As more patients undergo facial rejuvenation procedures for a more youthful look, there is a growing demand for rejuvenation of the décolletage (neck and chest) to achieve a more natural and seamless transition from the skin of the face to the chest. The same modalities that are used on the face to treat skin rhytides, texture, and discoloration have been used successfully in the décolletage area.

Vanaman and Fabi (Plast Reconstr Surg. 2015;136[suppl 5]:276S-281S) recently reviewed the chest anatomy and discussed the safe and effective use of cosmetic injectables alone or in combination with other modalities to address rhytides of the décolletage. The relatively low density of skin pilosebaceous units on the chest allows for slower healing and thus makes the area more vulnerable to scarring with the use of more invasive resurfacing modalities (eg, deeper chemical peels, ablative lasers). The use of cosmetic injectables offers a safer treatment option of chest rhytides. Furthermore, proper candidate selection excludes patients with known sensitivity to cosmetic injectables or their components, history of keloid or hypertrophic scar formation, and active inflammation in the treatment area.

Poly-L-lactic acid (PLLA) is a biodegradable, biocompatible, semipermanent, synthetic soft tissue biostimulator that promotes neocollagenesis by fibroblasts over time (3–6 months). The manufacturer’s recommendation for PLLA reconstitution is at least 2 hours prior to injection with sterile water of no less than 5 mL dilution. Vanaman and Fabi reported usually diluting the day prior to injection with 16 mL total volume. This technique showed the greatest improvement in chest rhytides with no adverse events reported in a retrospective analysis. Poly-L-lactic acid should be injected in a retrograde linear fashion in the plane of the subcutaneous fat, with injection boundaries on the suprasternal notch superiorly, the midclavicular line laterally, and the fourth rib inferolaterally for rejuvenation of the décolletage.

Nodule formation is a well-known complication of PLLA injection, although pain, bruising, edema, pruritus, and hematomas are more commonly seen. The risk of nodule formation can be decreased using several techniques, including avoiding overcorrection and excessive use of product in each individual session, avoiding intradermal injection, diluting to more than 5 mL with reconstitution at least overnight, massaging the area posttreatment (in office by the clinician and at home by the patient), and scheduling treatment sessions at least 4 weeks apart. Usually, 3 to 4 treatments are required and the results can last 2 years or longer without touch-ups.

Nonanimal stabilized hyaluronic acid (NASHA) fillers also can be used to correct chest rhytides; however, using NASHA fillers requires more syringes and results typically last only 6 to 8 months, making it more cost effective to use 2 to 3 vials of PLLA. Moreover, in Vanaman and Fabi’s experience, PLLA is associated with fewer nodules, possibly due to the depth of injection of PLLA into the subcutaneous fat versus injection into the deep dermis with NASHA fillers. Vanaman and Fabi currently are investigating the use of calcium hydroxylapatite fillers alone or in combination with an energy-based modality (microfocused ultrasound) with visualization in the treatment of rhytides in the décolletage.

What’s the Issue?

The availability of many modalities to keep facial skin looking fresh and rejuvenated has led to an increased demand for products and procedures to rejuvenate the décolletage. It is important for dermatologists to acknowledge the more delicate nature of the décolletage versus the face. Less invasive modalities such as cosmetic injectables can be employed in a safe and effective manner to correct rhytides of the chest with proper techniques, products, and patient selection. For a more natural transition from the skin of the face to the décolletage, it also may be necessary to adopt a multimodal approach by using botulinum toxin and fillers, as well as going beyond correction of rhytides to address skin texture and discoloration with chemical peels and lasers. Have you seen an increased demand for procedures to rejuvenate the décolletage in your practice?

We want to know your views! Tell us what you think.

As more patients undergo facial rejuvenation procedures for a more youthful look, there is a growing demand for rejuvenation of the décolletage (neck and chest) to achieve a more natural and seamless transition from the skin of the face to the chest. The same modalities that are used on the face to treat skin rhytides, texture, and discoloration have been used successfully in the décolletage area.

Vanaman and Fabi (Plast Reconstr Surg. 2015;136[suppl 5]:276S-281S) recently reviewed the chest anatomy and discussed the safe and effective use of cosmetic injectables alone or in combination with other modalities to address rhytides of the décolletage. The relatively low density of skin pilosebaceous units on the chest allows for slower healing and thus makes the area more vulnerable to scarring with the use of more invasive resurfacing modalities (eg, deeper chemical peels, ablative lasers). The use of cosmetic injectables offers a safer treatment option of chest rhytides. Furthermore, proper candidate selection excludes patients with known sensitivity to cosmetic injectables or their components, history of keloid or hypertrophic scar formation, and active inflammation in the treatment area.

Poly-L-lactic acid (PLLA) is a biodegradable, biocompatible, semipermanent, synthetic soft tissue biostimulator that promotes neocollagenesis by fibroblasts over time (3–6 months). The manufacturer’s recommendation for PLLA reconstitution is at least 2 hours prior to injection with sterile water of no less than 5 mL dilution. Vanaman and Fabi reported usually diluting the day prior to injection with 16 mL total volume. This technique showed the greatest improvement in chest rhytides with no adverse events reported in a retrospective analysis. Poly-L-lactic acid should be injected in a retrograde linear fashion in the plane of the subcutaneous fat, with injection boundaries on the suprasternal notch superiorly, the midclavicular line laterally, and the fourth rib inferolaterally for rejuvenation of the décolletage.

Nodule formation is a well-known complication of PLLA injection, although pain, bruising, edema, pruritus, and hematomas are more commonly seen. The risk of nodule formation can be decreased using several techniques, including avoiding overcorrection and excessive use of product in each individual session, avoiding intradermal injection, diluting to more than 5 mL with reconstitution at least overnight, massaging the area posttreatment (in office by the clinician and at home by the patient), and scheduling treatment sessions at least 4 weeks apart. Usually, 3 to 4 treatments are required and the results can last 2 years or longer without touch-ups.

Nonanimal stabilized hyaluronic acid (NASHA) fillers also can be used to correct chest rhytides; however, using NASHA fillers requires more syringes and results typically last only 6 to 8 months, making it more cost effective to use 2 to 3 vials of PLLA. Moreover, in Vanaman and Fabi’s experience, PLLA is associated with fewer nodules, possibly due to the depth of injection of PLLA into the subcutaneous fat versus injection into the deep dermis with NASHA fillers. Vanaman and Fabi currently are investigating the use of calcium hydroxylapatite fillers alone or in combination with an energy-based modality (microfocused ultrasound) with visualization in the treatment of rhytides in the décolletage.

What’s the Issue?

The availability of many modalities to keep facial skin looking fresh and rejuvenated has led to an increased demand for products and procedures to rejuvenate the décolletage. It is important for dermatologists to acknowledge the more delicate nature of the décolletage versus the face. Less invasive modalities such as cosmetic injectables can be employed in a safe and effective manner to correct rhytides of the chest with proper techniques, products, and patient selection. For a more natural transition from the skin of the face to the décolletage, it also may be necessary to adopt a multimodal approach by using botulinum toxin and fillers, as well as going beyond correction of rhytides to address skin texture and discoloration with chemical peels and lasers. Have you seen an increased demand for procedures to rejuvenate the décolletage in your practice?

We want to know your views! Tell us what you think.

As more patients undergo facial rejuvenation procedures for a more youthful look, there is a growing demand for rejuvenation of the décolletage (neck and chest) to achieve a more natural and seamless transition from the skin of the face to the chest. The same modalities that are used on the face to treat skin rhytides, texture, and discoloration have been used successfully in the décolletage area.

Vanaman and Fabi (Plast Reconstr Surg. 2015;136[suppl 5]:276S-281S) recently reviewed the chest anatomy and discussed the safe and effective use of cosmetic injectables alone or in combination with other modalities to address rhytides of the décolletage. The relatively low density of skin pilosebaceous units on the chest allows for slower healing and thus makes the area more vulnerable to scarring with the use of more invasive resurfacing modalities (eg, deeper chemical peels, ablative lasers). The use of cosmetic injectables offers a safer treatment option of chest rhytides. Furthermore, proper candidate selection excludes patients with known sensitivity to cosmetic injectables or their components, history of keloid or hypertrophic scar formation, and active inflammation in the treatment area.

Poly-L-lactic acid (PLLA) is a biodegradable, biocompatible, semipermanent, synthetic soft tissue biostimulator that promotes neocollagenesis by fibroblasts over time (3–6 months). The manufacturer’s recommendation for PLLA reconstitution is at least 2 hours prior to injection with sterile water of no less than 5 mL dilution. Vanaman and Fabi reported usually diluting the day prior to injection with 16 mL total volume. This technique showed the greatest improvement in chest rhytides with no adverse events reported in a retrospective analysis. Poly-L-lactic acid should be injected in a retrograde linear fashion in the plane of the subcutaneous fat, with injection boundaries on the suprasternal notch superiorly, the midclavicular line laterally, and the fourth rib inferolaterally for rejuvenation of the décolletage.

Nodule formation is a well-known complication of PLLA injection, although pain, bruising, edema, pruritus, and hematomas are more commonly seen. The risk of nodule formation can be decreased using several techniques, including avoiding overcorrection and excessive use of product in each individual session, avoiding intradermal injection, diluting to more than 5 mL with reconstitution at least overnight, massaging the area posttreatment (in office by the clinician and at home by the patient), and scheduling treatment sessions at least 4 weeks apart. Usually, 3 to 4 treatments are required and the results can last 2 years or longer without touch-ups.

Nonanimal stabilized hyaluronic acid (NASHA) fillers also can be used to correct chest rhytides; however, using NASHA fillers requires more syringes and results typically last only 6 to 8 months, making it more cost effective to use 2 to 3 vials of PLLA. Moreover, in Vanaman and Fabi’s experience, PLLA is associated with fewer nodules, possibly due to the depth of injection of PLLA into the subcutaneous fat versus injection into the deep dermis with NASHA fillers. Vanaman and Fabi currently are investigating the use of calcium hydroxylapatite fillers alone or in combination with an energy-based modality (microfocused ultrasound) with visualization in the treatment of rhytides in the décolletage.

What’s the Issue?

The availability of many modalities to keep facial skin looking fresh and rejuvenated has led to an increased demand for products and procedures to rejuvenate the décolletage. It is important for dermatologists to acknowledge the more delicate nature of the décolletage versus the face. Less invasive modalities such as cosmetic injectables can be employed in a safe and effective manner to correct rhytides of the chest with proper techniques, products, and patient selection. For a more natural transition from the skin of the face to the décolletage, it also may be necessary to adopt a multimodal approach by using botulinum toxin and fillers, as well as going beyond correction of rhytides to address skin texture and discoloration with chemical peels and lasers. Have you seen an increased demand for procedures to rejuvenate the décolletage in your practice?

We want to know your views! Tell us what you think.

Adding lixisenatide to usual care failed to prevent major cardiovascular events in an industry-sponsored clinical trial involving patients with type 2 diabetes who had a recent acute coronary syndrome, according to a report published online Dec. 3 in the New England Journal of Medicine.

Lixisenatide, a GLP-1-receptor agonist, is a glucose-lowering agent that inhibits glucagon secretion, prompts insulin production in response to hyperglycemia, and slows gastric emptying. In preliminary studies, lixisenatide showed some cardioprotective effects in myocardial ischemia and heart failure. To assess whether the drug would benefit diabetes patients at high CV risk, investigators conducted a randomized double-blind trial comparing lixisenatide with placebo in 6,068 patients who had type 2 diabetes and who had experienced acute coronary syndrome (ACS) during the preceding 6 months.

Volkan Ünalan/Thinkstock.com

In addition to receiving usual diabetes care provided by their treating physicians, these patients (mean age, 60 years) were randomly assigned to self-administer once-daily subcutaneous injections of lixisenatide (n = 3,034) or a matching placebo (n = 3,034) and were followed for a mean of 25 months at 49 medical centers worldwide, said Dr. Marc A. Pfeffer of the cardiovascular division, Brigham and Women’s Hospital, and Dzau Professor of Medicine a Harvard Medical School, Boston.

The primary endpoint of the study – a composite of death from CV causes, nonfatal MI, nonfatal stroke, or hospitalization for unstable angina – occurred in 13.4% of patients receiving lixisenatide and 13.2% of those receiving placebo, a nonsignificant difference. There were no differences between the two study groups in any of the individual components of this composite endpoint (N Engl J Med. 2015 Dec. 3. doi:10.1056/NEJMoa1509225).

Sensitivity analyses and post hoc analyses of several subgroups of patients yielded similar results. When hospitalization for heart failure and coronary revascularization procedures were added to the primary endpoint, lixisenatide still provided no cardioprotective effect compared with placebo. Mortality from any cause was not significantly different between the two study groups, at 7.0% with lixisenatide and 7.4% with placebo.

Adverse effects leading to withdrawal from the study were more common with lixisenatide (11.4%) than placebo (7.2%). In particular, treatment discontinuation due to nausea and vomiting occurred in 3.0% of patients taking active treatment, compared with 0.4% of those taking placebo.

Sanofi, maker of lixisenatide, funded the study. Dr. Pfeffer reported receiving grants and personal fees from Sanofi and 20 other drug companies; his associates reported ties to numerous industry sources.

Adding lixisenatide to usual care failed to prevent major cardiovascular events in an industry-sponsored clinical trial involving patients with type 2 diabetes who had a recent acute coronary syndrome, according to a report published online Dec. 3 in the New England Journal of Medicine.

Lixisenatide, a GLP-1-receptor agonist, is a glucose-lowering agent that inhibits glucagon secretion, prompts insulin production in response to hyperglycemia, and slows gastric emptying. In preliminary studies, lixisenatide showed some cardioprotective effects in myocardial ischemia and heart failure. To assess whether the drug would benefit diabetes patients at high CV risk, investigators conducted a randomized double-blind trial comparing lixisenatide with placebo in 6,068 patients who had type 2 diabetes and who had experienced acute coronary syndrome (ACS) during the preceding 6 months.

Volkan Ünalan/Thinkstock.com

In addition to receiving usual diabetes care provided by their treating physicians, these patients (mean age, 60 years) were randomly assigned to self-administer once-daily subcutaneous injections of lixisenatide (n = 3,034) or a matching placebo (n = 3,034) and were followed for a mean of 25 months at 49 medical centers worldwide, said Dr. Marc A. Pfeffer of the cardiovascular division, Brigham and Women’s Hospital, and Dzau Professor of Medicine a Harvard Medical School, Boston.

The primary endpoint of the study – a composite of death from CV causes, nonfatal MI, nonfatal stroke, or hospitalization for unstable angina – occurred in 13.4% of patients receiving lixisenatide and 13.2% of those receiving placebo, a nonsignificant difference. There were no differences between the two study groups in any of the individual components of this composite endpoint (N Engl J Med. 2015 Dec. 3. doi:10.1056/NEJMoa1509225).

Sensitivity analyses and post hoc analyses of several subgroups of patients yielded similar results. When hospitalization for heart failure and coronary revascularization procedures were added to the primary endpoint, lixisenatide still provided no cardioprotective effect compared with placebo. Mortality from any cause was not significantly different between the two study groups, at 7.0% with lixisenatide and 7.4% with placebo.

Adverse effects leading to withdrawal from the study were more common with lixisenatide (11.4%) than placebo (7.2%). In particular, treatment discontinuation due to nausea and vomiting occurred in 3.0% of patients taking active treatment, compared with 0.4% of those taking placebo.

Sanofi, maker of lixisenatide, funded the study. Dr. Pfeffer reported receiving grants and personal fees from Sanofi and 20 other drug companies; his associates reported ties to numerous industry sources.

Adding lixisenatide to usual care failed to prevent major cardiovascular events in an industry-sponsored clinical trial involving patients with type 2 diabetes who had a recent acute coronary syndrome, according to a report published online Dec. 3 in the New England Journal of Medicine.

Lixisenatide, a GLP-1-receptor agonist, is a glucose-lowering agent that inhibits glucagon secretion, prompts insulin production in response to hyperglycemia, and slows gastric emptying. In preliminary studies, lixisenatide showed some cardioprotective effects in myocardial ischemia and heart failure. To assess whether the drug would benefit diabetes patients at high CV risk, investigators conducted a randomized double-blind trial comparing lixisenatide with placebo in 6,068 patients who had type 2 diabetes and who had experienced acute coronary syndrome (ACS) during the preceding 6 months.

Volkan Ünalan/Thinkstock.com

In addition to receiving usual diabetes care provided by their treating physicians, these patients (mean age, 60 years) were randomly assigned to self-administer once-daily subcutaneous injections of lixisenatide (n = 3,034) or a matching placebo (n = 3,034) and were followed for a mean of 25 months at 49 medical centers worldwide, said Dr. Marc A. Pfeffer of the cardiovascular division, Brigham and Women’s Hospital, and Dzau Professor of Medicine a Harvard Medical School, Boston.

The primary endpoint of the study – a composite of death from CV causes, nonfatal MI, nonfatal stroke, or hospitalization for unstable angina – occurred in 13.4% of patients receiving lixisenatide and 13.2% of those receiving placebo, a nonsignificant difference. There were no differences between the two study groups in any of the individual components of this composite endpoint (N Engl J Med. 2015 Dec. 3. doi:10.1056/NEJMoa1509225).

Sensitivity analyses and post hoc analyses of several subgroups of patients yielded similar results. When hospitalization for heart failure and coronary revascularization procedures were added to the primary endpoint, lixisenatide still provided no cardioprotective effect compared with placebo. Mortality from any cause was not significantly different between the two study groups, at 7.0% with lixisenatide and 7.4% with placebo.

Adverse effects leading to withdrawal from the study were more common with lixisenatide (11.4%) than placebo (7.2%). In particular, treatment discontinuation due to nausea and vomiting occurred in 3.0% of patients taking active treatment, compared with 0.4% of those taking placebo.

Sanofi, maker of lixisenatide, funded the study. Dr. Pfeffer reported receiving grants and personal fees from Sanofi and 20 other drug companies; his associates reported ties to numerous industry sources.

Tinea versicolor

Tinea versicolor – also called pityriasis versicolor – is a benign superficial fungal skin infection caused by Malassezia. It presents as well-demarcated, oval, finely scaling macules, patches, or thin plaques, which can be hypopigmented, hyperpigmented, or erythematous.^1,2,3 . The name, tinea versicolor, highlights the variability in the color of lesions.⁴

Scale may be minimal, but becomes more noticeable when lesions are scraped, which is called the “evoked scale sign.”⁵ The lesions may be asymptomatic or slightly pruritic.¹ Lesions range in size from several millimeters to several centimeters and may coalesce.6 They are most commonly found on the chest, back, upper arms, and neck,^2,7 but in children the face may be affected.^1,3,8 Hypopigmented lesions may be most noticeable during the summer when the surrounding uninvolved skin darkens with sun exposure.9 Tinea versicolor is not contagious, but pigmentary changes may cause cosmetic concerns, and the condition may persist for years if not treated.^2,4

Malassezia is a dimorphic fungus that is part of the normal skin flora in its yeast form, but if Malassezia converts to its hyphal form, it is able penetrate the stratum corneum and cause the tinea versicolor rash.^1,10 The reason for the conversion from yeast to hyphal form is not fully understood.¹¹Malassezia is lipophilic, so it thrives when sebum production is high, which is why tinea versicolor most commonly develops in adolescence or young adulthood, although it may be seen in younger children and older adults.¹² Genetic predisposition, warm and humid environments, oily skin, use of oily creams, use of corticosteroids, hyperhidrosis, physical activity, malnutrition, immunosuppression, and exposure to sunlight increase susceptibility.^1,13,14

Tinea versicolor is most commonly caused by Malassezia globosa and Malassezia furfur.^13,15,16 Hypopigmentation may be caused by Malassezia’s production of azelaic acid, which inhibits the dopa-tyrosinase reaction that is part of melanin synthesis.^15,17,18 Hyperpigmentation may result from inflammation.^15,18 The evoked scale sign results from the production of keratinase, which disrupts the stratum corneum.⁵

Tinea versicolor often can be diagnosed by its characteristic clinical appearance and may fluoresce golden under a Wood’s ultraviolet lamp.¹⁹ Diagnosis can be confirmed by microscopic examination of skin scrapings treated with potassium hydroxide (KOH), which will have a “spaghetti and meatball” appearance, with the hyphae resembling spaghetti and spores resembling meatballs.¹ For young children, removing scale with transparent tape can be a good alternative to scraping skin with a blade.^2,19

Differential diagnosis

Postinflammatory pigment changes, both hypo and hyper, usually lack scale, may be anywhere on the body, and should have the same distribution as some original inflammation.

Pityriasis alba presents with hypopigmented patches, typically on the face, and has a more subtle “blotchy” appearance, without discrete oval patches. Pityriasis rosea may appear similar to tinea versicolor with erythema and scale, but it typically begins with a single, large herald patch, and scale is primarily at the outer border of the lesions.¹

Tinea corporis (“ringworm”), which is caused by a dermatophyte, is more distinctly ring shaped with a scaly, vesicular, papular, or pustular border and there is often a clear center that may not scale when scraped.^5,9 It is much more commonly localized, except in immunosuppressed patients or if mistreated with topical corticosteroids. Vitiligo lesions are completely depigmented, rather than just hypopigmented, and lack scale.¹ Psoriasis scale is thicker and is visible without any provocation.  

Treatment

First-line treatments for tinea versicolor include ketoconazole shampoo, selenium sulfide lotion or shampoo, and zinc pyrithione shampoo, which are left on for 5-10 minutes before rinsing.^1,20 Any of these treatments is a fine first choice, as all are effective, and there are no robust data establishing the superiority of any single treatment.20 The typical treatment duration is 1-4 weeks.¹ Longer treatment durations yield better cure rates.20 Ketoconazole and selenium sulfide also are available in foam formulations.11 Shampoo and foam formulations have the benefit of easily covering a large affected area.

Alternatively, terbinafine cream can be applied twice daily for a week or ketoconazole cream can be applied twice daily for 1-4 weeks.^1,21 It is advisable to treat the whole trunk, neck, arms, and legs down to the knees, even if only a small area is involved.^14,22 Antifungal treatments are well tolerated, with skin irritation and contact allergy being the most common adverse effects.1 Selenium sulfide has a strong odor.1

Hypopigmentation and hyperpigmentation can persist for months after the active infection has resolved and do not necessarily indicate a treatment failure.^2,20 However, because Malassezia is a part of the normal skin flora, recurrence is common, occurring in 60%-80% of patients within 2 years.¹⁴ Recurrence or persistence of an active infection can be proven by a positive KOH scrape test. If a first treatment fails, a different first-line topical medication should be tried.1 Referral to a dermatologist is recommended if the eruption is unresponsive to two treatments.1

Oral antifungals such as itraconazole, fluconazole, and pramiconazole are effective for tinea versicolor, but have more adverse effects than topicals and interact with other medications because of their inhibition of the cytochrome P450 system, so they are used only for refractory or widespread disease.^1,11 In 2013, the Food and Drug Administration issued a black box warning against oral ketoconazole due its ability to cause life-threatening hepatotoxicity and adrenal insufficiency^1,23,24; it should not be used to treat tinea versicolor. Topical ketoconazole is safe and remains a first-line treatment for tinea versicolor, as discussed above.24 Oral terbinafine is not effective for tinea versicolor despite its efficacy as a topical treatment.¹¹

Patients with recurrent tinea versicolor can try preventive therapy with ketoconazole shampoo, zinc pyrithione shampoo, or selenium sulfide lotion or shampoo one to four times per month.1 Oral antifungals also are effective for prevention of recurrence, but should be used only if the condition is refractory to topical prophylaxis.^20,25 It is important to remember that hypopigmentation and hyperpigmentation may persist for months after resolution of active infection; absence of hyphae on skin scraping prepared with KOH confirms absence of active disease.^15,16 

References

1. BMJ. 2015;350:h1394. doi:10.1136/bmj.h1394.
2. Lancet. 2004 Sep 25-Oct 1;364(9440):1173-82.
3. Pediatr Dermatol. 1991;8(1):9-12.
4. J Eur Acad Dermatol Venereol. 2002;16(1):19-33.
5. Arch Dermatol. 2009;145(9):1078.
6. Vitiligo and other disorders of pigmentation, in: “Dermatology,” Vol 1. 3rd ed. (Philadelphia: Elsevier Saunders, 2012, pp.1041-2.)
7. Am J Clin Dermatol. 2000 Mar-Apr;1(2):75-80.
8. Mycoses. 1995;38(5-6):227-8.
9. “Skin Disorders Due to Fungi,” in: Hurwitz Clinical Pediatric Dermatology 4th ed. (Philadelphia: Saunders, 2011, pp. 396-403).
10. Infect Control Hosp Epidemiol. 2002 Apr;23(4):212-6.
11. Expert Opin Pharmacother. 2014 Aug;15(12):1707-13.
12. Clin Microbiol Rev. 2002 Jan;15(1):21-57.
13. Clin Dermatol. 2010 Mar 4;28(2):185-9.
14. J Am Acad Dermatol. 1994 Sep;31(3 Pt 2):S18-20.
15. Int J Dermatol. 2014 Feb;53(2):137-41
16. Mycopathologia. 2006 Dec;162(6):373-6.
17. J Invest Dermatol. 1978 Sep;71(3):205-8.
18. Int J Dermatol. 1992 Apr;31(4):253-6.
19. Pediatr Dermatol. 2000 Jan-Feb;17(1):68-9.
20. Arch Dermatol. 2010 Oct;146(10):1132-40.
21. Dermatology (Basel). 1997;194(1):22-4. doi:10.1159/000246179.
22. Red Book Plus: 2009 Report of the Committee on Infectious Disease.
23. http://www.fda.gov/Drugs/DrugSafety/ucm362415.htm    
24. J Cutan Med Surg. 2015 Jul-Aug;19(4):352-7.
25. Arch Dermatol. 2002 Jan;138(1):69-73.

Dr. Eichenfield is chief of pediatric and adolescent dermatology at Rady Children’s Hospital-San Diego and professor of dermatology and pediatrics at the University of California, San Diego. Ms. Haddock is a medical student at the University of California, San Diego, and a research associate at the hospital. Dr. Eichenfield and Ms. Haddock said they have no relevant financial disclosures.

Email to [email protected].

Tinea versicolor

Tinea versicolor – also called pityriasis versicolor – is a benign superficial fungal skin infection caused by Malassezia. It presents as well-demarcated, oval, finely scaling macules, patches, or thin plaques, which can be hypopigmented, hyperpigmented, or erythematous.^1,2,3 . The name, tinea versicolor, highlights the variability in the color of lesions.⁴

Scale may be minimal, but becomes more noticeable when lesions are scraped, which is called the “evoked scale sign.”⁵ The lesions may be asymptomatic or slightly pruritic.¹ Lesions range in size from several millimeters to several centimeters and may coalesce.6 They are most commonly found on the chest, back, upper arms, and neck,^2,7 but in children the face may be affected.^1,3,8 Hypopigmented lesions may be most noticeable during the summer when the surrounding uninvolved skin darkens with sun exposure.9 Tinea versicolor is not contagious, but pigmentary changes may cause cosmetic concerns, and the condition may persist for years if not treated.^2,4

Malassezia is a dimorphic fungus that is part of the normal skin flora in its yeast form, but if Malassezia converts to its hyphal form, it is able penetrate the stratum corneum and cause the tinea versicolor rash.^1,10 The reason for the conversion from yeast to hyphal form is not fully understood.¹¹Malassezia is lipophilic, so it thrives when sebum production is high, which is why tinea versicolor most commonly develops in adolescence or young adulthood, although it may be seen in younger children and older adults.¹² Genetic predisposition, warm and humid environments, oily skin, use of oily creams, use of corticosteroids, hyperhidrosis, physical activity, malnutrition, immunosuppression, and exposure to sunlight increase susceptibility.^1,13,14

Tinea versicolor is most commonly caused by Malassezia globosa and Malassezia furfur.^13,15,16 Hypopigmentation may be caused by Malassezia’s production of azelaic acid, which inhibits the dopa-tyrosinase reaction that is part of melanin synthesis.^15,17,18 Hyperpigmentation may result from inflammation.^15,18 The evoked scale sign results from the production of keratinase, which disrupts the stratum corneum.⁵

Tinea versicolor often can be diagnosed by its characteristic clinical appearance and may fluoresce golden under a Wood’s ultraviolet lamp.¹⁹ Diagnosis can be confirmed by microscopic examination of skin scrapings treated with potassium hydroxide (KOH), which will have a “spaghetti and meatball” appearance, with the hyphae resembling spaghetti and spores resembling meatballs.¹ For young children, removing scale with transparent tape can be a good alternative to scraping skin with a blade.^2,19

Differential diagnosis

Postinflammatory pigment changes, both hypo and hyper, usually lack scale, may be anywhere on the body, and should have the same distribution as some original inflammation.

Pityriasis alba presents with hypopigmented patches, typically on the face, and has a more subtle “blotchy” appearance, without discrete oval patches. Pityriasis rosea may appear similar to tinea versicolor with erythema and scale, but it typically begins with a single, large herald patch, and scale is primarily at the outer border of the lesions.¹

Tinea corporis (“ringworm”), which is caused by a dermatophyte, is more distinctly ring shaped with a scaly, vesicular, papular, or pustular border and there is often a clear center that may not scale when scraped.^5,9 It is much more commonly localized, except in immunosuppressed patients or if mistreated with topical corticosteroids. Vitiligo lesions are completely depigmented, rather than just hypopigmented, and lack scale.¹ Psoriasis scale is thicker and is visible without any provocation.  

Treatment

First-line treatments for tinea versicolor include ketoconazole shampoo, selenium sulfide lotion or shampoo, and zinc pyrithione shampoo, which are left on for 5-10 minutes before rinsing.^1,20 Any of these treatments is a fine first choice, as all are effective, and there are no robust data establishing the superiority of any single treatment.20 The typical treatment duration is 1-4 weeks.¹ Longer treatment durations yield better cure rates.20 Ketoconazole and selenium sulfide also are available in foam formulations.11 Shampoo and foam formulations have the benefit of easily covering a large affected area.

Alternatively, terbinafine cream can be applied twice daily for a week or ketoconazole cream can be applied twice daily for 1-4 weeks.^1,21 It is advisable to treat the whole trunk, neck, arms, and legs down to the knees, even if only a small area is involved.^14,22 Antifungal treatments are well tolerated, with skin irritation and contact allergy being the most common adverse effects.1 Selenium sulfide has a strong odor.1

Hypopigmentation and hyperpigmentation can persist for months after the active infection has resolved and do not necessarily indicate a treatment failure.^2,20 However, because Malassezia is a part of the normal skin flora, recurrence is common, occurring in 60%-80% of patients within 2 years.¹⁴ Recurrence or persistence of an active infection can be proven by a positive KOH scrape test. If a first treatment fails, a different first-line topical medication should be tried.1 Referral to a dermatologist is recommended if the eruption is unresponsive to two treatments.1

Oral antifungals such as itraconazole, fluconazole, and pramiconazole are effective for tinea versicolor, but have more adverse effects than topicals and interact with other medications because of their inhibition of the cytochrome P450 system, so they are used only for refractory or widespread disease.^1,11 In 2013, the Food and Drug Administration issued a black box warning against oral ketoconazole due its ability to cause life-threatening hepatotoxicity and adrenal insufficiency^1,23,24; it should not be used to treat tinea versicolor. Topical ketoconazole is safe and remains a first-line treatment for tinea versicolor, as discussed above.24 Oral terbinafine is not effective for tinea versicolor despite its efficacy as a topical treatment.¹¹

Patients with recurrent tinea versicolor can try preventive therapy with ketoconazole shampoo, zinc pyrithione shampoo, or selenium sulfide lotion or shampoo one to four times per month.1 Oral antifungals also are effective for prevention of recurrence, but should be used only if the condition is refractory to topical prophylaxis.^20,25 It is important to remember that hypopigmentation and hyperpigmentation may persist for months after resolution of active infection; absence of hyphae on skin scraping prepared with KOH confirms absence of active disease.^15,16 

References

1. BMJ. 2015;350:h1394. doi:10.1136/bmj.h1394.
2. Lancet. 2004 Sep 25-Oct 1;364(9440):1173-82.
3. Pediatr Dermatol. 1991;8(1):9-12.
4. J Eur Acad Dermatol Venereol. 2002;16(1):19-33.
5. Arch Dermatol. 2009;145(9):1078.
6. Vitiligo and other disorders of pigmentation, in: “Dermatology,” Vol 1. 3rd ed. (Philadelphia: Elsevier Saunders, 2012, pp.1041-2.)
7. Am J Clin Dermatol. 2000 Mar-Apr;1(2):75-80.
8. Mycoses. 1995;38(5-6):227-8.
9. “Skin Disorders Due to Fungi,” in: Hurwitz Clinical Pediatric Dermatology 4th ed. (Philadelphia: Saunders, 2011, pp. 396-403).
10. Infect Control Hosp Epidemiol. 2002 Apr;23(4):212-6.
11. Expert Opin Pharmacother. 2014 Aug;15(12):1707-13.
12. Clin Microbiol Rev. 2002 Jan;15(1):21-57.
13. Clin Dermatol. 2010 Mar 4;28(2):185-9.
14. J Am Acad Dermatol. 1994 Sep;31(3 Pt 2):S18-20.
15. Int J Dermatol. 2014 Feb;53(2):137-41
16. Mycopathologia. 2006 Dec;162(6):373-6.
17. J Invest Dermatol. 1978 Sep;71(3):205-8.
18. Int J Dermatol. 1992 Apr;31(4):253-6.
19. Pediatr Dermatol. 2000 Jan-Feb;17(1):68-9.
20. Arch Dermatol. 2010 Oct;146(10):1132-40.
21. Dermatology (Basel). 1997;194(1):22-4. doi:10.1159/000246179.
22. Red Book Plus: 2009 Report of the Committee on Infectious Disease.
23. http://www.fda.gov/Drugs/DrugSafety/ucm362415.htm    
24. J Cutan Med Surg. 2015 Jul-Aug;19(4):352-7.
25. Arch Dermatol. 2002 Jan;138(1):69-73.

Dr. Eichenfield is chief of pediatric and adolescent dermatology at Rady Children’s Hospital-San Diego and professor of dermatology and pediatrics at the University of California, San Diego. Ms. Haddock is a medical student at the University of California, San Diego, and a research associate at the hospital. Dr. Eichenfield and Ms. Haddock said they have no relevant financial disclosures.

Email to [email protected].

Tinea versicolor

Tinea versicolor – also called pityriasis versicolor – is a benign superficial fungal skin infection caused by Malassezia. It presents as well-demarcated, oval, finely scaling macules, patches, or thin plaques, which can be hypopigmented, hyperpigmented, or erythematous.^1,2,3 . The name, tinea versicolor, highlights the variability in the color of lesions.⁴

Scale may be minimal, but becomes more noticeable when lesions are scraped, which is called the “evoked scale sign.”⁵ The lesions may be asymptomatic or slightly pruritic.¹ Lesions range in size from several millimeters to several centimeters and may coalesce.6 They are most commonly found on the chest, back, upper arms, and neck,^2,7 but in children the face may be affected.^1,3,8 Hypopigmented lesions may be most noticeable during the summer when the surrounding uninvolved skin darkens with sun exposure.9 Tinea versicolor is not contagious, but pigmentary changes may cause cosmetic concerns, and the condition may persist for years if not treated.^2,4

Malassezia is a dimorphic fungus that is part of the normal skin flora in its yeast form, but if Malassezia converts to its hyphal form, it is able penetrate the stratum corneum and cause the tinea versicolor rash.^1,10 The reason for the conversion from yeast to hyphal form is not fully understood.¹¹Malassezia is lipophilic, so it thrives when sebum production is high, which is why tinea versicolor most commonly develops in adolescence or young adulthood, although it may be seen in younger children and older adults.¹² Genetic predisposition, warm and humid environments, oily skin, use of oily creams, use of corticosteroids, hyperhidrosis, physical activity, malnutrition, immunosuppression, and exposure to sunlight increase susceptibility.^1,13,14

Tinea versicolor is most commonly caused by Malassezia globosa and Malassezia furfur.^13,15,16 Hypopigmentation may be caused by Malassezia’s production of azelaic acid, which inhibits the dopa-tyrosinase reaction that is part of melanin synthesis.^15,17,18 Hyperpigmentation may result from inflammation.^15,18 The evoked scale sign results from the production of keratinase, which disrupts the stratum corneum.⁵

Tinea versicolor often can be diagnosed by its characteristic clinical appearance and may fluoresce golden under a Wood’s ultraviolet lamp.¹⁹ Diagnosis can be confirmed by microscopic examination of skin scrapings treated with potassium hydroxide (KOH), which will have a “spaghetti and meatball” appearance, with the hyphae resembling spaghetti and spores resembling meatballs.¹ For young children, removing scale with transparent tape can be a good alternative to scraping skin with a blade.^2,19

Differential diagnosis

Postinflammatory pigment changes, both hypo and hyper, usually lack scale, may be anywhere on the body, and should have the same distribution as some original inflammation.

Pityriasis alba presents with hypopigmented patches, typically on the face, and has a more subtle “blotchy” appearance, without discrete oval patches. Pityriasis rosea may appear similar to tinea versicolor with erythema and scale, but it typically begins with a single, large herald patch, and scale is primarily at the outer border of the lesions.¹

Tinea corporis (“ringworm”), which is caused by a dermatophyte, is more distinctly ring shaped with a scaly, vesicular, papular, or pustular border and there is often a clear center that may not scale when scraped.^5,9 It is much more commonly localized, except in immunosuppressed patients or if mistreated with topical corticosteroids. Vitiligo lesions are completely depigmented, rather than just hypopigmented, and lack scale.¹ Psoriasis scale is thicker and is visible without any provocation.  

Treatment

First-line treatments for tinea versicolor include ketoconazole shampoo, selenium sulfide lotion or shampoo, and zinc pyrithione shampoo, which are left on for 5-10 minutes before rinsing.^1,20 Any of these treatments is a fine first choice, as all are effective, and there are no robust data establishing the superiority of any single treatment.20 The typical treatment duration is 1-4 weeks.¹ Longer treatment durations yield better cure rates.20 Ketoconazole and selenium sulfide also are available in foam formulations.11 Shampoo and foam formulations have the benefit of easily covering a large affected area.

Alternatively, terbinafine cream can be applied twice daily for a week or ketoconazole cream can be applied twice daily for 1-4 weeks.^1,21 It is advisable to treat the whole trunk, neck, arms, and legs down to the knees, even if only a small area is involved.^14,22 Antifungal treatments are well tolerated, with skin irritation and contact allergy being the most common adverse effects.1 Selenium sulfide has a strong odor.1

Hypopigmentation and hyperpigmentation can persist for months after the active infection has resolved and do not necessarily indicate a treatment failure.^2,20 However, because Malassezia is a part of the normal skin flora, recurrence is common, occurring in 60%-80% of patients within 2 years.¹⁴ Recurrence or persistence of an active infection can be proven by a positive KOH scrape test. If a first treatment fails, a different first-line topical medication should be tried.1 Referral to a dermatologist is recommended if the eruption is unresponsive to two treatments.1

Oral antifungals such as itraconazole, fluconazole, and pramiconazole are effective for tinea versicolor, but have more adverse effects than topicals and interact with other medications because of their inhibition of the cytochrome P450 system, so they are used only for refractory or widespread disease.^1,11 In 2013, the Food and Drug Administration issued a black box warning against oral ketoconazole due its ability to cause life-threatening hepatotoxicity and adrenal insufficiency^1,23,24; it should not be used to treat tinea versicolor. Topical ketoconazole is safe and remains a first-line treatment for tinea versicolor, as discussed above.24 Oral terbinafine is not effective for tinea versicolor despite its efficacy as a topical treatment.¹¹

Patients with recurrent tinea versicolor can try preventive therapy with ketoconazole shampoo, zinc pyrithione shampoo, or selenium sulfide lotion or shampoo one to four times per month.1 Oral antifungals also are effective for prevention of recurrence, but should be used only if the condition is refractory to topical prophylaxis.^20,25 It is important to remember that hypopigmentation and hyperpigmentation may persist for months after resolution of active infection; absence of hyphae on skin scraping prepared with KOH confirms absence of active disease.^15,16 

References

1. BMJ. 2015;350:h1394. doi:10.1136/bmj.h1394.
2. Lancet. 2004 Sep 25-Oct 1;364(9440):1173-82.
3. Pediatr Dermatol. 1991;8(1):9-12.
4. J Eur Acad Dermatol Venereol. 2002;16(1):19-33.
5. Arch Dermatol. 2009;145(9):1078.
6. Vitiligo and other disorders of pigmentation, in: “Dermatology,” Vol 1. 3rd ed. (Philadelphia: Elsevier Saunders, 2012, pp.1041-2.)
7. Am J Clin Dermatol. 2000 Mar-Apr;1(2):75-80.
8. Mycoses. 1995;38(5-6):227-8.
9. “Skin Disorders Due to Fungi,” in: Hurwitz Clinical Pediatric Dermatology 4th ed. (Philadelphia: Saunders, 2011, pp. 396-403).
10. Infect Control Hosp Epidemiol. 2002 Apr;23(4):212-6.
11. Expert Opin Pharmacother. 2014 Aug;15(12):1707-13.
12. Clin Microbiol Rev. 2002 Jan;15(1):21-57.
13. Clin Dermatol. 2010 Mar 4;28(2):185-9.
14. J Am Acad Dermatol. 1994 Sep;31(3 Pt 2):S18-20.
15. Int J Dermatol. 2014 Feb;53(2):137-41
16. Mycopathologia. 2006 Dec;162(6):373-6.
17. J Invest Dermatol. 1978 Sep;71(3):205-8.
18. Int J Dermatol. 1992 Apr;31(4):253-6.
19. Pediatr Dermatol. 2000 Jan-Feb;17(1):68-9.
20. Arch Dermatol. 2010 Oct;146(10):1132-40.
21. Dermatology (Basel). 1997;194(1):22-4. doi:10.1159/000246179.
22. Red Book Plus: 2009 Report of the Committee on Infectious Disease.
23. http://www.fda.gov/Drugs/DrugSafety/ucm362415.htm    
24. J Cutan Med Surg. 2015 Jul-Aug;19(4):352-7.
25. Arch Dermatol. 2002 Jan;138(1):69-73.

Dr. Eichenfield is chief of pediatric and adolescent dermatology at Rady Children’s Hospital-San Diego and professor of dermatology and pediatrics at the University of California, San Diego. Ms. Haddock is a medical student at the University of California, San Diego, and a research associate at the hospital. Dr. Eichenfield and Ms. Haddock said they have no relevant financial disclosures.

Email to [email protected].

To the Editor:

Missed appointments are a major issue in every discipline of medicine¹ and can be detrimental for dermatologists,^2,3 whose clinics often have long wait times for referred patients and can lose up to $200 for each missed appointment.⁴ The purpose of this study was to quantify the rate of missed appointments at an academic dermatology clinic and identify factors associated with patient nonattendance.

After approval by an institutional review board, appointment data was collected from the electronic medical record at the dermatology clinic at Wake Forest Baptist Health, Winston-Salem, North Carolina, for the period from May 1, 2013, to April 30, 2014. Variables that were evaluated included age, race, sex, primary language, employment status, zip code, appointment time, insurance coverage, scheduled provider, patient status (new vs returning), and the nature of the visit (cosmetic vs noncosmetic visits and procedural vs nonprocedural visits). Zip codes served as a representation of distance traveled and were stratified into 4 concentric zones: zone 1 represented the region corresponding to the clinic’s zip code; zone 2 represented regions with zip codes adjacent to zone 1; and the remaining zones were determined by regions with zip codes adjacent to the prior zone. Primary language spoken was categorized as English or non-English. Insurance coverage was categorized as private, Medicaid, Medicare, self-pay, and other. Using stepwise selection, both a univariate model and a multivariable logistic regression model were created (variable inclusion, P≤.10; variable exclusion, P>.05). Of the 28,772 appointments scheduled during the study period, 5584 (19.4%) were missed. Univariate and multivariable analyses of the factors associated with missed appointments are shown in Table 1.

A telephone survey also was conducted to evaluate patient-reported factors associated with missed dermatology appointments. A list of patients who missed appointments during the period from January 1, 2014, to April 30, 2014, was extracted and every fourth patient was called within 6 weeks of the appointment to minimize recall bias. Patients were excluded from the study if they could not be reached after 3 attempts. Of the 799 patients contacted, 300 (38%) responded to the survey; 98 (12%) had phone numbers on record that were incorrect or were no longer in service; and 401 (50%) could not be reached after 3 attempts. The results of the telephone survey are provided in Table 2.

The demographic data suggested that characteristics associated with higher rates of missed appointments tended to reflect physical or financial barriers, such as dependency on others for transportation (eg, pediatric patients), longer distance traveled to the clinic, and lack of insurance coverage; however, only 4% and 8% of the survey respondents reported that they missed their appointment due to financial reasons or that they were unable to obtain transportation, respectively. Of the patients surveyed, 35% cited that the reason they missed their appointment was that they forgot about the appointment; additionally, 24% of respondents reported that they had not been reminded of the appointment.

Although physicians cannot directly address physical or financial barriers to attendance, we can introduce more effective methods of communication for patient reminders. Of the 799 patients who were called for the telephone survey, 12.3% had phone numbers on record that were either incorrect or no longer in service. As these patients’ phone numbers were listed in the electronic medical record for contact purposes, they likely did not receive telephone calls reminding them about their appointments. Although it was not formally evaluated in this study, many respondents expressed that they had other preferred methods of receiving appointment reminders (eg, e-mail, text message) than those that are currently considered commonplace (ie, telephone calls, voicemails).

This study was limited in that the appointment data came from a single academic dermatology clinic. There also were limitations in the data set for subgroup analysis; for example, to appropriately assess socioeconomic barriers to attendance of dermatology appointments, it would be valuable to stratify income within established factors of socioeconomic barriers (eg, race, employment status) to avoid research bias. Although many variables assessed were statistically significant (P<.05), the odds ratios often were close to 1, suggesting that they may not be clinically or practically relevant.

By identifying factors associated with missed dermatology appointments, interventions can be instituted to target high-risk groups and alter patient reminder protocols. If possible, identifying patients’ preferred contact methods (eg, telephone call, text message, etc) and verifying contact information may be cost-effective ways to reduce missed appointments in dermatology offices.

To the Editor:

Missed appointments are a major issue in every discipline of medicine¹ and can be detrimental for dermatologists,^2,3 whose clinics often have long wait times for referred patients and can lose up to $200 for each missed appointment.⁴ The purpose of this study was to quantify the rate of missed appointments at an academic dermatology clinic and identify factors associated with patient nonattendance.

After approval by an institutional review board, appointment data was collected from the electronic medical record at the dermatology clinic at Wake Forest Baptist Health, Winston-Salem, North Carolina, for the period from May 1, 2013, to April 30, 2014. Variables that were evaluated included age, race, sex, primary language, employment status, zip code, appointment time, insurance coverage, scheduled provider, patient status (new vs returning), and the nature of the visit (cosmetic vs noncosmetic visits and procedural vs nonprocedural visits). Zip codes served as a representation of distance traveled and were stratified into 4 concentric zones: zone 1 represented the region corresponding to the clinic’s zip code; zone 2 represented regions with zip codes adjacent to zone 1; and the remaining zones were determined by regions with zip codes adjacent to the prior zone. Primary language spoken was categorized as English or non-English. Insurance coverage was categorized as private, Medicaid, Medicare, self-pay, and other. Using stepwise selection, both a univariate model and a multivariable logistic regression model were created (variable inclusion, P≤.10; variable exclusion, P>.05). Of the 28,772 appointments scheduled during the study period, 5584 (19.4%) were missed. Univariate and multivariable analyses of the factors associated with missed appointments are shown in Table 1.

A telephone survey also was conducted to evaluate patient-reported factors associated with missed dermatology appointments. A list of patients who missed appointments during the period from January 1, 2014, to April 30, 2014, was extracted and every fourth patient was called within 6 weeks of the appointment to minimize recall bias. Patients were excluded from the study if they could not be reached after 3 attempts. Of the 799 patients contacted, 300 (38%) responded to the survey; 98 (12%) had phone numbers on record that were incorrect or were no longer in service; and 401 (50%) could not be reached after 3 attempts. The results of the telephone survey are provided in Table 2.

The demographic data suggested that characteristics associated with higher rates of missed appointments tended to reflect physical or financial barriers, such as dependency on others for transportation (eg, pediatric patients), longer distance traveled to the clinic, and lack of insurance coverage; however, only 4% and 8% of the survey respondents reported that they missed their appointment due to financial reasons or that they were unable to obtain transportation, respectively. Of the patients surveyed, 35% cited that the reason they missed their appointment was that they forgot about the appointment; additionally, 24% of respondents reported that they had not been reminded of the appointment.

Although physicians cannot directly address physical or financial barriers to attendance, we can introduce more effective methods of communication for patient reminders. Of the 799 patients who were called for the telephone survey, 12.3% had phone numbers on record that were either incorrect or no longer in service. As these patients’ phone numbers were listed in the electronic medical record for contact purposes, they likely did not receive telephone calls reminding them about their appointments. Although it was not formally evaluated in this study, many respondents expressed that they had other preferred methods of receiving appointment reminders (eg, e-mail, text message) than those that are currently considered commonplace (ie, telephone calls, voicemails).

This study was limited in that the appointment data came from a single academic dermatology clinic. There also were limitations in the data set for subgroup analysis; for example, to appropriately assess socioeconomic barriers to attendance of dermatology appointments, it would be valuable to stratify income within established factors of socioeconomic barriers (eg, race, employment status) to avoid research bias. Although many variables assessed were statistically significant (P<.05), the odds ratios often were close to 1, suggesting that they may not be clinically or practically relevant.

By identifying factors associated with missed dermatology appointments, interventions can be instituted to target high-risk groups and alter patient reminder protocols. If possible, identifying patients’ preferred contact methods (eg, telephone call, text message, etc) and verifying contact information may be cost-effective ways to reduce missed appointments in dermatology offices.

To the Editor:

Missed appointments are a major issue in every discipline of medicine¹ and can be detrimental for dermatologists,^2,3 whose clinics often have long wait times for referred patients and can lose up to $200 for each missed appointment.⁴ The purpose of this study was to quantify the rate of missed appointments at an academic dermatology clinic and identify factors associated with patient nonattendance.

After approval by an institutional review board, appointment data was collected from the electronic medical record at the dermatology clinic at Wake Forest Baptist Health, Winston-Salem, North Carolina, for the period from May 1, 2013, to April 30, 2014. Variables that were evaluated included age, race, sex, primary language, employment status, zip code, appointment time, insurance coverage, scheduled provider, patient status (new vs returning), and the nature of the visit (cosmetic vs noncosmetic visits and procedural vs nonprocedural visits). Zip codes served as a representation of distance traveled and were stratified into 4 concentric zones: zone 1 represented the region corresponding to the clinic’s zip code; zone 2 represented regions with zip codes adjacent to zone 1; and the remaining zones were determined by regions with zip codes adjacent to the prior zone. Primary language spoken was categorized as English or non-English. Insurance coverage was categorized as private, Medicaid, Medicare, self-pay, and other. Using stepwise selection, both a univariate model and a multivariable logistic regression model were created (variable inclusion, P≤.10; variable exclusion, P>.05). Of the 28,772 appointments scheduled during the study period, 5584 (19.4%) were missed. Univariate and multivariable analyses of the factors associated with missed appointments are shown in Table 1.

A telephone survey also was conducted to evaluate patient-reported factors associated with missed dermatology appointments. A list of patients who missed appointments during the period from January 1, 2014, to April 30, 2014, was extracted and every fourth patient was called within 6 weeks of the appointment to minimize recall bias. Patients were excluded from the study if they could not be reached after 3 attempts. Of the 799 patients contacted, 300 (38%) responded to the survey; 98 (12%) had phone numbers on record that were incorrect or were no longer in service; and 401 (50%) could not be reached after 3 attempts. The results of the telephone survey are provided in Table 2.

The demographic data suggested that characteristics associated with higher rates of missed appointments tended to reflect physical or financial barriers, such as dependency on others for transportation (eg, pediatric patients), longer distance traveled to the clinic, and lack of insurance coverage; however, only 4% and 8% of the survey respondents reported that they missed their appointment due to financial reasons or that they were unable to obtain transportation, respectively. Of the patients surveyed, 35% cited that the reason they missed their appointment was that they forgot about the appointment; additionally, 24% of respondents reported that they had not been reminded of the appointment.

Although physicians cannot directly address physical or financial barriers to attendance, we can introduce more effective methods of communication for patient reminders. Of the 799 patients who were called for the telephone survey, 12.3% had phone numbers on record that were either incorrect or no longer in service. As these patients’ phone numbers were listed in the electronic medical record for contact purposes, they likely did not receive telephone calls reminding them about their appointments. Although it was not formally evaluated in this study, many respondents expressed that they had other preferred methods of receiving appointment reminders (eg, e-mail, text message) than those that are currently considered commonplace (ie, telephone calls, voicemails).

This study was limited in that the appointment data came from a single academic dermatology clinic. There also were limitations in the data set for subgroup analysis; for example, to appropriately assess socioeconomic barriers to attendance of dermatology appointments, it would be valuable to stratify income within established factors of socioeconomic barriers (eg, race, employment status) to avoid research bias. Although many variables assessed were statistically significant (P<.05), the odds ratios often were close to 1, suggesting that they may not be clinically or practically relevant.

By identifying factors associated with missed dermatology appointments, interventions can be instituted to target high-risk groups and alter patient reminder protocols. If possible, identifying patients’ preferred contact methods (eg, telephone call, text message, etc) and verifying contact information may be cost-effective ways to reduce missed appointments in dermatology offices.

In November 2014, following concerns regarding the use of electromechanical, or power, morcellation, we published a surgical technique called the extracorporeal C-incision tissue extraction, or ExCITE, technique, as an alternative to contained tissue extraction during minimally invasive gynecologic procedures such as myomectomy and hysterectomy.¹ This technique was developed to create a simple, reproducible, and minimally invasive approach to tissue extraction without the need for power morcellation. ExCITE is trainee-friendly and teachable.

In this article, we will review the steps for successful execution of the ExCITE technique. In addition, we will describe how to create your own cost-effective simulation model for teaching, learning, and practicing this technique with a few simple materials found in any craft or grocery store. Simulation is essential. It helps to troubleshoot issues that may arise in an actual case and allows for learning and practicing of surgical techniques to improve the learning curve and efficiency in the operating room (OR).

The model described here is viewable in the video, “The ExCITE technique, Part 2: Simulation made simple.” It is archived in Arnold Advincula’s Surgical Techniques Video Channel, which also is accessible through the “multimedia” section of this Web site.

ExCITE operative technique
“Traditional” intracorporeal tissue extraction techniques use power morcellation without specimen containment. The specimen is grasped with a tenaculum and pulled through the device. The specimen is essentially peeled like an apple and results in long strips of tissue with both a “cut” and “noncut” or intact surface due to the way the blade incises the tissue (FIGURE 1). When performing extracorporeal tissue extraction, we are replicating essentially the same mechanism of tissue removal. With ExCITE, however, the specimen is contained, there is no power morcellator, and tissue extraction is performed manually (FIGURE 2).

©Joe Gorman for OBG Management

The ExCITE technique can be broken down into 5 major steps:

1.    specimen retrieval and containment
2.    self-retaining retractor placement
3.    creation of the C-incision
4.    tissue extraction
5.    fascial closure.

1. Specimen retrieval and containment
First, place the specimen in an endoscopic specimen retrieval bag. Extend the incision at the umbilicus, to approximately 2.5 to 3.5 cm (roughly 2 good fingerbreadths), and exteriorize the bag at the level of the umbilicus.

2. Self-retaining retractor placement
Next, place a small disposable self-retaining retractor, (we prefer the extra-small Alexis-O) inside the bag, which helps keep the bag in position at the umbilicus (FIGURE 3).

Tip. When inserting the retractor, push it in all the way until the entire bottom ring is inside of the bag. This allows for the retractor ring to deploy. Allow some space between the specimen and the opening of the bag when placing the retractor. Do not pull the bag too tightly against the anterior abdominal wall as this may prevent the retractor ring from deploying fully and make the specimen extraction step more difficult.

3. Creation of C-incision
Grasp the specimen with a penetrating clamp (such as a tenaculum, Lahey, or towel clamp) and pull the specimen flush against the incision and retractor. Use a #11 or #10 blade scalpel to create a reverse “C-incision,” with the clamp in your nondominant hand and the scalpel starting the C-incision from your nondominant side moving toward your dominant side. (The curve of the “C” faces your dominant side.)

Tip. It is important to make your C-incision wide enough to get an adequate sized specimen strip through the umbilicus but not too wide (ie, too flush with the retractor), as this will decrease your workspace and increase the risk of cutting the retractor or the bag. It is helpful to hold the scalpel like a pencil and use a sawing-like motion rather than trying to advance the scalpel through the tissue in one motion.

4. Tissue extraction
Re-grasp the tissue flap, or “nub,” created by the C-incision with the penetrating clamp. While maintaining tension on the specimen, continue cutting with a sawing-like motion, using a reverse C coring technique, keeping one surface completely intact. (Generally this is the surface facing your nondominant side.) When cutting, the tissue becomes a strip, similar in appearance to when using a power morcellator. In fact, the technique is very similar to peeling an apple all the way around while trying to keep the skin of the fruit intact.

Tip. Try to angle the scalpel slightly when cutting the tissue, especially at the curve of the C. In other words, keep the tip of the scalpel toward the center of the strip and the handle away from the center, angled closer to the abdominal wall. When achieving an adequate strip of tissue, often the specimen will start rolling (similar to power morcellation). If this occurs, “go with the roll” by modifying the C-coring incision to a half C and incising along the top part of the C repeatedly until the specimen stops rolling. At that point, complete the C. Be sure to re-grasp near the specimen base as you continue the procedure and as the strip gets longer to prevent premature breakage of the strip and for ease of maintaining tension.

5. Fascial closure
After the specimen is completely extracted, remove the self-retaining retractor and specimen bag. Close the fascia at the umbilical incision. We prefer to close the fascia with an 0-polysorb (absorbable) suture in a running fashion, but you may consider an interrupted closure or use delayed absorbable sutures such as polyglyconate/polydioxanone (maxon/PDS).

Tip. To facilitate removal of the self-retaining retractor, pull on the specimen retrieval bag at one apex in order to collapse the retractor ring inside the bag. This allows removal of the bag and retractor simultaneously.

Keys to success

• Perfect the cutting technique; it is imperative to achieve tissue removal in long strip-like pieces for efficiency. Achieving the “saw cut” is like connecting the dots on a piece of paper with a pencil, where you try not to lift up the pencil (or the scalpel in this case). Rock the tissue back and forth with your nondominant hand and pull the specimen flush to the incision. This helps expose maximal surface area so you can continue to cut tissue pieces that are as large as possible. When rocking, move your dominant (cutting) and nondominant (holding the specimen with the tenaculum) hands in opposite directions.
• Ensure that the appropriate amount of tissue is cut when performing the C-incision. If the tissue strip is too thick, it becomes hard to see and incise the tissue, especially as you come around the back curve of the C. Limited visualization will increase your risk of cutting the retractor or the bag. If the cut is too thick, angle the scalpel in to make the tissue strip thinner (ie, make a “V-like” incision into the noncut surface). If the tissue strip becomes small, do the opposite; instead of cutting at a diagonal toward the noncut surface, aim out from your last incision (“V-out”). You should re-grasp below the narrowed area of the strip in this case before continuing to cut to prevent premature breakage of the strip.
• Maintain traction on the specimen. Keep it flush against the abdominal wall and the opening of the self-retaining rectractor. Use your finger to help “roll” the specimen when continuing the C-incision, if necessary. Maintaining traction will help avoid the need to use your finger.
• If you cannot remove the tissue fully intact, reorient or resect, and move forward. When the tissue is not easily extractable, try to roll the specimen by pushing near or behind the junction of the cut surface and the specimen. This helps reorient the specimen and exposes more smooth, noncut surfaces so coring can continue. The strip of tissue may need to be completely incised at times. If this occurs, drop the specimen back into the bag, find a smoother surface, re-grasp, and begin the C-incision again.

To view ExCITE performed in real-time during removal of an 8-cm, 130-g fibroid after a robot-assisted laparoscopic myomectomy, access the video “The Extracorporeal C-Incision Tissue Extraction (ExCITE) technique” at obgmanagement.com, found in Arnold Advincula’s Surgical Techniques Video Channel.

Building the ExCITE simulation model
Creation of the ExCITE simulation model can be broken down into 4 simple steps: creating the self-retaining retractor, building the torso, preparing the specimen, and simulating the ExCITE technique.

Supplies
To complete all 4 steps, you will need several materials, all of which are easily accessible and easy to prepare for simulation (FIGURE 4).

• 1 beef tongue (2−3 lb)
• 1 pantyhose
• 2 silicone rings (4−5 cm in diameter, such as those used as wrist bracelets for cancer awareness)
• 1-gallon resealable (Ziploc) plastic bags
• 8x12 cardboard/corrugated box (or plastic storage box)
• duct or masking tape
• instruments:
  – #11-blade (or your preference) scalpel
  – penetrating clamps (tenaculum, Lahey, or towel clamps)

Note that beef tongue, given its muscular texture, closely mimics uterine tissue and therefore is used to represent the fibroid or uterus during simulation. Sometimes, a piece of beef tongue can be marbleized, or fatty, in which case it can simulate a degenerated fibroid. Beef tongue usually comes in one large piece, which could be suitable for up to 4 surgical exercises. The cost of a single tongue is approximately $20 to $30, so it averages about $5 to $7 per exercise/surgical trainee.

1. Create the self-retaining retractor
Supplies: pantyhose, 2 silicone rings

A self-retaining retractor is tubular and made up of a thin plastic material that has a pliable ring on either end. The pantyhose is used to simulate the tubular plastic material, and the silicone bracelets serve as the ring ends of the retractor. The retractor should be large enough so that it does not slip through the incision.

First, cut off the toe end of the pantyhose. Measure and cut a pantyhose strip to approximately 38 cm (15 in). Place one end of the pantyhose through the center of one of the silicone bracelets and wrap it around the edges of the bracelet. Make it as even as possible all the way around the ring. Roll the pantyhose over the bracelet twice more to secure it. Repeat these steps for the other end of the pantyhose to create the simulated self-retaining retractor (FIGURE 5).

2. Build the torso
Supplies: cardboard (ie, office paper box) or plastic box, scissors, duct tape

Place the cardboard box upside down and cut a hole (approximately 2−3 cm wide) at the center of the box top (technically the bottom of the box) to simulate the umbilical incision. Cut another opening on either side of the box (large enough to fit a hand so that the specimen can be inserted inside the box). When performing the ExCITE technique, a constant upward traction is required. In order to keep the box from lifting off the table, tape the box to the table with masking or duct tape. Alternatively, place weights in the bottom of the inside of the box.

3. Prepare the specimen
Supplies: beef tongue, resealable plastic bag

To simulate the contained fibroid or uterus, slice the beef tongue into 3 to 4 pieces (approximately 1-lb pieces) and place one piece of beef tongue inside the resealable plastic bag. Using the side opening in the box, place the bag with the specimen inside the box, and pull the bag through the “umbilical incision” hole, just as you would in a real case. When exteriorizing the bag, ensure some slack so the simulated self-retaining retractor can be placed inside the bag with the ring rolled over it (FIGURE 6).

4. ExCITE technique simulation: Grasp, cut, extract
Supplies: #11-blade scalpel, penetrating clamps (tenaculum, Lahey, or towel clamps).

After exteriorizing the bag, place the self-retaining retractor inside the bag and roll the silicone ring until the retractor is flush with the anterior abdominal wall. Grab the specimen (beef tongue) inside the bag. Perform the ExCITE technique using the beef tongue and the simulated model to fully remove the specimen (FIGURE 7).

Ready, set, simulate
There are many advantages to being able to teach and practice the ExCITE technique outside of the OR. Simulation helps the surgeon to better understand the nuances of tissue extraction in a risk-free environment, and it can improve efficiency in the OR. Building the simulation model as we have described is simple, quick, and inexpensive. We hope that this technique will add to your surgical armamentarium so that you can continue to provide your patients minimally invasive gynecologic surgical options. We recommend that you view both of our videos related to the ExCITE technique and its simulation model at obgmanagement.com, and soon you will be ready to teach or practice the ExCITE technique.

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

In November 2014, following concerns regarding the use of electromechanical, or power, morcellation, we published a surgical technique called the extracorporeal C-incision tissue extraction, or ExCITE, technique, as an alternative to contained tissue extraction during minimally invasive gynecologic procedures such as myomectomy and hysterectomy.¹ This technique was developed to create a simple, reproducible, and minimally invasive approach to tissue extraction without the need for power morcellation. ExCITE is trainee-friendly and teachable.

In this article, we will review the steps for successful execution of the ExCITE technique. In addition, we will describe how to create your own cost-effective simulation model for teaching, learning, and practicing this technique with a few simple materials found in any craft or grocery store. Simulation is essential. It helps to troubleshoot issues that may arise in an actual case and allows for learning and practicing of surgical techniques to improve the learning curve and efficiency in the operating room (OR).

The model described here is viewable in the video, “The ExCITE technique, Part 2: Simulation made simple.” It is archived in Arnold Advincula’s Surgical Techniques Video Channel, which also is accessible through the “multimedia” section of this Web site.

ExCITE operative technique
“Traditional” intracorporeal tissue extraction techniques use power morcellation without specimen containment. The specimen is grasped with a tenaculum and pulled through the device. The specimen is essentially peeled like an apple and results in long strips of tissue with both a “cut” and “noncut” or intact surface due to the way the blade incises the tissue (FIGURE 1). When performing extracorporeal tissue extraction, we are replicating essentially the same mechanism of tissue removal. With ExCITE, however, the specimen is contained, there is no power morcellator, and tissue extraction is performed manually (FIGURE 2).

©Joe Gorman for OBG Management

The ExCITE technique can be broken down into 5 major steps:

1.    specimen retrieval and containment
2.    self-retaining retractor placement
3.    creation of the C-incision
4.    tissue extraction
5.    fascial closure.

1. Specimen retrieval and containment
First, place the specimen in an endoscopic specimen retrieval bag. Extend the incision at the umbilicus, to approximately 2.5 to 3.5 cm (roughly 2 good fingerbreadths), and exteriorize the bag at the level of the umbilicus.

2. Self-retaining retractor placement
Next, place a small disposable self-retaining retractor, (we prefer the extra-small Alexis-O) inside the bag, which helps keep the bag in position at the umbilicus (FIGURE 3).

Tip. When inserting the retractor, push it in all the way until the entire bottom ring is inside of the bag. This allows for the retractor ring to deploy. Allow some space between the specimen and the opening of the bag when placing the retractor. Do not pull the bag too tightly against the anterior abdominal wall as this may prevent the retractor ring from deploying fully and make the specimen extraction step more difficult.

3. Creation of C-incision
Grasp the specimen with a penetrating clamp (such as a tenaculum, Lahey, or towel clamp) and pull the specimen flush against the incision and retractor. Use a #11 or #10 blade scalpel to create a reverse “C-incision,” with the clamp in your nondominant hand and the scalpel starting the C-incision from your nondominant side moving toward your dominant side. (The curve of the “C” faces your dominant side.)

Tip. It is important to make your C-incision wide enough to get an adequate sized specimen strip through the umbilicus but not too wide (ie, too flush with the retractor), as this will decrease your workspace and increase the risk of cutting the retractor or the bag. It is helpful to hold the scalpel like a pencil and use a sawing-like motion rather than trying to advance the scalpel through the tissue in one motion.

4. Tissue extraction
Re-grasp the tissue flap, or “nub,” created by the C-incision with the penetrating clamp. While maintaining tension on the specimen, continue cutting with a sawing-like motion, using a reverse C coring technique, keeping one surface completely intact. (Generally this is the surface facing your nondominant side.) When cutting, the tissue becomes a strip, similar in appearance to when using a power morcellator. In fact, the technique is very similar to peeling an apple all the way around while trying to keep the skin of the fruit intact.

Tip. Try to angle the scalpel slightly when cutting the tissue, especially at the curve of the C. In other words, keep the tip of the scalpel toward the center of the strip and the handle away from the center, angled closer to the abdominal wall. When achieving an adequate strip of tissue, often the specimen will start rolling (similar to power morcellation). If this occurs, “go with the roll” by modifying the C-coring incision to a half C and incising along the top part of the C repeatedly until the specimen stops rolling. At that point, complete the C. Be sure to re-grasp near the specimen base as you continue the procedure and as the strip gets longer to prevent premature breakage of the strip and for ease of maintaining tension.

5. Fascial closure
After the specimen is completely extracted, remove the self-retaining retractor and specimen bag. Close the fascia at the umbilical incision. We prefer to close the fascia with an 0-polysorb (absorbable) suture in a running fashion, but you may consider an interrupted closure or use delayed absorbable sutures such as polyglyconate/polydioxanone (maxon/PDS).

Tip. To facilitate removal of the self-retaining retractor, pull on the specimen retrieval bag at one apex in order to collapse the retractor ring inside the bag. This allows removal of the bag and retractor simultaneously.

Keys to success

• Perfect the cutting technique; it is imperative to achieve tissue removal in long strip-like pieces for efficiency. Achieving the “saw cut” is like connecting the dots on a piece of paper with a pencil, where you try not to lift up the pencil (or the scalpel in this case). Rock the tissue back and forth with your nondominant hand and pull the specimen flush to the incision. This helps expose maximal surface area so you can continue to cut tissue pieces that are as large as possible. When rocking, move your dominant (cutting) and nondominant (holding the specimen with the tenaculum) hands in opposite directions.
• Ensure that the appropriate amount of tissue is cut when performing the C-incision. If the tissue strip is too thick, it becomes hard to see and incise the tissue, especially as you come around the back curve of the C. Limited visualization will increase your risk of cutting the retractor or the bag. If the cut is too thick, angle the scalpel in to make the tissue strip thinner (ie, make a “V-like” incision into the noncut surface). If the tissue strip becomes small, do the opposite; instead of cutting at a diagonal toward the noncut surface, aim out from your last incision (“V-out”). You should re-grasp below the narrowed area of the strip in this case before continuing to cut to prevent premature breakage of the strip.
• Maintain traction on the specimen. Keep it flush against the abdominal wall and the opening of the self-retaining rectractor. Use your finger to help “roll” the specimen when continuing the C-incision, if necessary. Maintaining traction will help avoid the need to use your finger.
• If you cannot remove the tissue fully intact, reorient or resect, and move forward. When the tissue is not easily extractable, try to roll the specimen by pushing near or behind the junction of the cut surface and the specimen. This helps reorient the specimen and exposes more smooth, noncut surfaces so coring can continue. The strip of tissue may need to be completely incised at times. If this occurs, drop the specimen back into the bag, find a smoother surface, re-grasp, and begin the C-incision again.

To view ExCITE performed in real-time during removal of an 8-cm, 130-g fibroid after a robot-assisted laparoscopic myomectomy, access the video “The Extracorporeal C-Incision Tissue Extraction (ExCITE) technique” at obgmanagement.com, found in Arnold Advincula’s Surgical Techniques Video Channel.

Building the ExCITE simulation model
Creation of the ExCITE simulation model can be broken down into 4 simple steps: creating the self-retaining retractor, building the torso, preparing the specimen, and simulating the ExCITE technique.

Supplies
To complete all 4 steps, you will need several materials, all of which are easily accessible and easy to prepare for simulation (FIGURE 4).

• 1 beef tongue (2−3 lb)
• 1 pantyhose
• 2 silicone rings (4−5 cm in diameter, such as those used as wrist bracelets for cancer awareness)
• 1-gallon resealable (Ziploc) plastic bags
• 8x12 cardboard/corrugated box (or plastic storage box)
• duct or masking tape
• instruments:
  – #11-blade (or your preference) scalpel
  – penetrating clamps (tenaculum, Lahey, or towel clamps)

Note that beef tongue, given its muscular texture, closely mimics uterine tissue and therefore is used to represent the fibroid or uterus during simulation. Sometimes, a piece of beef tongue can be marbleized, or fatty, in which case it can simulate a degenerated fibroid. Beef tongue usually comes in one large piece, which could be suitable for up to 4 surgical exercises. The cost of a single tongue is approximately $20 to $30, so it averages about $5 to $7 per exercise/surgical trainee.

1. Create the self-retaining retractor
Supplies: pantyhose, 2 silicone rings

A self-retaining retractor is tubular and made up of a thin plastic material that has a pliable ring on either end. The pantyhose is used to simulate the tubular plastic material, and the silicone bracelets serve as the ring ends of the retractor. The retractor should be large enough so that it does not slip through the incision.

First, cut off the toe end of the pantyhose. Measure and cut a pantyhose strip to approximately 38 cm (15 in). Place one end of the pantyhose through the center of one of the silicone bracelets and wrap it around the edges of the bracelet. Make it as even as possible all the way around the ring. Roll the pantyhose over the bracelet twice more to secure it. Repeat these steps for the other end of the pantyhose to create the simulated self-retaining retractor (FIGURE 5).

2. Build the torso
Supplies: cardboard (ie, office paper box) or plastic box, scissors, duct tape

Place the cardboard box upside down and cut a hole (approximately 2−3 cm wide) at the center of the box top (technically the bottom of the box) to simulate the umbilical incision. Cut another opening on either side of the box (large enough to fit a hand so that the specimen can be inserted inside the box). When performing the ExCITE technique, a constant upward traction is required. In order to keep the box from lifting off the table, tape the box to the table with masking or duct tape. Alternatively, place weights in the bottom of the inside of the box.

3. Prepare the specimen
Supplies: beef tongue, resealable plastic bag

To simulate the contained fibroid or uterus, slice the beef tongue into 3 to 4 pieces (approximately 1-lb pieces) and place one piece of beef tongue inside the resealable plastic bag. Using the side opening in the box, place the bag with the specimen inside the box, and pull the bag through the “umbilical incision” hole, just as you would in a real case. When exteriorizing the bag, ensure some slack so the simulated self-retaining retractor can be placed inside the bag with the ring rolled over it (FIGURE 6).

4. ExCITE technique simulation: Grasp, cut, extract
Supplies: #11-blade scalpel, penetrating clamps (tenaculum, Lahey, or towel clamps).

After exteriorizing the bag, place the self-retaining retractor inside the bag and roll the silicone ring until the retractor is flush with the anterior abdominal wall. Grab the specimen (beef tongue) inside the bag. Perform the ExCITE technique using the beef tongue and the simulated model to fully remove the specimen (FIGURE 7).

Ready, set, simulate
There are many advantages to being able to teach and practice the ExCITE technique outside of the OR. Simulation helps the surgeon to better understand the nuances of tissue extraction in a risk-free environment, and it can improve efficiency in the OR. Building the simulation model as we have described is simple, quick, and inexpensive. We hope that this technique will add to your surgical armamentarium so that you can continue to provide your patients minimally invasive gynecologic surgical options. We recommend that you view both of our videos related to the ExCITE technique and its simulation model at obgmanagement.com, and soon you will be ready to teach or practice the ExCITE technique.

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

In November 2014, following concerns regarding the use of electromechanical, or power, morcellation, we published a surgical technique called the extracorporeal C-incision tissue extraction, or ExCITE, technique, as an alternative to contained tissue extraction during minimally invasive gynecologic procedures such as myomectomy and hysterectomy.¹ This technique was developed to create a simple, reproducible, and minimally invasive approach to tissue extraction without the need for power morcellation. ExCITE is trainee-friendly and teachable.

In this article, we will review the steps for successful execution of the ExCITE technique. In addition, we will describe how to create your own cost-effective simulation model for teaching, learning, and practicing this technique with a few simple materials found in any craft or grocery store. Simulation is essential. It helps to troubleshoot issues that may arise in an actual case and allows for learning and practicing of surgical techniques to improve the learning curve and efficiency in the operating room (OR).

The model described here is viewable in the video, “The ExCITE technique, Part 2: Simulation made simple.” It is archived in Arnold Advincula’s Surgical Techniques Video Channel, which also is accessible through the “multimedia” section of this Web site.

ExCITE operative technique
“Traditional” intracorporeal tissue extraction techniques use power morcellation without specimen containment. The specimen is grasped with a tenaculum and pulled through the device. The specimen is essentially peeled like an apple and results in long strips of tissue with both a “cut” and “noncut” or intact surface due to the way the blade incises the tissue (FIGURE 1). When performing extracorporeal tissue extraction, we are replicating essentially the same mechanism of tissue removal. With ExCITE, however, the specimen is contained, there is no power morcellator, and tissue extraction is performed manually (FIGURE 2).

©Joe Gorman for OBG Management

The ExCITE technique can be broken down into 5 major steps:

1.    specimen retrieval and containment
2.    self-retaining retractor placement
3.    creation of the C-incision
4.    tissue extraction
5.    fascial closure.

1. Specimen retrieval and containment
First, place the specimen in an endoscopic specimen retrieval bag. Extend the incision at the umbilicus, to approximately 2.5 to 3.5 cm (roughly 2 good fingerbreadths), and exteriorize the bag at the level of the umbilicus.

2. Self-retaining retractor placement
Next, place a small disposable self-retaining retractor, (we prefer the extra-small Alexis-O) inside the bag, which helps keep the bag in position at the umbilicus (FIGURE 3).

Tip. When inserting the retractor, push it in all the way until the entire bottom ring is inside of the bag. This allows for the retractor ring to deploy. Allow some space between the specimen and the opening of the bag when placing the retractor. Do not pull the bag too tightly against the anterior abdominal wall as this may prevent the retractor ring from deploying fully and make the specimen extraction step more difficult.

3. Creation of C-incision
Grasp the specimen with a penetrating clamp (such as a tenaculum, Lahey, or towel clamp) and pull the specimen flush against the incision and retractor. Use a #11 or #10 blade scalpel to create a reverse “C-incision,” with the clamp in your nondominant hand and the scalpel starting the C-incision from your nondominant side moving toward your dominant side. (The curve of the “C” faces your dominant side.)

Tip. It is important to make your C-incision wide enough to get an adequate sized specimen strip through the umbilicus but not too wide (ie, too flush with the retractor), as this will decrease your workspace and increase the risk of cutting the retractor or the bag. It is helpful to hold the scalpel like a pencil and use a sawing-like motion rather than trying to advance the scalpel through the tissue in one motion.

4. Tissue extraction
Re-grasp the tissue flap, or “nub,” created by the C-incision with the penetrating clamp. While maintaining tension on the specimen, continue cutting with a sawing-like motion, using a reverse C coring technique, keeping one surface completely intact. (Generally this is the surface facing your nondominant side.) When cutting, the tissue becomes a strip, similar in appearance to when using a power morcellator. In fact, the technique is very similar to peeling an apple all the way around while trying to keep the skin of the fruit intact.

Tip. Try to angle the scalpel slightly when cutting the tissue, especially at the curve of the C. In other words, keep the tip of the scalpel toward the center of the strip and the handle away from the center, angled closer to the abdominal wall. When achieving an adequate strip of tissue, often the specimen will start rolling (similar to power morcellation). If this occurs, “go with the roll” by modifying the C-coring incision to a half C and incising along the top part of the C repeatedly until the specimen stops rolling. At that point, complete the C. Be sure to re-grasp near the specimen base as you continue the procedure and as the strip gets longer to prevent premature breakage of the strip and for ease of maintaining tension.

5. Fascial closure
After the specimen is completely extracted, remove the self-retaining retractor and specimen bag. Close the fascia at the umbilical incision. We prefer to close the fascia with an 0-polysorb (absorbable) suture in a running fashion, but you may consider an interrupted closure or use delayed absorbable sutures such as polyglyconate/polydioxanone (maxon/PDS).

Tip. To facilitate removal of the self-retaining retractor, pull on the specimen retrieval bag at one apex in order to collapse the retractor ring inside the bag. This allows removal of the bag and retractor simultaneously.

Keys to success

• Perfect the cutting technique; it is imperative to achieve tissue removal in long strip-like pieces for efficiency. Achieving the “saw cut” is like connecting the dots on a piece of paper with a pencil, where you try not to lift up the pencil (or the scalpel in this case). Rock the tissue back and forth with your nondominant hand and pull the specimen flush to the incision. This helps expose maximal surface area so you can continue to cut tissue pieces that are as large as possible. When rocking, move your dominant (cutting) and nondominant (holding the specimen with the tenaculum) hands in opposite directions.
• Ensure that the appropriate amount of tissue is cut when performing the C-incision. If the tissue strip is too thick, it becomes hard to see and incise the tissue, especially as you come around the back curve of the C. Limited visualization will increase your risk of cutting the retractor or the bag. If the cut is too thick, angle the scalpel in to make the tissue strip thinner (ie, make a “V-like” incision into the noncut surface). If the tissue strip becomes small, do the opposite; instead of cutting at a diagonal toward the noncut surface, aim out from your last incision (“V-out”). You should re-grasp below the narrowed area of the strip in this case before continuing to cut to prevent premature breakage of the strip.
• Maintain traction on the specimen. Keep it flush against the abdominal wall and the opening of the self-retaining rectractor. Use your finger to help “roll” the specimen when continuing the C-incision, if necessary. Maintaining traction will help avoid the need to use your finger.
• If you cannot remove the tissue fully intact, reorient or resect, and move forward. When the tissue is not easily extractable, try to roll the specimen by pushing near or behind the junction of the cut surface and the specimen. This helps reorient the specimen and exposes more smooth, noncut surfaces so coring can continue. The strip of tissue may need to be completely incised at times. If this occurs, drop the specimen back into the bag, find a smoother surface, re-grasp, and begin the C-incision again.

To view ExCITE performed in real-time during removal of an 8-cm, 130-g fibroid after a robot-assisted laparoscopic myomectomy, access the video “The Extracorporeal C-Incision Tissue Extraction (ExCITE) technique” at obgmanagement.com, found in Arnold Advincula’s Surgical Techniques Video Channel.

Building the ExCITE simulation model
Creation of the ExCITE simulation model can be broken down into 4 simple steps: creating the self-retaining retractor, building the torso, preparing the specimen, and simulating the ExCITE technique.

Supplies
To complete all 4 steps, you will need several materials, all of which are easily accessible and easy to prepare for simulation (FIGURE 4).

• 1 beef tongue (2−3 lb)
• 1 pantyhose
• 2 silicone rings (4−5 cm in diameter, such as those used as wrist bracelets for cancer awareness)
• 1-gallon resealable (Ziploc) plastic bags
• 8x12 cardboard/corrugated box (or plastic storage box)
• duct or masking tape
• instruments:
  – #11-blade (or your preference) scalpel
  – penetrating clamps (tenaculum, Lahey, or towel clamps)

Note that beef tongue, given its muscular texture, closely mimics uterine tissue and therefore is used to represent the fibroid or uterus during simulation. Sometimes, a piece of beef tongue can be marbleized, or fatty, in which case it can simulate a degenerated fibroid. Beef tongue usually comes in one large piece, which could be suitable for up to 4 surgical exercises. The cost of a single tongue is approximately $20 to $30, so it averages about $5 to $7 per exercise/surgical trainee.

1. Create the self-retaining retractor
Supplies: pantyhose, 2 silicone rings

A self-retaining retractor is tubular and made up of a thin plastic material that has a pliable ring on either end. The pantyhose is used to simulate the tubular plastic material, and the silicone bracelets serve as the ring ends of the retractor. The retractor should be large enough so that it does not slip through the incision.

First, cut off the toe end of the pantyhose. Measure and cut a pantyhose strip to approximately 38 cm (15 in). Place one end of the pantyhose through the center of one of the silicone bracelets and wrap it around the edges of the bracelet. Make it as even as possible all the way around the ring. Roll the pantyhose over the bracelet twice more to secure it. Repeat these steps for the other end of the pantyhose to create the simulated self-retaining retractor (FIGURE 5).

2. Build the torso
Supplies: cardboard (ie, office paper box) or plastic box, scissors, duct tape

Place the cardboard box upside down and cut a hole (approximately 2−3 cm wide) at the center of the box top (technically the bottom of the box) to simulate the umbilical incision. Cut another opening on either side of the box (large enough to fit a hand so that the specimen can be inserted inside the box). When performing the ExCITE technique, a constant upward traction is required. In order to keep the box from lifting off the table, tape the box to the table with masking or duct tape. Alternatively, place weights in the bottom of the inside of the box.

3. Prepare the specimen
Supplies: beef tongue, resealable plastic bag

To simulate the contained fibroid or uterus, slice the beef tongue into 3 to 4 pieces (approximately 1-lb pieces) and place one piece of beef tongue inside the resealable plastic bag. Using the side opening in the box, place the bag with the specimen inside the box, and pull the bag through the “umbilical incision” hole, just as you would in a real case. When exteriorizing the bag, ensure some slack so the simulated self-retaining retractor can be placed inside the bag with the ring rolled over it (FIGURE 6).

4. ExCITE technique simulation: Grasp, cut, extract
Supplies: #11-blade scalpel, penetrating clamps (tenaculum, Lahey, or towel clamps).

After exteriorizing the bag, place the self-retaining retractor inside the bag and roll the silicone ring until the retractor is flush with the anterior abdominal wall. Grab the specimen (beef tongue) inside the bag. Perform the ExCITE technique using the beef tongue and the simulated model to fully remove the specimen (FIGURE 7).

Ready, set, simulate
There are many advantages to being able to teach and practice the ExCITE technique outside of the OR. Simulation helps the surgeon to better understand the nuances of tissue extraction in a risk-free environment, and it can improve efficiency in the OR. Building the simulation model as we have described is simple, quick, and inexpensive. We hope that this technique will add to your surgical armamentarium so that you can continue to provide your patients minimally invasive gynecologic surgical options. We recommend that you view both of our videos related to the ExCITE technique and its simulation model at obgmanagement.com, and soon you will be ready to teach or practice the ExCITE technique.

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Careful attention to technique at the time of vaginal hysterectomy is vital. Equally important is prior consideration of potential complications and the best ways to address them. Four trouble spots include:

• uterine tissue extraction (Although this is not a complication of vaginal hysterectomy, tissue extraction aids in debulking and removal of a large uterus.)
• protection of the ureters (It is important to palpate these structures before placing cardinal pedicle clamps, to protect ureteral integrity.)
• repair of inadvertent cystotomy
• control of bleeding in the setting of adnexectomy.

I focus on optimal approaches to these 4 scenarios in this article.

For a review of vaginal hysterectomy technique, see “Vaginal hysterectomy with basic instrumentation,” by Barbara S. Levy, MD, which appeared in the October 2015 issue of OBG Management. For salpingectomy and salpingo-oophorectomy technique, see my article entitled “Salpingectomy after vaginal hysterectomy: Technique, tips, and pearls,” which appeared in the November issue of this journal.

Both articles are available in the archive at obgmanagement.com and, like this one, are based on the AAGL-produced Online Master Class on Vaginal Hysterectomy, a Web-based program cosponsored by the American College of Obstetricians and Gynecologists and the Society of Gynecologic Surgeons. That program is available at https://www.aagl.org/vaghystwebinar/.

A step toward success: Begin morcellation by splitting the uterus
Manual morcellation to reduce uterine size and ease transvaginal removal is a useful technique to know. Five aspects of manual morcellation warrant emphasis:

1. Anterior and posterior entry into the cul-de-sacs is essential before attempting morcellation.
2. The blood supply on both sides of the uterus must be controlled.
3. During resection, take care to cut only tissue that can be visualized. Avoid resection beyond what you can easily see.
4. Once morcellation is completed, always go back and check the pedicles for hemostasis. During morcellation, these pedicles tend to get stretched, and bleeding may arise that wasn’t present originally.
5. Morcellation should be performed only after malignancy has been ruled out—it is a technique intended for benign uteri only.

By bivalving the uterus it is possible to follow the endocervical canal up into the uterine cavity (FIGURE 1). Our technique at the Mayo Clinic is to place tenacula at the 3 and 9 o’clock positions prior to bivalving. A small amount of bleeding may occur because of collateral blood supply from the gonadal pedicles, but it should be minimal, as the uterine vessels have been secured.

FIGURE 1 Bivalve the uterus

To begin morcellation, split the uterus down the midline, with tenacula placed at the 3- and 9-o’clock positions, then follow the endocervical canal into the uterine cavity (A). Use a knife blade to take portions of myomas and other tissue to debulk the uterus (B).

Proceed with morcellation once the uterus is bivalved. Use a Jacobs tenaculum to grasp the serosal portion of the uterus. Apply downward traction with your nondominant hand, and use the knife blade to resect portions of the uterus so that it can be debulked.

When a large myoma is encountered during morcellation, it often is possible to “finger-fracture” some of the filmy adhesions holding it in place, or to follow the pseudo-capsule of the fibroid in order to shell it out. In many cases, fibroids can be removed intact using these methods. If intact removal is not possible, debulk the fibroid by taking individual “bites.”

Tip. When the uterus is greatly enlarged, grasp it with a tenaculum so that it does not retract when you incise it. When large myomas are anticipated, keep an extra tenaculum on hand, as well as extra knife blades, as blades dull quickly when used to cut through calcified tissue. Continue to apply traction with your nondominant hand to allow each piece of tissue to be more readily developed (FIGURE 2).

Tip. When managing the round-ligament complex on each side, stay between the round ligaments (your “goal posts”) to avoid getting too lateral. Keep the cervix intact for orientation purposes. Focus on diminishing the bulk of the uterus so that you can get around the utero-ovarian pedicles.

To control the utero-ovarian pedicle on the patient’s right side, place a finger underneath it, with traction applied. Place a Heaney clamp from the top down. Repeat this action on the patient’s left side, but place the Heaney clamp from the bottom up.

Manual morcellation of tissue is useful in small uteri that are tough to access, but the procedure is very helpful in large uteri in order to remove them transvaginally.

Protect the ureters: Palpate them before clamping the pedicles
Palpating the ureters at the time of hysterectomy can protect their integrity during the procedure. The following technique has been used at the Mayo Clinic for many years and allows for location of the ureter so a cardinal pedicle clamp can be placed without injury.

Enter the anterior cul-de-sac so that you can insert a finger and palpate the ureter before you place the cardinal pedicle clamp on each side. Place Deaver retractors at the 12 o’clock and 2- to 3-o’clock positions. Insert your nondominant index finger into the anterior cul-de-sac and palpate the ureter against the Deaver clamp in the 2- to 3-o’clock position (FIGURE 3). (The ureter can be felt between your index finger and the Deaver retractor.) The ureter will have the most descent in a uterus that has some prolapse, compared with a nonprolapsed uterus.

Tip. One common error is mistaking the edge of the vaginal cuff for the ureter. Be certain that you insert your finger deeply into the cul-de-sac so that it is the ureter you feel and not the cuff edge.

Successful cystotomy repair technique
Inadvertent cystotomy is a common fear for surgeons at the time of vaginal hysterectomy. I prefer to empty the bladder before beginning the hysterectomy because it reduces the target zone that a distended bladder pre­sents. Some surgeons prefer to maintain a bit of fluid in the bladder so that, if they cut into the bladder, a small urine stream results. The approach is a matter of preference.

Cystotomy is most common during anterior dissection. If it occurs, recognize it and mark the defect with suture. Do not attempt to repair the hole at this point, but opt to finish the hysterectomy.

Cystoscopy is an important element of cystotomy repair. Once the hysterectomy is completed, look inside the bladder and determine where the defect is in relationship to the ureteral orifices. Typically, it will be beyond the interureteric ridge, along the posterior portion of the bladder, usually in the midline.

As critical as the repair itself is management of bladder drainage afterward. If you repair the hole thoroughly and drain the bladder adequately for 14 days, the defect should heal fully.

Technique for entry into anterior cul-de-sac
One way to avert bladder injury is to enter the anterior cul-de-sac very carefully. Begin by ensuring that the bladder is empty and placing a Deaver retractor at the 12 o’clock position. Also place tenacula anteriorly and posteriorly to help direct traction. This will allow good visualization of the bladder reflection.

Tip. One common mistake is making the incision too low or too near the cervix, which makes dissection more difficult and increases the likelihood that you will enter the wrong plane. Be sure you know where the bladder is, and make an adequate incision that is not too distal. Otherwise, dissection will be harder to carry out.

I prefer to make one clean incision with the knife, rather than multiple incisions, because multiple cuts increase the likelihood that you will inadvertently injure the wrong tissue. Use good traction and countertraction, and hug the uterus. Work low on the uterus, but not in the uterus. If you cut into muscle, you will get more bleeding and may end up digging a hole.

After you make the incision, put your finger through it to help develop that space further. You can confirm entry into the peritoneum by noting the characteristic slippery feel of the peritoneal lining. After you insert a Deaver retractor anteriorly, reinsert your finger and mobilize the area further. Then you can easily reach in and tent the peritoneum to cut it.

Technique for cystotomy repair
Two-layer closure is a minimum. On occasion, a third layer may be beneficial. Begin with running closure of the first layer using 2-0 chromic suture—a good suture choice in the urinary tract. This suture is inflammatory, which will help seal the wound, but it also dissolves quickly, preventing stone formation.

Use through-and-through closure on the first layer, followed by a second imbricating layer. If desired, use the peritoneum as a third layer.

Horizontal repair is typical, although vertical closure may be necessary if the defect is near a ureteral orifice and horizontal closure might compromise that side. That decision must be made intraoperatively.

When vertical repair is necessary, begin your repair just above the defect, placing the suture through and through. The hole should be visible. There is no need to be extramucosal in needle placement. Simply get a good bite of the tissue and run the repair down the bladder wall.

Next, stop and apply traction to the repair to check for any small defects that may have been overlooked. By placing a little traction on that first suture tag, any such defects will become apparent. Then go back and close them in a secondary imbricating layer.

After 2-layer closure, fill the bladder retrograde. I prefer to use a couple of drops of methylene blue in normal saline and place a clean white piece of packing material beneath the wound. If the packing material remains unstained by blue, the repair is watertight.

Incorporate the peritoneum as another layer of repair of the defect. I imbricate 2 layers in the bladder. Then, if necessary, I use that peritoneum as an additional layer (FIGURE 4).

Strategies to control bleeding at adnexectomy
Be vigilant for bleeding when removing the tubes and/or ovaries. At salpingectomy, be extremely gentle with the mesosalpinx because it can be avulsed easily off of surrounding tissue. If bleeding occurs, oversewing, or even ovary removal, could end up being the only options.

Good visualization is essential during vaginal procedures. Retractors, lighted suction irrigators, a headlamp, good overhead lighting, and appropriate instrumentation are critical for success.

Heaney clamp technique for vaginal oophorectomy
Begin by placing an Allis clamp on the utero-ovarian pedicle. Then clamp the ovary and tube with a second Allis clamp. Next, insert a Heaney clamp through the small window between the cardinal pedicle and the utero-ovarian pedicle (FIGURE 5). Clamp the tissue and place a free tie around it.

Because this is a major vascular pedicle, doubly ligate it. As you tie the first suture, have an assistant flash the clamp open and closed, then excise the specimen. There is no need to worry about losing the pedicle because it already has been ligated once. Next, stick-tie it, placing the needle distal to the free tie to avoid piercing the gonadal vessels beyond.

The technique is standard. Be gentle, and ensure good hemostasis when finished.

Tip. In my experience, any bleeding runs down from the pedicle rather than out toward me. So be sure to look down and below the pedicle to ensure hemostasis.

Additional pearls

• When performing vaginal hysterectomy, the ovaries are almost always removable transvaginally. There is no need to begin the case laparoscopically to remove the tubes and/or ovaries and then perform the hysterectomy vaginally.
• Deaver retractors offer good exposure; visualization is critical.
• Make sure the tissue is dry before you cut the last suture.
• If you prefer to use a laparoscopic stapler to secure the pedicles, proceed as before: Place an Allis clamp on the pedicle. Place a second clamp on the ovary and tube. Now you can insert the stapler into the created window, as with the Heaney clamp (FIGURE 6).
• Use a 60-mm stapler to cut the pedicle in one try. If using a 45-mm device, the stapler may need to be fired twice. This makes the procedure more expensive and risks more bleeding.
• When closing the stapler jaws, avoid clamping small bowel or packing material. Ensure stapler tip visibility well before firing.

The round ligament technique
When transecting the round ligament, it is critical to stay just beneath it to avoid bleeding and venturing into the mesosalpinx. Gently hug the tissue inferior to the round ligament and let it retract (FIGURE 7). This will allow isolation of the gonadal vessels nicely, especially if an adnexal mass is present. Then isolate the specimen and remove it, stick-tying the pedicle afterward to secure it.

When tying the pedicle, place the suture around the distal aspect to ensure that the back of the pedicle is enclosed, and do not lose it when you release the clamp. A slightly different technique is to use an endoloop to cross the gonadal vessels and control them. Use a suction irrigator and good lighting to get good exposure.

Next, place the clamp, making sure you don’t inadvertently grasp the packing material. Visualize both tips of the clamp before incising. Trim the specimen flush with the clamp. Then you can thread an endoloop over the top of the clamp. This is an inexpensive technique that allows a higher reach into the pelvic cavity. Finally, cinch down the endoloop to control the vessels.

When performing bilateral salpingo-oophorectomy, a long, fine clamp, such as the M.D. Anderson clamp, can help you reach up to control the gonadal vessels in the event that you lose your initial grip on those vessels (FIGURE 8).

Be prepared
Have a plan in place to manage any complications that arise during surgery. Just as obstetricians plan ahead to prepare for shoulder dystocia and other emergencies, gynecologic surgeons must prepare for surgical complications. Tissue extraction strategies can aid in the debulking and removal of large uteri, and the proper tools, lighting, and assistance are critical to success.

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Careful attention to technique at the time of vaginal hysterectomy is vital. Equally important is prior consideration of potential complications and the best ways to address them. Four trouble spots include:

• uterine tissue extraction (Although this is not a complication of vaginal hysterectomy, tissue extraction aids in debulking and removal of a large uterus.)
• protection of the ureters (It is important to palpate these structures before placing cardinal pedicle clamps, to protect ureteral integrity.)
• repair of inadvertent cystotomy
• control of bleeding in the setting of adnexectomy.

I focus on optimal approaches to these 4 scenarios in this article.

For a review of vaginal hysterectomy technique, see “Vaginal hysterectomy with basic instrumentation,” by Barbara S. Levy, MD, which appeared in the October 2015 issue of OBG Management. For salpingectomy and salpingo-oophorectomy technique, see my article entitled “Salpingectomy after vaginal hysterectomy: Technique, tips, and pearls,” which appeared in the November issue of this journal.

Both articles are available in the archive at obgmanagement.com and, like this one, are based on the AAGL-produced Online Master Class on Vaginal Hysterectomy, a Web-based program cosponsored by the American College of Obstetricians and Gynecologists and the Society of Gynecologic Surgeons. That program is available at https://www.aagl.org/vaghystwebinar/.

A step toward success: Begin morcellation by splitting the uterus
Manual morcellation to reduce uterine size and ease transvaginal removal is a useful technique to know. Five aspects of manual morcellation warrant emphasis:

1. Anterior and posterior entry into the cul-de-sacs is essential before attempting morcellation.
2. The blood supply on both sides of the uterus must be controlled.
3. During resection, take care to cut only tissue that can be visualized. Avoid resection beyond what you can easily see.
4. Once morcellation is completed, always go back and check the pedicles for hemostasis. During morcellation, these pedicles tend to get stretched, and bleeding may arise that wasn’t present originally.
5. Morcellation should be performed only after malignancy has been ruled out—it is a technique intended for benign uteri only.

By bivalving the uterus it is possible to follow the endocervical canal up into the uterine cavity (FIGURE 1). Our technique at the Mayo Clinic is to place tenacula at the 3 and 9 o’clock positions prior to bivalving. A small amount of bleeding may occur because of collateral blood supply from the gonadal pedicles, but it should be minimal, as the uterine vessels have been secured.

FIGURE 1 Bivalve the uterus

To begin morcellation, split the uterus down the midline, with tenacula placed at the 3- and 9-o’clock positions, then follow the endocervical canal into the uterine cavity (A). Use a knife blade to take portions of myomas and other tissue to debulk the uterus (B).

Proceed with morcellation once the uterus is bivalved. Use a Jacobs tenaculum to grasp the serosal portion of the uterus. Apply downward traction with your nondominant hand, and use the knife blade to resect portions of the uterus so that it can be debulked.

When a large myoma is encountered during morcellation, it often is possible to “finger-fracture” some of the filmy adhesions holding it in place, or to follow the pseudo-capsule of the fibroid in order to shell it out. In many cases, fibroids can be removed intact using these methods. If intact removal is not possible, debulk the fibroid by taking individual “bites.”

Tip. When the uterus is greatly enlarged, grasp it with a tenaculum so that it does not retract when you incise it. When large myomas are anticipated, keep an extra tenaculum on hand, as well as extra knife blades, as blades dull quickly when used to cut through calcified tissue. Continue to apply traction with your nondominant hand to allow each piece of tissue to be more readily developed (FIGURE 2).

Tip. When managing the round-ligament complex on each side, stay between the round ligaments (your “goal posts”) to avoid getting too lateral. Keep the cervix intact for orientation purposes. Focus on diminishing the bulk of the uterus so that you can get around the utero-ovarian pedicles.

To control the utero-ovarian pedicle on the patient’s right side, place a finger underneath it, with traction applied. Place a Heaney clamp from the top down. Repeat this action on the patient’s left side, but place the Heaney clamp from the bottom up.

Manual morcellation of tissue is useful in small uteri that are tough to access, but the procedure is very helpful in large uteri in order to remove them transvaginally.

Protect the ureters: Palpate them before clamping the pedicles
Palpating the ureters at the time of hysterectomy can protect their integrity during the procedure. The following technique has been used at the Mayo Clinic for many years and allows for location of the ureter so a cardinal pedicle clamp can be placed without injury.

Enter the anterior cul-de-sac so that you can insert a finger and palpate the ureter before you place the cardinal pedicle clamp on each side. Place Deaver retractors at the 12 o’clock and 2- to 3-o’clock positions. Insert your nondominant index finger into the anterior cul-de-sac and palpate the ureter against the Deaver clamp in the 2- to 3-o’clock position (FIGURE 3). (The ureter can be felt between your index finger and the Deaver retractor.) The ureter will have the most descent in a uterus that has some prolapse, compared with a nonprolapsed uterus.

Tip. One common error is mistaking the edge of the vaginal cuff for the ureter. Be certain that you insert your finger deeply into the cul-de-sac so that it is the ureter you feel and not the cuff edge.

Successful cystotomy repair technique
Inadvertent cystotomy is a common fear for surgeons at the time of vaginal hysterectomy. I prefer to empty the bladder before beginning the hysterectomy because it reduces the target zone that a distended bladder pre­sents. Some surgeons prefer to maintain a bit of fluid in the bladder so that, if they cut into the bladder, a small urine stream results. The approach is a matter of preference.

Cystotomy is most common during anterior dissection. If it occurs, recognize it and mark the defect with suture. Do not attempt to repair the hole at this point, but opt to finish the hysterectomy.

Cystoscopy is an important element of cystotomy repair. Once the hysterectomy is completed, look inside the bladder and determine where the defect is in relationship to the ureteral orifices. Typically, it will be beyond the interureteric ridge, along the posterior portion of the bladder, usually in the midline.

As critical as the repair itself is management of bladder drainage afterward. If you repair the hole thoroughly and drain the bladder adequately for 14 days, the defect should heal fully.

Technique for entry into anterior cul-de-sac
One way to avert bladder injury is to enter the anterior cul-de-sac very carefully. Begin by ensuring that the bladder is empty and placing a Deaver retractor at the 12 o’clock position. Also place tenacula anteriorly and posteriorly to help direct traction. This will allow good visualization of the bladder reflection.

Tip. One common mistake is making the incision too low or too near the cervix, which makes dissection more difficult and increases the likelihood that you will enter the wrong plane. Be sure you know where the bladder is, and make an adequate incision that is not too distal. Otherwise, dissection will be harder to carry out.

I prefer to make one clean incision with the knife, rather than multiple incisions, because multiple cuts increase the likelihood that you will inadvertently injure the wrong tissue. Use good traction and countertraction, and hug the uterus. Work low on the uterus, but not in the uterus. If you cut into muscle, you will get more bleeding and may end up digging a hole.

After you make the incision, put your finger through it to help develop that space further. You can confirm entry into the peritoneum by noting the characteristic slippery feel of the peritoneal lining. After you insert a Deaver retractor anteriorly, reinsert your finger and mobilize the area further. Then you can easily reach in and tent the peritoneum to cut it.

Technique for cystotomy repair
Two-layer closure is a minimum. On occasion, a third layer may be beneficial. Begin with running closure of the first layer using 2-0 chromic suture—a good suture choice in the urinary tract. This suture is inflammatory, which will help seal the wound, but it also dissolves quickly, preventing stone formation.

Use through-and-through closure on the first layer, followed by a second imbricating layer. If desired, use the peritoneum as a third layer.

Horizontal repair is typical, although vertical closure may be necessary if the defect is near a ureteral orifice and horizontal closure might compromise that side. That decision must be made intraoperatively.

When vertical repair is necessary, begin your repair just above the defect, placing the suture through and through. The hole should be visible. There is no need to be extramucosal in needle placement. Simply get a good bite of the tissue and run the repair down the bladder wall.

Next, stop and apply traction to the repair to check for any small defects that may have been overlooked. By placing a little traction on that first suture tag, any such defects will become apparent. Then go back and close them in a secondary imbricating layer.

After 2-layer closure, fill the bladder retrograde. I prefer to use a couple of drops of methylene blue in normal saline and place a clean white piece of packing material beneath the wound. If the packing material remains unstained by blue, the repair is watertight.

Incorporate the peritoneum as another layer of repair of the defect. I imbricate 2 layers in the bladder. Then, if necessary, I use that peritoneum as an additional layer (FIGURE 4).

Strategies to control bleeding at adnexectomy
Be vigilant for bleeding when removing the tubes and/or ovaries. At salpingectomy, be extremely gentle with the mesosalpinx because it can be avulsed easily off of surrounding tissue. If bleeding occurs, oversewing, or even ovary removal, could end up being the only options.

Good visualization is essential during vaginal procedures. Retractors, lighted suction irrigators, a headlamp, good overhead lighting, and appropriate instrumentation are critical for success.

Heaney clamp technique for vaginal oophorectomy
Begin by placing an Allis clamp on the utero-ovarian pedicle. Then clamp the ovary and tube with a second Allis clamp. Next, insert a Heaney clamp through the small window between the cardinal pedicle and the utero-ovarian pedicle (FIGURE 5). Clamp the tissue and place a free tie around it.

Because this is a major vascular pedicle, doubly ligate it. As you tie the first suture, have an assistant flash the clamp open and closed, then excise the specimen. There is no need to worry about losing the pedicle because it already has been ligated once. Next, stick-tie it, placing the needle distal to the free tie to avoid piercing the gonadal vessels beyond.

The technique is standard. Be gentle, and ensure good hemostasis when finished.

Tip. In my experience, any bleeding runs down from the pedicle rather than out toward me. So be sure to look down and below the pedicle to ensure hemostasis.

Additional pearls

• When performing vaginal hysterectomy, the ovaries are almost always removable transvaginally. There is no need to begin the case laparoscopically to remove the tubes and/or ovaries and then perform the hysterectomy vaginally.
• Deaver retractors offer good exposure; visualization is critical.
• Make sure the tissue is dry before you cut the last suture.
• If you prefer to use a laparoscopic stapler to secure the pedicles, proceed as before: Place an Allis clamp on the pedicle. Place a second clamp on the ovary and tube. Now you can insert the stapler into the created window, as with the Heaney clamp (FIGURE 6).
• Use a 60-mm stapler to cut the pedicle in one try. If using a 45-mm device, the stapler may need to be fired twice. This makes the procedure more expensive and risks more bleeding.
• When closing the stapler jaws, avoid clamping small bowel or packing material. Ensure stapler tip visibility well before firing.

The round ligament technique
When transecting the round ligament, it is critical to stay just beneath it to avoid bleeding and venturing into the mesosalpinx. Gently hug the tissue inferior to the round ligament and let it retract (FIGURE 7). This will allow isolation of the gonadal vessels nicely, especially if an adnexal mass is present. Then isolate the specimen and remove it, stick-tying the pedicle afterward to secure it.

When tying the pedicle, place the suture around the distal aspect to ensure that the back of the pedicle is enclosed, and do not lose it when you release the clamp. A slightly different technique is to use an endoloop to cross the gonadal vessels and control them. Use a suction irrigator and good lighting to get good exposure.

Next, place the clamp, making sure you don’t inadvertently grasp the packing material. Visualize both tips of the clamp before incising. Trim the specimen flush with the clamp. Then you can thread an endoloop over the top of the clamp. This is an inexpensive technique that allows a higher reach into the pelvic cavity. Finally, cinch down the endoloop to control the vessels.

When performing bilateral salpingo-oophorectomy, a long, fine clamp, such as the M.D. Anderson clamp, can help you reach up to control the gonadal vessels in the event that you lose your initial grip on those vessels (FIGURE 8).

Be prepared
Have a plan in place to manage any complications that arise during surgery. Just as obstetricians plan ahead to prepare for shoulder dystocia and other emergencies, gynecologic surgeons must prepare for surgical complications. Tissue extraction strategies can aid in the debulking and removal of large uteri, and the proper tools, lighting, and assistance are critical to success.

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Careful attention to technique at the time of vaginal hysterectomy is vital. Equally important is prior consideration of potential complications and the best ways to address them. Four trouble spots include:

• uterine tissue extraction (Although this is not a complication of vaginal hysterectomy, tissue extraction aids in debulking and removal of a large uterus.)
• protection of the ureters (It is important to palpate these structures before placing cardinal pedicle clamps, to protect ureteral integrity.)
• repair of inadvertent cystotomy
• control of bleeding in the setting of adnexectomy.

I focus on optimal approaches to these 4 scenarios in this article.

For a review of vaginal hysterectomy technique, see “Vaginal hysterectomy with basic instrumentation,” by Barbara S. Levy, MD, which appeared in the October 2015 issue of OBG Management. For salpingectomy and salpingo-oophorectomy technique, see my article entitled “Salpingectomy after vaginal hysterectomy: Technique, tips, and pearls,” which appeared in the November issue of this journal.

Both articles are available in the archive at obgmanagement.com and, like this one, are based on the AAGL-produced Online Master Class on Vaginal Hysterectomy, a Web-based program cosponsored by the American College of Obstetricians and Gynecologists and the Society of Gynecologic Surgeons. That program is available at https://www.aagl.org/vaghystwebinar/.

A step toward success: Begin morcellation by splitting the uterus
Manual morcellation to reduce uterine size and ease transvaginal removal is a useful technique to know. Five aspects of manual morcellation warrant emphasis:

1. Anterior and posterior entry into the cul-de-sacs is essential before attempting morcellation.
2. The blood supply on both sides of the uterus must be controlled.
3. During resection, take care to cut only tissue that can be visualized. Avoid resection beyond what you can easily see.
4. Once morcellation is completed, always go back and check the pedicles for hemostasis. During morcellation, these pedicles tend to get stretched, and bleeding may arise that wasn’t present originally.
5. Morcellation should be performed only after malignancy has been ruled out—it is a technique intended for benign uteri only.

By bivalving the uterus it is possible to follow the endocervical canal up into the uterine cavity (FIGURE 1). Our technique at the Mayo Clinic is to place tenacula at the 3 and 9 o’clock positions prior to bivalving. A small amount of bleeding may occur because of collateral blood supply from the gonadal pedicles, but it should be minimal, as the uterine vessels have been secured.

FIGURE 1 Bivalve the uterus

To begin morcellation, split the uterus down the midline, with tenacula placed at the 3- and 9-o’clock positions, then follow the endocervical canal into the uterine cavity (A). Use a knife blade to take portions of myomas and other tissue to debulk the uterus (B).

Proceed with morcellation once the uterus is bivalved. Use a Jacobs tenaculum to grasp the serosal portion of the uterus. Apply downward traction with your nondominant hand, and use the knife blade to resect portions of the uterus so that it can be debulked.

When a large myoma is encountered during morcellation, it often is possible to “finger-fracture” some of the filmy adhesions holding it in place, or to follow the pseudo-capsule of the fibroid in order to shell it out. In many cases, fibroids can be removed intact using these methods. If intact removal is not possible, debulk the fibroid by taking individual “bites.”

Tip. When the uterus is greatly enlarged, grasp it with a tenaculum so that it does not retract when you incise it. When large myomas are anticipated, keep an extra tenaculum on hand, as well as extra knife blades, as blades dull quickly when used to cut through calcified tissue. Continue to apply traction with your nondominant hand to allow each piece of tissue to be more readily developed (FIGURE 2).

Tip. When managing the round-ligament complex on each side, stay between the round ligaments (your “goal posts”) to avoid getting too lateral. Keep the cervix intact for orientation purposes. Focus on diminishing the bulk of the uterus so that you can get around the utero-ovarian pedicles.

To control the utero-ovarian pedicle on the patient’s right side, place a finger underneath it, with traction applied. Place a Heaney clamp from the top down. Repeat this action on the patient’s left side, but place the Heaney clamp from the bottom up.

Manual morcellation of tissue is useful in small uteri that are tough to access, but the procedure is very helpful in large uteri in order to remove them transvaginally.

Protect the ureters: Palpate them before clamping the pedicles
Palpating the ureters at the time of hysterectomy can protect their integrity during the procedure. The following technique has been used at the Mayo Clinic for many years and allows for location of the ureter so a cardinal pedicle clamp can be placed without injury.

Enter the anterior cul-de-sac so that you can insert a finger and palpate the ureter before you place the cardinal pedicle clamp on each side. Place Deaver retractors at the 12 o’clock and 2- to 3-o’clock positions. Insert your nondominant index finger into the anterior cul-de-sac and palpate the ureter against the Deaver clamp in the 2- to 3-o’clock position (FIGURE 3). (The ureter can be felt between your index finger and the Deaver retractor.) The ureter will have the most descent in a uterus that has some prolapse, compared with a nonprolapsed uterus.

Tip. One common error is mistaking the edge of the vaginal cuff for the ureter. Be certain that you insert your finger deeply into the cul-de-sac so that it is the ureter you feel and not the cuff edge.

Successful cystotomy repair technique
Inadvertent cystotomy is a common fear for surgeons at the time of vaginal hysterectomy. I prefer to empty the bladder before beginning the hysterectomy because it reduces the target zone that a distended bladder pre­sents. Some surgeons prefer to maintain a bit of fluid in the bladder so that, if they cut into the bladder, a small urine stream results. The approach is a matter of preference.

Cystotomy is most common during anterior dissection. If it occurs, recognize it and mark the defect with suture. Do not attempt to repair the hole at this point, but opt to finish the hysterectomy.

Cystoscopy is an important element of cystotomy repair. Once the hysterectomy is completed, look inside the bladder and determine where the defect is in relationship to the ureteral orifices. Typically, it will be beyond the interureteric ridge, along the posterior portion of the bladder, usually in the midline.

As critical as the repair itself is management of bladder drainage afterward. If you repair the hole thoroughly and drain the bladder adequately for 14 days, the defect should heal fully.

Technique for entry into anterior cul-de-sac
One way to avert bladder injury is to enter the anterior cul-de-sac very carefully. Begin by ensuring that the bladder is empty and placing a Deaver retractor at the 12 o’clock position. Also place tenacula anteriorly and posteriorly to help direct traction. This will allow good visualization of the bladder reflection.

Tip. One common mistake is making the incision too low or too near the cervix, which makes dissection more difficult and increases the likelihood that you will enter the wrong plane. Be sure you know where the bladder is, and make an adequate incision that is not too distal. Otherwise, dissection will be harder to carry out.

I prefer to make one clean incision with the knife, rather than multiple incisions, because multiple cuts increase the likelihood that you will inadvertently injure the wrong tissue. Use good traction and countertraction, and hug the uterus. Work low on the uterus, but not in the uterus. If you cut into muscle, you will get more bleeding and may end up digging a hole.

After you make the incision, put your finger through it to help develop that space further. You can confirm entry into the peritoneum by noting the characteristic slippery feel of the peritoneal lining. After you insert a Deaver retractor anteriorly, reinsert your finger and mobilize the area further. Then you can easily reach in and tent the peritoneum to cut it.

Technique for cystotomy repair
Two-layer closure is a minimum. On occasion, a third layer may be beneficial. Begin with running closure of the first layer using 2-0 chromic suture—a good suture choice in the urinary tract. This suture is inflammatory, which will help seal the wound, but it also dissolves quickly, preventing stone formation.

Use through-and-through closure on the first layer, followed by a second imbricating layer. If desired, use the peritoneum as a third layer.

Horizontal repair is typical, although vertical closure may be necessary if the defect is near a ureteral orifice and horizontal closure might compromise that side. That decision must be made intraoperatively.

When vertical repair is necessary, begin your repair just above the defect, placing the suture through and through. The hole should be visible. There is no need to be extramucosal in needle placement. Simply get a good bite of the tissue and run the repair down the bladder wall.

Next, stop and apply traction to the repair to check for any small defects that may have been overlooked. By placing a little traction on that first suture tag, any such defects will become apparent. Then go back and close them in a secondary imbricating layer.

After 2-layer closure, fill the bladder retrograde. I prefer to use a couple of drops of methylene blue in normal saline and place a clean white piece of packing material beneath the wound. If the packing material remains unstained by blue, the repair is watertight.

Incorporate the peritoneum as another layer of repair of the defect. I imbricate 2 layers in the bladder. Then, if necessary, I use that peritoneum as an additional layer (FIGURE 4).

Strategies to control bleeding at adnexectomy
Be vigilant for bleeding when removing the tubes and/or ovaries. At salpingectomy, be extremely gentle with the mesosalpinx because it can be avulsed easily off of surrounding tissue. If bleeding occurs, oversewing, or even ovary removal, could end up being the only options.

Good visualization is essential during vaginal procedures. Retractors, lighted suction irrigators, a headlamp, good overhead lighting, and appropriate instrumentation are critical for success.

Heaney clamp technique for vaginal oophorectomy
Begin by placing an Allis clamp on the utero-ovarian pedicle. Then clamp the ovary and tube with a second Allis clamp. Next, insert a Heaney clamp through the small window between the cardinal pedicle and the utero-ovarian pedicle (FIGURE 5). Clamp the tissue and place a free tie around it.

Because this is a major vascular pedicle, doubly ligate it. As you tie the first suture, have an assistant flash the clamp open and closed, then excise the specimen. There is no need to worry about losing the pedicle because it already has been ligated once. Next, stick-tie it, placing the needle distal to the free tie to avoid piercing the gonadal vessels beyond.

The technique is standard. Be gentle, and ensure good hemostasis when finished.

Tip. In my experience, any bleeding runs down from the pedicle rather than out toward me. So be sure to look down and below the pedicle to ensure hemostasis.

Additional pearls

• When performing vaginal hysterectomy, the ovaries are almost always removable transvaginally. There is no need to begin the case laparoscopically to remove the tubes and/or ovaries and then perform the hysterectomy vaginally.
• Deaver retractors offer good exposure; visualization is critical.
• Make sure the tissue is dry before you cut the last suture.
• If you prefer to use a laparoscopic stapler to secure the pedicles, proceed as before: Place an Allis clamp on the pedicle. Place a second clamp on the ovary and tube. Now you can insert the stapler into the created window, as with the Heaney clamp (FIGURE 6).
• Use a 60-mm stapler to cut the pedicle in one try. If using a 45-mm device, the stapler may need to be fired twice. This makes the procedure more expensive and risks more bleeding.
• When closing the stapler jaws, avoid clamping small bowel or packing material. Ensure stapler tip visibility well before firing.

The round ligament technique
When transecting the round ligament, it is critical to stay just beneath it to avoid bleeding and venturing into the mesosalpinx. Gently hug the tissue inferior to the round ligament and let it retract (FIGURE 7). This will allow isolation of the gonadal vessels nicely, especially if an adnexal mass is present. Then isolate the specimen and remove it, stick-tying the pedicle afterward to secure it.

When tying the pedicle, place the suture around the distal aspect to ensure that the back of the pedicle is enclosed, and do not lose it when you release the clamp. A slightly different technique is to use an endoloop to cross the gonadal vessels and control them. Use a suction irrigator and good lighting to get good exposure.

Next, place the clamp, making sure you don’t inadvertently grasp the packing material. Visualize both tips of the clamp before incising. Trim the specimen flush with the clamp. Then you can thread an endoloop over the top of the clamp. This is an inexpensive technique that allows a higher reach into the pelvic cavity. Finally, cinch down the endoloop to control the vessels.

When performing bilateral salpingo-oophorectomy, a long, fine clamp, such as the M.D. Anderson clamp, can help you reach up to control the gonadal vessels in the event that you lose your initial grip on those vessels (FIGURE 8).

Be prepared
Have a plan in place to manage any complications that arise during surgery. Just as obstetricians plan ahead to prepare for shoulder dystocia and other emergencies, gynecologic surgeons must prepare for surgical complications. Tissue extraction strategies can aid in the debulking and removal of large uteri, and the proper tools, lighting, and assistance are critical to success.

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

The Cox-Maze IV procedure (CMPIV) has become the standard for surgical ablation for atrial fibrillation (AF), yet little information has been available on how late outcomes compare with catheter-based ablation. A recent analysis of 576 procedures found that after 5 years, most people who had the procedure remained free of atrial tachyarrhythmias and anticoagulation.

The study, by investigators from Washington University, Barnes-Jewish Hospital in St. Louis, was published in the Journal of Thoracic and Cardiovascular Surgery (J Thorac Cardiovasc Surg. 2015;150:1168-78). The researchers first presented the study in April at the American Association for Thoracic Surgery meeting in Seattle.

Courtesy of the American Association for Thoracic Surgery/JTCVS

“The results of the CMPIV remain superior to those reported for catheter ablation and other forms of surgical AF ablation, especially for patients with persistent or long-standing AF,” wrote Dr. Matthew C. Henn and his colleagues.

They set out to evaluate late outcomes after CMPIV using current consensus definitions of treatment failure, noting that such outcomes had yet to be reported. They followed 576 patients with atrial fibrillation who had a CMPIV from 2002 to 2014 and compared long-term freedom from atrial fibrillation on and off antiarrhythmic drugs (AADs) across various subgroups. They included the left-sided CMPIV lesion in the analysis because, they said, it had success rates similar to those of biatrial CMPIV.

The Cox-Maze procedure was first introduced by Dr. James Cox in 1987 and updated from the original “cut-and-sew” technique in 2002 to combine bipolar radiofrequency and cryothermal ablation lines in place of most surgical incisions. This iteration was called the Cox-Maze IV procedure. In 2005, CMPIV was modified to include a superior connecting lesion, which formed a “box lesion” by completely isolating the entire posterior left atrium. The study included 512 people who underwent the “box lesion” set procedure.

“The modifications of the CMPIV have allowed it to be performed through a right minithoracotomy (RMT) approach, which has further reduced major morbidity, mortality, and hospital stay compared to those who underwent sternotomy while enjoying equivalent outcomes with regards to freedom from AF,” wrote Dr. Henn and his coauthors.

In the entire cohort, the overall freedom from atrial tachyarrhythmias (ATAs) and anticoagulation were 92% at 1 year, 88% at 2 years, 87% at 3 years, 81% at 4 years, and 73% at 5 years. Overall freedom from ATAs off antiarrhythmic drugs for the entire cohort ranged from 81% at 1 year to 61% at 5 years, and freedom from anticoagulation ranged from 65% at 1 year to 55% at 5 years.

“Freedoms from ATAs on or off AADs were significantly higher in those who underwent box lesion sets when compared to those who did not at 5 years,” noted Dr. Henn and his coauthors. Among the box lesion set group, 78% of those on AADs remained free of ATAs vs. 45% in the non–box lesion set group, and for those off AADs, 66% had no ATAs at 5 years while 33% of the non–box lesion set group did.

Of the overall study population, 41% had paroxysmal AF and 58% had nonparoxysmal AF. Among the latter group, 20% had persistent and 80% had long-standing persistent AF. The nonparoxysmal AF group had a longer duration of preoperative AF, larger left atria and more failed catheter ablations, Dr. Henn and coauthors reported. But, the study showed no differences in freedom from atrial fibrillation on or off AADs at 5 years between patients with paroxysmal AF or persistent/long-standing persistent AF, or between those who underwent stand-alone procedure and those who received a concomitant Cox-Maze procedure. Among those who had a concomitant procedure, 50% had a concomitant mitral valve procedure and 23% had coronary artery bypass grafting.

“The CMPIV results in our series were better than what has been achieved with catheter ablation,” the researchers wrote. They cited studies that showed arrhythmia-free survival after a single ablation procedure ranging from 17% to 29% and “equally poor results.” (Circ Arrhythm Electrophysiol. 2015;8:18-24; J Am Coll Cardiol. 2011;57:160-166; J Am Heart Assoc. 2013;2:e004549.)

“The CMPIV remains the most successful surgical treatment for AF, even in patients with non-paroxysmal AF and regardless of the complexity of the concomitant procedures,” Dr. Henn and his coauthors concluded.

The Cox-Maze IV procedure (CMPIV) has become the standard for surgical ablation for atrial fibrillation (AF), yet little information has been available on how late outcomes compare with catheter-based ablation. A recent analysis of 576 procedures found that after 5 years, most people who had the procedure remained free of atrial tachyarrhythmias and anticoagulation.

The study, by investigators from Washington University, Barnes-Jewish Hospital in St. Louis, was published in the Journal of Thoracic and Cardiovascular Surgery (J Thorac Cardiovasc Surg. 2015;150:1168-78). The researchers first presented the study in April at the American Association for Thoracic Surgery meeting in Seattle.

Courtesy of the American Association for Thoracic Surgery/JTCVS

“The results of the CMPIV remain superior to those reported for catheter ablation and other forms of surgical AF ablation, especially for patients with persistent or long-standing AF,” wrote Dr. Matthew C. Henn and his colleagues.

They set out to evaluate late outcomes after CMPIV using current consensus definitions of treatment failure, noting that such outcomes had yet to be reported. They followed 576 patients with atrial fibrillation who had a CMPIV from 2002 to 2014 and compared long-term freedom from atrial fibrillation on and off antiarrhythmic drugs (AADs) across various subgroups. They included the left-sided CMPIV lesion in the analysis because, they said, it had success rates similar to those of biatrial CMPIV.

The Cox-Maze procedure was first introduced by Dr. James Cox in 1987 and updated from the original “cut-and-sew” technique in 2002 to combine bipolar radiofrequency and cryothermal ablation lines in place of most surgical incisions. This iteration was called the Cox-Maze IV procedure. In 2005, CMPIV was modified to include a superior connecting lesion, which formed a “box lesion” by completely isolating the entire posterior left atrium. The study included 512 people who underwent the “box lesion” set procedure.

“The modifications of the CMPIV have allowed it to be performed through a right minithoracotomy (RMT) approach, which has further reduced major morbidity, mortality, and hospital stay compared to those who underwent sternotomy while enjoying equivalent outcomes with regards to freedom from AF,” wrote Dr. Henn and his coauthors.

In the entire cohort, the overall freedom from atrial tachyarrhythmias (ATAs) and anticoagulation were 92% at 1 year, 88% at 2 years, 87% at 3 years, 81% at 4 years, and 73% at 5 years. Overall freedom from ATAs off antiarrhythmic drugs for the entire cohort ranged from 81% at 1 year to 61% at 5 years, and freedom from anticoagulation ranged from 65% at 1 year to 55% at 5 years.

“Freedoms from ATAs on or off AADs were significantly higher in those who underwent box lesion sets when compared to those who did not at 5 years,” noted Dr. Henn and his coauthors. Among the box lesion set group, 78% of those on AADs remained free of ATAs vs. 45% in the non–box lesion set group, and for those off AADs, 66% had no ATAs at 5 years while 33% of the non–box lesion set group did.

Of the overall study population, 41% had paroxysmal AF and 58% had nonparoxysmal AF. Among the latter group, 20% had persistent and 80% had long-standing persistent AF. The nonparoxysmal AF group had a longer duration of preoperative AF, larger left atria and more failed catheter ablations, Dr. Henn and coauthors reported. But, the study showed no differences in freedom from atrial fibrillation on or off AADs at 5 years between patients with paroxysmal AF or persistent/long-standing persistent AF, or between those who underwent stand-alone procedure and those who received a concomitant Cox-Maze procedure. Among those who had a concomitant procedure, 50% had a concomitant mitral valve procedure and 23% had coronary artery bypass grafting.

“The CMPIV results in our series were better than what has been achieved with catheter ablation,” the researchers wrote. They cited studies that showed arrhythmia-free survival after a single ablation procedure ranging from 17% to 29% and “equally poor results.” (Circ Arrhythm Electrophysiol. 2015;8:18-24; J Am Coll Cardiol. 2011;57:160-166; J Am Heart Assoc. 2013;2:e004549.)

“The CMPIV remains the most successful surgical treatment for AF, even in patients with non-paroxysmal AF and regardless of the complexity of the concomitant procedures,” Dr. Henn and his coauthors concluded.

The Cox-Maze IV procedure (CMPIV) has become the standard for surgical ablation for atrial fibrillation (AF), yet little information has been available on how late outcomes compare with catheter-based ablation. A recent analysis of 576 procedures found that after 5 years, most people who had the procedure remained free of atrial tachyarrhythmias and anticoagulation.

The study, by investigators from Washington University, Barnes-Jewish Hospital in St. Louis, was published in the Journal of Thoracic and Cardiovascular Surgery (J Thorac Cardiovasc Surg. 2015;150:1168-78). The researchers first presented the study in April at the American Association for Thoracic Surgery meeting in Seattle.

Courtesy of the American Association for Thoracic Surgery/JTCVS

“The results of the CMPIV remain superior to those reported for catheter ablation and other forms of surgical AF ablation, especially for patients with persistent or long-standing AF,” wrote Dr. Matthew C. Henn and his colleagues.

They set out to evaluate late outcomes after CMPIV using current consensus definitions of treatment failure, noting that such outcomes had yet to be reported. They followed 576 patients with atrial fibrillation who had a CMPIV from 2002 to 2014 and compared long-term freedom from atrial fibrillation on and off antiarrhythmic drugs (AADs) across various subgroups. They included the left-sided CMPIV lesion in the analysis because, they said, it had success rates similar to those of biatrial CMPIV.

The Cox-Maze procedure was first introduced by Dr. James Cox in 1987 and updated from the original “cut-and-sew” technique in 2002 to combine bipolar radiofrequency and cryothermal ablation lines in place of most surgical incisions. This iteration was called the Cox-Maze IV procedure. In 2005, CMPIV was modified to include a superior connecting lesion, which formed a “box lesion” by completely isolating the entire posterior left atrium. The study included 512 people who underwent the “box lesion” set procedure.

“The modifications of the CMPIV have allowed it to be performed through a right minithoracotomy (RMT) approach, which has further reduced major morbidity, mortality, and hospital stay compared to those who underwent sternotomy while enjoying equivalent outcomes with regards to freedom from AF,” wrote Dr. Henn and his coauthors.

In the entire cohort, the overall freedom from atrial tachyarrhythmias (ATAs) and anticoagulation were 92% at 1 year, 88% at 2 years, 87% at 3 years, 81% at 4 years, and 73% at 5 years. Overall freedom from ATAs off antiarrhythmic drugs for the entire cohort ranged from 81% at 1 year to 61% at 5 years, and freedom from anticoagulation ranged from 65% at 1 year to 55% at 5 years.

“Freedoms from ATAs on or off AADs were significantly higher in those who underwent box lesion sets when compared to those who did not at 5 years,” noted Dr. Henn and his coauthors. Among the box lesion set group, 78% of those on AADs remained free of ATAs vs. 45% in the non–box lesion set group, and for those off AADs, 66% had no ATAs at 5 years while 33% of the non–box lesion set group did.

Of the overall study population, 41% had paroxysmal AF and 58% had nonparoxysmal AF. Among the latter group, 20% had persistent and 80% had long-standing persistent AF. The nonparoxysmal AF group had a longer duration of preoperative AF, larger left atria and more failed catheter ablations, Dr. Henn and coauthors reported. But, the study showed no differences in freedom from atrial fibrillation on or off AADs at 5 years between patients with paroxysmal AF or persistent/long-standing persistent AF, or between those who underwent stand-alone procedure and those who received a concomitant Cox-Maze procedure. Among those who had a concomitant procedure, 50% had a concomitant mitral valve procedure and 23% had coronary artery bypass grafting.

“The CMPIV results in our series were better than what has been achieved with catheter ablation,” the researchers wrote. They cited studies that showed arrhythmia-free survival after a single ablation procedure ranging from 17% to 29% and “equally poor results.” (Circ Arrhythm Electrophysiol. 2015;8:18-24; J Am Coll Cardiol. 2011;57:160-166; J Am Heart Assoc. 2013;2:e004549.)

“The CMPIV remains the most successful surgical treatment for AF, even in patients with non-paroxysmal AF and regardless of the complexity of the concomitant procedures,” Dr. Henn and his coauthors concluded.

One-half of my practice is taking care of employees and dependents employed by the organization for which I work. Most of these patients sit … a lot … and present to me with musculoskeletal pain and weight concerns. My patients have a high degree of health literacy and are fully aware that 6 hours of sitting might have at least something to do with these problems.

We currently seem to be on the other side of the “walk station” mania. Sanity has been restored through a combination of concerns about medical liability for work-related treadmill injuries, expense, space issues, and reports that walkers were more forgetful and less focused. The last study resulted in some personal email for my own indulgences in walking while researching.

But let us not throw out an upright posture with the treadmill. Sitters have an increased risk for elevated blood sugars, cardiovascular disease, cancer, and death. Standers have been suggested to burn 50 more calories per hour. Some experts recommend that people should stand for at least 2 hours each day, and 4 hours is even better.

Dr. Graves and colleagues conducted a randomized controlled trial to evaluate the impact of a sit-stand workstation on sitting time, vascular, metabolic, and musculoskeletal outcomes and to investigate workstation acceptability and feasibility. Forty-seven participants without any bodily symptoms were randomized to either a sit-stand workstation or no intervention for 8 weeks. The sit-stand workstation was associated with decreased sit time (80 minutes per 8-hour work day), increased standing time (73 minutes per 8-hour work day), and a decrease in total cholesterol. No increase in musculoskeletal pain was observed with a suggestion of possible benefit in the neck and upper back (BMC Public Health. 2015;15:1145. doi 10.1186/s12889-015-2469-8).

Each of the devices cost about $550 to install for a single monitor ($20 more for a dual monitor). The intervention was only 8 weeks in duration and stronger effects in musculoskeletal and cardiovascular risk markers might be seen with longer durations of study. The qualitative work in this study suggested that several factors may influence use of a sit-stand desk such as social environment (for example, other colleagues not using it may decrease use), work tasks (for example, paperwork made difficult by limited elevated work surface), and design (for example, keyboard surface bounces too much). From personal experience, the sit-stand desk is ideal if the vast majority of work is on the computer. I’d also like to say I was standing when I wrote this. But I wasn’t. And I wasn’t walking either because I can’t remember where that desk is.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.

One-half of my practice is taking care of employees and dependents employed by the organization for which I work. Most of these patients sit … a lot … and present to me with musculoskeletal pain and weight concerns. My patients have a high degree of health literacy and are fully aware that 6 hours of sitting might have at least something to do with these problems.

We currently seem to be on the other side of the “walk station” mania. Sanity has been restored through a combination of concerns about medical liability for work-related treadmill injuries, expense, space issues, and reports that walkers were more forgetful and less focused. The last study resulted in some personal email for my own indulgences in walking while researching.

But let us not throw out an upright posture with the treadmill. Sitters have an increased risk for elevated blood sugars, cardiovascular disease, cancer, and death. Standers have been suggested to burn 50 more calories per hour. Some experts recommend that people should stand for at least 2 hours each day, and 4 hours is even better.

Dr. Graves and colleagues conducted a randomized controlled trial to evaluate the impact of a sit-stand workstation on sitting time, vascular, metabolic, and musculoskeletal outcomes and to investigate workstation acceptability and feasibility. Forty-seven participants without any bodily symptoms were randomized to either a sit-stand workstation or no intervention for 8 weeks. The sit-stand workstation was associated with decreased sit time (80 minutes per 8-hour work day), increased standing time (73 minutes per 8-hour work day), and a decrease in total cholesterol. No increase in musculoskeletal pain was observed with a suggestion of possible benefit in the neck and upper back (BMC Public Health. 2015;15:1145. doi 10.1186/s12889-015-2469-8).

Each of the devices cost about $550 to install for a single monitor ($20 more for a dual monitor). The intervention was only 8 weeks in duration and stronger effects in musculoskeletal and cardiovascular risk markers might be seen with longer durations of study. The qualitative work in this study suggested that several factors may influence use of a sit-stand desk such as social environment (for example, other colleagues not using it may decrease use), work tasks (for example, paperwork made difficult by limited elevated work surface), and design (for example, keyboard surface bounces too much). From personal experience, the sit-stand desk is ideal if the vast majority of work is on the computer. I’d also like to say I was standing when I wrote this. But I wasn’t. And I wasn’t walking either because I can’t remember where that desk is.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.

One-half of my practice is taking care of employees and dependents employed by the organization for which I work. Most of these patients sit … a lot … and present to me with musculoskeletal pain and weight concerns. My patients have a high degree of health literacy and are fully aware that 6 hours of sitting might have at least something to do with these problems.

We currently seem to be on the other side of the “walk station” mania. Sanity has been restored through a combination of concerns about medical liability for work-related treadmill injuries, expense, space issues, and reports that walkers were more forgetful and less focused. The last study resulted in some personal email for my own indulgences in walking while researching.

But let us not throw out an upright posture with the treadmill. Sitters have an increased risk for elevated blood sugars, cardiovascular disease, cancer, and death. Standers have been suggested to burn 50 more calories per hour. Some experts recommend that people should stand for at least 2 hours each day, and 4 hours is even better.

Dr. Graves and colleagues conducted a randomized controlled trial to evaluate the impact of a sit-stand workstation on sitting time, vascular, metabolic, and musculoskeletal outcomes and to investigate workstation acceptability and feasibility. Forty-seven participants without any bodily symptoms were randomized to either a sit-stand workstation or no intervention for 8 weeks. The sit-stand workstation was associated with decreased sit time (80 minutes per 8-hour work day), increased standing time (73 minutes per 8-hour work day), and a decrease in total cholesterol. No increase in musculoskeletal pain was observed with a suggestion of possible benefit in the neck and upper back (BMC Public Health. 2015;15:1145. doi 10.1186/s12889-015-2469-8).

Each of the devices cost about $550 to install for a single monitor ($20 more for a dual monitor). The intervention was only 8 weeks in duration and stronger effects in musculoskeletal and cardiovascular risk markers might be seen with longer durations of study. The qualitative work in this study suggested that several factors may influence use of a sit-stand desk such as social environment (for example, other colleagues not using it may decrease use), work tasks (for example, paperwork made difficult by limited elevated work surface), and design (for example, keyboard surface bounces too much). From personal experience, the sit-stand desk is ideal if the vast majority of work is on the computer. I’d also like to say I was standing when I wrote this. But I wasn’t. And I wasn’t walking either because I can’t remember where that desk is.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.

A quality improvement (QI) initiative can start with a single hospitalist, says Adam H. Corson, MD, a hospitalist at Seattle’s Swedish Medical Center.

In a study presented at SHM's annual meeting, Dr. Corson set out to determine whether critically evaluating how frequently common lab tests were ordered could help decrease hospital costs. Using a cohort of patients, Dr. Corson compared how often a complete blood count or a metabolic panel was ordered in a large hospitalist group. His QI intervention involved academic detailing, audit, and feedback, as well as transparent reporting of lab orders for 9,368 patients. At baseline, a mean of 2.06 common labs were ordered per patient day. The number of labs ordered post-intervention decreased by 10%.

“Within the hospitalist team itself, there was a 20% reduction,” Dr. Corson says. That percentage “got diluted down to 10% when you included all the other providers who care for a patient.” He found no adverse effects from this intervention on mortality, length-of-stay, or readmission rates. His report also cited a reduction in the volume of blood transfused per patient who received a transfusion and a $16.19 decrease in hospital costs—a total of $159,682—per admission annualized for the cohort.

Although better patient care was his main goal, a secondary goal was to demonstrate the potential value of hospitalists in today’s changing medical environment, particularly in terms of reimbursement. “In a fee-for-service world, hospitalists can’t participate as much as [physicians in] other areas of medicine,” he says. “But in a fee-for-outcome world, hospitalists can play a big role, and this is a demonstration of that.”

He also points out that this cost-effective intervention was basically done by him alone, “one hospitalist with access to electronic medical records and someone to pull some data out of there.”

Dr. Corson says he hopes his study will inspire other providers to look at this specific topic in their own practice and possibly expand it to other services they order each day. “The big headline these days is the United States spends more money on healthcare than everyone else does, but we don’t get better results,” he says. “Inherent in that is the idea that we do a lot of stuff that doesn’t need to be done or has no physical value. This is a small example of that.” TH

Visit our website for more information on other cost-cutting measures hospitalists can adopt.

A quality improvement (QI) initiative can start with a single hospitalist, says Adam H. Corson, MD, a hospitalist at Seattle’s Swedish Medical Center.

In a study presented at SHM's annual meeting, Dr. Corson set out to determine whether critically evaluating how frequently common lab tests were ordered could help decrease hospital costs. Using a cohort of patients, Dr. Corson compared how often a complete blood count or a metabolic panel was ordered in a large hospitalist group. His QI intervention involved academic detailing, audit, and feedback, as well as transparent reporting of lab orders for 9,368 patients. At baseline, a mean of 2.06 common labs were ordered per patient day. The number of labs ordered post-intervention decreased by 10%.

“Within the hospitalist team itself, there was a 20% reduction,” Dr. Corson says. That percentage “got diluted down to 10% when you included all the other providers who care for a patient.” He found no adverse effects from this intervention on mortality, length-of-stay, or readmission rates. His report also cited a reduction in the volume of blood transfused per patient who received a transfusion and a $16.19 decrease in hospital costs—a total of $159,682—per admission annualized for the cohort.

Although better patient care was his main goal, a secondary goal was to demonstrate the potential value of hospitalists in today’s changing medical environment, particularly in terms of reimbursement. “In a fee-for-service world, hospitalists can’t participate as much as [physicians in] other areas of medicine,” he says. “But in a fee-for-outcome world, hospitalists can play a big role, and this is a demonstration of that.”

He also points out that this cost-effective intervention was basically done by him alone, “one hospitalist with access to electronic medical records and someone to pull some data out of there.”

Dr. Corson says he hopes his study will inspire other providers to look at this specific topic in their own practice and possibly expand it to other services they order each day. “The big headline these days is the United States spends more money on healthcare than everyone else does, but we don’t get better results,” he says. “Inherent in that is the idea that we do a lot of stuff that doesn’t need to be done or has no physical value. This is a small example of that.” TH

Visit our website for more information on other cost-cutting measures hospitalists can adopt.

A quality improvement (QI) initiative can start with a single hospitalist, says Adam H. Corson, MD, a hospitalist at Seattle’s Swedish Medical Center.

In a study presented at SHM's annual meeting, Dr. Corson set out to determine whether critically evaluating how frequently common lab tests were ordered could help decrease hospital costs. Using a cohort of patients, Dr. Corson compared how often a complete blood count or a metabolic panel was ordered in a large hospitalist group. His QI intervention involved academic detailing, audit, and feedback, as well as transparent reporting of lab orders for 9,368 patients. At baseline, a mean of 2.06 common labs were ordered per patient day. The number of labs ordered post-intervention decreased by 10%.

“Within the hospitalist team itself, there was a 20% reduction,” Dr. Corson says. That percentage “got diluted down to 10% when you included all the other providers who care for a patient.” He found no adverse effects from this intervention on mortality, length-of-stay, or readmission rates. His report also cited a reduction in the volume of blood transfused per patient who received a transfusion and a $16.19 decrease in hospital costs—a total of $159,682—per admission annualized for the cohort.

Although better patient care was his main goal, a secondary goal was to demonstrate the potential value of hospitalists in today’s changing medical environment, particularly in terms of reimbursement. “In a fee-for-service world, hospitalists can’t participate as much as [physicians in] other areas of medicine,” he says. “But in a fee-for-outcome world, hospitalists can play a big role, and this is a demonstration of that.”

He also points out that this cost-effective intervention was basically done by him alone, “one hospitalist with access to electronic medical records and someone to pull some data out of there.”

Dr. Corson says he hopes his study will inspire other providers to look at this specific topic in their own practice and possibly expand it to other services they order each day. “The big headline these days is the United States spends more money on healthcare than everyone else does, but we don’t get better results,” he says. “Inherent in that is the idea that we do a lot of stuff that doesn’t need to be done or has no physical value. This is a small example of that.” TH

Visit our website for more information on other cost-cutting measures hospitalists can adopt.

The risk of epilepsy is increased in children with hospital-diagnosed pertussis infections, compared with the general population, but the absolute risk is low, according to a Danish study published in the November 3 issue of JAMA. Researchers used data from population-based medical registries covering all Danish hospitals to identify all patients with pertussis born between 1978 and 2011 and followed up through 2011. Investigators used the Civil Registration System to identify 10 individuals from the general population for each patient with pertussis, matched on sex and year of birth. They identified 4,700 patients with pertussis, of whom 90 developed epilepsy during the follow-up. The cumulative incidence of epilepsy at age 10 was 1.7% for patients with pertussis and 0.9% for the matched comparison cohort.

Chronic users of antiepileptic drugs have poorer standing balance, compared with nonusers, according to a longitudinal twin and sibling study published in the November issue of Epilepsia. Researchers studied 26 twin and sibling pairs. Siblings were of the same gender, but only one in each pair had exposure to antiepileptic drugs. Clinical and laboratory balance examinations were conducted twice, and at least one year elapsed between examinations. The mean within-pair differences in balance measures were calculated cross-sectionally at baseline and follow-up, and longitudinally. Researchers found no significant mean within-pair difference at baseline in age (mean, 44), weight, and height. Cross-sectional sway measures from posturography and clinical static balance tests showed poorer performance in antiepileptic drug users, compared with nonusers, on several test conditions at baseline and follow-up.

Treatment for symptomatic intracerebral hemorrhage (sICH) after thrombolysis for stroke does not significantly reduce the likelihood of in-hospital mortality or hematoma expansion, according to a retrospective study published online ahead of print October 26 in JAMA Neurology. Of 3,894 patients treated with IV rt-PA within 4.5 hours after onset of ischemic stroke symptoms, 128 had sICH. The median time from initiation of rt-PA to sICH diagnosis was 470 minutes, and the median time from diagnosis to treatment of sICH was 112 minutes. The in-hospital mortality rate was 52.3%, and 26.8% of participants had hematoma expansion. In multivariable models, code status change to comfort measures after sICH diagnosis was the sole factor associated with increased in-hospital mortality. Severe hypofibrinogenemia was associated with hematoma expansion and occurred in 36.3% of patients without hematoma expansion.

Gaucher disease or mutations in the β-glucocerebrosidase gene (GBA) may protect individuals from deficiency in visual color discrimination, according to a study published September 14 in Journal of Parkinson’s Disease. Investigators tested groups of patients on the Farnsworth-Munsell 100 hue test (FMHT) and calculated their mean Total Error Scores (TES). Patients were classified as having Parkinson’s disease only, Gaucher disease only, Parkinson’s disease and Gaucher disease, GBA mutations, GBA mutations and Parkinson’s disease, or as controls. Patients with Parkinson’s disease only had the highest mean TES, and patients with Gaucher disease only had the lowest mean TES. GBA carriers without Parkinson’s disease made more errors than patients with Gaucher disease only, which was approximately the same number of errors as healthy controls.

Brain scans of people in a coma may help predict who will regain consciousness, according to a study published online ahead of print November 11 in Neurology. Researchers compared 27 prospectively recruited comatose patients who had severe brain injury (14 with traumatic injury and 13 with anoxic injury) with 14 age-matched healthy participants. Standardized clinical assessment and functional MRI were performed at an average of four days after withdrawal of sedation. Patients who were comatose showed a significant disruption of functional connectivity of brain areas spontaneously synchronized with posterior cingulate cortex, regardless of etiology of injury. The functional connectivity strength between the posterior cingulate cortex and the medial prefrontal cortex was significantly different between comatose patients who subsequently recovered and those who subsequently scored an unfavorable outcome three months after brain injury.

Raloxifene does not have a significant cognitive effect for women with Alzheimer’s disease, according to a study published online ahead of print November 4 in Neurology. Investigators conducted a randomized, double-blind, placebo-controlled pilot study with a planned treatment period of 12 months. Women with mild to moderate late-onset Alzheimer’s disease were randomized to high-dose (ie, 120 mg) oral raloxifene or identical placebo provided once daily. Forty-two women randomized to raloxifene or placebo were included in intent-to-treat analyses, and 39 women contributed 12-month outcomes. Results on the Alzheimer’s Disease Assessment Scale, cognitive subscale showed no cognitive benefits in the raloxifene-treated group. Raloxifene and placebo groups did not differ significantly on secondary analyses of dementia rating, activities of daily living, behavior, or a global cognition composite score.

Nonpharmacologic sleep interventions may help optimize outcomes in patients with chronic pain, according to data published in the November issue of Sleep. Investigators analyzed 11 randomized controlled trials, involving 1,066 participants, that evaluated the effect of nonpharmacologic sleep treatments on self-reported sleep quality, pain, and well-being in patients with long-term pain. They extracted means and standard deviations of sleep quality, pain, fatigue, depression, anxiety, and physical and psychologic functioning for the treatment and control groups at baseline, post treatment, and final follow-up. Nonpharmacologic sleep treatments in patients with chronic pain were associated with a large improvement in sleep quality, a small reduction in pain, and moderate improvement in fatigue at post treatment. The effects on sleep quality and fatigue were maintained for as long as one year, when a moderate reduction in depression also was observed.

CSF biomarkers of angiogenesis are increased in Parkinson’s disease and associated with gait difficulties, blood–­brain barrier dysfunction, white matter lesions, and cerebral microbleeds, according to a study published online ahead of print October 28 in Neurology. This cross-sectional analysis included 38 elderly controls and 100 patients with Parkinson’s disease. Patients with Parkinson’s disease without dementia displayed higher CSF levels of vascular endothelial growth factor, placental growth factor, and vascular endothelial growth factor 2, and lower levels of angiopoietin 2, compared with controls. Similar alterations in vascular endothelial growth factor, placental growth factor, and angiopoietin 2 levels were observed in patients with Parkinson’s disease with dementia. Abnormal angiogenesis may be important in Parkinson’s disease pathogenesis and contribute to dopa-resistant symptoms, said the researchers.

Despite comparable reductions in total sleep time, partial sleep loss from sleep continuity disruption is more detrimental to positive mood than partial sleep loss from delaying bedtime, even when controlling for concomitant increases in negative mood, according to a study published in the November issue of Sleep. Participants were randomized to receive three consecutive nights of sleep continuity disruption by forced nocturnal awakenings, or one of the following two control conditions: restricted sleep opportunity or uninterrupted sleep. Compared with controls with restricted sleep opportunity, participants who underwent forced awakenings had significantly less slow wave sleep after the first night of sleep deprivation, and significantly lower positive mood after the second night of sleep deprivation. The differential change in slow wave sleep statistically mediated the observed group differences in positive mood.

Among patients who underwent transcatheter atrial septal defect closure (ASD), the use of clopidogrel and aspirin, compared with aspirin plus placebo, resulted in a lower monthly frequency of migraine attacks over three months, according to a study published online ahead of print November 9 in JAMA. A total of 171 patients without migraine were randomized to receive dual antiplatelet therapy or single antiplatelet therapy (ie, aspirin and placebo) for three months following transcatheter ASD closure. The mean age of the participants was 49, and 62% were women. Among patients with migraines following the procedure, those who received clopidogrel had less-severe migraine attacks. No patients who received clopidogrel had moderately or severely disabling migraine attacks, and 37% of the placebo group had such attacks.

The Consortium of Multiple Sclerosis Centers (CMSC) has issued a statement asserting that prescribers must retain the right to decide on the best treatment and medication for each patient with MS. “The varied and individualized course of MS mandates full access to symptomatic management as well as disease-modifying therapies, which, in the best judgment of the prescriber, offer optimal treatment outcomes. Medications to treat symptoms are carefully decided on an individual basis and by best-practice regimens,” said the CMSC. “Lack of understanding of the disease course and the challenges of MS treatment result in poor decision making practices by the insurance plans and specialty pharmacies and subsequent denial of prescribed medications.... CMSC proposes a collaborative care model in which providers, patients, and insurers work together to address these concerns.”

APOE4 greatly increases the likelihood of microbleeds in some men, according to a study published online ahead of print October 16 in Neurobiology of Aging. These microbleeds contribute to memory loss. Investigators examined brain scans of 658 participants (ages 48 to 91) in the Alzheimer’s Disease Neuroimaging Initiative. Of those subjects, 402 had mild cognitive impairment (MCI), 90 had early-stage Alzheimer’s disease, and 166 were cognitively normal. Researchers also analyzed scans of 448 other subjects (ages 36 to 88). Of those people, 152 had MCI, 152 had Alzheimer’s disease, and 144 were cognitively normal. Male carriers of APOE4 with MCI or Alzheimer’s disease had twice as many microbleeds in their brains as women with similar diagnoses. Researchers should evaluate whether sex steroids can reduce the microbleeds, said the authors.

The Lewy Body Composite Risk Score (LBCRS) increases the diagnostic probability that Lewy body pathology is contributing to dementia and may improve clinical detection and enrollment for clinical trials, according to a study published September 1 in Alzheimer’s Dementia. The LBCRS was tested in a consecutive series of 256 patients and compared with the Clinical Dementia Rating and gold-standard measures of cognition, motor symptoms, function, and behavior. Mean LBCRS scores were significantly different between patients with dementia with Lewy bodies and those with Alzheimer’s disease. Mean LBCRS scores also were significantly different between patients with mild cognitive impairment (MCI) due to dementia with Lewy bodies and patients with MCI due to Alzheimer’s disease. The LBCRS also was able to discriminate between dementia with Lewy bodies and other causes of dementia.

—Kimberly Williams

The risk of epilepsy is increased in children with hospital-diagnosed pertussis infections, compared with the general population, but the absolute risk is low, according to a Danish study published in the November 3 issue of JAMA. Researchers used data from population-based medical registries covering all Danish hospitals to identify all patients with pertussis born between 1978 and 2011 and followed up through 2011. Investigators used the Civil Registration System to identify 10 individuals from the general population for each patient with pertussis, matched on sex and year of birth. They identified 4,700 patients with pertussis, of whom 90 developed epilepsy during the follow-up. The cumulative incidence of epilepsy at age 10 was 1.7% for patients with pertussis and 0.9% for the matched comparison cohort.

Chronic users of antiepileptic drugs have poorer standing balance, compared with nonusers, according to a longitudinal twin and sibling study published in the November issue of Epilepsia. Researchers studied 26 twin and sibling pairs. Siblings were of the same gender, but only one in each pair had exposure to antiepileptic drugs. Clinical and laboratory balance examinations were conducted twice, and at least one year elapsed between examinations. The mean within-pair differences in balance measures were calculated cross-sectionally at baseline and follow-up, and longitudinally. Researchers found no significant mean within-pair difference at baseline in age (mean, 44), weight, and height. Cross-sectional sway measures from posturography and clinical static balance tests showed poorer performance in antiepileptic drug users, compared with nonusers, on several test conditions at baseline and follow-up.

Treatment for symptomatic intracerebral hemorrhage (sICH) after thrombolysis for stroke does not significantly reduce the likelihood of in-hospital mortality or hematoma expansion, according to a retrospective study published online ahead of print October 26 in JAMA Neurology. Of 3,894 patients treated with IV rt-PA within 4.5 hours after onset of ischemic stroke symptoms, 128 had sICH. The median time from initiation of rt-PA to sICH diagnosis was 470 minutes, and the median time from diagnosis to treatment of sICH was 112 minutes. The in-hospital mortality rate was 52.3%, and 26.8% of participants had hematoma expansion. In multivariable models, code status change to comfort measures after sICH diagnosis was the sole factor associated with increased in-hospital mortality. Severe hypofibrinogenemia was associated with hematoma expansion and occurred in 36.3% of patients without hematoma expansion.

Gaucher disease or mutations in the β-glucocerebrosidase gene (GBA) may protect individuals from deficiency in visual color discrimination, according to a study published September 14 in Journal of Parkinson’s Disease. Investigators tested groups of patients on the Farnsworth-Munsell 100 hue test (FMHT) and calculated their mean Total Error Scores (TES). Patients were classified as having Parkinson’s disease only, Gaucher disease only, Parkinson’s disease and Gaucher disease, GBA mutations, GBA mutations and Parkinson’s disease, or as controls. Patients with Parkinson’s disease only had the highest mean TES, and patients with Gaucher disease only had the lowest mean TES. GBA carriers without Parkinson’s disease made more errors than patients with Gaucher disease only, which was approximately the same number of errors as healthy controls.

Brain scans of people in a coma may help predict who will regain consciousness, according to a study published online ahead of print November 11 in Neurology. Researchers compared 27 prospectively recruited comatose patients who had severe brain injury (14 with traumatic injury and 13 with anoxic injury) with 14 age-matched healthy participants. Standardized clinical assessment and functional MRI were performed at an average of four days after withdrawal of sedation. Patients who were comatose showed a significant disruption of functional connectivity of brain areas spontaneously synchronized with posterior cingulate cortex, regardless of etiology of injury. The functional connectivity strength between the posterior cingulate cortex and the medial prefrontal cortex was significantly different between comatose patients who subsequently recovered and those who subsequently scored an unfavorable outcome three months after brain injury.

Raloxifene does not have a significant cognitive effect for women with Alzheimer’s disease, according to a study published online ahead of print November 4 in Neurology. Investigators conducted a randomized, double-blind, placebo-controlled pilot study with a planned treatment period of 12 months. Women with mild to moderate late-onset Alzheimer’s disease were randomized to high-dose (ie, 120 mg) oral raloxifene or identical placebo provided once daily. Forty-two women randomized to raloxifene or placebo were included in intent-to-treat analyses, and 39 women contributed 12-month outcomes. Results on the Alzheimer’s Disease Assessment Scale, cognitive subscale showed no cognitive benefits in the raloxifene-treated group. Raloxifene and placebo groups did not differ significantly on secondary analyses of dementia rating, activities of daily living, behavior, or a global cognition composite score.

Nonpharmacologic sleep interventions may help optimize outcomes in patients with chronic pain, according to data published in the November issue of Sleep. Investigators analyzed 11 randomized controlled trials, involving 1,066 participants, that evaluated the effect of nonpharmacologic sleep treatments on self-reported sleep quality, pain, and well-being in patients with long-term pain. They extracted means and standard deviations of sleep quality, pain, fatigue, depression, anxiety, and physical and psychologic functioning for the treatment and control groups at baseline, post treatment, and final follow-up. Nonpharmacologic sleep treatments in patients with chronic pain were associated with a large improvement in sleep quality, a small reduction in pain, and moderate improvement in fatigue at post treatment. The effects on sleep quality and fatigue were maintained for as long as one year, when a moderate reduction in depression also was observed.

CSF biomarkers of angiogenesis are increased in Parkinson’s disease and associated with gait difficulties, blood–­brain barrier dysfunction, white matter lesions, and cerebral microbleeds, according to a study published online ahead of print October 28 in Neurology. This cross-sectional analysis included 38 elderly controls and 100 patients with Parkinson’s disease. Patients with Parkinson’s disease without dementia displayed higher CSF levels of vascular endothelial growth factor, placental growth factor, and vascular endothelial growth factor 2, and lower levels of angiopoietin 2, compared with controls. Similar alterations in vascular endothelial growth factor, placental growth factor, and angiopoietin 2 levels were observed in patients with Parkinson’s disease with dementia. Abnormal angiogenesis may be important in Parkinson’s disease pathogenesis and contribute to dopa-resistant symptoms, said the researchers.

Despite comparable reductions in total sleep time, partial sleep loss from sleep continuity disruption is more detrimental to positive mood than partial sleep loss from delaying bedtime, even when controlling for concomitant increases in negative mood, according to a study published in the November issue of Sleep. Participants were randomized to receive three consecutive nights of sleep continuity disruption by forced nocturnal awakenings, or one of the following two control conditions: restricted sleep opportunity or uninterrupted sleep. Compared with controls with restricted sleep opportunity, participants who underwent forced awakenings had significantly less slow wave sleep after the first night of sleep deprivation, and significantly lower positive mood after the second night of sleep deprivation. The differential change in slow wave sleep statistically mediated the observed group differences in positive mood.

Among patients who underwent transcatheter atrial septal defect closure (ASD), the use of clopidogrel and aspirin, compared with aspirin plus placebo, resulted in a lower monthly frequency of migraine attacks over three months, according to a study published online ahead of print November 9 in JAMA. A total of 171 patients without migraine were randomized to receive dual antiplatelet therapy or single antiplatelet therapy (ie, aspirin and placebo) for three months following transcatheter ASD closure. The mean age of the participants was 49, and 62% were women. Among patients with migraines following the procedure, those who received clopidogrel had less-severe migraine attacks. No patients who received clopidogrel had moderately or severely disabling migraine attacks, and 37% of the placebo group had such attacks.

The Consortium of Multiple Sclerosis Centers (CMSC) has issued a statement asserting that prescribers must retain the right to decide on the best treatment and medication for each patient with MS. “The varied and individualized course of MS mandates full access to symptomatic management as well as disease-modifying therapies, which, in the best judgment of the prescriber, offer optimal treatment outcomes. Medications to treat symptoms are carefully decided on an individual basis and by best-practice regimens,” said the CMSC. “Lack of understanding of the disease course and the challenges of MS treatment result in poor decision making practices by the insurance plans and specialty pharmacies and subsequent denial of prescribed medications.... CMSC proposes a collaborative care model in which providers, patients, and insurers work together to address these concerns.”

APOE4 greatly increases the likelihood of microbleeds in some men, according to a study published online ahead of print October 16 in Neurobiology of Aging. These microbleeds contribute to memory loss. Investigators examined brain scans of 658 participants (ages 48 to 91) in the Alzheimer’s Disease Neuroimaging Initiative. Of those subjects, 402 had mild cognitive impairment (MCI), 90 had early-stage Alzheimer’s disease, and 166 were cognitively normal. Researchers also analyzed scans of 448 other subjects (ages 36 to 88). Of those people, 152 had MCI, 152 had Alzheimer’s disease, and 144 were cognitively normal. Male carriers of APOE4 with MCI or Alzheimer’s disease had twice as many microbleeds in their brains as women with similar diagnoses. Researchers should evaluate whether sex steroids can reduce the microbleeds, said the authors.

The Lewy Body Composite Risk Score (LBCRS) increases the diagnostic probability that Lewy body pathology is contributing to dementia and may improve clinical detection and enrollment for clinical trials, according to a study published September 1 in Alzheimer’s Dementia. The LBCRS was tested in a consecutive series of 256 patients and compared with the Clinical Dementia Rating and gold-standard measures of cognition, motor symptoms, function, and behavior. Mean LBCRS scores were significantly different between patients with dementia with Lewy bodies and those with Alzheimer’s disease. Mean LBCRS scores also were significantly different between patients with mild cognitive impairment (MCI) due to dementia with Lewy bodies and patients with MCI due to Alzheimer’s disease. The LBCRS also was able to discriminate between dementia with Lewy bodies and other causes of dementia.

—Kimberly Williams

The risk of epilepsy is increased in children with hospital-diagnosed pertussis infections, compared with the general population, but the absolute risk is low, according to a Danish study published in the November 3 issue of JAMA. Researchers used data from population-based medical registries covering all Danish hospitals to identify all patients with pertussis born between 1978 and 2011 and followed up through 2011. Investigators used the Civil Registration System to identify 10 individuals from the general population for each patient with pertussis, matched on sex and year of birth. They identified 4,700 patients with pertussis, of whom 90 developed epilepsy during the follow-up. The cumulative incidence of epilepsy at age 10 was 1.7% for patients with pertussis and 0.9% for the matched comparison cohort.

Chronic users of antiepileptic drugs have poorer standing balance, compared with nonusers, according to a longitudinal twin and sibling study published in the November issue of Epilepsia. Researchers studied 26 twin and sibling pairs. Siblings were of the same gender, but only one in each pair had exposure to antiepileptic drugs. Clinical and laboratory balance examinations were conducted twice, and at least one year elapsed between examinations. The mean within-pair differences in balance measures were calculated cross-sectionally at baseline and follow-up, and longitudinally. Researchers found no significant mean within-pair difference at baseline in age (mean, 44), weight, and height. Cross-sectional sway measures from posturography and clinical static balance tests showed poorer performance in antiepileptic drug users, compared with nonusers, on several test conditions at baseline and follow-up.

Treatment for symptomatic intracerebral hemorrhage (sICH) after thrombolysis for stroke does not significantly reduce the likelihood of in-hospital mortality or hematoma expansion, according to a retrospective study published online ahead of print October 26 in JAMA Neurology. Of 3,894 patients treated with IV rt-PA within 4.5 hours after onset of ischemic stroke symptoms, 128 had sICH. The median time from initiation of rt-PA to sICH diagnosis was 470 minutes, and the median time from diagnosis to treatment of sICH was 112 minutes. The in-hospital mortality rate was 52.3%, and 26.8% of participants had hematoma expansion. In multivariable models, code status change to comfort measures after sICH diagnosis was the sole factor associated with increased in-hospital mortality. Severe hypofibrinogenemia was associated with hematoma expansion and occurred in 36.3% of patients without hematoma expansion.

Gaucher disease or mutations in the β-glucocerebrosidase gene (GBA) may protect individuals from deficiency in visual color discrimination, according to a study published September 14 in Journal of Parkinson’s Disease. Investigators tested groups of patients on the Farnsworth-Munsell 100 hue test (FMHT) and calculated their mean Total Error Scores (TES). Patients were classified as having Parkinson’s disease only, Gaucher disease only, Parkinson’s disease and Gaucher disease, GBA mutations, GBA mutations and Parkinson’s disease, or as controls. Patients with Parkinson’s disease only had the highest mean TES, and patients with Gaucher disease only had the lowest mean TES. GBA carriers without Parkinson’s disease made more errors than patients with Gaucher disease only, which was approximately the same number of errors as healthy controls.

Brain scans of people in a coma may help predict who will regain consciousness, according to a study published online ahead of print November 11 in Neurology. Researchers compared 27 prospectively recruited comatose patients who had severe brain injury (14 with traumatic injury and 13 with anoxic injury) with 14 age-matched healthy participants. Standardized clinical assessment and functional MRI were performed at an average of four days after withdrawal of sedation. Patients who were comatose showed a significant disruption of functional connectivity of brain areas spontaneously synchronized with posterior cingulate cortex, regardless of etiology of injury. The functional connectivity strength between the posterior cingulate cortex and the medial prefrontal cortex was significantly different between comatose patients who subsequently recovered and those who subsequently scored an unfavorable outcome three months after brain injury.

Raloxifene does not have a significant cognitive effect for women with Alzheimer’s disease, according to a study published online ahead of print November 4 in Neurology. Investigators conducted a randomized, double-blind, placebo-controlled pilot study with a planned treatment period of 12 months. Women with mild to moderate late-onset Alzheimer’s disease were randomized to high-dose (ie, 120 mg) oral raloxifene or identical placebo provided once daily. Forty-two women randomized to raloxifene or placebo were included in intent-to-treat analyses, and 39 women contributed 12-month outcomes. Results on the Alzheimer’s Disease Assessment Scale, cognitive subscale showed no cognitive benefits in the raloxifene-treated group. Raloxifene and placebo groups did not differ significantly on secondary analyses of dementia rating, activities of daily living, behavior, or a global cognition composite score.

Nonpharmacologic sleep interventions may help optimize outcomes in patients with chronic pain, according to data published in the November issue of Sleep. Investigators analyzed 11 randomized controlled trials, involving 1,066 participants, that evaluated the effect of nonpharmacologic sleep treatments on self-reported sleep quality, pain, and well-being in patients with long-term pain. They extracted means and standard deviations of sleep quality, pain, fatigue, depression, anxiety, and physical and psychologic functioning for the treatment and control groups at baseline, post treatment, and final follow-up. Nonpharmacologic sleep treatments in patients with chronic pain were associated with a large improvement in sleep quality, a small reduction in pain, and moderate improvement in fatigue at post treatment. The effects on sleep quality and fatigue were maintained for as long as one year, when a moderate reduction in depression also was observed.

CSF biomarkers of angiogenesis are increased in Parkinson’s disease and associated with gait difficulties, blood–­brain barrier dysfunction, white matter lesions, and cerebral microbleeds, according to a study published online ahead of print October 28 in Neurology. This cross-sectional analysis included 38 elderly controls and 100 patients with Parkinson’s disease. Patients with Parkinson’s disease without dementia displayed higher CSF levels of vascular endothelial growth factor, placental growth factor, and vascular endothelial growth factor 2, and lower levels of angiopoietin 2, compared with controls. Similar alterations in vascular endothelial growth factor, placental growth factor, and angiopoietin 2 levels were observed in patients with Parkinson’s disease with dementia. Abnormal angiogenesis may be important in Parkinson’s disease pathogenesis and contribute to dopa-resistant symptoms, said the researchers.

Despite comparable reductions in total sleep time, partial sleep loss from sleep continuity disruption is more detrimental to positive mood than partial sleep loss from delaying bedtime, even when controlling for concomitant increases in negative mood, according to a study published in the November issue of Sleep. Participants were randomized to receive three consecutive nights of sleep continuity disruption by forced nocturnal awakenings, or one of the following two control conditions: restricted sleep opportunity or uninterrupted sleep. Compared with controls with restricted sleep opportunity, participants who underwent forced awakenings had significantly less slow wave sleep after the first night of sleep deprivation, and significantly lower positive mood after the second night of sleep deprivation. The differential change in slow wave sleep statistically mediated the observed group differences in positive mood.

Among patients who underwent transcatheter atrial septal defect closure (ASD), the use of clopidogrel and aspirin, compared with aspirin plus placebo, resulted in a lower monthly frequency of migraine attacks over three months, according to a study published online ahead of print November 9 in JAMA. A total of 171 patients without migraine were randomized to receive dual antiplatelet therapy or single antiplatelet therapy (ie, aspirin and placebo) for three months following transcatheter ASD closure. The mean age of the participants was 49, and 62% were women. Among patients with migraines following the procedure, those who received clopidogrel had less-severe migraine attacks. No patients who received clopidogrel had moderately or severely disabling migraine attacks, and 37% of the placebo group had such attacks.

The Consortium of Multiple Sclerosis Centers (CMSC) has issued a statement asserting that prescribers must retain the right to decide on the best treatment and medication for each patient with MS. “The varied and individualized course of MS mandates full access to symptomatic management as well as disease-modifying therapies, which, in the best judgment of the prescriber, offer optimal treatment outcomes. Medications to treat symptoms are carefully decided on an individual basis and by best-practice regimens,” said the CMSC. “Lack of understanding of the disease course and the challenges of MS treatment result in poor decision making practices by the insurance plans and specialty pharmacies and subsequent denial of prescribed medications.... CMSC proposes a collaborative care model in which providers, patients, and insurers work together to address these concerns.”

APOE4 greatly increases the likelihood of microbleeds in some men, according to a study published online ahead of print October 16 in Neurobiology of Aging. These microbleeds contribute to memory loss. Investigators examined brain scans of 658 participants (ages 48 to 91) in the Alzheimer’s Disease Neuroimaging Initiative. Of those subjects, 402 had mild cognitive impairment (MCI), 90 had early-stage Alzheimer’s disease, and 166 were cognitively normal. Researchers also analyzed scans of 448 other subjects (ages 36 to 88). Of those people, 152 had MCI, 152 had Alzheimer’s disease, and 144 were cognitively normal. Male carriers of APOE4 with MCI or Alzheimer’s disease had twice as many microbleeds in their brains as women with similar diagnoses. Researchers should evaluate whether sex steroids can reduce the microbleeds, said the authors.

The Lewy Body Composite Risk Score (LBCRS) increases the diagnostic probability that Lewy body pathology is contributing to dementia and may improve clinical detection and enrollment for clinical trials, according to a study published September 1 in Alzheimer’s Dementia. The LBCRS was tested in a consecutive series of 256 patients and compared with the Clinical Dementia Rating and gold-standard measures of cognition, motor symptoms, function, and behavior. Mean LBCRS scores were significantly different between patients with dementia with Lewy bodies and those with Alzheimer’s disease. Mean LBCRS scores also were significantly different between patients with mild cognitive impairment (MCI) due to dementia with Lewy bodies and patients with MCI due to Alzheimer’s disease. The LBCRS also was able to discriminate between dementia with Lewy bodies and other causes of dementia.

—Kimberly Williams