're not sure what is going on with your patient and you need to know right away if there is inflammation that needs to be addressed. “We use it in the in-between periods for that reason,” he said.

Ultrasound's convenience makes it an attractive imaging modality. “The beauty of ultrasound is that you can pull out the ultrasound machine while the patient is in the office. You can look at a few joints in the hand or the wrist or the elbow. You don't have to go through the process of MRI,” said Dr. Gaylis.

Ultrasound also can be used to visualize erosions, though this is very dependent on the experience of the technician and viewer. “Having experience in ultrasound is something that is critical for the management of these patients.”

Dr. Gaylis has an ultrasound technician in his office. He finds that it is easier to read the image if someone else is handling the technical component. He and the technologist will discuss the reading while it's being done. However, many rheumatologists perform their own ultrasound imaging.

It's almost mandatory to go to ultrasound courses to learn how to perform and read. He recommends 6 months of ultrasound practice without billing, just to become comfortable with the technique.

X-Ray

“X-rays don't help me much if at all in the diagnosis and management of rheumatoid arthritis, especially in the peripheral joints,” said Dr. Gaylis. X-ray doesn't help rheumatologists make biologic treatment choices for their patients with RA. “Changes occur so slowly on x-ray that it really just doesn't fit the rhythm of biologic therapy,” he said.

X-rays allow visualization of erosions and joint space narrowing. “I think if you were doing a SHARP score on every patient, then x-rays would have more validity because then you would be looking at joint-space narrowing and erosions in many joints. But that's a measurement used primarily in research alone and is totally impractical in clinical practice,” he said.

To view a video interview of Dr. Gaylis, go to

http://www.youtube.com/watch?v=8Q6iRPzJ3a8

Ultrasound is a good option when you're not sure what is going on with your patient and you need to know right away. DR. GAYLIS

T1 (left) and STIR imaging (right) reveal a profound, diffusely abnormal signal consistent with osteitis (arrows).

Near complete resolution of osteitis throughout the carpal bones and metacarpal bases (arrows) can be seen. Images courtesy Dr. Steven D. Needell

Resources

▸ ACR letter addressed to insurance companies clarifying the college's position on extremity MRI for rheumatologic conditions:

http://rheumatology.org/practice/advocacy/asc/letters/index.asp

▸ International Society of Extremity MRI in Rheumatology:

www.isemir.org

▸ American College of Radiology meetings:

www.acr.org/SecondaryMainMenuCategories/

Meetings andEvents.aspx

▸ American College of Radiology accreditation:

www.acr.org/accreditation/mri/mri_reqs.aspx

▸ Intersocietal Commission for the Accreditation of Magnetic Resonance Laboratories:

www.icamrl.org/icamrl/index.htm

In rheumatoid arthritis, imaging often helps contribute to early diagnosis, and can assess response to treatment. But all forms of imaging are not equal in RA.

While both ultrasound and MRI can visualize synovitis and erosions, only MRI can show osteitis.

Dr. Norman B. Gaylis, a practicing rheumatologist in Aventura, Fla., and the president of International Society of Extremity MRI in Rheumatology (ISEMIR), has been using imaging in his practice for many years.

He has a small-magnet (0.27 T) MRI extremity scanner, which he uses not only to diagnose RA but also to monitor patient response to treatment.

He also uses in-office ultrasound. “I think MRI and ultrasound are very different modalities. Everyone tries to compare them … but that's not how they're meant to be used. They should complement each other, not be alternatives.”

Here are Dr. Gaylis' thoughts on how different imaging modalities can help to better manage RA.

MRI

MRI is useful for much more than simply making an early diagnosis. MRI is also a powerful tool for helping to manage, maintain, and adjust a patient's treatment regimen.

We have 10 years' experience using MRI to evaluate and monitor rheumatoid arthritis changes. The detection of erosions that are not present on x-ray is not the exclusive reason for using MRI. Visualization of bone marrow edema is equally important, Dr. Gaylis noted.

In fact, osteitis and synovitis “are almost markers for disease activity in RA,” particularly in patients who appear to be free of inflammation by other indicators (sedimentation rates, CRP levels, and subjective perception of wellness). “On MRI, the presence of synovitis or osteitis may be a reason to continue treatment,” said Dr. Gaylis.

On the other hand, when no osteitis, synovitis, or active erosions are visible using MRI, it suggests the time has come to discontinue biologic treatment. If, on repeat MRI in 6-12 months, there are no signs of active disease, the patient is in remission. On the other hand, if there are signs of disease activity on repeat MRI, biologic treatment needs to be restarted.

It's generally adequate to repeat MRI scans on a yearly basis, regardless of the treatment. However, clinical or serologic findings may prompt rescanning sooner.

Some patients who are clinically and serologically in remission with no progression on MRI for several years of observation may not require continued yearly imaging, Dr. Gaylis said.

Getting paid for performing MRI scans for RA remains a challenge, largely because of the American College of Rheumatology white paper, “Evaluation of Low Field Extremity Magnetic Resonance Imaging (MRI),” which has been used as a basis to deny reimbursement.

In May 2008, however, the ACR issued a letter (see resources box), in which the organization stated that insurance companies should not be using the white paper to deny coverage or reimbursement for MRI scans to evaluate RA. “It's clear that MRI imaging, both high field and low field, is more sensitive than plain x-ray in detection of erosions and osteitis,” the letter stated.

“One still has to recognize that this is a problem with some insurance companies. There are other insurance companies that are very up to date with the literature,” he said. For the majority of insurance companies with which Dr. Gaylis works, “once I have documented the reason why, they are actually reimbursing.”

In-office MRI can be attractive to some rheumatologists. “The bulk of [RA] patients who need an MRI in a community environment would have to be referred to an MRI center,” said Dr. Gaylis. These facilities have a number of drawbacks. The first is scheduling, because RA patients must compete with patients from a number of other specialties.

In addition, these facilities typically use large, whole-body, high-field scanners. Positioning is very uncomfortable for RA patients in these large machines, which require hands above the head.

These scans are usually read by radiologists who do not have specific musculoskeletal training. These radiologists “are never going to have the ability to interpret and understand the nuances of RA findings to the same extent as someone who is a board-certified musculoskeletal radiologist, who is reading the scans of 100 RA patients a week,” he said.

Ultrasound

Ultrasound “definitely does help us see syno-vitis,” said Dr. Gaylis. “We know that clinically there may be no evidence of synovitis and yet in many cases the Doppler ultrasound imaging is going to be positive.” Ultrasound is very helpful in following disease activity by measuring synovial inflammation.

Ultrasound is a good option when you're not sure what is going on with your patient and you need to know right away if there is inflammation that needs to be addressed. “We use it in the in-between periods for that reason,” he said.

Ultrasound's convenience makes it an attractive imaging modality. “The beauty of ultrasound is that you can pull out the ultrasound machine while the patient is in the office. You can look at a few joints in the hand or the wrist or the elbow. You don't have to go through the process of MRI,” said Dr. Gaylis.

Ultrasound also can be used to visualize erosions, though this is very dependent on the experience of the technician and viewer. “Having experience in ultrasound is something that is critical for the management of these patients.”

Dr. Gaylis has an ultrasound technician in his office. He finds that it is easier to read the image if someone else is handling the technical component. He and the technologist will discuss the reading while it's being done. However, many rheumatologists perform their own ultrasound imaging.

It's almost mandatory to go to ultrasound courses to learn how to perform and read. He recommends 6 months of ultrasound practice without billing, just to become comfortable with the technique.

X-Ray

“X-rays don't help me much if at all in the diagnosis and management of rheumatoid arthritis, especially in the peripheral joints,” said Dr. Gaylis. X-ray doesn't help rheumatologists make biologic treatment choices for their patients with RA. “Changes occur so slowly on x-ray that it really just doesn't fit the rhythm of biologic therapy,” he said.

X-rays allow visualization of erosions and joint space narrowing. “I think if you were doing a SHARP score on every patient, then x-rays would have more validity because then you would be looking at joint-space narrowing and erosions in many joints. But that's a measurement used primarily in research alone and is totally impractical in clinical practice,” he said.

To view a video interview of Dr. Gaylis, go to

http://www.youtube.com/watch?v=8Q6iRPzJ3a8

Ultrasound is a good option when you're not sure what is going on with your patient and you need to know right away. DR. GAYLIS

T1 (left) and STIR imaging (right) reveal a profound, diffusely abnormal signal consistent with osteitis (arrows).

Near complete resolution of osteitis throughout the carpal bones and metacarpal bases (arrows) can be seen. Images courtesy Dr. Steven D. Needell

Resources

▸ ACR letter addressed to insurance companies clarifying the college's position on extremity MRI for rheumatologic conditions:

http://rheumatology.org/practice/advocacy/asc/letters/index.asp

▸ International Society of Extremity MRI in Rheumatology:

www.isemir.org

▸ American College of Radiology meetings:

www.acr.org/SecondaryMainMenuCategories/

Meetings andEvents.aspx

▸ American College of Radiology accreditation:

www.acr.org/accreditation/mri/mri_reqs.aspx

▸ Intersocietal Commission for the Accreditation of Magnetic Resonance Laboratories:

www.icamrl.org/icamrl/index.htm

In rheumatoid arthritis, imaging often helps contribute to early diagnosis, and can assess response to treatment. But all forms of imaging are not equal in RA.

While both ultrasound and MRI can visualize synovitis and erosions, only MRI can show osteitis.

Dr. Norman B. Gaylis, a practicing rheumatologist in Aventura, Fla., and the president of International Society of Extremity MRI in Rheumatology (ISEMIR), has been using imaging in his practice for many years.

He has a small-magnet (0.27 T) MRI extremity scanner, which he uses not only to diagnose RA but also to monitor patient response to treatment.

He also uses in-office ultrasound. “I think MRI and ultrasound are very different modalities. Everyone tries to compare them … but that's not how they're meant to be used. They should complement each other, not be alternatives.”

Here are Dr. Gaylis' thoughts on how different imaging modalities can help to better manage RA.

MRI

MRI is useful for much more than simply making an early diagnosis. MRI is also a powerful tool for helping to manage, maintain, and adjust a patient's treatment regimen.

We have 10 years' experience using MRI to evaluate and monitor rheumatoid arthritis changes. The detection of erosions that are not present on x-ray is not the exclusive reason for using MRI. Visualization of bone marrow edema is equally important, Dr. Gaylis noted.

In fact, osteitis and synovitis “are almost markers for disease activity in RA,” particularly in patients who appear to be free of inflammation by other indicators (sedimentation rates, CRP levels, and subjective perception of wellness). “On MRI, the presence of synovitis or osteitis may be a reason to continue treatment,” said Dr. Gaylis.

On the other hand, when no osteitis, synovitis, or active erosions are visible using MRI, it suggests the time has come to discontinue biologic treatment. If, on repeat MRI in 6-12 months, there are no signs of active disease, the patient is in remission. On the other hand, if there are signs of disease activity on repeat MRI, biologic treatment needs to be restarted.

It's generally adequate to repeat MRI scans on a yearly basis, regardless of the treatment. However, clinical or serologic findings may prompt rescanning sooner.

Some patients who are clinically and serologically in remission with no progression on MRI for several years of observation may not require continued yearly imaging, Dr. Gaylis said.

Getting paid for performing MRI scans for RA remains a challenge, largely because of the American College of Rheumatology white paper, “Evaluation of Low Field Extremity Magnetic Resonance Imaging (MRI),” which has been used as a basis to deny reimbursement.

In May 2008, however, the ACR issued a letter (see resources box), in which the organization stated that insurance companies should not be using the white paper to deny coverage or reimbursement for MRI scans to evaluate RA. “It's clear that MRI imaging, both high field and low field, is more sensitive than plain x-ray in detection of erosions and osteitis,” the letter stated.

“One still has to recognize that this is a problem with some insurance companies. There are other insurance companies that are very up to date with the literature,” he said. For the majority of insurance companies with which Dr. Gaylis works, “once I have documented the reason why, they are actually reimbursing.”

In-office MRI can be attractive to some rheumatologists. “The bulk of [RA] patients who need an MRI in a community environment would have to be referred to an MRI center,” said Dr. Gaylis. These facilities have a number of drawbacks. The first is scheduling, because RA patients must compete with patients from a number of other specialties.

In addition, these facilities typically use large, whole-body, high-field scanners. Positioning is very uncomfortable for RA patients in these large machines, which require hands above the head.

These scans are usually read by radiologists who do not have specific musculoskeletal training. These radiologists “are never going to have the ability to interpret and understand the nuances of RA findings to the same extent as someone who is a board-certified musculoskeletal radiologist, who is reading the scans of 100 RA patients a week,” he said.

Ultrasound

Ultrasound “definitely does help us see syno-vitis,” said Dr. Gaylis. “We know that clinically there may be no evidence of synovitis and yet in many cases the Doppler ultrasound imaging is going to be positive.” Ultrasound is very helpful in following disease activity by measuring synovial inflammation.

Ultrasound is a good option when you're not sure what is going on with your patient and you need to know right away if there is inflammation that needs to be addressed. “We use it in the in-between periods for that reason,” he said.

Ultrasound's convenience makes it an attractive imaging modality. “The beauty of ultrasound is that you can pull out the ultrasound machine while the patient is in the office. You can look at a few joints in the hand or the wrist or the elbow. You don't have to go through the process of MRI,” said Dr. Gaylis.

Ultrasound also can be used to visualize erosions, though this is very dependent on the experience of the technician and viewer. “Having experience in ultrasound is something that is critical for the management of these patients.”

Dr. Gaylis has an ultrasound technician in his office. He finds that it is easier to read the image if someone else is handling the technical component. He and the technologist will discuss the reading while it's being done. However, many rheumatologists perform their own ultrasound imaging.

It's almost mandatory to go to ultrasound courses to learn how to perform and read. He recommends 6 months of ultrasound practice without billing, just to become comfortable with the technique.

X-Ray

“X-rays don't help me much if at all in the diagnosis and management of rheumatoid arthritis, especially in the peripheral joints,” said Dr. Gaylis. X-ray doesn't help rheumatologists make biologic treatment choices for their patients with RA. “Changes occur so slowly on x-ray that it really just doesn't fit the rhythm of biologic therapy,” he said.

X-rays allow visualization of erosions and joint space narrowing. “I think if you were doing a SHARP score on every patient, then x-rays would have more validity because then you would be looking at joint-space narrowing and erosions in many joints. But that's a measurement used primarily in research alone and is totally impractical in clinical practice,” he said.

To view a video interview of Dr. Gaylis, go to

http://www.youtube.com/watch?v=8Q6iRPzJ3a8

Ultrasound is a good option when you're not sure what is going on with your patient and you need to know right away. DR. GAYLIS

T1 (left) and STIR imaging (right) reveal a profound, diffusely abnormal signal consistent with osteitis (arrows).

Near complete resolution of osteitis throughout the carpal bones and metacarpal bases (arrows) can be seen. Images courtesy Dr. Steven D. Needell

Resources

▸ ACR letter addressed to insurance companies clarifying the college's position on extremity MRI for rheumatologic conditions:

http://rheumatology.org/practice/advocacy/asc/letters/index.asp

▸ International Society of Extremity MRI in Rheumatology:

www.isemir.org

▸ American College of Radiology meetings:

www.acr.org/SecondaryMainMenuCategories/

Meetings andEvents.aspx

▸ American College of Radiology accreditation:

www.acr.org/accreditation/mri/mri_reqs.aspx

▸ Intersocietal Commission for the Accreditation of Magnetic Resonance Laboratories:

www.icamrl.org/icamrl/index.htm

WASHINGTON — Expanding the traditional window for influenza immunization would add vaccination opportunities by increasing the number of pediatric office visits, based on data for 77.6 million children from a nationwide survey during the 2004-2005 flu season.

By expanding the vaccination window 6 months, either earlier or later, the overall number of children aged between 0 and 18 years with at least one provider visit jumped from 11.1 million to 23.4 million (July through December) or to 18.2 million (October through March), Dr. Richard G. Judelsohn reported in a poster at the jointly held annual Interscience Conference on Antimicrobial Agents and Chemotherapy and the annual meeting of the Infectious Diseases Society of America. The study was sponsored by MedImmune LLC, which makes Flumist nasal influenza vaccine. Dr. Judelsohn's coauthors are employed by MedImmune.

In early 2008, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices expanded its recommendation that all children aged 6 months to 18 years receive the seasonal flu vaccine each year. However, many children do not visit a health care provider during the traditional flu vaccine window—October through December. The need for additional office visits for the vaccine could be a barrier to increasing flu vaccination.

For this study, the researchers used data from the Medical Expenditure Panel Survey, which is a federally funded survey of families, medical providers, and employers nationwide. Data from the 2004-2005 flu season was used to assess the number of children with existing medical provider office visits during specific monthly intervals. In particular, the researchers identified the number of children with one or more provider visit for various intervals by adding 1, 2, or 3 months before or after the typical flu vaccination window of Oct. 1-Dec. 31.

The researchers also looked at the data for five distinct age groups: less than 12 months, 12-23 months, 2-4 years, 5-8 years, and 9-18 years. Well visits were summarized separately from other provider visits because these may represent the greatest yield vaccination opportunity.

“With expansion of the traditional vaccination window, the largest percentage increase in the number of children with a provider visit is seen in children 5-18 years of age,” wrote Dr. Judelsohn, a professor of pediatrics at the State University of New York at Buffalo, and his coinvestigators. The percentage jumped from 27% between October and December to 46%-48% having a visit during either 6-month window.

“Overall, the proportion of children with existing visits decreases with increasing age,” they wrote. In all, 59% of children younger than 23 months had a visit between October and December, compared with 27% of children aged 5-18 years. Among children with a visit, the proportion with well child visits also decreases with increasing age.

ELSEVIER GLOBAL MEDICAL NEWS

WASHINGTON — Expanding the traditional window for influenza immunization would add vaccination opportunities by increasing the number of pediatric office visits, based on data for 77.6 million children from a nationwide survey during the 2004-2005 flu season.

By expanding the vaccination window 6 months, either earlier or later, the overall number of children aged between 0 and 18 years with at least one provider visit jumped from 11.1 million to 23.4 million (July through December) or to 18.2 million (October through March), Dr. Richard G. Judelsohn reported in a poster at the jointly held annual Interscience Conference on Antimicrobial Agents and Chemotherapy and the annual meeting of the Infectious Diseases Society of America. The study was sponsored by MedImmune LLC, which makes Flumist nasal influenza vaccine. Dr. Judelsohn's coauthors are employed by MedImmune.

In early 2008, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices expanded its recommendation that all children aged 6 months to 18 years receive the seasonal flu vaccine each year. However, many children do not visit a health care provider during the traditional flu vaccine window—October through December. The need for additional office visits for the vaccine could be a barrier to increasing flu vaccination.

For this study, the researchers used data from the Medical Expenditure Panel Survey, which is a federally funded survey of families, medical providers, and employers nationwide. Data from the 2004-2005 flu season was used to assess the number of children with existing medical provider office visits during specific monthly intervals. In particular, the researchers identified the number of children with one or more provider visit for various intervals by adding 1, 2, or 3 months before or after the typical flu vaccination window of Oct. 1-Dec. 31.

The researchers also looked at the data for five distinct age groups: less than 12 months, 12-23 months, 2-4 years, 5-8 years, and 9-18 years. Well visits were summarized separately from other provider visits because these may represent the greatest yield vaccination opportunity.

“With expansion of the traditional vaccination window, the largest percentage increase in the number of children with a provider visit is seen in children 5-18 years of age,” wrote Dr. Judelsohn, a professor of pediatrics at the State University of New York at Buffalo, and his coinvestigators. The percentage jumped from 27% between October and December to 46%-48% having a visit during either 6-month window.

“Overall, the proportion of children with existing visits decreases with increasing age,” they wrote. In all, 59% of children younger than 23 months had a visit between October and December, compared with 27% of children aged 5-18 years. Among children with a visit, the proportion with well child visits also decreases with increasing age.

ELSEVIER GLOBAL MEDICAL NEWS

WASHINGTON — Expanding the traditional window for influenza immunization would add vaccination opportunities by increasing the number of pediatric office visits, based on data for 77.6 million children from a nationwide survey during the 2004-2005 flu season.

By expanding the vaccination window 6 months, either earlier or later, the overall number of children aged between 0 and 18 years with at least one provider visit jumped from 11.1 million to 23.4 million (July through December) or to 18.2 million (October through March), Dr. Richard G. Judelsohn reported in a poster at the jointly held annual Interscience Conference on Antimicrobial Agents and Chemotherapy and the annual meeting of the Infectious Diseases Society of America. The study was sponsored by MedImmune LLC, which makes Flumist nasal influenza vaccine. Dr. Judelsohn's coauthors are employed by MedImmune.

In early 2008, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices expanded its recommendation that all children aged 6 months to 18 years receive the seasonal flu vaccine each year. However, many children do not visit a health care provider during the traditional flu vaccine window—October through December. The need for additional office visits for the vaccine could be a barrier to increasing flu vaccination.

For this study, the researchers used data from the Medical Expenditure Panel Survey, which is a federally funded survey of families, medical providers, and employers nationwide. Data from the 2004-2005 flu season was used to assess the number of children with existing medical provider office visits during specific monthly intervals. In particular, the researchers identified the number of children with one or more provider visit for various intervals by adding 1, 2, or 3 months before or after the typical flu vaccination window of Oct. 1-Dec. 31.

The researchers also looked at the data for five distinct age groups: less than 12 months, 12-23 months, 2-4 years, 5-8 years, and 9-18 years. Well visits were summarized separately from other provider visits because these may represent the greatest yield vaccination opportunity.

“With expansion of the traditional vaccination window, the largest percentage increase in the number of children with a provider visit is seen in children 5-18 years of age,” wrote Dr. Judelsohn, a professor of pediatrics at the State University of New York at Buffalo, and his coinvestigators. The percentage jumped from 27% between October and December to 46%-48% having a visit during either 6-month window.

“Overall, the proportion of children with existing visits decreases with increasing age,” they wrote. In all, 59% of children younger than 23 months had a visit between October and December, compared with 27% of children aged 5-18 years. Among children with a visit, the proportion with well child visits also decreases with increasing age.

ELSEVIER GLOBAL MEDICAL NEWS

WASHINGTON — Recent varicella infection and the presence of a specific virulence factor gene were strongly associated with the development of necrotizing fasciitis among Quebecois children with invasive group A streptococcal infections, according to a retrospective analysis involving 68 patients.

Children with varicella had a sixfold greater risk of necrotizing fasciitis (odds ratio 6.2) and those with the speC gene had a fourfold greater risk (odds ratio 4.0), on the basis of a multivariate analysis, Dr. Philippe Ovetchkine reported at the jointly held annual Interscience Conference on Antimicrobial Agents and Chemotherapy and the annual meeting of the Infectious Diseases Society of America.

“The story began a few years ago in Montreal, when we observed a high number of children hospitalized for invasive group A streptococcal infections. In particular, we noticed concomitant necrotizing fasciitis,” said Dr. Ovetchkine, a pediatrician at the Sainte-Justine Mother and Child University Hospital Center in Montreal. This observation was recently confirmed by the public health department of Quebec.

The researchers conducted a retrospective chart review of all children (younger than 18 years) with documented invasive group A streptococcal infections from January 1999 to December 2007, in order to understand the risk factors for necrotizing fasciitis. Necrotizing fasciitis (NF) cases occurred only during the years 2003-2005.

Invasive group A streptococcal infection was defined as the presence of a compatible clinical presentation and the isolation of group A streptococcus from a normally sterile body site; NF was defined as the presence of necrosis in the fascia and polymorphic infiltrate. A total of 68 children with invasive group A streptococcal infections (44% girls, mean age 60 months) were identified. Group A streptococcus was recovered from blood culture in 38 of the children, cerebrospinal fluid in 2, articular fluid in 4, pleural fluid in 7, and surgical intraoperative samples in 17. Eighteen children had NF, all of whom required surgical intervention.

Recent varicella was significantly more common in the children who developed NF than in those who did not—56% and 14%, respectively. Toxic shock syndrome was also significantly more common among those who developed NF (33%) than in those who did not (4%). On multivariate analysis, toxic shock syndrome was not found to be a significant factor in the development of necrotizing fasciitis. This may be because of the low number of cases (six in the NF group and two in the group without), Dr. Ovetchkine said in an interview.

Group A streptococcal isolates were evaluated for cell surface M virulence protein gene (emm) typing and the presence of several virulence factor genes (speA, speB, speC, ssa, smeZ, and sic). In terms of M protein genes, emm1 (30%) and emm12 (17%) were predominant. In some patients without NF, the researchers did observe speC genes in the streptococcal strains.

Dr. Ovetchkine hypothesizes that the presence of the speC gene can lead to a specific phenotype of invasive group A streptococcal infections: necrotizing fasciitis. “Moreover, speC could act as a superantigen and favors the occurrence of toxic shock syndrome in this context,” he said.

Dr. Ovetchkine stated that he had no conflicts of interest to disclose regarding his presentation.

WASHINGTON — Recent varicella infection and the presence of a specific virulence factor gene were strongly associated with the development of necrotizing fasciitis among Quebecois children with invasive group A streptococcal infections, according to a retrospective analysis involving 68 patients.

Children with varicella had a sixfold greater risk of necrotizing fasciitis (odds ratio 6.2) and those with the speC gene had a fourfold greater risk (odds ratio 4.0), on the basis of a multivariate analysis, Dr. Philippe Ovetchkine reported at the jointly held annual Interscience Conference on Antimicrobial Agents and Chemotherapy and the annual meeting of the Infectious Diseases Society of America.

“The story began a few years ago in Montreal, when we observed a high number of children hospitalized for invasive group A streptococcal infections. In particular, we noticed concomitant necrotizing fasciitis,” said Dr. Ovetchkine, a pediatrician at the Sainte-Justine Mother and Child University Hospital Center in Montreal. This observation was recently confirmed by the public health department of Quebec.

The researchers conducted a retrospective chart review of all children (younger than 18 years) with documented invasive group A streptococcal infections from January 1999 to December 2007, in order to understand the risk factors for necrotizing fasciitis. Necrotizing fasciitis (NF) cases occurred only during the years 2003-2005.

Invasive group A streptococcal infection was defined as the presence of a compatible clinical presentation and the isolation of group A streptococcus from a normally sterile body site; NF was defined as the presence of necrosis in the fascia and polymorphic infiltrate. A total of 68 children with invasive group A streptococcal infections (44% girls, mean age 60 months) were identified. Group A streptococcus was recovered from blood culture in 38 of the children, cerebrospinal fluid in 2, articular fluid in 4, pleural fluid in 7, and surgical intraoperative samples in 17. Eighteen children had NF, all of whom required surgical intervention.

Recent varicella was significantly more common in the children who developed NF than in those who did not—56% and 14%, respectively. Toxic shock syndrome was also significantly more common among those who developed NF (33%) than in those who did not (4%). On multivariate analysis, toxic shock syndrome was not found to be a significant factor in the development of necrotizing fasciitis. This may be because of the low number of cases (six in the NF group and two in the group without), Dr. Ovetchkine said in an interview.

Group A streptococcal isolates were evaluated for cell surface M virulence protein gene (emm) typing and the presence of several virulence factor genes (speA, speB, speC, ssa, smeZ, and sic). In terms of M protein genes, emm1 (30%) and emm12 (17%) were predominant. In some patients without NF, the researchers did observe speC genes in the streptococcal strains.

Dr. Ovetchkine hypothesizes that the presence of the speC gene can lead to a specific phenotype of invasive group A streptococcal infections: necrotizing fasciitis. “Moreover, speC could act as a superantigen and favors the occurrence of toxic shock syndrome in this context,” he said.

Dr. Ovetchkine stated that he had no conflicts of interest to disclose regarding his presentation.

WASHINGTON — Recent varicella infection and the presence of a specific virulence factor gene were strongly associated with the development of necrotizing fasciitis among Quebecois children with invasive group A streptococcal infections, according to a retrospective analysis involving 68 patients.

Children with varicella had a sixfold greater risk of necrotizing fasciitis (odds ratio 6.2) and those with the speC gene had a fourfold greater risk (odds ratio 4.0), on the basis of a multivariate analysis, Dr. Philippe Ovetchkine reported at the jointly held annual Interscience Conference on Antimicrobial Agents and Chemotherapy and the annual meeting of the Infectious Diseases Society of America.

“The story began a few years ago in Montreal, when we observed a high number of children hospitalized for invasive group A streptococcal infections. In particular, we noticed concomitant necrotizing fasciitis,” said Dr. Ovetchkine, a pediatrician at the Sainte-Justine Mother and Child University Hospital Center in Montreal. This observation was recently confirmed by the public health department of Quebec.

The researchers conducted a retrospective chart review of all children (younger than 18 years) with documented invasive group A streptococcal infections from January 1999 to December 2007, in order to understand the risk factors for necrotizing fasciitis. Necrotizing fasciitis (NF) cases occurred only during the years 2003-2005.

Invasive group A streptococcal infection was defined as the presence of a compatible clinical presentation and the isolation of group A streptococcus from a normally sterile body site; NF was defined as the presence of necrosis in the fascia and polymorphic infiltrate. A total of 68 children with invasive group A streptococcal infections (44% girls, mean age 60 months) were identified. Group A streptococcus was recovered from blood culture in 38 of the children, cerebrospinal fluid in 2, articular fluid in 4, pleural fluid in 7, and surgical intraoperative samples in 17. Eighteen children had NF, all of whom required surgical intervention.

Recent varicella was significantly more common in the children who developed NF than in those who did not—56% and 14%, respectively. Toxic shock syndrome was also significantly more common among those who developed NF (33%) than in those who did not (4%). On multivariate analysis, toxic shock syndrome was not found to be a significant factor in the development of necrotizing fasciitis. This may be because of the low number of cases (six in the NF group and two in the group without), Dr. Ovetchkine said in an interview.

Group A streptococcal isolates were evaluated for cell surface M virulence protein gene (emm) typing and the presence of several virulence factor genes (speA, speB, speC, ssa, smeZ, and sic). In terms of M protein genes, emm1 (30%) and emm12 (17%) were predominant. In some patients without NF, the researchers did observe speC genes in the streptococcal strains.

Dr. Ovetchkine hypothesizes that the presence of the speC gene can lead to a specific phenotype of invasive group A streptococcal infections: necrotizing fasciitis. “Moreover, speC could act as a superantigen and favors the occurrence of toxic shock syndrome in this context,” he said.

Dr. Ovetchkine stated that he had no conflicts of interest to disclose regarding his presentation.

WASHINGTON — Expanding the traditional window for influenza vaccination would expand the number of vaccination opportunities by increasing the number of pediatric office visits, based on data for 77.6 million children from a national survey during the 2004-2005 flu season.

By expanding the vaccination window either 6 months earlier or 6 months later, the overall number of children between 0-18 years with at least one provider visit jumped from 11.1 million to 23.4 million (July through December) or to 18.2 (October through March), Dr. Richard G. Judelsohn reported in a poster at the jointly held annual Interscience Conference on Antimicrobial Agents and Chemotherapy and the annual meeting of the Infectious Diseases Society of America. MedImmune LLC, which makes Flumist nasal influenza vaccine, sponsored the study. Dr. Judelsohn's coauthors are employed by MedImmune.

In 2008, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices expanded its recommendation that all children aged 6 months to 18 years receive the seasonal flu vaccine each year. But many children do not visit a health care provider during the traditional flu vaccine window (Oct. 1-Dec. 31). The need for additional office visits for the vaccine could be a barrier to increasing flu vaccination.

The researchers used data from the Medical Expenditure Panel Survey, a federally funded survey of families, medical providers, and employers nationwide. Data from the 2004-2005 flu season was used to assess the number of children with existing medical provider office visits during specific monthly intervals. In particular, they identified the number of children with one or more provider visit for various intervals by adding 1, 2, or 3 months before or after the Oct. 1-Dec. 31 period.

They also looked at the data for five distinct age groups: less than 12 months, 12-23 months, 2-4 years, 5-8 years, and 9-18 years. Well visits were summarized separately from other provider visits because these may represent the greatest yield vaccination opportunity.

“With expansion of the traditional vaccination window, the largest percentage increase in the number of children with a provider visit is seen in children 5-18 years of age,” wrote Dr. Judelsohn, a professor of pediatrics at the University at Buffalo (N.Y.), and his colleagues. The percentage jumped from 27% between October and December to 46%-48% having a visit during either 6-month window.

“Overall, the proportion of children with existing visits decreases with increasing age,” they wrote. In all, 59% of children younger than 23 months had a visit between October and December, compared with 27% of children aged 5-18 years. Among children with a visit, the proportion with well child visits also decreases with increasing age.

“The early months of July, August, and September appear to be important for reaching school-aged children during well visits, with the biggest increase seen including August,” they noted.

Estimated Number of Children With at Least One Provider Visit (in millions) ELSEVIER GLOBAL MEDICAL NEWS

WASHINGTON — Expanding the traditional window for influenza vaccination would expand the number of vaccination opportunities by increasing the number of pediatric office visits, based on data for 77.6 million children from a national survey during the 2004-2005 flu season.

By expanding the vaccination window either 6 months earlier or 6 months later, the overall number of children between 0-18 years with at least one provider visit jumped from 11.1 million to 23.4 million (July through December) or to 18.2 (October through March), Dr. Richard G. Judelsohn reported in a poster at the jointly held annual Interscience Conference on Antimicrobial Agents and Chemotherapy and the annual meeting of the Infectious Diseases Society of America. MedImmune LLC, which makes Flumist nasal influenza vaccine, sponsored the study. Dr. Judelsohn's coauthors are employed by MedImmune.

In 2008, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices expanded its recommendation that all children aged 6 months to 18 years receive the seasonal flu vaccine each year. But many children do not visit a health care provider during the traditional flu vaccine window (Oct. 1-Dec. 31). The need for additional office visits for the vaccine could be a barrier to increasing flu vaccination.

The researchers used data from the Medical Expenditure Panel Survey, a federally funded survey of families, medical providers, and employers nationwide. Data from the 2004-2005 flu season was used to assess the number of children with existing medical provider office visits during specific monthly intervals. In particular, they identified the number of children with one or more provider visit for various intervals by adding 1, 2, or 3 months before or after the Oct. 1-Dec. 31 period.

They also looked at the data for five distinct age groups: less than 12 months, 12-23 months, 2-4 years, 5-8 years, and 9-18 years. Well visits were summarized separately from other provider visits because these may represent the greatest yield vaccination opportunity.

“With expansion of the traditional vaccination window, the largest percentage increase in the number of children with a provider visit is seen in children 5-18 years of age,” wrote Dr. Judelsohn, a professor of pediatrics at the University at Buffalo (N.Y.), and his colleagues. The percentage jumped from 27% between October and December to 46%-48% having a visit during either 6-month window.

“Overall, the proportion of children with existing visits decreases with increasing age,” they wrote. In all, 59% of children younger than 23 months had a visit between October and December, compared with 27% of children aged 5-18 years. Among children with a visit, the proportion with well child visits also decreases with increasing age.

“The early months of July, August, and September appear to be important for reaching school-aged children during well visits, with the biggest increase seen including August,” they noted.

Estimated Number of Children With at Least One Provider Visit (in millions) ELSEVIER GLOBAL MEDICAL NEWS

WASHINGTON — Expanding the traditional window for influenza vaccination would expand the number of vaccination opportunities by increasing the number of pediatric office visits, based on data for 77.6 million children from a national survey during the 2004-2005 flu season.

By expanding the vaccination window either 6 months earlier or 6 months later, the overall number of children between 0-18 years with at least one provider visit jumped from 11.1 million to 23.4 million (July through December) or to 18.2 (October through March), Dr. Richard G. Judelsohn reported in a poster at the jointly held annual Interscience Conference on Antimicrobial Agents and Chemotherapy and the annual meeting of the Infectious Diseases Society of America. MedImmune LLC, which makes Flumist nasal influenza vaccine, sponsored the study. Dr. Judelsohn's coauthors are employed by MedImmune.

In 2008, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices expanded its recommendation that all children aged 6 months to 18 years receive the seasonal flu vaccine each year. But many children do not visit a health care provider during the traditional flu vaccine window (Oct. 1-Dec. 31). The need for additional office visits for the vaccine could be a barrier to increasing flu vaccination.

The researchers used data from the Medical Expenditure Panel Survey, a federally funded survey of families, medical providers, and employers nationwide. Data from the 2004-2005 flu season was used to assess the number of children with existing medical provider office visits during specific monthly intervals. In particular, they identified the number of children with one or more provider visit for various intervals by adding 1, 2, or 3 months before or after the Oct. 1-Dec. 31 period.

They also looked at the data for five distinct age groups: less than 12 months, 12-23 months, 2-4 years, 5-8 years, and 9-18 years. Well visits were summarized separately from other provider visits because these may represent the greatest yield vaccination opportunity.

“With expansion of the traditional vaccination window, the largest percentage increase in the number of children with a provider visit is seen in children 5-18 years of age,” wrote Dr. Judelsohn, a professor of pediatrics at the University at Buffalo (N.Y.), and his colleagues. The percentage jumped from 27% between October and December to 46%-48% having a visit during either 6-month window.

“Overall, the proportion of children with existing visits decreases with increasing age,” they wrote. In all, 59% of children younger than 23 months had a visit between October and December, compared with 27% of children aged 5-18 years. Among children with a visit, the proportion with well child visits also decreases with increasing age.

“The early months of July, August, and September appear to be important for reaching school-aged children during well visits, with the biggest increase seen including August,” they noted.

Estimated Number of Children With at Least One Provider Visit (in millions) ELSEVIER GLOBAL MEDICAL NEWS