Michele G. Sullivan

SAN FRANCISCO — While almost unheard of 10 years ago, community-associated methicillin-resistant Staphylococcus aureus has now become the single biggest cause of skin infections in the United States, Dr. Greg Moran said at the 12th International Conference on Emergency Medicine.

"We really don't know what's begun this sudden explosion of resistant staph in the community all over the United States, as well as in Canada and Europe," said Dr. Moran, an emergency physician at the Olive View-UCLA Medical Center, Sylmar, Calif. "One thing we do know is that this is not a phenomenon of the hospital strains moving into the community. These are genetically distinct strains."

The hospital strains are usually USA100 and 200, while the overwhelming majority of the community strains are USA300, he added.

In his 2006 study, virtually all the skin infections cultured from hospitals in 11 cities across the country were caused by community-associated strains; 78% of those were a single clone of USA300. "Almost all of [the skin infections] (98%) carried the Panton-Valentine leukocidin toxin gene and the SCCmec type IV gene," he said.

The SCCmec gene confers methicillin resistance, while the Panton-Valentine leukocidin toxin gene is associated with spontaneous skin and soft-tissue infections, as well as necrotizing pneumonia.

In addition to authoring a seminal paper on the topic (N. Engl. J. Med. 2006;355:666-74), Dr. Moran has kept track of the MRSA skin infections occurring in his own hospital since 1997. There were 25 cases documented that year. "That number rose to almost 450 per year in 2006 and 2007," he said. "In 2001, 29% of our skin infections were MRSA. That more than doubled by 2003-2004, to 64%."

There are a few clinical features associated with an increased risk of the community-associated MRSA infections, Dr. Moran said, including recent antibiotic use, abscess, a history of "spider bite" (insect bite of unknown origin), prior MRSA infection, and close contact with a MRSA-infected individual.

However, none of those was a strong predictor. "The reality is you can't use any of these risk factors to decide who you're going to treat for MRSA," he said. Despite their prevalence, most of these infections are not serious and don't grow the "killer flesh-eating super bugs" touted in grocery store tabloids, Dr. Moran said. "We still have a number of antibiotic options. More than 90% of the isolates in our study were susceptible to at least one agent."

Dr. Moran had the following comments about the available antibiotic choices:

▸ Vancomycin. "Even though this is the gold standard, we are now recognizing its limitations. We are seeing more resistance to this that we used to."

▸ Clindamycin. "Ninety-five percent of the isolates were susceptible to this in our study, although that appears to be decreasing. In our hospital, susceptibility is now down to about 85%."

▸ Linezolid. "It's very effective, but also very, very expensive. Post hoc data suggest that it may be clinically superior for hospital-acquired MRSA pneumonia, but there are no prospective data on this."

▸ Daptomycin. "Very good for skin infections, but we don't use it for MRSA pneumonia—it binds to the pulmonary surfactant and is inactivated."

▸ Tigecycline. "This is a good choice when you want to both gram-negative and gram-positive activity."

▸ Trimethoprim sulfa. "This is close to 100% effective in vitro, but there isn't much clinical data for its use in skin infections."

▸ Tetracycline. "It's a cheap generic with reasonable effectiveness."

Current studies conclude there's no real benefit to adding antibiotics to the treatment regimen, he said. However, there are quite a few limitations to those studies: Many had small treatment numbers and were done before the MRSA phenomenon, Dr. Moran added. Therefore, more aggressive treatment may be warranted now.

For most uncomplicated skin infections, he performs an incision and drainage, and doesn't give antibiotics. However, "I do give antibiotics if there is a fever, significant associated cellulitis, immune or vascular compromise, if the lesion is in a high-risk area like the hands or face, or if the patient has already failed an incision and drainage," Dr. Moran explained.

SAN FRANCISCO — While almost unheard of 10 years ago, community-associated methicillin-resistant Staphylococcus aureus has now become the single biggest cause of skin infections in the United States, Dr. Greg Moran said at the 12th International Conference on Emergency Medicine.

"We really don't know what's begun this sudden explosion of resistant staph in the community all over the United States, as well as in Canada and Europe," said Dr. Moran, an emergency physician at the Olive View-UCLA Medical Center, Sylmar, Calif. "One thing we do know is that this is not a phenomenon of the hospital strains moving into the community. These are genetically distinct strains."

The hospital strains are usually USA100 and 200, while the overwhelming majority of the community strains are USA300, he added.

In his 2006 study, virtually all the skin infections cultured from hospitals in 11 cities across the country were caused by community-associated strains; 78% of those were a single clone of USA300. "Almost all of [the skin infections] (98%) carried the Panton-Valentine leukocidin toxin gene and the SCCmec type IV gene," he said.

The SCCmec gene confers methicillin resistance, while the Panton-Valentine leukocidin toxin gene is associated with spontaneous skin and soft-tissue infections, as well as necrotizing pneumonia.

In addition to authoring a seminal paper on the topic (N. Engl. J. Med. 2006;355:666-74), Dr. Moran has kept track of the MRSA skin infections occurring in his own hospital since 1997. There were 25 cases documented that year. "That number rose to almost 450 per year in 2006 and 2007," he said. "In 2001, 29% of our skin infections were MRSA. That more than doubled by 2003-2004, to 64%."

There are a few clinical features associated with an increased risk of the community-associated MRSA infections, Dr. Moran said, including recent antibiotic use, abscess, a history of "spider bite" (insect bite of unknown origin), prior MRSA infection, and close contact with a MRSA-infected individual.

However, none of those was a strong predictor. "The reality is you can't use any of these risk factors to decide who you're going to treat for MRSA," he said. Despite their prevalence, most of these infections are not serious and don't grow the "killer flesh-eating super bugs" touted in grocery store tabloids, Dr. Moran said. "We still have a number of antibiotic options. More than 90% of the isolates in our study were susceptible to at least one agent."

Dr. Moran had the following comments about the available antibiotic choices:

▸ Vancomycin. "Even though this is the gold standard, we are now recognizing its limitations. We are seeing more resistance to this that we used to."

▸ Clindamycin. "Ninety-five percent of the isolates were susceptible to this in our study, although that appears to be decreasing. In our hospital, susceptibility is now down to about 85%."

▸ Linezolid. "It's very effective, but also very, very expensive. Post hoc data suggest that it may be clinically superior for hospital-acquired MRSA pneumonia, but there are no prospective data on this."

▸ Daptomycin. "Very good for skin infections, but we don't use it for MRSA pneumonia—it binds to the pulmonary surfactant and is inactivated."

▸ Tigecycline. "This is a good choice when you want to both gram-negative and gram-positive activity."

▸ Trimethoprim sulfa. "This is close to 100% effective in vitro, but there isn't much clinical data for its use in skin infections."

▸ Tetracycline. "It's a cheap generic with reasonable effectiveness."

Current studies conclude there's no real benefit to adding antibiotics to the treatment regimen, he said. However, there are quite a few limitations to those studies: Many had small treatment numbers and were done before the MRSA phenomenon, Dr. Moran added. Therefore, more aggressive treatment may be warranted now.

For most uncomplicated skin infections, he performs an incision and drainage, and doesn't give antibiotics. However, "I do give antibiotics if there is a fever, significant associated cellulitis, immune or vascular compromise, if the lesion is in a high-risk area like the hands or face, or if the patient has already failed an incision and drainage," Dr. Moran explained.

SAN FRANCISCO — While almost unheard of 10 years ago, community-associated methicillin-resistant Staphylococcus aureus has now become the single biggest cause of skin infections in the United States, Dr. Greg Moran said at the 12th International Conference on Emergency Medicine.

"We really don't know what's begun this sudden explosion of resistant staph in the community all over the United States, as well as in Canada and Europe," said Dr. Moran, an emergency physician at the Olive View-UCLA Medical Center, Sylmar, Calif. "One thing we do know is that this is not a phenomenon of the hospital strains moving into the community. These are genetically distinct strains."

The hospital strains are usually USA100 and 200, while the overwhelming majority of the community strains are USA300, he added.

In his 2006 study, virtually all the skin infections cultured from hospitals in 11 cities across the country were caused by community-associated strains; 78% of those were a single clone of USA300. "Almost all of [the skin infections] (98%) carried the Panton-Valentine leukocidin toxin gene and the SCCmec type IV gene," he said.

The SCCmec gene confers methicillin resistance, while the Panton-Valentine leukocidin toxin gene is associated with spontaneous skin and soft-tissue infections, as well as necrotizing pneumonia.

In addition to authoring a seminal paper on the topic (N. Engl. J. Med. 2006;355:666-74), Dr. Moran has kept track of the MRSA skin infections occurring in his own hospital since 1997. There were 25 cases documented that year. "That number rose to almost 450 per year in 2006 and 2007," he said. "In 2001, 29% of our skin infections were MRSA. That more than doubled by 2003-2004, to 64%."

There are a few clinical features associated with an increased risk of the community-associated MRSA infections, Dr. Moran said, including recent antibiotic use, abscess, a history of "spider bite" (insect bite of unknown origin), prior MRSA infection, and close contact with a MRSA-infected individual.

However, none of those was a strong predictor. "The reality is you can't use any of these risk factors to decide who you're going to treat for MRSA," he said. Despite their prevalence, most of these infections are not serious and don't grow the "killer flesh-eating super bugs" touted in grocery store tabloids, Dr. Moran said. "We still have a number of antibiotic options. More than 90% of the isolates in our study were susceptible to at least one agent."

Dr. Moran had the following comments about the available antibiotic choices:

▸ Vancomycin. "Even though this is the gold standard, we are now recognizing its limitations. We are seeing more resistance to this that we used to."

▸ Clindamycin. "Ninety-five percent of the isolates were susceptible to this in our study, although that appears to be decreasing. In our hospital, susceptibility is now down to about 85%."

▸ Linezolid. "It's very effective, but also very, very expensive. Post hoc data suggest that it may be clinically superior for hospital-acquired MRSA pneumonia, but there are no prospective data on this."

▸ Daptomycin. "Very good for skin infections, but we don't use it for MRSA pneumonia—it binds to the pulmonary surfactant and is inactivated."

▸ Tigecycline. "This is a good choice when you want to both gram-negative and gram-positive activity."

▸ Trimethoprim sulfa. "This is close to 100% effective in vitro, but there isn't much clinical data for its use in skin infections."

▸ Tetracycline. "It's a cheap generic with reasonable effectiveness."

Current studies conclude there's no real benefit to adding antibiotics to the treatment regimen, he said. However, there are quite a few limitations to those studies: Many had small treatment numbers and were done before the MRSA phenomenon, Dr. Moran added. Therefore, more aggressive treatment may be warranted now.

For most uncomplicated skin infections, he performs an incision and drainage, and doesn't give antibiotics. However, "I do give antibiotics if there is a fever, significant associated cellulitis, immune or vascular compromise, if the lesion is in a high-risk area like the hands or face, or if the patient has already failed an incision and drainage," Dr. Moran explained.

WILLIAMSBURG, VA. — More than half of patients who undergo organ transplantation will develop a skin cancer, often within the first 5 years after surgery, according to Dr. Henry Randle.

Most of the cancers associated with transplant surgery are squamous cell carcinomas (SCC), which tend to appear as multiple lesions that grow rapidly and exhibit a high rate of recurrence, said Dr. Randle of the Mayo Clinic, Jacksonville, Fla.

"These tumors are very aggressive and 5%-8% more likely to metastasize. They require aggressive treatment and frequent follow-up—like every 1-3 months. Don't let these patients get by without seeing you every 6 months to 1 year," he said at a meeting of the American Society for Mohs Surgery.

SCCs are up to 250 times more likely to develop in transplant patients than the rest of the population, according to Dr. Randle. These patients also have a 10-fold increased risk of basal cell carcinoma (BCC), a 3- to 5-fold increased risk of malignant melanoma, and up to an 85-fold increased risk of Kaposi sarcoma.

"It is now recognized that skin cancer constitutes 37%-50% of all de novo neoplasms in transplant patients. The typical patient has multiple actinic keratoses and warts, a reversal of the basal cell:squamous cell carcinoma ratio, and aggressive squamous cell carcinomas that may metastasize and cause death within months to years after the transplant."

He cited three severity groups:

▸ Isolated carcinogenesis. Patients have a few lesions scattered about, which can be treated with basic therapies.

▸ Moderate carcinogenesis. Patients have up to 10 skin cancers per year. They need more aggressive treatment (usually Mohs surgery), and more frequent follow-up.

▸ Catastrophic carcinogenesis. These patients can get more than 100 SCCs each year and are likely to die from the tumors. They require frequent visits and very aggressive treatment, perhaps with "megasessions," in which several lesions are removed with Mohs surgery in one treatment. This can be problematic as it usually requires general anesthesia and the sessions can be quite long, Dr. Randle said.

Mohs is not the only treatment that can benefit transplant patients, however. "We need to use all our options to treat them. That includes excisional surgery, Mohs, topical anticancer creams, and chemotherapy and radiation in selected patients," he said.

For superficial, low-risk SCC lesions, aggressive electrodesiccation and curettage or laser surgery should suffice. For large lesions, wide excision including the subcutaneous fat is necessary.

For high-risk, rapidly growing, or recurrent SCCs, Mohs is probably the choice. However, because these lesions are more prone to metastasize, a sentinel node biopsy should be considered, Dr. Randle said.

SCC lesions with in-transit metastases will require a wide excision plus radiation, "and very close follow-up, because this treatment will probably fail," Dr. Randle said.

Transplant patients with skin cancers will do better if they can reduce or eliminate their immunosuppressive medications, "but the transplant surgeons don't like that suggestion, of course. You need to walk a tightrope between rejection and skin cancer, and it's not easy," he said.

WILLIAMSBURG, VA. — More than half of patients who undergo organ transplantation will develop a skin cancer, often within the first 5 years after surgery, according to Dr. Henry Randle.

Most of the cancers associated with transplant surgery are squamous cell carcinomas (SCC), which tend to appear as multiple lesions that grow rapidly and exhibit a high rate of recurrence, said Dr. Randle of the Mayo Clinic, Jacksonville, Fla.

"These tumors are very aggressive and 5%-8% more likely to metastasize. They require aggressive treatment and frequent follow-up—like every 1-3 months. Don't let these patients get by without seeing you every 6 months to 1 year," he said at a meeting of the American Society for Mohs Surgery.

SCCs are up to 250 times more likely to develop in transplant patients than the rest of the population, according to Dr. Randle. These patients also have a 10-fold increased risk of basal cell carcinoma (BCC), a 3- to 5-fold increased risk of malignant melanoma, and up to an 85-fold increased risk of Kaposi sarcoma.

"It is now recognized that skin cancer constitutes 37%-50% of all de novo neoplasms in transplant patients. The typical patient has multiple actinic keratoses and warts, a reversal of the basal cell:squamous cell carcinoma ratio, and aggressive squamous cell carcinomas that may metastasize and cause death within months to years after the transplant."

He cited three severity groups:

▸ Isolated carcinogenesis. Patients have a few lesions scattered about, which can be treated with basic therapies.

▸ Moderate carcinogenesis. Patients have up to 10 skin cancers per year. They need more aggressive treatment (usually Mohs surgery), and more frequent follow-up.

▸ Catastrophic carcinogenesis. These patients can get more than 100 SCCs each year and are likely to die from the tumors. They require frequent visits and very aggressive treatment, perhaps with "megasessions," in which several lesions are removed with Mohs surgery in one treatment. This can be problematic as it usually requires general anesthesia and the sessions can be quite long, Dr. Randle said.

Mohs is not the only treatment that can benefit transplant patients, however. "We need to use all our options to treat them. That includes excisional surgery, Mohs, topical anticancer creams, and chemotherapy and radiation in selected patients," he said.

For superficial, low-risk SCC lesions, aggressive electrodesiccation and curettage or laser surgery should suffice. For large lesions, wide excision including the subcutaneous fat is necessary.

For high-risk, rapidly growing, or recurrent SCCs, Mohs is probably the choice. However, because these lesions are more prone to metastasize, a sentinel node biopsy should be considered, Dr. Randle said.

SCC lesions with in-transit metastases will require a wide excision plus radiation, "and very close follow-up, because this treatment will probably fail," Dr. Randle said.

Transplant patients with skin cancers will do better if they can reduce or eliminate their immunosuppressive medications, "but the transplant surgeons don't like that suggestion, of course. You need to walk a tightrope between rejection and skin cancer, and it's not easy," he said.

WILLIAMSBURG, VA. — More than half of patients who undergo organ transplantation will develop a skin cancer, often within the first 5 years after surgery, according to Dr. Henry Randle.

Most of the cancers associated with transplant surgery are squamous cell carcinomas (SCC), which tend to appear as multiple lesions that grow rapidly and exhibit a high rate of recurrence, said Dr. Randle of the Mayo Clinic, Jacksonville, Fla.

"These tumors are very aggressive and 5%-8% more likely to metastasize. They require aggressive treatment and frequent follow-up—like every 1-3 months. Don't let these patients get by without seeing you every 6 months to 1 year," he said at a meeting of the American Society for Mohs Surgery.

SCCs are up to 250 times more likely to develop in transplant patients than the rest of the population, according to Dr. Randle. These patients also have a 10-fold increased risk of basal cell carcinoma (BCC), a 3- to 5-fold increased risk of malignant melanoma, and up to an 85-fold increased risk of Kaposi sarcoma.

"It is now recognized that skin cancer constitutes 37%-50% of all de novo neoplasms in transplant patients. The typical patient has multiple actinic keratoses and warts, a reversal of the basal cell:squamous cell carcinoma ratio, and aggressive squamous cell carcinomas that may metastasize and cause death within months to years after the transplant."

He cited three severity groups:

▸ Isolated carcinogenesis. Patients have a few lesions scattered about, which can be treated with basic therapies.

▸ Moderate carcinogenesis. Patients have up to 10 skin cancers per year. They need more aggressive treatment (usually Mohs surgery), and more frequent follow-up.

▸ Catastrophic carcinogenesis. These patients can get more than 100 SCCs each year and are likely to die from the tumors. They require frequent visits and very aggressive treatment, perhaps with "megasessions," in which several lesions are removed with Mohs surgery in one treatment. This can be problematic as it usually requires general anesthesia and the sessions can be quite long, Dr. Randle said.

Mohs is not the only treatment that can benefit transplant patients, however. "We need to use all our options to treat them. That includes excisional surgery, Mohs, topical anticancer creams, and chemotherapy and radiation in selected patients," he said.

For superficial, low-risk SCC lesions, aggressive electrodesiccation and curettage or laser surgery should suffice. For large lesions, wide excision including the subcutaneous fat is necessary.

For high-risk, rapidly growing, or recurrent SCCs, Mohs is probably the choice. However, because these lesions are more prone to metastasize, a sentinel node biopsy should be considered, Dr. Randle said.

SCC lesions with in-transit metastases will require a wide excision plus radiation, "and very close follow-up, because this treatment will probably fail," Dr. Randle said.

Transplant patients with skin cancers will do better if they can reduce or eliminate their immunosuppressive medications, "but the transplant surgeons don't like that suggestion, of course. You need to walk a tightrope between rejection and skin cancer, and it's not easy," he said.

WILLIAMSBURG, VA. — Sentinel lymph node biopsy should be reserved only for squamous cell carcinoma patients whose primary tumors have a high-risk profile, according to Dr. Merrick Ross.

"Clearly, the routine use of sentinel node biopsy is not indicated in these patients, but its selective use in high-risk squamous cell carcinoma [SCC] seems rational," said Dr. Ross at a meeting of the American Society for Mohs Surgery. "This is why it's important for us to continue to define exactly what constitutes a high-risk squamous cell tumor."

High-risk features of SCC include anatomical location, thickness, size, perineural invasion, and the immunocompetence of the patient.

Increasing size is associated with decreased local control and the increased presence of positive lymph nodes. A size of 2 cm "seems to be the most relevant break point," said Dr. Ross, professor of surgical oncology at the University of Texas M.D. Anderson Cancer Center, Houston. "Studies have shown that up to 50% of SCCs larger than that will have nodal involvement. However, to date there is no multivariate analysis that demonstrates size as an independent predictor of nodal disease."

Most studies identify 4-5 cm as the high-risk break point for tumor thickness, he said. In a large German study of 550 patients, only 3% of those with tumors less than 5 mm thick had nodal metastasis, compared with more than 17% of those with thicker tumors, Dr. Ross noted (Cancer 1997;79:915-9).

High-grade tumors are more likely than low-grade tumors to have nodal disease, said Dr. Ross, with 17% of high-grade tumors showing metastasis, compared with 4% of lower-grade tumors. When the German investigators looked at grade distribution according to nodal involvement, 44% of node-positive patients had high-grade primary tumors, whereas only 5% of node-negative patients had high-grade tumors.

Local recurrence is strongly associated with nodal involvement, just as it is with larger size, thicker tumors, narrow excision margins, and anatomical site. Up to 45% of recurrent presentations will have nodal disease, Dr. Ross said.

Lesions that arise on the lip, around the ear, and in the anogenital region are particularly risky. A 2006 study found that 27% of SCCs on the external ear had nodal disease, as did more than 20% of T3- and T4-stage lip lesions (Aust. J Derm. 2006;47:28-33).

The overall health of the patient is another important risk factor. "Patients with HIV [disease] or other immunodeficiency diseases are at an increased risk for metastasis, as are those with any chronic hematologic malignancy" Dr. Ross said.

WILLIAMSBURG, VA. — Sentinel lymph node biopsy should be reserved only for squamous cell carcinoma patients whose primary tumors have a high-risk profile, according to Dr. Merrick Ross.

"Clearly, the routine use of sentinel node biopsy is not indicated in these patients, but its selective use in high-risk squamous cell carcinoma [SCC] seems rational," said Dr. Ross at a meeting of the American Society for Mohs Surgery. "This is why it's important for us to continue to define exactly what constitutes a high-risk squamous cell tumor."

High-risk features of SCC include anatomical location, thickness, size, perineural invasion, and the immunocompetence of the patient.

Increasing size is associated with decreased local control and the increased presence of positive lymph nodes. A size of 2 cm "seems to be the most relevant break point," said Dr. Ross, professor of surgical oncology at the University of Texas M.D. Anderson Cancer Center, Houston. "Studies have shown that up to 50% of SCCs larger than that will have nodal involvement. However, to date there is no multivariate analysis that demonstrates size as an independent predictor of nodal disease."

Most studies identify 4-5 cm as the high-risk break point for tumor thickness, he said. In a large German study of 550 patients, only 3% of those with tumors less than 5 mm thick had nodal metastasis, compared with more than 17% of those with thicker tumors, Dr. Ross noted (Cancer 1997;79:915-9).

High-grade tumors are more likely than low-grade tumors to have nodal disease, said Dr. Ross, with 17% of high-grade tumors showing metastasis, compared with 4% of lower-grade tumors. When the German investigators looked at grade distribution according to nodal involvement, 44% of node-positive patients had high-grade primary tumors, whereas only 5% of node-negative patients had high-grade tumors.

Local recurrence is strongly associated with nodal involvement, just as it is with larger size, thicker tumors, narrow excision margins, and anatomical site. Up to 45% of recurrent presentations will have nodal disease, Dr. Ross said.

Lesions that arise on the lip, around the ear, and in the anogenital region are particularly risky. A 2006 study found that 27% of SCCs on the external ear had nodal disease, as did more than 20% of T3- and T4-stage lip lesions (Aust. J Derm. 2006;47:28-33).

The overall health of the patient is another important risk factor. "Patients with HIV [disease] or other immunodeficiency diseases are at an increased risk for metastasis, as are those with any chronic hematologic malignancy" Dr. Ross said.

WILLIAMSBURG, VA. — Sentinel lymph node biopsy should be reserved only for squamous cell carcinoma patients whose primary tumors have a high-risk profile, according to Dr. Merrick Ross.

"Clearly, the routine use of sentinel node biopsy is not indicated in these patients, but its selective use in high-risk squamous cell carcinoma [SCC] seems rational," said Dr. Ross at a meeting of the American Society for Mohs Surgery. "This is why it's important for us to continue to define exactly what constitutes a high-risk squamous cell tumor."

High-risk features of SCC include anatomical location, thickness, size, perineural invasion, and the immunocompetence of the patient.

Increasing size is associated with decreased local control and the increased presence of positive lymph nodes. A size of 2 cm "seems to be the most relevant break point," said Dr. Ross, professor of surgical oncology at the University of Texas M.D. Anderson Cancer Center, Houston. "Studies have shown that up to 50% of SCCs larger than that will have nodal involvement. However, to date there is no multivariate analysis that demonstrates size as an independent predictor of nodal disease."

Most studies identify 4-5 cm as the high-risk break point for tumor thickness, he said. In a large German study of 550 patients, only 3% of those with tumors less than 5 mm thick had nodal metastasis, compared with more than 17% of those with thicker tumors, Dr. Ross noted (Cancer 1997;79:915-9).

High-grade tumors are more likely than low-grade tumors to have nodal disease, said Dr. Ross, with 17% of high-grade tumors showing metastasis, compared with 4% of lower-grade tumors. When the German investigators looked at grade distribution according to nodal involvement, 44% of node-positive patients had high-grade primary tumors, whereas only 5% of node-negative patients had high-grade tumors.

Local recurrence is strongly associated with nodal involvement, just as it is with larger size, thicker tumors, narrow excision margins, and anatomical site. Up to 45% of recurrent presentations will have nodal disease, Dr. Ross said.

Lesions that arise on the lip, around the ear, and in the anogenital region are particularly risky. A 2006 study found that 27% of SCCs on the external ear had nodal disease, as did more than 20% of T3- and T4-stage lip lesions (Aust. J Derm. 2006;47:28-33).

The overall health of the patient is another important risk factor. "Patients with HIV [disease] or other immunodeficiency diseases are at an increased risk for metastasis, as are those with any chronic hematologic malignancy" Dr. Ross said.

WILLIAMSBURG, VA. — Patients with prosthetic cardiac valves and recently implanted joint prostheses are among the few who should receive prophylactic antibiotics before surgical procedures, according to a dermatologic surgeon.

Prosthetic devices sometimes grow coagulase-negative Staphylococcus aureus, which can cause a life-threatening endocarditis or, in the case of joint prostheses, an intra-articular infection that can necessitate replacement of the device. "If a patient [in these categories] comes to me for surgery and has not been prophylaxed, I will not do the procedure," said Dr. Stephen Spencer of Port Charlotte, Fla.

Neither of the guidelines that address prophylactic antibiotics—the 2007 guidelines for preventing infective carditis and the 2003 guidelines for preventing hematogenous total joint infections—specifically deal with dermatologic surgery, but dermatologists can rationally extrapolate the recommendations to their own patients, Dr. Spencer said at a meeting of the American Society for Mohs Surgery.

For patients with prosthetic cardiac valves, the American Heart Association guidelines recommend 2 g of amoxicillin orally 30-60 minutes before the procedure. Penicillin-allergic patients can take cephalexin, clindamycin, or azithromycin (Circulation 2007;116:1736-54).

Patients who have had a total joint replacement in the past 2 years should take 2 g of cephalexin, cephradine, or amoxicillin 60 minutes before surgery. Penicillin-allergic patients can take clindamycin. Choices for injected antibiotics include clindamycin, cefazolin, or ampicillin, according to guidelines issued by the American Dental Association and the American Academy of Orthopedic Surgeons (J. Am. Dent. Assoc. 2003;134:895-9).

For most other patients, including healthy individuals with joint replacements more than 2 years old, the risks of adverse events associated with antibiotic treatment probably outweigh any potential benefit it might have in preventing infective complications, including infective endocarditis, said Dr. Spencer.

"Very few healthy people need these preoperative antibiotics," he said, citing a 2006 study from Australia that found an extremely low rate of wound infection after dermatologic surgery in the absence of prophylactic antibiotics (Dermatol. Surg. 2006;32:819-26).

The 3-year study included 5,091 lesions treated on 2,424 patients, none of whom received preoperative antibiotics. The overall infection incidence was 1.5%, and many individual procedures had similarly low rates: curettage (0.7%); skin flap repairs (3%); simple excision and closure (0.5%). Skin grafts and wedge excisions had higher rates (9% each).

The investigators concluded that surgery to the nose, ear, fingers, and lips; skin flap surgery; and surgery on diabetics, smokers, and those on anticoagulants did not warrant prophylactic antibiotic treatment. They did recommend antibiotics for procedures below the knee, wedge excisions of lip and ear, all skin grafts, and lesions in the groin, Dr. Spencer noted.

WILLIAMSBURG, VA. — Patients with prosthetic cardiac valves and recently implanted joint prostheses are among the few who should receive prophylactic antibiotics before surgical procedures, according to a dermatologic surgeon.

Prosthetic devices sometimes grow coagulase-negative Staphylococcus aureus, which can cause a life-threatening endocarditis or, in the case of joint prostheses, an intra-articular infection that can necessitate replacement of the device. "If a patient [in these categories] comes to me for surgery and has not been prophylaxed, I will not do the procedure," said Dr. Stephen Spencer of Port Charlotte, Fla.

Neither of the guidelines that address prophylactic antibiotics—the 2007 guidelines for preventing infective carditis and the 2003 guidelines for preventing hematogenous total joint infections—specifically deal with dermatologic surgery, but dermatologists can rationally extrapolate the recommendations to their own patients, Dr. Spencer said at a meeting of the American Society for Mohs Surgery.

For patients with prosthetic cardiac valves, the American Heart Association guidelines recommend 2 g of amoxicillin orally 30-60 minutes before the procedure. Penicillin-allergic patients can take cephalexin, clindamycin, or azithromycin (Circulation 2007;116:1736-54).

Patients who have had a total joint replacement in the past 2 years should take 2 g of cephalexin, cephradine, or amoxicillin 60 minutes before surgery. Penicillin-allergic patients can take clindamycin. Choices for injected antibiotics include clindamycin, cefazolin, or ampicillin, according to guidelines issued by the American Dental Association and the American Academy of Orthopedic Surgeons (J. Am. Dent. Assoc. 2003;134:895-9).

For most other patients, including healthy individuals with joint replacements more than 2 years old, the risks of adverse events associated with antibiotic treatment probably outweigh any potential benefit it might have in preventing infective complications, including infective endocarditis, said Dr. Spencer.

"Very few healthy people need these preoperative antibiotics," he said, citing a 2006 study from Australia that found an extremely low rate of wound infection after dermatologic surgery in the absence of prophylactic antibiotics (Dermatol. Surg. 2006;32:819-26).

The 3-year study included 5,091 lesions treated on 2,424 patients, none of whom received preoperative antibiotics. The overall infection incidence was 1.5%, and many individual procedures had similarly low rates: curettage (0.7%); skin flap repairs (3%); simple excision and closure (0.5%). Skin grafts and wedge excisions had higher rates (9% each).

The investigators concluded that surgery to the nose, ear, fingers, and lips; skin flap surgery; and surgery on diabetics, smokers, and those on anticoagulants did not warrant prophylactic antibiotic treatment. They did recommend antibiotics for procedures below the knee, wedge excisions of lip and ear, all skin grafts, and lesions in the groin, Dr. Spencer noted.

WILLIAMSBURG, VA. — Patients with prosthetic cardiac valves and recently implanted joint prostheses are among the few who should receive prophylactic antibiotics before surgical procedures, according to a dermatologic surgeon.

Prosthetic devices sometimes grow coagulase-negative Staphylococcus aureus, which can cause a life-threatening endocarditis or, in the case of joint prostheses, an intra-articular infection that can necessitate replacement of the device. "If a patient [in these categories] comes to me for surgery and has not been prophylaxed, I will not do the procedure," said Dr. Stephen Spencer of Port Charlotte, Fla.

Neither of the guidelines that address prophylactic antibiotics—the 2007 guidelines for preventing infective carditis and the 2003 guidelines for preventing hematogenous total joint infections—specifically deal with dermatologic surgery, but dermatologists can rationally extrapolate the recommendations to their own patients, Dr. Spencer said at a meeting of the American Society for Mohs Surgery.

For patients with prosthetic cardiac valves, the American Heart Association guidelines recommend 2 g of amoxicillin orally 30-60 minutes before the procedure. Penicillin-allergic patients can take cephalexin, clindamycin, or azithromycin (Circulation 2007;116:1736-54).

Patients who have had a total joint replacement in the past 2 years should take 2 g of cephalexin, cephradine, or amoxicillin 60 minutes before surgery. Penicillin-allergic patients can take clindamycin. Choices for injected antibiotics include clindamycin, cefazolin, or ampicillin, according to guidelines issued by the American Dental Association and the American Academy of Orthopedic Surgeons (J. Am. Dent. Assoc. 2003;134:895-9).

For most other patients, including healthy individuals with joint replacements more than 2 years old, the risks of adverse events associated with antibiotic treatment probably outweigh any potential benefit it might have in preventing infective complications, including infective endocarditis, said Dr. Spencer.

"Very few healthy people need these preoperative antibiotics," he said, citing a 2006 study from Australia that found an extremely low rate of wound infection after dermatologic surgery in the absence of prophylactic antibiotics (Dermatol. Surg. 2006;32:819-26).

The 3-year study included 5,091 lesions treated on 2,424 patients, none of whom received preoperative antibiotics. The overall infection incidence was 1.5%, and many individual procedures had similarly low rates: curettage (0.7%); skin flap repairs (3%); simple excision and closure (0.5%). Skin grafts and wedge excisions had higher rates (9% each).

The investigators concluded that surgery to the nose, ear, fingers, and lips; skin flap surgery; and surgery on diabetics, smokers, and those on anticoagulants did not warrant prophylactic antibiotic treatment. They did recommend antibiotics for procedures below the knee, wedge excisions of lip and ear, all skin grafts, and lesions in the groin, Dr. Spencer noted.

WILLIAMSBURG, VA. — Consistent application of tissue nicks and annotated tissue transfer cards can significantly reduce the chance of error in Mohs surgery.

"Recurrence after Mohs surgery is very low, only 1%-2% at most, but when we look at the reasons behind those recurrences, 75% are due to human error, and of these, 10% are due to incorrect mapping and excision," said Dr. Tri H. Nguyen, director of Mohs micrographic and dermatologic surgery at the University of Texas M.D. Anderson Cancer Center, Houston.

"This includes tissue-orientation mistakes, mapping inaccuracies, mislabeling of sections or slides, and insufficient resection," Dr. Nguyen said at a meeting of the American Society for Mohs Surgery.

He methodically employs a system of identification strategies that nearly eliminates the chance of orientation errors, but an informal survey of fellowship programs showed that few physicians may be using this same level of caution.

Dr. Nguyen asked his residents about orientation techniques taught in the 14 Mohs fellowship programs for which they applied. Only three programs used preprinted maps, and only one used preprinted tissue transfer cards. Only five programs used tissue nicks to orient the sample, and only two of those used double nicks to add an extra layer of security.

"There are tremendous variations in the way we practice mapping and orientation, and probably all are adequate for primary, low-risk, single-stage Mohs resections," he said. "We run into problems with high-risk tumors with multiple convolutions or convexities, and in surgeries with multiple stages and multiple sites."

Anatomical maps and transfer cards can help reduce these problems. The cards have preprinted maps with illustrations of anatomical areas, and they also absorb moisture from specimens, which decreases the chance that they will shift position or fall off during the transfer. Corresponding paper maps have the same information printed on them.

"We have preprinted maps and transfer cards for every conceivable [anatomical area] on the head and neck, and blank ones for drawing locations on the extremities," Dr. Nguyen said.

Strategic tissue nicking adds a second layer of security to the surgery. "The argument over tissue nicks is pointless. There is no doubt that a properly made nick of the patient and the excised tissue leaves an indelible mark to go back and orient your sample," he said.

Single nicks, however, aren't sufficient. "With a single, there is always a chance the tissue will get dropped or shifted and you will lose the accuracy of your orientation. If you have a second nick consistently placed, you will always know exactly how the tissue is oriented. Two nicks ensure specimen orientation with or without" an anatomical transfer card, Dr. Nguyen said.

In double nicking, there should be a little space between the incisions. "If you place the second nick close to the peripheral edge, you are prone to tissue folding, which can mask tumor," he said.

WILLIAMSBURG, VA. — Consistent application of tissue nicks and annotated tissue transfer cards can significantly reduce the chance of error in Mohs surgery.

"Recurrence after Mohs surgery is very low, only 1%-2% at most, but when we look at the reasons behind those recurrences, 75% are due to human error, and of these, 10% are due to incorrect mapping and excision," said Dr. Tri H. Nguyen, director of Mohs micrographic and dermatologic surgery at the University of Texas M.D. Anderson Cancer Center, Houston.

"This includes tissue-orientation mistakes, mapping inaccuracies, mislabeling of sections or slides, and insufficient resection," Dr. Nguyen said at a meeting of the American Society for Mohs Surgery.

He methodically employs a system of identification strategies that nearly eliminates the chance of orientation errors, but an informal survey of fellowship programs showed that few physicians may be using this same level of caution.

Dr. Nguyen asked his residents about orientation techniques taught in the 14 Mohs fellowship programs for which they applied. Only three programs used preprinted maps, and only one used preprinted tissue transfer cards. Only five programs used tissue nicks to orient the sample, and only two of those used double nicks to add an extra layer of security.

"There are tremendous variations in the way we practice mapping and orientation, and probably all are adequate for primary, low-risk, single-stage Mohs resections," he said. "We run into problems with high-risk tumors with multiple convolutions or convexities, and in surgeries with multiple stages and multiple sites."

Anatomical maps and transfer cards can help reduce these problems. The cards have preprinted maps with illustrations of anatomical areas, and they also absorb moisture from specimens, which decreases the chance that they will shift position or fall off during the transfer. Corresponding paper maps have the same information printed on them.

"We have preprinted maps and transfer cards for every conceivable [anatomical area] on the head and neck, and blank ones for drawing locations on the extremities," Dr. Nguyen said.

Strategic tissue nicking adds a second layer of security to the surgery. "The argument over tissue nicks is pointless. There is no doubt that a properly made nick of the patient and the excised tissue leaves an indelible mark to go back and orient your sample," he said.

Single nicks, however, aren't sufficient. "With a single, there is always a chance the tissue will get dropped or shifted and you will lose the accuracy of your orientation. If you have a second nick consistently placed, you will always know exactly how the tissue is oriented. Two nicks ensure specimen orientation with or without" an anatomical transfer card, Dr. Nguyen said.

In double nicking, there should be a little space between the incisions. "If you place the second nick close to the peripheral edge, you are prone to tissue folding, which can mask tumor," he said.

WILLIAMSBURG, VA. — Consistent application of tissue nicks and annotated tissue transfer cards can significantly reduce the chance of error in Mohs surgery.

"Recurrence after Mohs surgery is very low, only 1%-2% at most, but when we look at the reasons behind those recurrences, 75% are due to human error, and of these, 10% are due to incorrect mapping and excision," said Dr. Tri H. Nguyen, director of Mohs micrographic and dermatologic surgery at the University of Texas M.D. Anderson Cancer Center, Houston.

"This includes tissue-orientation mistakes, mapping inaccuracies, mislabeling of sections or slides, and insufficient resection," Dr. Nguyen said at a meeting of the American Society for Mohs Surgery.

He methodically employs a system of identification strategies that nearly eliminates the chance of orientation errors, but an informal survey of fellowship programs showed that few physicians may be using this same level of caution.

Dr. Nguyen asked his residents about orientation techniques taught in the 14 Mohs fellowship programs for which they applied. Only three programs used preprinted maps, and only one used preprinted tissue transfer cards. Only five programs used tissue nicks to orient the sample, and only two of those used double nicks to add an extra layer of security.

"There are tremendous variations in the way we practice mapping and orientation, and probably all are adequate for primary, low-risk, single-stage Mohs resections," he said. "We run into problems with high-risk tumors with multiple convolutions or convexities, and in surgeries with multiple stages and multiple sites."

Anatomical maps and transfer cards can help reduce these problems. The cards have preprinted maps with illustrations of anatomical areas, and they also absorb moisture from specimens, which decreases the chance that they will shift position or fall off during the transfer. Corresponding paper maps have the same information printed on them.

"We have preprinted maps and transfer cards for every conceivable [anatomical area] on the head and neck, and blank ones for drawing locations on the extremities," Dr. Nguyen said.

Strategic tissue nicking adds a second layer of security to the surgery. "The argument over tissue nicks is pointless. There is no doubt that a properly made nick of the patient and the excised tissue leaves an indelible mark to go back and orient your sample," he said.

Single nicks, however, aren't sufficient. "With a single, there is always a chance the tissue will get dropped or shifted and you will lose the accuracy of your orientation. If you have a second nick consistently placed, you will always know exactly how the tissue is oriented. Two nicks ensure specimen orientation with or without" an anatomical transfer card, Dr. Nguyen said.

In double nicking, there should be a little space between the incisions. "If you place the second nick close to the peripheral edge, you are prone to tissue folding, which can mask tumor," he said.

WILLIAMSBURG, VA. — Although large numbers of nevi—especially dysplastic nevi—are clearly associated with an increased melanoma risk, the lesions themselves do not appear to become cancerous, Dr. Terry L. Barrett said at the annual meeting of the American Society for Mohs Surgery.

"I remain unconvinced that either the common acquired nevus or the dysplastic nevus develops into melanoma," said Dr. Barrett, professor of pathology and dermatology at the University of Texas, Dallas. "I think they are both benign lesions the majority of the time. Usually, melanomas in these patients arise on normal-appearing skin and not the site of the nevus. When that happens, I think it's coincidental, not a nevus gone bad."

Few studies have actually investigated this point, although Dr. Barrett did mention a 2007 in vitro study that looked at levels of polycomb group protein EZH2, a cell regulatory protein markedly elevated in malignant skin lesions (J. Cutan. Pathol. 2007;34:597-600). The level in both in situ and invasive melanoma was almost three times that seen in acquired and dysplastic nevi—a finding that seems to support Dr. Barrett's opinion.

Regardless of the source, however, patients with large numbers of nevi are at a significantly increased risk of melanoma and other malignancies. The two commonly recognized nevi syndromes carry different risks, Dr. Barrett said.

Familial atypical mole/melanoma syndrome is an autosomal dominant disorder that increases the lifetime risk of melanoma by almost 100%. Sporadic dysplastic nevus syndrome is a spontaneous mutation that increases the relative risk of malignancy up to 46 times that of the general population, he said.

For patients with the sporadic syndrome, sun exposure seems to play a key role in the development of melanoma. "It's been suggested that intermittent sun exposure manifests the phenotype of the dysplastic nevi [and its attendant increased melanoma risk], while patients without sun exposure manifest the common acquired nevi," Dr. Barrett noted.

"There is no clear agreement among dermatologists about how these lesions should be handled," he said. "If you think a lesion is premalignant, you'll want to excise it, and if the report comes back 'severely atypical,' you'll probably want to have negative margins. If you think the lesions aren't premalignant, then after you exclude a diagnosis of melanoma, you probably won't do anything. We have people in our practice who do both."

The phase in which a dermatologist "catches" the nevus probably influences treatment decisions. "These lesions are dynamic, change throughout life, and can be acquired at any age. I think what's happening is that if we biopsy them in a quiescent phase, we don't see cytological atypia. And if we catch them in a dynamic phase, they have different cellular characteristics, which we then have to define as mild or severe atypia," Dr. Barrett said.

Since the lesions are so changeable, and patients are at such a significantly increased risk of melanoma, close follow-up at 3- to 11-month intervals is crucial. It's probably a good idea to screen first-degree relatives, too, he suggested.

WILLIAMSBURG, VA. — Although large numbers of nevi—especially dysplastic nevi—are clearly associated with an increased melanoma risk, the lesions themselves do not appear to become cancerous, Dr. Terry L. Barrett said at the annual meeting of the American Society for Mohs Surgery.

"I remain unconvinced that either the common acquired nevus or the dysplastic nevus develops into melanoma," said Dr. Barrett, professor of pathology and dermatology at the University of Texas, Dallas. "I think they are both benign lesions the majority of the time. Usually, melanomas in these patients arise on normal-appearing skin and not the site of the nevus. When that happens, I think it's coincidental, not a nevus gone bad."

Few studies have actually investigated this point, although Dr. Barrett did mention a 2007 in vitro study that looked at levels of polycomb group protein EZH2, a cell regulatory protein markedly elevated in malignant skin lesions (J. Cutan. Pathol. 2007;34:597-600). The level in both in situ and invasive melanoma was almost three times that seen in acquired and dysplastic nevi—a finding that seems to support Dr. Barrett's opinion.

Regardless of the source, however, patients with large numbers of nevi are at a significantly increased risk of melanoma and other malignancies. The two commonly recognized nevi syndromes carry different risks, Dr. Barrett said.

Familial atypical mole/melanoma syndrome is an autosomal dominant disorder that increases the lifetime risk of melanoma by almost 100%. Sporadic dysplastic nevus syndrome is a spontaneous mutation that increases the relative risk of malignancy up to 46 times that of the general population, he said.

For patients with the sporadic syndrome, sun exposure seems to play a key role in the development of melanoma. "It's been suggested that intermittent sun exposure manifests the phenotype of the dysplastic nevi [and its attendant increased melanoma risk], while patients without sun exposure manifest the common acquired nevi," Dr. Barrett noted.

"There is no clear agreement among dermatologists about how these lesions should be handled," he said. "If you think a lesion is premalignant, you'll want to excise it, and if the report comes back 'severely atypical,' you'll probably want to have negative margins. If you think the lesions aren't premalignant, then after you exclude a diagnosis of melanoma, you probably won't do anything. We have people in our practice who do both."

The phase in which a dermatologist "catches" the nevus probably influences treatment decisions. "These lesions are dynamic, change throughout life, and can be acquired at any age. I think what's happening is that if we biopsy them in a quiescent phase, we don't see cytological atypia. And if we catch them in a dynamic phase, they have different cellular characteristics, which we then have to define as mild or severe atypia," Dr. Barrett said.

Since the lesions are so changeable, and patients are at such a significantly increased risk of melanoma, close follow-up at 3- to 11-month intervals is crucial. It's probably a good idea to screen first-degree relatives, too, he suggested.

WILLIAMSBURG, VA. — Although large numbers of nevi—especially dysplastic nevi—are clearly associated with an increased melanoma risk, the lesions themselves do not appear to become cancerous, Dr. Terry L. Barrett said at the annual meeting of the American Society for Mohs Surgery.

"I remain unconvinced that either the common acquired nevus or the dysplastic nevus develops into melanoma," said Dr. Barrett, professor of pathology and dermatology at the University of Texas, Dallas. "I think they are both benign lesions the majority of the time. Usually, melanomas in these patients arise on normal-appearing skin and not the site of the nevus. When that happens, I think it's coincidental, not a nevus gone bad."

Few studies have actually investigated this point, although Dr. Barrett did mention a 2007 in vitro study that looked at levels of polycomb group protein EZH2, a cell regulatory protein markedly elevated in malignant skin lesions (J. Cutan. Pathol. 2007;34:597-600). The level in both in situ and invasive melanoma was almost three times that seen in acquired and dysplastic nevi—a finding that seems to support Dr. Barrett's opinion.

Regardless of the source, however, patients with large numbers of nevi are at a significantly increased risk of melanoma and other malignancies. The two commonly recognized nevi syndromes carry different risks, Dr. Barrett said.

Familial atypical mole/melanoma syndrome is an autosomal dominant disorder that increases the lifetime risk of melanoma by almost 100%. Sporadic dysplastic nevus syndrome is a spontaneous mutation that increases the relative risk of malignancy up to 46 times that of the general population, he said.

For patients with the sporadic syndrome, sun exposure seems to play a key role in the development of melanoma. "It's been suggested that intermittent sun exposure manifests the phenotype of the dysplastic nevi [and its attendant increased melanoma risk], while patients without sun exposure manifest the common acquired nevi," Dr. Barrett noted.

"There is no clear agreement among dermatologists about how these lesions should be handled," he said. "If you think a lesion is premalignant, you'll want to excise it, and if the report comes back 'severely atypical,' you'll probably want to have negative margins. If you think the lesions aren't premalignant, then after you exclude a diagnosis of melanoma, you probably won't do anything. We have people in our practice who do both."

The phase in which a dermatologist "catches" the nevus probably influences treatment decisions. "These lesions are dynamic, change throughout life, and can be acquired at any age. I think what's happening is that if we biopsy them in a quiescent phase, we don't see cytological atypia. And if we catch them in a dynamic phase, they have different cellular characteristics, which we then have to define as mild or severe atypia," Dr. Barrett said.

Since the lesions are so changeable, and patients are at such a significantly increased risk of melanoma, close follow-up at 3- to 11-month intervals is crucial. It's probably a good idea to screen first-degree relatives, too, he suggested.

Patients with serious mental disorders will be best served when psychiatrists starting thinking like primary care physicians, and primary care physicians start thinking like psychiatrists, experts said at a forum on integrating physical and mental health care.

“There has always been this disconnect between what we think of as physical illness and what we think of as mental illness,” said Dr. J. Sloan Manning, a family physician at the University of North Carolina, Chapel Hill. “The reality is that there is no disconnect. … We, the medical community, are the ones who are divided.”

This philosophical division has created a practical division as well, in which patients might receive therapy for their mental illness while their physical problems are ignored. This one-sided treatment can have serious repercussions—patients who are physically ill are less likely to be adherent to antipsychotic medications, fueling a vicious cycle of psychiatric crises.

“These patients require more than one clinician and more than one treatment approach,” Dr. Manning said in an interview. “Only when clinicians collaborate and communicate will their patients get the full benefit of multiple modes of therapy.”

Dr. Manning was speaking at the multidisciplinary forum cosponsored by the National Council for Community Behavioral Healthcare and Eli Lilly & Co.

It's not news that patients with mental illnesses carry a significantly increased risk for chronic physical disease, including diabetes and cardiovascular disease. Those with mental disorders also have significantly higher rates of modifiable risk factors for physical disease, such as smoking and poor diet and exercise habits. The result, said Dr. Joseph Parks, is that patients with serious mental illness typically lose more than 25 years from their normal lifespan, compared with the general U.S. population.

According to a 2006 study, compared with patients without mental disorders, discharged patients with mental illness were 10 times more likely to have abnormal physical findings in the clinic or in lab studies; 6 times more likely to die from pneumonia, influenza, or chronic respiratory disease; and 3 times more likely to die of heart disease or diabetes.

“While suicide and injury account for up to 40% of excess mortality in schizophrenia for example, about 60% of these premature deaths are attributable to 'natural causes,' such as cardiovascular, respiratory, and infectious disease and diabetes,” said Dr. Parks, chief clinical officer and director of comprehensive psychiatric services at the Missouri Department of Mental Health, Jefferson City.

Antipsychotic medications also play a role in comorbid illnesses—especially those related to excess weight—but the physical interplay of mind and body accounts for most of the problem, Dr. Manning said. Patients with bipolar disorder, for example, have dysregulation of the hypothalamic, pituitary, thyroid, and adrenal axes, predisposing them to diabetes as well as inflammation leading to atherosclerosis.

The chain of care begins when a psychiatrist makes physical health an equal part of the treatment plan, said Dr. Thomas F. Liffick, a psychiatrist and medical director emeritus of the Southwestern Indiana Mental Health Center in Evansville. “We definitely should have a role in screening for health abnormalities and making recommendations for risk reduction and lifestyle modification in this population. We can catch patients earlier, refer them for appropriate treatment, and improve their physical and mental outcomes,” since physically healthy patients are more likely to adhere to their medications.

Collaboration can be as simple as a personal connection with a primary care physician who will accept a mental health patient referral or as comprehensive as a large program specially designed to deliver integrated health services.

Formal programs are a successful option in some areas of the country, said Dr. Benjamin G. Druss of Emory University, Atlanta. Collaborative care clinics provide physical health care for patients with mental health disorders. One experimental program uses nurse practitioners.

Most successful programs start small and grow incrementally over time, Dr. Druss said in an interview. “Try something small and, if that doesn't work, try something else. But keep trying. Don't let the perfect be the enemy of the good.”

Patients with serious mental disorders will be best served when psychiatrists starting thinking like primary care physicians, and primary care physicians start thinking like psychiatrists, experts said at a forum on integrating physical and mental health care.

“There has always been this disconnect between what we think of as physical illness and what we think of as mental illness,” said Dr. J. Sloan Manning, a family physician at the University of North Carolina, Chapel Hill. “The reality is that there is no disconnect. … We, the medical community, are the ones who are divided.”

This philosophical division has created a practical division as well, in which patients might receive therapy for their mental illness while their physical problems are ignored. This one-sided treatment can have serious repercussions—patients who are physically ill are less likely to be adherent to antipsychotic medications, fueling a vicious cycle of psychiatric crises.

“These patients require more than one clinician and more than one treatment approach,” Dr. Manning said in an interview. “Only when clinicians collaborate and communicate will their patients get the full benefit of multiple modes of therapy.”

Dr. Manning was speaking at the multidisciplinary forum cosponsored by the National Council for Community Behavioral Healthcare and Eli Lilly & Co.

It's not news that patients with mental illnesses carry a significantly increased risk for chronic physical disease, including diabetes and cardiovascular disease. Those with mental disorders also have significantly higher rates of modifiable risk factors for physical disease, such as smoking and poor diet and exercise habits. The result, said Dr. Joseph Parks, is that patients with serious mental illness typically lose more than 25 years from their normal lifespan, compared with the general U.S. population.

According to a 2006 study, compared with patients without mental disorders, discharged patients with mental illness were 10 times more likely to have abnormal physical findings in the clinic or in lab studies; 6 times more likely to die from pneumonia, influenza, or chronic respiratory disease; and 3 times more likely to die of heart disease or diabetes.

“While suicide and injury account for up to 40% of excess mortality in schizophrenia for example, about 60% of these premature deaths are attributable to 'natural causes,' such as cardiovascular, respiratory, and infectious disease and diabetes,” said Dr. Parks, chief clinical officer and director of comprehensive psychiatric services at the Missouri Department of Mental Health, Jefferson City.

Antipsychotic medications also play a role in comorbid illnesses—especially those related to excess weight—but the physical interplay of mind and body accounts for most of the problem, Dr. Manning said. Patients with bipolar disorder, for example, have dysregulation of the hypothalamic, pituitary, thyroid, and adrenal axes, predisposing them to diabetes as well as inflammation leading to atherosclerosis.

The chain of care begins when a psychiatrist makes physical health an equal part of the treatment plan, said Dr. Thomas F. Liffick, a psychiatrist and medical director emeritus of the Southwestern Indiana Mental Health Center in Evansville. “We definitely should have a role in screening for health abnormalities and making recommendations for risk reduction and lifestyle modification in this population. We can catch patients earlier, refer them for appropriate treatment, and improve their physical and mental outcomes,” since physically healthy patients are more likely to adhere to their medications.

Collaboration can be as simple as a personal connection with a primary care physician who will accept a mental health patient referral or as comprehensive as a large program specially designed to deliver integrated health services.

Formal programs are a successful option in some areas of the country, said Dr. Benjamin G. Druss of Emory University, Atlanta. Collaborative care clinics provide physical health care for patients with mental health disorders. One experimental program uses nurse practitioners.

Most successful programs start small and grow incrementally over time, Dr. Druss said in an interview. “Try something small and, if that doesn't work, try something else. But keep trying. Don't let the perfect be the enemy of the good.”

Patients with serious mental disorders will be best served when psychiatrists starting thinking like primary care physicians, and primary care physicians start thinking like psychiatrists, experts said at a forum on integrating physical and mental health care.

“There has always been this disconnect between what we think of as physical illness and what we think of as mental illness,” said Dr. J. Sloan Manning, a family physician at the University of North Carolina, Chapel Hill. “The reality is that there is no disconnect. … We, the medical community, are the ones who are divided.”

This philosophical division has created a practical division as well, in which patients might receive therapy for their mental illness while their physical problems are ignored. This one-sided treatment can have serious repercussions—patients who are physically ill are less likely to be adherent to antipsychotic medications, fueling a vicious cycle of psychiatric crises.

“These patients require more than one clinician and more than one treatment approach,” Dr. Manning said in an interview. “Only when clinicians collaborate and communicate will their patients get the full benefit of multiple modes of therapy.”

Dr. Manning was speaking at the multidisciplinary forum cosponsored by the National Council for Community Behavioral Healthcare and Eli Lilly & Co.

It's not news that patients with mental illnesses carry a significantly increased risk for chronic physical disease, including diabetes and cardiovascular disease. Those with mental disorders also have significantly higher rates of modifiable risk factors for physical disease, such as smoking and poor diet and exercise habits. The result, said Dr. Joseph Parks, is that patients with serious mental illness typically lose more than 25 years from their normal lifespan, compared with the general U.S. population.

According to a 2006 study, compared with patients without mental disorders, discharged patients with mental illness were 10 times more likely to have abnormal physical findings in the clinic or in lab studies; 6 times more likely to die from pneumonia, influenza, or chronic respiratory disease; and 3 times more likely to die of heart disease or diabetes.

“While suicide and injury account for up to 40% of excess mortality in schizophrenia for example, about 60% of these premature deaths are attributable to 'natural causes,' such as cardiovascular, respiratory, and infectious disease and diabetes,” said Dr. Parks, chief clinical officer and director of comprehensive psychiatric services at the Missouri Department of Mental Health, Jefferson City.

Antipsychotic medications also play a role in comorbid illnesses—especially those related to excess weight—but the physical interplay of mind and body accounts for most of the problem, Dr. Manning said. Patients with bipolar disorder, for example, have dysregulation of the hypothalamic, pituitary, thyroid, and adrenal axes, predisposing them to diabetes as well as inflammation leading to atherosclerosis.

The chain of care begins when a psychiatrist makes physical health an equal part of the treatment plan, said Dr. Thomas F. Liffick, a psychiatrist and medical director emeritus of the Southwestern Indiana Mental Health Center in Evansville. “We definitely should have a role in screening for health abnormalities and making recommendations for risk reduction and lifestyle modification in this population. We can catch patients earlier, refer them for appropriate treatment, and improve their physical and mental outcomes,” since physically healthy patients are more likely to adhere to their medications.

Collaboration can be as simple as a personal connection with a primary care physician who will accept a mental health patient referral or as comprehensive as a large program specially designed to deliver integrated health services.

Formal programs are a successful option in some areas of the country, said Dr. Benjamin G. Druss of Emory University, Atlanta. Collaborative care clinics provide physical health care for patients with mental health disorders. One experimental program uses nurse practitioners.

Most successful programs start small and grow incrementally over time, Dr. Druss said in an interview. “Try something small and, if that doesn't work, try something else. But keep trying. Don't let the perfect be the enemy of the good.”

CHICAGO — A single 2-g dose of azithromycin cures early syphilis as effectively as injected penicillin G benzathine, Dr. Edward W. Hook III said at a conference on sexually transmitted disease prevention sponsored by the Centers for Disease Control and Prevention.

However, Dr. Hook cautioned that the federally sponsored randomized controlled trial did not include any HIV-positive patients, so its results can't support the use of azithromycin in this population.

“This is the very group in which macrolide-resistant Treponema pallidum mutations have emerged in association with azithromycin treatment,” said Dr. Hook of the University of Alabama, Birmingham. “I would certainly not recommend treating these patients with azithromycin for early syphilis.”

Neither should the drug be used for syphilis in pregnant women. “In light of the history of macrolide treatment failures among pregnant women, I would caution very, very strongly against treating them with azithromycin for syphilis,” Dr. Hook said.

The trial compared the efficacy and safety of 2 g of azithromycin given orally with those of 2.4 million U of penicillin G benzathine in 517 patients with early syphilis. Most of the patients (80%) were in Madagascar; the rest were seen at U.S. clinics.

The patients' mean age was 24 years; 26% had primary syphilis, 46% had secondary syphilis, and 28% had presumed early latent syphilis (a sexual partner in the past 12 months with confirmed syphilis).

Serologic cure rates at 3 months were similar in both groups in the intent-to-treat analysis (74% azithromycin vs. 76% penicillin). At 6 months, the cure rates were still not significantly different (77% azithromycin vs. 78% penicillin). Results at 3 and 6 months in the per-protocol analysis were almost identical, Dr. Hook said.

U.S. patients exhibited slightly, but not significantly, higher cure rates than did patients in Madagascar.

Serious adverse events were slightly more common in the penicillin group than they were in the azithromycin group (10 vs. 8, respectively). However, none of these was considered related to the study medication. Nonserious adverse events, especially gastrointestinal distress, were significantly more common among the patients taking azithromycin (61% vs. 46% for penicillin).

The most common adverse events were gastrointestinal, with 24% of the azithromycin group experiencing some upset, compared with 7% of the penicillin group. However, only three patients taking azithromycin vomited.

Cutaneous reactions were more common among those taking penicillin (4% vs. 1%), as were administration-related adverse events (10% vs. 5%).

CHICAGO — A single 2-g dose of azithromycin cures early syphilis as effectively as injected penicillin G benzathine, Dr. Edward W. Hook III said at a conference on sexually transmitted disease prevention sponsored by the Centers for Disease Control and Prevention.

However, Dr. Hook cautioned that the federally sponsored randomized controlled trial did not include any HIV-positive patients, so its results can't support the use of azithromycin in this population.

“This is the very group in which macrolide-resistant Treponema pallidum mutations have emerged in association with azithromycin treatment,” said Dr. Hook of the University of Alabama, Birmingham. “I would certainly not recommend treating these patients with azithromycin for early syphilis.”

Neither should the drug be used for syphilis in pregnant women. “In light of the history of macrolide treatment failures among pregnant women, I would caution very, very strongly against treating them with azithromycin for syphilis,” Dr. Hook said.

The trial compared the efficacy and safety of 2 g of azithromycin given orally with those of 2.4 million U of penicillin G benzathine in 517 patients with early syphilis. Most of the patients (80%) were in Madagascar; the rest were seen at U.S. clinics.

The patients' mean age was 24 years; 26% had primary syphilis, 46% had secondary syphilis, and 28% had presumed early latent syphilis (a sexual partner in the past 12 months with confirmed syphilis).

Serologic cure rates at 3 months were similar in both groups in the intent-to-treat analysis (74% azithromycin vs. 76% penicillin). At 6 months, the cure rates were still not significantly different (77% azithromycin vs. 78% penicillin). Results at 3 and 6 months in the per-protocol analysis were almost identical, Dr. Hook said.

U.S. patients exhibited slightly, but not significantly, higher cure rates than did patients in Madagascar.

Serious adverse events were slightly more common in the penicillin group than they were in the azithromycin group (10 vs. 8, respectively). However, none of these was considered related to the study medication. Nonserious adverse events, especially gastrointestinal distress, were significantly more common among the patients taking azithromycin (61% vs. 46% for penicillin).

The most common adverse events were gastrointestinal, with 24% of the azithromycin group experiencing some upset, compared with 7% of the penicillin group. However, only three patients taking azithromycin vomited.

Cutaneous reactions were more common among those taking penicillin (4% vs. 1%), as were administration-related adverse events (10% vs. 5%).

CHICAGO — A single 2-g dose of azithromycin cures early syphilis as effectively as injected penicillin G benzathine, Dr. Edward W. Hook III said at a conference on sexually transmitted disease prevention sponsored by the Centers for Disease Control and Prevention.

However, Dr. Hook cautioned that the federally sponsored randomized controlled trial did not include any HIV-positive patients, so its results can't support the use of azithromycin in this population.

“This is the very group in which macrolide-resistant Treponema pallidum mutations have emerged in association with azithromycin treatment,” said Dr. Hook of the University of Alabama, Birmingham. “I would certainly not recommend treating these patients with azithromycin for early syphilis.”

Neither should the drug be used for syphilis in pregnant women. “In light of the history of macrolide treatment failures among pregnant women, I would caution very, very strongly against treating them with azithromycin for syphilis,” Dr. Hook said.

The trial compared the efficacy and safety of 2 g of azithromycin given orally with those of 2.4 million U of penicillin G benzathine in 517 patients with early syphilis. Most of the patients (80%) were in Madagascar; the rest were seen at U.S. clinics.

The patients' mean age was 24 years; 26% had primary syphilis, 46% had secondary syphilis, and 28% had presumed early latent syphilis (a sexual partner in the past 12 months with confirmed syphilis).

Serologic cure rates at 3 months were similar in both groups in the intent-to-treat analysis (74% azithromycin vs. 76% penicillin). At 6 months, the cure rates were still not significantly different (77% azithromycin vs. 78% penicillin). Results at 3 and 6 months in the per-protocol analysis were almost identical, Dr. Hook said.

U.S. patients exhibited slightly, but not significantly, higher cure rates than did patients in Madagascar.

Serious adverse events were slightly more common in the penicillin group than they were in the azithromycin group (10 vs. 8, respectively). However, none of these was considered related to the study medication. Nonserious adverse events, especially gastrointestinal distress, were significantly more common among the patients taking azithromycin (61% vs. 46% for penicillin).

The most common adverse events were gastrointestinal, with 24% of the azithromycin group experiencing some upset, compared with 7% of the penicillin group. However, only three patients taking azithromycin vomited.

Cutaneous reactions were more common among those taking penicillin (4% vs. 1%), as were administration-related adverse events (10% vs. 5%).

CHICAGO — The biggest risk factor for bacterial vaginosis among gay or bisexual women is having a sex partner with a history of the disorder, data from a 1-year longitudinal study of 335 women indicate.

In fact, that association increases the chances of bacterial vaginosis by more than 400%, Dr. Jeanne Marrazzo said at a meeting on the prevention of sexually transmitted diseases. Moreover, sharing sexual toys almost doubled the risk of developing bacterial vaginosis (BV) among gay or bisexual women, said Dr. Marrazzo of the University of Washington, Seattle. And although the latter factor was not statistically significant, when it is combined with the risk of a partner's positive history, it suggests that the exchange of vaginal fluids plays a key role in the development of BV for this population, she said.

Dr. Marrazzo presented the preliminary results of the 1-year study examining the rates of BV in a total of 335 women, including 47 couples. The women's median age was 25 years; 88% were white. Most (305) reported sexual activity within the last 3 months; of these, 276 reported having had at least one female partner, and 18% reported both male and female partners. For those reporting sex with a male within the last 3 months, only 25% reported having used a condom.

A third of the women had a history of BV—a somewhat high prevalence, especially in light of the group's very low rate of douching (6%), a behavior that is strongly associated with the disorder, Dr. Marrazzo said.

All of the women completed a detailed computer survey of their sexual habits. Their symptoms were assessed clinically by Amsel criteria; BV was confirmed with Gram stain of vaginal fluid and Nugent criteria. The overall prevalence of BV was 29%, which is higher than that usually seen at clinics in the United States, Dr. Marrazzo said. Of these women, 40% were symptomatic at the time of clinical assessment.

In terms of sexual practice, all of the sexually active women had experienced receptive vaginal or oral sex, including penetration with fingers, a penis, or toys; 40% had experienced receptive anal sex with fingers, penis, or toys; and 22% reported sharing a vaginal toy with a female partner.

In the univariate analysis, only having a partner with a history of BV was associated with a significant increase in the risk of developing BV (odds ratio 5.0). Other associations that were positive but nonsignificant included age under 26 years, sharing a sex toy (OR 2.0), and using vaginal lubricant (OR 2.0).

In the multivariate analysis, having a partner with a history of BV was still significantly associated with an increased risk (OR 4.5). Shared vaginal toys and the use of vaginal lubricant were still associated with a nonsignificant doubling of risk.

“We did not see any significant relationships with … race and douching,” Dr. Marrazzo said.

She then examined the prevalence of BV in the subset of 47 couples in the study. Partners were negative for BV in 22 couples, discordant in 5, and positive in 20.

“This degree of concordance for the presence or absence of the infection is strikingly different than what we would expect if we calculated the likelihood of BV based on the overall population prevalence,” Dr. Marrazzo said. “If it was just a random sample, it would be about 13 couples negative, 11 discordant, and 24 positive. This supports the idea that there may be some mechanistic process involved in being in a sexual relationship with a woman with BV.”

The association with sexual toys and vaginal lubricant is difficult to untangle, she said, because the two are most often used simultaneously. However, she noted that one of the most popular brands of lubricant contains hexachloradine, which may interfere with normal vaginal flora. In addition, “the pH of the most commonly used lubricants ranges from 5.8 to 6.1, so it's possible that they may modify the vaginal pH directly,” said Dr. Marrazzo.

CHICAGO — The biggest risk factor for bacterial vaginosis among gay or bisexual women is having a sex partner with a history of the disorder, data from a 1-year longitudinal study of 335 women indicate.

In fact, that association increases the chances of bacterial vaginosis by more than 400%, Dr. Jeanne Marrazzo said at a meeting on the prevention of sexually transmitted diseases. Moreover, sharing sexual toys almost doubled the risk of developing bacterial vaginosis (BV) among gay or bisexual women, said Dr. Marrazzo of the University of Washington, Seattle. And although the latter factor was not statistically significant, when it is combined with the risk of a partner's positive history, it suggests that the exchange of vaginal fluids plays a key role in the development of BV for this population, she said.

Dr. Marrazzo presented the preliminary results of the 1-year study examining the rates of BV in a total of 335 women, including 47 couples. The women's median age was 25 years; 88% were white. Most (305) reported sexual activity within the last 3 months; of these, 276 reported having had at least one female partner, and 18% reported both male and female partners. For those reporting sex with a male within the last 3 months, only 25% reported having used a condom.

A third of the women had a history of BV—a somewhat high prevalence, especially in light of the group's very low rate of douching (6%), a behavior that is strongly associated with the disorder, Dr. Marrazzo said.

All of the women completed a detailed computer survey of their sexual habits. Their symptoms were assessed clinically by Amsel criteria; BV was confirmed with Gram stain of vaginal fluid and Nugent criteria. The overall prevalence of BV was 29%, which is higher than that usually seen at clinics in the United States, Dr. Marrazzo said. Of these women, 40% were symptomatic at the time of clinical assessment.

In terms of sexual practice, all of the sexually active women had experienced receptive vaginal or oral sex, including penetration with fingers, a penis, or toys; 40% had experienced receptive anal sex with fingers, penis, or toys; and 22% reported sharing a vaginal toy with a female partner.

In the univariate analysis, only having a partner with a history of BV was associated with a significant increase in the risk of developing BV (odds ratio 5.0). Other associations that were positive but nonsignificant included age under 26 years, sharing a sex toy (OR 2.0), and using vaginal lubricant (OR 2.0).

In the multivariate analysis, having a partner with a history of BV was still significantly associated with an increased risk (OR 4.5). Shared vaginal toys and the use of vaginal lubricant were still associated with a nonsignificant doubling of risk.

“We did not see any significant relationships with … race and douching,” Dr. Marrazzo said.

She then examined the prevalence of BV in the subset of 47 couples in the study. Partners were negative for BV in 22 couples, discordant in 5, and positive in 20.

“This degree of concordance for the presence or absence of the infection is strikingly different than what we would expect if we calculated the likelihood of BV based on the overall population prevalence,” Dr. Marrazzo said. “If it was just a random sample, it would be about 13 couples negative, 11 discordant, and 24 positive. This supports the idea that there may be some mechanistic process involved in being in a sexual relationship with a woman with BV.”

The association with sexual toys and vaginal lubricant is difficult to untangle, she said, because the two are most often used simultaneously. However, she noted that one of the most popular brands of lubricant contains hexachloradine, which may interfere with normal vaginal flora. In addition, “the pH of the most commonly used lubricants ranges from 5.8 to 6.1, so it's possible that they may modify the vaginal pH directly,” said Dr. Marrazzo.

CHICAGO — The biggest risk factor for bacterial vaginosis among gay or bisexual women is having a sex partner with a history of the disorder, data from a 1-year longitudinal study of 335 women indicate.

In fact, that association increases the chances of bacterial vaginosis by more than 400%, Dr. Jeanne Marrazzo said at a meeting on the prevention of sexually transmitted diseases. Moreover, sharing sexual toys almost doubled the risk of developing bacterial vaginosis (BV) among gay or bisexual women, said Dr. Marrazzo of the University of Washington, Seattle. And although the latter factor was not statistically significant, when it is combined with the risk of a partner's positive history, it suggests that the exchange of vaginal fluids plays a key role in the development of BV for this population, she said.

Dr. Marrazzo presented the preliminary results of the 1-year study examining the rates of BV in a total of 335 women, including 47 couples. The women's median age was 25 years; 88% were white. Most (305) reported sexual activity within the last 3 months; of these, 276 reported having had at least one female partner, and 18% reported both male and female partners. For those reporting sex with a male within the last 3 months, only 25% reported having used a condom.

A third of the women had a history of BV—a somewhat high prevalence, especially in light of the group's very low rate of douching (6%), a behavior that is strongly associated with the disorder, Dr. Marrazzo said.

All of the women completed a detailed computer survey of their sexual habits. Their symptoms were assessed clinically by Amsel criteria; BV was confirmed with Gram stain of vaginal fluid and Nugent criteria. The overall prevalence of BV was 29%, which is higher than that usually seen at clinics in the United States, Dr. Marrazzo said. Of these women, 40% were symptomatic at the time of clinical assessment.

In terms of sexual practice, all of the sexually active women had experienced receptive vaginal or oral sex, including penetration with fingers, a penis, or toys; 40% had experienced receptive anal sex with fingers, penis, or toys; and 22% reported sharing a vaginal toy with a female partner.

In the univariate analysis, only having a partner with a history of BV was associated with a significant increase in the risk of developing BV (odds ratio 5.0). Other associations that were positive but nonsignificant included age under 26 years, sharing a sex toy (OR 2.0), and using vaginal lubricant (OR 2.0).

In the multivariate analysis, having a partner with a history of BV was still significantly associated with an increased risk (OR 4.5). Shared vaginal toys and the use of vaginal lubricant were still associated with a nonsignificant doubling of risk.

“We did not see any significant relationships with … race and douching,” Dr. Marrazzo said.

She then examined the prevalence of BV in the subset of 47 couples in the study. Partners were negative for BV in 22 couples, discordant in 5, and positive in 20.

“This degree of concordance for the presence or absence of the infection is strikingly different than what we would expect if we calculated the likelihood of BV based on the overall population prevalence,” Dr. Marrazzo said. “If it was just a random sample, it would be about 13 couples negative, 11 discordant, and 24 positive. This supports the idea that there may be some mechanistic process involved in being in a sexual relationship with a woman with BV.”

The association with sexual toys and vaginal lubricant is difficult to untangle, she said, because the two are most often used simultaneously. However, she noted that one of the most popular brands of lubricant contains hexachloradine, which may interfere with normal vaginal flora. In addition, “the pH of the most commonly used lubricants ranges from 5.8 to 6.1, so it's possible that they may modify the vaginal pH directly,” said Dr. Marrazzo.

WASHINGTON — A firm federal commitment to increased biomedical-research funding is the best defense against the wave of Alzheimer's disease predicted to hit over the next 40 years, according to Newt Gingrich, former Speaker of the U.S. House of Representatives.

Addressing a hearing called by the Senate Special Committee on Aging, Mr. Gingrich urged annual overall funding increases of “at least” 7% after inflation for the National Institutes of Health.

He urged similarly broad financial support for the National Science Foundation (NSF), which sponsors research in math, physics, and chemistry that, Mr. Gingrich said, provides the foundation for both the drugs and imaging systems necessary to fight Alzheimer's. “The biggest mistake I made as Speaker was not tripling the National Science Foundation budget and, as a result, we are not getting the investments we need [in these areas],” he said. “Most of the research that underlies the imaging technology we have today, which allows us to have real-time images of a living brain, was developed at the NSF.”

Mr. Gingrich addressed the Senate committee in his role as the founder and a member of the Alzheimer's Study Group, a bipartisan think tank urging a national strategic plan to deal with the projected surge in Alzheimer's disease. Studies indicate worldwide prevalence could quadruple by 2050, reaching 107 million people. In the United States, prevalence could rise from the current 4.5 million to more than 13 million during the same period. Such an increase would devastate the country's health care system and seriously harm the economy, Mr. Gingrich told the committee.

By 2050, federal government spending on care for Alzheimer's patients could dwarf the current annual bill of $150 million. “Federal spending on Alzheimer's [care] will increase to more than $1 trillion per year by 2050, in today's dollars—that is more than one-tenth of America's current economy.”

Retired U.S. Supreme Court Justice Sandra Day O'Connor, whose husband, John O'Connor, suffers from advanced Alzheimer's, also urged the committee to support research. While a cure would be the “Holy Grail,” she said, even a drug that could delay the onset of Alzheimer's would reap huge savings.

The government could also step up the pace of research with legislation encouraging private investment, Mr. Gingrich said. “I would strongly urge you to amend the Orphan Drug Act to include all brain research as orphan drug activity.”

The downside of following the orphan-drug path would be longer-than-normal patents on any drugs developed, Mr. Gingrich said. But the benefit to patients would be worth the increase in costs resulting from drugs being slow to go generic, he asserted.

Sen. Herb Kohl (D-Wis.), committee chairman, called the hearing to support a bill that would double the funding specifically for Alzheimer's research at the National Institutes of Health to $1.3 billion. The Alzheimer's Breakthrough Act was introduced last year. It passed through the Senate Committee on Health, Education, Labor, and Pensions last July and made the Senate Legislative Calendar in August but hasn't received further action since then.

Retired Supreme Court Justice O'Connor and former Speaker of the House Gingrich testified at the Senate hearing. Michele G. Sullivan/Elsevier Global Medical News

WASHINGTON — A firm federal commitment to increased biomedical-research funding is the best defense against the wave of Alzheimer's disease predicted to hit over the next 40 years, according to Newt Gingrich, former Speaker of the U.S. House of Representatives.

Addressing a hearing called by the Senate Special Committee on Aging, Mr. Gingrich urged annual overall funding increases of “at least” 7% after inflation for the National Institutes of Health.

He urged similarly broad financial support for the National Science Foundation (NSF), which sponsors research in math, physics, and chemistry that, Mr. Gingrich said, provides the foundation for both the drugs and imaging systems necessary to fight Alzheimer's. “The biggest mistake I made as Speaker was not tripling the National Science Foundation budget and, as a result, we are not getting the investments we need [in these areas],” he said. “Most of the research that underlies the imaging technology we have today, which allows us to have real-time images of a living brain, was developed at the NSF.”

Mr. Gingrich addressed the Senate committee in his role as the founder and a member of the Alzheimer's Study Group, a bipartisan think tank urging a national strategic plan to deal with the projected surge in Alzheimer's disease. Studies indicate worldwide prevalence could quadruple by 2050, reaching 107 million people. In the United States, prevalence could rise from the current 4.5 million to more than 13 million during the same period. Such an increase would devastate the country's health care system and seriously harm the economy, Mr. Gingrich told the committee.

By 2050, federal government spending on care for Alzheimer's patients could dwarf the current annual bill of $150 million. “Federal spending on Alzheimer's [care] will increase to more than $1 trillion per year by 2050, in today's dollars—that is more than one-tenth of America's current economy.”

Retired U.S. Supreme Court Justice Sandra Day O'Connor, whose husband, John O'Connor, suffers from advanced Alzheimer's, also urged the committee to support research. While a cure would be the “Holy Grail,” she said, even a drug that could delay the onset of Alzheimer's would reap huge savings.

The government could also step up the pace of research with legislation encouraging private investment, Mr. Gingrich said. “I would strongly urge you to amend the Orphan Drug Act to include all brain research as orphan drug activity.”

The downside of following the orphan-drug path would be longer-than-normal patents on any drugs developed, Mr. Gingrich said. But the benefit to patients would be worth the increase in costs resulting from drugs being slow to go generic, he asserted.

Sen. Herb Kohl (D-Wis.), committee chairman, called the hearing to support a bill that would double the funding specifically for Alzheimer's research at the National Institutes of Health to $1.3 billion. The Alzheimer's Breakthrough Act was introduced last year. It passed through the Senate Committee on Health, Education, Labor, and Pensions last July and made the Senate Legislative Calendar in August but hasn't received further action since then.

Retired Supreme Court Justice O'Connor and former Speaker of the House Gingrich testified at the Senate hearing. Michele G. Sullivan/Elsevier Global Medical News

WASHINGTON — A firm federal commitment to increased biomedical-research funding is the best defense against the wave of Alzheimer's disease predicted to hit over the next 40 years, according to Newt Gingrich, former Speaker of the U.S. House of Representatives.

Addressing a hearing called by the Senate Special Committee on Aging, Mr. Gingrich urged annual overall funding increases of “at least” 7% after inflation for the National Institutes of Health.

He urged similarly broad financial support for the National Science Foundation (NSF), which sponsors research in math, physics, and chemistry that, Mr. Gingrich said, provides the foundation for both the drugs and imaging systems necessary to fight Alzheimer's. “The biggest mistake I made as Speaker was not tripling the National Science Foundation budget and, as a result, we are not getting the investments we need [in these areas],” he said. “Most of the research that underlies the imaging technology we have today, which allows us to have real-time images of a living brain, was developed at the NSF.”

Mr. Gingrich addressed the Senate committee in his role as the founder and a member of the Alzheimer's Study Group, a bipartisan think tank urging a national strategic plan to deal with the projected surge in Alzheimer's disease. Studies indicate worldwide prevalence could quadruple by 2050, reaching 107 million people. In the United States, prevalence could rise from the current 4.5 million to more than 13 million during the same period. Such an increase would devastate the country's health care system and seriously harm the economy, Mr. Gingrich told the committee.

By 2050, federal government spending on care for Alzheimer's patients could dwarf the current annual bill of $150 million. “Federal spending on Alzheimer's [care] will increase to more than $1 trillion per year by 2050, in today's dollars—that is more than one-tenth of America's current economy.”

Retired U.S. Supreme Court Justice Sandra Day O'Connor, whose husband, John O'Connor, suffers from advanced Alzheimer's, also urged the committee to support research. While a cure would be the “Holy Grail,” she said, even a drug that could delay the onset of Alzheimer's would reap huge savings.

The government could also step up the pace of research with legislation encouraging private investment, Mr. Gingrich said. “I would strongly urge you to amend the Orphan Drug Act to include all brain research as orphan drug activity.”

The downside of following the orphan-drug path would be longer-than-normal patents on any drugs developed, Mr. Gingrich said. But the benefit to patients would be worth the increase in costs resulting from drugs being slow to go generic, he asserted.

Sen. Herb Kohl (D-Wis.), committee chairman, called the hearing to support a bill that would double the funding specifically for Alzheimer's research at the National Institutes of Health to $1.3 billion. The Alzheimer's Breakthrough Act was introduced last year. It passed through the Senate Committee on Health, Education, Labor, and Pensions last July and made the Senate Legislative Calendar in August but hasn't received further action since then.

Retired Supreme Court Justice O'Connor and former Speaker of the House Gingrich testified at the Senate hearing. Michele G. Sullivan/Elsevier Global Medical News