Bariatric surgery can offer a variety of benefits to mothers and improve neonatal outcomes but also offers substantial risk, according to a systematic literature review.

“Bariatric surgery, with patients matched for presurgery body mass index [BMI], resulted in a reduction in gestational diabetes mellitus, large-for-gestational-age infants, large babies (composite of large for gestational age and macrosomia), gestational hypertension, all hypertensive disorders, postpartum hemorrhage, and cesarean delivery rates,” wrote Wilson Kwong, MD, of the University of Toronto, and his colleagues. “However, there was an increase in small-for-gestational age infants, intrauterine growth restriction, small babies (composite of small for gestational age and intrauterine growth restriction), and preterm deliveries.”

Dr. Kwong and his research team developed this study to investigate the benefits and risks of bariatric surgery on neonatal outcomes. They designed a systematic review that involved a literature search of 2,616 abstracts using MEDLINE, Embase, Cochrane, Web of Science, and PubMed. They searched all from initiation of the databases to Dec. 12, 2016. Ultimately, this yielded 20 cohort studies and approximately 2.8 million subjects for review and meta-analysis. From this data, pooled odds ratios were estimated, as well as the number needed to benefit (NNTB) and the number need to harm (NNTH) to display the pooled absolute risk difference.

The results of the primary analysis, in which BMIs were similar between control subjects and the presurgery BMIs of women receiving treatment, yielded positives for mothers who underwent bariatric surgery and their newborns. As stated by Dr. Kwong and his research team, newborns were less likely to be large-for-gestational-age babies or deal with macrosomia (odds ratio, 0.36; 95% confidence interval, 0.20-0.66; NNTB, 7) and mothers were less likely to experience hypertensive disorders (OR, 0.38; 95% CI, 0.27-0.53, NNTB, 8) and postpartum hemorrhage (OR, 0.32; 95% CI, 0.08-1.37; NNTB, 9).

Despite the positives, the risk for harm was higher in a number of outcomes. Babies were more likely to be small for gestational age, have intrauterine growth restriction (OR, 2.16; 95% CI, 1.34-3.48; NNTH, 21) ,and be delivered preterm (OR, 1.35; 95% CI, 1.02-1.79; NNTH, 35).

A secondary analysis revealed that malabsorptive surgeries resulted in a significantly greater decrease (P = .012) in large babies (OR, 0.28; 95% CI, 0.22-0.36), compared with restrictive surgeries (OR, 0.50; 95% CI, 0.35-0.73). This analysis also revealed that malabsorptive bariatric surgeries corresponded to an increase in the number of small babies (OR, 2.39; 95% CI, 1.94-2.94; P = .023).

The increased risk of smaller babies may be caused by micronutrient deficiencies in pregnancy, according to Dr. Kwong. Nutritional deficiencies are reported in up to 80% of bariatric surgery patients, malabsorptive patients in particular.

“Common nutrient deficiencies after bariatric surgery include protein, B vitamins, fat-soluble vitamins, essential fatty acids, and minerals (zinc and copper), which may persist throughout pregnancy,” wrote Dr. Kwong and his colleagues.

Similar nutrient deficiencies have been identified in a case study of a woman who underwent a duodenal switch published in the Journal of Obstetrics & Gynaecology Canada. After several failed pregnancies from complications from malnutrition, the patient presented herself to physicians 10 weeks into her next pregnancy and was found to be deficient in vitamins A, D, E, and K, and minerals iron and zinc. After supplementation with a daily nutritional drink containing vitamins and protein, her vitamin levels were near normal at week 24. She eventually delivered a healthy newborn with normal-appearing features. The researchers from this study recommended that patients seeking bariatric surgery should avoid malabsorptive surgeries and defer to less extreme surgical methods.

A strength of the systematic review was the matching of studies based on presurgery and prepregnancy BMI. This was a departure from previous studies that combined all studies. Additionally, this study compared the outcomes based on the type of data source that was used. Despite these strengths, the design and results of the studies in the analysis limited the results of the review. None of the included studies were randomized; instead, they consisted of observational cohort studies, which are prone for confounding by indication.

“In counseling patients of childbearing potential who are interested in pursuing bariatric surgery, a discussion of both possible benefits and risks on pregnancy outcomes must take place,” cautioned Dr. Kwong and his associates. “Future studies should explore the causes of these potential adverse pregnancy outcomes and develop strategies that may prevent them.”

All authors affiliated with the study had no relevant financial conflicts of interest to report.

ilacy@frontlinemedcom.com

SOURCE: Kwong W et al. Am J Obstet Gynecol. 2018 Feb 15. doi: 10.1016/j.ajog.2018.02.003.
 

Bariatric surgery can offer a variety of benefits to mothers and improve neonatal outcomes but also offers substantial risk, according to a systematic literature review.

“Bariatric surgery, with patients matched for presurgery body mass index [BMI], resulted in a reduction in gestational diabetes mellitus, large-for-gestational-age infants, large babies (composite of large for gestational age and macrosomia), gestational hypertension, all hypertensive disorders, postpartum hemorrhage, and cesarean delivery rates,” wrote Wilson Kwong, MD, of the University of Toronto, and his colleagues. “However, there was an increase in small-for-gestational age infants, intrauterine growth restriction, small babies (composite of small for gestational age and intrauterine growth restriction), and preterm deliveries.”

Dr. Kwong and his research team developed this study to investigate the benefits and risks of bariatric surgery on neonatal outcomes. They designed a systematic review that involved a literature search of 2,616 abstracts using MEDLINE, Embase, Cochrane, Web of Science, and PubMed. They searched all from initiation of the databases to Dec. 12, 2016. Ultimately, this yielded 20 cohort studies and approximately 2.8 million subjects for review and meta-analysis. From this data, pooled odds ratios were estimated, as well as the number needed to benefit (NNTB) and the number need to harm (NNTH) to display the pooled absolute risk difference.

The results of the primary analysis, in which BMIs were similar between control subjects and the presurgery BMIs of women receiving treatment, yielded positives for mothers who underwent bariatric surgery and their newborns. As stated by Dr. Kwong and his research team, newborns were less likely to be large-for-gestational-age babies or deal with macrosomia (odds ratio, 0.36; 95% confidence interval, 0.20-0.66; NNTB, 7) and mothers were less likely to experience hypertensive disorders (OR, 0.38; 95% CI, 0.27-0.53, NNTB, 8) and postpartum hemorrhage (OR, 0.32; 95% CI, 0.08-1.37; NNTB, 9).

Despite the positives, the risk for harm was higher in a number of outcomes. Babies were more likely to be small for gestational age, have intrauterine growth restriction (OR, 2.16; 95% CI, 1.34-3.48; NNTH, 21) ,and be delivered preterm (OR, 1.35; 95% CI, 1.02-1.79; NNTH, 35).

A secondary analysis revealed that malabsorptive surgeries resulted in a significantly greater decrease (P = .012) in large babies (OR, 0.28; 95% CI, 0.22-0.36), compared with restrictive surgeries (OR, 0.50; 95% CI, 0.35-0.73). This analysis also revealed that malabsorptive bariatric surgeries corresponded to an increase in the number of small babies (OR, 2.39; 95% CI, 1.94-2.94; P = .023).

The increased risk of smaller babies may be caused by micronutrient deficiencies in pregnancy, according to Dr. Kwong. Nutritional deficiencies are reported in up to 80% of bariatric surgery patients, malabsorptive patients in particular.

“Common nutrient deficiencies after bariatric surgery include protein, B vitamins, fat-soluble vitamins, essential fatty acids, and minerals (zinc and copper), which may persist throughout pregnancy,” wrote Dr. Kwong and his colleagues.

Similar nutrient deficiencies have been identified in a case study of a woman who underwent a duodenal switch published in the Journal of Obstetrics & Gynaecology Canada. After several failed pregnancies from complications from malnutrition, the patient presented herself to physicians 10 weeks into her next pregnancy and was found to be deficient in vitamins A, D, E, and K, and minerals iron and zinc. After supplementation with a daily nutritional drink containing vitamins and protein, her vitamin levels were near normal at week 24. She eventually delivered a healthy newborn with normal-appearing features. The researchers from this study recommended that patients seeking bariatric surgery should avoid malabsorptive surgeries and defer to less extreme surgical methods.

A strength of the systematic review was the matching of studies based on presurgery and prepregnancy BMI. This was a departure from previous studies that combined all studies. Additionally, this study compared the outcomes based on the type of data source that was used. Despite these strengths, the design and results of the studies in the analysis limited the results of the review. None of the included studies were randomized; instead, they consisted of observational cohort studies, which are prone for confounding by indication.

“In counseling patients of childbearing potential who are interested in pursuing bariatric surgery, a discussion of both possible benefits and risks on pregnancy outcomes must take place,” cautioned Dr. Kwong and his associates. “Future studies should explore the causes of these potential adverse pregnancy outcomes and develop strategies that may prevent them.”

All authors affiliated with the study had no relevant financial conflicts of interest to report.

ilacy@frontlinemedcom.com

SOURCE: Kwong W et al. Am J Obstet Gynecol. 2018 Feb 15. doi: 10.1016/j.ajog.2018.02.003.
 

Bariatric surgery can offer a variety of benefits to mothers and improve neonatal outcomes but also offers substantial risk, according to a systematic literature review.

“Bariatric surgery, with patients matched for presurgery body mass index [BMI], resulted in a reduction in gestational diabetes mellitus, large-for-gestational-age infants, large babies (composite of large for gestational age and macrosomia), gestational hypertension, all hypertensive disorders, postpartum hemorrhage, and cesarean delivery rates,” wrote Wilson Kwong, MD, of the University of Toronto, and his colleagues. “However, there was an increase in small-for-gestational age infants, intrauterine growth restriction, small babies (composite of small for gestational age and intrauterine growth restriction), and preterm deliveries.”

Dr. Kwong and his research team developed this study to investigate the benefits and risks of bariatric surgery on neonatal outcomes. They designed a systematic review that involved a literature search of 2,616 abstracts using MEDLINE, Embase, Cochrane, Web of Science, and PubMed. They searched all from initiation of the databases to Dec. 12, 2016. Ultimately, this yielded 20 cohort studies and approximately 2.8 million subjects for review and meta-analysis. From this data, pooled odds ratios were estimated, as well as the number needed to benefit (NNTB) and the number need to harm (NNTH) to display the pooled absolute risk difference.

The results of the primary analysis, in which BMIs were similar between control subjects and the presurgery BMIs of women receiving treatment, yielded positives for mothers who underwent bariatric surgery and their newborns. As stated by Dr. Kwong and his research team, newborns were less likely to be large-for-gestational-age babies or deal with macrosomia (odds ratio, 0.36; 95% confidence interval, 0.20-0.66; NNTB, 7) and mothers were less likely to experience hypertensive disorders (OR, 0.38; 95% CI, 0.27-0.53, NNTB, 8) and postpartum hemorrhage (OR, 0.32; 95% CI, 0.08-1.37; NNTB, 9).

Despite the positives, the risk for harm was higher in a number of outcomes. Babies were more likely to be small for gestational age, have intrauterine growth restriction (OR, 2.16; 95% CI, 1.34-3.48; NNTH, 21) ,and be delivered preterm (OR, 1.35; 95% CI, 1.02-1.79; NNTH, 35).

A secondary analysis revealed that malabsorptive surgeries resulted in a significantly greater decrease (P = .012) in large babies (OR, 0.28; 95% CI, 0.22-0.36), compared with restrictive surgeries (OR, 0.50; 95% CI, 0.35-0.73). This analysis also revealed that malabsorptive bariatric surgeries corresponded to an increase in the number of small babies (OR, 2.39; 95% CI, 1.94-2.94; P = .023).

The increased risk of smaller babies may be caused by micronutrient deficiencies in pregnancy, according to Dr. Kwong. Nutritional deficiencies are reported in up to 80% of bariatric surgery patients, malabsorptive patients in particular.

“Common nutrient deficiencies after bariatric surgery include protein, B vitamins, fat-soluble vitamins, essential fatty acids, and minerals (zinc and copper), which may persist throughout pregnancy,” wrote Dr. Kwong and his colleagues.

Similar nutrient deficiencies have been identified in a case study of a woman who underwent a duodenal switch published in the Journal of Obstetrics & Gynaecology Canada. After several failed pregnancies from complications from malnutrition, the patient presented herself to physicians 10 weeks into her next pregnancy and was found to be deficient in vitamins A, D, E, and K, and minerals iron and zinc. After supplementation with a daily nutritional drink containing vitamins and protein, her vitamin levels were near normal at week 24. She eventually delivered a healthy newborn with normal-appearing features. The researchers from this study recommended that patients seeking bariatric surgery should avoid malabsorptive surgeries and defer to less extreme surgical methods.

A strength of the systematic review was the matching of studies based on presurgery and prepregnancy BMI. This was a departure from previous studies that combined all studies. Additionally, this study compared the outcomes based on the type of data source that was used. Despite these strengths, the design and results of the studies in the analysis limited the results of the review. None of the included studies were randomized; instead, they consisted of observational cohort studies, which are prone for confounding by indication.

“In counseling patients of childbearing potential who are interested in pursuing bariatric surgery, a discussion of both possible benefits and risks on pregnancy outcomes must take place,” cautioned Dr. Kwong and his associates. “Future studies should explore the causes of these potential adverse pregnancy outcomes and develop strategies that may prevent them.”

All authors affiliated with the study had no relevant financial conflicts of interest to report.

ilacy@frontlinemedcom.com

SOURCE: Kwong W et al. Am J Obstet Gynecol. 2018 Feb 15. doi: 10.1016/j.ajog.2018.02.003.
 

Shift work – and the various light exposures that go with it – can place some people at a greater risk of weight gain and obesity. But the impact of various light exposures inherent in shift work appear to affect the metabolism of each person differently, reported Edward L. Melanson, PhD, and his coinvestigators.

“Such individual differences were not explained by sex, age, weight, fat mass, or fat free mass,” Dr. Melanson and his coinvestigators wrote. “Thus, understanding mechanisms underlying such individual differences in waking and sleep energy metabolism and how they may or may not contribute to health outcomes ... requires additional research.”

The investigators’ conclusions are based on the results of two studies. Both studies used whole-room, indirect calorimetry to measure energy expenditure. The participants, all of whom were free of medications and illicit drugs, maintained a consistent 8-hour sleep schedule before the study took place, and consumed a specified diet throughout the study. Meal tests were used to assess the participants’ glucose metabolism responses, a protocol cited as one of the study’s limitations.

The first study, comprising 15 healthy young adults, looked for changes in energy expenditure and glucose metabolism in response to different lighting conditions, such as full-spectrum bright light or blue-enriched bright light. In that study, no effects were found on patients’ metabolism. The other study, comprising 14 healthy young adults, used a simulated shift work protocol and found a decrease in 24-hour energy expenditure in certain individuals in response to circadian misalignment. “This finding may help identify individuals who may be at a higher risk of unwanted weight gain and obesity during shift work,” the investigators wrote.

Read the full report in Neurobiology of Sleep and Circadian Rhythms.

cpalmer@frontlinemedcom.com

SOURCE: Melanson EL et al. Neurobiol Sleep Circadian Rhythms. 2017 Dec 29. doi: 10.1016/j.nbscr.2017.12.002.

Shift work – and the various light exposures that go with it – can place some people at a greater risk of weight gain and obesity. But the impact of various light exposures inherent in shift work appear to affect the metabolism of each person differently, reported Edward L. Melanson, PhD, and his coinvestigators.

“Such individual differences were not explained by sex, age, weight, fat mass, or fat free mass,” Dr. Melanson and his coinvestigators wrote. “Thus, understanding mechanisms underlying such individual differences in waking and sleep energy metabolism and how they may or may not contribute to health outcomes ... requires additional research.”

The investigators’ conclusions are based on the results of two studies. Both studies used whole-room, indirect calorimetry to measure energy expenditure. The participants, all of whom were free of medications and illicit drugs, maintained a consistent 8-hour sleep schedule before the study took place, and consumed a specified diet throughout the study. Meal tests were used to assess the participants’ glucose metabolism responses, a protocol cited as one of the study’s limitations.

The first study, comprising 15 healthy young adults, looked for changes in energy expenditure and glucose metabolism in response to different lighting conditions, such as full-spectrum bright light or blue-enriched bright light. In that study, no effects were found on patients’ metabolism. The other study, comprising 14 healthy young adults, used a simulated shift work protocol and found a decrease in 24-hour energy expenditure in certain individuals in response to circadian misalignment. “This finding may help identify individuals who may be at a higher risk of unwanted weight gain and obesity during shift work,” the investigators wrote.

Read the full report in Neurobiology of Sleep and Circadian Rhythms.

cpalmer@frontlinemedcom.com

SOURCE: Melanson EL et al. Neurobiol Sleep Circadian Rhythms. 2017 Dec 29. doi: 10.1016/j.nbscr.2017.12.002.

Shift work – and the various light exposures that go with it – can place some people at a greater risk of weight gain and obesity. But the impact of various light exposures inherent in shift work appear to affect the metabolism of each person differently, reported Edward L. Melanson, PhD, and his coinvestigators.

“Such individual differences were not explained by sex, age, weight, fat mass, or fat free mass,” Dr. Melanson and his coinvestigators wrote. “Thus, understanding mechanisms underlying such individual differences in waking and sleep energy metabolism and how they may or may not contribute to health outcomes ... requires additional research.”

The investigators’ conclusions are based on the results of two studies. Both studies used whole-room, indirect calorimetry to measure energy expenditure. The participants, all of whom were free of medications and illicit drugs, maintained a consistent 8-hour sleep schedule before the study took place, and consumed a specified diet throughout the study. Meal tests were used to assess the participants’ glucose metabolism responses, a protocol cited as one of the study’s limitations.

The first study, comprising 15 healthy young adults, looked for changes in energy expenditure and glucose metabolism in response to different lighting conditions, such as full-spectrum bright light or blue-enriched bright light. In that study, no effects were found on patients’ metabolism. The other study, comprising 14 healthy young adults, used a simulated shift work protocol and found a decrease in 24-hour energy expenditure in certain individuals in response to circadian misalignment. “This finding may help identify individuals who may be at a higher risk of unwanted weight gain and obesity during shift work,” the investigators wrote.

Read the full report in Neurobiology of Sleep and Circadian Rhythms.

cpalmer@frontlinemedcom.com

SOURCE: Melanson EL et al. Neurobiol Sleep Circadian Rhythms. 2017 Dec 29. doi: 10.1016/j.nbscr.2017.12.002.

The FP recognized this to be a nevus spilus (speckled nevus).

He explained that this was a benign nevus and that no treatment was indicated—especially because the only effective treatment would be deep excision down to the subcutaneous fat layer (requiring a graft for closure). The patient probably wouldn’t like the cosmetic result and the risks of this surgery (pain, infection, graft not taking) are not acceptable for this condition. Also, the procedure would not be covered by insurance, as this would be considered cosmetic surgery.

The physician explained that in the unlikely event of significant changes in the nevus, she should seek further evaluation. The patient understood the reality of the situation and thanked the doctor for explaining the diagnosis to her. She was reassured that this was benign.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M, Usatine R. Benign nevi. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:945-952.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

The FP recognized this to be a nevus spilus (speckled nevus).

He explained that this was a benign nevus and that no treatment was indicated—especially because the only effective treatment would be deep excision down to the subcutaneous fat layer (requiring a graft for closure). The patient probably wouldn’t like the cosmetic result and the risks of this surgery (pain, infection, graft not taking) are not acceptable for this condition. Also, the procedure would not be covered by insurance, as this would be considered cosmetic surgery.

The physician explained that in the unlikely event of significant changes in the nevus, she should seek further evaluation. The patient understood the reality of the situation and thanked the doctor for explaining the diagnosis to her. She was reassured that this was benign.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M, Usatine R. Benign nevi. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:945-952.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

The FP recognized this to be a nevus spilus (speckled nevus).

He explained that this was a benign nevus and that no treatment was indicated—especially because the only effective treatment would be deep excision down to the subcutaneous fat layer (requiring a graft for closure). The patient probably wouldn’t like the cosmetic result and the risks of this surgery (pain, infection, graft not taking) are not acceptable for this condition. Also, the procedure would not be covered by insurance, as this would be considered cosmetic surgery.

The physician explained that in the unlikely event of significant changes in the nevus, she should seek further evaluation. The patient understood the reality of the situation and thanked the doctor for explaining the diagnosis to her. She was reassured that this was benign.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M, Usatine R. Benign nevi. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:945-952.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

Current staging systems for cutaneous squamous cell carcinoma (cSCC) poorly discerned between patients with and without metastases, according to researchers.

In a population-based case-control study of 6,721 cSCC patients, the American Joint Committee on Cancer, 7th edition (AJCC 7) staging system had the lowest rate of correctly classified cases (61.8%), followed by the AJCC 8 (68.2%), the Brigham and Women’s Hospital (BWH) system (72.3%), and the Breuninger system (76.2%). The Breuninger system performed best, with sensitivity of 77.3%, specificity of 75%, correctly classified tumor rate of 76.2%, and concordance index (C-index) of 0.81, reported Ingrid Roscher, MD, of the department of dermatology at Oslo University Hospital, and her coauthors. The report was published in JAMA Dermatology.

Investigators used data from the Cancer Registry of Norway to identify 6,721 patients with a first cSCC diagnosis between Jan. 1, 2000, and Dec. 31, 2004. Metastasis status was split into one of two categories: no metastases (local disease only) and metastasis (regional lymph node or distant metastasis).

Within 5 years follow-up, 112 patients had developed metastasis, and 112 patients without metastasis were selected at random as controls. Tumor tissue was collected for all 224 patients and checked by a pathologist. Tumors were classified under all four staging systems, and a chi-squared test was performed to compare patients with and without metastasis. Relative risk of metastasis was calculated via logistic regression analyses.

Sensitivity, specificity, and correctly identified cases were used to evaluate performance of the staging systems, and C-index was used to measure discriminatory ability, wrote Dr. Roscher and her colleagues.

AJCC 7 had a sensitivity of 85.6%, specificity of 33.3%, and C-index value of 0.59; compared with AJCC scores of 67.1%, 69.6%, and 0.70 for sensitivity, specificity, and C-index, respectively. BWH had a sensitivity of 68.9%, specificity of 76.5%, and C-index of 0.75.

Within the AJCC 7 system, 85.6% of patients with metastasis and 66.7% without metastasis fell into the T2 category, and no patients were grouped into T3 or T4 (P = .003). Under the BWH system, patients without metastasis fell mostly into the T1 category, while those with metastasis were about equally distributed among T1, T2a, and T2b (P less than .001). With the Breuninger system, more patients with metastasis than without metastasis fell into the high-risk categories for tumor diameter and depth (P less than .001). Lastly, under AJCC 8, 10% of all patients fell into the T2 category, while less than 20% of patients without metastasis and more than 50% of patients with metastasis fell into the T3 category (P less than .001).

Risk of metastasis for T2 patients was greater than for T1 patients under the AJCC 7 system (odds ratio = 2.96; 95% confidence interval, 1.43-6.15). Under BWH, OR for metastasis were 4.6 (95% CI, 2.23-9.49) for T2a patients and 21.31 (95% CI, 6.07-74.88) for T2b patients. Under the Breuninger system, tumor diameter greater than 2 cm (OR = 5.92; 95% CI, 2.18-16.07) and depth of invasion greater than 6 mm (OR = 9.00; 95% CI, 3.51-32.31) increased risk of metastasis. The AJCC 8 system showed increased metastasis risk for T2 (OR = 2.00; 95% CI, 0.62-6.44) and T3 (OR = 6.14; 95% CI, 0.41-1.09) patients, the authors reported.

The results suggest that the current staging systems “distinguished poorly to moderately between patients who developed metastases and those who did not,” Dr. Roscher and her coauthors wrote. Moreover, “the poorest results were found for the AJCC 7 system, which is most widely used,” they added.

“Our findings indicate a need for a more reliable, easy-to-perform, and clinically useful staging system than those presently available,” they concluded.

Oslo University Hospital and the Cancer Registry of Norway funded the study. No other disclosures were reported.
 

SOURCE: Roscher et al. JAMA Dermatol. 2018 March 7 doi: 10.1001/jamadermatol.2017.6428.

Current staging systems for cutaneous squamous cell carcinoma (cSCC) poorly discerned between patients with and without metastases, according to researchers.

In a population-based case-control study of 6,721 cSCC patients, the American Joint Committee on Cancer, 7th edition (AJCC 7) staging system had the lowest rate of correctly classified cases (61.8%), followed by the AJCC 8 (68.2%), the Brigham and Women’s Hospital (BWH) system (72.3%), and the Breuninger system (76.2%). The Breuninger system performed best, with sensitivity of 77.3%, specificity of 75%, correctly classified tumor rate of 76.2%, and concordance index (C-index) of 0.81, reported Ingrid Roscher, MD, of the department of dermatology at Oslo University Hospital, and her coauthors. The report was published in JAMA Dermatology.

Investigators used data from the Cancer Registry of Norway to identify 6,721 patients with a first cSCC diagnosis between Jan. 1, 2000, and Dec. 31, 2004. Metastasis status was split into one of two categories: no metastases (local disease only) and metastasis (regional lymph node or distant metastasis).

Within 5 years follow-up, 112 patients had developed metastasis, and 112 patients without metastasis were selected at random as controls. Tumor tissue was collected for all 224 patients and checked by a pathologist. Tumors were classified under all four staging systems, and a chi-squared test was performed to compare patients with and without metastasis. Relative risk of metastasis was calculated via logistic regression analyses.

Sensitivity, specificity, and correctly identified cases were used to evaluate performance of the staging systems, and C-index was used to measure discriminatory ability, wrote Dr. Roscher and her colleagues.

AJCC 7 had a sensitivity of 85.6%, specificity of 33.3%, and C-index value of 0.59; compared with AJCC scores of 67.1%, 69.6%, and 0.70 for sensitivity, specificity, and C-index, respectively. BWH had a sensitivity of 68.9%, specificity of 76.5%, and C-index of 0.75.

Within the AJCC 7 system, 85.6% of patients with metastasis and 66.7% without metastasis fell into the T2 category, and no patients were grouped into T3 or T4 (P = .003). Under the BWH system, patients without metastasis fell mostly into the T1 category, while those with metastasis were about equally distributed among T1, T2a, and T2b (P less than .001). With the Breuninger system, more patients with metastasis than without metastasis fell into the high-risk categories for tumor diameter and depth (P less than .001). Lastly, under AJCC 8, 10% of all patients fell into the T2 category, while less than 20% of patients without metastasis and more than 50% of patients with metastasis fell into the T3 category (P less than .001).

Risk of metastasis for T2 patients was greater than for T1 patients under the AJCC 7 system (odds ratio = 2.96; 95% confidence interval, 1.43-6.15). Under BWH, OR for metastasis were 4.6 (95% CI, 2.23-9.49) for T2a patients and 21.31 (95% CI, 6.07-74.88) for T2b patients. Under the Breuninger system, tumor diameter greater than 2 cm (OR = 5.92; 95% CI, 2.18-16.07) and depth of invasion greater than 6 mm (OR = 9.00; 95% CI, 3.51-32.31) increased risk of metastasis. The AJCC 8 system showed increased metastasis risk for T2 (OR = 2.00; 95% CI, 0.62-6.44) and T3 (OR = 6.14; 95% CI, 0.41-1.09) patients, the authors reported.

The results suggest that the current staging systems “distinguished poorly to moderately between patients who developed metastases and those who did not,” Dr. Roscher and her coauthors wrote. Moreover, “the poorest results were found for the AJCC 7 system, which is most widely used,” they added.

“Our findings indicate a need for a more reliable, easy-to-perform, and clinically useful staging system than those presently available,” they concluded.

Oslo University Hospital and the Cancer Registry of Norway funded the study. No other disclosures were reported.
 

SOURCE: Roscher et al. JAMA Dermatol. 2018 March 7 doi: 10.1001/jamadermatol.2017.6428.

Current staging systems for cutaneous squamous cell carcinoma (cSCC) poorly discerned between patients with and without metastases, according to researchers.

In a population-based case-control study of 6,721 cSCC patients, the American Joint Committee on Cancer, 7th edition (AJCC 7) staging system had the lowest rate of correctly classified cases (61.8%), followed by the AJCC 8 (68.2%), the Brigham and Women’s Hospital (BWH) system (72.3%), and the Breuninger system (76.2%). The Breuninger system performed best, with sensitivity of 77.3%, specificity of 75%, correctly classified tumor rate of 76.2%, and concordance index (C-index) of 0.81, reported Ingrid Roscher, MD, of the department of dermatology at Oslo University Hospital, and her coauthors. The report was published in JAMA Dermatology.

Investigators used data from the Cancer Registry of Norway to identify 6,721 patients with a first cSCC diagnosis between Jan. 1, 2000, and Dec. 31, 2004. Metastasis status was split into one of two categories: no metastases (local disease only) and metastasis (regional lymph node or distant metastasis).

Within 5 years follow-up, 112 patients had developed metastasis, and 112 patients without metastasis were selected at random as controls. Tumor tissue was collected for all 224 patients and checked by a pathologist. Tumors were classified under all four staging systems, and a chi-squared test was performed to compare patients with and without metastasis. Relative risk of metastasis was calculated via logistic regression analyses.

Sensitivity, specificity, and correctly identified cases were used to evaluate performance of the staging systems, and C-index was used to measure discriminatory ability, wrote Dr. Roscher and her colleagues.

AJCC 7 had a sensitivity of 85.6%, specificity of 33.3%, and C-index value of 0.59; compared with AJCC scores of 67.1%, 69.6%, and 0.70 for sensitivity, specificity, and C-index, respectively. BWH had a sensitivity of 68.9%, specificity of 76.5%, and C-index of 0.75.

Within the AJCC 7 system, 85.6% of patients with metastasis and 66.7% without metastasis fell into the T2 category, and no patients were grouped into T3 or T4 (P = .003). Under the BWH system, patients without metastasis fell mostly into the T1 category, while those with metastasis were about equally distributed among T1, T2a, and T2b (P less than .001). With the Breuninger system, more patients with metastasis than without metastasis fell into the high-risk categories for tumor diameter and depth (P less than .001). Lastly, under AJCC 8, 10% of all patients fell into the T2 category, while less than 20% of patients without metastasis and more than 50% of patients with metastasis fell into the T3 category (P less than .001).

Risk of metastasis for T2 patients was greater than for T1 patients under the AJCC 7 system (odds ratio = 2.96; 95% confidence interval, 1.43-6.15). Under BWH, OR for metastasis were 4.6 (95% CI, 2.23-9.49) for T2a patients and 21.31 (95% CI, 6.07-74.88) for T2b patients. Under the Breuninger system, tumor diameter greater than 2 cm (OR = 5.92; 95% CI, 2.18-16.07) and depth of invasion greater than 6 mm (OR = 9.00; 95% CI, 3.51-32.31) increased risk of metastasis. The AJCC 8 system showed increased metastasis risk for T2 (OR = 2.00; 95% CI, 0.62-6.44) and T3 (OR = 6.14; 95% CI, 0.41-1.09) patients, the authors reported.

The results suggest that the current staging systems “distinguished poorly to moderately between patients who developed metastases and those who did not,” Dr. Roscher and her coauthors wrote. Moreover, “the poorest results were found for the AJCC 7 system, which is most widely used,” they added.

“Our findings indicate a need for a more reliable, easy-to-perform, and clinically useful staging system than those presently available,” they concluded.

Oslo University Hospital and the Cancer Registry of Norway funded the study. No other disclosures were reported.
 

SOURCE: Roscher et al. JAMA Dermatol. 2018 March 7 doi: 10.1001/jamadermatol.2017.6428.

Despite the rise in pediatric concussions, two-thirds of these youth do not return for recommended follow-up care in Ontario, reported Liraz Fridman, PhD, of York University, Toronto, and associates.

In a 10-year, retrospective, population-based study, 126,654 children aged 5-18 years presented with concussions to emergency departments and physician offices in Ontario between April 1, 2003, and March 31, 2014. In 2003, 7,126 children were evaluated for a concussion, compared with 21,681 children by 2013.

James Boulette/iStockphoto

SOURCE: Fridman L et al. J Pediatr. 2018;192:184-8

Despite the rise in pediatric concussions, two-thirds of these youth do not return for recommended follow-up care in Ontario, reported Liraz Fridman, PhD, of York University, Toronto, and associates.

In a 10-year, retrospective, population-based study, 126,654 children aged 5-18 years presented with concussions to emergency departments and physician offices in Ontario between April 1, 2003, and March 31, 2014. In 2003, 7,126 children were evaluated for a concussion, compared with 21,681 children by 2013.

James Boulette/iStockphoto

SOURCE: Fridman L et al. J Pediatr. 2018;192:184-8

Despite the rise in pediatric concussions, two-thirds of these youth do not return for recommended follow-up care in Ontario, reported Liraz Fridman, PhD, of York University, Toronto, and associates.

In a 10-year, retrospective, population-based study, 126,654 children aged 5-18 years presented with concussions to emergency departments and physician offices in Ontario between April 1, 2003, and March 31, 2014. In 2003, 7,126 children were evaluated for a concussion, compared with 21,681 children by 2013.

James Boulette/iStockphoto

SOURCE: Fridman L et al. J Pediatr. 2018;192:184-8

When it comes to populating deep space, “we want to learn the rules of the road” by studying the effects of space radiation and other factors on male and female fertility, according to Teresa K. Woodruff, PhD, the Thomas J. Watkins Memorial Professor of Obstetrics & Gynecology, the vice chair of research for the department of obstetrics and gynecology, and the chief of the division of reproductive science and medicine at Northwestern University, Chicago, who is chairing a session on March 17 at the 2018 Endocrine Society annual meeting entitled: “Mission to Mars.”

NASA/Greg Shirah

The project was developed based on the anticipation that “we will continue to explore space as an inhabitable frontier.” The talks in this session will examine endocrine-based reproduction such as sperm function and biologic fertilization that has occurred in space, noted Dr. Woodruff, who is also professor of molecular biosciences in the Weinberg College of Arts and Sciences and professor of biomedical engineering in the McCormick School of Engineering, both at Northwestern University.

Dr. Woodruff currently has a grant under review by the National Aeronautics and Space Administration that is relevant to the mission of populating space. “If we are going to populate space, which we will need to do based on the length of time we will be there, we are going to have to get gametes into space,” she said. There will be more and more research effort focused on the needs of the humans who are “non-Earth dwelling,” she said.

The next step might be to study embryo development in that environment. Such research would take place at the International Space Station.

“I am interested in endocrine disruptors. What we learn from the study of the challenges to reproduction in space we will be able to apply on earth,” Dr. Woodruff said.

Also on the panel will be Joseph S. Tash, PhD, of Kansas University, Kansas City, whose grant on Space Flight Impacts on Gonadal and Gamete Function already has NASA funding, according to Dr. Woodruff.

When it comes to populating deep space, “we want to learn the rules of the road” by studying the effects of space radiation and other factors on male and female fertility, according to Teresa K. Woodruff, PhD, the Thomas J. Watkins Memorial Professor of Obstetrics & Gynecology, the vice chair of research for the department of obstetrics and gynecology, and the chief of the division of reproductive science and medicine at Northwestern University, Chicago, who is chairing a session on March 17 at the 2018 Endocrine Society annual meeting entitled: “Mission to Mars.”

NASA/Greg Shirah

The project was developed based on the anticipation that “we will continue to explore space as an inhabitable frontier.” The talks in this session will examine endocrine-based reproduction such as sperm function and biologic fertilization that has occurred in space, noted Dr. Woodruff, who is also professor of molecular biosciences in the Weinberg College of Arts and Sciences and professor of biomedical engineering in the McCormick School of Engineering, both at Northwestern University.

Dr. Woodruff currently has a grant under review by the National Aeronautics and Space Administration that is relevant to the mission of populating space. “If we are going to populate space, which we will need to do based on the length of time we will be there, we are going to have to get gametes into space,” she said. There will be more and more research effort focused on the needs of the humans who are “non-Earth dwelling,” she said.

The next step might be to study embryo development in that environment. Such research would take place at the International Space Station.

“I am interested in endocrine disruptors. What we learn from the study of the challenges to reproduction in space we will be able to apply on earth,” Dr. Woodruff said.

Also on the panel will be Joseph S. Tash, PhD, of Kansas University, Kansas City, whose grant on Space Flight Impacts on Gonadal and Gamete Function already has NASA funding, according to Dr. Woodruff.

When it comes to populating deep space, “we want to learn the rules of the road” by studying the effects of space radiation and other factors on male and female fertility, according to Teresa K. Woodruff, PhD, the Thomas J. Watkins Memorial Professor of Obstetrics & Gynecology, the vice chair of research for the department of obstetrics and gynecology, and the chief of the division of reproductive science and medicine at Northwestern University, Chicago, who is chairing a session on March 17 at the 2018 Endocrine Society annual meeting entitled: “Mission to Mars.”

NASA/Greg Shirah

The project was developed based on the anticipation that “we will continue to explore space as an inhabitable frontier.” The talks in this session will examine endocrine-based reproduction such as sperm function and biologic fertilization that has occurred in space, noted Dr. Woodruff, who is also professor of molecular biosciences in the Weinberg College of Arts and Sciences and professor of biomedical engineering in the McCormick School of Engineering, both at Northwestern University.

Dr. Woodruff currently has a grant under review by the National Aeronautics and Space Administration that is relevant to the mission of populating space. “If we are going to populate space, which we will need to do based on the length of time we will be there, we are going to have to get gametes into space,” she said. There will be more and more research effort focused on the needs of the humans who are “non-Earth dwelling,” she said.

The next step might be to study embryo development in that environment. Such research would take place at the International Space Station.

“I am interested in endocrine disruptors. What we learn from the study of the challenges to reproduction in space we will be able to apply on earth,” Dr. Woodruff said.

Also on the panel will be Joseph S. Tash, PhD, of Kansas University, Kansas City, whose grant on Space Flight Impacts on Gonadal and Gamete Function already has NASA funding, according to Dr. Woodruff.

ORLANDO – The complication rate is lower with laparoscopic hysterectomy than with abdominal or vaginal hysterectomy – even for uteri over 500 g, according to findings from a nationwide cohort of more than 27,000 women.

After adjusting for numerous potential confounding factors, including medical risk factors, procedure-related variables, and patient demographics, increasing uterine weight was significantly associated with increasing odds of complications – particularly after hysterectomy for uteri over 500 g, Michelle Louie, MD, reported during an oral poster session at the annual scientific meeting of the Society of Gynecologic Surgeons.

Sharon Worcester/Frontline Medical News

This secondary analysis was performed using prospectively collected quality improvement data abstracted from the American College of Surgeons National Surgical Quality Improvement Program database, which includes patient information and 30-day outcomes from more than 500 U.S. hospitals. Patients included in the analysis were 27,167 women who underwent a hysterectomy for benign conditions during 2014-2015 for whom uterine size was reported. Complications assessed included infection, vascular complications, reoperation, and readmission.

“Our study suggests that uterine weight is not an appropriate indication for abdominal hysterectomy – that we can, and should, offer a laparoscopic approach even for a markedly enlarged uterus,” she said. “We believe, therefore, that patients may benefit from referral to specialty surgeons who are able to offer a laparoscopic approach, even for a very large uterus.”

In response to a question from the audience about the role of physician experience in the findings, Dr. Louie said that it was not a covariate for which information was available, thus it was not included in the analysis.

“However, I think all of us realize that surgeon volume and surgeon experience is an important factor for patient safety,” she said.

Dr. Louie has received consulting fees from Teleflex.

sworcester@frontlinemedcom.com

SOURCE: Louie M et al. SGS 2018, Oral Poster 06.

ORLANDO – The complication rate is lower with laparoscopic hysterectomy than with abdominal or vaginal hysterectomy – even for uteri over 500 g, according to findings from a nationwide cohort of more than 27,000 women.

After adjusting for numerous potential confounding factors, including medical risk factors, procedure-related variables, and patient demographics, increasing uterine weight was significantly associated with increasing odds of complications – particularly after hysterectomy for uteri over 500 g, Michelle Louie, MD, reported during an oral poster session at the annual scientific meeting of the Society of Gynecologic Surgeons.

Sharon Worcester/Frontline Medical News

This secondary analysis was performed using prospectively collected quality improvement data abstracted from the American College of Surgeons National Surgical Quality Improvement Program database, which includes patient information and 30-day outcomes from more than 500 U.S. hospitals. Patients included in the analysis were 27,167 women who underwent a hysterectomy for benign conditions during 2014-2015 for whom uterine size was reported. Complications assessed included infection, vascular complications, reoperation, and readmission.

“Our study suggests that uterine weight is not an appropriate indication for abdominal hysterectomy – that we can, and should, offer a laparoscopic approach even for a markedly enlarged uterus,” she said. “We believe, therefore, that patients may benefit from referral to specialty surgeons who are able to offer a laparoscopic approach, even for a very large uterus.”

In response to a question from the audience about the role of physician experience in the findings, Dr. Louie said that it was not a covariate for which information was available, thus it was not included in the analysis.

“However, I think all of us realize that surgeon volume and surgeon experience is an important factor for patient safety,” she said.

Dr. Louie has received consulting fees from Teleflex.

sworcester@frontlinemedcom.com

SOURCE: Louie M et al. SGS 2018, Oral Poster 06.

ORLANDO – The complication rate is lower with laparoscopic hysterectomy than with abdominal or vaginal hysterectomy – even for uteri over 500 g, according to findings from a nationwide cohort of more than 27,000 women.

After adjusting for numerous potential confounding factors, including medical risk factors, procedure-related variables, and patient demographics, increasing uterine weight was significantly associated with increasing odds of complications – particularly after hysterectomy for uteri over 500 g, Michelle Louie, MD, reported during an oral poster session at the annual scientific meeting of the Society of Gynecologic Surgeons.

Sharon Worcester/Frontline Medical News

This secondary analysis was performed using prospectively collected quality improvement data abstracted from the American College of Surgeons National Surgical Quality Improvement Program database, which includes patient information and 30-day outcomes from more than 500 U.S. hospitals. Patients included in the analysis were 27,167 women who underwent a hysterectomy for benign conditions during 2014-2015 for whom uterine size was reported. Complications assessed included infection, vascular complications, reoperation, and readmission.

“Our study suggests that uterine weight is not an appropriate indication for abdominal hysterectomy – that we can, and should, offer a laparoscopic approach even for a markedly enlarged uterus,” she said. “We believe, therefore, that patients may benefit from referral to specialty surgeons who are able to offer a laparoscopic approach, even for a very large uterus.”

In response to a question from the audience about the role of physician experience in the findings, Dr. Louie said that it was not a covariate for which information was available, thus it was not included in the analysis.

“However, I think all of us realize that surgeon volume and surgeon experience is an important factor for patient safety,” she said.

Dr. Louie has received consulting fees from Teleflex.

sworcester@frontlinemedcom.com

SOURCE: Louie M et al. SGS 2018, Oral Poster 06.

Could gut bacteria trigger autoimmune diseases? Vouchers might improve post–heart-attack drug compliance. How education affects depression risks for women. And why confusion reigns over the COPD-asthma overlap.

Listen to the MDedge Daily News podcast for all the details on today’s top news.


 

Could gut bacteria trigger autoimmune diseases? Vouchers might improve post–heart-attack drug compliance. How education affects depression risks for women. And why confusion reigns over the COPD-asthma overlap.

Listen to the MDedge Daily News podcast for all the details on today’s top news.


 

Could gut bacteria trigger autoimmune diseases? Vouchers might improve post–heart-attack drug compliance. How education affects depression risks for women. And why confusion reigns over the COPD-asthma overlap.

Listen to the MDedge Daily News podcast for all the details on today’s top news.


 

Living in a neighborhood with poor access to food and poor walkability puts people at risk for cardiovascular disease (CVD)—and according to researchers from Morehouse School of Medicine in Atlanta, Georgia, African Americans seemed to have the highest risk.

In a CDC-funded study, the researchers examined the relationship between neighborhood-level food access and walkability on premature CVD mortality rates in Atlanta, using census tracts to map neighborhoods. Atlanta is in Fulton County, which has a food insecurity rating of nearly 20%. Food access was defined as the percentage of no-vehicle households living beyond a 0.9-mile radius of a food outlet in 2012. Walkability was measured in relationship to amenities, population density, and road metrics.

The researchers found no significant difference in walkability scores between high-poverty and low-poverty census tracts. However, they found significant racial differences: Census tracts with high concentrations of minority populations had higher levels of poor food access, poor walkability, and premature CVD mortality.

Of 124 census tracts, 87 contained 73% of the city’s population aged 35 to 64 years and accounted for 1,225 deaths between 2010-2014, with a premature CVD mortality rate of 11 per 1,000. Black premature CVD deaths accounted for nearly 85% of the premature CVD deaths in all census tracts—a “disproportionate number,” the researchers say, because blacks make up only 52% of the city’s total population aged 35 to 64 years.

The  findings can be used to “calibrate” neighborhood interventions, based on racial/ethnic or other demographic characteristics, the researchers suggest. They add that the results highlight the need to examine racially stratified health outcomes.

Living in a neighborhood with poor access to food and poor walkability puts people at risk for cardiovascular disease (CVD)—and according to researchers from Morehouse School of Medicine in Atlanta, Georgia, African Americans seemed to have the highest risk.

In a CDC-funded study, the researchers examined the relationship between neighborhood-level food access and walkability on premature CVD mortality rates in Atlanta, using census tracts to map neighborhoods. Atlanta is in Fulton County, which has a food insecurity rating of nearly 20%. Food access was defined as the percentage of no-vehicle households living beyond a 0.9-mile radius of a food outlet in 2012. Walkability was measured in relationship to amenities, population density, and road metrics.

The researchers found no significant difference in walkability scores between high-poverty and low-poverty census tracts. However, they found significant racial differences: Census tracts with high concentrations of minority populations had higher levels of poor food access, poor walkability, and premature CVD mortality.

Of 124 census tracts, 87 contained 73% of the city’s population aged 35 to 64 years and accounted for 1,225 deaths between 2010-2014, with a premature CVD mortality rate of 11 per 1,000. Black premature CVD deaths accounted for nearly 85% of the premature CVD deaths in all census tracts—a “disproportionate number,” the researchers say, because blacks make up only 52% of the city’s total population aged 35 to 64 years.

The  findings can be used to “calibrate” neighborhood interventions, based on racial/ethnic or other demographic characteristics, the researchers suggest. They add that the results highlight the need to examine racially stratified health outcomes.

Living in a neighborhood with poor access to food and poor walkability puts people at risk for cardiovascular disease (CVD)—and according to researchers from Morehouse School of Medicine in Atlanta, Georgia, African Americans seemed to have the highest risk.

In a CDC-funded study, the researchers examined the relationship between neighborhood-level food access and walkability on premature CVD mortality rates in Atlanta, using census tracts to map neighborhoods. Atlanta is in Fulton County, which has a food insecurity rating of nearly 20%. Food access was defined as the percentage of no-vehicle households living beyond a 0.9-mile radius of a food outlet in 2012. Walkability was measured in relationship to amenities, population density, and road metrics.

The researchers found no significant difference in walkability scores between high-poverty and low-poverty census tracts. However, they found significant racial differences: Census tracts with high concentrations of minority populations had higher levels of poor food access, poor walkability, and premature CVD mortality.

Of 124 census tracts, 87 contained 73% of the city’s population aged 35 to 64 years and accounted for 1,225 deaths between 2010-2014, with a premature CVD mortality rate of 11 per 1,000. Black premature CVD deaths accounted for nearly 85% of the premature CVD deaths in all census tracts—a “disproportionate number,” the researchers say, because blacks make up only 52% of the city’s total population aged 35 to 64 years.

The  findings can be used to “calibrate” neighborhood interventions, based on racial/ethnic or other demographic characteristics, the researchers suggest. They add that the results highlight the need to examine racially stratified health outcomes.

The lesion on this 8-year-old girl’s face was first noted about a year ago. Recently, however, it has started to grow, prompting her parents to consult the child’s primary care provider (PCP). The lesion is completely asymptomatic but nonetheless concerning to the parents and to the PCP, who has no idea what it could be. He therefore refers them to dermatology.

The child is otherwise healthy. There is no family history of chronic or inheritable disease.

EXAMINATION
The lesion is a 2-cm subcutaneous firm round mass located along the superior aspect of the right jawline. The only overlying skin change is a bluish discoloration. No surface punctum is seen. No other lesions are seen or felt on examination of the rest of the head and neck.

What is the diagnosis?

This patient’s lesion was typical in size, although they can vary from 3 mm (the smallest I’ve seen) to more than 20 cm. The firm feel, lack of a punctum (which would suggest an epidermal cyst), and bluish discoloration are all typical features.

These lesions generally merit little or no concern. However, in the rare instance when the patient has multiple lesions, the possibility of at least two conditions should be considered: Gardner disease and myotonic seizure.

In terms of treatment, pilomatricoma can be safely left alone; understandably, though, most parents will only be satisfied by excision. It is important to note that, unlike most true cysts, pilomatricomas have a very poorly defined cyst wall with contents that are equally odd—watery and full of tiny white flecks that represent calcified cells. All of this must be totally removed to prevent recurrence. In most cases, defects must be closed in two layers, to minimize “dead” space that might otherwise fill with blood.

One could argue that this child’s lesion should have been removed by a plastic surgeon—but the family had no insurance. Excision was therefore the treatment of choice; the most difficult aspect was persuading the patient to cooperate. (Sometimes, you have to wait years for the child to mature before you attempt it.) The outcome in this case proved to be quite acceptable. Of course, the lesion was sent to pathology, which confirmed the pre-op diagnosis.

The differential includes epidermal cysts (which are almost unknown in prepubertal children), and sweat gland cysts. 

TAKE-HOME LEARNING POINTS

• Pilomatricomas are benign cysts that originate from hair matrix cells, usually appearing on the head, neck, face, and upper extremities of children.
• The cysts are typically firm and round and often display a faintly bluish tone (as seen in this case).
• As solitary lesions, they are of little or no significance; when seen in multiples, however, pilomatricomas suggest the possibility of Gardner syndrome or myotonic seizure.
• Excision is the best treatment, though these can be left alone long enough to allow the patient to mature sufficiently to cooperate with the surgical process.

The lesion on this 8-year-old girl’s face was first noted about a year ago. Recently, however, it has started to grow, prompting her parents to consult the child’s primary care provider (PCP). The lesion is completely asymptomatic but nonetheless concerning to the parents and to the PCP, who has no idea what it could be. He therefore refers them to dermatology.

The child is otherwise healthy. There is no family history of chronic or inheritable disease.

EXAMINATION
The lesion is a 2-cm subcutaneous firm round mass located along the superior aspect of the right jawline. The only overlying skin change is a bluish discoloration. No surface punctum is seen. No other lesions are seen or felt on examination of the rest of the head and neck.

What is the diagnosis?

This patient’s lesion was typical in size, although they can vary from 3 mm (the smallest I’ve seen) to more than 20 cm. The firm feel, lack of a punctum (which would suggest an epidermal cyst), and bluish discoloration are all typical features.

These lesions generally merit little or no concern. However, in the rare instance when the patient has multiple lesions, the possibility of at least two conditions should be considered: Gardner disease and myotonic seizure.

In terms of treatment, pilomatricoma can be safely left alone; understandably, though, most parents will only be satisfied by excision. It is important to note that, unlike most true cysts, pilomatricomas have a very poorly defined cyst wall with contents that are equally odd—watery and full of tiny white flecks that represent calcified cells. All of this must be totally removed to prevent recurrence. In most cases, defects must be closed in two layers, to minimize “dead” space that might otherwise fill with blood.

One could argue that this child’s lesion should have been removed by a plastic surgeon—but the family had no insurance. Excision was therefore the treatment of choice; the most difficult aspect was persuading the patient to cooperate. (Sometimes, you have to wait years for the child to mature before you attempt it.) The outcome in this case proved to be quite acceptable. Of course, the lesion was sent to pathology, which confirmed the pre-op diagnosis.

The differential includes epidermal cysts (which are almost unknown in prepubertal children), and sweat gland cysts. 

TAKE-HOME LEARNING POINTS

• Pilomatricomas are benign cysts that originate from hair matrix cells, usually appearing on the head, neck, face, and upper extremities of children.
• The cysts are typically firm and round and often display a faintly bluish tone (as seen in this case).
• As solitary lesions, they are of little or no significance; when seen in multiples, however, pilomatricomas suggest the possibility of Gardner syndrome or myotonic seizure.
• Excision is the best treatment, though these can be left alone long enough to allow the patient to mature sufficiently to cooperate with the surgical process.

The lesion on this 8-year-old girl’s face was first noted about a year ago. Recently, however, it has started to grow, prompting her parents to consult the child’s primary care provider (PCP). The lesion is completely asymptomatic but nonetheless concerning to the parents and to the PCP, who has no idea what it could be. He therefore refers them to dermatology.

The child is otherwise healthy. There is no family history of chronic or inheritable disease.

EXAMINATION
The lesion is a 2-cm subcutaneous firm round mass located along the superior aspect of the right jawline. The only overlying skin change is a bluish discoloration. No surface punctum is seen. No other lesions are seen or felt on examination of the rest of the head and neck.

What is the diagnosis?

This patient’s lesion was typical in size, although they can vary from 3 mm (the smallest I’ve seen) to more than 20 cm. The firm feel, lack of a punctum (which would suggest an epidermal cyst), and bluish discoloration are all typical features.

These lesions generally merit little or no concern. However, in the rare instance when the patient has multiple lesions, the possibility of at least two conditions should be considered: Gardner disease and myotonic seizure.

In terms of treatment, pilomatricoma can be safely left alone; understandably, though, most parents will only be satisfied by excision. It is important to note that, unlike most true cysts, pilomatricomas have a very poorly defined cyst wall with contents that are equally odd—watery and full of tiny white flecks that represent calcified cells. All of this must be totally removed to prevent recurrence. In most cases, defects must be closed in two layers, to minimize “dead” space that might otherwise fill with blood.

One could argue that this child’s lesion should have been removed by a plastic surgeon—but the family had no insurance. Excision was therefore the treatment of choice; the most difficult aspect was persuading the patient to cooperate. (Sometimes, you have to wait years for the child to mature before you attempt it.) The outcome in this case proved to be quite acceptable. Of course, the lesion was sent to pathology, which confirmed the pre-op diagnosis.

The differential includes epidermal cysts (which are almost unknown in prepubertal children), and sweat gland cysts. 

TAKE-HOME LEARNING POINTS

• Pilomatricomas are benign cysts that originate from hair matrix cells, usually appearing on the head, neck, face, and upper extremities of children.
• The cysts are typically firm and round and often display a faintly bluish tone (as seen in this case).
• As solitary lesions, they are of little or no significance; when seen in multiples, however, pilomatricomas suggest the possibility of Gardner syndrome or myotonic seizure.
• Excision is the best treatment, though these can be left alone long enough to allow the patient to mature sufficiently to cooperate with the surgical process.