Laird Harrison

LOS ANGELES – New ultrasound devices have shown promise in healing wounds, according to Dr. Jonathan Rosenblum, a podiatrist at Shaare Zedek Medical Center, Jerusalem.

"In the right hands, with the right modality, it could be a sonic boom," he punned. He cautioned that "there is no good evidence yet for ultrasound for any aspect of wound care." But in his presentation at the Diabetic Foot Global Conference, he said that many encouraging cases have been reported, along with impressive laboratory research, and that he hopes to launch randomized, controlled trials soon.

Dr. Rosenblum first became interested in the technology when he tried it out on a painful venous ulcer and found that the treatment not only reduced pain but seemed to speed the healing. "With a simple saline dressing and no compression, within 10 days we went from a nasty, sloughy wound bed to a soft epithelial covering," he said at the conference, which was presented by Valley Presbyterian Hospital.

He has since tried it out on a wide variety of wounds with good success.

Researchers have experimented with ultrasound therapy using longitudinal, shear, and acoustic waves, he said. And they’ve tried high and low frequency, and high and low intensity.

Some high-frequency ultrasound devices are being used to treat pain in soft tissue, said Dr. Rosenblum. But they aren’t effective for wound care because the energy isn’t focused on the dermis, he said. "A lot of it is being wasted deeper than you need it, and you’re not getting the effect that you want."

To address that problem several years ago, inventors experimented with low-frequency devices, but these machines were too large to be commercially viable, said Dr. Rosenblum. "They took up whole rooms," he said. "These were 6-foot-tall devices."

More recently, smaller devices have been created using surface acoustic waves, a technology that is also used in some touch screens, he said. It is this technology that looks promising for wound care, said Dr. Rosenblum.

Experiments by John Loike, Ph.D., at Columbia University in New York have shown that the migration of neutrophils and epithelial cells can be significantly influenced by this type of ultrasound waves, said Dr. Rosenblum.

Other researchers have shown increased local uptake of systemic gentamicin in pseudomonas biofilms, increasing the kill rate of the antibiotic.

In addition to fighting pathogens, ultrasound may spur skin growth, said Dr. Rosenblum. "It has been shown effective in all types of collagen synthesis, including cartilage, tendon, [and] skin," he said. And it has shown capacity to reawaken senescent cells, he added.

So how can ultrasound cause these effects?

One possibility is the heat generated by the energy from the waves, said Dr. Rosenblum, which could affect various aspects of healing. For example, collagenase is sensitive to temperature.

But heat itself is probably not the whole story, he said. One other possibility is that ultrasound may stimulate cells to produce nitrous oxide. In addition to being a powerful analgesic, ultrasound is a potent vasodilator.

"We came to the conclusion that ultrasound may be beneficial to wound healing," Dr. Rosenblum concluded. "I’d like to see a couple of good studies that could change that to ‘is beneficial to wound healing.’ "

Dr. Rosenblum disclosed that he an independent consultant to NanoVibronix and a consultant to BRH Health.

LOS ANGELES – New ultrasound devices have shown promise in healing wounds, according to Dr. Jonathan Rosenblum, a podiatrist at Shaare Zedek Medical Center, Jerusalem.

"In the right hands, with the right modality, it could be a sonic boom," he punned. He cautioned that "there is no good evidence yet for ultrasound for any aspect of wound care." But in his presentation at the Diabetic Foot Global Conference, he said that many encouraging cases have been reported, along with impressive laboratory research, and that he hopes to launch randomized, controlled trials soon.

Dr. Rosenblum first became interested in the technology when he tried it out on a painful venous ulcer and found that the treatment not only reduced pain but seemed to speed the healing. "With a simple saline dressing and no compression, within 10 days we went from a nasty, sloughy wound bed to a soft epithelial covering," he said at the conference, which was presented by Valley Presbyterian Hospital.

He has since tried it out on a wide variety of wounds with good success.

Researchers have experimented with ultrasound therapy using longitudinal, shear, and acoustic waves, he said. And they’ve tried high and low frequency, and high and low intensity.

Some high-frequency ultrasound devices are being used to treat pain in soft tissue, said Dr. Rosenblum. But they aren’t effective for wound care because the energy isn’t focused on the dermis, he said. "A lot of it is being wasted deeper than you need it, and you’re not getting the effect that you want."

To address that problem several years ago, inventors experimented with low-frequency devices, but these machines were too large to be commercially viable, said Dr. Rosenblum. "They took up whole rooms," he said. "These were 6-foot-tall devices."

More recently, smaller devices have been created using surface acoustic waves, a technology that is also used in some touch screens, he said. It is this technology that looks promising for wound care, said Dr. Rosenblum.

Experiments by John Loike, Ph.D., at Columbia University in New York have shown that the migration of neutrophils and epithelial cells can be significantly influenced by this type of ultrasound waves, said Dr. Rosenblum.

Other researchers have shown increased local uptake of systemic gentamicin in pseudomonas biofilms, increasing the kill rate of the antibiotic.

In addition to fighting pathogens, ultrasound may spur skin growth, said Dr. Rosenblum. "It has been shown effective in all types of collagen synthesis, including cartilage, tendon, [and] skin," he said. And it has shown capacity to reawaken senescent cells, he added.

So how can ultrasound cause these effects?

One possibility is the heat generated by the energy from the waves, said Dr. Rosenblum, which could affect various aspects of healing. For example, collagenase is sensitive to temperature.

But heat itself is probably not the whole story, he said. One other possibility is that ultrasound may stimulate cells to produce nitrous oxide. In addition to being a powerful analgesic, ultrasound is a potent vasodilator.

"We came to the conclusion that ultrasound may be beneficial to wound healing," Dr. Rosenblum concluded. "I’d like to see a couple of good studies that could change that to ‘is beneficial to wound healing.’ "

Dr. Rosenblum disclosed that he an independent consultant to NanoVibronix and a consultant to BRH Health.

LOS ANGELES – New ultrasound devices have shown promise in healing wounds, according to Dr. Jonathan Rosenblum, a podiatrist at Shaare Zedek Medical Center, Jerusalem.

"In the right hands, with the right modality, it could be a sonic boom," he punned. He cautioned that "there is no good evidence yet for ultrasound for any aspect of wound care." But in his presentation at the Diabetic Foot Global Conference, he said that many encouraging cases have been reported, along with impressive laboratory research, and that he hopes to launch randomized, controlled trials soon.

Dr. Rosenblum first became interested in the technology when he tried it out on a painful venous ulcer and found that the treatment not only reduced pain but seemed to speed the healing. "With a simple saline dressing and no compression, within 10 days we went from a nasty, sloughy wound bed to a soft epithelial covering," he said at the conference, which was presented by Valley Presbyterian Hospital.

He has since tried it out on a wide variety of wounds with good success.

Researchers have experimented with ultrasound therapy using longitudinal, shear, and acoustic waves, he said. And they’ve tried high and low frequency, and high and low intensity.

Some high-frequency ultrasound devices are being used to treat pain in soft tissue, said Dr. Rosenblum. But they aren’t effective for wound care because the energy isn’t focused on the dermis, he said. "A lot of it is being wasted deeper than you need it, and you’re not getting the effect that you want."

To address that problem several years ago, inventors experimented with low-frequency devices, but these machines were too large to be commercially viable, said Dr. Rosenblum. "They took up whole rooms," he said. "These were 6-foot-tall devices."

More recently, smaller devices have been created using surface acoustic waves, a technology that is also used in some touch screens, he said. It is this technology that looks promising for wound care, said Dr. Rosenblum.

Experiments by John Loike, Ph.D., at Columbia University in New York have shown that the migration of neutrophils and epithelial cells can be significantly influenced by this type of ultrasound waves, said Dr. Rosenblum.

Other researchers have shown increased local uptake of systemic gentamicin in pseudomonas biofilms, increasing the kill rate of the antibiotic.

In addition to fighting pathogens, ultrasound may spur skin growth, said Dr. Rosenblum. "It has been shown effective in all types of collagen synthesis, including cartilage, tendon, [and] skin," he said. And it has shown capacity to reawaken senescent cells, he added.

So how can ultrasound cause these effects?

One possibility is the heat generated by the energy from the waves, said Dr. Rosenblum, which could affect various aspects of healing. For example, collagenase is sensitive to temperature.

But heat itself is probably not the whole story, he said. One other possibility is that ultrasound may stimulate cells to produce nitrous oxide. In addition to being a powerful analgesic, ultrasound is a potent vasodilator.

"We came to the conclusion that ultrasound may be beneficial to wound healing," Dr. Rosenblum concluded. "I’d like to see a couple of good studies that could change that to ‘is beneficial to wound healing.’ "

Dr. Rosenblum disclosed that he an independent consultant to NanoVibronix and a consultant to BRH Health.

LOS ANGELES – Older Charcot patients may fare better than young ones after arthrodesis of the foot and ankle, according to Dr. Dane Wukich, a University of Pittsburgh orthopedic surgeon.

In a study comparing Charcot patients with and without diabetes mellitus, those with diabetes fared much worse, as did patients who smoked or had peripheral neuropathy, Dr. Wukich reported at the Diabetic Foot Global Conference.

Such data could help surgeons determine which Charcot foot patients are the best candidates for surgery, he said. "Surgical treatment is controversial, and I think it lacks sound scientific evidence to support what we do," he said at the conference, presented by Valley Presbyterian Hospital, Van Nuys, Calif.

But helping Charcot patients is important because they report themselves to be more disabled than people with Parkinson’s, heart failure, or hemodialysis (Foot Ankle Int. 2005;26:717-31).

The surgery is challenging, with a high risk of complications, said Dr. Wukich. But in his experience, patients’ expectations are relatively low. Surgeons aim to eliminate pain, avoid amputation, and maintain ambulation. "Limb salvage should be 90% with proper technique and good patient selection," he said.

In a review of the literature on the surgical management of Charcot foot, Dr. Wukich and his colleagues found about 95 studies looking at 1,129 diabetic patients who had surgery. But there were no prospective trials; most of the studies were expert opinions and case reports, or at best case series, and half the reports came from only four surgeons.

"When people get up and talk to you about these things, half the evidence is based on opinion," Dr. Wukich warned. "It’s really not sound scientific evidence."

Such as it is, the literature suggests that the results of surgery in the acute stages are encouraging, he said. "But there has never been a study comparing operating on somebody when it first happens to operating on somebody in the chronic phase. So it’s inconclusive at this time. We have no evidence telling you when you should operate."

Most procedures – 59% – were in the midfoot, with 29% in the ankle and relatively few in the hindfoot.

Using grades from A to D, with A meeting the strongest standards for evidence, the researchers attached a grade of C to the evidence for exostectomy, in which surgeons shape bone on the bottom of the foot. And this is a relatively simple procedure.

They gave a B to Achilles tendon lengthening. "It reduces forefoot pressure. It improves the alignment of the ankle with regard to the forefoot," said Dr. Wukich.

They also gave a grade of C to arthrodesis, in which bones are fused to reduce pain, instability, and recurrent ulcers. "We know that about 25% of these people are not going to fuse properly," he said.

As for fixation, the researchers gave it an I for incomplete. "We get all excited about these new technologies, and we spend $12,000 just putting a frame on a patient, but quite honestly I can’t sit here and tell you based on all the evidence whether I should use internal fixation or external fixation," said Dr. Wukich.

Finding so little of use in the literature, Dr. Wukich and his colleagues undertook their own study of arthrodesis of the foot and ankle, comparing 74 diabetes patients to 74 patients without diabetes. The diabetes patients weighed more, but they were closely matched to the comparison group in terms of age, sex, and previous surgery.

Comparing the complication rates, the researchers found that diabetes conferred a risk factor of 2.9.

However, age was associated with fewer complications. "That’s a surprising fact, because you would expect the opposite," said Dr. Wukich. "Perhaps it’s that our older patients are less active postoperatively that results in fewer complications."

Diabetes patients were 17 times as likely to get an infection. In addition, patients with a hemoglobin A_1c level of more than 7% were five times as likely to suffer an infection. Not surprisingly, tobacco use, peripheral neuropathy, and peripheral artery disease also increased the risk of infection.

Turning to noninfectious complications, such as hardware failure, symptomatic hardware, and failure to fuse, the researchers found that patients with diabetes, a history of tobacco use, or a history of a transplant were more likely to suffer.

"Diabetes and tobacco are a bad combination," said Dr. Wukich. "That’s something you can tell the patient."

LOS ANGELES – Older Charcot patients may fare better than young ones after arthrodesis of the foot and ankle, according to Dr. Dane Wukich, a University of Pittsburgh orthopedic surgeon.

In a study comparing Charcot patients with and without diabetes mellitus, those with diabetes fared much worse, as did patients who smoked or had peripheral neuropathy, Dr. Wukich reported at the Diabetic Foot Global Conference.

Such data could help surgeons determine which Charcot foot patients are the best candidates for surgery, he said. "Surgical treatment is controversial, and I think it lacks sound scientific evidence to support what we do," he said at the conference, presented by Valley Presbyterian Hospital, Van Nuys, Calif.

But helping Charcot patients is important because they report themselves to be more disabled than people with Parkinson’s, heart failure, or hemodialysis (Foot Ankle Int. 2005;26:717-31).

The surgery is challenging, with a high risk of complications, said Dr. Wukich. But in his experience, patients’ expectations are relatively low. Surgeons aim to eliminate pain, avoid amputation, and maintain ambulation. "Limb salvage should be 90% with proper technique and good patient selection," he said.

In a review of the literature on the surgical management of Charcot foot, Dr. Wukich and his colleagues found about 95 studies looking at 1,129 diabetic patients who had surgery. But there were no prospective trials; most of the studies were expert opinions and case reports, or at best case series, and half the reports came from only four surgeons.

"When people get up and talk to you about these things, half the evidence is based on opinion," Dr. Wukich warned. "It’s really not sound scientific evidence."

Such as it is, the literature suggests that the results of surgery in the acute stages are encouraging, he said. "But there has never been a study comparing operating on somebody when it first happens to operating on somebody in the chronic phase. So it’s inconclusive at this time. We have no evidence telling you when you should operate."

Most procedures – 59% – were in the midfoot, with 29% in the ankle and relatively few in the hindfoot.

Using grades from A to D, with A meeting the strongest standards for evidence, the researchers attached a grade of C to the evidence for exostectomy, in which surgeons shape bone on the bottom of the foot. And this is a relatively simple procedure.

They gave a B to Achilles tendon lengthening. "It reduces forefoot pressure. It improves the alignment of the ankle with regard to the forefoot," said Dr. Wukich.

They also gave a grade of C to arthrodesis, in which bones are fused to reduce pain, instability, and recurrent ulcers. "We know that about 25% of these people are not going to fuse properly," he said.

As for fixation, the researchers gave it an I for incomplete. "We get all excited about these new technologies, and we spend $12,000 just putting a frame on a patient, but quite honestly I can’t sit here and tell you based on all the evidence whether I should use internal fixation or external fixation," said Dr. Wukich.

Finding so little of use in the literature, Dr. Wukich and his colleagues undertook their own study of arthrodesis of the foot and ankle, comparing 74 diabetes patients to 74 patients without diabetes. The diabetes patients weighed more, but they were closely matched to the comparison group in terms of age, sex, and previous surgery.

Comparing the complication rates, the researchers found that diabetes conferred a risk factor of 2.9.

However, age was associated with fewer complications. "That’s a surprising fact, because you would expect the opposite," said Dr. Wukich. "Perhaps it’s that our older patients are less active postoperatively that results in fewer complications."

Diabetes patients were 17 times as likely to get an infection. In addition, patients with a hemoglobin A_1c level of more than 7% were five times as likely to suffer an infection. Not surprisingly, tobacco use, peripheral neuropathy, and peripheral artery disease also increased the risk of infection.

Turning to noninfectious complications, such as hardware failure, symptomatic hardware, and failure to fuse, the researchers found that patients with diabetes, a history of tobacco use, or a history of a transplant were more likely to suffer.

"Diabetes and tobacco are a bad combination," said Dr. Wukich. "That’s something you can tell the patient."

LOS ANGELES – Older Charcot patients may fare better than young ones after arthrodesis of the foot and ankle, according to Dr. Dane Wukich, a University of Pittsburgh orthopedic surgeon.

In a study comparing Charcot patients with and without diabetes mellitus, those with diabetes fared much worse, as did patients who smoked or had peripheral neuropathy, Dr. Wukich reported at the Diabetic Foot Global Conference.

Such data could help surgeons determine which Charcot foot patients are the best candidates for surgery, he said. "Surgical treatment is controversial, and I think it lacks sound scientific evidence to support what we do," he said at the conference, presented by Valley Presbyterian Hospital, Van Nuys, Calif.

But helping Charcot patients is important because they report themselves to be more disabled than people with Parkinson’s, heart failure, or hemodialysis (Foot Ankle Int. 2005;26:717-31).

The surgery is challenging, with a high risk of complications, said Dr. Wukich. But in his experience, patients’ expectations are relatively low. Surgeons aim to eliminate pain, avoid amputation, and maintain ambulation. "Limb salvage should be 90% with proper technique and good patient selection," he said.

In a review of the literature on the surgical management of Charcot foot, Dr. Wukich and his colleagues found about 95 studies looking at 1,129 diabetic patients who had surgery. But there were no prospective trials; most of the studies were expert opinions and case reports, or at best case series, and half the reports came from only four surgeons.

"When people get up and talk to you about these things, half the evidence is based on opinion," Dr. Wukich warned. "It’s really not sound scientific evidence."

Such as it is, the literature suggests that the results of surgery in the acute stages are encouraging, he said. "But there has never been a study comparing operating on somebody when it first happens to operating on somebody in the chronic phase. So it’s inconclusive at this time. We have no evidence telling you when you should operate."

Most procedures – 59% – were in the midfoot, with 29% in the ankle and relatively few in the hindfoot.

Using grades from A to D, with A meeting the strongest standards for evidence, the researchers attached a grade of C to the evidence for exostectomy, in which surgeons shape bone on the bottom of the foot. And this is a relatively simple procedure.

They gave a B to Achilles tendon lengthening. "It reduces forefoot pressure. It improves the alignment of the ankle with regard to the forefoot," said Dr. Wukich.

They also gave a grade of C to arthrodesis, in which bones are fused to reduce pain, instability, and recurrent ulcers. "We know that about 25% of these people are not going to fuse properly," he said.

As for fixation, the researchers gave it an I for incomplete. "We get all excited about these new technologies, and we spend $12,000 just putting a frame on a patient, but quite honestly I can’t sit here and tell you based on all the evidence whether I should use internal fixation or external fixation," said Dr. Wukich.

Finding so little of use in the literature, Dr. Wukich and his colleagues undertook their own study of arthrodesis of the foot and ankle, comparing 74 diabetes patients to 74 patients without diabetes. The diabetes patients weighed more, but they were closely matched to the comparison group in terms of age, sex, and previous surgery.

Comparing the complication rates, the researchers found that diabetes conferred a risk factor of 2.9.

However, age was associated with fewer complications. "That’s a surprising fact, because you would expect the opposite," said Dr. Wukich. "Perhaps it’s that our older patients are less active postoperatively that results in fewer complications."

Diabetes patients were 17 times as likely to get an infection. In addition, patients with a hemoglobin A_1c level of more than 7% were five times as likely to suffer an infection. Not surprisingly, tobacco use, peripheral neuropathy, and peripheral artery disease also increased the risk of infection.

Turning to noninfectious complications, such as hardware failure, symptomatic hardware, and failure to fuse, the researchers found that patients with diabetes, a history of tobacco use, or a history of a transplant were more likely to suffer.

"Diabetes and tobacco are a bad combination," said Dr. Wukich. "That’s something you can tell the patient."

LOS ANGELES – Older Charcot patients may fare better than young ones after arthrodesis of the foot and ankle, according to Dr. Dane Wukich, a University of Pittsburgh orthopedic surgeon.

In a study comparing Charcot patients with and without diabetes mellitus, those with diabetes fared much worse, as did patients who smoked or had peripheral neuropathy, Dr. Wukich reported at the Diabetic Foot Global Conference.

Such data could help surgeons determine which Charcot foot patients are the best candidates for surgery, he said. "Surgical treatment is controversial, and I think it lacks sound scientific evidence to support what we do," he said at the conference, presented by Valley Presbyterian Hospital, Van Nuys, Calif.

But helping Charcot patients is important because they report themselves to be more disabled than people with Parkinson’s, heart failure, or hemodialysis (Foot Ankle Int. 2005;26:717-31).

The surgery is challenging, with a high risk of complications, said Dr. Wukich. But in his experience, patients’ expectations are relatively low. Surgeons aim to eliminate pain, avoid amputation, and maintain ambulation. "Limb salvage should be 90% with proper technique and good patient selection," he said.

In a review of the literature on the surgical management of Charcot foot, Dr. Wukich and his colleagues found about 95 studies looking at 1,129 diabetic patients who had surgery. But there were no prospective trials; most of the studies were expert opinions and case reports, or at best case series, and half the reports came from only four surgeons.

"When people get up and talk to you about these things, half the evidence is based on opinion," Dr. Wukich warned. "It’s really not sound scientific evidence."

Such as it is, the literature suggests that the results of surgery in the acute stages are encouraging, he said. "But there has never been a study comparing operating on somebody when it first happens to operating on somebody in the chronic phase. So it’s inconclusive at this time. We have no evidence telling you when you should operate."

Most procedures – 59% – were in the midfoot, with 29% in the ankle and relatively few in the hindfoot.

Using grades from A to D, with A meeting the strongest standards for evidence, the researchers attached a grade of C to the evidence for exostectomy, in which surgeons shape bone on the bottom of the foot. And this is a relatively simple procedure.

They gave a B to Achilles tendon lengthening. "It reduces forefoot pressure. It improves the alignment of the ankle with regard to the forefoot," said Dr. Wukich.

They also gave a grade of C to arthrodesis, in which bones are fused to reduce pain, instability, and recurrent ulcers. "We know that about 25% of these people are not going to fuse properly," he said.

As for fixation, the researchers gave it an I for incomplete. "We get all excited about these new technologies, and we spend $12,000 just putting a frame on a patient, but quite honestly I can’t sit here and tell you based on all the evidence whether I should use internal fixation or external fixation," said Dr. Wukich.

Finding so little of use in the literature, Dr. Wukich and his colleagues undertook their own study of arthrodesis of the foot and ankle, comparing 74 diabetes patients to 74 patients without diabetes. The diabetes patients weighed more, but they were closely matched to the comparison group in terms of age, sex, and previous surgery.

Comparing the complication rates, the researchers found that diabetes conferred a risk factor of 2.9.

However, age was associated with fewer complications. "That’s a surprising fact, because you would expect the opposite," said Dr. Wukich. "Perhaps it’s that our older patients are less active postoperatively that results in fewer complications."

Diabetes patients were 17 times as likely to get an infection. In addition, patients with a hemoglobin A_1c level of more than 7% were five times as likely to suffer an infection. Not surprisingly, tobacco use, peripheral neuropathy, and peripheral artery disease also increased the risk of infection.

Turning to noninfectious complications, such as hardware failure, symptomatic hardware, and failure to fuse, the researchers found that patients with diabetes, a history of tobacco use, or a history of a transplant were more likely to suffer.

"Diabetes and tobacco are a bad combination," said Dr. Wukich. "That’s something you can tell the patient."

LOS ANGELES – Older Charcot patients may fare better than young ones after arthrodesis of the foot and ankle, according to Dr. Dane Wukich, a University of Pittsburgh orthopedic surgeon.

In a study comparing Charcot patients with and without diabetes mellitus, those with diabetes fared much worse, as did patients who smoked or had peripheral neuropathy, Dr. Wukich reported at the Diabetic Foot Global Conference.

Such data could help surgeons determine which Charcot foot patients are the best candidates for surgery, he said. "Surgical treatment is controversial, and I think it lacks sound scientific evidence to support what we do," he said at the conference, presented by Valley Presbyterian Hospital, Van Nuys, Calif.

But helping Charcot patients is important because they report themselves to be more disabled than people with Parkinson’s, heart failure, or hemodialysis (Foot Ankle Int. 2005;26:717-31).

The surgery is challenging, with a high risk of complications, said Dr. Wukich. But in his experience, patients’ expectations are relatively low. Surgeons aim to eliminate pain, avoid amputation, and maintain ambulation. "Limb salvage should be 90% with proper technique and good patient selection," he said.

In a review of the literature on the surgical management of Charcot foot, Dr. Wukich and his colleagues found about 95 studies looking at 1,129 diabetic patients who had surgery. But there were no prospective trials; most of the studies were expert opinions and case reports, or at best case series, and half the reports came from only four surgeons.

"When people get up and talk to you about these things, half the evidence is based on opinion," Dr. Wukich warned. "It’s really not sound scientific evidence."

Such as it is, the literature suggests that the results of surgery in the acute stages are encouraging, he said. "But there has never been a study comparing operating on somebody when it first happens to operating on somebody in the chronic phase. So it’s inconclusive at this time. We have no evidence telling you when you should operate."

Most procedures – 59% – were in the midfoot, with 29% in the ankle and relatively few in the hindfoot.

Using grades from A to D, with A meeting the strongest standards for evidence, the researchers attached a grade of C to the evidence for exostectomy, in which surgeons shape bone on the bottom of the foot. And this is a relatively simple procedure.

They gave a B to Achilles tendon lengthening. "It reduces forefoot pressure. It improves the alignment of the ankle with regard to the forefoot," said Dr. Wukich.

They also gave a grade of C to arthrodesis, in which bones are fused to reduce pain, instability, and recurrent ulcers. "We know that about 25% of these people are not going to fuse properly," he said.

As for fixation, the researchers gave it an I for incomplete. "We get all excited about these new technologies, and we spend $12,000 just putting a frame on a patient, but quite honestly I can’t sit here and tell you based on all the evidence whether I should use internal fixation or external fixation," said Dr. Wukich.

Finding so little of use in the literature, Dr. Wukich and his colleagues undertook their own study of arthrodesis of the foot and ankle, comparing 74 diabetes patients to 74 patients without diabetes. The diabetes patients weighed more, but they were closely matched to the comparison group in terms of age, sex, and previous surgery.

Comparing the complication rates, the researchers found that diabetes conferred a risk factor of 2.9.

However, age was associated with fewer complications. "That’s a surprising fact, because you would expect the opposite," said Dr. Wukich. "Perhaps it’s that our older patients are less active postoperatively that results in fewer complications."

Diabetes patients were 17 times as likely to get an infection. In addition, patients with a hemoglobin A_1c level of more than 7% were five times as likely to suffer an infection. Not surprisingly, tobacco use, peripheral neuropathy, and peripheral artery disease also increased the risk of infection.

Turning to noninfectious complications, such as hardware failure, symptomatic hardware, and failure to fuse, the researchers found that patients with diabetes, a history of tobacco use, or a history of a transplant were more likely to suffer.

"Diabetes and tobacco are a bad combination," said Dr. Wukich. "That’s something you can tell the patient."

LOS ANGELES – Older Charcot patients may fare better than young ones after arthrodesis of the foot and ankle, according to Dr. Dane Wukich, a University of Pittsburgh orthopedic surgeon.

In a study comparing Charcot patients with and without diabetes mellitus, those with diabetes fared much worse, as did patients who smoked or had peripheral neuropathy, Dr. Wukich reported at the Diabetic Foot Global Conference.

Such data could help surgeons determine which Charcot foot patients are the best candidates for surgery, he said. "Surgical treatment is controversial, and I think it lacks sound scientific evidence to support what we do," he said at the conference, presented by Valley Presbyterian Hospital, Van Nuys, Calif.

But helping Charcot patients is important because they report themselves to be more disabled than people with Parkinson’s, heart failure, or hemodialysis (Foot Ankle Int. 2005;26:717-31).

The surgery is challenging, with a high risk of complications, said Dr. Wukich. But in his experience, patients’ expectations are relatively low. Surgeons aim to eliminate pain, avoid amputation, and maintain ambulation. "Limb salvage should be 90% with proper technique and good patient selection," he said.

In a review of the literature on the surgical management of Charcot foot, Dr. Wukich and his colleagues found about 95 studies looking at 1,129 diabetic patients who had surgery. But there were no prospective trials; most of the studies were expert opinions and case reports, or at best case series, and half the reports came from only four surgeons.

"When people get up and talk to you about these things, half the evidence is based on opinion," Dr. Wukich warned. "It’s really not sound scientific evidence."

Such as it is, the literature suggests that the results of surgery in the acute stages are encouraging, he said. "But there has never been a study comparing operating on somebody when it first happens to operating on somebody in the chronic phase. So it’s inconclusive at this time. We have no evidence telling you when you should operate."

Most procedures – 59% – were in the midfoot, with 29% in the ankle and relatively few in the hindfoot.

Using grades from A to D, with A meeting the strongest standards for evidence, the researchers attached a grade of C to the evidence for exostectomy, in which surgeons shape bone on the bottom of the foot. And this is a relatively simple procedure.

They gave a B to Achilles tendon lengthening. "It reduces forefoot pressure. It improves the alignment of the ankle with regard to the forefoot," said Dr. Wukich.

They also gave a grade of C to arthrodesis, in which bones are fused to reduce pain, instability, and recurrent ulcers. "We know that about 25% of these people are not going to fuse properly," he said.

As for fixation, the researchers gave it an I for incomplete. "We get all excited about these new technologies, and we spend $12,000 just putting a frame on a patient, but quite honestly I can’t sit here and tell you based on all the evidence whether I should use internal fixation or external fixation," said Dr. Wukich.

Finding so little of use in the literature, Dr. Wukich and his colleagues undertook their own study of arthrodesis of the foot and ankle, comparing 74 diabetes patients to 74 patients without diabetes. The diabetes patients weighed more, but they were closely matched to the comparison group in terms of age, sex, and previous surgery.

Comparing the complication rates, the researchers found that diabetes conferred a risk factor of 2.9.

However, age was associated with fewer complications. "That’s a surprising fact, because you would expect the opposite," said Dr. Wukich. "Perhaps it’s that our older patients are less active postoperatively that results in fewer complications."

Diabetes patients were 17 times as likely to get an infection. In addition, patients with a hemoglobin A_1c level of more than 7% were five times as likely to suffer an infection. Not surprisingly, tobacco use, peripheral neuropathy, and peripheral artery disease also increased the risk of infection.

Turning to noninfectious complications, such as hardware failure, symptomatic hardware, and failure to fuse, the researchers found that patients with diabetes, a history of tobacco use, or a history of a transplant were more likely to suffer.

"Diabetes and tobacco are a bad combination," said Dr. Wukich. "That’s something you can tell the patient."

LOS ANGELES – Older Charcot patients may fare better than young ones after arthrodesis of the foot and ankle, according to Dr. Dane Wukich, a University of Pittsburgh orthopedic surgeon.

In a study comparing Charcot patients with and without diabetes mellitus, those with diabetes fared much worse, as did patients who smoked or had peripheral neuropathy, Dr. Wukich reported at the Diabetic Foot Global Conference.

Such data could help surgeons determine which Charcot foot patients are the best candidates for surgery, he said. "Surgical treatment is controversial, and I think it lacks sound scientific evidence to support what we do," he said at the conference, presented by Valley Presbyterian Hospital, Van Nuys, Calif.

But helping Charcot patients is important because they report themselves to be more disabled than people with Parkinson’s, heart failure, or hemodialysis (Foot Ankle Int. 2005;26:717-31).

The surgery is challenging, with a high risk of complications, said Dr. Wukich. But in his experience, patients’ expectations are relatively low. Surgeons aim to eliminate pain, avoid amputation, and maintain ambulation. "Limb salvage should be 90% with proper technique and good patient selection," he said.

In a review of the literature on the surgical management of Charcot foot, Dr. Wukich and his colleagues found about 95 studies looking at 1,129 diabetic patients who had surgery. But there were no prospective trials; most of the studies were expert opinions and case reports, or at best case series, and half the reports came from only four surgeons.

"When people get up and talk to you about these things, half the evidence is based on opinion," Dr. Wukich warned. "It’s really not sound scientific evidence."

Such as it is, the literature suggests that the results of surgery in the acute stages are encouraging, he said. "But there has never been a study comparing operating on somebody when it first happens to operating on somebody in the chronic phase. So it’s inconclusive at this time. We have no evidence telling you when you should operate."

Most procedures – 59% – were in the midfoot, with 29% in the ankle and relatively few in the hindfoot.

Using grades from A to D, with A meeting the strongest standards for evidence, the researchers attached a grade of C to the evidence for exostectomy, in which surgeons shape bone on the bottom of the foot. And this is a relatively simple procedure.

They gave a B to Achilles tendon lengthening. "It reduces forefoot pressure. It improves the alignment of the ankle with regard to the forefoot," said Dr. Wukich.

They also gave a grade of C to arthrodesis, in which bones are fused to reduce pain, instability, and recurrent ulcers. "We know that about 25% of these people are not going to fuse properly," he said.

As for fixation, the researchers gave it an I for incomplete. "We get all excited about these new technologies, and we spend $12,000 just putting a frame on a patient, but quite honestly I can’t sit here and tell you based on all the evidence whether I should use internal fixation or external fixation," said Dr. Wukich.

Finding so little of use in the literature, Dr. Wukich and his colleagues undertook their own study of arthrodesis of the foot and ankle, comparing 74 diabetes patients to 74 patients without diabetes. The diabetes patients weighed more, but they were closely matched to the comparison group in terms of age, sex, and previous surgery.

Comparing the complication rates, the researchers found that diabetes conferred a risk factor of 2.9.

However, age was associated with fewer complications. "That’s a surprising fact, because you would expect the opposite," said Dr. Wukich. "Perhaps it’s that our older patients are less active postoperatively that results in fewer complications."

Diabetes patients were 17 times as likely to get an infection. In addition, patients with a hemoglobin A_1c level of more than 7% were five times as likely to suffer an infection. Not surprisingly, tobacco use, peripheral neuropathy, and peripheral artery disease also increased the risk of infection.

Turning to noninfectious complications, such as hardware failure, symptomatic hardware, and failure to fuse, the researchers found that patients with diabetes, a history of tobacco use, or a history of a transplant were more likely to suffer.

"Diabetes and tobacco are a bad combination," said Dr. Wukich. "That’s something you can tell the patient."

LOS ANGELES – Older Charcot patients may fare better than young ones after arthrodesis of the foot and ankle, according to Dr. Dane Wukich, a University of Pittsburgh orthopedic surgeon.

In a study comparing Charcot patients with and without diabetes mellitus, those with diabetes fared much worse, as did patients who smoked or had peripheral neuropathy, Dr. Wukich reported at the Diabetic Foot Global Conference.

Such data could help surgeons determine which Charcot foot patients are the best candidates for surgery, he said. "Surgical treatment is controversial, and I think it lacks sound scientific evidence to support what we do," he said at the conference, presented by Valley Presbyterian Hospital, Van Nuys, Calif.

But helping Charcot patients is important because they report themselves to be more disabled than people with Parkinson’s, heart failure, or hemodialysis (Foot Ankle Int. 2005;26:717-31).

The surgery is challenging, with a high risk of complications, said Dr. Wukich. But in his experience, patients’ expectations are relatively low. Surgeons aim to eliminate pain, avoid amputation, and maintain ambulation. "Limb salvage should be 90% with proper technique and good patient selection," he said.

In a review of the literature on the surgical management of Charcot foot, Dr. Wukich and his colleagues found about 95 studies looking at 1,129 diabetic patients who had surgery. But there were no prospective trials; most of the studies were expert opinions and case reports, or at best case series, and half the reports came from only four surgeons.

"When people get up and talk to you about these things, half the evidence is based on opinion," Dr. Wukich warned. "It’s really not sound scientific evidence."

Such as it is, the literature suggests that the results of surgery in the acute stages are encouraging, he said. "But there has never been a study comparing operating on somebody when it first happens to operating on somebody in the chronic phase. So it’s inconclusive at this time. We have no evidence telling you when you should operate."

Most procedures – 59% – were in the midfoot, with 29% in the ankle and relatively few in the hindfoot.

Using grades from A to D, with A meeting the strongest standards for evidence, the researchers attached a grade of C to the evidence for exostectomy, in which surgeons shape bone on the bottom of the foot. And this is a relatively simple procedure.

They gave a B to Achilles tendon lengthening. "It reduces forefoot pressure. It improves the alignment of the ankle with regard to the forefoot," said Dr. Wukich.

They also gave a grade of C to arthrodesis, in which bones are fused to reduce pain, instability, and recurrent ulcers. "We know that about 25% of these people are not going to fuse properly," he said.

As for fixation, the researchers gave it an I for incomplete. "We get all excited about these new technologies, and we spend $12,000 just putting a frame on a patient, but quite honestly I can’t sit here and tell you based on all the evidence whether I should use internal fixation or external fixation," said Dr. Wukich.

Finding so little of use in the literature, Dr. Wukich and his colleagues undertook their own study of arthrodesis of the foot and ankle, comparing 74 diabetes patients to 74 patients without diabetes. The diabetes patients weighed more, but they were closely matched to the comparison group in terms of age, sex, and previous surgery.

Comparing the complication rates, the researchers found that diabetes conferred a risk factor of 2.9.

However, age was associated with fewer complications. "That’s a surprising fact, because you would expect the opposite," said Dr. Wukich. "Perhaps it’s that our older patients are less active postoperatively that results in fewer complications."

Diabetes patients were 17 times as likely to get an infection. In addition, patients with a hemoglobin A_1c level of more than 7% were five times as likely to suffer an infection. Not surprisingly, tobacco use, peripheral neuropathy, and peripheral artery disease also increased the risk of infection.

Turning to noninfectious complications, such as hardware failure, symptomatic hardware, and failure to fuse, the researchers found that patients with diabetes, a history of tobacco use, or a history of a transplant were more likely to suffer.

"Diabetes and tobacco are a bad combination," said Dr. Wukich. "That’s something you can tell the patient."

LOS ANGELES – Older Charcot patients may fare better than young ones after arthrodesis of the foot and ankle, according to Dr. Dane Wukich, a University of Pittsburgh orthopedic surgeon.

In a study comparing Charcot patients with and without diabetes mellitus, those with diabetes fared much worse, as did patients who smoked or had peripheral neuropathy, Dr. Wukich reported at the Diabetic Foot Global Conference.

Such data could help surgeons determine which Charcot foot patients are the best candidates for surgery, he said. "Surgical treatment is controversial, and I think it lacks sound scientific evidence to support what we do," he said at the conference, presented by Valley Presbyterian Hospital, Van Nuys, Calif.

But helping Charcot patients is important because they report themselves to be more disabled than people with Parkinson’s, heart failure, or hemodialysis (Foot Ankle Int. 2005;26:717-31).

The surgery is challenging, with a high risk of complications, said Dr. Wukich. But in his experience, patients’ expectations are relatively low. Surgeons aim to eliminate pain, avoid amputation, and maintain ambulation. "Limb salvage should be 90% with proper technique and good patient selection," he said.

In a review of the literature on the surgical management of Charcot foot, Dr. Wukich and his colleagues found about 95 studies looking at 1,129 diabetic patients who had surgery. But there were no prospective trials; most of the studies were expert opinions and case reports, or at best case series, and half the reports came from only four surgeons.

"When people get up and talk to you about these things, half the evidence is based on opinion," Dr. Wukich warned. "It’s really not sound scientific evidence."

Such as it is, the literature suggests that the results of surgery in the acute stages are encouraging, he said. "But there has never been a study comparing operating on somebody when it first happens to operating on somebody in the chronic phase. So it’s inconclusive at this time. We have no evidence telling you when you should operate."

Most procedures – 59% – were in the midfoot, with 29% in the ankle and relatively few in the hindfoot.

Using grades from A to D, with A meeting the strongest standards for evidence, the researchers attached a grade of C to the evidence for exostectomy, in which surgeons shape bone on the bottom of the foot. And this is a relatively simple procedure.

They gave a B to Achilles tendon lengthening. "It reduces forefoot pressure. It improves the alignment of the ankle with regard to the forefoot," said Dr. Wukich.

They also gave a grade of C to arthrodesis, in which bones are fused to reduce pain, instability, and recurrent ulcers. "We know that about 25% of these people are not going to fuse properly," he said.

As for fixation, the researchers gave it an I for incomplete. "We get all excited about these new technologies, and we spend $12,000 just putting a frame on a patient, but quite honestly I can’t sit here and tell you based on all the evidence whether I should use internal fixation or external fixation," said Dr. Wukich.

Finding so little of use in the literature, Dr. Wukich and his colleagues undertook their own study of arthrodesis of the foot and ankle, comparing 74 diabetes patients to 74 patients without diabetes. The diabetes patients weighed more, but they were closely matched to the comparison group in terms of age, sex, and previous surgery.

Comparing the complication rates, the researchers found that diabetes conferred a risk factor of 2.9.

However, age was associated with fewer complications. "That’s a surprising fact, because you would expect the opposite," said Dr. Wukich. "Perhaps it’s that our older patients are less active postoperatively that results in fewer complications."

Diabetes patients were 17 times as likely to get an infection. In addition, patients with a hemoglobin A_1c level of more than 7% were five times as likely to suffer an infection. Not surprisingly, tobacco use, peripheral neuropathy, and peripheral artery disease also increased the risk of infection.

Turning to noninfectious complications, such as hardware failure, symptomatic hardware, and failure to fuse, the researchers found that patients with diabetes, a history of tobacco use, or a history of a transplant were more likely to suffer.

"Diabetes and tobacco are a bad combination," said Dr. Wukich. "That’s something you can tell the patient."

LAS VEGAS – Competition among large retailers is bringing down the cost of terbinafine, but griseofulvin is still better for many fungal infections, according to Dr. Lawrence F. Eichenfield.

The ideal prescription depends on the type of fungus and the site of the infection, Dr. Eichenfield, chief of pediatric and adolescent dermatology at the University of California, San Diego, said at the update, sponsored by the American Academy of Pediatrics California Chapter 9.

Topical medications alone can seldom cure tinea capitis because the fungus finds protection inside hair follicles, but he advised using them in combination with systemic drugs.

Signs of tinea capitis include scaling, pustules, kerion, black dots, alopecia, adenopathy, and autoeczematization (also known as id reaction). The condition can resemble seborrheic dermatitis, psoriasis, folliculitis, and other diseases.

“So it's worth doing a routine culture,” said Dr. Eichenfield, adding that it's fairly easy to obtain a specimen with a toothbrush, cotton swab, or bacterial culturette.

The most common culprit is Trichophyton tonsurans, spread by human contact. The second most common cause is Microsporum canis, spread by cats.

Family coinfection can contribute to treatment failure, so inquire about tinea capitis and tinea corporis in other affected family members and pets, said Dr. Eichenfield. Standard therapy for tinea capitis is microsized griseofulvin (20 mg/kg) for 6–8 weeks, he advised.

The only other approved drug is terbinafine granules, and these are hard to obtain, he said, but itraconazole and fluconazole might work.

Particularly if griseofulvin fails, Dr. Eichenfield recommended terbinafine 4–8 mg/kg per day for 4 weeks. But one study found that griseofulvin was much better than terbinafine for M. canis (J. Am. Acad. Dermatol. 2008;59:41-54).

The same organisms, along with T. rubrum and T. mentagrophytes, can cause tinea corporis. Patients present with red scaling plaque, often with an active border. Central clearing may give the lesions a ring shape. They can be treated with topical drugs, including clotrimazole, econazole, oxiconazole, ciclopirox, terbinafine, and ketoconazole.

Systemic treatment should be reserved for extensive disease or special circumstances, such as for wrestlers. The best systemic treatment is griseofulvin, 15–20 mg/kg (5–10 mg/kg ultramicrosize), he said.

Dr. Eichenfield said he had no relevant financial disclosures.

'So it's worth doing a routine culture' for tinea capitis.

Source DR. EICHENFIELD

LAS VEGAS – Competition among large retailers is bringing down the cost of terbinafine, but griseofulvin is still better for many fungal infections, according to Dr. Lawrence F. Eichenfield.

The ideal prescription depends on the type of fungus and the site of the infection, Dr. Eichenfield, chief of pediatric and adolescent dermatology at the University of California, San Diego, said at the update, sponsored by the American Academy of Pediatrics California Chapter 9.

Topical medications alone can seldom cure tinea capitis because the fungus finds protection inside hair follicles, but he advised using them in combination with systemic drugs.

Signs of tinea capitis include scaling, pustules, kerion, black dots, alopecia, adenopathy, and autoeczematization (also known as id reaction). The condition can resemble seborrheic dermatitis, psoriasis, folliculitis, and other diseases.

“So it's worth doing a routine culture,” said Dr. Eichenfield, adding that it's fairly easy to obtain a specimen with a toothbrush, cotton swab, or bacterial culturette.

The most common culprit is Trichophyton tonsurans, spread by human contact. The second most common cause is Microsporum canis, spread by cats.

Family coinfection can contribute to treatment failure, so inquire about tinea capitis and tinea corporis in other affected family members and pets, said Dr. Eichenfield. Standard therapy for tinea capitis is microsized griseofulvin (20 mg/kg) for 6–8 weeks, he advised.

The only other approved drug is terbinafine granules, and these are hard to obtain, he said, but itraconazole and fluconazole might work.

Particularly if griseofulvin fails, Dr. Eichenfield recommended terbinafine 4–8 mg/kg per day for 4 weeks. But one study found that griseofulvin was much better than terbinafine for M. canis (J. Am. Acad. Dermatol. 2008;59:41-54).

The same organisms, along with T. rubrum and T. mentagrophytes, can cause tinea corporis. Patients present with red scaling plaque, often with an active border. Central clearing may give the lesions a ring shape. They can be treated with topical drugs, including clotrimazole, econazole, oxiconazole, ciclopirox, terbinafine, and ketoconazole.

Systemic treatment should be reserved for extensive disease or special circumstances, such as for wrestlers. The best systemic treatment is griseofulvin, 15–20 mg/kg (5–10 mg/kg ultramicrosize), he said.

Dr. Eichenfield said he had no relevant financial disclosures.

'So it's worth doing a routine culture' for tinea capitis.

Source DR. EICHENFIELD

LAS VEGAS – Competition among large retailers is bringing down the cost of terbinafine, but griseofulvin is still better for many fungal infections, according to Dr. Lawrence F. Eichenfield.

The ideal prescription depends on the type of fungus and the site of the infection, Dr. Eichenfield, chief of pediatric and adolescent dermatology at the University of California, San Diego, said at the update, sponsored by the American Academy of Pediatrics California Chapter 9.

Topical medications alone can seldom cure tinea capitis because the fungus finds protection inside hair follicles, but he advised using them in combination with systemic drugs.

Signs of tinea capitis include scaling, pustules, kerion, black dots, alopecia, adenopathy, and autoeczematization (also known as id reaction). The condition can resemble seborrheic dermatitis, psoriasis, folliculitis, and other diseases.

“So it's worth doing a routine culture,” said Dr. Eichenfield, adding that it's fairly easy to obtain a specimen with a toothbrush, cotton swab, or bacterial culturette.

The most common culprit is Trichophyton tonsurans, spread by human contact. The second most common cause is Microsporum canis, spread by cats.

Family coinfection can contribute to treatment failure, so inquire about tinea capitis and tinea corporis in other affected family members and pets, said Dr. Eichenfield. Standard therapy for tinea capitis is microsized griseofulvin (20 mg/kg) for 6–8 weeks, he advised.

The only other approved drug is terbinafine granules, and these are hard to obtain, he said, but itraconazole and fluconazole might work.

Particularly if griseofulvin fails, Dr. Eichenfield recommended terbinafine 4–8 mg/kg per day for 4 weeks. But one study found that griseofulvin was much better than terbinafine for M. canis (J. Am. Acad. Dermatol. 2008;59:41-54).

The same organisms, along with T. rubrum and T. mentagrophytes, can cause tinea corporis. Patients present with red scaling plaque, often with an active border. Central clearing may give the lesions a ring shape. They can be treated with topical drugs, including clotrimazole, econazole, oxiconazole, ciclopirox, terbinafine, and ketoconazole.

Systemic treatment should be reserved for extensive disease or special circumstances, such as for wrestlers. The best systemic treatment is griseofulvin, 15–20 mg/kg (5–10 mg/kg ultramicrosize), he said.

Dr. Eichenfield said he had no relevant financial disclosures.

'So it's worth doing a routine culture' for tinea capitis.

Source DR. EICHENFIELD

SAN FRANCISCO – It’s easy to find someone willing to take your money for a brain scan. It’s a lot harder to use these scans in understanding mental illness, according to Dr. Robert L. Hendren.

"We can’t really find the kind of images that can help us make the diagnosis of a mental disorder," said Dr. Hendren, director of child and adolescent psychiatry at the University of California, San Francisco. Genetic, metabolic, and other kinds of screening for biomarkers are only slightly more useful, he said at the annual meeting of the American Academy of Pediatrics. 

It still makes sense to look for biologic causes for mental illness. "Increasingly, we’re finding that disorders like conduct disorder have a neurological, neurodevelopmental etiology," Dr. Hendren said. After all, brains grow and change as they interact with the environment.

And physicians need better tools for diagnosing such illnesses. Signs and symptoms don’t always fit neatly into the categories laid out in the Diagnostic and Statistical Manual of Mental Disorders.

So researchers have tried MRI and other approaches to look for patterns that might reveal mental illness. They have found some correlations.

And some imaging centers have leaped on these findings to market their services to families of children with mental illness. "You probably are aware of people doing that," Dr. Hendren said. "Families will pay $3,000 or $4,000 to have these scans performed and shown to them. And then they get recommendations based on a good history that aren’t much different than if the scans had not been done."

The problem is that researchers have not traced any common diagnosis to a particular site in the brain. Multiple sites may be involved.

Imaging can help only in very specific instances. Among the accepted indications for MRI include microcephaly, macrocephaly, unusual head shapes, regression, or an abnormal neurologic examination.

Some of the same limitations that apply to MRI apply to other types of tests for biomarkers. Researchers have realized that no single gene is responsible for autism, schizophrenia, or most of the other common mental disorders. "We’ve learned that these are very complex disorders with multiple genes involved," Dr. Hendren said.

But when there is reason to believe genes are involved, genetic testing might be in order. For example, he said some experts recommend a comparative genomic hybridization array for various intellectual disabilities, developmental disorders, and autism. Autistic children also might benefit from further genetic tests, including a test for fragile X, since about 3% have this genetic condition.

Other authorities have recommended a chromosomal microarray for patients with developmental delay, intellectual disabilities, autism spectrum disorder, or multiple congenital anomalies. For patients with clear chromosomal rearrangements – or a family history of these rearrangements, or multiple miscarriages, G-banded karyotyping might be in order, Dr. Hendren said.

Metabolic screening also can yield some information about mental disorders, but is really worthwhile only in patients with clear signs of metabolic disorder, such as a history of lethargy, cyclic vomiting, early seizures, dysmorphisms, mental retardation, or regression. And if these tests are a part of newborn screening – as they often are –there’s no need to repeat them, he said.

Some authorities also recommend a complete blood count for mental disorders. Naturally, other tests, such as thyroid function, serum organic and amino acids, serum lactate and pyruvate, lead screening, iron deficiency, methyl CpG binding protein 2, and Wood’s lamp, might prove helpful when specific conditions are expected,. Most other tests are more controversial.

So while waiting for researchers to find a high-tech solution for diagnosing mental illness, what can physicians do to identify mental illness in their patients? "Evaluation should be guided by in-depth history and family history, and a good physical examination," Dr. Hendren said.

He said he has received funding for clinical trials from Forest Laboratories, BioMarin, Curemark, the National Institute of Mental Health, and Autism Speaks.

SAN FRANCISCO – It’s easy to find someone willing to take your money for a brain scan. It’s a lot harder to use these scans in understanding mental illness, according to Dr. Robert L. Hendren.

"We can’t really find the kind of images that can help us make the diagnosis of a mental disorder," said Dr. Hendren, director of child and adolescent psychiatry at the University of California, San Francisco. Genetic, metabolic, and other kinds of screening for biomarkers are only slightly more useful, he said at the annual meeting of the American Academy of Pediatrics. 

It still makes sense to look for biologic causes for mental illness. "Increasingly, we’re finding that disorders like conduct disorder have a neurological, neurodevelopmental etiology," Dr. Hendren said. After all, brains grow and change as they interact with the environment.

And physicians need better tools for diagnosing such illnesses. Signs and symptoms don’t always fit neatly into the categories laid out in the Diagnostic and Statistical Manual of Mental Disorders.

So researchers have tried MRI and other approaches to look for patterns that might reveal mental illness. They have found some correlations.

And some imaging centers have leaped on these findings to market their services to families of children with mental illness. "You probably are aware of people doing that," Dr. Hendren said. "Families will pay $3,000 or $4,000 to have these scans performed and shown to them. And then they get recommendations based on a good history that aren’t much different than if the scans had not been done."

The problem is that researchers have not traced any common diagnosis to a particular site in the brain. Multiple sites may be involved.

Imaging can help only in very specific instances. Among the accepted indications for MRI include microcephaly, macrocephaly, unusual head shapes, regression, or an abnormal neurologic examination.

Some of the same limitations that apply to MRI apply to other types of tests for biomarkers. Researchers have realized that no single gene is responsible for autism, schizophrenia, or most of the other common mental disorders. "We’ve learned that these are very complex disorders with multiple genes involved," Dr. Hendren said.

But when there is reason to believe genes are involved, genetic testing might be in order. For example, he said some experts recommend a comparative genomic hybridization array for various intellectual disabilities, developmental disorders, and autism. Autistic children also might benefit from further genetic tests, including a test for fragile X, since about 3% have this genetic condition.

Other authorities have recommended a chromosomal microarray for patients with developmental delay, intellectual disabilities, autism spectrum disorder, or multiple congenital anomalies. For patients with clear chromosomal rearrangements – or a family history of these rearrangements, or multiple miscarriages, G-banded karyotyping might be in order, Dr. Hendren said.

Metabolic screening also can yield some information about mental disorders, but is really worthwhile only in patients with clear signs of metabolic disorder, such as a history of lethargy, cyclic vomiting, early seizures, dysmorphisms, mental retardation, or regression. And if these tests are a part of newborn screening – as they often are –there’s no need to repeat them, he said.

Some authorities also recommend a complete blood count for mental disorders. Naturally, other tests, such as thyroid function, serum organic and amino acids, serum lactate and pyruvate, lead screening, iron deficiency, methyl CpG binding protein 2, and Wood’s lamp, might prove helpful when specific conditions are expected,. Most other tests are more controversial.

So while waiting for researchers to find a high-tech solution for diagnosing mental illness, what can physicians do to identify mental illness in their patients? "Evaluation should be guided by in-depth history and family history, and a good physical examination," Dr. Hendren said.

He said he has received funding for clinical trials from Forest Laboratories, BioMarin, Curemark, the National Institute of Mental Health, and Autism Speaks.

SAN FRANCISCO – It’s easy to find someone willing to take your money for a brain scan. It’s a lot harder to use these scans in understanding mental illness, according to Dr. Robert L. Hendren.

"We can’t really find the kind of images that can help us make the diagnosis of a mental disorder," said Dr. Hendren, director of child and adolescent psychiatry at the University of California, San Francisco. Genetic, metabolic, and other kinds of screening for biomarkers are only slightly more useful, he said at the annual meeting of the American Academy of Pediatrics. 

It still makes sense to look for biologic causes for mental illness. "Increasingly, we’re finding that disorders like conduct disorder have a neurological, neurodevelopmental etiology," Dr. Hendren said. After all, brains grow and change as they interact with the environment.

And physicians need better tools for diagnosing such illnesses. Signs and symptoms don’t always fit neatly into the categories laid out in the Diagnostic and Statistical Manual of Mental Disorders.

So researchers have tried MRI and other approaches to look for patterns that might reveal mental illness. They have found some correlations.

And some imaging centers have leaped on these findings to market their services to families of children with mental illness. "You probably are aware of people doing that," Dr. Hendren said. "Families will pay $3,000 or $4,000 to have these scans performed and shown to them. And then they get recommendations based on a good history that aren’t much different than if the scans had not been done."

The problem is that researchers have not traced any common diagnosis to a particular site in the brain. Multiple sites may be involved.

Imaging can help only in very specific instances. Among the accepted indications for MRI include microcephaly, macrocephaly, unusual head shapes, regression, or an abnormal neurologic examination.

Some of the same limitations that apply to MRI apply to other types of tests for biomarkers. Researchers have realized that no single gene is responsible for autism, schizophrenia, or most of the other common mental disorders. "We’ve learned that these are very complex disorders with multiple genes involved," Dr. Hendren said.

But when there is reason to believe genes are involved, genetic testing might be in order. For example, he said some experts recommend a comparative genomic hybridization array for various intellectual disabilities, developmental disorders, and autism. Autistic children also might benefit from further genetic tests, including a test for fragile X, since about 3% have this genetic condition.

Other authorities have recommended a chromosomal microarray for patients with developmental delay, intellectual disabilities, autism spectrum disorder, or multiple congenital anomalies. For patients with clear chromosomal rearrangements – or a family history of these rearrangements, or multiple miscarriages, G-banded karyotyping might be in order, Dr. Hendren said.

Metabolic screening also can yield some information about mental disorders, but is really worthwhile only in patients with clear signs of metabolic disorder, such as a history of lethargy, cyclic vomiting, early seizures, dysmorphisms, mental retardation, or regression. And if these tests are a part of newborn screening – as they often are –there’s no need to repeat them, he said.

Some authorities also recommend a complete blood count for mental disorders. Naturally, other tests, such as thyroid function, serum organic and amino acids, serum lactate and pyruvate, lead screening, iron deficiency, methyl CpG binding protein 2, and Wood’s lamp, might prove helpful when specific conditions are expected,. Most other tests are more controversial.

So while waiting for researchers to find a high-tech solution for diagnosing mental illness, what can physicians do to identify mental illness in their patients? "Evaluation should be guided by in-depth history and family history, and a good physical examination," Dr. Hendren said.

He said he has received funding for clinical trials from Forest Laboratories, BioMarin, Curemark, the National Institute of Mental Health, and Autism Speaks.

LAS VEGAS – Four common acute shoulder injuries can occur during sports or as a result of a fall, according to Dr. Gregory L. Landry, who is professor of pediatrics and head team physician at the University of Wisconsin, Madison.

Dr. Landry presented his overview of these acute injuries, along with treatment tips:

▸ Clavicle fractures. A lateral blow to the shoulder is typically the cause of a clavicle fracture, Dr. Landry said.

The injury is characterized by tenderness, often with deformity. The treatment usually includes a plain sling, which is now preferred over the old figure-eight.

Surgeons are getting more involved in comminuted fractures, especially if they are not midshaft. “If there's more than 2 cm overlap, especially if it's the dominant shoulder, you should usually refer,” he said at the meeting.

Athletes with clavicle fractures should not return to collision sports for a minimum of 10-12 weeks, he said.

▸ Acromioclavicular sprains. These injuries most often occur with a fall on an outstretched hand or a direct blow to the joint just above or to the side of the shoulder.

There are multiple degrees of acromioclavicular sprains, ranging from first degree – tenderness over the joint – to sixth degree with severe tenderness, swelling, and deformity, Dr. Landry said.

With the exception of mild cases, he advised ordering x-rays including axillary views.

For grade 1-3 sprains, surgery isn't usually needed unless there is severe swelling, pain, and deformity or the patient desires it for cosmesis, Dr. Landry said. Grade 4-6 injuries need to be referred to an orthopedic surgeon.

For mild to moderate cases, a sling provides comfort, but the patient should begin rehabilitation as soon as possible, he recommended. This includes range of motion exercises, such as Codman exercises, or wall walks in which patients face a wall and gradually walk their hands up the wall.

As for returning to activity, “as long as they have good function and strength, I let them go back,” he said.

▸ Sternoclavicular sprains. Common in football and wrestling, these sprains usually result from a side blow. Patients with anterior sprains experience anterior pain and deformity. Posterior sprains are tender without much deformity. Anterior-posterior x-rays won't usually show these sprains, though you can try a serendipity view. Usually, a computed tomography (CT) scan is needed to image a posterior sternoclavicular sprain.

Posterior sprains can be life threatening if they impair the trachea, so it's important to recognize them on the field during sports. The impairment can be reduced with posterior traction of the shoulder.

Most of these sprains don't require surgery, unless the airway is compromised.

In adolescents, this injury is usually physeal; the proximal clavicle is one of the last to close.

▸ Glenohumeral subluxations and dislocations. These injuries sometimes occur as the result of a football tackle. Patients feel their shoulder go out or their arms go numb.

Subluxation is more common than full dislocation. A dislocation usually results in an obvious deformity; typically, the head of the humerus ends up inferior and anterior to the glenoid.

Although posterior dislocations are rare, posterior subluxations are not. These occur with a slide into base or from a football block using an extended arm. The patient may feel the shoulder slide.

Patients generally feel tenderness posteriorly, and experience pain loading the joint posteriorly (which you can assess with a posterior glide test).

If there is acute anterior dislocation, check for axillary nerve involvement.

At the time of the injury, pain typically limits examination. If the physician is certain of the diagnosis, sometimes he or she can relocate the shoulder immediately after the injury, before more pain and spasms occur. But it is important to make sure the pain is not below the head of the humerus, which could indicate a fracture. Although there are many methods of relocation, the key is traction inferiorly.

If the patient has good range of motion and only mild pain, assess the instability of the joint using the apprehension sign, the posterior glide (jerk test), and the sulcus sign.

Take a minimum of two x-ray views: the acromioclavicular joint, usually anterior and posterior; and an axillary view of the glenoid.

Once the shoulder has been reduced, check the x-rays for the presence of a Bankart lesion (an avulsion of the glenoid) or Hill-Sachs lesion (a dent in the head of the humerus).

For acute anterior dislocation, a sling will provide some comfort. The patient should begin an aggressive rehabilitation program as soon as he or she is able. Surgery is usually necessary only if the rehabilitation fails or if the injury recurs, according to Dr. Landry.

If locking or catching occurs along with the instability, a labral tear might be the cause. Labral tears can usually be diagnosed with an MRI arthrogram, he said.

Dr. Landry said that he had no relevant financial disclosures.

LAS VEGAS – Four common acute shoulder injuries can occur during sports or as a result of a fall, according to Dr. Gregory L. Landry, who is professor of pediatrics and head team physician at the University of Wisconsin, Madison.

Dr. Landry presented his overview of these acute injuries, along with treatment tips:

▸ Clavicle fractures. A lateral blow to the shoulder is typically the cause of a clavicle fracture, Dr. Landry said.

The injury is characterized by tenderness, often with deformity. The treatment usually includes a plain sling, which is now preferred over the old figure-eight.

Surgeons are getting more involved in comminuted fractures, especially if they are not midshaft. “If there's more than 2 cm overlap, especially if it's the dominant shoulder, you should usually refer,” he said at the meeting.

Athletes with clavicle fractures should not return to collision sports for a minimum of 10-12 weeks, he said.

▸ Acromioclavicular sprains. These injuries most often occur with a fall on an outstretched hand or a direct blow to the joint just above or to the side of the shoulder.

There are multiple degrees of acromioclavicular sprains, ranging from first degree – tenderness over the joint – to sixth degree with severe tenderness, swelling, and deformity, Dr. Landry said.

With the exception of mild cases, he advised ordering x-rays including axillary views.

For grade 1-3 sprains, surgery isn't usually needed unless there is severe swelling, pain, and deformity or the patient desires it for cosmesis, Dr. Landry said. Grade 4-6 injuries need to be referred to an orthopedic surgeon.

For mild to moderate cases, a sling provides comfort, but the patient should begin rehabilitation as soon as possible, he recommended. This includes range of motion exercises, such as Codman exercises, or wall walks in which patients face a wall and gradually walk their hands up the wall.

As for returning to activity, “as long as they have good function and strength, I let them go back,” he said.

▸ Sternoclavicular sprains. Common in football and wrestling, these sprains usually result from a side blow. Patients with anterior sprains experience anterior pain and deformity. Posterior sprains are tender without much deformity. Anterior-posterior x-rays won't usually show these sprains, though you can try a serendipity view. Usually, a computed tomography (CT) scan is needed to image a posterior sternoclavicular sprain.

Posterior sprains can be life threatening if they impair the trachea, so it's important to recognize them on the field during sports. The impairment can be reduced with posterior traction of the shoulder.

Most of these sprains don't require surgery, unless the airway is compromised.

In adolescents, this injury is usually physeal; the proximal clavicle is one of the last to close.

▸ Glenohumeral subluxations and dislocations. These injuries sometimes occur as the result of a football tackle. Patients feel their shoulder go out or their arms go numb.

Subluxation is more common than full dislocation. A dislocation usually results in an obvious deformity; typically, the head of the humerus ends up inferior and anterior to the glenoid.

Although posterior dislocations are rare, posterior subluxations are not. These occur with a slide into base or from a football block using an extended arm. The patient may feel the shoulder slide.

Patients generally feel tenderness posteriorly, and experience pain loading the joint posteriorly (which you can assess with a posterior glide test).

If there is acute anterior dislocation, check for axillary nerve involvement.

At the time of the injury, pain typically limits examination. If the physician is certain of the diagnosis, sometimes he or she can relocate the shoulder immediately after the injury, before more pain and spasms occur. But it is important to make sure the pain is not below the head of the humerus, which could indicate a fracture. Although there are many methods of relocation, the key is traction inferiorly.

If the patient has good range of motion and only mild pain, assess the instability of the joint using the apprehension sign, the posterior glide (jerk test), and the sulcus sign.

Take a minimum of two x-ray views: the acromioclavicular joint, usually anterior and posterior; and an axillary view of the glenoid.

Once the shoulder has been reduced, check the x-rays for the presence of a Bankart lesion (an avulsion of the glenoid) or Hill-Sachs lesion (a dent in the head of the humerus).

For acute anterior dislocation, a sling will provide some comfort. The patient should begin an aggressive rehabilitation program as soon as he or she is able. Surgery is usually necessary only if the rehabilitation fails or if the injury recurs, according to Dr. Landry.

If locking or catching occurs along with the instability, a labral tear might be the cause. Labral tears can usually be diagnosed with an MRI arthrogram, he said.

Dr. Landry said that he had no relevant financial disclosures.

LAS VEGAS – Four common acute shoulder injuries can occur during sports or as a result of a fall, according to Dr. Gregory L. Landry, who is professor of pediatrics and head team physician at the University of Wisconsin, Madison.

Dr. Landry presented his overview of these acute injuries, along with treatment tips:

▸ Clavicle fractures. A lateral blow to the shoulder is typically the cause of a clavicle fracture, Dr. Landry said.

The injury is characterized by tenderness, often with deformity. The treatment usually includes a plain sling, which is now preferred over the old figure-eight.

Surgeons are getting more involved in comminuted fractures, especially if they are not midshaft. “If there's more than 2 cm overlap, especially if it's the dominant shoulder, you should usually refer,” he said at the meeting.

Athletes with clavicle fractures should not return to collision sports for a minimum of 10-12 weeks, he said.

▸ Acromioclavicular sprains. These injuries most often occur with a fall on an outstretched hand or a direct blow to the joint just above or to the side of the shoulder.

There are multiple degrees of acromioclavicular sprains, ranging from first degree – tenderness over the joint – to sixth degree with severe tenderness, swelling, and deformity, Dr. Landry said.

With the exception of mild cases, he advised ordering x-rays including axillary views.

For grade 1-3 sprains, surgery isn't usually needed unless there is severe swelling, pain, and deformity or the patient desires it for cosmesis, Dr. Landry said. Grade 4-6 injuries need to be referred to an orthopedic surgeon.

For mild to moderate cases, a sling provides comfort, but the patient should begin rehabilitation as soon as possible, he recommended. This includes range of motion exercises, such as Codman exercises, or wall walks in which patients face a wall and gradually walk their hands up the wall.

As for returning to activity, “as long as they have good function and strength, I let them go back,” he said.

▸ Sternoclavicular sprains. Common in football and wrestling, these sprains usually result from a side blow. Patients with anterior sprains experience anterior pain and deformity. Posterior sprains are tender without much deformity. Anterior-posterior x-rays won't usually show these sprains, though you can try a serendipity view. Usually, a computed tomography (CT) scan is needed to image a posterior sternoclavicular sprain.

Posterior sprains can be life threatening if they impair the trachea, so it's important to recognize them on the field during sports. The impairment can be reduced with posterior traction of the shoulder.

Most of these sprains don't require surgery, unless the airway is compromised.

In adolescents, this injury is usually physeal; the proximal clavicle is one of the last to close.

▸ Glenohumeral subluxations and dislocations. These injuries sometimes occur as the result of a football tackle. Patients feel their shoulder go out or their arms go numb.

Subluxation is more common than full dislocation. A dislocation usually results in an obvious deformity; typically, the head of the humerus ends up inferior and anterior to the glenoid.

Although posterior dislocations are rare, posterior subluxations are not. These occur with a slide into base or from a football block using an extended arm. The patient may feel the shoulder slide.

Patients generally feel tenderness posteriorly, and experience pain loading the joint posteriorly (which you can assess with a posterior glide test).

If there is acute anterior dislocation, check for axillary nerve involvement.

At the time of the injury, pain typically limits examination. If the physician is certain of the diagnosis, sometimes he or she can relocate the shoulder immediately after the injury, before more pain and spasms occur. But it is important to make sure the pain is not below the head of the humerus, which could indicate a fracture. Although there are many methods of relocation, the key is traction inferiorly.

If the patient has good range of motion and only mild pain, assess the instability of the joint using the apprehension sign, the posterior glide (jerk test), and the sulcus sign.

Take a minimum of two x-ray views: the acromioclavicular joint, usually anterior and posterior; and an axillary view of the glenoid.

Once the shoulder has been reduced, check the x-rays for the presence of a Bankart lesion (an avulsion of the glenoid) or Hill-Sachs lesion (a dent in the head of the humerus).

For acute anterior dislocation, a sling will provide some comfort. The patient should begin an aggressive rehabilitation program as soon as he or she is able. Surgery is usually necessary only if the rehabilitation fails or if the injury recurs, according to Dr. Landry.

If locking or catching occurs along with the instability, a labral tear might be the cause. Labral tears can usually be diagnosed with an MRI arthrogram, he said.

Dr. Landry said that he had no relevant financial disclosures.

SAN FRANCISCO – The annual risk of an intracranial aneurysm rupturing may be lower than most previous estimates, according to calculations based on data from a large Norwegian population-based study.

Although earlier studies have placed the annual risk of rupture at 0.5%-5%, Dr. Tomm Brostrup Müller of St. Olav’s Hospital/Trondheim (Norway) University Hospital and his colleagues came up with the figure of 0.83%.

Neurologists have long debated the management of unruptured intracranial aneurysms. "Our patients want to know the risk of rupture, and they want to know the risk of treatment," he said at the meeting. "We now have quite good data on the risk of treatment. The controversy is mainly related to the risk of rupture."

Researchers have found two methods for estimating the risk of rupture. One is to look at the natural history of ruptured aneurysms in which a group of patients is followed over time. This provides some information about the size and location of the aneurysms most likely to rupture, but the data in all these studies are confounded by selection bias, Dr. Müller said.

The second method is to study a large population, dividing the incidence of ruptures by the prevalence of aneurysms. "We have good data on aneurysmal subarachnoid hemorrhage from all over the world," Dr. Müller said. "However, the incidence of unruptured intracranial aneurysms is another story." This may explain why previous studies have resulted in a wide range of estimates of risk.

The Norwegian researchers hoped to come up with a more accurate estimate of risk by studying more people for a longer period of time. So they used data from the Nord-Trøndelag Health Study (HUNT), one of the largest population-based studies ever conducted.

All inhabitants of the county of Nord-Trøndelag in central Norway older than 20 years were invited to participate. A total of 95,097 people were followed during 1984-1986 or during 1995-1997. The investigators recorded the number of aneurysmal subarachnoid hemorrhages that occurred in these first two waves of the study.

"To our knowledge, this is the first time that the incidence of unruptured intracranial aneurysms and the prevalence of subarachnoid hemorrhage has been established for one large population cohort," he said.

The researchers then randomly selected 1,000 participants aged 50-65 years from the third wave of the study (which took place during 2006-2008) and scanned them with magnetic resonance angiography. They found that 19 participants had aneurysms: 17 had one aneurysm each, 1 had two aneurysms and 1 had three aneurysms. The prevalence was therefore 1.9%.

They verified all but two of these aneurysms either intraoperatively or by CT scan or digital subtraction angiography.

The aneurysms measured 2-6 mm in diameter in 13 cases and 7-9 mm in 9 cases.

Clinicians handled these aneurysms according to their practice. They treated two of the patients endovascularly and five surgically. In the patient with three aneurysms, they clipped two and coiled the other. They took a conservative approach with the remaining 11 patients, following up by MRI and CT.

From this survey, the investigators calculated the incidence of aneurysmal subarachnoid hemorrhage in participants aged 50-65 years as 15.7/100,000 person-years. Dividing the incidence by the prevalence (0.000157/0.019) yielded an annual rupture risk of 0.83%.

In the total HUNT population, the incidence of aneurysmal subarachnoid hemorrhage was 10.2/100,000 person years. If the annual rupture risk is the same in this population, that would mean its overall prevalence of unruptured intracranial aneurysms was 1.2%.

Dr. Müller said the study had limitations. People aged 50-65 years may not represent the whole population, though this age group is particularly relevant for the study of aneurysm ruptures. Also, the population-based approach does not allow for analysis of the size and location of aneurysms that rupture.

The investigators reported no relevant disclosures.

SAN FRANCISCO – The annual risk of an intracranial aneurysm rupturing may be lower than most previous estimates, according to calculations based on data from a large Norwegian population-based study.

Although earlier studies have placed the annual risk of rupture at 0.5%-5%, Dr. Tomm Brostrup Müller of St. Olav’s Hospital/Trondheim (Norway) University Hospital and his colleagues came up with the figure of 0.83%.

Neurologists have long debated the management of unruptured intracranial aneurysms. "Our patients want to know the risk of rupture, and they want to know the risk of treatment," he said at the meeting. "We now have quite good data on the risk of treatment. The controversy is mainly related to the risk of rupture."

Researchers have found two methods for estimating the risk of rupture. One is to look at the natural history of ruptured aneurysms in which a group of patients is followed over time. This provides some information about the size and location of the aneurysms most likely to rupture, but the data in all these studies are confounded by selection bias, Dr. Müller said.

The second method is to study a large population, dividing the incidence of ruptures by the prevalence of aneurysms. "We have good data on aneurysmal subarachnoid hemorrhage from all over the world," Dr. Müller said. "However, the incidence of unruptured intracranial aneurysms is another story." This may explain why previous studies have resulted in a wide range of estimates of risk.

The Norwegian researchers hoped to come up with a more accurate estimate of risk by studying more people for a longer period of time. So they used data from the Nord-Trøndelag Health Study (HUNT), one of the largest population-based studies ever conducted.

All inhabitants of the county of Nord-Trøndelag in central Norway older than 20 years were invited to participate. A total of 95,097 people were followed during 1984-1986 or during 1995-1997. The investigators recorded the number of aneurysmal subarachnoid hemorrhages that occurred in these first two waves of the study.

"To our knowledge, this is the first time that the incidence of unruptured intracranial aneurysms and the prevalence of subarachnoid hemorrhage has been established for one large population cohort," he said.

The researchers then randomly selected 1,000 participants aged 50-65 years from the third wave of the study (which took place during 2006-2008) and scanned them with magnetic resonance angiography. They found that 19 participants had aneurysms: 17 had one aneurysm each, 1 had two aneurysms and 1 had three aneurysms. The prevalence was therefore 1.9%.

They verified all but two of these aneurysms either intraoperatively or by CT scan or digital subtraction angiography.

The aneurysms measured 2-6 mm in diameter in 13 cases and 7-9 mm in 9 cases.

Clinicians handled these aneurysms according to their practice. They treated two of the patients endovascularly and five surgically. In the patient with three aneurysms, they clipped two and coiled the other. They took a conservative approach with the remaining 11 patients, following up by MRI and CT.

From this survey, the investigators calculated the incidence of aneurysmal subarachnoid hemorrhage in participants aged 50-65 years as 15.7/100,000 person-years. Dividing the incidence by the prevalence (0.000157/0.019) yielded an annual rupture risk of 0.83%.

In the total HUNT population, the incidence of aneurysmal subarachnoid hemorrhage was 10.2/100,000 person years. If the annual rupture risk is the same in this population, that would mean its overall prevalence of unruptured intracranial aneurysms was 1.2%.

Dr. Müller said the study had limitations. People aged 50-65 years may not represent the whole population, though this age group is particularly relevant for the study of aneurysm ruptures. Also, the population-based approach does not allow for analysis of the size and location of aneurysms that rupture.

The investigators reported no relevant disclosures.

SAN FRANCISCO – The annual risk of an intracranial aneurysm rupturing may be lower than most previous estimates, according to calculations based on data from a large Norwegian population-based study.

Although earlier studies have placed the annual risk of rupture at 0.5%-5%, Dr. Tomm Brostrup Müller of St. Olav’s Hospital/Trondheim (Norway) University Hospital and his colleagues came up with the figure of 0.83%.

Neurologists have long debated the management of unruptured intracranial aneurysms. "Our patients want to know the risk of rupture, and they want to know the risk of treatment," he said at the meeting. "We now have quite good data on the risk of treatment. The controversy is mainly related to the risk of rupture."

Researchers have found two methods for estimating the risk of rupture. One is to look at the natural history of ruptured aneurysms in which a group of patients is followed over time. This provides some information about the size and location of the aneurysms most likely to rupture, but the data in all these studies are confounded by selection bias, Dr. Müller said.

The second method is to study a large population, dividing the incidence of ruptures by the prevalence of aneurysms. "We have good data on aneurysmal subarachnoid hemorrhage from all over the world," Dr. Müller said. "However, the incidence of unruptured intracranial aneurysms is another story." This may explain why previous studies have resulted in a wide range of estimates of risk.

The Norwegian researchers hoped to come up with a more accurate estimate of risk by studying more people for a longer period of time. So they used data from the Nord-Trøndelag Health Study (HUNT), one of the largest population-based studies ever conducted.

All inhabitants of the county of Nord-Trøndelag in central Norway older than 20 years were invited to participate. A total of 95,097 people were followed during 1984-1986 or during 1995-1997. The investigators recorded the number of aneurysmal subarachnoid hemorrhages that occurred in these first two waves of the study.

"To our knowledge, this is the first time that the incidence of unruptured intracranial aneurysms and the prevalence of subarachnoid hemorrhage has been established for one large population cohort," he said.

The researchers then randomly selected 1,000 participants aged 50-65 years from the third wave of the study (which took place during 2006-2008) and scanned them with magnetic resonance angiography. They found that 19 participants had aneurysms: 17 had one aneurysm each, 1 had two aneurysms and 1 had three aneurysms. The prevalence was therefore 1.9%.

They verified all but two of these aneurysms either intraoperatively or by CT scan or digital subtraction angiography.

The aneurysms measured 2-6 mm in diameter in 13 cases and 7-9 mm in 9 cases.

Clinicians handled these aneurysms according to their practice. They treated two of the patients endovascularly and five surgically. In the patient with three aneurysms, they clipped two and coiled the other. They took a conservative approach with the remaining 11 patients, following up by MRI and CT.

From this survey, the investigators calculated the incidence of aneurysmal subarachnoid hemorrhage in participants aged 50-65 years as 15.7/100,000 person-years. Dividing the incidence by the prevalence (0.000157/0.019) yielded an annual rupture risk of 0.83%.

In the total HUNT population, the incidence of aneurysmal subarachnoid hemorrhage was 10.2/100,000 person years. If the annual rupture risk is the same in this population, that would mean its overall prevalence of unruptured intracranial aneurysms was 1.2%.

Dr. Müller said the study had limitations. People aged 50-65 years may not represent the whole population, though this age group is particularly relevant for the study of aneurysm ruptures. Also, the population-based approach does not allow for analysis of the size and location of aneurysms that rupture.

The investigators reported no relevant disclosures.

LAS VEGAS – New testing protocols are helping clinicians with the challenging diagnosis of celiac disease, according to Dr. Ivor D. Hill, a professor of pediatrics at Wake Forest University, Winston-Salem, N.C.

While the only treatment for celiac disease is a gluten-free diet, Dr. Hill said, the diet is expensive and imposes social costs, so it should not be prescribed lightly. "Confirm before you treat," he said.

Researchers believe the disease affects about 1% of the population. "You can expect to see 5-20 affected children in an average pediatric practice," Dr. Hill said at a pediatric update sponsored by the American Academy of Pediatrics California District 9.

Among the symptoms in young children are failure to grow, diarrhea, bloating, flatulence, abdominal distension, and transaminitis.

In older children, the symptoms are often milder and can vary tremendously. In addition to having gastrointestinal symptoms, some patients have dermatitis herpetiformis characterized by papules on the elbows, buttocks, or knees. About 10% are short of stature. Iron-deficient anemia, rickets, arthritis, neuropathy, ataxia, and other neurological symptoms all can be manifestations of celiac disease. Many children are irritable. Poor dental enamel formation that looks similar to fluorosis or tetracycline staining also can be signs of celiac disease.

Some people with the syndrome are totally asymptomatic.

Autoimmune diseases, including type 1 diabetes, thyroiditis, autoimmune hepatitis, Sjögren's syndrome, and arthritis are associated with an increased risk of celiac disease. So is IgA deficiency; a family history of celiac disease; and Down, Turner, and Williams syndromes. Whether to screen these or any other individuals for celiac disease if they are not symptomatic, is controversial.

"When it comes to symptomatic patients, there is a consensus," said Dr. Hill. "There’s a difference of opinion on testing asymptomatic patients."

In patients with typical gastrointestinal symptoms, begin with the serologic tests. While tests for the antigliadin antibody (AGA) IgG and IgA are inexpensive and easy to perform, they have low sensitivity and specificity. By contrast, the test for the IgA endomysial antibody (EMA) has high sensitivity and specificity, but is expensive, time consuming, operator dependent, and of no use in IgA-deficient patients.

Testing for IgA anti-tissue transglutaminase (TTG), on the other hand, is easier and less expensive than testing for EMA, and newer versions are now considered as sensitive and specific as EMA. But it is also of no use in the case of IgA deficiency.

A new version of the antigliadin test, using deamidated gliadin antibodies, has shown much higher sensitivity and specificity than the AGA test in recent studies (Dig. Dis. Sci. 2008;53:1582-8), but this test is still not as good as the TTG or the EMA tests, said Dr. Hill.

So he advocated a combination of TTG and serum IgA level, although EMA may work better in diabetics. There is no benefit to a panel of tests, he said.

However, he warned that all these tests are less accurate in the real world than in the laboratory. And sensitivity declines in children less than 2 years of age, so combining TTG with the newer deamidated gliadin tests might be warranted in this young age group.

If these tests are positive, proceed to biopsies, Dr. Hill recommended. Clinicians should also consider biopsies if the tests are negative but they strongly suspect celiac disease.

Another key element in diagnosing celiac disease is that patients with the syndrome will improve on a gluten-free diet. And this diet is the standard treatment. But some other possibilities have appeared on the horizon. "It’s exciting," said Dr. Hill.

Intraluminal approaches include modification of wheat protein or transamidation of wheat flour. "It’s looking promising but hasn’t been confirmed yet," said Dr. Hill.

Several digestive enzymes have been developed with the intention of digesting the proteins before they can be taken up by the intestinal mucosa. Peptide-binding agents also are being tested to prevent the proteins from reaching the mucosa.

Biological antagonists include a zonulin inhibitor, TTG inhibitors, cytokine inhibitors, and DQ2 and DQ8 inhibitors. A vaccine is in the works as well. In addition, the timing of the introduction of gluten might be manipulated to build up tolerance.

These approaches are not yet ready for prime time, leaving diet as the primary treatment. But many patients find it hard to stick to the diet. Dr. Hill advocated a self-administered questionnaire, or better yet, assessment by a trained interviewer, as well as continued monitoring through TTG testing at 3 months, 6 months, 12 months, and then annually, combined with a dietary review, to see how well the patient is adhering to the diet. Repeat biopsies should be done only in select cases.

Dr. Hill disclosed that he is a consultant to AstraZeneca.

LAS VEGAS – New testing protocols are helping clinicians with the challenging diagnosis of celiac disease, according to Dr. Ivor D. Hill, a professor of pediatrics at Wake Forest University, Winston-Salem, N.C.

While the only treatment for celiac disease is a gluten-free diet, Dr. Hill said, the diet is expensive and imposes social costs, so it should not be prescribed lightly. "Confirm before you treat," he said.

Researchers believe the disease affects about 1% of the population. "You can expect to see 5-20 affected children in an average pediatric practice," Dr. Hill said at a pediatric update sponsored by the American Academy of Pediatrics California District 9.

Among the symptoms in young children are failure to grow, diarrhea, bloating, flatulence, abdominal distension, and transaminitis.

In older children, the symptoms are often milder and can vary tremendously. In addition to having gastrointestinal symptoms, some patients have dermatitis herpetiformis characterized by papules on the elbows, buttocks, or knees. About 10% are short of stature. Iron-deficient anemia, rickets, arthritis, neuropathy, ataxia, and other neurological symptoms all can be manifestations of celiac disease. Many children are irritable. Poor dental enamel formation that looks similar to fluorosis or tetracycline staining also can be signs of celiac disease.

Some people with the syndrome are totally asymptomatic.

Autoimmune diseases, including type 1 diabetes, thyroiditis, autoimmune hepatitis, Sjögren's syndrome, and arthritis are associated with an increased risk of celiac disease. So is IgA deficiency; a family history of celiac disease; and Down, Turner, and Williams syndromes. Whether to screen these or any other individuals for celiac disease if they are not symptomatic, is controversial.

"When it comes to symptomatic patients, there is a consensus," said Dr. Hill. "There’s a difference of opinion on testing asymptomatic patients."

In patients with typical gastrointestinal symptoms, begin with the serologic tests. While tests for the antigliadin antibody (AGA) IgG and IgA are inexpensive and easy to perform, they have low sensitivity and specificity. By contrast, the test for the IgA endomysial antibody (EMA) has high sensitivity and specificity, but is expensive, time consuming, operator dependent, and of no use in IgA-deficient patients.

Testing for IgA anti-tissue transglutaminase (TTG), on the other hand, is easier and less expensive than testing for EMA, and newer versions are now considered as sensitive and specific as EMA. But it is also of no use in the case of IgA deficiency.

A new version of the antigliadin test, using deamidated gliadin antibodies, has shown much higher sensitivity and specificity than the AGA test in recent studies (Dig. Dis. Sci. 2008;53:1582-8), but this test is still not as good as the TTG or the EMA tests, said Dr. Hill.

So he advocated a combination of TTG and serum IgA level, although EMA may work better in diabetics. There is no benefit to a panel of tests, he said.

However, he warned that all these tests are less accurate in the real world than in the laboratory. And sensitivity declines in children less than 2 years of age, so combining TTG with the newer deamidated gliadin tests might be warranted in this young age group.

If these tests are positive, proceed to biopsies, Dr. Hill recommended. Clinicians should also consider biopsies if the tests are negative but they strongly suspect celiac disease.

Another key element in diagnosing celiac disease is that patients with the syndrome will improve on a gluten-free diet. And this diet is the standard treatment. But some other possibilities have appeared on the horizon. "It’s exciting," said Dr. Hill.

Intraluminal approaches include modification of wheat protein or transamidation of wheat flour. "It’s looking promising but hasn’t been confirmed yet," said Dr. Hill.

Several digestive enzymes have been developed with the intention of digesting the proteins before they can be taken up by the intestinal mucosa. Peptide-binding agents also are being tested to prevent the proteins from reaching the mucosa.

Biological antagonists include a zonulin inhibitor, TTG inhibitors, cytokine inhibitors, and DQ2 and DQ8 inhibitors. A vaccine is in the works as well. In addition, the timing of the introduction of gluten might be manipulated to build up tolerance.

These approaches are not yet ready for prime time, leaving diet as the primary treatment. But many patients find it hard to stick to the diet. Dr. Hill advocated a self-administered questionnaire, or better yet, assessment by a trained interviewer, as well as continued monitoring through TTG testing at 3 months, 6 months, 12 months, and then annually, combined with a dietary review, to see how well the patient is adhering to the diet. Repeat biopsies should be done only in select cases.

Dr. Hill disclosed that he is a consultant to AstraZeneca.

LAS VEGAS – New testing protocols are helping clinicians with the challenging diagnosis of celiac disease, according to Dr. Ivor D. Hill, a professor of pediatrics at Wake Forest University, Winston-Salem, N.C.

While the only treatment for celiac disease is a gluten-free diet, Dr. Hill said, the diet is expensive and imposes social costs, so it should not be prescribed lightly. "Confirm before you treat," he said.

Researchers believe the disease affects about 1% of the population. "You can expect to see 5-20 affected children in an average pediatric practice," Dr. Hill said at a pediatric update sponsored by the American Academy of Pediatrics California District 9.

Among the symptoms in young children are failure to grow, diarrhea, bloating, flatulence, abdominal distension, and transaminitis.

In older children, the symptoms are often milder and can vary tremendously. In addition to having gastrointestinal symptoms, some patients have dermatitis herpetiformis characterized by papules on the elbows, buttocks, or knees. About 10% are short of stature. Iron-deficient anemia, rickets, arthritis, neuropathy, ataxia, and other neurological symptoms all can be manifestations of celiac disease. Many children are irritable. Poor dental enamel formation that looks similar to fluorosis or tetracycline staining also can be signs of celiac disease.

Some people with the syndrome are totally asymptomatic.

Autoimmune diseases, including type 1 diabetes, thyroiditis, autoimmune hepatitis, Sjögren's syndrome, and arthritis are associated with an increased risk of celiac disease. So is IgA deficiency; a family history of celiac disease; and Down, Turner, and Williams syndromes. Whether to screen these or any other individuals for celiac disease if they are not symptomatic, is controversial.

"When it comes to symptomatic patients, there is a consensus," said Dr. Hill. "There’s a difference of opinion on testing asymptomatic patients."

In patients with typical gastrointestinal symptoms, begin with the serologic tests. While tests for the antigliadin antibody (AGA) IgG and IgA are inexpensive and easy to perform, they have low sensitivity and specificity. By contrast, the test for the IgA endomysial antibody (EMA) has high sensitivity and specificity, but is expensive, time consuming, operator dependent, and of no use in IgA-deficient patients.

Testing for IgA anti-tissue transglutaminase (TTG), on the other hand, is easier and less expensive than testing for EMA, and newer versions are now considered as sensitive and specific as EMA. But it is also of no use in the case of IgA deficiency.

A new version of the antigliadin test, using deamidated gliadin antibodies, has shown much higher sensitivity and specificity than the AGA test in recent studies (Dig. Dis. Sci. 2008;53:1582-8), but this test is still not as good as the TTG or the EMA tests, said Dr. Hill.

So he advocated a combination of TTG and serum IgA level, although EMA may work better in diabetics. There is no benefit to a panel of tests, he said.

However, he warned that all these tests are less accurate in the real world than in the laboratory. And sensitivity declines in children less than 2 years of age, so combining TTG with the newer deamidated gliadin tests might be warranted in this young age group.

If these tests are positive, proceed to biopsies, Dr. Hill recommended. Clinicians should also consider biopsies if the tests are negative but they strongly suspect celiac disease.

Another key element in diagnosing celiac disease is that patients with the syndrome will improve on a gluten-free diet. And this diet is the standard treatment. But some other possibilities have appeared on the horizon. "It’s exciting," said Dr. Hill.

Intraluminal approaches include modification of wheat protein or transamidation of wheat flour. "It’s looking promising but hasn’t been confirmed yet," said Dr. Hill.

Several digestive enzymes have been developed with the intention of digesting the proteins before they can be taken up by the intestinal mucosa. Peptide-binding agents also are being tested to prevent the proteins from reaching the mucosa.

Biological antagonists include a zonulin inhibitor, TTG inhibitors, cytokine inhibitors, and DQ2 and DQ8 inhibitors. A vaccine is in the works as well. In addition, the timing of the introduction of gluten might be manipulated to build up tolerance.

These approaches are not yet ready for prime time, leaving diet as the primary treatment. But many patients find it hard to stick to the diet. Dr. Hill advocated a self-administered questionnaire, or better yet, assessment by a trained interviewer, as well as continued monitoring through TTG testing at 3 months, 6 months, 12 months, and then annually, combined with a dietary review, to see how well the patient is adhering to the diet. Repeat biopsies should be done only in select cases.

Dr. Hill disclosed that he is a consultant to AstraZeneca.

LAS VEGAS – New combination drugs have given clinicians powerful weapons against acne, according to Dr. Lawrence F. Eichenfield, assistant chief of pediatric and adolescent dermatology at the University of California, San Diego.

"I can wipe out virtually anyone’s acne," Dr. Eichenfield said at a pediatric update sponsored by the American Academy of Pediatrics California District 9. "We are capable of doing it with the broad range of medications we have."

The condition varies widely in the number of lesions, the amount of scarring, and the patient’s perception. "There are some teenagers who might have one pimple, but to them it’s like a volcano," he said.

Retinoids are now considered the base therapy for any significant acne because they target microcomedos, the precursors to acne lesions. Topical retinoids are usually enough for comedonal acne. Benzoyl peroxide can be used as an alternative. For more moderate cases, a topical antibiotic may be needed.

The bacterium implicated in acne, Propionibacterium acnes, can develop resistance to topical antibiotics. But combining antibiotics with benzoyl peroxide minimizes this resistance. So some of the new gels combine benzoyl peroxide with clindamycin. There are also tretinoin-clindamycin and adapalene–benzoyl peroxide combinations.

"These are excellent products," said Dr. Eichenfield. "Probably the only negative is the cost." Some can run as much as $160 a tube, he noted. He encourages patients to look for coupons on the Internet.

If these treatments fail or if the acne is very severe, an oral antibiotic may be needed. Oral antibiotics should be used only in combination with topical retinoids. Finally, if these fail, Dr. Eichenfield said, you can prescribe isotretinoin.

Once the acne is under control, the medication can be scaled back and should be predominantly topical. In older adolescent females, hormonal therapy may be an alternative. "We try to minimize the use of systemic antibiotics," said Dr. Eichenfield. "Get control over 2-3 months, and then try to back down."

No medication is approved for acne in patients under age 12 years, he said. But acne vulgaris is reported in more than three-quarters of children in this age range, so it’s not unreasonable to think about treating them with a topical retinoid.

Dr. Eichenfield and his colleagues investigated this possibility in an open-label study of 40 patients 8-12 years of age with mild-to-moderate acne (Pediatrics 2010;125:e1316-23). After 12 weeks of treatment with 0.04% tretinoin microsphere gel supplied in a pump, 75% of cases were graded as almost clear or mild.

The total lesion count decreased 49.8%, and there were significant improvements in both the Evaluator’s Global Severity Score and the Alternative Evaluator’s Global Severity Score.

Patients experienced only mild adverse reactions, mostly mild skin irritation in the first 3 weeks of therapy. Only one patient discontinued use of the medication.

Such data have made Dr. Eichenfield an advocate of taking acne seriously. "It’s much easier to prevent scarring than to get rid of it later," he concluded.

Dr. Eichenfield disclosed that he has served as an investigator without personal compensation, a consultant, or an adviser for the following companies: Astellas Pharma, Coria Laboratories, Galderma, Ortho Dermatologics, GlaxoSmithKline (Stiefel), Sanofi-Aventis, and Johnson & Johnson.

LAS VEGAS – New combination drugs have given clinicians powerful weapons against acne, according to Dr. Lawrence F. Eichenfield, assistant chief of pediatric and adolescent dermatology at the University of California, San Diego.

"I can wipe out virtually anyone’s acne," Dr. Eichenfield said at a pediatric update sponsored by the American Academy of Pediatrics California District 9. "We are capable of doing it with the broad range of medications we have."

The condition varies widely in the number of lesions, the amount of scarring, and the patient’s perception. "There are some teenagers who might have one pimple, but to them it’s like a volcano," he said.

Retinoids are now considered the base therapy for any significant acne because they target microcomedos, the precursors to acne lesions. Topical retinoids are usually enough for comedonal acne. Benzoyl peroxide can be used as an alternative. For more moderate cases, a topical antibiotic may be needed.

The bacterium implicated in acne, Propionibacterium acnes, can develop resistance to topical antibiotics. But combining antibiotics with benzoyl peroxide minimizes this resistance. So some of the new gels combine benzoyl peroxide with clindamycin. There are also tretinoin-clindamycin and adapalene–benzoyl peroxide combinations.

"These are excellent products," said Dr. Eichenfield. "Probably the only negative is the cost." Some can run as much as $160 a tube, he noted. He encourages patients to look for coupons on the Internet.

If these treatments fail or if the acne is very severe, an oral antibiotic may be needed. Oral antibiotics should be used only in combination with topical retinoids. Finally, if these fail, Dr. Eichenfield said, you can prescribe isotretinoin.

Once the acne is under control, the medication can be scaled back and should be predominantly topical. In older adolescent females, hormonal therapy may be an alternative. "We try to minimize the use of systemic antibiotics," said Dr. Eichenfield. "Get control over 2-3 months, and then try to back down."

No medication is approved for acne in patients under age 12 years, he said. But acne vulgaris is reported in more than three-quarters of children in this age range, so it’s not unreasonable to think about treating them with a topical retinoid.

Dr. Eichenfield and his colleagues investigated this possibility in an open-label study of 40 patients 8-12 years of age with mild-to-moderate acne (Pediatrics 2010;125:e1316-23). After 12 weeks of treatment with 0.04% tretinoin microsphere gel supplied in a pump, 75% of cases were graded as almost clear or mild.

The total lesion count decreased 49.8%, and there were significant improvements in both the Evaluator’s Global Severity Score and the Alternative Evaluator’s Global Severity Score.

Patients experienced only mild adverse reactions, mostly mild skin irritation in the first 3 weeks of therapy. Only one patient discontinued use of the medication.

Such data have made Dr. Eichenfield an advocate of taking acne seriously. "It’s much easier to prevent scarring than to get rid of it later," he concluded.

Dr. Eichenfield disclosed that he has served as an investigator without personal compensation, a consultant, or an adviser for the following companies: Astellas Pharma, Coria Laboratories, Galderma, Ortho Dermatologics, GlaxoSmithKline (Stiefel), Sanofi-Aventis, and Johnson & Johnson.

LAS VEGAS – New combination drugs have given clinicians powerful weapons against acne, according to Dr. Lawrence F. Eichenfield, assistant chief of pediatric and adolescent dermatology at the University of California, San Diego.

"I can wipe out virtually anyone’s acne," Dr. Eichenfield said at a pediatric update sponsored by the American Academy of Pediatrics California District 9. "We are capable of doing it with the broad range of medications we have."

The condition varies widely in the number of lesions, the amount of scarring, and the patient’s perception. "There are some teenagers who might have one pimple, but to them it’s like a volcano," he said.

Retinoids are now considered the base therapy for any significant acne because they target microcomedos, the precursors to acne lesions. Topical retinoids are usually enough for comedonal acne. Benzoyl peroxide can be used as an alternative. For more moderate cases, a topical antibiotic may be needed.

The bacterium implicated in acne, Propionibacterium acnes, can develop resistance to topical antibiotics. But combining antibiotics with benzoyl peroxide minimizes this resistance. So some of the new gels combine benzoyl peroxide with clindamycin. There are also tretinoin-clindamycin and adapalene–benzoyl peroxide combinations.

"These are excellent products," said Dr. Eichenfield. "Probably the only negative is the cost." Some can run as much as $160 a tube, he noted. He encourages patients to look for coupons on the Internet.

If these treatments fail or if the acne is very severe, an oral antibiotic may be needed. Oral antibiotics should be used only in combination with topical retinoids. Finally, if these fail, Dr. Eichenfield said, you can prescribe isotretinoin.

Once the acne is under control, the medication can be scaled back and should be predominantly topical. In older adolescent females, hormonal therapy may be an alternative. "We try to minimize the use of systemic antibiotics," said Dr. Eichenfield. "Get control over 2-3 months, and then try to back down."

No medication is approved for acne in patients under age 12 years, he said. But acne vulgaris is reported in more than three-quarters of children in this age range, so it’s not unreasonable to think about treating them with a topical retinoid.

Dr. Eichenfield and his colleagues investigated this possibility in an open-label study of 40 patients 8-12 years of age with mild-to-moderate acne (Pediatrics 2010;125:e1316-23). After 12 weeks of treatment with 0.04% tretinoin microsphere gel supplied in a pump, 75% of cases were graded as almost clear or mild.

The total lesion count decreased 49.8%, and there were significant improvements in both the Evaluator’s Global Severity Score and the Alternative Evaluator’s Global Severity Score.

Patients experienced only mild adverse reactions, mostly mild skin irritation in the first 3 weeks of therapy. Only one patient discontinued use of the medication.

Such data have made Dr. Eichenfield an advocate of taking acne seriously. "It’s much easier to prevent scarring than to get rid of it later," he concluded.

Dr. Eichenfield disclosed that he has served as an investigator without personal compensation, a consultant, or an adviser for the following companies: Astellas Pharma, Coria Laboratories, Galderma, Ortho Dermatologics, GlaxoSmithKline (Stiefel), Sanofi-Aventis, and Johnson & Johnson.