Denise Napoli

Hospitals with high volumes of patients who have myocardial infarction, heart failure, and pneumonia have lower 30-day mortality rates for each of those conditions, compared with hospitals that treat fewer such patients.

The relationship between hospital volume and mortality diminished among high-volume hospitals, and was no longer significant once the number of patients exceeded a threshold for each condition, according to a cross-sectional analysis of Medicare claims from more than 4,000 hospitals.

The study is the first to examine the relationship between hospital volume and death from heart failure.

It is one of the few studies that examines the link between volume and mortality in myocardial infarction and pneumonia, wrote Dr. Joseph S. Ross of the Mount Sinai School of Medicine, New York, and his associates (N. Engl. J. Med. 2010;362:1110–8).

The researchers analyzed data on fee-for-service Medicare patients aged 65 or older who were hospitalized between Jan. 1, 2004, and Dec. 31, 2006, with myocardial infarction, heart failure, or pneumonia. The mean age for all patients was 80 years. To avoid survival bias, for each patient who had multiple admissions for one of the three conditions in a given year, one admission per year was selected at random for inclusion in the analysis. Transfers between facilities were tallied with the index hospital.

To categorize hospital volume as low, medium, or high, the investigators stratified into quartiles the mean annual number of patients hospitalized for each condition during the 3-year study period.

Hospitals in the first and second quartiles were categorized as low volume, those in the third quartile as medium, and those in the fourth quartile as high.

“A substantial proportion of hospitals in the first quartile of volume were subsequently excluded for having 10 or fewer cases with each condition,” the authors wrote.

For MI, 734,972 patients were included in the analysis. About 10% of hospitals were classified as low volume for MI (17 mean annual patients), 22% as medium volume (70 patients), and 68% as high volume (236 patients). For the 1,324,287 heart failure patients, 13% of hospitals were classified as low volume (42 mean annual patients), 24% as medium volume (157 patients), and 62% as high volume (422 patients). And for the 1,418,252 pneumonia patients, 18% of hospitals were classified as low volume (59 mean annual patients), 26% as medium volume (179 patients), and 56% as high volume (405 patients).

When mortality was compared for low-, medium-, and high-volume hospitals, a jump from a lower category to the next-higher category carried a risk-adjusted odds ratio for 30-day mortality of 0.89 for MI, 0.91 for heart failure, and 0.95 for pneumonia. All three odds ratios were statistically significant.

For each condition, there was a volume threshold above which an increase of 100 patients in the annual volume was not significantly associated with lower 30-day mortality. The threshold was 610 patients for MI, 500 patients for heart failure, and 210 patients for pneumonia, Dr. Ross and his associates reported.

The findings could pave the way for policy makers to “attempt to increase volume at only the smallest-volume hospitals, perhaps by ensuring that small hospitals are not located in proximity to one another” through the use of certificate-of-need regulations or critical-access hospital programs, the authors said.

The study was partly supported by the Centers for Medicare and Medicaid Services and the National Institute on Aging. Several investigators reported financial or other relationships with pharmaceutical firms and insurance companies.

Hospitals with high volumes of patients who have myocardial infarction, heart failure, and pneumonia have lower 30-day mortality rates for each of those conditions, compared with hospitals that treat fewer such patients.

The relationship between hospital volume and mortality diminished among high-volume hospitals, and was no longer significant once the number of patients exceeded a threshold for each condition, according to a cross-sectional analysis of Medicare claims from more than 4,000 hospitals.

The study is the first to examine the relationship between hospital volume and death from heart failure.

It is one of the few studies that examines the link between volume and mortality in myocardial infarction and pneumonia, wrote Dr. Joseph S. Ross of the Mount Sinai School of Medicine, New York, and his associates (N. Engl. J. Med. 2010;362:1110–8).

The researchers analyzed data on fee-for-service Medicare patients aged 65 or older who were hospitalized between Jan. 1, 2004, and Dec. 31, 2006, with myocardial infarction, heart failure, or pneumonia. The mean age for all patients was 80 years. To avoid survival bias, for each patient who had multiple admissions for one of the three conditions in a given year, one admission per year was selected at random for inclusion in the analysis. Transfers between facilities were tallied with the index hospital.

To categorize hospital volume as low, medium, or high, the investigators stratified into quartiles the mean annual number of patients hospitalized for each condition during the 3-year study period.

Hospitals in the first and second quartiles were categorized as low volume, those in the third quartile as medium, and those in the fourth quartile as high.

“A substantial proportion of hospitals in the first quartile of volume were subsequently excluded for having 10 or fewer cases with each condition,” the authors wrote.

For MI, 734,972 patients were included in the analysis. About 10% of hospitals were classified as low volume for MI (17 mean annual patients), 22% as medium volume (70 patients), and 68% as high volume (236 patients). For the 1,324,287 heart failure patients, 13% of hospitals were classified as low volume (42 mean annual patients), 24% as medium volume (157 patients), and 62% as high volume (422 patients). And for the 1,418,252 pneumonia patients, 18% of hospitals were classified as low volume (59 mean annual patients), 26% as medium volume (179 patients), and 56% as high volume (405 patients).

When mortality was compared for low-, medium-, and high-volume hospitals, a jump from a lower category to the next-higher category carried a risk-adjusted odds ratio for 30-day mortality of 0.89 for MI, 0.91 for heart failure, and 0.95 for pneumonia. All three odds ratios were statistically significant.

For each condition, there was a volume threshold above which an increase of 100 patients in the annual volume was not significantly associated with lower 30-day mortality. The threshold was 610 patients for MI, 500 patients for heart failure, and 210 patients for pneumonia, Dr. Ross and his associates reported.

The findings could pave the way for policy makers to “attempt to increase volume at only the smallest-volume hospitals, perhaps by ensuring that small hospitals are not located in proximity to one another” through the use of certificate-of-need regulations or critical-access hospital programs, the authors said.

The study was partly supported by the Centers for Medicare and Medicaid Services and the National Institute on Aging. Several investigators reported financial or other relationships with pharmaceutical firms and insurance companies.

Hospitals with high volumes of patients who have myocardial infarction, heart failure, and pneumonia have lower 30-day mortality rates for each of those conditions, compared with hospitals that treat fewer such patients.

The relationship between hospital volume and mortality diminished among high-volume hospitals, and was no longer significant once the number of patients exceeded a threshold for each condition, according to a cross-sectional analysis of Medicare claims from more than 4,000 hospitals.

The study is the first to examine the relationship between hospital volume and death from heart failure.

It is one of the few studies that examines the link between volume and mortality in myocardial infarction and pneumonia, wrote Dr. Joseph S. Ross of the Mount Sinai School of Medicine, New York, and his associates (N. Engl. J. Med. 2010;362:1110–8).

The researchers analyzed data on fee-for-service Medicare patients aged 65 or older who were hospitalized between Jan. 1, 2004, and Dec. 31, 2006, with myocardial infarction, heart failure, or pneumonia. The mean age for all patients was 80 years. To avoid survival bias, for each patient who had multiple admissions for one of the three conditions in a given year, one admission per year was selected at random for inclusion in the analysis. Transfers between facilities were tallied with the index hospital.

To categorize hospital volume as low, medium, or high, the investigators stratified into quartiles the mean annual number of patients hospitalized for each condition during the 3-year study period.

Hospitals in the first and second quartiles were categorized as low volume, those in the third quartile as medium, and those in the fourth quartile as high.

“A substantial proportion of hospitals in the first quartile of volume were subsequently excluded for having 10 or fewer cases with each condition,” the authors wrote.

For MI, 734,972 patients were included in the analysis. About 10% of hospitals were classified as low volume for MI (17 mean annual patients), 22% as medium volume (70 patients), and 68% as high volume (236 patients). For the 1,324,287 heart failure patients, 13% of hospitals were classified as low volume (42 mean annual patients), 24% as medium volume (157 patients), and 62% as high volume (422 patients). And for the 1,418,252 pneumonia patients, 18% of hospitals were classified as low volume (59 mean annual patients), 26% as medium volume (179 patients), and 56% as high volume (405 patients).

When mortality was compared for low-, medium-, and high-volume hospitals, a jump from a lower category to the next-higher category carried a risk-adjusted odds ratio for 30-day mortality of 0.89 for MI, 0.91 for heart failure, and 0.95 for pneumonia. All three odds ratios were statistically significant.

For each condition, there was a volume threshold above which an increase of 100 patients in the annual volume was not significantly associated with lower 30-day mortality. The threshold was 610 patients for MI, 500 patients for heart failure, and 210 patients for pneumonia, Dr. Ross and his associates reported.

The findings could pave the way for policy makers to “attempt to increase volume at only the smallest-volume hospitals, perhaps by ensuring that small hospitals are not located in proximity to one another” through the use of certificate-of-need regulations or critical-access hospital programs, the authors said.

The study was partly supported by the Centers for Medicare and Medicaid Services and the National Institute on Aging. Several investigators reported financial or other relationships with pharmaceutical firms and insurance companies.

Major Finding: Pancreas transplant recipients had a cumulative incidence of subsequent skin cancer of 4.7% at 2 years, 12.7% by 5 years, and 19.6% by 10 years after transplant.

Data Source: A single-center chart review of patients seen at a tertiary care center from 1996 to 2007, presented in a poster.

Disclosures: Dr. Spanogle stated that he had no relevant financial conflicts to disclose.

NEW YORK — Recipients of pancreas transplants had a 19.6% cumulative incidence of developing skin cancer 10 years after transplant.

Moreover, those patients who developed squamous cell carcinoma (SCC) following transplant were found to have a 56% likelihood of developing a second SCC within 2 years, while patients who developed basal cell carcinoma (BCC) had a 36% chance of recurrence at 2 years.

The data, presented in a poster at the meeting, show that “intensive educational and preventative strategies should be targeted at the pancreas transplant population,” according to Dr. Joshua Spanogle, a resident in the department of dermatology at the Mayo Clinic in Rochester, Minn.

Dr. Spanogle and his colleagues looked at 216 pancreas transplant recipients seen at a tertiary care center between 1996 and 2007. About half of the subjects were male, and the average age was 43 years, with a range of 21–71 years.

Overall, 107 patients in the study received their pancreas transplant following a prior kidney transplant and were referred to as the “pancreas after kidney” group.

A total of 67 patients received a pancreas transplant and did not receive a new kidney, and were known as the “pancreas transplant alone” group. Forty-two patients were in the “simultaneous pancreas-kidney” transplant group.

For all transplant recipients, the cumulative incidence of developing any skin cancer was 4.7% by 2 years. The cumulative incidence rose to 12.7% by 5 years and 19.6% by 10 years post transplant, Dr. Spanogle reported at the meeting.

Looking at SCC specifically, the cumulative incidence was 2.8% at 2 years, 10.3% at 5 years, and 16.7% at 10 years. For BCC, the cumulative incidence rates were 2.4%, 7.8%, and 17.4% at 2, 5, and 10 years, respectively, he wrote.

Once patients were found to have an SCC, however, the chance of developing a second SCC within 2 years rose: There was a 56% cumulative incidence of subsequent SCC in that population.

The risk for a second BCC after an initial posttransplant BCC diagnosis was also high, though less dramatic: The cumulative incidence for BCCs in the posttransplant, post–BCC-diagnosis population was 36%.

“None of the following variables were associated with an increased risk of skin cancer: type of transplant, induction therapy, initial immunosuppressive regimen, rejection status, or sex,” he pointed out.

Only age was a significant predictor of the development of skin cancer, with a hazard ratio of 1.05, according to the investigation findings.

Major Finding: Pancreas transplant recipients had a cumulative incidence of subsequent skin cancer of 4.7% at 2 years, 12.7% by 5 years, and 19.6% by 10 years after transplant.

Data Source: A single-center chart review of patients seen at a tertiary care center from 1996 to 2007, presented in a poster.

Disclosures: Dr. Spanogle stated that he had no relevant financial conflicts to disclose.

NEW YORK — Recipients of pancreas transplants had a 19.6% cumulative incidence of developing skin cancer 10 years after transplant.

Moreover, those patients who developed squamous cell carcinoma (SCC) following transplant were found to have a 56% likelihood of developing a second SCC within 2 years, while patients who developed basal cell carcinoma (BCC) had a 36% chance of recurrence at 2 years.

The data, presented in a poster at the meeting, show that “intensive educational and preventative strategies should be targeted at the pancreas transplant population,” according to Dr. Joshua Spanogle, a resident in the department of dermatology at the Mayo Clinic in Rochester, Minn.

Dr. Spanogle and his colleagues looked at 216 pancreas transplant recipients seen at a tertiary care center between 1996 and 2007. About half of the subjects were male, and the average age was 43 years, with a range of 21–71 years.

Overall, 107 patients in the study received their pancreas transplant following a prior kidney transplant and were referred to as the “pancreas after kidney” group.

A total of 67 patients received a pancreas transplant and did not receive a new kidney, and were known as the “pancreas transplant alone” group. Forty-two patients were in the “simultaneous pancreas-kidney” transplant group.

For all transplant recipients, the cumulative incidence of developing any skin cancer was 4.7% by 2 years. The cumulative incidence rose to 12.7% by 5 years and 19.6% by 10 years post transplant, Dr. Spanogle reported at the meeting.

Looking at SCC specifically, the cumulative incidence was 2.8% at 2 years, 10.3% at 5 years, and 16.7% at 10 years. For BCC, the cumulative incidence rates were 2.4%, 7.8%, and 17.4% at 2, 5, and 10 years, respectively, he wrote.

Once patients were found to have an SCC, however, the chance of developing a second SCC within 2 years rose: There was a 56% cumulative incidence of subsequent SCC in that population.

The risk for a second BCC after an initial posttransplant BCC diagnosis was also high, though less dramatic: The cumulative incidence for BCCs in the posttransplant, post–BCC-diagnosis population was 36%.

“None of the following variables were associated with an increased risk of skin cancer: type of transplant, induction therapy, initial immunosuppressive regimen, rejection status, or sex,” he pointed out.

Only age was a significant predictor of the development of skin cancer, with a hazard ratio of 1.05, according to the investigation findings.

Major Finding: Pancreas transplant recipients had a cumulative incidence of subsequent skin cancer of 4.7% at 2 years, 12.7% by 5 years, and 19.6% by 10 years after transplant.

Data Source: A single-center chart review of patients seen at a tertiary care center from 1996 to 2007, presented in a poster.

Disclosures: Dr. Spanogle stated that he had no relevant financial conflicts to disclose.

NEW YORK — Recipients of pancreas transplants had a 19.6% cumulative incidence of developing skin cancer 10 years after transplant.

Moreover, those patients who developed squamous cell carcinoma (SCC) following transplant were found to have a 56% likelihood of developing a second SCC within 2 years, while patients who developed basal cell carcinoma (BCC) had a 36% chance of recurrence at 2 years.

The data, presented in a poster at the meeting, show that “intensive educational and preventative strategies should be targeted at the pancreas transplant population,” according to Dr. Joshua Spanogle, a resident in the department of dermatology at the Mayo Clinic in Rochester, Minn.

Dr. Spanogle and his colleagues looked at 216 pancreas transplant recipients seen at a tertiary care center between 1996 and 2007. About half of the subjects were male, and the average age was 43 years, with a range of 21–71 years.

Overall, 107 patients in the study received their pancreas transplant following a prior kidney transplant and were referred to as the “pancreas after kidney” group.

A total of 67 patients received a pancreas transplant and did not receive a new kidney, and were known as the “pancreas transplant alone” group. Forty-two patients were in the “simultaneous pancreas-kidney” transplant group.

For all transplant recipients, the cumulative incidence of developing any skin cancer was 4.7% by 2 years. The cumulative incidence rose to 12.7% by 5 years and 19.6% by 10 years post transplant, Dr. Spanogle reported at the meeting.

Looking at SCC specifically, the cumulative incidence was 2.8% at 2 years, 10.3% at 5 years, and 16.7% at 10 years. For BCC, the cumulative incidence rates were 2.4%, 7.8%, and 17.4% at 2, 5, and 10 years, respectively, he wrote.

Once patients were found to have an SCC, however, the chance of developing a second SCC within 2 years rose: There was a 56% cumulative incidence of subsequent SCC in that population.

The risk for a second BCC after an initial posttransplant BCC diagnosis was also high, though less dramatic: The cumulative incidence for BCCs in the posttransplant, post–BCC-diagnosis population was 36%.

“None of the following variables were associated with an increased risk of skin cancer: type of transplant, induction therapy, initial immunosuppressive regimen, rejection status, or sex,” he pointed out.

Only age was a significant predictor of the development of skin cancer, with a hazard ratio of 1.05, according to the investigation findings.

NEW YORK - Regular examination of the vulva for skin cancer may be indicated for women with at least one first- or second-degree relative with melanoma.

However, in a small pilot study, only one out of seven dermatologists surveyed reported always examining the vulvar on routine examinations.

In a poster presented at the annual meeting of the American College of Mohs Surgery, Dr. Michael Krathen and Dr. Daniel S. Loo of the dermatology department at Tufts Medical Center in Boston, surveyed 13 attending gynecologists and dermatologists recruited from both Tufts and the Boston Medical Center.

Among the gynecologists, 12 of 13 responded that they "agree or agree strongly that the diagnosis of vulvar melanoma is their responsibility," although 11 of 13 agreed that it is the coresponsibility of the dermatologist to diagnose vulvar melanoma.

Meanwhile, among the dermatologists, only one out of the seven agreed with the statement that they "always" examine the vulva on routine annular exams; four said they do "sometimes," and two stated that they do so "often."
Dr. Krathen and Dr. Loo also examined the charts of 10 patients with malignant melanoma (MM) diagnoses and 3 patients who had malignant melanoma in situ (MMIS).

"The medical charts reviewed were almost all from Tufts," said Dr. Krathen in an interview. "Only one case of vulvar melanoma was identified from Boston Medical Center, perhaps because of the greater diversity in racial groups served by this hospital."

For the MM patients, the average depth of invasion was 4.1 mm, the mean age was 69 years, and at least seven were white. Two of the patients had a brother with MM. Five cases presented as persistent bleeding, itching, or as a "nonhealing erosion."

Looking at the MMIS patients, the average age was 24 years. One case had a second-degree relative with a MM history. Only one of the three presented to the gynecologist specifically because of the melanoma (after becoming concerned about pigment change); the other two presented complaining of dysmenorrheal and abdominal pain, and the lesion was discovered incidentally.

"The standard of care should be to offer examination of the external genitalia in all patients, especially those with a family history of malignant melanoma," said Dr. Krathen.

"Furthermore, reminding female patients to self-examine this area with a hand-held mirror and to ensure that their gynecologist examines the external genitalia during regular examinations is recommended as well."

Dr. Loo and Dr. Krathen reported having no disclosures.

NEW YORK - Regular examination of the vulva for skin cancer may be indicated for women with at least one first- or second-degree relative with melanoma.

However, in a small pilot study, only one out of seven dermatologists surveyed reported always examining the vulvar on routine examinations.

In a poster presented at the annual meeting of the American College of Mohs Surgery, Dr. Michael Krathen and Dr. Daniel S. Loo of the dermatology department at Tufts Medical Center in Boston, surveyed 13 attending gynecologists and dermatologists recruited from both Tufts and the Boston Medical Center.

Among the gynecologists, 12 of 13 responded that they "agree or agree strongly that the diagnosis of vulvar melanoma is their responsibility," although 11 of 13 agreed that it is the coresponsibility of the dermatologist to diagnose vulvar melanoma.

Meanwhile, among the dermatologists, only one out of the seven agreed with the statement that they "always" examine the vulva on routine annular exams; four said they do "sometimes," and two stated that they do so "often."
Dr. Krathen and Dr. Loo also examined the charts of 10 patients with malignant melanoma (MM) diagnoses and 3 patients who had malignant melanoma in situ (MMIS).

"The medical charts reviewed were almost all from Tufts," said Dr. Krathen in an interview. "Only one case of vulvar melanoma was identified from Boston Medical Center, perhaps because of the greater diversity in racial groups served by this hospital."

For the MM patients, the average depth of invasion was 4.1 mm, the mean age was 69 years, and at least seven were white. Two of the patients had a brother with MM. Five cases presented as persistent bleeding, itching, or as a "nonhealing erosion."

Looking at the MMIS patients, the average age was 24 years. One case had a second-degree relative with a MM history. Only one of the three presented to the gynecologist specifically because of the melanoma (after becoming concerned about pigment change); the other two presented complaining of dysmenorrheal and abdominal pain, and the lesion was discovered incidentally.

"The standard of care should be to offer examination of the external genitalia in all patients, especially those with a family history of malignant melanoma," said Dr. Krathen.

"Furthermore, reminding female patients to self-examine this area with a hand-held mirror and to ensure that their gynecologist examines the external genitalia during regular examinations is recommended as well."

Dr. Loo and Dr. Krathen reported having no disclosures.

NEW YORK - Regular examination of the vulva for skin cancer may be indicated for women with at least one first- or second-degree relative with melanoma.

However, in a small pilot study, only one out of seven dermatologists surveyed reported always examining the vulvar on routine examinations.

In a poster presented at the annual meeting of the American College of Mohs Surgery, Dr. Michael Krathen and Dr. Daniel S. Loo of the dermatology department at Tufts Medical Center in Boston, surveyed 13 attending gynecologists and dermatologists recruited from both Tufts and the Boston Medical Center.

Among the gynecologists, 12 of 13 responded that they "agree or agree strongly that the diagnosis of vulvar melanoma is their responsibility," although 11 of 13 agreed that it is the coresponsibility of the dermatologist to diagnose vulvar melanoma.

Meanwhile, among the dermatologists, only one out of the seven agreed with the statement that they "always" examine the vulva on routine annular exams; four said they do "sometimes," and two stated that they do so "often."
Dr. Krathen and Dr. Loo also examined the charts of 10 patients with malignant melanoma (MM) diagnoses and 3 patients who had malignant melanoma in situ (MMIS).

"The medical charts reviewed were almost all from Tufts," said Dr. Krathen in an interview. "Only one case of vulvar melanoma was identified from Boston Medical Center, perhaps because of the greater diversity in racial groups served by this hospital."

For the MM patients, the average depth of invasion was 4.1 mm, the mean age was 69 years, and at least seven were white. Two of the patients had a brother with MM. Five cases presented as persistent bleeding, itching, or as a "nonhealing erosion."

Looking at the MMIS patients, the average age was 24 years. One case had a second-degree relative with a MM history. Only one of the three presented to the gynecologist specifically because of the melanoma (after becoming concerned about pigment change); the other two presented complaining of dysmenorrheal and abdominal pain, and the lesion was discovered incidentally.

"The standard of care should be to offer examination of the external genitalia in all patients, especially those with a family history of malignant melanoma," said Dr. Krathen.

"Furthermore, reminding female patients to self-examine this area with a hand-held mirror and to ensure that their gynecologist examines the external genitalia during regular examinations is recommended as well."

Dr. Loo and Dr. Krathen reported having no disclosures.

Improper use of "physician extenders," a lack of informed consent, and patient dissatisfaction are some of the top reasons why patients sue, and all are easily preventable, according to Dr. David J. Goldberg.

The first - the use of unsupervised or improperly trained physician assistants, nurse practitioners, or other physician extenders - hits home for many dermatologists. According to the American Academy of Dermatology, in 2010, 36% of physicians will use NPs and PAs in their practice, up from 30% in 2007 and 20% in 2002, Dr. Goldberg said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation in Santa Monica, Calif.

"NPs and PAs who work for core physicians are clearly the most qualified nonphysicians to perform these procedures," said Dr. Goldberg, director of dermatologic laser research at Mount Sinai School of Medicine, New York. Many have received cosmetic training through the Aesthetic Extender Symposium (www.aestheticextendersymposium.com), he said.

However, there are still risks. A 2006 American Society for Dermatologic Surgery survey found that 51% of ASDS members reported seeing nonphysician, nonsupervised physician-extender complications in their practice, with the two most common being misdiagnosed skin cancer and scarring following dermatologic procedures.

"If the [physician extender] is sued, so will be the provider who is affiliated with the PE," said Dr. Goldberg, who also is on the faculty of Fordham University School of Law in New York.

Poorly informed or uninformed consent is another moneymaker for medical malpractice lawyers in the field of dermatology, according to Dr. Goldberg. "Because dermatologists tend to see large numbers of patients, there is a tendency to be overwhelmed by the paperwork associated with quality informed consent," he said.

One procedure to be especially careful about is botulinum toxin type A injections - there were 2,464,123 in 2008, according to the American Society for Aesthetic Plastic Surgery. The black box warning on Botox reads "swallowing and breathing difficulties can be life threatening and there have been reports of death."

Dr. Goldberg encouraged physicians to instruct patients to read the warning on botulinum toxin "each and every time" they receive it. He also encouraged discussion about these risks and the procedure's other rare but potential side effects, including generalized muscle weakness, diplopia, ptosis, dysphagia, dysphonia, dysarthria, and urinary incontinence.

He noted that many of these potential complications have never been reported with the cosmetic use of botulinum toxin.

Finally, Dr. Goldberg said that dermatologists can keep legal troubles at bay simply by keeping patients happy. He cited a 2006 retrospective chart study of all patients who received botulinum toxin injections over a 2-year period at a private dermatology clinic. The retention rate was 55%. However, the "institution of a 2-week posttreatment evaluation increased the retention rate from 55% to 67%," said Dr. Goldberg (Dermatol. Surg. 2006;32:212-5).

"Probably more important in keeping patients happy - and keeping them coming back - is to communicate with patients," he advised. "Treat each patient as if they are special. Pay total attention to their concerns. They will appreciate your one-on-one interaction with them."

Dr. Goldberg is a founding director of the Aesthetic Extended Symposium. SDEF and this news organization are owned by Elsevier.

Improper use of "physician extenders," a lack of informed consent, and patient dissatisfaction are some of the top reasons why patients sue, and all are easily preventable, according to Dr. David J. Goldberg.

The first - the use of unsupervised or improperly trained physician assistants, nurse practitioners, or other physician extenders - hits home for many dermatologists. According to the American Academy of Dermatology, in 2010, 36% of physicians will use NPs and PAs in their practice, up from 30% in 2007 and 20% in 2002, Dr. Goldberg said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation in Santa Monica, Calif.

"NPs and PAs who work for core physicians are clearly the most qualified nonphysicians to perform these procedures," said Dr. Goldberg, director of dermatologic laser research at Mount Sinai School of Medicine, New York. Many have received cosmetic training through the Aesthetic Extender Symposium (www.aestheticextendersymposium.com), he said.

However, there are still risks. A 2006 American Society for Dermatologic Surgery survey found that 51% of ASDS members reported seeing nonphysician, nonsupervised physician-extender complications in their practice, with the two most common being misdiagnosed skin cancer and scarring following dermatologic procedures.

"If the [physician extender] is sued, so will be the provider who is affiliated with the PE," said Dr. Goldberg, who also is on the faculty of Fordham University School of Law in New York.

Poorly informed or uninformed consent is another moneymaker for medical malpractice lawyers in the field of dermatology, according to Dr. Goldberg. "Because dermatologists tend to see large numbers of patients, there is a tendency to be overwhelmed by the paperwork associated with quality informed consent," he said.

One procedure to be especially careful about is botulinum toxin type A injections - there were 2,464,123 in 2008, according to the American Society for Aesthetic Plastic Surgery. The black box warning on Botox reads "swallowing and breathing difficulties can be life threatening and there have been reports of death."

Dr. Goldberg encouraged physicians to instruct patients to read the warning on botulinum toxin "each and every time" they receive it. He also encouraged discussion about these risks and the procedure's other rare but potential side effects, including generalized muscle weakness, diplopia, ptosis, dysphagia, dysphonia, dysarthria, and urinary incontinence.

He noted that many of these potential complications have never been reported with the cosmetic use of botulinum toxin.

Finally, Dr. Goldberg said that dermatologists can keep legal troubles at bay simply by keeping patients happy. He cited a 2006 retrospective chart study of all patients who received botulinum toxin injections over a 2-year period at a private dermatology clinic. The retention rate was 55%. However, the "institution of a 2-week posttreatment evaluation increased the retention rate from 55% to 67%," said Dr. Goldberg (Dermatol. Surg. 2006;32:212-5).

"Probably more important in keeping patients happy - and keeping them coming back - is to communicate with patients," he advised. "Treat each patient as if they are special. Pay total attention to their concerns. They will appreciate your one-on-one interaction with them."

Dr. Goldberg is a founding director of the Aesthetic Extended Symposium. SDEF and this news organization are owned by Elsevier.

Improper use of "physician extenders," a lack of informed consent, and patient dissatisfaction are some of the top reasons why patients sue, and all are easily preventable, according to Dr. David J. Goldberg.

The first - the use of unsupervised or improperly trained physician assistants, nurse practitioners, or other physician extenders - hits home for many dermatologists. According to the American Academy of Dermatology, in 2010, 36% of physicians will use NPs and PAs in their practice, up from 30% in 2007 and 20% in 2002, Dr. Goldberg said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation in Santa Monica, Calif.

"NPs and PAs who work for core physicians are clearly the most qualified nonphysicians to perform these procedures," said Dr. Goldberg, director of dermatologic laser research at Mount Sinai School of Medicine, New York. Many have received cosmetic training through the Aesthetic Extender Symposium (www.aestheticextendersymposium.com), he said.

However, there are still risks. A 2006 American Society for Dermatologic Surgery survey found that 51% of ASDS members reported seeing nonphysician, nonsupervised physician-extender complications in their practice, with the two most common being misdiagnosed skin cancer and scarring following dermatologic procedures.

"If the [physician extender] is sued, so will be the provider who is affiliated with the PE," said Dr. Goldberg, who also is on the faculty of Fordham University School of Law in New York.

Poorly informed or uninformed consent is another moneymaker for medical malpractice lawyers in the field of dermatology, according to Dr. Goldberg. "Because dermatologists tend to see large numbers of patients, there is a tendency to be overwhelmed by the paperwork associated with quality informed consent," he said.

One procedure to be especially careful about is botulinum toxin type A injections - there were 2,464,123 in 2008, according to the American Society for Aesthetic Plastic Surgery. The black box warning on Botox reads "swallowing and breathing difficulties can be life threatening and there have been reports of death."

Dr. Goldberg encouraged physicians to instruct patients to read the warning on botulinum toxin "each and every time" they receive it. He also encouraged discussion about these risks and the procedure's other rare but potential side effects, including generalized muscle weakness, diplopia, ptosis, dysphagia, dysphonia, dysarthria, and urinary incontinence.

He noted that many of these potential complications have never been reported with the cosmetic use of botulinum toxin.

Finally, Dr. Goldberg said that dermatologists can keep legal troubles at bay simply by keeping patients happy. He cited a 2006 retrospective chart study of all patients who received botulinum toxin injections over a 2-year period at a private dermatology clinic. The retention rate was 55%. However, the "institution of a 2-week posttreatment evaluation increased the retention rate from 55% to 67%," said Dr. Goldberg (Dermatol. Surg. 2006;32:212-5).

"Probably more important in keeping patients happy - and keeping them coming back - is to communicate with patients," he advised. "Treat each patient as if they are special. Pay total attention to their concerns. They will appreciate your one-on-one interaction with them."

Dr. Goldberg is a founding director of the Aesthetic Extended Symposium. SDEF and this news organization are owned by Elsevier.

Ultrasound and related radiofrequency technologies are relatively novel, effective, and noninvasive methods for body contouring and localized skin tightening, according to Dr. David J. Goldberg.

The only cosmetic ultrasound therapy currently approved by the Food and Drug Administration is the Ulthera System for skin tightening, Dr. Goldberg said at a cosmetic dermatology seminar sponsored by the Skin Disease Education Foundation in Santa Monica, Calif. The device non-specifically heats deep dermal collagen, which is thought to tighten cellulite.

In a 2008 study led by Dr. Goldberg, director of dermatologic laser research at Mount Sinai School of Medicine, New York, 30 female patients underwent six treatments with a unipolar radiofrequency device directed at cellulite on their upper thighs.

Following treatment, 27 of 30 patients had clinical improvements, with a mean decrease in thigh circumference of 2.45 cm (Dermatol. Surg. 2008;34:204-9).

The treatment was "fairly painless," he said. Side effects included post treatment erythema, which lasted for about 30-120 minutes; there were no blisters, scars, or pigmentary changes.

Another technology, known as UltraShape, delivers focused ultrasound to dissolve unwanted fat. In a recent multi-center, single-treatment, controlled study, 82% of 162 patients had measurable reductions in the circumference of their thighs, abdomens, and flanks. The decreases averaged 2 cm at 28 days, and were maintained at 84 days post treatment.

In the study, presented at the 2009 International Masters Course on Aging Skin in Paris, 76% of patients reported being satisfied with a single treatment, and 92% reported having no pain or discomfort.

According to Dr. Goldberg, UltraShape is currently used in over 57 countries. Approval has not yet been granted in the United States.

Dr. Goldberg disclosed receiving research grants from Alma Lasers, Thermage, Cynosure, UltraShape and Zeltiq, all makers of laser, ultrasound and radiofrequency skin-tightening and body-contouring technologies. SDEF and this news organization are owned by Elsevier.

Ultrasound and related radiofrequency technologies are relatively novel, effective, and noninvasive methods for body contouring and localized skin tightening, according to Dr. David J. Goldberg.

The only cosmetic ultrasound therapy currently approved by the Food and Drug Administration is the Ulthera System for skin tightening, Dr. Goldberg said at a cosmetic dermatology seminar sponsored by the Skin Disease Education Foundation in Santa Monica, Calif. The device non-specifically heats deep dermal collagen, which is thought to tighten cellulite.

In a 2008 study led by Dr. Goldberg, director of dermatologic laser research at Mount Sinai School of Medicine, New York, 30 female patients underwent six treatments with a unipolar radiofrequency device directed at cellulite on their upper thighs.

Following treatment, 27 of 30 patients had clinical improvements, with a mean decrease in thigh circumference of 2.45 cm (Dermatol. Surg. 2008;34:204-9).

The treatment was "fairly painless," he said. Side effects included post treatment erythema, which lasted for about 30-120 minutes; there were no blisters, scars, or pigmentary changes.

Another technology, known as UltraShape, delivers focused ultrasound to dissolve unwanted fat. In a recent multi-center, single-treatment, controlled study, 82% of 162 patients had measurable reductions in the circumference of their thighs, abdomens, and flanks. The decreases averaged 2 cm at 28 days, and were maintained at 84 days post treatment.

In the study, presented at the 2009 International Masters Course on Aging Skin in Paris, 76% of patients reported being satisfied with a single treatment, and 92% reported having no pain or discomfort.

According to Dr. Goldberg, UltraShape is currently used in over 57 countries. Approval has not yet been granted in the United States.

Dr. Goldberg disclosed receiving research grants from Alma Lasers, Thermage, Cynosure, UltraShape and Zeltiq, all makers of laser, ultrasound and radiofrequency skin-tightening and body-contouring technologies. SDEF and this news organization are owned by Elsevier.

Ultrasound and related radiofrequency technologies are relatively novel, effective, and noninvasive methods for body contouring and localized skin tightening, according to Dr. David J. Goldberg.

The only cosmetic ultrasound therapy currently approved by the Food and Drug Administration is the Ulthera System for skin tightening, Dr. Goldberg said at a cosmetic dermatology seminar sponsored by the Skin Disease Education Foundation in Santa Monica, Calif. The device non-specifically heats deep dermal collagen, which is thought to tighten cellulite.

In a 2008 study led by Dr. Goldberg, director of dermatologic laser research at Mount Sinai School of Medicine, New York, 30 female patients underwent six treatments with a unipolar radiofrequency device directed at cellulite on their upper thighs.

Following treatment, 27 of 30 patients had clinical improvements, with a mean decrease in thigh circumference of 2.45 cm (Dermatol. Surg. 2008;34:204-9).

The treatment was "fairly painless," he said. Side effects included post treatment erythema, which lasted for about 30-120 minutes; there were no blisters, scars, or pigmentary changes.

Another technology, known as UltraShape, delivers focused ultrasound to dissolve unwanted fat. In a recent multi-center, single-treatment, controlled study, 82% of 162 patients had measurable reductions in the circumference of their thighs, abdomens, and flanks. The decreases averaged 2 cm at 28 days, and were maintained at 84 days post treatment.

In the study, presented at the 2009 International Masters Course on Aging Skin in Paris, 76% of patients reported being satisfied with a single treatment, and 92% reported having no pain or discomfort.

According to Dr. Goldberg, UltraShape is currently used in over 57 countries. Approval has not yet been granted in the United States.

Dr. Goldberg disclosed receiving research grants from Alma Lasers, Thermage, Cynosure, UltraShape and Zeltiq, all makers of laser, ultrasound and radiofrequency skin-tightening and body-contouring technologies. SDEF and this news organization are owned by Elsevier.

NEW YORK – Recipients of pancreas transplants had a 19.6% cumulative incidence of developing skin cancer 10 years after transplant.

Moreover, those patients who developed squamous cell carcinoma (SCC) following transplant were found to have a 56% likelihood of developing a second SCC within 2 years, while patients who developed basal cell carcinoma (BCC) had a 36% chance of recurrence at 2 years.

The data, presented in a poster at the annual meeting of the American College of Mohs Surgery, show that “intensive educational and preventative strategies should be targeted at the pancreas transplant population,” according to Dr. Joshua Spanogle, a resident in the department of dermatology at the Mayo Clinic in Rochester, Minnesota.

Dr. Spanogle and his colleagues looked at 216 pancreas transplant recipients seen at a tertiary care center between 1996 and 2007. About half of the subjects were male, and the average age was 43 years, with a range of 21-71 years.

Overall, 107 patients received their pancreas transplant following a prior kidney transplant and were referred to as the “pancreas after kidney” group. A total of 67 patients received a pancreas transplant and did not receive a new kidney, and were known as the “pancreas transplant alone” group. Forty-two patients were in the “simultaneous pancreas-kidney” transplant group.

For all transplant recipients, the cumulative incidence of developing any skin cancer was 4.7% by 2 years. The cumulative incidence rose to 12.7% by 5 years and 19.6% by 10 years post transplant, Dr. Spanogle reported.

Looking at SCC specifically, the cumulative incidence was 2.8% at 2 years, 10.3% at 5 years, and 16.7% at 10 years. For BCC, the cumulative incidence rates were 2.4%, 7.8%, and 17.4% at 2, 5, and 10 years, respectively, he wrote.

Once patients were found to have an SCC, however, the chance of developing a second SCC within 2 years rose: There was a 56% cumulative incidence of subsequent SCC in that population. The risk for a second BCC after an initial post-transplant BCC diagnosis was also high, though less dramatic: The cumulative incidence for BCCs in the post-transplant, post-BCC-diagnosis population was 36%.

“None of the following variables were associated with an increased risk of skin cancer: type of transplant, induction therapy, initial immunosuppressive regimen, rejection status, or sex,” he pointed out. Only age was a significant predictor of the development of skin cancer, with a hazard ratio of 1.05.

Dr. Spanogle stated that he had no conflicts of interest to disclose.

NEW YORK – Recipients of pancreas transplants had a 19.6% cumulative incidence of developing skin cancer 10 years after transplant.

Moreover, those patients who developed squamous cell carcinoma (SCC) following transplant were found to have a 56% likelihood of developing a second SCC within 2 years, while patients who developed basal cell carcinoma (BCC) had a 36% chance of recurrence at 2 years.

The data, presented in a poster at the annual meeting of the American College of Mohs Surgery, show that “intensive educational and preventative strategies should be targeted at the pancreas transplant population,” according to Dr. Joshua Spanogle, a resident in the department of dermatology at the Mayo Clinic in Rochester, Minnesota.

Dr. Spanogle and his colleagues looked at 216 pancreas transplant recipients seen at a tertiary care center between 1996 and 2007. About half of the subjects were male, and the average age was 43 years, with a range of 21-71 years.

Overall, 107 patients received their pancreas transplant following a prior kidney transplant and were referred to as the “pancreas after kidney” group. A total of 67 patients received a pancreas transplant and did not receive a new kidney, and were known as the “pancreas transplant alone” group. Forty-two patients were in the “simultaneous pancreas-kidney” transplant group.

For all transplant recipients, the cumulative incidence of developing any skin cancer was 4.7% by 2 years. The cumulative incidence rose to 12.7% by 5 years and 19.6% by 10 years post transplant, Dr. Spanogle reported.

Looking at SCC specifically, the cumulative incidence was 2.8% at 2 years, 10.3% at 5 years, and 16.7% at 10 years. For BCC, the cumulative incidence rates were 2.4%, 7.8%, and 17.4% at 2, 5, and 10 years, respectively, he wrote.

Once patients were found to have an SCC, however, the chance of developing a second SCC within 2 years rose: There was a 56% cumulative incidence of subsequent SCC in that population. The risk for a second BCC after an initial post-transplant BCC diagnosis was also high, though less dramatic: The cumulative incidence for BCCs in the post-transplant, post-BCC-diagnosis population was 36%.

“None of the following variables were associated with an increased risk of skin cancer: type of transplant, induction therapy, initial immunosuppressive regimen, rejection status, or sex,” he pointed out. Only age was a significant predictor of the development of skin cancer, with a hazard ratio of 1.05.

Dr. Spanogle stated that he had no conflicts of interest to disclose.

NEW YORK – Recipients of pancreas transplants had a 19.6% cumulative incidence of developing skin cancer 10 years after transplant.

Moreover, those patients who developed squamous cell carcinoma (SCC) following transplant were found to have a 56% likelihood of developing a second SCC within 2 years, while patients who developed basal cell carcinoma (BCC) had a 36% chance of recurrence at 2 years.

The data, presented in a poster at the annual meeting of the American College of Mohs Surgery, show that “intensive educational and preventative strategies should be targeted at the pancreas transplant population,” according to Dr. Joshua Spanogle, a resident in the department of dermatology at the Mayo Clinic in Rochester, Minnesota.

Dr. Spanogle and his colleagues looked at 216 pancreas transplant recipients seen at a tertiary care center between 1996 and 2007. About half of the subjects were male, and the average age was 43 years, with a range of 21-71 years.

Overall, 107 patients received their pancreas transplant following a prior kidney transplant and were referred to as the “pancreas after kidney” group. A total of 67 patients received a pancreas transplant and did not receive a new kidney, and were known as the “pancreas transplant alone” group. Forty-two patients were in the “simultaneous pancreas-kidney” transplant group.

For all transplant recipients, the cumulative incidence of developing any skin cancer was 4.7% by 2 years. The cumulative incidence rose to 12.7% by 5 years and 19.6% by 10 years post transplant, Dr. Spanogle reported.

Looking at SCC specifically, the cumulative incidence was 2.8% at 2 years, 10.3% at 5 years, and 16.7% at 10 years. For BCC, the cumulative incidence rates were 2.4%, 7.8%, and 17.4% at 2, 5, and 10 years, respectively, he wrote.

Once patients were found to have an SCC, however, the chance of developing a second SCC within 2 years rose: There was a 56% cumulative incidence of subsequent SCC in that population. The risk for a second BCC after an initial post-transplant BCC diagnosis was also high, though less dramatic: The cumulative incidence for BCCs in the post-transplant, post-BCC-diagnosis population was 36%.

“None of the following variables were associated with an increased risk of skin cancer: type of transplant, induction therapy, initial immunosuppressive regimen, rejection status, or sex,” he pointed out. Only age was a significant predictor of the development of skin cancer, with a hazard ratio of 1.05.

Dr. Spanogle stated that he had no conflicts of interest to disclose.

NEW YORK - The risk of developing a primary malignancy of the salivary gland, bone, prostate, and other areas is significantly--and in some cases dramatically--increased following a cutaneous melanoma diagnosis.

That's according to research by Dr. Joshua Spanogle, a resident in the department of dermatology at the Mayo Clinic in Rochester, Minn., presented during an abstract session at the American College of Mohs Surgery annual meeting.

Dr. Spanogle looked at data from the Surveillance, Epidemiology and End Results database (SEER) from 1973 to 2003, which included "over 1.3 million person years of observation," he said.

A total of 151,996 patients were found to have a cutaneous melanoma diagnosis during that period; 16,591 (11%) of these patients had a second documented primary malignancy sometime in the next 120 months. That observed rate was 32% higher than what would be expected among a healthy population in that time period, he said.

Further analysis of the results revealed that particular cancers carried a significantly higher risk than others.

The most striking, perhaps not surprisingly, is for a second primary cutaneous melanoma: there were 3,923 through 120 months of follow-up, for a standardized incidence ratio of 8.99. "This is the 600-pound elephant in the room," said Dr. Spanogle.

But other cancers have high standardized incidence ratios (SIRs) as well. Salivary gland malignancies following carcinoma had a SIR of 2.18 overall. Prostate cancer had a SIR of 1.13 following melanoma. Breast cancer showed a SIR of 1.07. And soft tissue cancers, including malignancies of the heart, had a SIR of 2.80.

On the other hand, "Quite a few cancers had a decreased incidence following melanoma," said Dr. Spanogle, including cancer of the liver (SIR 0.77), lungs (0.83), cervix (0.57), and pharynx (0.61).

That could be because risk factors for melanoma are associated with higher socioeconomic status, like fair skin and intermittent high intensity UV exposure (tanning), said Dr. Spanogle. In contrast, risk factors for lung cancer and liver cancer are associated with comorbidities commonly found in lower socioeconomic patients, like smoking and hepatitis.

Moreover, according to Dr. Spanogle, the risks of secondary cancers of the prostate gland, bone, soft tissue, and salivary gland remained elevated throughout the study period, "implying no surveillance bias."
Instead, he speculated that the link could be genetic, and said that future research into the possibility is warranted.

Dr. Spanogle reported having no disclosures relevant to his presentation. He added that this study has been accepted for publication in the Journal of the American Academy of Dermatology.

NEW YORK - The risk of developing a primary malignancy of the salivary gland, bone, prostate, and other areas is significantly--and in some cases dramatically--increased following a cutaneous melanoma diagnosis.

That's according to research by Dr. Joshua Spanogle, a resident in the department of dermatology at the Mayo Clinic in Rochester, Minn., presented during an abstract session at the American College of Mohs Surgery annual meeting.

Dr. Spanogle looked at data from the Surveillance, Epidemiology and End Results database (SEER) from 1973 to 2003, which included "over 1.3 million person years of observation," he said.

A total of 151,996 patients were found to have a cutaneous melanoma diagnosis during that period; 16,591 (11%) of these patients had a second documented primary malignancy sometime in the next 120 months. That observed rate was 32% higher than what would be expected among a healthy population in that time period, he said.

Further analysis of the results revealed that particular cancers carried a significantly higher risk than others.

The most striking, perhaps not surprisingly, is for a second primary cutaneous melanoma: there were 3,923 through 120 months of follow-up, for a standardized incidence ratio of 8.99. "This is the 600-pound elephant in the room," said Dr. Spanogle.

But other cancers have high standardized incidence ratios (SIRs) as well. Salivary gland malignancies following carcinoma had a SIR of 2.18 overall. Prostate cancer had a SIR of 1.13 following melanoma. Breast cancer showed a SIR of 1.07. And soft tissue cancers, including malignancies of the heart, had a SIR of 2.80.

On the other hand, "Quite a few cancers had a decreased incidence following melanoma," said Dr. Spanogle, including cancer of the liver (SIR 0.77), lungs (0.83), cervix (0.57), and pharynx (0.61).

That could be because risk factors for melanoma are associated with higher socioeconomic status, like fair skin and intermittent high intensity UV exposure (tanning), said Dr. Spanogle. In contrast, risk factors for lung cancer and liver cancer are associated with comorbidities commonly found in lower socioeconomic patients, like smoking and hepatitis.

Moreover, according to Dr. Spanogle, the risks of secondary cancers of the prostate gland, bone, soft tissue, and salivary gland remained elevated throughout the study period, "implying no surveillance bias."
Instead, he speculated that the link could be genetic, and said that future research into the possibility is warranted.

Dr. Spanogle reported having no disclosures relevant to his presentation. He added that this study has been accepted for publication in the Journal of the American Academy of Dermatology.

NEW YORK - The risk of developing a primary malignancy of the salivary gland, bone, prostate, and other areas is significantly--and in some cases dramatically--increased following a cutaneous melanoma diagnosis.

That's according to research by Dr. Joshua Spanogle, a resident in the department of dermatology at the Mayo Clinic in Rochester, Minn., presented during an abstract session at the American College of Mohs Surgery annual meeting.

Dr. Spanogle looked at data from the Surveillance, Epidemiology and End Results database (SEER) from 1973 to 2003, which included "over 1.3 million person years of observation," he said.

A total of 151,996 patients were found to have a cutaneous melanoma diagnosis during that period; 16,591 (11%) of these patients had a second documented primary malignancy sometime in the next 120 months. That observed rate was 32% higher than what would be expected among a healthy population in that time period, he said.

Further analysis of the results revealed that particular cancers carried a significantly higher risk than others.

The most striking, perhaps not surprisingly, is for a second primary cutaneous melanoma: there were 3,923 through 120 months of follow-up, for a standardized incidence ratio of 8.99. "This is the 600-pound elephant in the room," said Dr. Spanogle.

But other cancers have high standardized incidence ratios (SIRs) as well. Salivary gland malignancies following carcinoma had a SIR of 2.18 overall. Prostate cancer had a SIR of 1.13 following melanoma. Breast cancer showed a SIR of 1.07. And soft tissue cancers, including malignancies of the heart, had a SIR of 2.80.

On the other hand, "Quite a few cancers had a decreased incidence following melanoma," said Dr. Spanogle, including cancer of the liver (SIR 0.77), lungs (0.83), cervix (0.57), and pharynx (0.61).

That could be because risk factors for melanoma are associated with higher socioeconomic status, like fair skin and intermittent high intensity UV exposure (tanning), said Dr. Spanogle. In contrast, risk factors for lung cancer and liver cancer are associated with comorbidities commonly found in lower socioeconomic patients, like smoking and hepatitis.

Moreover, according to Dr. Spanogle, the risks of secondary cancers of the prostate gland, bone, soft tissue, and salivary gland remained elevated throughout the study period, "implying no surveillance bias."
Instead, he speculated that the link could be genetic, and said that future research into the possibility is warranted.

Dr. Spanogle reported having no disclosures relevant to his presentation. He added that this study has been accepted for publication in the Journal of the American Academy of Dermatology.

Radiation exposure from CT scans for the diagnosis of acute pancreatitis is significant, even though the condition is often easily diagnosed with laboratory tests, Dr. Desiree E. Morgan and her colleagues reported.

Dr. Morgan of the department of radiology at the University of Alabama at Birmingham ck her colleagues looked at 869 patients who had 1,036 admissions for acute pancreatitis between October 2001 and September 2006 (mean age 51 years; 65% women). The most common etiologies included gallstones (32%) and alcohol abuse (23%).

Most patients (746 of 869) had a single hospital admission with a mean stay of 9.4 days. Those with multiple stays had a mean of 2.5 stays and 15.9 days.

Of 869 patients, 566 (65%) had at least one abdominopelvic CT scan. A total of 220 patients underwent one CT scan, 135 patients had two, and 211 received three or more.

“Patients with [Balthazar CT severity] grades A-C had mean total effective radiation dose estimated at 43.4 mSv … which was less than those with grades D-E,” who had a mean of 77.8 mSv, they wrote (Clin. Gastroenterol. Hepatol. 2010;8:303–8).

There was no correlation between CT scans and patient age. Indeed, a grade A patient aged 30 years or younger had a higher mean effective radiation dose estimate (34.38 mSv) than did a patient older than 70 years (33.78 mSv). The same pattern was seen in grade E patients (68.82 mSv vs. 57.91 mSv).

“Since the impact of radiation dose on cancer risk is greatest in young patients and less significant in older patients, we are alarmed that there was no attempt to limit exposure by employing alternate imaging strategies in our younger patients with severe pancreatitis,” they said. These might include “educating referring physicians about imaging utilization” and “performing single phase rather than multiphasic exams.”

Abdominal imaging using newer MRI units capable of breathing-independent MRI sequences and more rapid examinations also may be a valid alternative to CT, they added.

Dr. Morgan conceded several limitations to the study, including the fact that “individual patients' radiation exposure estimate was calculated using published average CT effective dose estimates rather than true measurement at the time of scanning.” However, “because our calculations did not take into account CT scans of other body regions in our patients or CTs obtained elsewhere … we have likely underestimated exposure,” she added.

“In the U.S., the average person receives an effective dose of about 3 mSv per year from naturally occurring radioactive materials and radiation from space. A typical CT scan produces the equivalent of more than 3 years of natural, background radiation,” the authors noted. “Discussion … regarding the merits and appropriateness of additional CTs in younger acute pancreatitis patients should be a priority.”

Disclosures: Dr. Morgan and her colleagues reported no relevant conflicts of interest.

Radiation exposure from CT scans for the diagnosis of acute pancreatitis is significant, even though the condition is often easily diagnosed with laboratory tests, Dr. Desiree E. Morgan and her colleagues reported.

Dr. Morgan of the department of radiology at the University of Alabama at Birmingham ck her colleagues looked at 869 patients who had 1,036 admissions for acute pancreatitis between October 2001 and September 2006 (mean age 51 years; 65% women). The most common etiologies included gallstones (32%) and alcohol abuse (23%).

Most patients (746 of 869) had a single hospital admission with a mean stay of 9.4 days. Those with multiple stays had a mean of 2.5 stays and 15.9 days.

Of 869 patients, 566 (65%) had at least one abdominopelvic CT scan. A total of 220 patients underwent one CT scan, 135 patients had two, and 211 received three or more.

“Patients with [Balthazar CT severity] grades A-C had mean total effective radiation dose estimated at 43.4 mSv … which was less than those with grades D-E,” who had a mean of 77.8 mSv, they wrote (Clin. Gastroenterol. Hepatol. 2010;8:303–8).

There was no correlation between CT scans and patient age. Indeed, a grade A patient aged 30 years or younger had a higher mean effective radiation dose estimate (34.38 mSv) than did a patient older than 70 years (33.78 mSv). The same pattern was seen in grade E patients (68.82 mSv vs. 57.91 mSv).

“Since the impact of radiation dose on cancer risk is greatest in young patients and less significant in older patients, we are alarmed that there was no attempt to limit exposure by employing alternate imaging strategies in our younger patients with severe pancreatitis,” they said. These might include “educating referring physicians about imaging utilization” and “performing single phase rather than multiphasic exams.”

Abdominal imaging using newer MRI units capable of breathing-independent MRI sequences and more rapid examinations also may be a valid alternative to CT, they added.

Dr. Morgan conceded several limitations to the study, including the fact that “individual patients' radiation exposure estimate was calculated using published average CT effective dose estimates rather than true measurement at the time of scanning.” However, “because our calculations did not take into account CT scans of other body regions in our patients or CTs obtained elsewhere … we have likely underestimated exposure,” she added.

“In the U.S., the average person receives an effective dose of about 3 mSv per year from naturally occurring radioactive materials and radiation from space. A typical CT scan produces the equivalent of more than 3 years of natural, background radiation,” the authors noted. “Discussion … regarding the merits and appropriateness of additional CTs in younger acute pancreatitis patients should be a priority.”

Disclosures: Dr. Morgan and her colleagues reported no relevant conflicts of interest.

Radiation exposure from CT scans for the diagnosis of acute pancreatitis is significant, even though the condition is often easily diagnosed with laboratory tests, Dr. Desiree E. Morgan and her colleagues reported.

Dr. Morgan of the department of radiology at the University of Alabama at Birmingham ck her colleagues looked at 869 patients who had 1,036 admissions for acute pancreatitis between October 2001 and September 2006 (mean age 51 years; 65% women). The most common etiologies included gallstones (32%) and alcohol abuse (23%).

Most patients (746 of 869) had a single hospital admission with a mean stay of 9.4 days. Those with multiple stays had a mean of 2.5 stays and 15.9 days.

Of 869 patients, 566 (65%) had at least one abdominopelvic CT scan. A total of 220 patients underwent one CT scan, 135 patients had two, and 211 received three or more.

“Patients with [Balthazar CT severity] grades A-C had mean total effective radiation dose estimated at 43.4 mSv … which was less than those with grades D-E,” who had a mean of 77.8 mSv, they wrote (Clin. Gastroenterol. Hepatol. 2010;8:303–8).

There was no correlation between CT scans and patient age. Indeed, a grade A patient aged 30 years or younger had a higher mean effective radiation dose estimate (34.38 mSv) than did a patient older than 70 years (33.78 mSv). The same pattern was seen in grade E patients (68.82 mSv vs. 57.91 mSv).

“Since the impact of radiation dose on cancer risk is greatest in young patients and less significant in older patients, we are alarmed that there was no attempt to limit exposure by employing alternate imaging strategies in our younger patients with severe pancreatitis,” they said. These might include “educating referring physicians about imaging utilization” and “performing single phase rather than multiphasic exams.”

Abdominal imaging using newer MRI units capable of breathing-independent MRI sequences and more rapid examinations also may be a valid alternative to CT, they added.

Dr. Morgan conceded several limitations to the study, including the fact that “individual patients' radiation exposure estimate was calculated using published average CT effective dose estimates rather than true measurement at the time of scanning.” However, “because our calculations did not take into account CT scans of other body regions in our patients or CTs obtained elsewhere … we have likely underestimated exposure,” she added.

“In the U.S., the average person receives an effective dose of about 3 mSv per year from naturally occurring radioactive materials and radiation from space. A typical CT scan produces the equivalent of more than 3 years of natural, background radiation,” the authors noted. “Discussion … regarding the merits and appropriateness of additional CTs in younger acute pancreatitis patients should be a priority.”

Disclosures: Dr. Morgan and her colleagues reported no relevant conflicts of interest.

Major Finding: Each step up in trunk fat quintile conferred a 1.7 increased odds ratio for elevated ALT in men and a 1.4 increased OR for women.

Data Source: 11,821 participants (5,918 men and 5,903 women) in NHANES between 1999 and 2004.

Disclosures: Dr. Ruhl and Dr. Everhart reported having no conflicts of interest. The study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases, a division of the National Institutes of Health, where Dr. Everhart is employed.

Increased trunk fat on dual-energy x-ray absorptiometry was independently associated with elevated serum ALT levels, a measure of liver injury—more so than was extremity fat, body mass index, or waist circumference, reported Dr. Constance E. Ruhl and Dr. James E. Everhart.

The findings “support the hypothesis that liver injury can be induced by metabolically active intra-abdominal fat,” the authors wrote, noting that “obesity is an important risk factor for liver injury” (Gastroenterology 2010;138:1346–56).

Dr. Ruhl of Social & Scientific Systems Inc., a research support company, and Dr. Everhart of the National Institute of Diabetes and Digestive and Kidney Diseases studied data from patients in the National Health and Nutrition Examination Survey. In all, 11,821 participants (5,918 men and 5,903 women) in NHANES in 1999–2004 were ultimately included in the analysis. Study participants had DXA measurements to determine trunk fat, trunk lean mass, extremity fat, and extremity lean mass, and were then divided into quintiles within each category. Missing DXA measurements were imputed by the National Center for Health Statistics. Serum ALT levels, a marker of liver damage, were considered elevated above 44 U/L in men and above 31 U/L in women.

“The prevalence of elevated ALT was 11.1% among men and 10.1% among women,” wrote the authors. Among men, each step up in trunk fat quintile conferred a 1.7 increased odds ratio for elevated ALT (P less than .001). In women, each step up in trunk fat quintile was associated with a 1.4 increased OR (P less than .001). The results were adjusted for ethnicity, age, glucose status, serum total cholesterol, cigarette smoking, and alcohol consumption.

In contrast, having an increased amount of extremity fat actually was protective against elevated ALT. Among men, every increased quintile conferred a 0.87 OR of elevated ALT (P = .002), and for women, each increasing quintile conferred a 0.86 OR (P = .001). Trunk lean mass and extremity lean mass, on the other hand, showed no significant relationship with ALT concentration.

“Having established that elevated ALT was most strongly associated with trunk fat, we considered its effect on the association of BMI and waist circumference with elevated ALT,” wrote the authors. “When trunk fat, BMI, and waist circumference were included together in multivariate-adjusted models, higher trunk fat remained independently associated with elevated ALT among both men [P = .002] and women [P = .011], but BMI and waist circumference were not.”

Regarding the “unexpected” finding that extremity fat was protective against elevated ALT, the researchers postulated that the “uptake and storage of free fatty acids by femoral adipose tissue could lead to protection of other organs such as the liver from exposure to fatty acids and ectopic fat deposition.”

The authors conceded that DXA measurements of abdominal fat are not as accurate as CT or MRI, and the use of ALT levels alone as a marker of liver damage cannot be entirely accurate. “Participants were included in the elevated ALT group who would not have been, had repeat ALT measurements been available.”

DXA images show total and regional BMD (left) and body composition (fat, muscle mass; right).

Source © 2008 Elsevier, Inc.

Major Finding: Each step up in trunk fat quintile conferred a 1.7 increased odds ratio for elevated ALT in men and a 1.4 increased OR for women.

Data Source: 11,821 participants (5,918 men and 5,903 women) in NHANES between 1999 and 2004.

Disclosures: Dr. Ruhl and Dr. Everhart reported having no conflicts of interest. The study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases, a division of the National Institutes of Health, where Dr. Everhart is employed.

Increased trunk fat on dual-energy x-ray absorptiometry was independently associated with elevated serum ALT levels, a measure of liver injury—more so than was extremity fat, body mass index, or waist circumference, reported Dr. Constance E. Ruhl and Dr. James E. Everhart.

The findings “support the hypothesis that liver injury can be induced by metabolically active intra-abdominal fat,” the authors wrote, noting that “obesity is an important risk factor for liver injury” (Gastroenterology 2010;138:1346–56).

Dr. Ruhl of Social & Scientific Systems Inc., a research support company, and Dr. Everhart of the National Institute of Diabetes and Digestive and Kidney Diseases studied data from patients in the National Health and Nutrition Examination Survey. In all, 11,821 participants (5,918 men and 5,903 women) in NHANES in 1999–2004 were ultimately included in the analysis. Study participants had DXA measurements to determine trunk fat, trunk lean mass, extremity fat, and extremity lean mass, and were then divided into quintiles within each category. Missing DXA measurements were imputed by the National Center for Health Statistics. Serum ALT levels, a marker of liver damage, were considered elevated above 44 U/L in men and above 31 U/L in women.

“The prevalence of elevated ALT was 11.1% among men and 10.1% among women,” wrote the authors. Among men, each step up in trunk fat quintile conferred a 1.7 increased odds ratio for elevated ALT (P less than .001). In women, each step up in trunk fat quintile was associated with a 1.4 increased OR (P less than .001). The results were adjusted for ethnicity, age, glucose status, serum total cholesterol, cigarette smoking, and alcohol consumption.

In contrast, having an increased amount of extremity fat actually was protective against elevated ALT. Among men, every increased quintile conferred a 0.87 OR of elevated ALT (P = .002), and for women, each increasing quintile conferred a 0.86 OR (P = .001). Trunk lean mass and extremity lean mass, on the other hand, showed no significant relationship with ALT concentration.

“Having established that elevated ALT was most strongly associated with trunk fat, we considered its effect on the association of BMI and waist circumference with elevated ALT,” wrote the authors. “When trunk fat, BMI, and waist circumference were included together in multivariate-adjusted models, higher trunk fat remained independently associated with elevated ALT among both men [P = .002] and women [P = .011], but BMI and waist circumference were not.”

Regarding the “unexpected” finding that extremity fat was protective against elevated ALT, the researchers postulated that the “uptake and storage of free fatty acids by femoral adipose tissue could lead to protection of other organs such as the liver from exposure to fatty acids and ectopic fat deposition.”

The authors conceded that DXA measurements of abdominal fat are not as accurate as CT or MRI, and the use of ALT levels alone as a marker of liver damage cannot be entirely accurate. “Participants were included in the elevated ALT group who would not have been, had repeat ALT measurements been available.”

DXA images show total and regional BMD (left) and body composition (fat, muscle mass; right).

Source © 2008 Elsevier, Inc.

Major Finding: Each step up in trunk fat quintile conferred a 1.7 increased odds ratio for elevated ALT in men and a 1.4 increased OR for women.

Data Source: 11,821 participants (5,918 men and 5,903 women) in NHANES between 1999 and 2004.

Disclosures: Dr. Ruhl and Dr. Everhart reported having no conflicts of interest. The study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases, a division of the National Institutes of Health, where Dr. Everhart is employed.

Increased trunk fat on dual-energy x-ray absorptiometry was independently associated with elevated serum ALT levels, a measure of liver injury—more so than was extremity fat, body mass index, or waist circumference, reported Dr. Constance E. Ruhl and Dr. James E. Everhart.

The findings “support the hypothesis that liver injury can be induced by metabolically active intra-abdominal fat,” the authors wrote, noting that “obesity is an important risk factor for liver injury” (Gastroenterology 2010;138:1346–56).

Dr. Ruhl of Social & Scientific Systems Inc., a research support company, and Dr. Everhart of the National Institute of Diabetes and Digestive and Kidney Diseases studied data from patients in the National Health and Nutrition Examination Survey. In all, 11,821 participants (5,918 men and 5,903 women) in NHANES in 1999–2004 were ultimately included in the analysis. Study participants had DXA measurements to determine trunk fat, trunk lean mass, extremity fat, and extremity lean mass, and were then divided into quintiles within each category. Missing DXA measurements were imputed by the National Center for Health Statistics. Serum ALT levels, a marker of liver damage, were considered elevated above 44 U/L in men and above 31 U/L in women.

“The prevalence of elevated ALT was 11.1% among men and 10.1% among women,” wrote the authors. Among men, each step up in trunk fat quintile conferred a 1.7 increased odds ratio for elevated ALT (P less than .001). In women, each step up in trunk fat quintile was associated with a 1.4 increased OR (P less than .001). The results were adjusted for ethnicity, age, glucose status, serum total cholesterol, cigarette smoking, and alcohol consumption.

In contrast, having an increased amount of extremity fat actually was protective against elevated ALT. Among men, every increased quintile conferred a 0.87 OR of elevated ALT (P = .002), and for women, each increasing quintile conferred a 0.86 OR (P = .001). Trunk lean mass and extremity lean mass, on the other hand, showed no significant relationship with ALT concentration.

“Having established that elevated ALT was most strongly associated with trunk fat, we considered its effect on the association of BMI and waist circumference with elevated ALT,” wrote the authors. “When trunk fat, BMI, and waist circumference were included together in multivariate-adjusted models, higher trunk fat remained independently associated with elevated ALT among both men [P = .002] and women [P = .011], but BMI and waist circumference were not.”

Regarding the “unexpected” finding that extremity fat was protective against elevated ALT, the researchers postulated that the “uptake and storage of free fatty acids by femoral adipose tissue could lead to protection of other organs such as the liver from exposure to fatty acids and ectopic fat deposition.”

The authors conceded that DXA measurements of abdominal fat are not as accurate as CT or MRI, and the use of ALT levels alone as a marker of liver damage cannot be entirely accurate. “Participants were included in the elevated ALT group who would not have been, had repeat ALT measurements been available.”

DXA images show total and regional BMD (left) and body composition (fat, muscle mass; right).

Source © 2008 Elsevier, Inc.

Increased trunk fat on dual-energy x-ray absorptiometry was independently associated with elevated serum alanine aminotransferase levels, a measure of liver injury—more so than was extremity fat, body mass index, or waist circumference, according to an analysis of the National Health and Nutrition Examination Survey.

The findings “support the hypothesis that liver injury can be induced by metabolically active intra-abdominal fat,” wrote Dr. Constance E. Ruhl and Dr. James E. Everhart, noting that “obesity is an important risk factor for liver injury.”

Dr. Ruhl of Social & Scientific Systems Inc., a research support company, and Dr. Everhart of the National Institute of Diabetes and Digestive and Kidney Diseases studied data from patients in the National Health and Nutrition Examination Survey (NHANES). Pregnant women and survey participants who were positive for serum hepatitis B surface antigen or were positive or indeterminate for hepatitis C antibody were excluded, as were patients whose hepatitis status could not be determined. Patients were aged 20 years and older.

In all, 11,821 participants (5,918 men and 5,903 women) who participated in NHANES between 1999 and 2004 were ultimately included in the analysis. Study participants had dual-energy x-ray absorptiometry (DXA) measurements to determine trunk fat, trunk lean mass, extremity fat, and extremity lean mass, and were then divided into quintiles within each category. Missing DXA measurements were imputed by the National Center for Health Statistics. Serum alanine aminotransferase (ALT) levels, a marker of liver damage, were considered elevated above 44 U/L in men and above 31 U/L in women.

“The prevalence of elevated ALT was 11.1% among men and 10.1% among women,” wrote the authors.

Among men, each step up in trunk fat quintile conferred a 1.7 increased odds ratio for elevated ALT (P less than .001). In women, each step up in trunk fat quintile was associated with a 1.4 increased OR (P less than .001). The results were adjusted for ethnicity, age, glucose status, serum total cholesterol, cigarette smoking, and alcohol consumption.

In contrast, having an increased amount of extremity fat actually was protective against elevated ALT. Among men, every increased quintile conferred a 0.87 OR of elevated ALT (P = .002), and for women, each increasing quintile conferred a 0.86 OR (P = .001).

Trunk lean mass and extremity lean mass, however, showed no significant relationship with ALT level.

“Having established that elevated ALT was most strongly associated with trunk fat, we considered its effect on the association of BMI and waist circumference with elevated ALT,” wrote the authors. “When trunk fat, BMI, and waist circumference were included together in multivariate-adjusted models, higher trunk fat remained independently associated with elevated ALT among both men [P = .002] and women [P = .011], but BMI and waist circumference were not.”

Regarding the “unexpected” finding that extremity fat was protective against elevated ALT, the researchers postulated that the “uptake and storage of free fatty acids by femoral adipose tissue could lead to protection of other organs such as the liver from exposure to fatty acids and ectopic fat deposition.”

The authors conceded several limitations to their study. First, DXA measurements of abdominal fat are not as accurate as CT or MRI, although the technology “is still considered a relatively accurate and precise method to estimate body fat and lean soft tissue mass components.” Second, the use of ALT levels alone as a marker of liver damage cannot be entirely accurate. “Inevitably, participants were included in the elevated ALT group who would not have been had repeat ALT measurements been available.”

Dr. Ruhl and Dr. Everhart reported having no conflicts of interest. The study was supported by NIDDK.

Trunk fat, as measured by DXA (right image), was significantly associated with elevated ALT levels.

Source ©2008 Elsevier, Inc.

Increased trunk fat on dual-energy x-ray absorptiometry was independently associated with elevated serum alanine aminotransferase levels, a measure of liver injury—more so than was extremity fat, body mass index, or waist circumference, according to an analysis of the National Health and Nutrition Examination Survey.

The findings “support the hypothesis that liver injury can be induced by metabolically active intra-abdominal fat,” wrote Dr. Constance E. Ruhl and Dr. James E. Everhart, noting that “obesity is an important risk factor for liver injury.”

Dr. Ruhl of Social & Scientific Systems Inc., a research support company, and Dr. Everhart of the National Institute of Diabetes and Digestive and Kidney Diseases studied data from patients in the National Health and Nutrition Examination Survey (NHANES). Pregnant women and survey participants who were positive for serum hepatitis B surface antigen or were positive or indeterminate for hepatitis C antibody were excluded, as were patients whose hepatitis status could not be determined. Patients were aged 20 years and older.

In all, 11,821 participants (5,918 men and 5,903 women) who participated in NHANES between 1999 and 2004 were ultimately included in the analysis. Study participants had dual-energy x-ray absorptiometry (DXA) measurements to determine trunk fat, trunk lean mass, extremity fat, and extremity lean mass, and were then divided into quintiles within each category. Missing DXA measurements were imputed by the National Center for Health Statistics. Serum alanine aminotransferase (ALT) levels, a marker of liver damage, were considered elevated above 44 U/L in men and above 31 U/L in women.

“The prevalence of elevated ALT was 11.1% among men and 10.1% among women,” wrote the authors.

Among men, each step up in trunk fat quintile conferred a 1.7 increased odds ratio for elevated ALT (P less than .001). In women, each step up in trunk fat quintile was associated with a 1.4 increased OR (P less than .001). The results were adjusted for ethnicity, age, glucose status, serum total cholesterol, cigarette smoking, and alcohol consumption.

In contrast, having an increased amount of extremity fat actually was protective against elevated ALT. Among men, every increased quintile conferred a 0.87 OR of elevated ALT (P = .002), and for women, each increasing quintile conferred a 0.86 OR (P = .001).

Trunk lean mass and extremity lean mass, however, showed no significant relationship with ALT level.

“Having established that elevated ALT was most strongly associated with trunk fat, we considered its effect on the association of BMI and waist circumference with elevated ALT,” wrote the authors. “When trunk fat, BMI, and waist circumference were included together in multivariate-adjusted models, higher trunk fat remained independently associated with elevated ALT among both men [P = .002] and women [P = .011], but BMI and waist circumference were not.”

Regarding the “unexpected” finding that extremity fat was protective against elevated ALT, the researchers postulated that the “uptake and storage of free fatty acids by femoral adipose tissue could lead to protection of other organs such as the liver from exposure to fatty acids and ectopic fat deposition.”

The authors conceded several limitations to their study. First, DXA measurements of abdominal fat are not as accurate as CT or MRI, although the technology “is still considered a relatively accurate and precise method to estimate body fat and lean soft tissue mass components.” Second, the use of ALT levels alone as a marker of liver damage cannot be entirely accurate. “Inevitably, participants were included in the elevated ALT group who would not have been had repeat ALT measurements been available.”

Dr. Ruhl and Dr. Everhart reported having no conflicts of interest. The study was supported by NIDDK.

Trunk fat, as measured by DXA (right image), was significantly associated with elevated ALT levels.

Source ©2008 Elsevier, Inc.

Increased trunk fat on dual-energy x-ray absorptiometry was independently associated with elevated serum alanine aminotransferase levels, a measure of liver injury—more so than was extremity fat, body mass index, or waist circumference, according to an analysis of the National Health and Nutrition Examination Survey.

The findings “support the hypothesis that liver injury can be induced by metabolically active intra-abdominal fat,” wrote Dr. Constance E. Ruhl and Dr. James E. Everhart, noting that “obesity is an important risk factor for liver injury.”

Dr. Ruhl of Social & Scientific Systems Inc., a research support company, and Dr. Everhart of the National Institute of Diabetes and Digestive and Kidney Diseases studied data from patients in the National Health and Nutrition Examination Survey (NHANES). Pregnant women and survey participants who were positive for serum hepatitis B surface antigen or were positive or indeterminate for hepatitis C antibody were excluded, as were patients whose hepatitis status could not be determined. Patients were aged 20 years and older.

In all, 11,821 participants (5,918 men and 5,903 women) who participated in NHANES between 1999 and 2004 were ultimately included in the analysis. Study participants had dual-energy x-ray absorptiometry (DXA) measurements to determine trunk fat, trunk lean mass, extremity fat, and extremity lean mass, and were then divided into quintiles within each category. Missing DXA measurements were imputed by the National Center for Health Statistics. Serum alanine aminotransferase (ALT) levels, a marker of liver damage, were considered elevated above 44 U/L in men and above 31 U/L in women.

“The prevalence of elevated ALT was 11.1% among men and 10.1% among women,” wrote the authors.

Among men, each step up in trunk fat quintile conferred a 1.7 increased odds ratio for elevated ALT (P less than .001). In women, each step up in trunk fat quintile was associated with a 1.4 increased OR (P less than .001). The results were adjusted for ethnicity, age, glucose status, serum total cholesterol, cigarette smoking, and alcohol consumption.

In contrast, having an increased amount of extremity fat actually was protective against elevated ALT. Among men, every increased quintile conferred a 0.87 OR of elevated ALT (P = .002), and for women, each increasing quintile conferred a 0.86 OR (P = .001).

Trunk lean mass and extremity lean mass, however, showed no significant relationship with ALT level.

“Having established that elevated ALT was most strongly associated with trunk fat, we considered its effect on the association of BMI and waist circumference with elevated ALT,” wrote the authors. “When trunk fat, BMI, and waist circumference were included together in multivariate-adjusted models, higher trunk fat remained independently associated with elevated ALT among both men [P = .002] and women [P = .011], but BMI and waist circumference were not.”

Regarding the “unexpected” finding that extremity fat was protective against elevated ALT, the researchers postulated that the “uptake and storage of free fatty acids by femoral adipose tissue could lead to protection of other organs such as the liver from exposure to fatty acids and ectopic fat deposition.”

The authors conceded several limitations to their study. First, DXA measurements of abdominal fat are not as accurate as CT or MRI, although the technology “is still considered a relatively accurate and precise method to estimate body fat and lean soft tissue mass components.” Second, the use of ALT levels alone as a marker of liver damage cannot be entirely accurate. “Inevitably, participants were included in the elevated ALT group who would not have been had repeat ALT measurements been available.”

Dr. Ruhl and Dr. Everhart reported having no conflicts of interest. The study was supported by NIDDK.

Trunk fat, as measured by DXA (right image), was significantly associated with elevated ALT levels.

Source ©2008 Elsevier, Inc.