Damian McNamara

SAN DIEGO – Compelling findings in a genetically engineered mouse model of multiple sclerosis identify mechanisms of how adolescence and gut dysbiosis contribute to the risk of MS. In addition, disparities in gut microbiome species could explain why some people are at higher risk for developing multiple sclerosis, while others seem to enjoy a protective effect against development of this and other autoimmune diseases.

The hope is that these findings could pave the way for clinicians to potentially prevent development of multiple sclerosis in people at higher risk, perhaps through altering the gut flora and probiotic therapy, Suhayl Dhib-Jalbut, MD, said in a video interview at ACTRIMS Forum 2018, held by the Americas Committee for Treatment and Research in Multiple Sclerosis.

Dr. Dhib-Jalbut and his team discovered these findings using humanized transgenic mice – in other words, mice containing risk genes for triggering disease transferred from a patient with multiple sclerosis. The mice were more likely to develop MS-like disease at certain ages and in the presence of an altered gut microbiome or gut dysbiosis (Proc Natl Acad Sci U S A. 2017 Oct 31;114[44]:E9318-27).

Dr. Dhib-Jalbut is past president of ACTRIMS and is professor and chairman of the departments of neurology at Rutgers–Robert Wood Johnson Medical School, New Brunswick, N.J., and New Jersey Medical School, Newark. He has received research grants from Biogen and Teva, and is a consultant for Genzyme, Teva, Celgene, and, Mallinckrodt.

SAN DIEGO – Compelling findings in a genetically engineered mouse model of multiple sclerosis identify mechanisms of how adolescence and gut dysbiosis contribute to the risk of MS. In addition, disparities in gut microbiome species could explain why some people are at higher risk for developing multiple sclerosis, while others seem to enjoy a protective effect against development of this and other autoimmune diseases.

The hope is that these findings could pave the way for clinicians to potentially prevent development of multiple sclerosis in people at higher risk, perhaps through altering the gut flora and probiotic therapy, Suhayl Dhib-Jalbut, MD, said in a video interview at ACTRIMS Forum 2018, held by the Americas Committee for Treatment and Research in Multiple Sclerosis.

Dr. Dhib-Jalbut and his team discovered these findings using humanized transgenic mice – in other words, mice containing risk genes for triggering disease transferred from a patient with multiple sclerosis. The mice were more likely to develop MS-like disease at certain ages and in the presence of an altered gut microbiome or gut dysbiosis (Proc Natl Acad Sci U S A. 2017 Oct 31;114[44]:E9318-27).

Dr. Dhib-Jalbut is past president of ACTRIMS and is professor and chairman of the departments of neurology at Rutgers–Robert Wood Johnson Medical School, New Brunswick, N.J., and New Jersey Medical School, Newark. He has received research grants from Biogen and Teva, and is a consultant for Genzyme, Teva, Celgene, and, Mallinckrodt.

SAN DIEGO – Compelling findings in a genetically engineered mouse model of multiple sclerosis identify mechanisms of how adolescence and gut dysbiosis contribute to the risk of MS. In addition, disparities in gut microbiome species could explain why some people are at higher risk for developing multiple sclerosis, while others seem to enjoy a protective effect against development of this and other autoimmune diseases.

The hope is that these findings could pave the way for clinicians to potentially prevent development of multiple sclerosis in people at higher risk, perhaps through altering the gut flora and probiotic therapy, Suhayl Dhib-Jalbut, MD, said in a video interview at ACTRIMS Forum 2018, held by the Americas Committee for Treatment and Research in Multiple Sclerosis.

Dr. Dhib-Jalbut and his team discovered these findings using humanized transgenic mice – in other words, mice containing risk genes for triggering disease transferred from a patient with multiple sclerosis. The mice were more likely to develop MS-like disease at certain ages and in the presence of an altered gut microbiome or gut dysbiosis (Proc Natl Acad Sci U S A. 2017 Oct 31;114[44]:E9318-27).

Dr. Dhib-Jalbut is past president of ACTRIMS and is professor and chairman of the departments of neurology at Rutgers–Robert Wood Johnson Medical School, New Brunswick, N.J., and New Jersey Medical School, Newark. He has received research grants from Biogen and Teva, and is a consultant for Genzyme, Teva, Celgene, and, Mallinckrodt.

Pediatric patients with relapsing remitting multiple sclerosis (MS) had fewer relapses after receiving the oral drug fingolimod when compared with patients who received intramuscular interferon beta-1a in the randomized, double-blind PARADIGMS study, suggesting that the sphingosine-1-phosphate receptor modulator could offer a new treatment option to patients younger than 18 years.

A new agent in this patient population is particularly important because most children and adolescents have the relapsing remitting form of the disease, and generally experience a relapse rate that is two to three times higher than that seen in people with adult-onset multiple sclerosis.

“These results indicate that fingolimod is more effective than the current standard of care, beta-interferon, in patients aged 10-17 and is a consideration for treatment in teenagers,” said Dr. Chitnis, director of the Partners Pediatric MS Center at the MassGeneral Hospital for Children, Boston. “The overall safety profile was reasonable, and there were no new major adverse events observed in comparison to adult studies.”

Participants were primarily Caucasian (92%) and female (62%). The mean age of each group at randomization was similar: 15.2 years in the fingolimod group and 15.4 years in the interferon beta-1a group. Disease duration since onset of first symptom was shorter in the fingolimod patients, a mean of 1.9 years, compared with a mean 2.4 years in the interferon beta-1a patients. At baseline, patients in both groups reported a mean 1.5 relapses in the previous year and a median Expanded Disability Status Scale (EDSS) score of 1.5.

To be included in the study, the children and teenagers had to have an EDSS score of 0 to 5.5; one or more relapses in the past year or two relapses in the previous two years; or MRI evidence of one or more gadolinium-enhancing lesions in the 6 months prior to trial randomization.

Fingolimod (Gilenya) is approved for the first-line treatment of relapsing forms of MS in adults in the United States. It is not yet FDA-approved for treatment of pediatric patients.

Dr. Chitnis said she was somewhat surprised by the strength of the findings in the PARADIGMS study. “These results showed very strong efficacy in young patients. However, as this study was being conducted, our group looked in more detail at the young adult subpopulation in the pivotal fingolimod adult studies, there was an improved effect in younger adults [those younger than 20 or younger than 30], compared to the entire group. Thus, one could extrapolate that the effects in adolescents would follow and show even greater efficacy.”

The study was sponsored by Novartis, the maker of fingolimod. Dr. Chitnis and nearly all of her coauthors disclosed financial ties to Novartis. Three authors are employees of Novartis.

SOURCE: Chitnis T et al. ACTRIMS Forum 2018, Abstract P025.
 

Pediatric patients with relapsing remitting multiple sclerosis (MS) had fewer relapses after receiving the oral drug fingolimod when compared with patients who received intramuscular interferon beta-1a in the randomized, double-blind PARADIGMS study, suggesting that the sphingosine-1-phosphate receptor modulator could offer a new treatment option to patients younger than 18 years.

A new agent in this patient population is particularly important because most children and adolescents have the relapsing remitting form of the disease, and generally experience a relapse rate that is two to three times higher than that seen in people with adult-onset multiple sclerosis.

“These results indicate that fingolimod is more effective than the current standard of care, beta-interferon, in patients aged 10-17 and is a consideration for treatment in teenagers,” said Dr. Chitnis, director of the Partners Pediatric MS Center at the MassGeneral Hospital for Children, Boston. “The overall safety profile was reasonable, and there were no new major adverse events observed in comparison to adult studies.”

Participants were primarily Caucasian (92%) and female (62%). The mean age of each group at randomization was similar: 15.2 years in the fingolimod group and 15.4 years in the interferon beta-1a group. Disease duration since onset of first symptom was shorter in the fingolimod patients, a mean of 1.9 years, compared with a mean 2.4 years in the interferon beta-1a patients. At baseline, patients in both groups reported a mean 1.5 relapses in the previous year and a median Expanded Disability Status Scale (EDSS) score of 1.5.

To be included in the study, the children and teenagers had to have an EDSS score of 0 to 5.5; one or more relapses in the past year or two relapses in the previous two years; or MRI evidence of one or more gadolinium-enhancing lesions in the 6 months prior to trial randomization.

Fingolimod (Gilenya) is approved for the first-line treatment of relapsing forms of MS in adults in the United States. It is not yet FDA-approved for treatment of pediatric patients.

Dr. Chitnis said she was somewhat surprised by the strength of the findings in the PARADIGMS study. “These results showed very strong efficacy in young patients. However, as this study was being conducted, our group looked in more detail at the young adult subpopulation in the pivotal fingolimod adult studies, there was an improved effect in younger adults [those younger than 20 or younger than 30], compared to the entire group. Thus, one could extrapolate that the effects in adolescents would follow and show even greater efficacy.”

The study was sponsored by Novartis, the maker of fingolimod. Dr. Chitnis and nearly all of her coauthors disclosed financial ties to Novartis. Three authors are employees of Novartis.

SOURCE: Chitnis T et al. ACTRIMS Forum 2018, Abstract P025.
 

Pediatric patients with relapsing remitting multiple sclerosis (MS) had fewer relapses after receiving the oral drug fingolimod when compared with patients who received intramuscular interferon beta-1a in the randomized, double-blind PARADIGMS study, suggesting that the sphingosine-1-phosphate receptor modulator could offer a new treatment option to patients younger than 18 years.

A new agent in this patient population is particularly important because most children and adolescents have the relapsing remitting form of the disease, and generally experience a relapse rate that is two to three times higher than that seen in people with adult-onset multiple sclerosis.

“These results indicate that fingolimod is more effective than the current standard of care, beta-interferon, in patients aged 10-17 and is a consideration for treatment in teenagers,” said Dr. Chitnis, director of the Partners Pediatric MS Center at the MassGeneral Hospital for Children, Boston. “The overall safety profile was reasonable, and there were no new major adverse events observed in comparison to adult studies.”

Participants were primarily Caucasian (92%) and female (62%). The mean age of each group at randomization was similar: 15.2 years in the fingolimod group and 15.4 years in the interferon beta-1a group. Disease duration since onset of first symptom was shorter in the fingolimod patients, a mean of 1.9 years, compared with a mean 2.4 years in the interferon beta-1a patients. At baseline, patients in both groups reported a mean 1.5 relapses in the previous year and a median Expanded Disability Status Scale (EDSS) score of 1.5.

To be included in the study, the children and teenagers had to have an EDSS score of 0 to 5.5; one or more relapses in the past year or two relapses in the previous two years; or MRI evidence of one or more gadolinium-enhancing lesions in the 6 months prior to trial randomization.

Fingolimod (Gilenya) is approved for the first-line treatment of relapsing forms of MS in adults in the United States. It is not yet FDA-approved for treatment of pediatric patients.

Dr. Chitnis said she was somewhat surprised by the strength of the findings in the PARADIGMS study. “These results showed very strong efficacy in young patients. However, as this study was being conducted, our group looked in more detail at the young adult subpopulation in the pivotal fingolimod adult studies, there was an improved effect in younger adults [those younger than 20 or younger than 30], compared to the entire group. Thus, one could extrapolate that the effects in adolescents would follow and show even greater efficacy.”

The study was sponsored by Novartis, the maker of fingolimod. Dr. Chitnis and nearly all of her coauthors disclosed financial ties to Novartis. Three authors are employees of Novartis.

SOURCE: Chitnis T et al. ACTRIMS Forum 2018, Abstract P025.
 

MIAMI – Bringing more men into an aesthetic dermatology practice can expand the patient population, increase business revenue, and pay long-term dividends in terms of patient loyalty and repeat business.

But men aren’t like women when it comes to aesthetic concerns, so the strategies used to market your aesthetic offerings to female patients might miss the mark with men, cautioned Terrence Keaney, MD.

James Dick

Marketing to men is different

Although growing a male anesthetic patient base is more difficult, Dr. Keaney recommends it, especially for dermatology practices in a competitive market.

This tactic of targeting untapped markets to grow a business, rather than competing on the same level as everyone else, is outlined in a book he recommends, “Blue Ocean Strategy,” by W. Chan Kim and Renée Mauborgne. “It’s about unlocking new demand, and I will argue that, in aesthetic medicine, it’s those male patients.”

“The male aesthetic market is truly untapped and shows tremendous growth potential,” Dr. Keaney said. “Particularly as millennials age, the demand for cosmetic procedures in men will only increase.”

A first step is to make male aesthetic patients feel welcome and comfortable. “Think about a reluctant male patient walking into your office; it can be intimidating if the staff and everyone in the waiting room is female,” Dr. Keaney said. “But you don’t need to put a keg in the corner, either.” He added more wood and changed the colors of his office, for example.

Don’t go overboard

Marketing aesthetic services to men is also different, a lesson Dr. Keaney learned from the outset.

“When I first started a practice, I wanted to attract more male cosmetic patients, and I decided to throw a male cosmetics seminar,” he recalled. “I thought it would be a great opportunity to educate them.”

He partnered with a plastic surgeon, rented a ballroom, sent out an e-blast, and mailed flyers. “We had zero RSVPs. We canceled it.”

He added, “Men are not sitting at the computer thinking, ‘I wish someone would throw a seminar on aesthetics.’”

A better strategy came the following year as a men’s health event with a broader scope. A urologist, internist, dermatologist, and plastic surgeon talked about a variety of health issues. “They were blown away by the options from the dermatologist and the plastic surgeon.”
 

A growing market

An American Society for Dermatologic Surgery annual survey reveals dermatologic surgeons performed nearly 10.5 million medically necessary and cosmetic procedures in 2016, the latest year for which results are available. The rate is up 5% from the year before, and up by more than 30%, compared with 2012.

“Within the growth of procedures performed, the male and millennial demographics’ interest in cosmetic treatments also continues to rise,” the survey authors noted. “In the last 5 years, men receiving wrinkle relaxers has increased 9%, and men using soft-tissue fillers grew from 2% to 9%.” The survey also reveals that patients younger than 30 years are seeking more cosmetic treatments. In fact, millennials’ use of wrinkle relaxers increased 20% from 2015, and 50% since 2012.

Address the top male aesthetic concerns

Men are interested in looking healthy, young, and staying fit, Dr. Keaney said, but there is often a disconnect in the male market. “I would argue the real rate limiter is education,” he explained, “and that both the industry and physicians are at fault.”

Most messages about aesthetic procedures have not been targeted toward men. For example, only 39% of 600 aesthetically inclined men knew about dermal fillers in a study Dr. Keaney co-authored (Dermatol Surg. 2016 Oct;42[10]:1155-63).

“I talk to men in my practice about dermal fillers, and most think they’re only for injection in the lips,” he said. The results of the online survey came from men “cosmetically on the cusp,” as he described them – men familiar with neuromodulators for facial rejuvenation, but who had never tried such a therapy.

Tear troughs, double chin, crow’s feet, and forehead lines were the most common concerns, in order, reported by study participants. Dr. Keaney said. “You’ll notice what is missing here: the cheeks, the nasolabial folds, and the lips. And what are those? The FDA-approved indications for dermal fillers.”

Even though it doesn’t top the list of men’s concerns in this study, overall, “if you’re looking to grow your male aesthetic patient population, the number one cosmetic concern among men remains hair loss,” noted Dr. Keaney. “You cannot ignore hair loss. It has a large psychosocial impact.”

During a full-body exam, Dr. Keaney recommends using a scalp exam as an opportunity to ask about any hair-loss concerns.

Encouraging signs from other industries

Other industries are showing a rise in the appearance-conscious male consumer, Dr. Keaney said. Men’s skin care, grooming, and luxury fashion industries are all growing, for example.

Worldwide, the personal care market for men is forecast to grow to $166 billion globally by 2022, according to a report from Allied Market Research. The compound average growth rate is expected to grow more than 5% each year between now and then.

“Men are spending money on their hair and skin,” Dr. Keaney said. “The question is, Why aren’t they spending money on their face? It’s how we interact with the world.”

Dr. Keaney has served on the advisory board of, consulted for, and was a speaker for Allergan. He was also a speaker for Eclipse, Sciton, and Syneron Candela, and served on the advisory boards for Aclaris and Merz.

MIAMI – Bringing more men into an aesthetic dermatology practice can expand the patient population, increase business revenue, and pay long-term dividends in terms of patient loyalty and repeat business.

But men aren’t like women when it comes to aesthetic concerns, so the strategies used to market your aesthetic offerings to female patients might miss the mark with men, cautioned Terrence Keaney, MD.

James Dick

Marketing to men is different

Although growing a male anesthetic patient base is more difficult, Dr. Keaney recommends it, especially for dermatology practices in a competitive market.

This tactic of targeting untapped markets to grow a business, rather than competing on the same level as everyone else, is outlined in a book he recommends, “Blue Ocean Strategy,” by W. Chan Kim and Renée Mauborgne. “It’s about unlocking new demand, and I will argue that, in aesthetic medicine, it’s those male patients.”

“The male aesthetic market is truly untapped and shows tremendous growth potential,” Dr. Keaney said. “Particularly as millennials age, the demand for cosmetic procedures in men will only increase.”

A first step is to make male aesthetic patients feel welcome and comfortable. “Think about a reluctant male patient walking into your office; it can be intimidating if the staff and everyone in the waiting room is female,” Dr. Keaney said. “But you don’t need to put a keg in the corner, either.” He added more wood and changed the colors of his office, for example.

Don’t go overboard

Marketing aesthetic services to men is also different, a lesson Dr. Keaney learned from the outset.

“When I first started a practice, I wanted to attract more male cosmetic patients, and I decided to throw a male cosmetics seminar,” he recalled. “I thought it would be a great opportunity to educate them.”

He partnered with a plastic surgeon, rented a ballroom, sent out an e-blast, and mailed flyers. “We had zero RSVPs. We canceled it.”

He added, “Men are not sitting at the computer thinking, ‘I wish someone would throw a seminar on aesthetics.’”

A better strategy came the following year as a men’s health event with a broader scope. A urologist, internist, dermatologist, and plastic surgeon talked about a variety of health issues. “They were blown away by the options from the dermatologist and the plastic surgeon.”
 

A growing market

An American Society for Dermatologic Surgery annual survey reveals dermatologic surgeons performed nearly 10.5 million medically necessary and cosmetic procedures in 2016, the latest year for which results are available. The rate is up 5% from the year before, and up by more than 30%, compared with 2012.

“Within the growth of procedures performed, the male and millennial demographics’ interest in cosmetic treatments also continues to rise,” the survey authors noted. “In the last 5 years, men receiving wrinkle relaxers has increased 9%, and men using soft-tissue fillers grew from 2% to 9%.” The survey also reveals that patients younger than 30 years are seeking more cosmetic treatments. In fact, millennials’ use of wrinkle relaxers increased 20% from 2015, and 50% since 2012.

Address the top male aesthetic concerns

Men are interested in looking healthy, young, and staying fit, Dr. Keaney said, but there is often a disconnect in the male market. “I would argue the real rate limiter is education,” he explained, “and that both the industry and physicians are at fault.”

Most messages about aesthetic procedures have not been targeted toward men. For example, only 39% of 600 aesthetically inclined men knew about dermal fillers in a study Dr. Keaney co-authored (Dermatol Surg. 2016 Oct;42[10]:1155-63).

“I talk to men in my practice about dermal fillers, and most think they’re only for injection in the lips,” he said. The results of the online survey came from men “cosmetically on the cusp,” as he described them – men familiar with neuromodulators for facial rejuvenation, but who had never tried such a therapy.

Tear troughs, double chin, crow’s feet, and forehead lines were the most common concerns, in order, reported by study participants. Dr. Keaney said. “You’ll notice what is missing here: the cheeks, the nasolabial folds, and the lips. And what are those? The FDA-approved indications for dermal fillers.”

Even though it doesn’t top the list of men’s concerns in this study, overall, “if you’re looking to grow your male aesthetic patient population, the number one cosmetic concern among men remains hair loss,” noted Dr. Keaney. “You cannot ignore hair loss. It has a large psychosocial impact.”

During a full-body exam, Dr. Keaney recommends using a scalp exam as an opportunity to ask about any hair-loss concerns.

Encouraging signs from other industries

Other industries are showing a rise in the appearance-conscious male consumer, Dr. Keaney said. Men’s skin care, grooming, and luxury fashion industries are all growing, for example.

Worldwide, the personal care market for men is forecast to grow to $166 billion globally by 2022, according to a report from Allied Market Research. The compound average growth rate is expected to grow more than 5% each year between now and then.

“Men are spending money on their hair and skin,” Dr. Keaney said. “The question is, Why aren’t they spending money on their face? It’s how we interact with the world.”

Dr. Keaney has served on the advisory board of, consulted for, and was a speaker for Allergan. He was also a speaker for Eclipse, Sciton, and Syneron Candela, and served on the advisory boards for Aclaris and Merz.

MIAMI – Bringing more men into an aesthetic dermatology practice can expand the patient population, increase business revenue, and pay long-term dividends in terms of patient loyalty and repeat business.

But men aren’t like women when it comes to aesthetic concerns, so the strategies used to market your aesthetic offerings to female patients might miss the mark with men, cautioned Terrence Keaney, MD.

James Dick

Marketing to men is different

Although growing a male anesthetic patient base is more difficult, Dr. Keaney recommends it, especially for dermatology practices in a competitive market.

This tactic of targeting untapped markets to grow a business, rather than competing on the same level as everyone else, is outlined in a book he recommends, “Blue Ocean Strategy,” by W. Chan Kim and Renée Mauborgne. “It’s about unlocking new demand, and I will argue that, in aesthetic medicine, it’s those male patients.”

“The male aesthetic market is truly untapped and shows tremendous growth potential,” Dr. Keaney said. “Particularly as millennials age, the demand for cosmetic procedures in men will only increase.”

A first step is to make male aesthetic patients feel welcome and comfortable. “Think about a reluctant male patient walking into your office; it can be intimidating if the staff and everyone in the waiting room is female,” Dr. Keaney said. “But you don’t need to put a keg in the corner, either.” He added more wood and changed the colors of his office, for example.

Don’t go overboard

Marketing aesthetic services to men is also different, a lesson Dr. Keaney learned from the outset.

“When I first started a practice, I wanted to attract more male cosmetic patients, and I decided to throw a male cosmetics seminar,” he recalled. “I thought it would be a great opportunity to educate them.”

He partnered with a plastic surgeon, rented a ballroom, sent out an e-blast, and mailed flyers. “We had zero RSVPs. We canceled it.”

He added, “Men are not sitting at the computer thinking, ‘I wish someone would throw a seminar on aesthetics.’”

A better strategy came the following year as a men’s health event with a broader scope. A urologist, internist, dermatologist, and plastic surgeon talked about a variety of health issues. “They were blown away by the options from the dermatologist and the plastic surgeon.”
 

A growing market

An American Society for Dermatologic Surgery annual survey reveals dermatologic surgeons performed nearly 10.5 million medically necessary and cosmetic procedures in 2016, the latest year for which results are available. The rate is up 5% from the year before, and up by more than 30%, compared with 2012.

“Within the growth of procedures performed, the male and millennial demographics’ interest in cosmetic treatments also continues to rise,” the survey authors noted. “In the last 5 years, men receiving wrinkle relaxers has increased 9%, and men using soft-tissue fillers grew from 2% to 9%.” The survey also reveals that patients younger than 30 years are seeking more cosmetic treatments. In fact, millennials’ use of wrinkle relaxers increased 20% from 2015, and 50% since 2012.

Address the top male aesthetic concerns

Men are interested in looking healthy, young, and staying fit, Dr. Keaney said, but there is often a disconnect in the male market. “I would argue the real rate limiter is education,” he explained, “and that both the industry and physicians are at fault.”

Most messages about aesthetic procedures have not been targeted toward men. For example, only 39% of 600 aesthetically inclined men knew about dermal fillers in a study Dr. Keaney co-authored (Dermatol Surg. 2016 Oct;42[10]:1155-63).

“I talk to men in my practice about dermal fillers, and most think they’re only for injection in the lips,” he said. The results of the online survey came from men “cosmetically on the cusp,” as he described them – men familiar with neuromodulators for facial rejuvenation, but who had never tried such a therapy.

Tear troughs, double chin, crow’s feet, and forehead lines were the most common concerns, in order, reported by study participants. Dr. Keaney said. “You’ll notice what is missing here: the cheeks, the nasolabial folds, and the lips. And what are those? The FDA-approved indications for dermal fillers.”

Even though it doesn’t top the list of men’s concerns in this study, overall, “if you’re looking to grow your male aesthetic patient population, the number one cosmetic concern among men remains hair loss,” noted Dr. Keaney. “You cannot ignore hair loss. It has a large psychosocial impact.”

During a full-body exam, Dr. Keaney recommends using a scalp exam as an opportunity to ask about any hair-loss concerns.

Encouraging signs from other industries

Other industries are showing a rise in the appearance-conscious male consumer, Dr. Keaney said. Men’s skin care, grooming, and luxury fashion industries are all growing, for example.

Worldwide, the personal care market for men is forecast to grow to $166 billion globally by 2022, according to a report from Allied Market Research. The compound average growth rate is expected to grow more than 5% each year between now and then.

“Men are spending money on their hair and skin,” Dr. Keaney said. “The question is, Why aren’t they spending money on their face? It’s how we interact with the world.”

Dr. Keaney has served on the advisory board of, consulted for, and was a speaker for Allergan. He was also a speaker for Eclipse, Sciton, and Syneron Candela, and served on the advisory boards for Aclaris and Merz.

MIAMI – Pearls for providers of photodynamic therapy (PDT) include tips on skin preparation, eye protection, and use of three new codes to maximize reimbursement. Also trending in medical dermatology are best practices for intralesional injections of 5-FU to treat the often challenging isomorphic squamous cell carcinomas (SCCs) or keratoacanthomas on the lower leg, as well as use of neoadjuvant hedgehog inhibitors to shrink large skin cancer lesions, according to Glenn David Goldman, MD.

“This talk is about what you can do medically as a dermatologic surgeon,” Dr. Goldman said at the Orlando Dermatology Aesthetic and Clinical Conference.
 

Use new billing codes for photodynamic therapy

There are now three new PDT billing codes. “Make sure your coders are using these properly. They are active now, and if you don’t use them, you won’t get paid properly,” said Dr. Goldman, professor and medical director of dermatology at the University of Vermont, Burlington. Specifically, 96567 is for standard PDT applied by staff; 96573 is for PDT applied by a physician; and 96574 is for PDT and curettage performed by a physician.

“Be involved, don’t delegate,” Dr. Goldman added. “If you do, you will get paid half as much as you used to, which means you will lose money on every single patient you treat.”

What type of PDT physicians choose to use in their practice remains controversial. “Do you do short-contact PDT, do you do daylight PDT? We’ve gone back and forth in our practice,” Dr. Goldman said. “I’m not impressed with daylight PDT. I know this is at odds with some of the people here, but at least in Vermont, it doesn’t work very well.”

The way PDT was described in the original trials (a photosensitizer applied in the office followed by PDT) “works the best, with one caveat,” Dr. Goldman said. The caveat is that dermatologists should aim for a PDT clearance that approaches the efficacy of 5-fluorouracil (5-FU). “If you can get to that – which is difficult by the way – I think your patients will really appreciate this.”

An additional PDT pearl Dr. Goldman shared involves skin preparation: the use of acetone to defat the skin, even in patients with very thick lesions. Apply acetone with gauze to the site for 5 minutes and “all of that hyperkeratosis just wipes away,” curette off any residual hyperkeratosis – and consider a ring anesthetic block to control pain for the patient with severe disease, he advised.

Another tip is to forgo the goggles that come with most PDT kits. Instead, purchase smaller, disposable laser eye shields for PDT patients, Dr. Goldman said. “They work better. You can get closer to the eye … and they are more comfortable for the patient.”

Dr. Goldman’s practice is providing more PDT and much less 5-FU for patient convenience. “I believe if someone is willing to go through 3 weeks of 5-FU or 12-16 weeks of imiquimod, they get the best results. However, most people don’t want to do that if they can sit in front of a light for 15 minutes.”
 

Consider intralesional injections for SCCs and KAs on the legs

An ongoing challenge in medical dermatology is preventing rapid recurrence of SCCs and/or keratoacanthomas (KAs) near sites of previous excision on the legs. “We all see this quite a bit. Often you get lesions on the leg, you cut them out, and they come right back” close to the excision site, Dr. Goldman said.

He does not recommend methotrexate injections for these lesions. “Methotrexate does not work. It doesn’t hurt, but I’ve injected methotrexate into squamous cell carcinomas many times and they’ve never gone away.” In contrast, 5-FU “works incredibly well. They go away, I’ve had tremendous success. This has changed the way we treat these lesions.” 5-FU is inexpensive and can be obtained from oncology pharmacies. One caveat is 5-FU injections can be painful and patients require anesthesia prior to injection.

Using a 25-gauge or 27-gauge needle, Dr. Goldman injects 5-FU “exactly as I would a hypertrophic scar. I inject a squamous cell carcinoma carefully and ‘expand’ the tumor.” He typically injects a lesion every 2 weeks until it resolves completely, which typically takes two or three sessions.

“I want to emphasize that that’s really true about intralesional 5-FU for those KAs and scars on the legs,” said session moderator James Spencer, MD, a dermatologist in private practice in St. Petersburg, Florida. “Otherwise, you’re just chasing your tail trying to cut them out. You’ll do much better with the intralesional 5-FU; it’s easy to get, it’s affordable, it comes as 50 mg/mL … just keep it in the office.”
 

A recommended role for hedgehog inhibitors

Hedgehog inhibitors work best as neoadjuvant therapy to shrink large skin cancer tumors prior to excision, Dr. Goldman said. “Hedgehog inhibitors don’t cure anything … except for rare cases of small basal cell carcinomas.” For most lesions, however, the strategy is not curative.

“I don’t believe in hedgehog inhibitors for things that are readily resectable. We use them to shrink things down,” he added.

Dr. Goldman recommended treating patients with neoadjuvant hedgehog inhibitors to achieve the maximum tumor shrinking effect. Adverse effects tend to develop slowly over time, typically after a 6-week “grace period.” Nighttime leg muscle cramps, loss of taste, hair loss, and weight loss can occur. Also, electrolyte imbalances can occur, particularly in older patients with renal clearance issues. When the patient can no longer reasonably tolerate the adverse effects, which is usually the case, “then you do the surgery,” Dr. Goldman said.

“The benefits of neoadjuvant hedgehog inhibitors include predictable shrinkage of tumors,” and manufacturers have been helpful with financial issues, he noted.

Dr. Goldman had no relevant financial disclosures. Dr. Spencer has served on the speakers bureau for Genentech and Leo Pharma.

MIAMI – Pearls for providers of photodynamic therapy (PDT) include tips on skin preparation, eye protection, and use of three new codes to maximize reimbursement. Also trending in medical dermatology are best practices for intralesional injections of 5-FU to treat the often challenging isomorphic squamous cell carcinomas (SCCs) or keratoacanthomas on the lower leg, as well as use of neoadjuvant hedgehog inhibitors to shrink large skin cancer lesions, according to Glenn David Goldman, MD.

“This talk is about what you can do medically as a dermatologic surgeon,” Dr. Goldman said at the Orlando Dermatology Aesthetic and Clinical Conference.
 

Use new billing codes for photodynamic therapy

There are now three new PDT billing codes. “Make sure your coders are using these properly. They are active now, and if you don’t use them, you won’t get paid properly,” said Dr. Goldman, professor and medical director of dermatology at the University of Vermont, Burlington. Specifically, 96567 is for standard PDT applied by staff; 96573 is for PDT applied by a physician; and 96574 is for PDT and curettage performed by a physician.

“Be involved, don’t delegate,” Dr. Goldman added. “If you do, you will get paid half as much as you used to, which means you will lose money on every single patient you treat.”

What type of PDT physicians choose to use in their practice remains controversial. “Do you do short-contact PDT, do you do daylight PDT? We’ve gone back and forth in our practice,” Dr. Goldman said. “I’m not impressed with daylight PDT. I know this is at odds with some of the people here, but at least in Vermont, it doesn’t work very well.”

The way PDT was described in the original trials (a photosensitizer applied in the office followed by PDT) “works the best, with one caveat,” Dr. Goldman said. The caveat is that dermatologists should aim for a PDT clearance that approaches the efficacy of 5-fluorouracil (5-FU). “If you can get to that – which is difficult by the way – I think your patients will really appreciate this.”

An additional PDT pearl Dr. Goldman shared involves skin preparation: the use of acetone to defat the skin, even in patients with very thick lesions. Apply acetone with gauze to the site for 5 minutes and “all of that hyperkeratosis just wipes away,” curette off any residual hyperkeratosis – and consider a ring anesthetic block to control pain for the patient with severe disease, he advised.

Another tip is to forgo the goggles that come with most PDT kits. Instead, purchase smaller, disposable laser eye shields for PDT patients, Dr. Goldman said. “They work better. You can get closer to the eye … and they are more comfortable for the patient.”

Dr. Goldman’s practice is providing more PDT and much less 5-FU for patient convenience. “I believe if someone is willing to go through 3 weeks of 5-FU or 12-16 weeks of imiquimod, they get the best results. However, most people don’t want to do that if they can sit in front of a light for 15 minutes.”
 

Consider intralesional injections for SCCs and KAs on the legs

An ongoing challenge in medical dermatology is preventing rapid recurrence of SCCs and/or keratoacanthomas (KAs) near sites of previous excision on the legs. “We all see this quite a bit. Often you get lesions on the leg, you cut them out, and they come right back” close to the excision site, Dr. Goldman said.

He does not recommend methotrexate injections for these lesions. “Methotrexate does not work. It doesn’t hurt, but I’ve injected methotrexate into squamous cell carcinomas many times and they’ve never gone away.” In contrast, 5-FU “works incredibly well. They go away, I’ve had tremendous success. This has changed the way we treat these lesions.” 5-FU is inexpensive and can be obtained from oncology pharmacies. One caveat is 5-FU injections can be painful and patients require anesthesia prior to injection.

Using a 25-gauge or 27-gauge needle, Dr. Goldman injects 5-FU “exactly as I would a hypertrophic scar. I inject a squamous cell carcinoma carefully and ‘expand’ the tumor.” He typically injects a lesion every 2 weeks until it resolves completely, which typically takes two or three sessions.

“I want to emphasize that that’s really true about intralesional 5-FU for those KAs and scars on the legs,” said session moderator James Spencer, MD, a dermatologist in private practice in St. Petersburg, Florida. “Otherwise, you’re just chasing your tail trying to cut them out. You’ll do much better with the intralesional 5-FU; it’s easy to get, it’s affordable, it comes as 50 mg/mL … just keep it in the office.”
 

A recommended role for hedgehog inhibitors

Hedgehog inhibitors work best as neoadjuvant therapy to shrink large skin cancer tumors prior to excision, Dr. Goldman said. “Hedgehog inhibitors don’t cure anything … except for rare cases of small basal cell carcinomas.” For most lesions, however, the strategy is not curative.

“I don’t believe in hedgehog inhibitors for things that are readily resectable. We use them to shrink things down,” he added.

Dr. Goldman recommended treating patients with neoadjuvant hedgehog inhibitors to achieve the maximum tumor shrinking effect. Adverse effects tend to develop slowly over time, typically after a 6-week “grace period.” Nighttime leg muscle cramps, loss of taste, hair loss, and weight loss can occur. Also, electrolyte imbalances can occur, particularly in older patients with renal clearance issues. When the patient can no longer reasonably tolerate the adverse effects, which is usually the case, “then you do the surgery,” Dr. Goldman said.

“The benefits of neoadjuvant hedgehog inhibitors include predictable shrinkage of tumors,” and manufacturers have been helpful with financial issues, he noted.

Dr. Goldman had no relevant financial disclosures. Dr. Spencer has served on the speakers bureau for Genentech and Leo Pharma.

MIAMI – Pearls for providers of photodynamic therapy (PDT) include tips on skin preparation, eye protection, and use of three new codes to maximize reimbursement. Also trending in medical dermatology are best practices for intralesional injections of 5-FU to treat the often challenging isomorphic squamous cell carcinomas (SCCs) or keratoacanthomas on the lower leg, as well as use of neoadjuvant hedgehog inhibitors to shrink large skin cancer lesions, according to Glenn David Goldman, MD.

“This talk is about what you can do medically as a dermatologic surgeon,” Dr. Goldman said at the Orlando Dermatology Aesthetic and Clinical Conference.
 

Use new billing codes for photodynamic therapy

There are now three new PDT billing codes. “Make sure your coders are using these properly. They are active now, and if you don’t use them, you won’t get paid properly,” said Dr. Goldman, professor and medical director of dermatology at the University of Vermont, Burlington. Specifically, 96567 is for standard PDT applied by staff; 96573 is for PDT applied by a physician; and 96574 is for PDT and curettage performed by a physician.

“Be involved, don’t delegate,” Dr. Goldman added. “If you do, you will get paid half as much as you used to, which means you will lose money on every single patient you treat.”

What type of PDT physicians choose to use in their practice remains controversial. “Do you do short-contact PDT, do you do daylight PDT? We’ve gone back and forth in our practice,” Dr. Goldman said. “I’m not impressed with daylight PDT. I know this is at odds with some of the people here, but at least in Vermont, it doesn’t work very well.”

The way PDT was described in the original trials (a photosensitizer applied in the office followed by PDT) “works the best, with one caveat,” Dr. Goldman said. The caveat is that dermatologists should aim for a PDT clearance that approaches the efficacy of 5-fluorouracil (5-FU). “If you can get to that – which is difficult by the way – I think your patients will really appreciate this.”

An additional PDT pearl Dr. Goldman shared involves skin preparation: the use of acetone to defat the skin, even in patients with very thick lesions. Apply acetone with gauze to the site for 5 minutes and “all of that hyperkeratosis just wipes away,” curette off any residual hyperkeratosis – and consider a ring anesthetic block to control pain for the patient with severe disease, he advised.

Another tip is to forgo the goggles that come with most PDT kits. Instead, purchase smaller, disposable laser eye shields for PDT patients, Dr. Goldman said. “They work better. You can get closer to the eye … and they are more comfortable for the patient.”

Dr. Goldman’s practice is providing more PDT and much less 5-FU for patient convenience. “I believe if someone is willing to go through 3 weeks of 5-FU or 12-16 weeks of imiquimod, they get the best results. However, most people don’t want to do that if they can sit in front of a light for 15 minutes.”
 

Consider intralesional injections for SCCs and KAs on the legs

An ongoing challenge in medical dermatology is preventing rapid recurrence of SCCs and/or keratoacanthomas (KAs) near sites of previous excision on the legs. “We all see this quite a bit. Often you get lesions on the leg, you cut them out, and they come right back” close to the excision site, Dr. Goldman said.

He does not recommend methotrexate injections for these lesions. “Methotrexate does not work. It doesn’t hurt, but I’ve injected methotrexate into squamous cell carcinomas many times and they’ve never gone away.” In contrast, 5-FU “works incredibly well. They go away, I’ve had tremendous success. This has changed the way we treat these lesions.” 5-FU is inexpensive and can be obtained from oncology pharmacies. One caveat is 5-FU injections can be painful and patients require anesthesia prior to injection.

Using a 25-gauge or 27-gauge needle, Dr. Goldman injects 5-FU “exactly as I would a hypertrophic scar. I inject a squamous cell carcinoma carefully and ‘expand’ the tumor.” He typically injects a lesion every 2 weeks until it resolves completely, which typically takes two or three sessions.

“I want to emphasize that that’s really true about intralesional 5-FU for those KAs and scars on the legs,” said session moderator James Spencer, MD, a dermatologist in private practice in St. Petersburg, Florida. “Otherwise, you’re just chasing your tail trying to cut them out. You’ll do much better with the intralesional 5-FU; it’s easy to get, it’s affordable, it comes as 50 mg/mL … just keep it in the office.”
 

A recommended role for hedgehog inhibitors

Hedgehog inhibitors work best as neoadjuvant therapy to shrink large skin cancer tumors prior to excision, Dr. Goldman said. “Hedgehog inhibitors don’t cure anything … except for rare cases of small basal cell carcinomas.” For most lesions, however, the strategy is not curative.

“I don’t believe in hedgehog inhibitors for things that are readily resectable. We use them to shrink things down,” he added.

Dr. Goldman recommended treating patients with neoadjuvant hedgehog inhibitors to achieve the maximum tumor shrinking effect. Adverse effects tend to develop slowly over time, typically after a 6-week “grace period.” Nighttime leg muscle cramps, loss of taste, hair loss, and weight loss can occur. Also, electrolyte imbalances can occur, particularly in older patients with renal clearance issues. When the patient can no longer reasonably tolerate the adverse effects, which is usually the case, “then you do the surgery,” Dr. Goldman said.

“The benefits of neoadjuvant hedgehog inhibitors include predictable shrinkage of tumors,” and manufacturers have been helpful with financial issues, he noted.

Dr. Goldman had no relevant financial disclosures. Dr. Spencer has served on the speakers bureau for Genentech and Leo Pharma.

MIAMI – Another reason not to prescribe opioids for postoperative pain – besides potentially adding to the epidemic the nation – comes from evidence showing these agents can impair wound healing.

In addition, epidermal sutures to close dermatologic surgery sites may be unnecessary if deep suturing is done proficiently. These and other pearls to optimize wound closure were suggested by Robert S. Kirsner, MD, PhD, professor and chair of the department of dermatology and cutaneous surgery at the University of Miami.
 

Avoid opioids for postoperative pain

“We know the opioid epidemic is a big problem. An estimated 5-8 million Americans use them for chronic pain,” Dr. Kirsner said at the Orlando Dermatology Aesthetic and Clinical Conference. “And there has been a steady increase in the use of illicit and prescription opioids.”

Consider skipping epidermal sutures in some cases

Dermatologists who place really good deep sutures when closing a wound might be able to forgo traditional epidural suturing, Dr. Kirsner said. “If you believe the literature, you can actually forget epidermal sutures. That’s hard for us. We’re trained to put epidermal sutures in, and changing habits can be difficult.”

A prospective, randomized study demonstrated no difference in cosmesis at 6 months, for example, in a split scar study where half of each wound was closed with epidural suturing and half was not (Dermatol. Surg. 2015;41:1257-63). In another randomized study, researchers found something similar when comparing buried interrupted subcuticular suturing of wounds with and without adhesive strips to close the epidermis (JAMA Dermatol. 2015;15:862-7). “When they looked at the scars, complications, and cosmesis at 6 months, there was no difference,” Dr. Kirsner said.

“Forget epidermal sutures if you’re brave enough,” he said.

Dr. Kirsner acknowledged that some dermatologists might point out a requirement to evert wound edges with epidermal stitches. “It turns out you don’t need to, again, if you believe the literature.” He cited a randomized, controlled, split scar trial that revealed no difference in cosmetic outcomes according to blinded physician ratings or patient reports at 3 months (J Am Acad Dermatol. 2015;72;668-73). “So maybe the concept of wound eversion is not as important as we were originally taught.”

And speaking of wound edges …
 

When debriding a nonhealing wound ...

There may be something highly abnormal about a nonhealing wound edge, Dr. Kirsner said. In fact, they can be phenotypically and genotypically different from surrounding tissue, including characteristic overexpression of c-Myc and beta catenin. These two factors in higher amounts can inhibit the migration of keratinocytes into a wound to promote healing.

“Sometimes we debride the wound because it’s necrotic,” Dr. Kirsner said. But in the case of a nonhealing wound, it can be more effective to debride the edges to remove the abnormal tissue. “You can change the fortune of a wound by debriding the edge. You want to remove all the abnormal tissue, and give it a chance to heal.” Pathology supports the elevated presence of the c-Myc and beta catenin factors in the “healing incompetent” tissue around the edges of nonhealing wounds, he added.
 

If a patient is unusually anxious or stressed

Stress can impair wound healing by 40%, Dr. Kirsner said (Psychosom Med. 1998;60:362-5). Some anxiety before a dermatologic surgery procedure is normal for many patients, but there also are unusual circumstances. For example, “if a patient comes for cyst excision but learns while in the waiting room that his dog just died,” he said. It’s often better to reschedule the procedure than to proceed.

“What you can do on a daily basis is create a stress-free environment” as well, Dr. Kirsner said.

“From a practical standpoint, things that can impair healing include patient depression, negativism, isolation, and postoperative pain,” he added. The mechanism between elevated stress and impaired wound healing includes release of catecholamines that induce the action of endogenous steroids. This, in turn, can cause a cascade of events that reduce inflammatory cells and their pro-healing cytokines, thereby leading to poor healing.

“All of this is mediated through the love hormone, oxytocin. Maybe someday we will be able to give oxytocin to speed healing.”
 

Two technologies still look good for scarless donor sites

Epidermal grafting and technology based on fractional laser treatments continue to show promise for achieving a scarless donor site for patients who need grafting to promote wound healing, Dr. Kirsner said.

With epidermal grafting, dermatologists can apply a device to lift up on the epidermis from a donor site. The CelluTome Epidermal Harvesting System, for example, achieves this feat by applying both a little heat and some suction. “It creates little domes [of epidermis] in this Easy Bake oven looking device,” Dr. Kirsner said. Without any anesthetic, you place this device on the skin and you get these epidermal grafts in 30 minutes. Then you can transfer them to a sterile dressing and place them on the wound.”

As pointed out in a previous report in Dermatology News, avoiding the need for donor site anesthesia is one advantage of the epidermal grafting technique. In addition, the procedure is generally bloodless because the device does not go deep enough to reach the blood vessels, Dr. Kirsner said. In addition, healing of the donor site can be seen on histology in as little as 2 days.

Transferring the epidermis can promote healing because it also transfers keratinocytes and melanocytes to the wound.

“This technique is also excellent to add skin or cells to someone with pyoderma gangrenosum,” Dr. Kirsner said. “Because of the simplicity and the lack of trauma, you don’t get the pathergy you normally see on someone with pyoderma gangrenosum.”

An Autologous Regeneration of Tissue or ART device that transfers columns of healthy skin to a wound to help regenerate tissue and promote healing is a second technology with a lot of potential, Dr. Kirsner said. “With a fractional laser, you create a hole, and that hole heals without scarring. Instead of making holes, R. Rox Anderson, MD, professor of dermatology at Harvard University, Boston, created a device that picks out the microcolumns of skin.” When these full skin thickness columns of skin are transferred to a wound, Dr. Kirsner noted, “in 3 weeks you can pretty much have no visible or a much improved cosmetic scar. Histologically you don’t see a scar either.”

Dr. Kirsner said he had no relevant financial disclosures.

MIAMI – Another reason not to prescribe opioids for postoperative pain – besides potentially adding to the epidemic the nation – comes from evidence showing these agents can impair wound healing.

In addition, epidermal sutures to close dermatologic surgery sites may be unnecessary if deep suturing is done proficiently. These and other pearls to optimize wound closure were suggested by Robert S. Kirsner, MD, PhD, professor and chair of the department of dermatology and cutaneous surgery at the University of Miami.
 

Avoid opioids for postoperative pain

“We know the opioid epidemic is a big problem. An estimated 5-8 million Americans use them for chronic pain,” Dr. Kirsner said at the Orlando Dermatology Aesthetic and Clinical Conference. “And there has been a steady increase in the use of illicit and prescription opioids.”

Consider skipping epidermal sutures in some cases

Dermatologists who place really good deep sutures when closing a wound might be able to forgo traditional epidural suturing, Dr. Kirsner said. “If you believe the literature, you can actually forget epidermal sutures. That’s hard for us. We’re trained to put epidermal sutures in, and changing habits can be difficult.”

A prospective, randomized study demonstrated no difference in cosmesis at 6 months, for example, in a split scar study where half of each wound was closed with epidural suturing and half was not (Dermatol. Surg. 2015;41:1257-63). In another randomized study, researchers found something similar when comparing buried interrupted subcuticular suturing of wounds with and without adhesive strips to close the epidermis (JAMA Dermatol. 2015;15:862-7). “When they looked at the scars, complications, and cosmesis at 6 months, there was no difference,” Dr. Kirsner said.

“Forget epidermal sutures if you’re brave enough,” he said.

Dr. Kirsner acknowledged that some dermatologists might point out a requirement to evert wound edges with epidermal stitches. “It turns out you don’t need to, again, if you believe the literature.” He cited a randomized, controlled, split scar trial that revealed no difference in cosmetic outcomes according to blinded physician ratings or patient reports at 3 months (J Am Acad Dermatol. 2015;72;668-73). “So maybe the concept of wound eversion is not as important as we were originally taught.”

And speaking of wound edges …
 

When debriding a nonhealing wound ...

There may be something highly abnormal about a nonhealing wound edge, Dr. Kirsner said. In fact, they can be phenotypically and genotypically different from surrounding tissue, including characteristic overexpression of c-Myc and beta catenin. These two factors in higher amounts can inhibit the migration of keratinocytes into a wound to promote healing.

“Sometimes we debride the wound because it’s necrotic,” Dr. Kirsner said. But in the case of a nonhealing wound, it can be more effective to debride the edges to remove the abnormal tissue. “You can change the fortune of a wound by debriding the edge. You want to remove all the abnormal tissue, and give it a chance to heal.” Pathology supports the elevated presence of the c-Myc and beta catenin factors in the “healing incompetent” tissue around the edges of nonhealing wounds, he added.
 

If a patient is unusually anxious or stressed

Stress can impair wound healing by 40%, Dr. Kirsner said (Psychosom Med. 1998;60:362-5). Some anxiety before a dermatologic surgery procedure is normal for many patients, but there also are unusual circumstances. For example, “if a patient comes for cyst excision but learns while in the waiting room that his dog just died,” he said. It’s often better to reschedule the procedure than to proceed.

“What you can do on a daily basis is create a stress-free environment” as well, Dr. Kirsner said.

“From a practical standpoint, things that can impair healing include patient depression, negativism, isolation, and postoperative pain,” he added. The mechanism between elevated stress and impaired wound healing includes release of catecholamines that induce the action of endogenous steroids. This, in turn, can cause a cascade of events that reduce inflammatory cells and their pro-healing cytokines, thereby leading to poor healing.

“All of this is mediated through the love hormone, oxytocin. Maybe someday we will be able to give oxytocin to speed healing.”
 

Two technologies still look good for scarless donor sites

Epidermal grafting and technology based on fractional laser treatments continue to show promise for achieving a scarless donor site for patients who need grafting to promote wound healing, Dr. Kirsner said.

With epidermal grafting, dermatologists can apply a device to lift up on the epidermis from a donor site. The CelluTome Epidermal Harvesting System, for example, achieves this feat by applying both a little heat and some suction. “It creates little domes [of epidermis] in this Easy Bake oven looking device,” Dr. Kirsner said. Without any anesthetic, you place this device on the skin and you get these epidermal grafts in 30 minutes. Then you can transfer them to a sterile dressing and place them on the wound.”

As pointed out in a previous report in Dermatology News, avoiding the need for donor site anesthesia is one advantage of the epidermal grafting technique. In addition, the procedure is generally bloodless because the device does not go deep enough to reach the blood vessels, Dr. Kirsner said. In addition, healing of the donor site can be seen on histology in as little as 2 days.

Transferring the epidermis can promote healing because it also transfers keratinocytes and melanocytes to the wound.

“This technique is also excellent to add skin or cells to someone with pyoderma gangrenosum,” Dr. Kirsner said. “Because of the simplicity and the lack of trauma, you don’t get the pathergy you normally see on someone with pyoderma gangrenosum.”

An Autologous Regeneration of Tissue or ART device that transfers columns of healthy skin to a wound to help regenerate tissue and promote healing is a second technology with a lot of potential, Dr. Kirsner said. “With a fractional laser, you create a hole, and that hole heals without scarring. Instead of making holes, R. Rox Anderson, MD, professor of dermatology at Harvard University, Boston, created a device that picks out the microcolumns of skin.” When these full skin thickness columns of skin are transferred to a wound, Dr. Kirsner noted, “in 3 weeks you can pretty much have no visible or a much improved cosmetic scar. Histologically you don’t see a scar either.”

Dr. Kirsner said he had no relevant financial disclosures.

MIAMI – Another reason not to prescribe opioids for postoperative pain – besides potentially adding to the epidemic the nation – comes from evidence showing these agents can impair wound healing.

In addition, epidermal sutures to close dermatologic surgery sites may be unnecessary if deep suturing is done proficiently. These and other pearls to optimize wound closure were suggested by Robert S. Kirsner, MD, PhD, professor and chair of the department of dermatology and cutaneous surgery at the University of Miami.
 

Avoid opioids for postoperative pain

“We know the opioid epidemic is a big problem. An estimated 5-8 million Americans use them for chronic pain,” Dr. Kirsner said at the Orlando Dermatology Aesthetic and Clinical Conference. “And there has been a steady increase in the use of illicit and prescription opioids.”

Consider skipping epidermal sutures in some cases

Dermatologists who place really good deep sutures when closing a wound might be able to forgo traditional epidural suturing, Dr. Kirsner said. “If you believe the literature, you can actually forget epidermal sutures. That’s hard for us. We’re trained to put epidermal sutures in, and changing habits can be difficult.”

A prospective, randomized study demonstrated no difference in cosmesis at 6 months, for example, in a split scar study where half of each wound was closed with epidural suturing and half was not (Dermatol. Surg. 2015;41:1257-63). In another randomized study, researchers found something similar when comparing buried interrupted subcuticular suturing of wounds with and without adhesive strips to close the epidermis (JAMA Dermatol. 2015;15:862-7). “When they looked at the scars, complications, and cosmesis at 6 months, there was no difference,” Dr. Kirsner said.

“Forget epidermal sutures if you’re brave enough,” he said.

Dr. Kirsner acknowledged that some dermatologists might point out a requirement to evert wound edges with epidermal stitches. “It turns out you don’t need to, again, if you believe the literature.” He cited a randomized, controlled, split scar trial that revealed no difference in cosmetic outcomes according to blinded physician ratings or patient reports at 3 months (J Am Acad Dermatol. 2015;72;668-73). “So maybe the concept of wound eversion is not as important as we were originally taught.”

And speaking of wound edges …
 

When debriding a nonhealing wound ...

There may be something highly abnormal about a nonhealing wound edge, Dr. Kirsner said. In fact, they can be phenotypically and genotypically different from surrounding tissue, including characteristic overexpression of c-Myc and beta catenin. These two factors in higher amounts can inhibit the migration of keratinocytes into a wound to promote healing.

“Sometimes we debride the wound because it’s necrotic,” Dr. Kirsner said. But in the case of a nonhealing wound, it can be more effective to debride the edges to remove the abnormal tissue. “You can change the fortune of a wound by debriding the edge. You want to remove all the abnormal tissue, and give it a chance to heal.” Pathology supports the elevated presence of the c-Myc and beta catenin factors in the “healing incompetent” tissue around the edges of nonhealing wounds, he added.
 

If a patient is unusually anxious or stressed

Stress can impair wound healing by 40%, Dr. Kirsner said (Psychosom Med. 1998;60:362-5). Some anxiety before a dermatologic surgery procedure is normal for many patients, but there also are unusual circumstances. For example, “if a patient comes for cyst excision but learns while in the waiting room that his dog just died,” he said. It’s often better to reschedule the procedure than to proceed.

“What you can do on a daily basis is create a stress-free environment” as well, Dr. Kirsner said.

“From a practical standpoint, things that can impair healing include patient depression, negativism, isolation, and postoperative pain,” he added. The mechanism between elevated stress and impaired wound healing includes release of catecholamines that induce the action of endogenous steroids. This, in turn, can cause a cascade of events that reduce inflammatory cells and their pro-healing cytokines, thereby leading to poor healing.

“All of this is mediated through the love hormone, oxytocin. Maybe someday we will be able to give oxytocin to speed healing.”
 

Two technologies still look good for scarless donor sites

Epidermal grafting and technology based on fractional laser treatments continue to show promise for achieving a scarless donor site for patients who need grafting to promote wound healing, Dr. Kirsner said.

With epidermal grafting, dermatologists can apply a device to lift up on the epidermis from a donor site. The CelluTome Epidermal Harvesting System, for example, achieves this feat by applying both a little heat and some suction. “It creates little domes [of epidermis] in this Easy Bake oven looking device,” Dr. Kirsner said. Without any anesthetic, you place this device on the skin and you get these epidermal grafts in 30 minutes. Then you can transfer them to a sterile dressing and place them on the wound.”

As pointed out in a previous report in Dermatology News, avoiding the need for donor site anesthesia is one advantage of the epidermal grafting technique. In addition, the procedure is generally bloodless because the device does not go deep enough to reach the blood vessels, Dr. Kirsner said. In addition, healing of the donor site can be seen on histology in as little as 2 days.

Transferring the epidermis can promote healing because it also transfers keratinocytes and melanocytes to the wound.

“This technique is also excellent to add skin or cells to someone with pyoderma gangrenosum,” Dr. Kirsner said. “Because of the simplicity and the lack of trauma, you don’t get the pathergy you normally see on someone with pyoderma gangrenosum.”

An Autologous Regeneration of Tissue or ART device that transfers columns of healthy skin to a wound to help regenerate tissue and promote healing is a second technology with a lot of potential, Dr. Kirsner said. “With a fractional laser, you create a hole, and that hole heals without scarring. Instead of making holes, R. Rox Anderson, MD, professor of dermatology at Harvard University, Boston, created a device that picks out the microcolumns of skin.” When these full skin thickness columns of skin are transferred to a wound, Dr. Kirsner noted, “in 3 weeks you can pretty much have no visible or a much improved cosmetic scar. Histologically you don’t see a scar either.”

Dr. Kirsner said he had no relevant financial disclosures.

Practice makes perfect. It also makes the perfect setting for real-world research in rheumatology. Traditionally, however, rheumatologists in day-to-day private practice settings have been hampered by limited opportunities, time constraints, and competition from larger academic medical centers to conduct cutting edge research.

That could soon change. The Norman B. Gaylis, MD, Research Award for Rheumatologists in Community Practice is being relaunched to offer rheumatologists research grants from $50,000-$200,000 per year, for up to 2 years, to drive the field forward. The program stems from a generous $1 million commitment from Dr. Gaylis, a rheumatologist in private practice in Aventura, Fla., in partnership with the Rheumatology Research Foundation.

Courtesy Dr. Norman Gaylis

Investigator-driven initiatives

In addition to financial support, the program will help community rheumatologists with viable ideas, including clinicians with less research experience, to refine their hypothesis and methodology as appropriate. “For example, if someone submits a proposal to study the effect of diet on gout, we, as part of the application process, will help them develop the application so it meets the quality expectations of the review committee,” Dr. Gaylis said. “We want it to be their idea, uniquely, the idea of the application. We can guide them so it will be a quality application,” Dr. Gaylis said. “Then it’s up to them.”

Support from the Foundation will remain available and periodic reports will be required to ensure the research is progressing on schedule. “We don’t expect them to get this turned around in 6 months,” Dr. Gaylis said. “It could be a 2-year study ... or even longer.”

“Understanding their priorities and research interests are very different from their colleagues in academia, the Foundation wants to encourage rheumatologists in a clinical setting to explore their own, independent research ideas,” said Shelley A. Malcolm, director of marketing and communication at the Rheumatology Research Foundation.

“The application process and award terms are tailored for rheumatology health professionals who may not have experience in writing grant proposals, or have time to draft applications similar to those required for NIH funding, because their priority lies in patient care and practice management,” Ms. Malcolm said. The Foundation will begin accepting proposals in March 2018 and up until the July 1, 2018 deadline.
 

Smart but not academic

Dr. Gaylis and the Rheumatology Research Foundation worked together to streamline the process with busy clinicians in mind.

This award is really for the rheumatologist in practice … who is not affiliated with academic institutions. They can be attached as a clinical professor, but they’re not really supported by an institution,” Dr. Gaylis said. “Effectively, this should really allow them to have the flexibility to do the research they feel needs to be done without having to go through the whole administrative process you would normally find in an academic institution.”

Recipients will not be competing with academic medical centers that have “the reputation, the manpower, and the capabilities that in general can swallow up all the research awards available.” This recognizes what the practicing clinician brings to the table without making them feel like they’re wasting their time by applying, Dr. Gaylis added.

“This is not saying that academia doesn’t have its role.” But the award program “levels the playing field.”
 

Keeping it real

Clinical practice “is really a real-world environment. Whether one is trying to understand the possibilities in using treatments differently, approaching patients differently, or seeing outcomes you’re seeing that are different from the standard, controlled, double-blind placebo study that is the norm in academic research,” Dr. Gaylis said.

“This is much more focused on the patient who walks into your office,” he continued. “I believe there are many, many more rheumatologists like me who could embrace this opportunity.” He added, “If I was allowed to, I would apply for it myself.”

The research award program can serve as a platform not only for making new discoveries but also taking drugs that are on the marketplace and using them in different forms or fashions in a successful way, Dr. Gaylis said. “And it doesn’t just have to be medications; it could be behavior mechanisms – understanding which patients might be more responsive to therapies, for example.”

The purpose is to initiate research, including but not limited to, health services research or outcome studies, practice supply and demand, and/or patient communications, Ms. Malcolm said. “The goal of the award is to provide independent investigators with the funding they need to pursue ideas that could lead to important breakthroughs in discovering new treatments and, one day, a cure.”

“Clinical practice is an incredible petri dish for research,” Dr. Gaylis said. “We end up losing a lot of opportunities by pigeonholing most research in academic centers. So if we can show the value and validity and identify clinicians who have the aptitude for this kind of clinical research, I think not only will this award program become more exciting, it will become more valuable.”
 

Maintain career-long clinical curiosity

Clinical practice is a very important point in the journey of being a rheumatologist, Dr. Gaylis said, but research shouldn’t end when you complete your fellowship. “It should continue for your whole career. One should be putting into effect the principles of investigation, the principles of observation, and the principle of generating ideas that are instilled in everyone during their education, but they get diluted as time goes on. We’re trying to prevent that.”

Rheumatologists, or rheumatology health professionals, with an idea or discovery they want to explore are encouraged to reach out to the Foundation staff with any questions or concerns at (404) 365-1373 or [email protected]. Foundation staff will provide assistance, including connecting applicants with a mentor to help simplify the process.

Practice makes perfect. It also makes the perfect setting for real-world research in rheumatology. Traditionally, however, rheumatologists in day-to-day private practice settings have been hampered by limited opportunities, time constraints, and competition from larger academic medical centers to conduct cutting edge research.

That could soon change. The Norman B. Gaylis, MD, Research Award for Rheumatologists in Community Practice is being relaunched to offer rheumatologists research grants from $50,000-$200,000 per year, for up to 2 years, to drive the field forward. The program stems from a generous $1 million commitment from Dr. Gaylis, a rheumatologist in private practice in Aventura, Fla., in partnership with the Rheumatology Research Foundation.

Courtesy Dr. Norman Gaylis

Investigator-driven initiatives

In addition to financial support, the program will help community rheumatologists with viable ideas, including clinicians with less research experience, to refine their hypothesis and methodology as appropriate. “For example, if someone submits a proposal to study the effect of diet on gout, we, as part of the application process, will help them develop the application so it meets the quality expectations of the review committee,” Dr. Gaylis said. “We want it to be their idea, uniquely, the idea of the application. We can guide them so it will be a quality application,” Dr. Gaylis said. “Then it’s up to them.”

Support from the Foundation will remain available and periodic reports will be required to ensure the research is progressing on schedule. “We don’t expect them to get this turned around in 6 months,” Dr. Gaylis said. “It could be a 2-year study ... or even longer.”

“Understanding their priorities and research interests are very different from their colleagues in academia, the Foundation wants to encourage rheumatologists in a clinical setting to explore their own, independent research ideas,” said Shelley A. Malcolm, director of marketing and communication at the Rheumatology Research Foundation.

“The application process and award terms are tailored for rheumatology health professionals who may not have experience in writing grant proposals, or have time to draft applications similar to those required for NIH funding, because their priority lies in patient care and practice management,” Ms. Malcolm said. The Foundation will begin accepting proposals in March 2018 and up until the July 1, 2018 deadline.
 

Smart but not academic

Dr. Gaylis and the Rheumatology Research Foundation worked together to streamline the process with busy clinicians in mind.

This award is really for the rheumatologist in practice … who is not affiliated with academic institutions. They can be attached as a clinical professor, but they’re not really supported by an institution,” Dr. Gaylis said. “Effectively, this should really allow them to have the flexibility to do the research they feel needs to be done without having to go through the whole administrative process you would normally find in an academic institution.”

Recipients will not be competing with academic medical centers that have “the reputation, the manpower, and the capabilities that in general can swallow up all the research awards available.” This recognizes what the practicing clinician brings to the table without making them feel like they’re wasting their time by applying, Dr. Gaylis added.

“This is not saying that academia doesn’t have its role.” But the award program “levels the playing field.”
 

Keeping it real

Clinical practice “is really a real-world environment. Whether one is trying to understand the possibilities in using treatments differently, approaching patients differently, or seeing outcomes you’re seeing that are different from the standard, controlled, double-blind placebo study that is the norm in academic research,” Dr. Gaylis said.

“This is much more focused on the patient who walks into your office,” he continued. “I believe there are many, many more rheumatologists like me who could embrace this opportunity.” He added, “If I was allowed to, I would apply for it myself.”

The research award program can serve as a platform not only for making new discoveries but also taking drugs that are on the marketplace and using them in different forms or fashions in a successful way, Dr. Gaylis said. “And it doesn’t just have to be medications; it could be behavior mechanisms – understanding which patients might be more responsive to therapies, for example.”

The purpose is to initiate research, including but not limited to, health services research or outcome studies, practice supply and demand, and/or patient communications, Ms. Malcolm said. “The goal of the award is to provide independent investigators with the funding they need to pursue ideas that could lead to important breakthroughs in discovering new treatments and, one day, a cure.”

“Clinical practice is an incredible petri dish for research,” Dr. Gaylis said. “We end up losing a lot of opportunities by pigeonholing most research in academic centers. So if we can show the value and validity and identify clinicians who have the aptitude for this kind of clinical research, I think not only will this award program become more exciting, it will become more valuable.”
 

Maintain career-long clinical curiosity

Clinical practice is a very important point in the journey of being a rheumatologist, Dr. Gaylis said, but research shouldn’t end when you complete your fellowship. “It should continue for your whole career. One should be putting into effect the principles of investigation, the principles of observation, and the principle of generating ideas that are instilled in everyone during their education, but they get diluted as time goes on. We’re trying to prevent that.”

Rheumatologists, or rheumatology health professionals, with an idea or discovery they want to explore are encouraged to reach out to the Foundation staff with any questions or concerns at (404) 365-1373 or [email protected]. Foundation staff will provide assistance, including connecting applicants with a mentor to help simplify the process.

Practice makes perfect. It also makes the perfect setting for real-world research in rheumatology. Traditionally, however, rheumatologists in day-to-day private practice settings have been hampered by limited opportunities, time constraints, and competition from larger academic medical centers to conduct cutting edge research.

That could soon change. The Norman B. Gaylis, MD, Research Award for Rheumatologists in Community Practice is being relaunched to offer rheumatologists research grants from $50,000-$200,000 per year, for up to 2 years, to drive the field forward. The program stems from a generous $1 million commitment from Dr. Gaylis, a rheumatologist in private practice in Aventura, Fla., in partnership with the Rheumatology Research Foundation.

Courtesy Dr. Norman Gaylis

Investigator-driven initiatives

In addition to financial support, the program will help community rheumatologists with viable ideas, including clinicians with less research experience, to refine their hypothesis and methodology as appropriate. “For example, if someone submits a proposal to study the effect of diet on gout, we, as part of the application process, will help them develop the application so it meets the quality expectations of the review committee,” Dr. Gaylis said. “We want it to be their idea, uniquely, the idea of the application. We can guide them so it will be a quality application,” Dr. Gaylis said. “Then it’s up to them.”

Support from the Foundation will remain available and periodic reports will be required to ensure the research is progressing on schedule. “We don’t expect them to get this turned around in 6 months,” Dr. Gaylis said. “It could be a 2-year study ... or even longer.”

“Understanding their priorities and research interests are very different from their colleagues in academia, the Foundation wants to encourage rheumatologists in a clinical setting to explore their own, independent research ideas,” said Shelley A. Malcolm, director of marketing and communication at the Rheumatology Research Foundation.

“The application process and award terms are tailored for rheumatology health professionals who may not have experience in writing grant proposals, or have time to draft applications similar to those required for NIH funding, because their priority lies in patient care and practice management,” Ms. Malcolm said. The Foundation will begin accepting proposals in March 2018 and up until the July 1, 2018 deadline.
 

Smart but not academic

Dr. Gaylis and the Rheumatology Research Foundation worked together to streamline the process with busy clinicians in mind.

This award is really for the rheumatologist in practice … who is not affiliated with academic institutions. They can be attached as a clinical professor, but they’re not really supported by an institution,” Dr. Gaylis said. “Effectively, this should really allow them to have the flexibility to do the research they feel needs to be done without having to go through the whole administrative process you would normally find in an academic institution.”

Recipients will not be competing with academic medical centers that have “the reputation, the manpower, and the capabilities that in general can swallow up all the research awards available.” This recognizes what the practicing clinician brings to the table without making them feel like they’re wasting their time by applying, Dr. Gaylis added.

“This is not saying that academia doesn’t have its role.” But the award program “levels the playing field.”
 

Keeping it real

Clinical practice “is really a real-world environment. Whether one is trying to understand the possibilities in using treatments differently, approaching patients differently, or seeing outcomes you’re seeing that are different from the standard, controlled, double-blind placebo study that is the norm in academic research,” Dr. Gaylis said.

“This is much more focused on the patient who walks into your office,” he continued. “I believe there are many, many more rheumatologists like me who could embrace this opportunity.” He added, “If I was allowed to, I would apply for it myself.”

The research award program can serve as a platform not only for making new discoveries but also taking drugs that are on the marketplace and using them in different forms or fashions in a successful way, Dr. Gaylis said. “And it doesn’t just have to be medications; it could be behavior mechanisms – understanding which patients might be more responsive to therapies, for example.”

The purpose is to initiate research, including but not limited to, health services research or outcome studies, practice supply and demand, and/or patient communications, Ms. Malcolm said. “The goal of the award is to provide independent investigators with the funding they need to pursue ideas that could lead to important breakthroughs in discovering new treatments and, one day, a cure.”

“Clinical practice is an incredible petri dish for research,” Dr. Gaylis said. “We end up losing a lot of opportunities by pigeonholing most research in academic centers. So if we can show the value and validity and identify clinicians who have the aptitude for this kind of clinical research, I think not only will this award program become more exciting, it will become more valuable.”
 

Maintain career-long clinical curiosity

Clinical practice is a very important point in the journey of being a rheumatologist, Dr. Gaylis said, but research shouldn’t end when you complete your fellowship. “It should continue for your whole career. One should be putting into effect the principles of investigation, the principles of observation, and the principle of generating ideas that are instilled in everyone during their education, but they get diluted as time goes on. We’re trying to prevent that.”

Rheumatologists, or rheumatology health professionals, with an idea or discovery they want to explore are encouraged to reach out to the Foundation staff with any questions or concerns at (404) 365-1373 or [email protected]. Foundation staff will provide assistance, including connecting applicants with a mentor to help simplify the process.

CHICAGO – “All that vomits is not necessarily GERD,” so distinguishing gastroesophageal reflux disease (GERD) from nonerosive reflux disease (NERD) remains essential when doing a differential diagnosis. Fortunately, five questions backed by increasing evidence can help you make the call.

“Everyone in the room knows babies puke, and babies can puke a lot,” Barry K. Wershil, MD, said at the annual meeting of the American Academy of Pediatrics. The approach to diagnosing GERD is age specific. “Kids who puke tend to outgrow it over time. With development, 95% or more are no longer refluxing at 18 months of age.”

captain_galaxy/Thinkstock

Considerations backed by evidence

Unfortunately, symptoms alone do not always differentiate erosive versus nonerosive esophagitis, Dr. Wershil said, although recurrent vomiting, poor weight gain, anemia, feeding problems, and respiratory problems can be signs of complicated GERD.

He recommended the following five considerations to distinguish GERD from NERD:

• Is the patient exhibiting normal weight gain? If not, ask questions about how the child is being fed. Have the parents started diluting the formula because they think that will take care of the vomiting? Have they begun limiting the amount of formula after observing that the child throws up at 4 ounces but not at 2 ounces?
• Is the patient bleeding or anemic? Hematemesis is rarely the presentation of infants with GERD, but anemia may be.
• Does the patient have respiratory problems (for example, a history of aspiration, recurring wheezing, or cough)?
• Is the patient neurologically normal? If so, that can present a special class of patients in which vomiting may not be just normal infant vomiting.
• Is the patient older than 2 years? We expect 95% of children to outgrow reflux by 18 months, and most children who have physiological reflux will outgrow it by 2 years.

“Those five questions in 1983 had little evidence, but in 2017 there is more evidence that these are the questions to focus on,” Dr. Wershil said.
 

The role of diagnostic testing

Diagnostic testing, such as pH monitoring, impedance testing, and endoscopy, can be useful in specific situations but carry limitations for widespread use, Dr. Wershil said. “Each test has reasons and limitations.”

An upper GI tract series looks only for anatomic anomalies, for example. pH monitoring is still used in many centers, but in general, impedance monitoring has become more common because it can detect both acid and nonacid reflux: “You can get a very detailed analysis of events happening in the esophagus over time.” One caveat Dr. Wershil added is that, “in some instances, we’re unsure how to define this in the pediatric age ranges we treat.”

Endoscopy has a limited role for the rare patients with mucosal changes or erosive esophagitis, he added. Endoscopy is ordered to detect mucosal changes that confirm esophageal erosion. “In all the kids we scope with positive pH, we rarely find erosive esophagitis,” Dr. Wershil said. “What we find more often is NERD. That really represents more of what we see in our patient population.”

“I hope this information is a good starting point to understand the algorithms that get generated,” Dr. Wershil said.

He recommended an algorithm for gastroesophageal reflux prepared by the American Academy of Pediatrics’ Section on Gastroenterology, Hepatology, and Nutrition (Pediatrics. 2013 May. doi: 10.1542/peds.2013-0421). “I think this information is really solidly grounded in evidence.”

Dr. Wershil is a consultant for Alexion Pharmaceuticals; is a member of the speakers bureau for Abbott Nutrition, Mead Johnson Nutrition, and Nutricia; and receives funding from the National Institutes of Health Consortium of Eosinophilic Gastrointestinal Disease Researchers.

CHICAGO – “All that vomits is not necessarily GERD,” so distinguishing gastroesophageal reflux disease (GERD) from nonerosive reflux disease (NERD) remains essential when doing a differential diagnosis. Fortunately, five questions backed by increasing evidence can help you make the call.

“Everyone in the room knows babies puke, and babies can puke a lot,” Barry K. Wershil, MD, said at the annual meeting of the American Academy of Pediatrics. The approach to diagnosing GERD is age specific. “Kids who puke tend to outgrow it over time. With development, 95% or more are no longer refluxing at 18 months of age.”

captain_galaxy/Thinkstock

Considerations backed by evidence

Unfortunately, symptoms alone do not always differentiate erosive versus nonerosive esophagitis, Dr. Wershil said, although recurrent vomiting, poor weight gain, anemia, feeding problems, and respiratory problems can be signs of complicated GERD.

He recommended the following five considerations to distinguish GERD from NERD:

• Is the patient exhibiting normal weight gain? If not, ask questions about how the child is being fed. Have the parents started diluting the formula because they think that will take care of the vomiting? Have they begun limiting the amount of formula after observing that the child throws up at 4 ounces but not at 2 ounces?
• Is the patient bleeding or anemic? Hematemesis is rarely the presentation of infants with GERD, but anemia may be.
• Does the patient have respiratory problems (for example, a history of aspiration, recurring wheezing, or cough)?
• Is the patient neurologically normal? If so, that can present a special class of patients in which vomiting may not be just normal infant vomiting.
• Is the patient older than 2 years? We expect 95% of children to outgrow reflux by 18 months, and most children who have physiological reflux will outgrow it by 2 years.

“Those five questions in 1983 had little evidence, but in 2017 there is more evidence that these are the questions to focus on,” Dr. Wershil said.
 

The role of diagnostic testing

Diagnostic testing, such as pH monitoring, impedance testing, and endoscopy, can be useful in specific situations but carry limitations for widespread use, Dr. Wershil said. “Each test has reasons and limitations.”

An upper GI tract series looks only for anatomic anomalies, for example. pH monitoring is still used in many centers, but in general, impedance monitoring has become more common because it can detect both acid and nonacid reflux: “You can get a very detailed analysis of events happening in the esophagus over time.” One caveat Dr. Wershil added is that, “in some instances, we’re unsure how to define this in the pediatric age ranges we treat.”

Endoscopy has a limited role for the rare patients with mucosal changes or erosive esophagitis, he added. Endoscopy is ordered to detect mucosal changes that confirm esophageal erosion. “In all the kids we scope with positive pH, we rarely find erosive esophagitis,” Dr. Wershil said. “What we find more often is NERD. That really represents more of what we see in our patient population.”

“I hope this information is a good starting point to understand the algorithms that get generated,” Dr. Wershil said.

He recommended an algorithm for gastroesophageal reflux prepared by the American Academy of Pediatrics’ Section on Gastroenterology, Hepatology, and Nutrition (Pediatrics. 2013 May. doi: 10.1542/peds.2013-0421). “I think this information is really solidly grounded in evidence.”

Dr. Wershil is a consultant for Alexion Pharmaceuticals; is a member of the speakers bureau for Abbott Nutrition, Mead Johnson Nutrition, and Nutricia; and receives funding from the National Institutes of Health Consortium of Eosinophilic Gastrointestinal Disease Researchers.

CHICAGO – “All that vomits is not necessarily GERD,” so distinguishing gastroesophageal reflux disease (GERD) from nonerosive reflux disease (NERD) remains essential when doing a differential diagnosis. Fortunately, five questions backed by increasing evidence can help you make the call.

“Everyone in the room knows babies puke, and babies can puke a lot,” Barry K. Wershil, MD, said at the annual meeting of the American Academy of Pediatrics. The approach to diagnosing GERD is age specific. “Kids who puke tend to outgrow it over time. With development, 95% or more are no longer refluxing at 18 months of age.”

captain_galaxy/Thinkstock

Considerations backed by evidence

Unfortunately, symptoms alone do not always differentiate erosive versus nonerosive esophagitis, Dr. Wershil said, although recurrent vomiting, poor weight gain, anemia, feeding problems, and respiratory problems can be signs of complicated GERD.

He recommended the following five considerations to distinguish GERD from NERD:

• Is the patient exhibiting normal weight gain? If not, ask questions about how the child is being fed. Have the parents started diluting the formula because they think that will take care of the vomiting? Have they begun limiting the amount of formula after observing that the child throws up at 4 ounces but not at 2 ounces?
• Is the patient bleeding or anemic? Hematemesis is rarely the presentation of infants with GERD, but anemia may be.
• Does the patient have respiratory problems (for example, a history of aspiration, recurring wheezing, or cough)?
• Is the patient neurologically normal? If so, that can present a special class of patients in which vomiting may not be just normal infant vomiting.
• Is the patient older than 2 years? We expect 95% of children to outgrow reflux by 18 months, and most children who have physiological reflux will outgrow it by 2 years.

“Those five questions in 1983 had little evidence, but in 2017 there is more evidence that these are the questions to focus on,” Dr. Wershil said.
 

The role of diagnostic testing

Diagnostic testing, such as pH monitoring, impedance testing, and endoscopy, can be useful in specific situations but carry limitations for widespread use, Dr. Wershil said. “Each test has reasons and limitations.”

An upper GI tract series looks only for anatomic anomalies, for example. pH monitoring is still used in many centers, but in general, impedance monitoring has become more common because it can detect both acid and nonacid reflux: “You can get a very detailed analysis of events happening in the esophagus over time.” One caveat Dr. Wershil added is that, “in some instances, we’re unsure how to define this in the pediatric age ranges we treat.”

Endoscopy has a limited role for the rare patients with mucosal changes or erosive esophagitis, he added. Endoscopy is ordered to detect mucosal changes that confirm esophageal erosion. “In all the kids we scope with positive pH, we rarely find erosive esophagitis,” Dr. Wershil said. “What we find more often is NERD. That really represents more of what we see in our patient population.”

“I hope this information is a good starting point to understand the algorithms that get generated,” Dr. Wershil said.

He recommended an algorithm for gastroesophageal reflux prepared by the American Academy of Pediatrics’ Section on Gastroenterology, Hepatology, and Nutrition (Pediatrics. 2013 May. doi: 10.1542/peds.2013-0421). “I think this information is really solidly grounded in evidence.”

Dr. Wershil is a consultant for Alexion Pharmaceuticals; is a member of the speakers bureau for Abbott Nutrition, Mead Johnson Nutrition, and Nutricia; and receives funding from the National Institutes of Health Consortium of Eosinophilic Gastrointestinal Disease Researchers.

CHICAGO – Syncope often is misdiagnosed in pediatric patients complaining of chest pain, and a new guideline released in 2017 could guide clinicians toward a more accurate differential diagnosis and help them know when immediate referral to cardiology or the emergency department is warranted.

“There are recent guidelines published this year which are helpful,” said Dr. Barbara Deal, the Getz Professor of Cardiology at Northwestern University in Chicago. “I’d like you to pay attention to the fact that the [guideline states] that a 12-lead ECG should be performed in all pediatric patients presenting with syncope,” which is defined as transient loss of consciousness.

hepatus/iStockphoto

Refer to a pediatric cardiologist

For this reason and others, referral to a pediatric cardiologist is indicated instead of a consult with an adult cardiologist, Dr. Deal said. “You know how your kids will start with ‘no offense.’ Like, ‘no offense, Mom, but your hair looks awful.’ With moderate offense intended, having an adult cardiologist read a pediatric ECG and clear them is not adequate. They will be looking for ischemia or A-fib [atrial fibrillation]; they’re not looking for long QT syndrome, arrhythmogenic cardiomyopathy, or abnormal T waves.”

Early detection of long QT syndrome is optimal, Dr. Deal said, because symptom onset often is between infancy and age 7 years. In addition, mortality is highest in the first 2 decades of life. “I think this could be why adult cardiologists are not as concerned as we are,” Dr. Deal said. “The bad ones die before they reach adulthood.”
 

Ruling out a cardiac cause

The 2017 joint guideline defined syncope as a transient loss of consciousness. “By definition, you pass out, you’re not aware of where you are, and you cannot hear,” Dr. Deal said. If a patient reports they could hear people talking, they may have lost postural tone, but they did not have syncope, she added.

“Sometimes, we see teenagers who are said to pass out and are unresponsive for 5 minutes, 10 minutes, or 20 minutes. I’m usually relieved to hear that because that gets cardiac off the hook,” Dr. Deal said. “There is nothing cardiac that makes you pass out for 20 minutes, unless people are resuscitating you.” She added, “I’m not suggesting it’s not a significant problem that you need to get to the bottom of.”

Noncardiac etiologies can be neurologic, metabolic, drug-induced, or psychogenic. “This is where the detective work comes in.”

Keep clinical suspicion high for psychogenic syncope, Dr. Deal said. Psychogenic episodes stem from significant psychological stress, often something so profoundly bothersome that they cannot cope, such as sexual abuse.

A helpful tip for diagnosing the less worrisome vasovagal syncope is asking whether a patient was sitting to standing or standing a long time before an episode, Dr. Deal said. “A common complaint is that the family went to airport, got up early, didn’t eat, and ended up standing for a long time. Kids will say they don’t feel well, they fall down, and all hell breaks loose.” Other causes of vasovagal syncope include stress, pain, or a situational trigger, for example, when a person faints during a blood draw or immunization.

The 2017 guideline also set forth the evidence behind various medications used to lower the risk of syncope. However, Dr. Deal said, “If syncope only happens every 3 years when you go to an airport, it’s probably not worth daily therapy to prevent that.”

‘The world’s most boring test’

For the most part, lifestyle measures should work to address vasovagal syncope. A tilt table test can be useful to aid the differential diagnosis, but it’s recommended only when the etiology is unclear, Dr. Deal said. On the plus side, the tilt table test allows clinicians to reproduce symptoms in a controlled environment. On the downside, she added, “It’s the world’s most boring test. It’s a challenge for the cardiologist to stay awake. It’s very boring, until all hell breaks loose.”

“I find this helpful in the setting of kids with seizures and for kids with this atypical syncope where you just cannot convince the family that these 20-minute episodes of loss of consciousness are not near-death episodes.”

Dr. Deal had no relevant financial disclosures.

[email protected]

*​This article was updated on 10/25/2017.

CHICAGO – Syncope often is misdiagnosed in pediatric patients complaining of chest pain, and a new guideline released in 2017 could guide clinicians toward a more accurate differential diagnosis and help them know when immediate referral to cardiology or the emergency department is warranted.

“There are recent guidelines published this year which are helpful,” said Dr. Barbara Deal, the Getz Professor of Cardiology at Northwestern University in Chicago. “I’d like you to pay attention to the fact that the [guideline states] that a 12-lead ECG should be performed in all pediatric patients presenting with syncope,” which is defined as transient loss of consciousness.

hepatus/iStockphoto

Refer to a pediatric cardiologist

For this reason and others, referral to a pediatric cardiologist is indicated instead of a consult with an adult cardiologist, Dr. Deal said. “You know how your kids will start with ‘no offense.’ Like, ‘no offense, Mom, but your hair looks awful.’ With moderate offense intended, having an adult cardiologist read a pediatric ECG and clear them is not adequate. They will be looking for ischemia or A-fib [atrial fibrillation]; they’re not looking for long QT syndrome, arrhythmogenic cardiomyopathy, or abnormal T waves.”

Early detection of long QT syndrome is optimal, Dr. Deal said, because symptom onset often is between infancy and age 7 years. In addition, mortality is highest in the first 2 decades of life. “I think this could be why adult cardiologists are not as concerned as we are,” Dr. Deal said. “The bad ones die before they reach adulthood.”
 

Ruling out a cardiac cause

The 2017 joint guideline defined syncope as a transient loss of consciousness. “By definition, you pass out, you’re not aware of where you are, and you cannot hear,” Dr. Deal said. If a patient reports they could hear people talking, they may have lost postural tone, but they did not have syncope, she added.

“Sometimes, we see teenagers who are said to pass out and are unresponsive for 5 minutes, 10 minutes, or 20 minutes. I’m usually relieved to hear that because that gets cardiac off the hook,” Dr. Deal said. “There is nothing cardiac that makes you pass out for 20 minutes, unless people are resuscitating you.” She added, “I’m not suggesting it’s not a significant problem that you need to get to the bottom of.”

Noncardiac etiologies can be neurologic, metabolic, drug-induced, or psychogenic. “This is where the detective work comes in.”

Keep clinical suspicion high for psychogenic syncope, Dr. Deal said. Psychogenic episodes stem from significant psychological stress, often something so profoundly bothersome that they cannot cope, such as sexual abuse.

A helpful tip for diagnosing the less worrisome vasovagal syncope is asking whether a patient was sitting to standing or standing a long time before an episode, Dr. Deal said. “A common complaint is that the family went to airport, got up early, didn’t eat, and ended up standing for a long time. Kids will say they don’t feel well, they fall down, and all hell breaks loose.” Other causes of vasovagal syncope include stress, pain, or a situational trigger, for example, when a person faints during a blood draw or immunization.

The 2017 guideline also set forth the evidence behind various medications used to lower the risk of syncope. However, Dr. Deal said, “If syncope only happens every 3 years when you go to an airport, it’s probably not worth daily therapy to prevent that.”

‘The world’s most boring test’

For the most part, lifestyle measures should work to address vasovagal syncope. A tilt table test can be useful to aid the differential diagnosis, but it’s recommended only when the etiology is unclear, Dr. Deal said. On the plus side, the tilt table test allows clinicians to reproduce symptoms in a controlled environment. On the downside, she added, “It’s the world’s most boring test. It’s a challenge for the cardiologist to stay awake. It’s very boring, until all hell breaks loose.”

“I find this helpful in the setting of kids with seizures and for kids with this atypical syncope where you just cannot convince the family that these 20-minute episodes of loss of consciousness are not near-death episodes.”

Dr. Deal had no relevant financial disclosures.

[email protected]

*​This article was updated on 10/25/2017.

CHICAGO – Syncope often is misdiagnosed in pediatric patients complaining of chest pain, and a new guideline released in 2017 could guide clinicians toward a more accurate differential diagnosis and help them know when immediate referral to cardiology or the emergency department is warranted.

“There are recent guidelines published this year which are helpful,” said Dr. Barbara Deal, the Getz Professor of Cardiology at Northwestern University in Chicago. “I’d like you to pay attention to the fact that the [guideline states] that a 12-lead ECG should be performed in all pediatric patients presenting with syncope,” which is defined as transient loss of consciousness.

hepatus/iStockphoto

Refer to a pediatric cardiologist

For this reason and others, referral to a pediatric cardiologist is indicated instead of a consult with an adult cardiologist, Dr. Deal said. “You know how your kids will start with ‘no offense.’ Like, ‘no offense, Mom, but your hair looks awful.’ With moderate offense intended, having an adult cardiologist read a pediatric ECG and clear them is not adequate. They will be looking for ischemia or A-fib [atrial fibrillation]; they’re not looking for long QT syndrome, arrhythmogenic cardiomyopathy, or abnormal T waves.”

Early detection of long QT syndrome is optimal, Dr. Deal said, because symptom onset often is between infancy and age 7 years. In addition, mortality is highest in the first 2 decades of life. “I think this could be why adult cardiologists are not as concerned as we are,” Dr. Deal said. “The bad ones die before they reach adulthood.”
 

Ruling out a cardiac cause

The 2017 joint guideline defined syncope as a transient loss of consciousness. “By definition, you pass out, you’re not aware of where you are, and you cannot hear,” Dr. Deal said. If a patient reports they could hear people talking, they may have lost postural tone, but they did not have syncope, she added.

“Sometimes, we see teenagers who are said to pass out and are unresponsive for 5 minutes, 10 minutes, or 20 minutes. I’m usually relieved to hear that because that gets cardiac off the hook,” Dr. Deal said. “There is nothing cardiac that makes you pass out for 20 minutes, unless people are resuscitating you.” She added, “I’m not suggesting it’s not a significant problem that you need to get to the bottom of.”

Noncardiac etiologies can be neurologic, metabolic, drug-induced, or psychogenic. “This is where the detective work comes in.”

Keep clinical suspicion high for psychogenic syncope, Dr. Deal said. Psychogenic episodes stem from significant psychological stress, often something so profoundly bothersome that they cannot cope, such as sexual abuse.

A helpful tip for diagnosing the less worrisome vasovagal syncope is asking whether a patient was sitting to standing or standing a long time before an episode, Dr. Deal said. “A common complaint is that the family went to airport, got up early, didn’t eat, and ended up standing for a long time. Kids will say they don’t feel well, they fall down, and all hell breaks loose.” Other causes of vasovagal syncope include stress, pain, or a situational trigger, for example, when a person faints during a blood draw or immunization.

The 2017 guideline also set forth the evidence behind various medications used to lower the risk of syncope. However, Dr. Deal said, “If syncope only happens every 3 years when you go to an airport, it’s probably not worth daily therapy to prevent that.”

‘The world’s most boring test’

For the most part, lifestyle measures should work to address vasovagal syncope. A tilt table test can be useful to aid the differential diagnosis, but it’s recommended only when the etiology is unclear, Dr. Deal said. On the plus side, the tilt table test allows clinicians to reproduce symptoms in a controlled environment. On the downside, she added, “It’s the world’s most boring test. It’s a challenge for the cardiologist to stay awake. It’s very boring, until all hell breaks loose.”

“I find this helpful in the setting of kids with seizures and for kids with this atypical syncope where you just cannot convince the family that these 20-minute episodes of loss of consciousness are not near-death episodes.”

Dr. Deal had no relevant financial disclosures.

[email protected]

*​This article was updated on 10/25/2017.

CHICAGO – When prescribing probiotics in a primary care setting, evidence in the literature supports the efficacy of specific probiotic strains for specific indications. Outside of that, things are less clear.

“In terms of diarrhea, the evidence is positive, but probiotics only provide about 25 hours of benefit. And treatment of antibiotic-associated diarrhea is really dependent on patient adherence,” said Michael D. Cabana, MD. When it comes to treating colic, there is a particular probiotic that looks promising, he added, but the research so far demonstrating effectiveness is limited to breastfed babies. Also, the probiotic therapy appears to work best when started relatively early.

CharlieAJA/Thinkstock

Treating diarrhea and antibiotic-associated diarrhea

When it comes to probiotics for treating acute diarrhea in children, “the literature is actually fairly good here,” Dr. Cabana said. More than 60 studies with an excess of 8,000 participants, the majority with rotavirus infection, suggests probiotics are not associated with any adverse effects and generally shorten duration of diarrhea.

In fact, Dr. Cabana added, multiple meta-analyses support a shorter course of diarrhea. He added, “Look at the units here – it’s hours, not days. You can treat, but on average it’s only 25 hours.” He added that a day less of diarrhea can be significant for patients and parents, however.

In another meta-analysis probiotics, particularly Lactobacillus strains, were analyzed for prevention of antibiotic-associated diarrhea (JAMA. 2012 May 9;307[18]:1959-69). Researchers assessed 63 randomized controlled trials with nearly 12,000 participants. The pooled results showed a statistically significant positive reduction in antibiotic-associated diarrhea (relative risk, 0.58; P less than .001). “Note the number needed to treat to see the effect is 13, so it won’t work in every patient,” Dr. Cabana said.

“So prevention of antibiotic-associated diarrhea is well documented. However, it’s also highly dependent on patent adherence,” he emphasized.
 

The clinical evidence on colic

For treating babies with colic, the best evidence is behind use of Lactobacilus reuteri DSM 17938, Dr. Cabana said. It tends to work best in breastfed infants, babies not on any gastrointestinal meds, and babies that start therapy early in the course of symptoms. “Use in formula-fed infants is unknown, because there are not enough data so far,” he said.

In some cases, during a prenatal visit, soon-to-be-parents will ask if they should start a probiotic to prevent colic. Dr. Cabana has seen only one prophylaxis study for this indication (JAMA Pediatr. 2014 Mar;168[3]:228-33). In the study, 589 infants were randomly allocated to take L. reuteri DSM 17938 or placebo daily for 90 days. At 3 months of age, the researchers discovered a significantly shorter mean duration of daily crying in the probiotic group (38 vs. 71 minutes; P less than .01).
 

What’s known about efficacy for eczema

The evidence for treating a child who presents with eczema with probiotics does not support efficacy in general, Dr. Cabana said. And the evidence on prevention of atopic eczema is mixed.

For example, in a randomized, controlled study from Finland, investigators randomized mothers to receive Lactobacillus GG or placebo during the prenatal period (Lancet. 2001;357:1076-9). Of 132 of the children, 35% were later diagnosed with atopic eczema, and the rate in the probiotic group, 23%, was half the 46% rate in the placebo group.

In contrast, researchers found no benefit regarding prevention of atopic dermatitis when 105 pregnant women were randomized to Lactobacillus GG or placebo. At the age of 2 years, atopic dermatitis was diagnosed in 28% of the 50 children in the probiotic group and 27.3% of the 44 in the placebo group (Pediatrics. 2008;121:e850-6).

The region of Germany where the study was conducted was rural/agricultural, so the diet could be different, Dr. Cabana said. Also, the median duration of breastfeeding differed between the Finnish and German study population, 6.8 months versus 9.2 months, respectively. “So that could potentially explain it, or there are just differences that cannot be explained.”

For more information, Dr. Cabana recommended information provided by the International Scientific Association of Prebiotics & Probiotics (https://isappscience.org/infographics/). The association’s website has easy to understand infographics including: What are probiotics and what can they do for you?; What’s so special about fermented foods?; and How do you read a probiotic label?

Dr. Cabana reported he receives research support from the National Institutes of Health, Wyeth Nutrition, and Nestle; is on the speakers bureau for Merck; owns stocks or bonds in Abbot and AbbVie; and is a consultant for Mead Johnson, Abbott, Genentech, Biogaia, General Mills, and Nestle.

[email protected]

CHICAGO – When prescribing probiotics in a primary care setting, evidence in the literature supports the efficacy of specific probiotic strains for specific indications. Outside of that, things are less clear.

“In terms of diarrhea, the evidence is positive, but probiotics only provide about 25 hours of benefit. And treatment of antibiotic-associated diarrhea is really dependent on patient adherence,” said Michael D. Cabana, MD. When it comes to treating colic, there is a particular probiotic that looks promising, he added, but the research so far demonstrating effectiveness is limited to breastfed babies. Also, the probiotic therapy appears to work best when started relatively early.

CharlieAJA/Thinkstock

Treating diarrhea and antibiotic-associated diarrhea

When it comes to probiotics for treating acute diarrhea in children, “the literature is actually fairly good here,” Dr. Cabana said. More than 60 studies with an excess of 8,000 participants, the majority with rotavirus infection, suggests probiotics are not associated with any adverse effects and generally shorten duration of diarrhea.

In fact, Dr. Cabana added, multiple meta-analyses support a shorter course of diarrhea. He added, “Look at the units here – it’s hours, not days. You can treat, but on average it’s only 25 hours.” He added that a day less of diarrhea can be significant for patients and parents, however.

In another meta-analysis probiotics, particularly Lactobacillus strains, were analyzed for prevention of antibiotic-associated diarrhea (JAMA. 2012 May 9;307[18]:1959-69). Researchers assessed 63 randomized controlled trials with nearly 12,000 participants. The pooled results showed a statistically significant positive reduction in antibiotic-associated diarrhea (relative risk, 0.58; P less than .001). “Note the number needed to treat to see the effect is 13, so it won’t work in every patient,” Dr. Cabana said.

“So prevention of antibiotic-associated diarrhea is well documented. However, it’s also highly dependent on patent adherence,” he emphasized.
 

The clinical evidence on colic

For treating babies with colic, the best evidence is behind use of Lactobacilus reuteri DSM 17938, Dr. Cabana said. It tends to work best in breastfed infants, babies not on any gastrointestinal meds, and babies that start therapy early in the course of symptoms. “Use in formula-fed infants is unknown, because there are not enough data so far,” he said.

In some cases, during a prenatal visit, soon-to-be-parents will ask if they should start a probiotic to prevent colic. Dr. Cabana has seen only one prophylaxis study for this indication (JAMA Pediatr. 2014 Mar;168[3]:228-33). In the study, 589 infants were randomly allocated to take L. reuteri DSM 17938 or placebo daily for 90 days. At 3 months of age, the researchers discovered a significantly shorter mean duration of daily crying in the probiotic group (38 vs. 71 minutes; P less than .01).
 

What’s known about efficacy for eczema

The evidence for treating a child who presents with eczema with probiotics does not support efficacy in general, Dr. Cabana said. And the evidence on prevention of atopic eczema is mixed.

For example, in a randomized, controlled study from Finland, investigators randomized mothers to receive Lactobacillus GG or placebo during the prenatal period (Lancet. 2001;357:1076-9). Of 132 of the children, 35% were later diagnosed with atopic eczema, and the rate in the probiotic group, 23%, was half the 46% rate in the placebo group.

In contrast, researchers found no benefit regarding prevention of atopic dermatitis when 105 pregnant women were randomized to Lactobacillus GG or placebo. At the age of 2 years, atopic dermatitis was diagnosed in 28% of the 50 children in the probiotic group and 27.3% of the 44 in the placebo group (Pediatrics. 2008;121:e850-6).

The region of Germany where the study was conducted was rural/agricultural, so the diet could be different, Dr. Cabana said. Also, the median duration of breastfeeding differed between the Finnish and German study population, 6.8 months versus 9.2 months, respectively. “So that could potentially explain it, or there are just differences that cannot be explained.”

For more information, Dr. Cabana recommended information provided by the International Scientific Association of Prebiotics & Probiotics (https://isappscience.org/infographics/). The association’s website has easy to understand infographics including: What are probiotics and what can they do for you?; What’s so special about fermented foods?; and How do you read a probiotic label?

Dr. Cabana reported he receives research support from the National Institutes of Health, Wyeth Nutrition, and Nestle; is on the speakers bureau for Merck; owns stocks or bonds in Abbot and AbbVie; and is a consultant for Mead Johnson, Abbott, Genentech, Biogaia, General Mills, and Nestle.

[email protected]

CHICAGO – When prescribing probiotics in a primary care setting, evidence in the literature supports the efficacy of specific probiotic strains for specific indications. Outside of that, things are less clear.

“In terms of diarrhea, the evidence is positive, but probiotics only provide about 25 hours of benefit. And treatment of antibiotic-associated diarrhea is really dependent on patient adherence,” said Michael D. Cabana, MD. When it comes to treating colic, there is a particular probiotic that looks promising, he added, but the research so far demonstrating effectiveness is limited to breastfed babies. Also, the probiotic therapy appears to work best when started relatively early.

CharlieAJA/Thinkstock

Treating diarrhea and antibiotic-associated diarrhea

When it comes to probiotics for treating acute diarrhea in children, “the literature is actually fairly good here,” Dr. Cabana said. More than 60 studies with an excess of 8,000 participants, the majority with rotavirus infection, suggests probiotics are not associated with any adverse effects and generally shorten duration of diarrhea.

In fact, Dr. Cabana added, multiple meta-analyses support a shorter course of diarrhea. He added, “Look at the units here – it’s hours, not days. You can treat, but on average it’s only 25 hours.” He added that a day less of diarrhea can be significant for patients and parents, however.

In another meta-analysis probiotics, particularly Lactobacillus strains, were analyzed for prevention of antibiotic-associated diarrhea (JAMA. 2012 May 9;307[18]:1959-69). Researchers assessed 63 randomized controlled trials with nearly 12,000 participants. The pooled results showed a statistically significant positive reduction in antibiotic-associated diarrhea (relative risk, 0.58; P less than .001). “Note the number needed to treat to see the effect is 13, so it won’t work in every patient,” Dr. Cabana said.

“So prevention of antibiotic-associated diarrhea is well documented. However, it’s also highly dependent on patent adherence,” he emphasized.
 

The clinical evidence on colic

For treating babies with colic, the best evidence is behind use of Lactobacilus reuteri DSM 17938, Dr. Cabana said. It tends to work best in breastfed infants, babies not on any gastrointestinal meds, and babies that start therapy early in the course of symptoms. “Use in formula-fed infants is unknown, because there are not enough data so far,” he said.

In some cases, during a prenatal visit, soon-to-be-parents will ask if they should start a probiotic to prevent colic. Dr. Cabana has seen only one prophylaxis study for this indication (JAMA Pediatr. 2014 Mar;168[3]:228-33). In the study, 589 infants were randomly allocated to take L. reuteri DSM 17938 or placebo daily for 90 days. At 3 months of age, the researchers discovered a significantly shorter mean duration of daily crying in the probiotic group (38 vs. 71 minutes; P less than .01).
 

What’s known about efficacy for eczema

The evidence for treating a child who presents with eczema with probiotics does not support efficacy in general, Dr. Cabana said. And the evidence on prevention of atopic eczema is mixed.

For example, in a randomized, controlled study from Finland, investigators randomized mothers to receive Lactobacillus GG or placebo during the prenatal period (Lancet. 2001;357:1076-9). Of 132 of the children, 35% were later diagnosed with atopic eczema, and the rate in the probiotic group, 23%, was half the 46% rate in the placebo group.

In contrast, researchers found no benefit regarding prevention of atopic dermatitis when 105 pregnant women were randomized to Lactobacillus GG or placebo. At the age of 2 years, atopic dermatitis was diagnosed in 28% of the 50 children in the probiotic group and 27.3% of the 44 in the placebo group (Pediatrics. 2008;121:e850-6).

The region of Germany where the study was conducted was rural/agricultural, so the diet could be different, Dr. Cabana said. Also, the median duration of breastfeeding differed between the Finnish and German study population, 6.8 months versus 9.2 months, respectively. “So that could potentially explain it, or there are just differences that cannot be explained.”

For more information, Dr. Cabana recommended information provided by the International Scientific Association of Prebiotics & Probiotics (https://isappscience.org/infographics/). The association’s website has easy to understand infographics including: What are probiotics and what can they do for you?; What’s so special about fermented foods?; and How do you read a probiotic label?

Dr. Cabana reported he receives research support from the National Institutes of Health, Wyeth Nutrition, and Nestle; is on the speakers bureau for Merck; owns stocks or bonds in Abbot and AbbVie; and is a consultant for Mead Johnson, Abbott, Genentech, Biogaia, General Mills, and Nestle.

[email protected]

CHICAGO – Among physicians using generic propranolol to treat infantile hemangioma, 30% reported at least one patient experienced a miscalculation dosing error, a new survey showed. Among respondents who prescribed Hemangeol (Pierre Fabre Pharmaceuticals), 10% reported a similar error. The errors were made by either a provider or caregiver.

Confusion may have contributed to a second source of errors, said Elaine Siegfried, MD, professor of pediatrics and dermatology at St. Louis University in Missouri. Generic propranolol is supplied as a 20-mg/5-mL oral solution and a 40-mg/5-mL oral solution. “Any time you have more than one formulation, it’s a nidus for dispensing error by the pharmacy.”

Wikimedia Commons/Zeimusu/Public Domain

Addressing cost concerns

“When this [branded] drug became available, I wondered why everyone was not prescribing it,” Dr. Siegfried said.

“One of the pushbacks with this drug is that people didn’t want to prescribe it because they thought it was too expensive.” She acknowledged the higher cost, but added the manufacturer has a program to provide the agent free-of-charge to families without health insurance who cannot afford the medicine. She added, “People with private insurance do have higher copays, but insurance generally pays for most of it, depending on the plan.”

Dr. Siegfried also emphasized that the manufacturer invested considerable time and money to bring the agent and its specific pediatric indication to market, generating scientific data on its safety and efficacy along the way. In contrast, generic propranolol has been available in the United States for decades as a beta-blocker. The discovery that the agent also could effectively treat infantile hemangioma was serendipitous, not based on preclinical efficacy, safety, or dosing studies.

An additional benefit of the single-concentration branded formulation is pediatric clinicians might be more comfortable using this agent, Dr. Siegfried said. She described the package insert instructions as straightforward and easy to follow. Also, given a sometimes longer wait to see a pediatric dermatologist because of their shortage in certain parts of the country, having general pediatricians or family physicians gain proficiency in administering the medication could mean earlier treatment of hemangioma. “If you have to wait to get into a specialist, that can delay treatment. The caveat about hemangiomas is the earlier you treat them, the more effective the treatment is.”

“Using propranolol to treat hemangiomas is probably one of the biggest positive changes in my practice. It was very difficult to treat hemangiomas with steroids, vincristine, or other alternatives. Now treatment is ‘cookbook’ and well-tolerated. It’s amazing,” Dr. Siegfried said. “I only prescribe the branded propranolol because of the specialty pharmacy issue, because of the formulation issue, and because we have data that Pierre Fabre paid for,” she added.

Dr. Siegfried is a consultant for Pierre Fabre and served as a principle investigator on phase 3 research. The company did not sponsor the current study, but a coauthor and employee of Pierre Fabre assisted with the logistics of the survey.

CHICAGO – Among physicians using generic propranolol to treat infantile hemangioma, 30% reported at least one patient experienced a miscalculation dosing error, a new survey showed. Among respondents who prescribed Hemangeol (Pierre Fabre Pharmaceuticals), 10% reported a similar error. The errors were made by either a provider or caregiver.

Confusion may have contributed to a second source of errors, said Elaine Siegfried, MD, professor of pediatrics and dermatology at St. Louis University in Missouri. Generic propranolol is supplied as a 20-mg/5-mL oral solution and a 40-mg/5-mL oral solution. “Any time you have more than one formulation, it’s a nidus for dispensing error by the pharmacy.”

Wikimedia Commons/Zeimusu/Public Domain

Addressing cost concerns

“When this [branded] drug became available, I wondered why everyone was not prescribing it,” Dr. Siegfried said.

“One of the pushbacks with this drug is that people didn’t want to prescribe it because they thought it was too expensive.” She acknowledged the higher cost, but added the manufacturer has a program to provide the agent free-of-charge to families without health insurance who cannot afford the medicine. She added, “People with private insurance do have higher copays, but insurance generally pays for most of it, depending on the plan.”

Dr. Siegfried also emphasized that the manufacturer invested considerable time and money to bring the agent and its specific pediatric indication to market, generating scientific data on its safety and efficacy along the way. In contrast, generic propranolol has been available in the United States for decades as a beta-blocker. The discovery that the agent also could effectively treat infantile hemangioma was serendipitous, not based on preclinical efficacy, safety, or dosing studies.

An additional benefit of the single-concentration branded formulation is pediatric clinicians might be more comfortable using this agent, Dr. Siegfried said. She described the package insert instructions as straightforward and easy to follow. Also, given a sometimes longer wait to see a pediatric dermatologist because of their shortage in certain parts of the country, having general pediatricians or family physicians gain proficiency in administering the medication could mean earlier treatment of hemangioma. “If you have to wait to get into a specialist, that can delay treatment. The caveat about hemangiomas is the earlier you treat them, the more effective the treatment is.”

“Using propranolol to treat hemangiomas is probably one of the biggest positive changes in my practice. It was very difficult to treat hemangiomas with steroids, vincristine, or other alternatives. Now treatment is ‘cookbook’ and well-tolerated. It’s amazing,” Dr. Siegfried said. “I only prescribe the branded propranolol because of the specialty pharmacy issue, because of the formulation issue, and because we have data that Pierre Fabre paid for,” she added.

Dr. Siegfried is a consultant for Pierre Fabre and served as a principle investigator on phase 3 research. The company did not sponsor the current study, but a coauthor and employee of Pierre Fabre assisted with the logistics of the survey.

CHICAGO – Among physicians using generic propranolol to treat infantile hemangioma, 30% reported at least one patient experienced a miscalculation dosing error, a new survey showed. Among respondents who prescribed Hemangeol (Pierre Fabre Pharmaceuticals), 10% reported a similar error. The errors were made by either a provider or caregiver.

Confusion may have contributed to a second source of errors, said Elaine Siegfried, MD, professor of pediatrics and dermatology at St. Louis University in Missouri. Generic propranolol is supplied as a 20-mg/5-mL oral solution and a 40-mg/5-mL oral solution. “Any time you have more than one formulation, it’s a nidus for dispensing error by the pharmacy.”

Wikimedia Commons/Zeimusu/Public Domain

Addressing cost concerns

“When this [branded] drug became available, I wondered why everyone was not prescribing it,” Dr. Siegfried said.

“One of the pushbacks with this drug is that people didn’t want to prescribe it because they thought it was too expensive.” She acknowledged the higher cost, but added the manufacturer has a program to provide the agent free-of-charge to families without health insurance who cannot afford the medicine. She added, “People with private insurance do have higher copays, but insurance generally pays for most of it, depending on the plan.”

Dr. Siegfried also emphasized that the manufacturer invested considerable time and money to bring the agent and its specific pediatric indication to market, generating scientific data on its safety and efficacy along the way. In contrast, generic propranolol has been available in the United States for decades as a beta-blocker. The discovery that the agent also could effectively treat infantile hemangioma was serendipitous, not based on preclinical efficacy, safety, or dosing studies.

An additional benefit of the single-concentration branded formulation is pediatric clinicians might be more comfortable using this agent, Dr. Siegfried said. She described the package insert instructions as straightforward and easy to follow. Also, given a sometimes longer wait to see a pediatric dermatologist because of their shortage in certain parts of the country, having general pediatricians or family physicians gain proficiency in administering the medication could mean earlier treatment of hemangioma. “If you have to wait to get into a specialist, that can delay treatment. The caveat about hemangiomas is the earlier you treat them, the more effective the treatment is.”

“Using propranolol to treat hemangiomas is probably one of the biggest positive changes in my practice. It was very difficult to treat hemangiomas with steroids, vincristine, or other alternatives. Now treatment is ‘cookbook’ and well-tolerated. It’s amazing,” Dr. Siegfried said. “I only prescribe the branded propranolol because of the specialty pharmacy issue, because of the formulation issue, and because we have data that Pierre Fabre paid for,” she added.

Dr. Siegfried is a consultant for Pierre Fabre and served as a principle investigator on phase 3 research. The company did not sponsor the current study, but a coauthor and employee of Pierre Fabre assisted with the logistics of the survey.