Michele G. Sullivan

An updated guideline for emergency cardiovascular care has changed the A-B-C mnemonic of cardiopulmonary resuscitation to C-A-B, emphasizing the need to start chest compressions as quickly as possible and worry about the airway second.

It’s the biggest – and most important – change in the 2010 update of the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, said coauthor Dr. Michael Sayre, chairman of the American Heart Association’s Emergency Cardiovascular Care (ECC) Committee.

“For more than 40 years, CPR training has emphasized the ABCs of CPR, which instructed people to open a victim’s airway by tilting their head back, pinching the nose and breathing into the victim’s mouth, and only then giving chest compressions,” Dr. Sayre said in a press statement. “This approach was causing significant delays in starting chest compressions, which are essential for keeping oxygen-rich blood circulating through the body. Changing the sequence from A-B-C to C-A-B for adults and children allows all rescuers to begin chest compressions right away.”

Any delay in chest compression, either by bystanders squeamish about mouth-to-mouth or clinicians searching for ventilation equipment, increases the risk of death, the statement noted. This change correlates with a British study published recently in Lancet, which found that nonprofessional rescuers are most effective when they use compression-only CPR (Lancet 2010 [doi:10.1016/S0140-6736(10)61454-7]).

The AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care were last updated in 2005, the authors said. Since then, a plethora of evidence has changed the clinical approach to emergency cardiovascular care. The committee, which included 356 resuscitation experts from 29 countries, produced 411 new evidence-based reviews, from which the updates were drawn.

The new recommendations also call for an increase in the rate of chest compressions, to at least 100/minute. “Rescuers should push deeper on the chest, compressing at least two inches in adults and children and 1.5 inches in infants,” the statement notes. “Between each compression, rescuers should avoid leaning on the chest to allow it to return to its starting position.”

The guidelines recommend the new C-A-B approach for adults, teens, and children who suddenly collapse and stop breathing, or display ineffective respiration during collapse. For neonates with no known cardiac etiology, however, the A-B-Cs remain in effect. Ventilation with room air is best for term babies in arrest; to avoid the negative impact of pure oxygen on newborns, the statement calls for a blend of room air and oxygen for infants who need supplemental oxygen. For these babies, the recommendation for a 3:1 chest compression-ventilation ratio remains in effect, because ventilation is critical to reversing neonatal asphyxia arrest.

Advanced Life Support. In addition to providing information for bystander rescue attempts, the guidelines suggest some changes in the way cardiac arrest and stroke patients are treated by emergency medical services, emergency room physicians, and those involved with postincident care.

In keeping with the new C-A-B format, the document urges EMS personnel to minimize interruptions in chest compression any longer than needed for rescue ventilation. Even taking time for pulse checks is no longer advised, since pulse is not an effective indicator of cardiac status when blood pressure is low or absent.

Electrical therapy should be employed as soon as possible after CPR begins, but CPR should not cease while readying the defibrillator, the guidelines say. “Rescuers should minimize the interval between stopping compressions and delivering shocks, and should resume CPR immediately after shock delivery.”

The statement recommends an initial biphasic energy dose of 120-200 joules for atrial fibrillation and 50-100 joules for atrial flutter or other supraventricular tachycardias. If the initial shock fails, providers should increase the dose in a stepwise fashion.

For patients with symptomatic arrhythmias, the updates now recommend adenosine for diagnosing and treating stable undifferentiated wide-complex tachycardia when the rhythm is regular and the QRS wave is monomorphic. For symptomatic or unstable bradycardia, intravenous chronotropic agents can be an effective alternative to external pacing if adenosine is ineffective.

The guidelines include a major new Class I recommendation for adult airway management: the use of quantitative waveform capnography for confirmation and monitoring endotracheal tube placement. Additionally, they no longer endorse the routine use of cricoid pressure during airway management.

After the Cardiac Arrest. The recommendations don’t stop when the patient regains spontaneous circulation. An entire section of the document is devoted to post–cardiac arrest care, pushing for an integrated, multidisciplinary approach. “Patients with suspected acute coronary syndrome should be triaged to a facility with reperfusion capabilities and a multidisciplinary team prepared to monitor patients for multi-organ dysfunction and initiate appropriate post–cardiac arrest therapy, including hypothermia.”

The guidelines deal with stroke separately, summarizing what should occur during out-of-hospital care through the first hours of therapy. One new recommendation is that acute stroke patients be triaged to a stroke center or dedicated stroke unit within 3 hours of presentation. The guidelines also expand the time window for administration of recombinant tissue plasminogen activator, and recommend it also be used in patients with acute ischemic stroke.

Many of the 33 writing members of the guidelines committee disclosed financial relationships, which are listed on the last page of the executive summary (Circulation 2010;122:S640-56).

An updated guideline for emergency cardiovascular care has changed the A-B-C mnemonic of cardiopulmonary resuscitation to C-A-B, emphasizing the need to start chest compressions as quickly as possible and worry about the airway second.

It’s the biggest – and most important – change in the 2010 update of the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, said coauthor Dr. Michael Sayre, chairman of the American Heart Association’s Emergency Cardiovascular Care (ECC) Committee.

“For more than 40 years, CPR training has emphasized the ABCs of CPR, which instructed people to open a victim’s airway by tilting their head back, pinching the nose and breathing into the victim’s mouth, and only then giving chest compressions,” Dr. Sayre said in a press statement. “This approach was causing significant delays in starting chest compressions, which are essential for keeping oxygen-rich blood circulating through the body. Changing the sequence from A-B-C to C-A-B for adults and children allows all rescuers to begin chest compressions right away.”

Any delay in chest compression, either by bystanders squeamish about mouth-to-mouth or clinicians searching for ventilation equipment, increases the risk of death, the statement noted. This change correlates with a British study published recently in Lancet, which found that nonprofessional rescuers are most effective when they use compression-only CPR (Lancet 2010 [doi:10.1016/S0140-6736(10)61454-7]).

The AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care were last updated in 2005, the authors said. Since then, a plethora of evidence has changed the clinical approach to emergency cardiovascular care. The committee, which included 356 resuscitation experts from 29 countries, produced 411 new evidence-based reviews, from which the updates were drawn.

The new recommendations also call for an increase in the rate of chest compressions, to at least 100/minute. “Rescuers should push deeper on the chest, compressing at least two inches in adults and children and 1.5 inches in infants,” the statement notes. “Between each compression, rescuers should avoid leaning on the chest to allow it to return to its starting position.”

The guidelines recommend the new C-A-B approach for adults, teens, and children who suddenly collapse and stop breathing, or display ineffective respiration during collapse. For neonates with no known cardiac etiology, however, the A-B-Cs remain in effect. Ventilation with room air is best for term babies in arrest; to avoid the negative impact of pure oxygen on newborns, the statement calls for a blend of room air and oxygen for infants who need supplemental oxygen. For these babies, the recommendation for a 3:1 chest compression-ventilation ratio remains in effect, because ventilation is critical to reversing neonatal asphyxia arrest.

Advanced Life Support. In addition to providing information for bystander rescue attempts, the guidelines suggest some changes in the way cardiac arrest and stroke patients are treated by emergency medical services, emergency room physicians, and those involved with postincident care.

In keeping with the new C-A-B format, the document urges EMS personnel to minimize interruptions in chest compression any longer than needed for rescue ventilation. Even taking time for pulse checks is no longer advised, since pulse is not an effective indicator of cardiac status when blood pressure is low or absent.

Electrical therapy should be employed as soon as possible after CPR begins, but CPR should not cease while readying the defibrillator, the guidelines say. “Rescuers should minimize the interval between stopping compressions and delivering shocks, and should resume CPR immediately after shock delivery.”

The statement recommends an initial biphasic energy dose of 120-200 joules for atrial fibrillation and 50-100 joules for atrial flutter or other supraventricular tachycardias. If the initial shock fails, providers should increase the dose in a stepwise fashion.

For patients with symptomatic arrhythmias, the updates now recommend adenosine for diagnosing and treating stable undifferentiated wide-complex tachycardia when the rhythm is regular and the QRS wave is monomorphic. For symptomatic or unstable bradycardia, intravenous chronotropic agents can be an effective alternative to external pacing if adenosine is ineffective.

The guidelines include a major new Class I recommendation for adult airway management: the use of quantitative waveform capnography for confirmation and monitoring endotracheal tube placement. Additionally, they no longer endorse the routine use of cricoid pressure during airway management.

After the Cardiac Arrest. The recommendations don’t stop when the patient regains spontaneous circulation. An entire section of the document is devoted to post–cardiac arrest care, pushing for an integrated, multidisciplinary approach. “Patients with suspected acute coronary syndrome should be triaged to a facility with reperfusion capabilities and a multidisciplinary team prepared to monitor patients for multi-organ dysfunction and initiate appropriate post–cardiac arrest therapy, including hypothermia.”

The guidelines deal with stroke separately, summarizing what should occur during out-of-hospital care through the first hours of therapy. One new recommendation is that acute stroke patients be triaged to a stroke center or dedicated stroke unit within 3 hours of presentation. The guidelines also expand the time window for administration of recombinant tissue plasminogen activator, and recommend it also be used in patients with acute ischemic stroke.

Many of the 33 writing members of the guidelines committee disclosed financial relationships, which are listed on the last page of the executive summary (Circulation 2010;122:S640-56).

An updated guideline for emergency cardiovascular care has changed the A-B-C mnemonic of cardiopulmonary resuscitation to C-A-B, emphasizing the need to start chest compressions as quickly as possible and worry about the airway second.

It’s the biggest – and most important – change in the 2010 update of the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, said coauthor Dr. Michael Sayre, chairman of the American Heart Association’s Emergency Cardiovascular Care (ECC) Committee.

“For more than 40 years, CPR training has emphasized the ABCs of CPR, which instructed people to open a victim’s airway by tilting their head back, pinching the nose and breathing into the victim’s mouth, and only then giving chest compressions,” Dr. Sayre said in a press statement. “This approach was causing significant delays in starting chest compressions, which are essential for keeping oxygen-rich blood circulating through the body. Changing the sequence from A-B-C to C-A-B for adults and children allows all rescuers to begin chest compressions right away.”

Any delay in chest compression, either by bystanders squeamish about mouth-to-mouth or clinicians searching for ventilation equipment, increases the risk of death, the statement noted. This change correlates with a British study published recently in Lancet, which found that nonprofessional rescuers are most effective when they use compression-only CPR (Lancet 2010 [doi:10.1016/S0140-6736(10)61454-7]).

The AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care were last updated in 2005, the authors said. Since then, a plethora of evidence has changed the clinical approach to emergency cardiovascular care. The committee, which included 356 resuscitation experts from 29 countries, produced 411 new evidence-based reviews, from which the updates were drawn.

The new recommendations also call for an increase in the rate of chest compressions, to at least 100/minute. “Rescuers should push deeper on the chest, compressing at least two inches in adults and children and 1.5 inches in infants,” the statement notes. “Between each compression, rescuers should avoid leaning on the chest to allow it to return to its starting position.”

The guidelines recommend the new C-A-B approach for adults, teens, and children who suddenly collapse and stop breathing, or display ineffective respiration during collapse. For neonates with no known cardiac etiology, however, the A-B-Cs remain in effect. Ventilation with room air is best for term babies in arrest; to avoid the negative impact of pure oxygen on newborns, the statement calls for a blend of room air and oxygen for infants who need supplemental oxygen. For these babies, the recommendation for a 3:1 chest compression-ventilation ratio remains in effect, because ventilation is critical to reversing neonatal asphyxia arrest.

Advanced Life Support. In addition to providing information for bystander rescue attempts, the guidelines suggest some changes in the way cardiac arrest and stroke patients are treated by emergency medical services, emergency room physicians, and those involved with postincident care.

In keeping with the new C-A-B format, the document urges EMS personnel to minimize interruptions in chest compression any longer than needed for rescue ventilation. Even taking time for pulse checks is no longer advised, since pulse is not an effective indicator of cardiac status when blood pressure is low or absent.

Electrical therapy should be employed as soon as possible after CPR begins, but CPR should not cease while readying the defibrillator, the guidelines say. “Rescuers should minimize the interval between stopping compressions and delivering shocks, and should resume CPR immediately after shock delivery.”

The statement recommends an initial biphasic energy dose of 120-200 joules for atrial fibrillation and 50-100 joules for atrial flutter or other supraventricular tachycardias. If the initial shock fails, providers should increase the dose in a stepwise fashion.

For patients with symptomatic arrhythmias, the updates now recommend adenosine for diagnosing and treating stable undifferentiated wide-complex tachycardia when the rhythm is regular and the QRS wave is monomorphic. For symptomatic or unstable bradycardia, intravenous chronotropic agents can be an effective alternative to external pacing if adenosine is ineffective.

The guidelines include a major new Class I recommendation for adult airway management: the use of quantitative waveform capnography for confirmation and monitoring endotracheal tube placement. Additionally, they no longer endorse the routine use of cricoid pressure during airway management.

After the Cardiac Arrest. The recommendations don’t stop when the patient regains spontaneous circulation. An entire section of the document is devoted to post–cardiac arrest care, pushing for an integrated, multidisciplinary approach. “Patients with suspected acute coronary syndrome should be triaged to a facility with reperfusion capabilities and a multidisciplinary team prepared to monitor patients for multi-organ dysfunction and initiate appropriate post–cardiac arrest therapy, including hypothermia.”

The guidelines deal with stroke separately, summarizing what should occur during out-of-hospital care through the first hours of therapy. One new recommendation is that acute stroke patients be triaged to a stroke center or dedicated stroke unit within 3 hours of presentation. The guidelines also expand the time window for administration of recombinant tissue plasminogen activator, and recommend it also be used in patients with acute ischemic stroke.

Many of the 33 writing members of the guidelines committee disclosed financial relationships, which are listed on the last page of the executive summary (Circulation 2010;122:S640-56).

PARIS – Vascular invasion is highly predictive of long-term survival in thyroid cancer, and its presence or absence should be considered when determining a patient’s postsurgical follow-up plan, an investigator concluded from long-term follow-up of 725 patients.

Vascular invasion was present in 30% of the entire patient cohort. Their survival rates at 5, 10, and 20 years were significantly worse than the rates seen among those patients without vascular invasion (89% vs. 98%; 75% vs. 96%; and 70% vs. 92%, respectively).

“This is a very important prognostic factor for both follicular and papillary thyroid cancer,” Dr. Francoise Bonichon said at the International Thyroid Congress.

“If vascular invasion is present, the risk of thyroid cancer–related death is higher, and we classify the patient as ‘intermediate risk,’ with radioiodine ablation, suppression of thyroid-stimulating hormone, and follow-up every year that includes thyroglobulin and ultrasound,” she reported.

“If, on the other hand, there is no vascular invasion, we classify the patient as ‘low risk,’ except if there is another poor prognostic factor. This patient does not receive radioiodine ablation, and we keep the TSH normal.”

Dr. Bonichon of the Institut Bergoni? in Bordeaux presented the long-term follow-up data on patients treated at the hospital from 1960 to 2008. All had histologically confirmed nonmetastatic thyroid cancer with a tumor size of more than 1 cm. Most of the tumors (594) were papillary. Follicular thyroid cancer was confirmed in 128 patients; the remainder had poorly differentiated thyroid tumors.

Most of the patients (75%) were women; their mean age at diagnosis was 48 years. The median follow-up period was 12 years. About a quarter (22%) had already been exposed to neck radiation, most of them for Hodgkin’s disease.

For the analysis, Dr. Bonichon and her colleagues described vascular invasion as a cluster of tumor cells attached to the wall or protruding into the lumen of a vessel located at the periphery of the tumor, within or immediately outside the tumor capsule.

At the last follow-up, 70% of the cohort was alive with no evidence of thyroid cancer, 3% were alive with thyroid cancer, and 10% were dead from thyroid cancer. Another 2% were alive with other cancers, and 3% were dead from other cancers. In addition, 4% were alive with no information on health status, 7% had died from other problems, and 1% was lost to follow-up.

At 5 years, the overall survival rate was 92%; at 10 years, it was 83%. Those with papillary thyroid cancer had the best cancer-specific survival rates at 5, 10, and 20 years (98%, 95%, and 90%, respectively). Follicular cancer followed (95%, 85%, and 67%, respectively). Poorly differentiated cancers had the lowest survival rates (70%, 65%, and 40%, respectively).

“In our multivariate analysis, vascular invasion was as significant a risk factor for poor prognosis as age older than 45 years, tumor size more than 4 cm, and nodal status,” Dr. Bonichon said. “Vascular invasion is a simple, inexpensive factor that we can use in conjunction with age and other postoperative staging factors to tailor our decisions about radioiodine ablation, TSH suppression, and follow-up intensity.”

Dr. Bonichon had no potential conflicts of interest.

PARIS – Vascular invasion is highly predictive of long-term survival in thyroid cancer, and its presence or absence should be considered when determining a patient’s postsurgical follow-up plan, an investigator concluded from long-term follow-up of 725 patients.

Vascular invasion was present in 30% of the entire patient cohort. Their survival rates at 5, 10, and 20 years were significantly worse than the rates seen among those patients without vascular invasion (89% vs. 98%; 75% vs. 96%; and 70% vs. 92%, respectively).

“This is a very important prognostic factor for both follicular and papillary thyroid cancer,” Dr. Francoise Bonichon said at the International Thyroid Congress.

“If vascular invasion is present, the risk of thyroid cancer–related death is higher, and we classify the patient as ‘intermediate risk,’ with radioiodine ablation, suppression of thyroid-stimulating hormone, and follow-up every year that includes thyroglobulin and ultrasound,” she reported.

“If, on the other hand, there is no vascular invasion, we classify the patient as ‘low risk,’ except if there is another poor prognostic factor. This patient does not receive radioiodine ablation, and we keep the TSH normal.”

Dr. Bonichon of the Institut Bergoni? in Bordeaux presented the long-term follow-up data on patients treated at the hospital from 1960 to 2008. All had histologically confirmed nonmetastatic thyroid cancer with a tumor size of more than 1 cm. Most of the tumors (594) were papillary. Follicular thyroid cancer was confirmed in 128 patients; the remainder had poorly differentiated thyroid tumors.

Most of the patients (75%) were women; their mean age at diagnosis was 48 years. The median follow-up period was 12 years. About a quarter (22%) had already been exposed to neck radiation, most of them for Hodgkin’s disease.

For the analysis, Dr. Bonichon and her colleagues described vascular invasion as a cluster of tumor cells attached to the wall or protruding into the lumen of a vessel located at the periphery of the tumor, within or immediately outside the tumor capsule.

At the last follow-up, 70% of the cohort was alive with no evidence of thyroid cancer, 3% were alive with thyroid cancer, and 10% were dead from thyroid cancer. Another 2% were alive with other cancers, and 3% were dead from other cancers. In addition, 4% were alive with no information on health status, 7% had died from other problems, and 1% was lost to follow-up.

At 5 years, the overall survival rate was 92%; at 10 years, it was 83%. Those with papillary thyroid cancer had the best cancer-specific survival rates at 5, 10, and 20 years (98%, 95%, and 90%, respectively). Follicular cancer followed (95%, 85%, and 67%, respectively). Poorly differentiated cancers had the lowest survival rates (70%, 65%, and 40%, respectively).

“In our multivariate analysis, vascular invasion was as significant a risk factor for poor prognosis as age older than 45 years, tumor size more than 4 cm, and nodal status,” Dr. Bonichon said. “Vascular invasion is a simple, inexpensive factor that we can use in conjunction with age and other postoperative staging factors to tailor our decisions about radioiodine ablation, TSH suppression, and follow-up intensity.”

Dr. Bonichon had no potential conflicts of interest.

PARIS – Vascular invasion is highly predictive of long-term survival in thyroid cancer, and its presence or absence should be considered when determining a patient’s postsurgical follow-up plan, an investigator concluded from long-term follow-up of 725 patients.

Vascular invasion was present in 30% of the entire patient cohort. Their survival rates at 5, 10, and 20 years were significantly worse than the rates seen among those patients without vascular invasion (89% vs. 98%; 75% vs. 96%; and 70% vs. 92%, respectively).

“This is a very important prognostic factor for both follicular and papillary thyroid cancer,” Dr. Francoise Bonichon said at the International Thyroid Congress.

“If vascular invasion is present, the risk of thyroid cancer–related death is higher, and we classify the patient as ‘intermediate risk,’ with radioiodine ablation, suppression of thyroid-stimulating hormone, and follow-up every year that includes thyroglobulin and ultrasound,” she reported.

“If, on the other hand, there is no vascular invasion, we classify the patient as ‘low risk,’ except if there is another poor prognostic factor. This patient does not receive radioiodine ablation, and we keep the TSH normal.”

Dr. Bonichon of the Institut Bergoni? in Bordeaux presented the long-term follow-up data on patients treated at the hospital from 1960 to 2008. All had histologically confirmed nonmetastatic thyroid cancer with a tumor size of more than 1 cm. Most of the tumors (594) were papillary. Follicular thyroid cancer was confirmed in 128 patients; the remainder had poorly differentiated thyroid tumors.

Most of the patients (75%) were women; their mean age at diagnosis was 48 years. The median follow-up period was 12 years. About a quarter (22%) had already been exposed to neck radiation, most of them for Hodgkin’s disease.

For the analysis, Dr. Bonichon and her colleagues described vascular invasion as a cluster of tumor cells attached to the wall or protruding into the lumen of a vessel located at the periphery of the tumor, within or immediately outside the tumor capsule.

At the last follow-up, 70% of the cohort was alive with no evidence of thyroid cancer, 3% were alive with thyroid cancer, and 10% were dead from thyroid cancer. Another 2% were alive with other cancers, and 3% were dead from other cancers. In addition, 4% were alive with no information on health status, 7% had died from other problems, and 1% was lost to follow-up.

At 5 years, the overall survival rate was 92%; at 10 years, it was 83%. Those with papillary thyroid cancer had the best cancer-specific survival rates at 5, 10, and 20 years (98%, 95%, and 90%, respectively). Follicular cancer followed (95%, 85%, and 67%, respectively). Poorly differentiated cancers had the lowest survival rates (70%, 65%, and 40%, respectively).

“In our multivariate analysis, vascular invasion was as significant a risk factor for poor prognosis as age older than 45 years, tumor size more than 4 cm, and nodal status,” Dr. Bonichon said. “Vascular invasion is a simple, inexpensive factor that we can use in conjunction with age and other postoperative staging factors to tailor our decisions about radioiodine ablation, TSH suppression, and follow-up intensity.”

Dr. Bonichon had no potential conflicts of interest.

CHICAGO – In the not-too-distant future, dermatologists may be sending patients to the beach with a bagful of chemoprevention tricks to outwit ultraviolet radiation and reduce the risk of sun-related skin cancers.

“In addition to sunscreen, we'll be using these chemopreventive agents not only to reduce histologic response to ultraviolet light, but to repair the DNA damage that occurs as a result of overexposure to the sun,” said Dr. Craig Elmets. “Instead of sending patients to the beach covered up with long pants, long sleeves, and a hat, we can send them off to engage in their normal behavior with less worry about the long-term consequences.”

Sunscreens remain the first line of defense against cancer-inducing ultraviolet radiation, but they need backup, said Dr. Elmets, professor and chair of the department of dermatology and director of the Skin Disease Research Center at the University of Alabama, Birmingham. “They are greasy and messy, and people don't really enjoy applying them. And most people don't use nearly enough to achieve the sun protection factor stated on the label; in fact, studies show that most people only use about 25% of the necessary amount.” Sunscreens also have limited effect, he said. “Over a 5-year period, sunscreens will reduce squamous cell carcinomas by about 35%, but they have very little effect on basal cell carcinoma.”

A number of agents being investigated for the chemoprevention of skin cancers have shown promising results in both animal and human studies.

Dimericine is a form of the bacterial enzyme T4 endonuclease. When encapsulated in a liposome and applied topically, the compound appears to boost the body's DNA repair response by increasing base excision repair, Dr. Elmets said.

A 2001 study allocated 30 patients with xeroderma pigmentosum to dimericine or placebo for 1 year, in addition to sunscreen. Patients in the active group had a 68% reduction in actinic keratoses and a 30% reduction in basal cell carcinoma (Lancet 2001;24:926-9).

Dr. Elmets is the lead investigator in one of two ongoing dimericine trials. The first is a phase II study randomizing kidney transplant patients with nonmelanoma skin cancer to the drug or placebo for 12 months, with an outcome of new nonmelanoma skin cancers. The second, a phase III study, aimsino recruit up to 30 patients with xeroderma pigmentosum who will be allocated to dimericine or placebo, with the primary end point of new actinic keratoses.

“Another exciting molecule that may have good chemopreventive potential is GDC-0449,” Dr. Elmets said. The compound is a systemic hedgehog pathway antagonist. “The hedgehog pathway is an important regulator of cell growth and differentiation during embryogenesis. But mutations are associated with basal cell carcinomas in both children and adults,” he said. Animal research has shown that inhibiting this pathway can reduce tumor growth.

In a study ofi33 patients with metastatic or locally advanced basal cell carcinoma who took the drug at different doses,. 18Eachieved a response; 2 were complete and 16 were partial. Disease stabilized in 15 patients and progressed in 4 (N. Engl. J. Med. 2009;361:1164-72).

Twenty-four trials, in progress or recruiting, focus on GDC-0449's safety and efficacy in a variety of cancers, including basal cell nevus syndrome, and pancreatic, gastrointestinal, lung, breast, and brain cancers.

DMFO (alpha-difluoromethylornithine, also known as eflornithine) irreversibly inhibits ornithine decarboxylase, an enzyme unregulated in many tumors. In a recent phase III trial of 219 patients with a history of nonmelanoma skin cancer, there was no significant difference in the total numbers of nonmelanoma skin cancers between the active and placebo group after 4-5 years of follow-up (more than 1,200 person-years). But new basal cell carcinomas were 33% less common in the active group than in the placebo group (Cancer Prev. Res. 2010;3:35-47).

There are 20 active or completed trials looking at this agent in relation to several cancers, including bladder, GI, neuroblastoma, and trypanosomosis.

The cyclooxygenase-2 inhibitor celecoxib is also in the skin cancer race. “COX-2 is dramatically upregulated in actinic keratoses and squamous cell carcinomas, and also in the interstitial space around basal carcinoma tumor islands,” Dr. Elmets said. “When given orally, it inhibits COX-2 expression, reducing the prostaglandin E2 production implicated in skin cancers.”

A recent study of 60 patients with basal cell nevus syndrome treated with celecoxib found that those with less severe disease had a 20% increase in the number of basal cell carcinomas over 24 months, compared with a 50% increase in those taking placebo (Cancer Prev. Res. 2010;3:25-34).

Finally, Dr. Elmets said, an ancient and familiar drink holds intriguing possibilities. The primary catechin in green tea, EGCG, (epigallocatechin-3-gallate) is a potent antioxidant that appears to reduce histologic and clinical damage from exposure to ultraviolet lights A and B. “When ECGC is applied topically or given to animals to drink in their water, they show a dramatic reduction in new skin cancers. In humans, it reduces UVA and UVB erythema,” he said.

Dr. Elmets disclosed that he has received research support from Pfizer Inc. and holds an intellectual property right on the use of EGCG as a skin cancer chemopreventive agent.

CHICAGO – In the not-too-distant future, dermatologists may be sending patients to the beach with a bagful of chemoprevention tricks to outwit ultraviolet radiation and reduce the risk of sun-related skin cancers.

“In addition to sunscreen, we'll be using these chemopreventive agents not only to reduce histologic response to ultraviolet light, but to repair the DNA damage that occurs as a result of overexposure to the sun,” said Dr. Craig Elmets. “Instead of sending patients to the beach covered up with long pants, long sleeves, and a hat, we can send them off to engage in their normal behavior with less worry about the long-term consequences.”

Sunscreens remain the first line of defense against cancer-inducing ultraviolet radiation, but they need backup, said Dr. Elmets, professor and chair of the department of dermatology and director of the Skin Disease Research Center at the University of Alabama, Birmingham. “They are greasy and messy, and people don't really enjoy applying them. And most people don't use nearly enough to achieve the sun protection factor stated on the label; in fact, studies show that most people only use about 25% of the necessary amount.” Sunscreens also have limited effect, he said. “Over a 5-year period, sunscreens will reduce squamous cell carcinomas by about 35%, but they have very little effect on basal cell carcinoma.”

A number of agents being investigated for the chemoprevention of skin cancers have shown promising results in both animal and human studies.

Dimericine is a form of the bacterial enzyme T4 endonuclease. When encapsulated in a liposome and applied topically, the compound appears to boost the body's DNA repair response by increasing base excision repair, Dr. Elmets said.

A 2001 study allocated 30 patients with xeroderma pigmentosum to dimericine or placebo for 1 year, in addition to sunscreen. Patients in the active group had a 68% reduction in actinic keratoses and a 30% reduction in basal cell carcinoma (Lancet 2001;24:926-9).

Dr. Elmets is the lead investigator in one of two ongoing dimericine trials. The first is a phase II study randomizing kidney transplant patients with nonmelanoma skin cancer to the drug or placebo for 12 months, with an outcome of new nonmelanoma skin cancers. The second, a phase III study, aimsino recruit up to 30 patients with xeroderma pigmentosum who will be allocated to dimericine or placebo, with the primary end point of new actinic keratoses.

“Another exciting molecule that may have good chemopreventive potential is GDC-0449,” Dr. Elmets said. The compound is a systemic hedgehog pathway antagonist. “The hedgehog pathway is an important regulator of cell growth and differentiation during embryogenesis. But mutations are associated with basal cell carcinomas in both children and adults,” he said. Animal research has shown that inhibiting this pathway can reduce tumor growth.

In a study ofi33 patients with metastatic or locally advanced basal cell carcinoma who took the drug at different doses,. 18Eachieved a response; 2 were complete and 16 were partial. Disease stabilized in 15 patients and progressed in 4 (N. Engl. J. Med. 2009;361:1164-72).

Twenty-four trials, in progress or recruiting, focus on GDC-0449's safety and efficacy in a variety of cancers, including basal cell nevus syndrome, and pancreatic, gastrointestinal, lung, breast, and brain cancers.

DMFO (alpha-difluoromethylornithine, also known as eflornithine) irreversibly inhibits ornithine decarboxylase, an enzyme unregulated in many tumors. In a recent phase III trial of 219 patients with a history of nonmelanoma skin cancer, there was no significant difference in the total numbers of nonmelanoma skin cancers between the active and placebo group after 4-5 years of follow-up (more than 1,200 person-years). But new basal cell carcinomas were 33% less common in the active group than in the placebo group (Cancer Prev. Res. 2010;3:35-47).

There are 20 active or completed trials looking at this agent in relation to several cancers, including bladder, GI, neuroblastoma, and trypanosomosis.

The cyclooxygenase-2 inhibitor celecoxib is also in the skin cancer race. “COX-2 is dramatically upregulated in actinic keratoses and squamous cell carcinomas, and also in the interstitial space around basal carcinoma tumor islands,” Dr. Elmets said. “When given orally, it inhibits COX-2 expression, reducing the prostaglandin E2 production implicated in skin cancers.”

A recent study of 60 patients with basal cell nevus syndrome treated with celecoxib found that those with less severe disease had a 20% increase in the number of basal cell carcinomas over 24 months, compared with a 50% increase in those taking placebo (Cancer Prev. Res. 2010;3:25-34).

Finally, Dr. Elmets said, an ancient and familiar drink holds intriguing possibilities. The primary catechin in green tea, EGCG, (epigallocatechin-3-gallate) is a potent antioxidant that appears to reduce histologic and clinical damage from exposure to ultraviolet lights A and B. “When ECGC is applied topically or given to animals to drink in their water, they show a dramatic reduction in new skin cancers. In humans, it reduces UVA and UVB erythema,” he said.

Dr. Elmets disclosed that he has received research support from Pfizer Inc. and holds an intellectual property right on the use of EGCG as a skin cancer chemopreventive agent.

CHICAGO – In the not-too-distant future, dermatologists may be sending patients to the beach with a bagful of chemoprevention tricks to outwit ultraviolet radiation and reduce the risk of sun-related skin cancers.

“In addition to sunscreen, we'll be using these chemopreventive agents not only to reduce histologic response to ultraviolet light, but to repair the DNA damage that occurs as a result of overexposure to the sun,” said Dr. Craig Elmets. “Instead of sending patients to the beach covered up with long pants, long sleeves, and a hat, we can send them off to engage in their normal behavior with less worry about the long-term consequences.”

Sunscreens remain the first line of defense against cancer-inducing ultraviolet radiation, but they need backup, said Dr. Elmets, professor and chair of the department of dermatology and director of the Skin Disease Research Center at the University of Alabama, Birmingham. “They are greasy and messy, and people don't really enjoy applying them. And most people don't use nearly enough to achieve the sun protection factor stated on the label; in fact, studies show that most people only use about 25% of the necessary amount.” Sunscreens also have limited effect, he said. “Over a 5-year period, sunscreens will reduce squamous cell carcinomas by about 35%, but they have very little effect on basal cell carcinoma.”

A number of agents being investigated for the chemoprevention of skin cancers have shown promising results in both animal and human studies.

Dimericine is a form of the bacterial enzyme T4 endonuclease. When encapsulated in a liposome and applied topically, the compound appears to boost the body's DNA repair response by increasing base excision repair, Dr. Elmets said.

A 2001 study allocated 30 patients with xeroderma pigmentosum to dimericine or placebo for 1 year, in addition to sunscreen. Patients in the active group had a 68% reduction in actinic keratoses and a 30% reduction in basal cell carcinoma (Lancet 2001;24:926-9).

Dr. Elmets is the lead investigator in one of two ongoing dimericine trials. The first is a phase II study randomizing kidney transplant patients with nonmelanoma skin cancer to the drug or placebo for 12 months, with an outcome of new nonmelanoma skin cancers. The second, a phase III study, aimsino recruit up to 30 patients with xeroderma pigmentosum who will be allocated to dimericine or placebo, with the primary end point of new actinic keratoses.

“Another exciting molecule that may have good chemopreventive potential is GDC-0449,” Dr. Elmets said. The compound is a systemic hedgehog pathway antagonist. “The hedgehog pathway is an important regulator of cell growth and differentiation during embryogenesis. But mutations are associated with basal cell carcinomas in both children and adults,” he said. Animal research has shown that inhibiting this pathway can reduce tumor growth.

In a study ofi33 patients with metastatic or locally advanced basal cell carcinoma who took the drug at different doses,. 18Eachieved a response; 2 were complete and 16 were partial. Disease stabilized in 15 patients and progressed in 4 (N. Engl. J. Med. 2009;361:1164-72).

Twenty-four trials, in progress or recruiting, focus on GDC-0449's safety and efficacy in a variety of cancers, including basal cell nevus syndrome, and pancreatic, gastrointestinal, lung, breast, and brain cancers.

DMFO (alpha-difluoromethylornithine, also known as eflornithine) irreversibly inhibits ornithine decarboxylase, an enzyme unregulated in many tumors. In a recent phase III trial of 219 patients with a history of nonmelanoma skin cancer, there was no significant difference in the total numbers of nonmelanoma skin cancers between the active and placebo group after 4-5 years of follow-up (more than 1,200 person-years). But new basal cell carcinomas were 33% less common in the active group than in the placebo group (Cancer Prev. Res. 2010;3:35-47).

There are 20 active or completed trials looking at this agent in relation to several cancers, including bladder, GI, neuroblastoma, and trypanosomosis.

The cyclooxygenase-2 inhibitor celecoxib is also in the skin cancer race. “COX-2 is dramatically upregulated in actinic keratoses and squamous cell carcinomas, and also in the interstitial space around basal carcinoma tumor islands,” Dr. Elmets said. “When given orally, it inhibits COX-2 expression, reducing the prostaglandin E2 production implicated in skin cancers.”

A recent study of 60 patients with basal cell nevus syndrome treated with celecoxib found that those with less severe disease had a 20% increase in the number of basal cell carcinomas over 24 months, compared with a 50% increase in those taking placebo (Cancer Prev. Res. 2010;3:25-34).

Finally, Dr. Elmets said, an ancient and familiar drink holds intriguing possibilities. The primary catechin in green tea, EGCG, (epigallocatechin-3-gallate) is a potent antioxidant that appears to reduce histologic and clinical damage from exposure to ultraviolet lights A and B. “When ECGC is applied topically or given to animals to drink in their water, they show a dramatic reduction in new skin cancers. In humans, it reduces UVA and UVB erythema,” he said.

Dr. Elmets disclosed that he has received research support from Pfizer Inc. and holds an intellectual property right on the use of EGCG as a skin cancer chemopreventive agent.

CHICAGO – Patient education is just as important as clinical therapy when treating acne in skin of color.

Even the best acne treatments can cause post-inflammatory hyperpigmentation in dark skin, Dr. Heather Woolery-Lloyd said.

“I always tell patients that these medications can be a little irritating and if you feel too dry or irritated, go to every other day or discontinue its use and try something else, because they can develop hyperpigmentation if the irritation continues,” said Dr. Woolery-Lloyd, director of ethnic skin care at the Baumann Cosmetic and Research Institute, Miami.

Black patients have about a 29% incidence of acne – a very common cause of hyperpigmentation. “The hyperpigmented acne macule is very common,” she said. “But, in black skin, comedonal lesions also show significant histologic signs of inflammation. So, if you are treating acne in skin of color, you're also going to be treating hyperpigmentation.”

Because of this tendency, physicians should help patients understand the potential risks, as well as the benefits, of acne therapies. For example, she said, “About 5% of the population is sensitive to benzoyl peroxide. Black patients who are sensitive can develop an irritation that results in hyperpigmentation.”

Retinoids can cause the same problem. “Some [physicans] avoid retinoids in dark skin, but I don't. I educate my patients; they should decrease the frequency of use to three times a week if irritation develops. If they do have hyperpigmentation associated with retinoids, it's going to come on very suddenly but also it typically resolves after the agent is discontinued.”

Tretinoin and tazarotene are the most likely culprits, she said; adapalene is less likely to cause hyperpigmentation.

Minocycline can also cause an overall darkening of the skin. “I recently saw a patient with darkening of the lips, and have also seen reports of darkening of scars and lesions of the legs,” Dr. Woolery-Lloyd said. “For this reason, I don't use minocycline as my first line of antibiotic therapy.”

If you treat a lot of acne in skin of color, you'll also use a lot of hydroquinone, for dealing with post-inflammatory hyperpigmentation, she said. The drug is available in 2% strength over the counter, 4% prescription strength and can be compounded at strengths of 6%–8%. “In my practice I use the 6%–8%. It's very important to instruct the patient to apply it only to the affected area and to avoid long-term use. I don't go longer than 2 months, and then I maintain results with a different therapy.”

Some patients – particularly blacks from South Africa – can develop ochronosis, a paradoxical darkening of skin associated with long-term hydroquinone use, she said. “It always starts with erythema, so again, tell your patients to discontinue if they have any irritation.” After erythema, ochronosis manifests blue-black patches that can contain milia, papules, and nodules. “Histologically, you see a classic banana-shaped, ocher-colored pigment in the dermis, which can be surrounded by a granulomatous response.”

Although 60% of her patients are black, Dr. Woolery-Lloyd said she only sees one or two cases of ochronosis each year. “It's typically seen in patients who have been using over-the-counter hydroquinone every day for 20-30 years, without sunscreen,” she said. “You have to emphasize to them to stop using it immediately.”

A small subset of patients will have an allergic reaction when using hydroquinone – typically to the sodium meta-bisulfite preservative in the cream. “If they continue use, the irritation can cause a very severe hyperpigmentation,” she added.

A tip for applying hydroquinone is to carefully treat only the hyperpigmented area – and not by applying the cream with a fingertip. If rubbed around, the cream can cause a halo-type affect of circular lightening. “I tell [patients] to use just a small amount and apply it with a cotton swab right on the lesion. And if they apply their retinoid over top of that, it will help to disperse it.”

Dr. Woolery-Lloyd has received research funding and honoraria from Allergen, which manufactures tazarotene, and is on the advisory board and has received honoraria from Galderma, which manufactures adapalene.

CHICAGO – Patient education is just as important as clinical therapy when treating acne in skin of color.

Even the best acne treatments can cause post-inflammatory hyperpigmentation in dark skin, Dr. Heather Woolery-Lloyd said.

“I always tell patients that these medications can be a little irritating and if you feel too dry or irritated, go to every other day or discontinue its use and try something else, because they can develop hyperpigmentation if the irritation continues,” said Dr. Woolery-Lloyd, director of ethnic skin care at the Baumann Cosmetic and Research Institute, Miami.

Black patients have about a 29% incidence of acne – a very common cause of hyperpigmentation. “The hyperpigmented acne macule is very common,” she said. “But, in black skin, comedonal lesions also show significant histologic signs of inflammation. So, if you are treating acne in skin of color, you're also going to be treating hyperpigmentation.”

Because of this tendency, physicians should help patients understand the potential risks, as well as the benefits, of acne therapies. For example, she said, “About 5% of the population is sensitive to benzoyl peroxide. Black patients who are sensitive can develop an irritation that results in hyperpigmentation.”

Retinoids can cause the same problem. “Some [physicans] avoid retinoids in dark skin, but I don't. I educate my patients; they should decrease the frequency of use to three times a week if irritation develops. If they do have hyperpigmentation associated with retinoids, it's going to come on very suddenly but also it typically resolves after the agent is discontinued.”

Tretinoin and tazarotene are the most likely culprits, she said; adapalene is less likely to cause hyperpigmentation.

Minocycline can also cause an overall darkening of the skin. “I recently saw a patient with darkening of the lips, and have also seen reports of darkening of scars and lesions of the legs,” Dr. Woolery-Lloyd said. “For this reason, I don't use minocycline as my first line of antibiotic therapy.”

If you treat a lot of acne in skin of color, you'll also use a lot of hydroquinone, for dealing with post-inflammatory hyperpigmentation, she said. The drug is available in 2% strength over the counter, 4% prescription strength and can be compounded at strengths of 6%–8%. “In my practice I use the 6%–8%. It's very important to instruct the patient to apply it only to the affected area and to avoid long-term use. I don't go longer than 2 months, and then I maintain results with a different therapy.”

Some patients – particularly blacks from South Africa – can develop ochronosis, a paradoxical darkening of skin associated with long-term hydroquinone use, she said. “It always starts with erythema, so again, tell your patients to discontinue if they have any irritation.” After erythema, ochronosis manifests blue-black patches that can contain milia, papules, and nodules. “Histologically, you see a classic banana-shaped, ocher-colored pigment in the dermis, which can be surrounded by a granulomatous response.”

Although 60% of her patients are black, Dr. Woolery-Lloyd said she only sees one or two cases of ochronosis each year. “It's typically seen in patients who have been using over-the-counter hydroquinone every day for 20-30 years, without sunscreen,” she said. “You have to emphasize to them to stop using it immediately.”

A small subset of patients will have an allergic reaction when using hydroquinone – typically to the sodium meta-bisulfite preservative in the cream. “If they continue use, the irritation can cause a very severe hyperpigmentation,” she added.

A tip for applying hydroquinone is to carefully treat only the hyperpigmented area – and not by applying the cream with a fingertip. If rubbed around, the cream can cause a halo-type affect of circular lightening. “I tell [patients] to use just a small amount and apply it with a cotton swab right on the lesion. And if they apply their retinoid over top of that, it will help to disperse it.”

Dr. Woolery-Lloyd has received research funding and honoraria from Allergen, which manufactures tazarotene, and is on the advisory board and has received honoraria from Galderma, which manufactures adapalene.

CHICAGO – Patient education is just as important as clinical therapy when treating acne in skin of color.

Even the best acne treatments can cause post-inflammatory hyperpigmentation in dark skin, Dr. Heather Woolery-Lloyd said.

“I always tell patients that these medications can be a little irritating and if you feel too dry or irritated, go to every other day or discontinue its use and try something else, because they can develop hyperpigmentation if the irritation continues,” said Dr. Woolery-Lloyd, director of ethnic skin care at the Baumann Cosmetic and Research Institute, Miami.

Black patients have about a 29% incidence of acne – a very common cause of hyperpigmentation. “The hyperpigmented acne macule is very common,” she said. “But, in black skin, comedonal lesions also show significant histologic signs of inflammation. So, if you are treating acne in skin of color, you're also going to be treating hyperpigmentation.”

Because of this tendency, physicians should help patients understand the potential risks, as well as the benefits, of acne therapies. For example, she said, “About 5% of the population is sensitive to benzoyl peroxide. Black patients who are sensitive can develop an irritation that results in hyperpigmentation.”

Retinoids can cause the same problem. “Some [physicans] avoid retinoids in dark skin, but I don't. I educate my patients; they should decrease the frequency of use to three times a week if irritation develops. If they do have hyperpigmentation associated with retinoids, it's going to come on very suddenly but also it typically resolves after the agent is discontinued.”

Tretinoin and tazarotene are the most likely culprits, she said; adapalene is less likely to cause hyperpigmentation.

Minocycline can also cause an overall darkening of the skin. “I recently saw a patient with darkening of the lips, and have also seen reports of darkening of scars and lesions of the legs,” Dr. Woolery-Lloyd said. “For this reason, I don't use minocycline as my first line of antibiotic therapy.”

If you treat a lot of acne in skin of color, you'll also use a lot of hydroquinone, for dealing with post-inflammatory hyperpigmentation, she said. The drug is available in 2% strength over the counter, 4% prescription strength and can be compounded at strengths of 6%–8%. “In my practice I use the 6%–8%. It's very important to instruct the patient to apply it only to the affected area and to avoid long-term use. I don't go longer than 2 months, and then I maintain results with a different therapy.”

Some patients – particularly blacks from South Africa – can develop ochronosis, a paradoxical darkening of skin associated with long-term hydroquinone use, she said. “It always starts with erythema, so again, tell your patients to discontinue if they have any irritation.” After erythema, ochronosis manifests blue-black patches that can contain milia, papules, and nodules. “Histologically, you see a classic banana-shaped, ocher-colored pigment in the dermis, which can be surrounded by a granulomatous response.”

Although 60% of her patients are black, Dr. Woolery-Lloyd said she only sees one or two cases of ochronosis each year. “It's typically seen in patients who have been using over-the-counter hydroquinone every day for 20-30 years, without sunscreen,” she said. “You have to emphasize to them to stop using it immediately.”

A small subset of patients will have an allergic reaction when using hydroquinone – typically to the sodium meta-bisulfite preservative in the cream. “If they continue use, the irritation can cause a very severe hyperpigmentation,” she added.

A tip for applying hydroquinone is to carefully treat only the hyperpigmented area – and not by applying the cream with a fingertip. If rubbed around, the cream can cause a halo-type affect of circular lightening. “I tell [patients] to use just a small amount and apply it with a cotton swab right on the lesion. And if they apply their retinoid over top of that, it will help to disperse it.”

Dr. Woolery-Lloyd has received research funding and honoraria from Allergen, which manufactures tazarotene, and is on the advisory board and has received honoraria from Galderma, which manufactures adapalene.

Private and public sources are launching two massive efforts to identify biomarkers for Parkinson's disease – an effort they say will speed drug research, providing more efficient ways to track disease progress and monitor therapeutic response.

In late September, the Michael J. Fox Foundation kicked off its Parkinson's Progression Markers Initiative (PPMI) and the National Institute for Neurological Disorders and Stroke sent out a request for applications to create the Parkinson's Disease Biomarker Identification Network (PD-BIN). The 5-year PPMI is the first large-scale clinical study to focus exclusively on identifying and validating both chemical and imaging biomarkers of the disease. The multiproject PD-BIN will be similarly devoted to identifying biological markers that contribute to an individual's risk for Parkinson's disease, as well as its onset and progression.

“We expect that the biomarkers we discover will help us better understand the disease and accelerate therapeutic trials, with the goal of assessing whether a drug can modify the progression of Parkinson's,” PPMI primary investigator Dr. Kenneth Marek said in an interview. “In a way, this is much more complex than a clinical treatment trial. We are not testing a drug, but ideally, we will find markers that can pave the way to accomplish more effective drug testing, and speed the development of much-needed therapies for this disease.”

Speaking from the World Parkinson Congress in Glasgow, Scotland, where he unveiled the PPMI to the scientific community, Dr. Marek stressed the need for objective, measurable disease markers in diagnosis and disease progression, as well as in research studies. The diagnosis of Parkinson's disease remains solely based on clinical signs and symptoms, with no concrete diagnostic measure. And with no objective clinical measurements in hand, researchers are “shooting in the dark” when assessing response to candidate drugs, he said.

“We have been conducting these clinical trials, but we there is no way to assess when a drug is ineffective, or how to get a better sense of whether the next one will actually work,” said Dr. Marek, who also is president of the Institute for Neurodegenerative Disorders in New Haven, Conn.

Having a set of biomarkers will speed research in a way that is not now possible, said PPMI co-investigator Dr. Tanya Simuni, director of the Parkinson's Disease and Movement Disorders Center at Northwestern University, Chicago.

“We have many ongoing clinical trials of potential disease-modifying agents, but they are slow to progress because clinical assessment is the primary efficacy measure,” Dr. Simuni said in an interview. “Because of this, these studies take a long time and need a large number of patients – and they still sometimes end up with inconclusive results. If we had an objective measure of disease progression, that would speed drug development by reducing the duration of the studies and the number of participants needed for each one.”

The discovery of a biomarker could also help clinicians identify patients in the very earliest – perhaps even prodromal – disease state, she said. “By the time symptoms of Parkinson's appear, patients can have lost up to 70% of their dopamine-producing cells, which tells us that there is a prodromal or preclinical phase during which damage is occurring without clinical signs. Biomarkers could not only help us develop better interventions but also screening tools. It's conceivable that in the future, we could screen for Parkinson's in the same way that we now screen for breast cancer or other medical conditions.”

PPMI will be conducted at 14 U.S. centers and at centers in Innsbruck, Austria; Kassel and Tubingen Germany; and Naples, Italy. It aims to recruit 200 healthy control patients and 400 patients newly diagnosed with Parkinson's disease who are not yet receiving medication.

The absence of Parkinson's disease medications is one key to a successful biomarker hunt, said Dr. Simuni, the principal investigator for the Midwestern region of the United States. “We want to make sure there is no over-signal of the therapy – that we are looking at the progression of disease unmasked by interventions.”

This should not be a problem with this patient population – at least initially. “For many patients with a new diagnosis, symptoms don't interfere with their function, so it's quite common not to start treatment at this time,” Dr. Simuni said. “At the point when the patient needs treatment, of course, it will start. They can remain in the study and count toward the follow-up. But our aim is to recruit patients early enough that we get at least 6 months of data without medication.”

Funding for the $40 million PPMI study will come from the Michael J. Fox Foundation, private contributions, Pfizer Inc., and – Dr. Marek hopes – federal grants.

In fact, he said, PPMI leaders hope to become involved in the PD-BIN.

Although the request for applications for the PD-BIN was just released (http://grants.nih.gov/grants/guide/rfa-files/RFA-NS-11-005.html

“The deputy director of NINDS [Dr. Walter J. Koroshetz] made it clear that the goal of this project is to bring as many resources as possible to bear on advancing neuroprotective therapy for Parkinson's,” Dr. Hallett said in an interview.

Although not officially connected, the PD-BIN and the PPMI may join forces, Dr. Marek said.

“We'll be applying for [the federal project] and we would love for these processes to be complementary. We would be delighted to have the government, through NIH, partner with us.”

Both projects were largely inspired by the Alzheimer's Disease Neuroimaging Initiative (ADNI), a public-private collaboration launched in 2004. ADNI discoveries have shown that cerebrospinal fluid carries disease-specific biomarkers that change with disease progression, including levels of phosphorylated and unphosphorylated tau protein and amyloid-beta-42. The project also investigated new imaging compounds which allow, for the first time, visualization of amyloid plaques and tau neurofibrillary tangles in the brain and how they change during disease progression.

Like the ADNI, both the PPMI and the PD-BIN could amass an enormous bio-bank of samples, which will be available without cost to scientists with approved research projects. In fact, Dr. Marek said, PPMI data sets will be maintained by the same lab that administers ADNI data: the Laboratory of Neuroimaging at the University of California, Los Angeles.

“In addition to accessing the data, researchers will be able to apply for PPMI's imaging and samples of CSF, blood, and urine from a biorepository we intend to maintain,” Dr. Marek said.

PPMI already has specific biomarkers targeted for research. Preliminary data indicate that alpha-synuclein, urate, and expression of the Parkinson's genetic marker DJ-1 change according to disease stage. Some data suggest that total tau, phosphorylated tau, and amyloid-beta might change as cognitive function is altered. Therefore, each of the 12 study visits will include blood, cerebrospinal fluid, urine, and DNA sampling as well as motor, neuropsychiatric, and cognitive assessments.

Both Dr. Hallett and Dr. Marek noted that the PPMI investigation and any others that join the federal program may uncover additional biomarkers. “The constant concern about looking for things that you know is that you might overlook something that you don't know, which could turn out to be something even better,” Dr. Hallett said.

Dr. Simuni has served as a consultant and received honorarium from GE Healthcare. She has received research support from the NIH and the Michael J. Fox Foundation. Dr. Marek is a member of the scientific advisory board for the Michael J. Fox Foundation and has been a consultant for Pfizer and GE Healthcare. He has an equity interest in Molecular NeuroImaging LLC. Dr. Hallet has no relevant disclosures.

PPMI will use single-photon emission CT scanning to track dopaminergic neurodegeneration in Parkinson's patients.

Source Courtesy Dr. John Seibyl, Institute for Neurodegenerative Disorders

How to Get Involved in PPMI

“Recruitment is the first, second, and third issue in a study like this,” said PPMI lead investigator Dr. Kenneth Marek. “We know we are asking a lot of our participants, but from what we have seen so far, a lot of patients with Parkinson's, and their friends and families who could be controls, understand the need for this approach and are willing and excited about participating in it.”

Both Dr. Marek and his coinvestigator Dr. Tanya Simuni admitted that the repeat lumbar punctures the study calls for could intimidate potential subjects. “It's important that they know that for most people, the possible side effects of a lumbar puncture are just about the same as for a blood draw,” Dr. Simuni said.

The first stop for information is the PPMI website,

www.ppmi-info.org

By clicking on the “For Physicians” button, doctors can download the Physician Tool Kit, which includes brochures about the study; a poster; a pocket card with the study overview; and research referral forms (

www.ppmi-info.org/about/for-physicians

Researchers who are interested in working with biological samples from the study also can find information about submitting requests for potential projects (

www.ppmi-info.org/for-researchers

www.ppmi-info.org/about/for-pd-and-control-participants

Private and public sources are launching two massive efforts to identify biomarkers for Parkinson's disease – an effort they say will speed drug research, providing more efficient ways to track disease progress and monitor therapeutic response.

In late September, the Michael J. Fox Foundation kicked off its Parkinson's Progression Markers Initiative (PPMI) and the National Institute for Neurological Disorders and Stroke sent out a request for applications to create the Parkinson's Disease Biomarker Identification Network (PD-BIN). The 5-year PPMI is the first large-scale clinical study to focus exclusively on identifying and validating both chemical and imaging biomarkers of the disease. The multiproject PD-BIN will be similarly devoted to identifying biological markers that contribute to an individual's risk for Parkinson's disease, as well as its onset and progression.

“We expect that the biomarkers we discover will help us better understand the disease and accelerate therapeutic trials, with the goal of assessing whether a drug can modify the progression of Parkinson's,” PPMI primary investigator Dr. Kenneth Marek said in an interview. “In a way, this is much more complex than a clinical treatment trial. We are not testing a drug, but ideally, we will find markers that can pave the way to accomplish more effective drug testing, and speed the development of much-needed therapies for this disease.”

Speaking from the World Parkinson Congress in Glasgow, Scotland, where he unveiled the PPMI to the scientific community, Dr. Marek stressed the need for objective, measurable disease markers in diagnosis and disease progression, as well as in research studies. The diagnosis of Parkinson's disease remains solely based on clinical signs and symptoms, with no concrete diagnostic measure. And with no objective clinical measurements in hand, researchers are “shooting in the dark” when assessing response to candidate drugs, he said.

“We have been conducting these clinical trials, but we there is no way to assess when a drug is ineffective, or how to get a better sense of whether the next one will actually work,” said Dr. Marek, who also is president of the Institute for Neurodegenerative Disorders in New Haven, Conn.

Having a set of biomarkers will speed research in a way that is not now possible, said PPMI co-investigator Dr. Tanya Simuni, director of the Parkinson's Disease and Movement Disorders Center at Northwestern University, Chicago.

“We have many ongoing clinical trials of potential disease-modifying agents, but they are slow to progress because clinical assessment is the primary efficacy measure,” Dr. Simuni said in an interview. “Because of this, these studies take a long time and need a large number of patients – and they still sometimes end up with inconclusive results. If we had an objective measure of disease progression, that would speed drug development by reducing the duration of the studies and the number of participants needed for each one.”

The discovery of a biomarker could also help clinicians identify patients in the very earliest – perhaps even prodromal – disease state, she said. “By the time symptoms of Parkinson's appear, patients can have lost up to 70% of their dopamine-producing cells, which tells us that there is a prodromal or preclinical phase during which damage is occurring without clinical signs. Biomarkers could not only help us develop better interventions but also screening tools. It's conceivable that in the future, we could screen for Parkinson's in the same way that we now screen for breast cancer or other medical conditions.”

PPMI will be conducted at 14 U.S. centers and at centers in Innsbruck, Austria; Kassel and Tubingen Germany; and Naples, Italy. It aims to recruit 200 healthy control patients and 400 patients newly diagnosed with Parkinson's disease who are not yet receiving medication.

The absence of Parkinson's disease medications is one key to a successful biomarker hunt, said Dr. Simuni, the principal investigator for the Midwestern region of the United States. “We want to make sure there is no over-signal of the therapy – that we are looking at the progression of disease unmasked by interventions.”

This should not be a problem with this patient population – at least initially. “For many patients with a new diagnosis, symptoms don't interfere with their function, so it's quite common not to start treatment at this time,” Dr. Simuni said. “At the point when the patient needs treatment, of course, it will start. They can remain in the study and count toward the follow-up. But our aim is to recruit patients early enough that we get at least 6 months of data without medication.”

Funding for the $40 million PPMI study will come from the Michael J. Fox Foundation, private contributions, Pfizer Inc., and – Dr. Marek hopes – federal grants.

In fact, he said, PPMI leaders hope to become involved in the PD-BIN.

Although the request for applications for the PD-BIN was just released (http://grants.nih.gov/grants/guide/rfa-files/RFA-NS-11-005.html

“The deputy director of NINDS [Dr. Walter J. Koroshetz] made it clear that the goal of this project is to bring as many resources as possible to bear on advancing neuroprotective therapy for Parkinson's,” Dr. Hallett said in an interview.

Although not officially connected, the PD-BIN and the PPMI may join forces, Dr. Marek said.

“We'll be applying for [the federal project] and we would love for these processes to be complementary. We would be delighted to have the government, through NIH, partner with us.”

Both projects were largely inspired by the Alzheimer's Disease Neuroimaging Initiative (ADNI), a public-private collaboration launched in 2004. ADNI discoveries have shown that cerebrospinal fluid carries disease-specific biomarkers that change with disease progression, including levels of phosphorylated and unphosphorylated tau protein and amyloid-beta-42. The project also investigated new imaging compounds which allow, for the first time, visualization of amyloid plaques and tau neurofibrillary tangles in the brain and how they change during disease progression.

Like the ADNI, both the PPMI and the PD-BIN could amass an enormous bio-bank of samples, which will be available without cost to scientists with approved research projects. In fact, Dr. Marek said, PPMI data sets will be maintained by the same lab that administers ADNI data: the Laboratory of Neuroimaging at the University of California, Los Angeles.

“In addition to accessing the data, researchers will be able to apply for PPMI's imaging and samples of CSF, blood, and urine from a biorepository we intend to maintain,” Dr. Marek said.

PPMI already has specific biomarkers targeted for research. Preliminary data indicate that alpha-synuclein, urate, and expression of the Parkinson's genetic marker DJ-1 change according to disease stage. Some data suggest that total tau, phosphorylated tau, and amyloid-beta might change as cognitive function is altered. Therefore, each of the 12 study visits will include blood, cerebrospinal fluid, urine, and DNA sampling as well as motor, neuropsychiatric, and cognitive assessments.

Both Dr. Hallett and Dr. Marek noted that the PPMI investigation and any others that join the federal program may uncover additional biomarkers. “The constant concern about looking for things that you know is that you might overlook something that you don't know, which could turn out to be something even better,” Dr. Hallett said.

Dr. Simuni has served as a consultant and received honorarium from GE Healthcare. She has received research support from the NIH and the Michael J. Fox Foundation. Dr. Marek is a member of the scientific advisory board for the Michael J. Fox Foundation and has been a consultant for Pfizer and GE Healthcare. He has an equity interest in Molecular NeuroImaging LLC. Dr. Hallet has no relevant disclosures.

PPMI will use single-photon emission CT scanning to track dopaminergic neurodegeneration in Parkinson's patients.

Source Courtesy Dr. John Seibyl, Institute for Neurodegenerative Disorders

How to Get Involved in PPMI

“Recruitment is the first, second, and third issue in a study like this,” said PPMI lead investigator Dr. Kenneth Marek. “We know we are asking a lot of our participants, but from what we have seen so far, a lot of patients with Parkinson's, and their friends and families who could be controls, understand the need for this approach and are willing and excited about participating in it.”

Both Dr. Marek and his coinvestigator Dr. Tanya Simuni admitted that the repeat lumbar punctures the study calls for could intimidate potential subjects. “It's important that they know that for most people, the possible side effects of a lumbar puncture are just about the same as for a blood draw,” Dr. Simuni said.

The first stop for information is the PPMI website,

www.ppmi-info.org

By clicking on the “For Physicians” button, doctors can download the Physician Tool Kit, which includes brochures about the study; a poster; a pocket card with the study overview; and research referral forms (

www.ppmi-info.org/about/for-physicians

Researchers who are interested in working with biological samples from the study also can find information about submitting requests for potential projects (

www.ppmi-info.org/for-researchers

www.ppmi-info.org/about/for-pd-and-control-participants

Private and public sources are launching two massive efforts to identify biomarkers for Parkinson's disease – an effort they say will speed drug research, providing more efficient ways to track disease progress and monitor therapeutic response.

In late September, the Michael J. Fox Foundation kicked off its Parkinson's Progression Markers Initiative (PPMI) and the National Institute for Neurological Disorders and Stroke sent out a request for applications to create the Parkinson's Disease Biomarker Identification Network (PD-BIN). The 5-year PPMI is the first large-scale clinical study to focus exclusively on identifying and validating both chemical and imaging biomarkers of the disease. The multiproject PD-BIN will be similarly devoted to identifying biological markers that contribute to an individual's risk for Parkinson's disease, as well as its onset and progression.

“We expect that the biomarkers we discover will help us better understand the disease and accelerate therapeutic trials, with the goal of assessing whether a drug can modify the progression of Parkinson's,” PPMI primary investigator Dr. Kenneth Marek said in an interview. “In a way, this is much more complex than a clinical treatment trial. We are not testing a drug, but ideally, we will find markers that can pave the way to accomplish more effective drug testing, and speed the development of much-needed therapies for this disease.”

Speaking from the World Parkinson Congress in Glasgow, Scotland, where he unveiled the PPMI to the scientific community, Dr. Marek stressed the need for objective, measurable disease markers in diagnosis and disease progression, as well as in research studies. The diagnosis of Parkinson's disease remains solely based on clinical signs and symptoms, with no concrete diagnostic measure. And with no objective clinical measurements in hand, researchers are “shooting in the dark” when assessing response to candidate drugs, he said.

“We have been conducting these clinical trials, but we there is no way to assess when a drug is ineffective, or how to get a better sense of whether the next one will actually work,” said Dr. Marek, who also is president of the Institute for Neurodegenerative Disorders in New Haven, Conn.

Having a set of biomarkers will speed research in a way that is not now possible, said PPMI co-investigator Dr. Tanya Simuni, director of the Parkinson's Disease and Movement Disorders Center at Northwestern University, Chicago.

“We have many ongoing clinical trials of potential disease-modifying agents, but they are slow to progress because clinical assessment is the primary efficacy measure,” Dr. Simuni said in an interview. “Because of this, these studies take a long time and need a large number of patients – and they still sometimes end up with inconclusive results. If we had an objective measure of disease progression, that would speed drug development by reducing the duration of the studies and the number of participants needed for each one.”

The discovery of a biomarker could also help clinicians identify patients in the very earliest – perhaps even prodromal – disease state, she said. “By the time symptoms of Parkinson's appear, patients can have lost up to 70% of their dopamine-producing cells, which tells us that there is a prodromal or preclinical phase during which damage is occurring without clinical signs. Biomarkers could not only help us develop better interventions but also screening tools. It's conceivable that in the future, we could screen for Parkinson's in the same way that we now screen for breast cancer or other medical conditions.”

PPMI will be conducted at 14 U.S. centers and at centers in Innsbruck, Austria; Kassel and Tubingen Germany; and Naples, Italy. It aims to recruit 200 healthy control patients and 400 patients newly diagnosed with Parkinson's disease who are not yet receiving medication.

The absence of Parkinson's disease medications is one key to a successful biomarker hunt, said Dr. Simuni, the principal investigator for the Midwestern region of the United States. “We want to make sure there is no over-signal of the therapy – that we are looking at the progression of disease unmasked by interventions.”

This should not be a problem with this patient population – at least initially. “For many patients with a new diagnosis, symptoms don't interfere with their function, so it's quite common not to start treatment at this time,” Dr. Simuni said. “At the point when the patient needs treatment, of course, it will start. They can remain in the study and count toward the follow-up. But our aim is to recruit patients early enough that we get at least 6 months of data without medication.”

Funding for the $40 million PPMI study will come from the Michael J. Fox Foundation, private contributions, Pfizer Inc., and – Dr. Marek hopes – federal grants.

In fact, he said, PPMI leaders hope to become involved in the PD-BIN.

Although the request for applications for the PD-BIN was just released (http://grants.nih.gov/grants/guide/rfa-files/RFA-NS-11-005.html

“The deputy director of NINDS [Dr. Walter J. Koroshetz] made it clear that the goal of this project is to bring as many resources as possible to bear on advancing neuroprotective therapy for Parkinson's,” Dr. Hallett said in an interview.

Although not officially connected, the PD-BIN and the PPMI may join forces, Dr. Marek said.

“We'll be applying for [the federal project] and we would love for these processes to be complementary. We would be delighted to have the government, through NIH, partner with us.”

Both projects were largely inspired by the Alzheimer's Disease Neuroimaging Initiative (ADNI), a public-private collaboration launched in 2004. ADNI discoveries have shown that cerebrospinal fluid carries disease-specific biomarkers that change with disease progression, including levels of phosphorylated and unphosphorylated tau protein and amyloid-beta-42. The project also investigated new imaging compounds which allow, for the first time, visualization of amyloid plaques and tau neurofibrillary tangles in the brain and how they change during disease progression.

Like the ADNI, both the PPMI and the PD-BIN could amass an enormous bio-bank of samples, which will be available without cost to scientists with approved research projects. In fact, Dr. Marek said, PPMI data sets will be maintained by the same lab that administers ADNI data: the Laboratory of Neuroimaging at the University of California, Los Angeles.

“In addition to accessing the data, researchers will be able to apply for PPMI's imaging and samples of CSF, blood, and urine from a biorepository we intend to maintain,” Dr. Marek said.

PPMI already has specific biomarkers targeted for research. Preliminary data indicate that alpha-synuclein, urate, and expression of the Parkinson's genetic marker DJ-1 change according to disease stage. Some data suggest that total tau, phosphorylated tau, and amyloid-beta might change as cognitive function is altered. Therefore, each of the 12 study visits will include blood, cerebrospinal fluid, urine, and DNA sampling as well as motor, neuropsychiatric, and cognitive assessments.

Both Dr. Hallett and Dr. Marek noted that the PPMI investigation and any others that join the federal program may uncover additional biomarkers. “The constant concern about looking for things that you know is that you might overlook something that you don't know, which could turn out to be something even better,” Dr. Hallett said.

Dr. Simuni has served as a consultant and received honorarium from GE Healthcare. She has received research support from the NIH and the Michael J. Fox Foundation. Dr. Marek is a member of the scientific advisory board for the Michael J. Fox Foundation and has been a consultant for Pfizer and GE Healthcare. He has an equity interest in Molecular NeuroImaging LLC. Dr. Hallet has no relevant disclosures.

PPMI will use single-photon emission CT scanning to track dopaminergic neurodegeneration in Parkinson's patients.

Source Courtesy Dr. John Seibyl, Institute for Neurodegenerative Disorders

How to Get Involved in PPMI

“Recruitment is the first, second, and third issue in a study like this,” said PPMI lead investigator Dr. Kenneth Marek. “We know we are asking a lot of our participants, but from what we have seen so far, a lot of patients with Parkinson's, and their friends and families who could be controls, understand the need for this approach and are willing and excited about participating in it.”

Both Dr. Marek and his coinvestigator Dr. Tanya Simuni admitted that the repeat lumbar punctures the study calls for could intimidate potential subjects. “It's important that they know that for most people, the possible side effects of a lumbar puncture are just about the same as for a blood draw,” Dr. Simuni said.

The first stop for information is the PPMI website,

www.ppmi-info.org

By clicking on the “For Physicians” button, doctors can download the Physician Tool Kit, which includes brochures about the study; a poster; a pocket card with the study overview; and research referral forms (

www.ppmi-info.org/about/for-physicians

Researchers who are interested in working with biological samples from the study also can find information about submitting requests for potential projects (

www.ppmi-info.org/for-researchers

www.ppmi-info.org/about/for-pd-and-control-participants

CHICAGO – Infections from dermatologic surgery are rare, but possible, especially in high-risk patients, such as the immunosuppressed and those with joint or cardiac prostheses.

“Data from the four largest studies on this topic suggest an infective bacteremia of about 1.9% associated with all derm surgeries, which is actually less than you see with normal daily activities, like brushing your teeth and flossing,” Christopher C. Gasbarre, D.O. said at the meeting . “Add to that the fact that the American Heart Association guidelines note that antibiotic prophylaxis doesn’t decrease the risk of infection to 0%,” and the decision of whether to give the drugs becomes problematic.

Patients who are at high risk of postoperative infections, however, should receive preoperative or immediately postoperative antibiotics, said Dr. Gasbarre, a dermatologist at the Cleveland Clinic. “It’s important to remember that infective endocarditis and prosthetic joint infections secondary to dermatologic surgery are a well-known phenomenon, and a distant skin infection is the leading cause of prosthetic joint infections.”

The American Heart Association reviewed and updated its surgical antibiotic guidelines in 2007, “making a significant shift in focus compared to their previous guidelines,” Dr. Gasbarre said. The guidelines now recommend prophylaxis for patients with any prosthetic implanted material including cardiac valve replacements; cardiac patients with valvular disease; those with a history of infective pericarditis; anyone with unrepaired cyanotic congenital heart disease or a defect repaired within the past 6 months; and any congenital heart disease with a residual defect.

The American Dental Association updated its surgical antibiotic guidelines recently as well. “The guidelines recommend prophylaxis for high-risk patients undergoing oral procedures with a high risk of bleeding,” he said.

Guidelines issued by the American Association of Orthopaedic Surgeons identify similar high-risk groups that should receive presurgical antibiotic therapy, including anyone who is less than 2 years out from a joint replacement, who is immunosuppressed, and who has hemophilia. “In dermatologic surgery, there are no studies on antibiotic prophylaxis, so we have to make do with these other recommendations,” Dr Gasbarre said.

Preventing wound infections is a major goal of surgical antibiotic treatment, he said. “In the dermatologic literature, the numbers range from 0.7% to %, depending on what study you’re looking at.”

Surgical site is a major consideration in anticipating postsurgical infections. “Ears, the nose, and lower leg below the knee have a greater risk of infection. Flaps and grafts have a higher risk, especially flaps on the nose. And a major cosmetic reconstruction that results in necrosis and scarring should also be a consideration.”

The Mayo Clinic’s 2008 surgical antibiotic prophylaxis guidelines suggest antibiotics for dermatologic surgeries of the lower extremities, groin, and perineum; wedge excisions of the lip or ear; and other procedures with reported infection rates of at least 5%. Again, patients with immunosuppression require specific attention, as do those with inflammatory skin diseases, “who may carry a higher staphylococcus load on the skin,” Dr. Gasbarre said.

The literature suggests other high-risk groups might be those who undergo several procedures in 1 day, have high-tension wound closures, and have surgery on the hands, he added.

“The one thing that gets the most debate is whether to give antibiotics for a wound that’s exposed more than 3 hours, Dr. Gasbarre said. “I often do, although there are no guidelines. I take into consideration comorbidities, but certainly any surgery of the nasal mucosa and long procedures are worthy of consideration.”

Culture is important for high-risk patients. “Culture for both community- and hospital-acquired methicillin-resistant Staphylococcus aureus and jump on those infections and eradicate them as quickly as possible.”

Timing is another consideration. “Ideally we give antibiotics 30-60 minutes before the procedure to get enough antibiotic in the coagulum. But the new AHA guidelines say you can give them up to 2 hours after the procedure if not given before.”

Select antibiotics carefully. “Beta hemolytic streptococcus and S. aureus are most likely to cause endocarditis from skin sites. You see a lot of gram-negative infections in the lower extremities and perineum. Pseudomonas can show up in the ear, but more than 90% of cultured ear isolates are staph and strep, not pseudomonas.”

If the patient is not allergic to penicillin, Dr. Gasbarre prefers 2 g oral cephalexin or treatment with dicloxacillin or amoxicillin. “For oral mucosa, amoxicillin is the drug of choice. For patients who are allergic, I stick with 600 mg of clindamycin or 500 mg of azithromycin.”

Ciprofloxacin, trimethoprim, and levofloxacin are choice for the ear, groin, and lower extremities.

“If patients can’t take anything orally, ceftriaxone 1 g given intramuscularly or intravenously is acceptable, with or without gentamicin for gram-negative coverage,” Dr. Gasbarre said.

Dr. Gasbarre said he had no relevant financial conflicts.

CHICAGO – Infections from dermatologic surgery are rare, but possible, especially in high-risk patients, such as the immunosuppressed and those with joint or cardiac prostheses.

“Data from the four largest studies on this topic suggest an infective bacteremia of about 1.9% associated with all derm surgeries, which is actually less than you see with normal daily activities, like brushing your teeth and flossing,” Christopher C. Gasbarre, D.O. said at the meeting . “Add to that the fact that the American Heart Association guidelines note that antibiotic prophylaxis doesn’t decrease the risk of infection to 0%,” and the decision of whether to give the drugs becomes problematic.

Patients who are at high risk of postoperative infections, however, should receive preoperative or immediately postoperative antibiotics, said Dr. Gasbarre, a dermatologist at the Cleveland Clinic. “It’s important to remember that infective endocarditis and prosthetic joint infections secondary to dermatologic surgery are a well-known phenomenon, and a distant skin infection is the leading cause of prosthetic joint infections.”

The American Heart Association reviewed and updated its surgical antibiotic guidelines in 2007, “making a significant shift in focus compared to their previous guidelines,” Dr. Gasbarre said. The guidelines now recommend prophylaxis for patients with any prosthetic implanted material including cardiac valve replacements; cardiac patients with valvular disease; those with a history of infective pericarditis; anyone with unrepaired cyanotic congenital heart disease or a defect repaired within the past 6 months; and any congenital heart disease with a residual defect.

The American Dental Association updated its surgical antibiotic guidelines recently as well. “The guidelines recommend prophylaxis for high-risk patients undergoing oral procedures with a high risk of bleeding,” he said.

Guidelines issued by the American Association of Orthopaedic Surgeons identify similar high-risk groups that should receive presurgical antibiotic therapy, including anyone who is less than 2 years out from a joint replacement, who is immunosuppressed, and who has hemophilia. “In dermatologic surgery, there are no studies on antibiotic prophylaxis, so we have to make do with these other recommendations,” Dr Gasbarre said.

Preventing wound infections is a major goal of surgical antibiotic treatment, he said. “In the dermatologic literature, the numbers range from 0.7% to %, depending on what study you’re looking at.”

Surgical site is a major consideration in anticipating postsurgical infections. “Ears, the nose, and lower leg below the knee have a greater risk of infection. Flaps and grafts have a higher risk, especially flaps on the nose. And a major cosmetic reconstruction that results in necrosis and scarring should also be a consideration.”

The Mayo Clinic’s 2008 surgical antibiotic prophylaxis guidelines suggest antibiotics for dermatologic surgeries of the lower extremities, groin, and perineum; wedge excisions of the lip or ear; and other procedures with reported infection rates of at least 5%. Again, patients with immunosuppression require specific attention, as do those with inflammatory skin diseases, “who may carry a higher staphylococcus load on the skin,” Dr. Gasbarre said.

The literature suggests other high-risk groups might be those who undergo several procedures in 1 day, have high-tension wound closures, and have surgery on the hands, he added.

“The one thing that gets the most debate is whether to give antibiotics for a wound that’s exposed more than 3 hours, Dr. Gasbarre said. “I often do, although there are no guidelines. I take into consideration comorbidities, but certainly any surgery of the nasal mucosa and long procedures are worthy of consideration.”

Culture is important for high-risk patients. “Culture for both community- and hospital-acquired methicillin-resistant Staphylococcus aureus and jump on those infections and eradicate them as quickly as possible.”

Timing is another consideration. “Ideally we give antibiotics 30-60 minutes before the procedure to get enough antibiotic in the coagulum. But the new AHA guidelines say you can give them up to 2 hours after the procedure if not given before.”

Select antibiotics carefully. “Beta hemolytic streptococcus and S. aureus are most likely to cause endocarditis from skin sites. You see a lot of gram-negative infections in the lower extremities and perineum. Pseudomonas can show up in the ear, but more than 90% of cultured ear isolates are staph and strep, not pseudomonas.”

If the patient is not allergic to penicillin, Dr. Gasbarre prefers 2 g oral cephalexin or treatment with dicloxacillin or amoxicillin. “For oral mucosa, amoxicillin is the drug of choice. For patients who are allergic, I stick with 600 mg of clindamycin or 500 mg of azithromycin.”

Ciprofloxacin, trimethoprim, and levofloxacin are choice for the ear, groin, and lower extremities.

“If patients can’t take anything orally, ceftriaxone 1 g given intramuscularly or intravenously is acceptable, with or without gentamicin for gram-negative coverage,” Dr. Gasbarre said.

Dr. Gasbarre said he had no relevant financial conflicts.

CHICAGO – Infections from dermatologic surgery are rare, but possible, especially in high-risk patients, such as the immunosuppressed and those with joint or cardiac prostheses.

“Data from the four largest studies on this topic suggest an infective bacteremia of about 1.9% associated with all derm surgeries, which is actually less than you see with normal daily activities, like brushing your teeth and flossing,” Christopher C. Gasbarre, D.O. said at the meeting . “Add to that the fact that the American Heart Association guidelines note that antibiotic prophylaxis doesn’t decrease the risk of infection to 0%,” and the decision of whether to give the drugs becomes problematic.

Patients who are at high risk of postoperative infections, however, should receive preoperative or immediately postoperative antibiotics, said Dr. Gasbarre, a dermatologist at the Cleveland Clinic. “It’s important to remember that infective endocarditis and prosthetic joint infections secondary to dermatologic surgery are a well-known phenomenon, and a distant skin infection is the leading cause of prosthetic joint infections.”

The American Heart Association reviewed and updated its surgical antibiotic guidelines in 2007, “making a significant shift in focus compared to their previous guidelines,” Dr. Gasbarre said. The guidelines now recommend prophylaxis for patients with any prosthetic implanted material including cardiac valve replacements; cardiac patients with valvular disease; those with a history of infective pericarditis; anyone with unrepaired cyanotic congenital heart disease or a defect repaired within the past 6 months; and any congenital heart disease with a residual defect.

The American Dental Association updated its surgical antibiotic guidelines recently as well. “The guidelines recommend prophylaxis for high-risk patients undergoing oral procedures with a high risk of bleeding,” he said.

Guidelines issued by the American Association of Orthopaedic Surgeons identify similar high-risk groups that should receive presurgical antibiotic therapy, including anyone who is less than 2 years out from a joint replacement, who is immunosuppressed, and who has hemophilia. “In dermatologic surgery, there are no studies on antibiotic prophylaxis, so we have to make do with these other recommendations,” Dr Gasbarre said.

Preventing wound infections is a major goal of surgical antibiotic treatment, he said. “In the dermatologic literature, the numbers range from 0.7% to %, depending on what study you’re looking at.”

Surgical site is a major consideration in anticipating postsurgical infections. “Ears, the nose, and lower leg below the knee have a greater risk of infection. Flaps and grafts have a higher risk, especially flaps on the nose. And a major cosmetic reconstruction that results in necrosis and scarring should also be a consideration.”

The Mayo Clinic’s 2008 surgical antibiotic prophylaxis guidelines suggest antibiotics for dermatologic surgeries of the lower extremities, groin, and perineum; wedge excisions of the lip or ear; and other procedures with reported infection rates of at least 5%. Again, patients with immunosuppression require specific attention, as do those with inflammatory skin diseases, “who may carry a higher staphylococcus load on the skin,” Dr. Gasbarre said.

The literature suggests other high-risk groups might be those who undergo several procedures in 1 day, have high-tension wound closures, and have surgery on the hands, he added.

“The one thing that gets the most debate is whether to give antibiotics for a wound that’s exposed more than 3 hours, Dr. Gasbarre said. “I often do, although there are no guidelines. I take into consideration comorbidities, but certainly any surgery of the nasal mucosa and long procedures are worthy of consideration.”

Culture is important for high-risk patients. “Culture for both community- and hospital-acquired methicillin-resistant Staphylococcus aureus and jump on those infections and eradicate them as quickly as possible.”

Timing is another consideration. “Ideally we give antibiotics 30-60 minutes before the procedure to get enough antibiotic in the coagulum. But the new AHA guidelines say you can give them up to 2 hours after the procedure if not given before.”

Select antibiotics carefully. “Beta hemolytic streptococcus and S. aureus are most likely to cause endocarditis from skin sites. You see a lot of gram-negative infections in the lower extremities and perineum. Pseudomonas can show up in the ear, but more than 90% of cultured ear isolates are staph and strep, not pseudomonas.”

If the patient is not allergic to penicillin, Dr. Gasbarre prefers 2 g oral cephalexin or treatment with dicloxacillin or amoxicillin. “For oral mucosa, amoxicillin is the drug of choice. For patients who are allergic, I stick with 600 mg of clindamycin or 500 mg of azithromycin.”

Ciprofloxacin, trimethoprim, and levofloxacin are choice for the ear, groin, and lower extremities.

“If patients can’t take anything orally, ceftriaxone 1 g given intramuscularly or intravenously is acceptable, with or without gentamicin for gram-negative coverage,” Dr. Gasbarre said.

Dr. Gasbarre said he had no relevant financial conflicts.

CHICAGO – Infections from dermatologic surgery are rare, but possible, especially in high-risk patients, such as the immunosuppressed and those with joint or cardiac prostheses.

"Data from the four largest studies on this topic suggest an infective bacteremia of about 1.9% associated with all derm surgeries, which is actually less than you see with normal daily activities, like brushing your teeth and flossing," Christopher C. Gasbarre, D.O. said at the meeting . "Add to that the fact that the American Heart Association guidelines note that antibiotic prophylaxis doesn’t decrease the risk of infection to 0%," and the decision of whether to give the drugs becomes problematic.

Patients who are at high risk of postoperative infections, however, should receive preoperative or immediately postoperative antibiotics, said Dr. Gasbarre, a dermatologist at the Cleveland Clinic. "It’s important to remember that infective endocarditis and prosthetic joint infections secondary to dermatologic surgery are a well-known phenomenon, and a distant skin infection is the leading cause of prosthetic joint infections."

The American Heart Association reviewed and updated its surgical antibiotic guidelines in 2007, "making a significant shift in focus compared to their previous guidelines," Dr. Gasbarre said. The guidelines now recommend prophylaxis for patients with any prosthetic implanted material including cardiac valve replacements; cardiac patients with valvular disease; those with a history of infective pericarditis; anyone with unrepaired cyanotic congenital heart disease or a defect repaired within the past 6 months; and any congenital heart disease with a residual defect.

The American Dental Association updated its surgical antibiotic guidelines recently as well. "The guidelines recommend prophylaxis for high-risk patients undergoing oral procedures with a high risk of bleeding," he said.

Guidelines issued by the American Association of Orthopaedic Surgeons identify similar high-risk groups that should receive presurgical antibiotic therapy, including anyone who is less than 2 years out from a joint replacement, who is immunosuppressed, and who has hemophilia. "In dermatologic surgery, there are no studies on antibiotic prophylaxis, so we have to make do with these other recommendations," Dr. Gasbarre said.

Preventing wound infections is a major goal of surgical antibiotic treatment, he said. “In the dermatologic literature, the numbers range from 0.7% to 8%, depending on what study you’re looking at.”

Surgical site is a major consideration in anticipating postsurgical infections. "Ears, the nose, and lower leg below the knee have a greater risk of infection. Flaps and grafts have a higher risk, especially flaps on the nose. And a major cosmetic reconstruction that results in necrosis and scarring should also be a consideration."

The Mayo Clinic’s 2008 surgical antibiotic prophylaxis guidelines suggest antibiotics for dermatologic surgeries of the lower extremities, groin, and perineum; wedge excisions of the lip or ear; and other procedures with reported infection rates of at least 5%. Again, patients with immunosuppression require specific attention, as do those with inflammatory skin diseases, “who may carry a higher staphylococcus load on the skin,” Dr. Gasbarre said.

The literature suggests other high-risk groups might be those who undergo several procedures in 1 day, have high-tension wound closures, and have surgery on the hands, he added.

"The one thing that gets the most debate is whether to give antibiotics for a wound that’s exposed more than 3 hours," Dr. Gasbarre said. "I often do, although there are no guidelines. I take into consideration comorbidities, but certainly any surgery of the nasal mucosa and long procedures are worthy of consideration."

Culture is important for high-risk patients. "Culture for both community- and hospital-acquired methicillin-resistant Staphylococcus aureus and jump on those infections and eradicate them as quickly as possible."

Timing is another consideration. "Ideally we give antibiotics 30-60 minutes before the procedure to get enough antibiotic in the coagulum. But the new AHA guidelines say you can give them up to 2 hours after the procedure if not given before."

Select antibiotics carefully. "Beta hemolytic streptococcus and S. aureus are most likely to cause endocarditis from skin sites. You see a lot of gram-negative infections in the lower extremities and perineum. Pseudomonas can show up in the ear, but more than 90% of cultured ear isolates are staph and strep, not pseudomonas."

If the patient is not allergic to penicillin, Dr. Gasbarre prefers 2 g oral cephalexin or treatment with dicloxacillin or amoxicillin. "For oral mucosa, amoxicillin is the drug of choice. For patients who are allergic, I stick with 600 mg of clindamycin or 500 mg of azithromycin."

Ciprofloxacin, trimethoprim, and levofloxacin are choice for the ear, groin, and lower extremities.

"If patients can’t take anything orally, ceftriaxone 1 g given intramuscularly or intravenously is acceptable, with or without gentamicin for gram-negative coverage," Dr. Gasbarre said.

Dr. Gasbarre said he had no relevant financial conflicts.

CHICAGO – Infections from dermatologic surgery are rare, but possible, especially in high-risk patients, such as the immunosuppressed and those with joint or cardiac prostheses.

"Data from the four largest studies on this topic suggest an infective bacteremia of about 1.9% associated with all derm surgeries, which is actually less than you see with normal daily activities, like brushing your teeth and flossing," Christopher C. Gasbarre, D.O. said at the meeting . "Add to that the fact that the American Heart Association guidelines note that antibiotic prophylaxis doesn’t decrease the risk of infection to 0%," and the decision of whether to give the drugs becomes problematic.

Patients who are at high risk of postoperative infections, however, should receive preoperative or immediately postoperative antibiotics, said Dr. Gasbarre, a dermatologist at the Cleveland Clinic. "It’s important to remember that infective endocarditis and prosthetic joint infections secondary to dermatologic surgery are a well-known phenomenon, and a distant skin infection is the leading cause of prosthetic joint infections."

The American Heart Association reviewed and updated its surgical antibiotic guidelines in 2007, "making a significant shift in focus compared to their previous guidelines," Dr. Gasbarre said. The guidelines now recommend prophylaxis for patients with any prosthetic implanted material including cardiac valve replacements; cardiac patients with valvular disease; those with a history of infective pericarditis; anyone with unrepaired cyanotic congenital heart disease or a defect repaired within the past 6 months; and any congenital heart disease with a residual defect.

The American Dental Association updated its surgical antibiotic guidelines recently as well. "The guidelines recommend prophylaxis for high-risk patients undergoing oral procedures with a high risk of bleeding," he said.

Guidelines issued by the American Association of Orthopaedic Surgeons identify similar high-risk groups that should receive presurgical antibiotic therapy, including anyone who is less than 2 years out from a joint replacement, who is immunosuppressed, and who has hemophilia. "In dermatologic surgery, there are no studies on antibiotic prophylaxis, so we have to make do with these other recommendations," Dr. Gasbarre said.

Preventing wound infections is a major goal of surgical antibiotic treatment, he said. “In the dermatologic literature, the numbers range from 0.7% to 8%, depending on what study you’re looking at.”

Surgical site is a major consideration in anticipating postsurgical infections. "Ears, the nose, and lower leg below the knee have a greater risk of infection. Flaps and grafts have a higher risk, especially flaps on the nose. And a major cosmetic reconstruction that results in necrosis and scarring should also be a consideration."

The Mayo Clinic’s 2008 surgical antibiotic prophylaxis guidelines suggest antibiotics for dermatologic surgeries of the lower extremities, groin, and perineum; wedge excisions of the lip or ear; and other procedures with reported infection rates of at least 5%. Again, patients with immunosuppression require specific attention, as do those with inflammatory skin diseases, “who may carry a higher staphylococcus load on the skin,” Dr. Gasbarre said.

The literature suggests other high-risk groups might be those who undergo several procedures in 1 day, have high-tension wound closures, and have surgery on the hands, he added.

"The one thing that gets the most debate is whether to give antibiotics for a wound that’s exposed more than 3 hours," Dr. Gasbarre said. "I often do, although there are no guidelines. I take into consideration comorbidities, but certainly any surgery of the nasal mucosa and long procedures are worthy of consideration."

Culture is important for high-risk patients. "Culture for both community- and hospital-acquired methicillin-resistant Staphylococcus aureus and jump on those infections and eradicate them as quickly as possible."

Timing is another consideration. "Ideally we give antibiotics 30-60 minutes before the procedure to get enough antibiotic in the coagulum. But the new AHA guidelines say you can give them up to 2 hours after the procedure if not given before."

Select antibiotics carefully. "Beta hemolytic streptococcus and S. aureus are most likely to cause endocarditis from skin sites. You see a lot of gram-negative infections in the lower extremities and perineum. Pseudomonas can show up in the ear, but more than 90% of cultured ear isolates are staph and strep, not pseudomonas."

If the patient is not allergic to penicillin, Dr. Gasbarre prefers 2 g oral cephalexin or treatment with dicloxacillin or amoxicillin. "For oral mucosa, amoxicillin is the drug of choice. For patients who are allergic, I stick with 600 mg of clindamycin or 500 mg of azithromycin."

Ciprofloxacin, trimethoprim, and levofloxacin are choice for the ear, groin, and lower extremities.

"If patients can’t take anything orally, ceftriaxone 1 g given intramuscularly or intravenously is acceptable, with or without gentamicin for gram-negative coverage," Dr. Gasbarre said.

Dr. Gasbarre said he had no relevant financial conflicts.

CHICAGO – Infections from dermatologic surgery are rare, but possible, especially in high-risk patients, such as the immunosuppressed and those with joint or cardiac prostheses.

"Data from the four largest studies on this topic suggest an infective bacteremia of about 1.9% associated with all derm surgeries, which is actually less than you see with normal daily activities, like brushing your teeth and flossing," Christopher C. Gasbarre, D.O. said at the meeting . "Add to that the fact that the American Heart Association guidelines note that antibiotic prophylaxis doesn’t decrease the risk of infection to 0%," and the decision of whether to give the drugs becomes problematic.

Patients who are at high risk of postoperative infections, however, should receive preoperative or immediately postoperative antibiotics, said Dr. Gasbarre, a dermatologist at the Cleveland Clinic. "It’s important to remember that infective endocarditis and prosthetic joint infections secondary to dermatologic surgery are a well-known phenomenon, and a distant skin infection is the leading cause of prosthetic joint infections."

The American Heart Association reviewed and updated its surgical antibiotic guidelines in 2007, "making a significant shift in focus compared to their previous guidelines," Dr. Gasbarre said. The guidelines now recommend prophylaxis for patients with any prosthetic implanted material including cardiac valve replacements; cardiac patients with valvular disease; those with a history of infective pericarditis; anyone with unrepaired cyanotic congenital heart disease or a defect repaired within the past 6 months; and any congenital heart disease with a residual defect.

The American Dental Association updated its surgical antibiotic guidelines recently as well. "The guidelines recommend prophylaxis for high-risk patients undergoing oral procedures with a high risk of bleeding," he said.

Guidelines issued by the American Association of Orthopaedic Surgeons identify similar high-risk groups that should receive presurgical antibiotic therapy, including anyone who is less than 2 years out from a joint replacement, who is immunosuppressed, and who has hemophilia. "In dermatologic surgery, there are no studies on antibiotic prophylaxis, so we have to make do with these other recommendations," Dr. Gasbarre said.

Preventing wound infections is a major goal of surgical antibiotic treatment, he said. “In the dermatologic literature, the numbers range from 0.7% to 8%, depending on what study you’re looking at.”

Surgical site is a major consideration in anticipating postsurgical infections. "Ears, the nose, and lower leg below the knee have a greater risk of infection. Flaps and grafts have a higher risk, especially flaps on the nose. And a major cosmetic reconstruction that results in necrosis and scarring should also be a consideration."

The Mayo Clinic’s 2008 surgical antibiotic prophylaxis guidelines suggest antibiotics for dermatologic surgeries of the lower extremities, groin, and perineum; wedge excisions of the lip or ear; and other procedures with reported infection rates of at least 5%. Again, patients with immunosuppression require specific attention, as do those with inflammatory skin diseases, “who may carry a higher staphylococcus load on the skin,” Dr. Gasbarre said.

The literature suggests other high-risk groups might be those who undergo several procedures in 1 day, have high-tension wound closures, and have surgery on the hands, he added.

"The one thing that gets the most debate is whether to give antibiotics for a wound that’s exposed more than 3 hours," Dr. Gasbarre said. "I often do, although there are no guidelines. I take into consideration comorbidities, but certainly any surgery of the nasal mucosa and long procedures are worthy of consideration."

Culture is important for high-risk patients. "Culture for both community- and hospital-acquired methicillin-resistant Staphylococcus aureus and jump on those infections and eradicate them as quickly as possible."

Timing is another consideration. "Ideally we give antibiotics 30-60 minutes before the procedure to get enough antibiotic in the coagulum. But the new AHA guidelines say you can give them up to 2 hours after the procedure if not given before."

Select antibiotics carefully. "Beta hemolytic streptococcus and S. aureus are most likely to cause endocarditis from skin sites. You see a lot of gram-negative infections in the lower extremities and perineum. Pseudomonas can show up in the ear, but more than 90% of cultured ear isolates are staph and strep, not pseudomonas."

If the patient is not allergic to penicillin, Dr. Gasbarre prefers 2 g oral cephalexin or treatment with dicloxacillin or amoxicillin. "For oral mucosa, amoxicillin is the drug of choice. For patients who are allergic, I stick with 600 mg of clindamycin or 500 mg of azithromycin."

Ciprofloxacin, trimethoprim, and levofloxacin are choice for the ear, groin, and lower extremities.

"If patients can’t take anything orally, ceftriaxone 1 g given intramuscularly or intravenously is acceptable, with or without gentamicin for gram-negative coverage," Dr. Gasbarre said.

Dr. Gasbarre said he had no relevant financial conflicts.

CHICAGO – Infections from dermatologic surgery are rare, but possible, especially in high-risk patients, such as the immunosuppressed and those with joint or cardiac prostheses.

“Data from the four largest studies on this topic suggest an infective bacteremia of about 1.9% associated with all derm surgeries, which is actually less than you see with normal daily activities, like brushing your teeth and flossing,” Christopher C. Gasbarre, D.O. said at the meeting . “Add to that the fact that the American Heart Association guidelines note that antibiotic prophylaxis doesn’t decrease the risk of infection to 0%,” and the decision of whether to give the drugs becomes problematic.

Patients who are at high risk of postoperative infections, however, should receive preoperative or immediately postoperative antibiotics, said Dr. Gasbarre, a dermatologist at the Cleveland Clinic. “It’s important to remember that infective endocarditis and prosthetic joint infections secondary to dermatologic surgery are a well-known phenomenon, and a distant skin infection is the leading cause of prosthetic joint infections.”

The American Heart Association reviewed and updated its surgical antibiotic guidelines in 2007, “making a significant shift in focus compared to their previous guidelines,” Dr. Gasbarre said. The guidelines now recommend prophylaxis for patients with any prosthetic implanted material including cardiac valve replacements; cardiac patients with valvular disease; those with a history of infective pericarditis; anyone with unrepaired cyanotic congenital heart disease or a defect repaired within the past 6 months; and any congenital heart disease with a residual defect.

The American Dental Association updated its surgical antibiotic guidelines recently as well. “The guidelines recommend prophylaxis for high-risk patients undergoing oral procedures with a high risk of bleeding,” he said.

Guidelines issued by the American Association of Orthopaedic Surgeons identify similar high-risk groups that should receive presurgical antibiotic therapy, including anyone who is less than 2 years out from a joint replacement, who is immunosuppressed, and who has hemophilia. “In dermatologic surgery, there are no studies on antibiotic prophylaxis, so we have to make do with these other recommendations,” Dr Gasbarre said.

Preventing wound infections is a major goal of surgical antibiotic treatment, he said. “In the dermatologic literature, the numbers range from 0.7% to %, depending on what study you’re looking at.”

Surgical site is a major consideration in anticipating postsurgical infections. “Ears, the nose, and lower leg below the knee have a greater risk of infection. Flaps and grafts have a higher risk, especially flaps on the nose. And a major cosmetic reconstruction that results in necrosis and scarring should also be a consideration.”

The Mayo Clinic’s 2008 surgical antibiotic prophylaxis guidelines suggest antibiotics for dermatologic surgeries of the lower extremities, groin, and perineum; wedge excisions of the lip or ear; and other procedures with reported infection rates of at least 5%. Again, patients with immunosuppression require specific attention, as do those with inflammatory skin diseases, “who may carry a higher staphylococcus load on the skin,” Dr. Gasbarre said.

The literature suggests other high-risk groups might be those who undergo several procedures in 1 day, have high-tension wound closures, and have surgery on the hands, he added.

“The one thing that gets the most debate is whether to give antibiotics for a wound that’s exposed more than 3 hours, Dr. Gasbarre said. “I often do, although there are no guidelines. I take into consideration comorbidities, but certainly any surgery of the nasal mucosa and long procedures are worthy of consideration.”

Culture is important for high-risk patients. “Culture for both community- and hospital-acquired methicillin-resistant Staphylococcus aureus and jump on those infections and eradicate them as quickly as possible.”

Timing is another consideration. “Ideally we give antibiotics 30-60 minutes before the procedure to get enough antibiotic in the coagulum. But the new AHA guidelines say you can give them up to 2 hours after the procedure if not given before.”

Select antibiotics carefully. “Beta hemolytic streptococcus and S. aureus are most likely to cause endocarditis from skin sites. You see a lot of gram-negative infections in the lower extremities and perineum. Pseudomonas can show up in the ear, but more than 90% of cultured ear isolates are staph and strep, not pseudomonas.”

If the patient is not allergic to penicillin, Dr. Gasbarre prefers 2 g oral cephalexin or treatment with dicloxacillin or amoxicillin. “For oral mucosa, amoxicillin is the drug of choice. For patients who are allergic, I stick with 600 mg of clindamycin or 500 mg of azithromycin.”

Ciprofloxacin, trimethoprim, and levofloxacin are choice for the ear, groin, and lower extremities.

“If patients can’t take anything orally, ceftriaxone 1 g given intramuscularly or intravenously is acceptable, with or without gentamicin for gram-negative coverage,” Dr. Gasbarre said.

Dr. Gasbarre said he had no relevant financial conflicts.

CHICAGO – Infections from dermatologic surgery are rare, but possible, especially in high-risk patients, such as the immunosuppressed and those with joint or cardiac prostheses.

“Data from the four largest studies on this topic suggest an infective bacteremia of about 1.9% associated with all derm surgeries, which is actually less than you see with normal daily activities, like brushing your teeth and flossing,” Christopher C. Gasbarre, D.O. said at the meeting . “Add to that the fact that the American Heart Association guidelines note that antibiotic prophylaxis doesn’t decrease the risk of infection to 0%,” and the decision of whether to give the drugs becomes problematic.

Patients who are at high risk of postoperative infections, however, should receive preoperative or immediately postoperative antibiotics, said Dr. Gasbarre, a dermatologist at the Cleveland Clinic. “It’s important to remember that infective endocarditis and prosthetic joint infections secondary to dermatologic surgery are a well-known phenomenon, and a distant skin infection is the leading cause of prosthetic joint infections.”

The American Heart Association reviewed and updated its surgical antibiotic guidelines in 2007, “making a significant shift in focus compared to their previous guidelines,” Dr. Gasbarre said. The guidelines now recommend prophylaxis for patients with any prosthetic implanted material including cardiac valve replacements; cardiac patients with valvular disease; those with a history of infective pericarditis; anyone with unrepaired cyanotic congenital heart disease or a defect repaired within the past 6 months; and any congenital heart disease with a residual defect.

The American Dental Association updated its surgical antibiotic guidelines recently as well. “The guidelines recommend prophylaxis for high-risk patients undergoing oral procedures with a high risk of bleeding,” he said.

Guidelines issued by the American Association of Orthopaedic Surgeons identify similar high-risk groups that should receive presurgical antibiotic therapy, including anyone who is less than 2 years out from a joint replacement, who is immunosuppressed, and who has hemophilia. “In dermatologic surgery, there are no studies on antibiotic prophylaxis, so we have to make do with these other recommendations,” Dr Gasbarre said.

Preventing wound infections is a major goal of surgical antibiotic treatment, he said. “In the dermatologic literature, the numbers range from 0.7% to %, depending on what study you’re looking at.”

Surgical site is a major consideration in anticipating postsurgical infections. “Ears, the nose, and lower leg below the knee have a greater risk of infection. Flaps and grafts have a higher risk, especially flaps on the nose. And a major cosmetic reconstruction that results in necrosis and scarring should also be a consideration.”

The Mayo Clinic’s 2008 surgical antibiotic prophylaxis guidelines suggest antibiotics for dermatologic surgeries of the lower extremities, groin, and perineum; wedge excisions of the lip or ear; and other procedures with reported infection rates of at least 5%. Again, patients with immunosuppression require specific attention, as do those with inflammatory skin diseases, “who may carry a higher staphylococcus load on the skin,” Dr. Gasbarre said.

The literature suggests other high-risk groups might be those who undergo several procedures in 1 day, have high-tension wound closures, and have surgery on the hands, he added.

“The one thing that gets the most debate is whether to give antibiotics for a wound that’s exposed more than 3 hours, Dr. Gasbarre said. “I often do, although there are no guidelines. I take into consideration comorbidities, but certainly any surgery of the nasal mucosa and long procedures are worthy of consideration.”

Culture is important for high-risk patients. “Culture for both community- and hospital-acquired methicillin-resistant Staphylococcus aureus and jump on those infections and eradicate them as quickly as possible.”

Timing is another consideration. “Ideally we give antibiotics 30-60 minutes before the procedure to get enough antibiotic in the coagulum. But the new AHA guidelines say you can give them up to 2 hours after the procedure if not given before.”

Select antibiotics carefully. “Beta hemolytic streptococcus and S. aureus are most likely to cause endocarditis from skin sites. You see a lot of gram-negative infections in the lower extremities and perineum. Pseudomonas can show up in the ear, but more than 90% of cultured ear isolates are staph and strep, not pseudomonas.”

If the patient is not allergic to penicillin, Dr. Gasbarre prefers 2 g oral cephalexin or treatment with dicloxacillin or amoxicillin. “For oral mucosa, amoxicillin is the drug of choice. For patients who are allergic, I stick with 600 mg of clindamycin or 500 mg of azithromycin.”

Ciprofloxacin, trimethoprim, and levofloxacin are choice for the ear, groin, and lower extremities.

“If patients can’t take anything orally, ceftriaxone 1 g given intramuscularly or intravenously is acceptable, with or without gentamicin for gram-negative coverage,” Dr. Gasbarre said.

Dr. Gasbarre said he had no relevant financial conflicts.

CHICAGO – Infections from dermatologic surgery are rare, but possible, especially in high-risk patients, such as the immunosuppressed and those with joint or cardiac prostheses.

“Data from the four largest studies on this topic suggest an infective bacteremia of about 1.9% associated with all derm surgeries, which is actually less than you see with normal daily activities, like brushing your teeth and flossing,” Christopher C. Gasbarre, D.O. said at the meeting . “Add to that the fact that the American Heart Association guidelines note that antibiotic prophylaxis doesn’t decrease the risk of infection to 0%,” and the decision of whether to give the drugs becomes problematic.

Patients who are at high risk of postoperative infections, however, should receive preoperative or immediately postoperative antibiotics, said Dr. Gasbarre, a dermatologist at the Cleveland Clinic. “It’s important to remember that infective endocarditis and prosthetic joint infections secondary to dermatologic surgery are a well-known phenomenon, and a distant skin infection is the leading cause of prosthetic joint infections.”

The American Heart Association reviewed and updated its surgical antibiotic guidelines in 2007, “making a significant shift in focus compared to their previous guidelines,” Dr. Gasbarre said. The guidelines now recommend prophylaxis for patients with any prosthetic implanted material including cardiac valve replacements; cardiac patients with valvular disease; those with a history of infective pericarditis; anyone with unrepaired cyanotic congenital heart disease or a defect repaired within the past 6 months; and any congenital heart disease with a residual defect.

The American Dental Association updated its surgical antibiotic guidelines recently as well. “The guidelines recommend prophylaxis for high-risk patients undergoing oral procedures with a high risk of bleeding,” he said.

Guidelines issued by the American Association of Orthopaedic Surgeons identify similar high-risk groups that should receive presurgical antibiotic therapy, including anyone who is less than 2 years out from a joint replacement, who is immunosuppressed, and who has hemophilia. “In dermatologic surgery, there are no studies on antibiotic prophylaxis, so we have to make do with these other recommendations,” Dr Gasbarre said.

Preventing wound infections is a major goal of surgical antibiotic treatment, he said. “In the dermatologic literature, the numbers range from 0.7% to %, depending on what study you’re looking at.”

Surgical site is a major consideration in anticipating postsurgical infections. “Ears, the nose, and lower leg below the knee have a greater risk of infection. Flaps and grafts have a higher risk, especially flaps on the nose. And a major cosmetic reconstruction that results in necrosis and scarring should also be a consideration.”

The Mayo Clinic’s 2008 surgical antibiotic prophylaxis guidelines suggest antibiotics for dermatologic surgeries of the lower extremities, groin, and perineum; wedge excisions of the lip or ear; and other procedures with reported infection rates of at least 5%. Again, patients with immunosuppression require specific attention, as do those with inflammatory skin diseases, “who may carry a higher staphylococcus load on the skin,” Dr. Gasbarre said.

The literature suggests other high-risk groups might be those who undergo several procedures in 1 day, have high-tension wound closures, and have surgery on the hands, he added.

“The one thing that gets the most debate is whether to give antibiotics for a wound that’s exposed more than 3 hours, Dr. Gasbarre said. “I often do, although there are no guidelines. I take into consideration comorbidities, but certainly any surgery of the nasal mucosa and long procedures are worthy of consideration.”

Culture is important for high-risk patients. “Culture for both community- and hospital-acquired methicillin-resistant Staphylococcus aureus and jump on those infections and eradicate them as quickly as possible.”

Timing is another consideration. “Ideally we give antibiotics 30-60 minutes before the procedure to get enough antibiotic in the coagulum. But the new AHA guidelines say you can give them up to 2 hours after the procedure if not given before.”

Select antibiotics carefully. “Beta hemolytic streptococcus and S. aureus are most likely to cause endocarditis from skin sites. You see a lot of gram-negative infections in the lower extremities and perineum. Pseudomonas can show up in the ear, but more than 90% of cultured ear isolates are staph and strep, not pseudomonas.”

If the patient is not allergic to penicillin, Dr. Gasbarre prefers 2 g oral cephalexin or treatment with dicloxacillin or amoxicillin. “For oral mucosa, amoxicillin is the drug of choice. For patients who are allergic, I stick with 600 mg of clindamycin or 500 mg of azithromycin.”

Ciprofloxacin, trimethoprim, and levofloxacin are choice for the ear, groin, and lower extremities.

“If patients can’t take anything orally, ceftriaxone 1 g given intramuscularly or intravenously is acceptable, with or without gentamicin for gram-negative coverage,” Dr. Gasbarre said.

Dr. Gasbarre said he had no relevant financial conflicts.

VALENCIA, Spain  – An acrylic dental splint that is gradually adjusted over a long treatment period can accelerate mandibular growth in children with temporomandibular joint involvement in juvenile idiopathic arthritis, lengthening the affected side and normalizing jaw appearance and function.

“We found that we were able to speed up the metabolic growth rate of the affected side more than the unaffected side,” when the splint was used, Peter Stoustrup, D.D.S., reported at the congress of the Pediatric Rheumatology European Society. “We have also seen that this splint treatment seems to exert a protective effect on the inflamed joint, which can reduce soft-tissue damage and pain.”

He reported results of a series of 22 patients with JIA that was complicated by TMJ arthritis. Their mean age at disease onset was 7.5 years, and the mean treatment time was 57 months, although this varied widely (1-11 years).

The primary outcomes, as determined by baseline and final radiographs, were changes in the ratio between the unaffected and affected sides in condylar height, vertical ramus length, and total vertical mandibular height.

At the end of the study, the ratio of condylar height between the affected and unaffected sides was reduced from 1.18 to 1.14, which was not a significant change.

The ratio for vertical ramus length did change significantly, from 1.11 to 1.03. The ratio for total vertical mandibular height also significantly improved, dropping from 1.12 to 1.06.

The treatment was deemed successful in 19 (86%) of the patients. Three did not have satisfactory results and were referred for surgery.

TMJ arthritis occurs in about 62% of children with JIA, at least as confirmed by radiologic studies, said Dr. Stoustrup of the school of dentistry at Aarhus (Denmark) University. However, he noted, contrast-enhanced MRI suggests that the disorder could be even more common.

TMJ arthritis can lead to mandibular growth deviation resulting in micrognathia and shortened ramus length, an external rotation of the joint, open mandibular angle, cystic bone in the joint, and pain during chewing. The asymmetric growth can also result in a very specific appearance to the lower face. This facial deformity, often referred to as “bird face,” gives the lateral profile a reduced mandibular projection, with mandibular retrognathia, an open anterior bite, lower incisor crowding, and incisal protrusion.

“This is very difficult to correct orthodontically,” Dr. Stoustrup said. Most children are eventually referred for surgical correction.

The acrylic temporomandibular splint was first described by Dr. Thomas Pedersen in 1995 (Eur. J. Orthod. 1995;17:385-94). The splint covers the occlusal surfaces of the teeth in the lower dental arch and is worn 24 hours a day. The splint’s posterior height is adjusted slightly upward every 8-10 weeks on the affected side. “This normalizes dentoalveolar vertical development,” Dr. Stoustrup said.

What does this mean clinically for children who were successfully treated? Dr. Stoustrup described the case of a 13-year-old boy whose left TMJ arthritis was beginning to manifest as mandibular asymmetry. A frontal facial photo before treatment showed that the patient’s chin had deviated to the side of the affected joint, because of shortening of the mandible. He also displayed an open mandibular angle and posterior joint rotation pattern.

“We treated him with the distraction splint for 1.5 years, " Dr. Stoustrup said. At the end of treatment, the patient showed a much more anterior joint rotation pattern “because the mandible angle was increased.” The associated soft-tissue appearance was also much improved; the final facial photos showed that his chin was much more centered because of symmetrical jaw lengths.

Dr. Stoustrup did not disclose any financial conflicts.

VALENCIA, Spain  – An acrylic dental splint that is gradually adjusted over a long treatment period can accelerate mandibular growth in children with temporomandibular joint involvement in juvenile idiopathic arthritis, lengthening the affected side and normalizing jaw appearance and function.

“We found that we were able to speed up the metabolic growth rate of the affected side more than the unaffected side,” when the splint was used, Peter Stoustrup, D.D.S., reported at the congress of the Pediatric Rheumatology European Society. “We have also seen that this splint treatment seems to exert a protective effect on the inflamed joint, which can reduce soft-tissue damage and pain.”

He reported results of a series of 22 patients with JIA that was complicated by TMJ arthritis. Their mean age at disease onset was 7.5 years, and the mean treatment time was 57 months, although this varied widely (1-11 years).

The primary outcomes, as determined by baseline and final radiographs, were changes in the ratio between the unaffected and affected sides in condylar height, vertical ramus length, and total vertical mandibular height.

At the end of the study, the ratio of condylar height between the affected and unaffected sides was reduced from 1.18 to 1.14, which was not a significant change.

The ratio for vertical ramus length did change significantly, from 1.11 to 1.03. The ratio for total vertical mandibular height also significantly improved, dropping from 1.12 to 1.06.

The treatment was deemed successful in 19 (86%) of the patients. Three did not have satisfactory results and were referred for surgery.

TMJ arthritis occurs in about 62% of children with JIA, at least as confirmed by radiologic studies, said Dr. Stoustrup of the school of dentistry at Aarhus (Denmark) University. However, he noted, contrast-enhanced MRI suggests that the disorder could be even more common.

TMJ arthritis can lead to mandibular growth deviation resulting in micrognathia and shortened ramus length, an external rotation of the joint, open mandibular angle, cystic bone in the joint, and pain during chewing. The asymmetric growth can also result in a very specific appearance to the lower face. This facial deformity, often referred to as “bird face,” gives the lateral profile a reduced mandibular projection, with mandibular retrognathia, an open anterior bite, lower incisor crowding, and incisal protrusion.

“This is very difficult to correct orthodontically,” Dr. Stoustrup said. Most children are eventually referred for surgical correction.

The acrylic temporomandibular splint was first described by Dr. Thomas Pedersen in 1995 (Eur. J. Orthod. 1995;17:385-94). The splint covers the occlusal surfaces of the teeth in the lower dental arch and is worn 24 hours a day. The splint’s posterior height is adjusted slightly upward every 8-10 weeks on the affected side. “This normalizes dentoalveolar vertical development,” Dr. Stoustrup said.

What does this mean clinically for children who were successfully treated? Dr. Stoustrup described the case of a 13-year-old boy whose left TMJ arthritis was beginning to manifest as mandibular asymmetry. A frontal facial photo before treatment showed that the patient’s chin had deviated to the side of the affected joint, because of shortening of the mandible. He also displayed an open mandibular angle and posterior joint rotation pattern.

“We treated him with the distraction splint for 1.5 years, " Dr. Stoustrup said. At the end of treatment, the patient showed a much more anterior joint rotation pattern “because the mandible angle was increased.” The associated soft-tissue appearance was also much improved; the final facial photos showed that his chin was much more centered because of symmetrical jaw lengths.

Dr. Stoustrup did not disclose any financial conflicts.

VALENCIA, Spain  – An acrylic dental splint that is gradually adjusted over a long treatment period can accelerate mandibular growth in children with temporomandibular joint involvement in juvenile idiopathic arthritis, lengthening the affected side and normalizing jaw appearance and function.

“We found that we were able to speed up the metabolic growth rate of the affected side more than the unaffected side,” when the splint was used, Peter Stoustrup, D.D.S., reported at the congress of the Pediatric Rheumatology European Society. “We have also seen that this splint treatment seems to exert a protective effect on the inflamed joint, which can reduce soft-tissue damage and pain.”

He reported results of a series of 22 patients with JIA that was complicated by TMJ arthritis. Their mean age at disease onset was 7.5 years, and the mean treatment time was 57 months, although this varied widely (1-11 years).

The primary outcomes, as determined by baseline and final radiographs, were changes in the ratio between the unaffected and affected sides in condylar height, vertical ramus length, and total vertical mandibular height.

At the end of the study, the ratio of condylar height between the affected and unaffected sides was reduced from 1.18 to 1.14, which was not a significant change.

The ratio for vertical ramus length did change significantly, from 1.11 to 1.03. The ratio for total vertical mandibular height also significantly improved, dropping from 1.12 to 1.06.

The treatment was deemed successful in 19 (86%) of the patients. Three did not have satisfactory results and were referred for surgery.

TMJ arthritis occurs in about 62% of children with JIA, at least as confirmed by radiologic studies, said Dr. Stoustrup of the school of dentistry at Aarhus (Denmark) University. However, he noted, contrast-enhanced MRI suggests that the disorder could be even more common.

TMJ arthritis can lead to mandibular growth deviation resulting in micrognathia and shortened ramus length, an external rotation of the joint, open mandibular angle, cystic bone in the joint, and pain during chewing. The asymmetric growth can also result in a very specific appearance to the lower face. This facial deformity, often referred to as “bird face,” gives the lateral profile a reduced mandibular projection, with mandibular retrognathia, an open anterior bite, lower incisor crowding, and incisal protrusion.

“This is very difficult to correct orthodontically,” Dr. Stoustrup said. Most children are eventually referred for surgical correction.

The acrylic temporomandibular splint was first described by Dr. Thomas Pedersen in 1995 (Eur. J. Orthod. 1995;17:385-94). The splint covers the occlusal surfaces of the teeth in the lower dental arch and is worn 24 hours a day. The splint’s posterior height is adjusted slightly upward every 8-10 weeks on the affected side. “This normalizes dentoalveolar vertical development,” Dr. Stoustrup said.

What does this mean clinically for children who were successfully treated? Dr. Stoustrup described the case of a 13-year-old boy whose left TMJ arthritis was beginning to manifest as mandibular asymmetry. A frontal facial photo before treatment showed that the patient’s chin had deviated to the side of the affected joint, because of shortening of the mandible. He also displayed an open mandibular angle and posterior joint rotation pattern.

“We treated him with the distraction splint for 1.5 years, " Dr. Stoustrup said. At the end of treatment, the patient showed a much more anterior joint rotation pattern “because the mandible angle was increased.” The associated soft-tissue appearance was also much improved; the final facial photos showed that his chin was much more centered because of symmetrical jaw lengths.

Dr. Stoustrup did not disclose any financial conflicts.

VALENCIA, Spain  – An acrylic dental splint that is gradually adjusted over a long treatment period can accelerate mandibular growth in children with temporomandibular joint involvement in juvenile idiopathic arthritis, lengthening the affected side and normalizing jaw appearance and function.

“We found that we were able to speed up the metabolic growth rate of the affected side more than the unaffected side,” when the splint was used, Peter Stoustrup, D.D.S., reported at the congress of the Pediatric Rheumatology European Society. “We have also seen that this splint treatment seems to exert a protective effect on the inflamed joint, which can reduce soft-tissue damage and pain.”

He reported results of a series of 22 patients with JIA that was complicated by TMJ arthritis. Their mean age at disease onset was 7.5 years, and the mean treatment time was 57 months, although this varied widely (1-11 years).

The primary outcomes, as determined by baseline and final radiographs, were changes in the ratio between the unaffected and affected sides in condylar height, vertical ramus length, and total vertical mandibular height.

At the end of the study, the ratio of condylar height between the affected and unaffected sides was reduced from 1.18 to 1.14, which was not a significant change.

The ratio for vertical ramus length did change significantly, from 1.11 to 1.03. The ratio for total vertical mandibular height also significantly improved, dropping from 1.12 to 1.06.

The treatment was deemed successful in 19 (86%) of the patients. Three did not have satisfactory results and were referred for surgery.

TMJ arthritis occurs in about 62% of children with JIA, at least as confirmed by radiologic studies, said Dr. Stoustrup of the school of dentistry at Aarhus (Denmark) University. However, he noted, contrast-enhanced MRI suggests that the disorder could be even more common.

TMJ arthritis can lead to mandibular growth deviation resulting in micrognathia and shortened ramus length, an external rotation of the joint, open mandibular angle, cystic bone in the joint, and pain during chewing. The asymmetric growth can also result in a very specific appearance to the lower face. This facial deformity, often referred to as “bird face,” gives the lateral profile a reduced mandibular projection, with mandibular retrognathia, an open anterior bite, lower incisor crowding, and incisal protrusion.

“This is very difficult to correct orthodontically,” Dr. Stoustrup said. Most children are eventually referred for surgical correction.

The acrylic temporomandibular splint was first described by Dr. Thomas Pedersen in 1995 (Eur. J. Orthod. 1995;17:385-94). The splint covers the occlusal surfaces of the teeth in the lower dental arch and is worn 24 hours a day. The splint’s posterior height is adjusted slightly upward every 8-10 weeks on the affected side. “This normalizes dentoalveolar vertical development,” Dr. Stoustrup said.

What does this mean clinically for children who were successfully treated? Dr. Stoustrup described the case of a 13-year-old boy whose left TMJ arthritis was beginning to manifest as mandibular asymmetry. A frontal facial photo before treatment showed that the patient’s chin had deviated to the side of the affected joint, because of shortening of the mandible. He also displayed an open mandibular angle and posterior joint rotation pattern.

“We treated him with the distraction splint for 1.5 years, " Dr. Stoustrup said. At the end of treatment, the patient showed a much more anterior joint rotation pattern “because the mandible angle was increased.” The associated soft-tissue appearance was also much improved; the final facial photos showed that his chin was much more centered because of symmetrical jaw lengths.

Dr. Stoustrup did not disclose any financial conflicts.

VALENCIA, Spain  – An acrylic dental splint that is gradually adjusted over a long treatment period can accelerate mandibular growth in children with temporomandibular joint involvement in juvenile idiopathic arthritis, lengthening the affected side and normalizing jaw appearance and function.

“We found that we were able to speed up the metabolic growth rate of the affected side more than the unaffected side,” when the splint was used, Peter Stoustrup, D.D.S., reported at the congress of the Pediatric Rheumatology European Society. “We have also seen that this splint treatment seems to exert a protective effect on the inflamed joint, which can reduce soft-tissue damage and pain.”

He reported results of a series of 22 patients with JIA that was complicated by TMJ arthritis. Their mean age at disease onset was 7.5 years, and the mean treatment time was 57 months, although this varied widely (1-11 years).

The primary outcomes, as determined by baseline and final radiographs, were changes in the ratio between the unaffected and affected sides in condylar height, vertical ramus length, and total vertical mandibular height.

At the end of the study, the ratio of condylar height between the affected and unaffected sides was reduced from 1.18 to 1.14, which was not a significant change.

The ratio for vertical ramus length did change significantly, from 1.11 to 1.03. The ratio for total vertical mandibular height also significantly improved, dropping from 1.12 to 1.06.

The treatment was deemed successful in 19 (86%) of the patients. Three did not have satisfactory results and were referred for surgery.

TMJ arthritis occurs in about 62% of children with JIA, at least as confirmed by radiologic studies, said Dr. Stoustrup of the school of dentistry at Aarhus (Denmark) University. However, he noted, contrast-enhanced MRI suggests that the disorder could be even more common.

TMJ arthritis can lead to mandibular growth deviation resulting in micrognathia and shortened ramus length, an external rotation of the joint, open mandibular angle, cystic bone in the joint, and pain during chewing. The asymmetric growth can also result in a very specific appearance to the lower face. This facial deformity, often referred to as “bird face,” gives the lateral profile a reduced mandibular projection, with mandibular retrognathia, an open anterior bite, lower incisor crowding, and incisal protrusion.

“This is very difficult to correct orthodontically,” Dr. Stoustrup said. Most children are eventually referred for surgical correction.

The acrylic temporomandibular splint was first described by Dr. Thomas Pedersen in 1995 (Eur. J. Orthod. 1995;17:385-94). The splint covers the occlusal surfaces of the teeth in the lower dental arch and is worn 24 hours a day. The splint’s posterior height is adjusted slightly upward every 8-10 weeks on the affected side. “This normalizes dentoalveolar vertical development,” Dr. Stoustrup said.

What does this mean clinically for children who were successfully treated? Dr. Stoustrup described the case of a 13-year-old boy whose left TMJ arthritis was beginning to manifest as mandibular asymmetry. A frontal facial photo before treatment showed that the patient’s chin had deviated to the side of the affected joint, because of shortening of the mandible. He also displayed an open mandibular angle and posterior joint rotation pattern.

“We treated him with the distraction splint for 1.5 years, " Dr. Stoustrup said. At the end of treatment, the patient showed a much more anterior joint rotation pattern “because the mandible angle was increased.” The associated soft-tissue appearance was also much improved; the final facial photos showed that his chin was much more centered because of symmetrical jaw lengths.

Dr. Stoustrup did not disclose any financial conflicts.

VALENCIA, Spain  – An acrylic dental splint that is gradually adjusted over a long treatment period can accelerate mandibular growth in children with temporomandibular joint involvement in juvenile idiopathic arthritis, lengthening the affected side and normalizing jaw appearance and function.

“We found that we were able to speed up the metabolic growth rate of the affected side more than the unaffected side,” when the splint was used, Peter Stoustrup, D.D.S., reported at the congress of the Pediatric Rheumatology European Society. “We have also seen that this splint treatment seems to exert a protective effect on the inflamed joint, which can reduce soft-tissue damage and pain.”

He reported results of a series of 22 patients with JIA that was complicated by TMJ arthritis. Their mean age at disease onset was 7.5 years, and the mean treatment time was 57 months, although this varied widely (1-11 years).

The primary outcomes, as determined by baseline and final radiographs, were changes in the ratio between the unaffected and affected sides in condylar height, vertical ramus length, and total vertical mandibular height.

At the end of the study, the ratio of condylar height between the affected and unaffected sides was reduced from 1.18 to 1.14, which was not a significant change.

The ratio for vertical ramus length did change significantly, from 1.11 to 1.03. The ratio for total vertical mandibular height also significantly improved, dropping from 1.12 to 1.06.

The treatment was deemed successful in 19 (86%) of the patients. Three did not have satisfactory results and were referred for surgery.

TMJ arthritis occurs in about 62% of children with JIA, at least as confirmed by radiologic studies, said Dr. Stoustrup of the school of dentistry at Aarhus (Denmark) University. However, he noted, contrast-enhanced MRI suggests that the disorder could be even more common.

TMJ arthritis can lead to mandibular growth deviation resulting in micrognathia and shortened ramus length, an external rotation of the joint, open mandibular angle, cystic bone in the joint, and pain during chewing. The asymmetric growth can also result in a very specific appearance to the lower face. This facial deformity, often referred to as “bird face,” gives the lateral profile a reduced mandibular projection, with mandibular retrognathia, an open anterior bite, lower incisor crowding, and incisal protrusion.

“This is very difficult to correct orthodontically,” Dr. Stoustrup said. Most children are eventually referred for surgical correction.

The acrylic temporomandibular splint was first described by Dr. Thomas Pedersen in 1995 (Eur. J. Orthod. 1995;17:385-94). The splint covers the occlusal surfaces of the teeth in the lower dental arch and is worn 24 hours a day. The splint’s posterior height is adjusted slightly upward every 8-10 weeks on the affected side. “This normalizes dentoalveolar vertical development,” Dr. Stoustrup said.

What does this mean clinically for children who were successfully treated? Dr. Stoustrup described the case of a 13-year-old boy whose left TMJ arthritis was beginning to manifest as mandibular asymmetry. A frontal facial photo before treatment showed that the patient’s chin had deviated to the side of the affected joint, because of shortening of the mandible. He also displayed an open mandibular angle and posterior joint rotation pattern.

“We treated him with the distraction splint for 1.5 years, " Dr. Stoustrup said. At the end of treatment, the patient showed a much more anterior joint rotation pattern “because the mandible angle was increased.” The associated soft-tissue appearance was also much improved; the final facial photos showed that his chin was much more centered because of symmetrical jaw lengths.

Dr. Stoustrup did not disclose any financial conflicts.