Nancy Walsh

Nodular melanoma, unlike superficial spreading melanoma, is typically round, elevated, red or pink, and uniform in color. Courtesy Dr. Sally McCormack

GLASGOW, SCOTLAND — The success in recent years of public- and professional-relations efforts to spread awareness of early signs of melanoma has had one unfortunate downside: The common checklists that identify worrisome features of skin lesions do not apply to the highly lethal nodular form of the disease, according to Sally McCormack, M.B., and her colleagues at the department of dermatology, Royal Infirmary of Edinburgh in Scotland.

Educational efforts aimed at increasing the early recognition of melanoma during the past 20 years have been beneficial, with many more early, thin lesions being identified and removed. Mnemonics like “ABCD”—asymmetry, border irregularity, color variation, and diameter exceeding 6 mm—are helpful tip-offs for the more common forms of the disease, such as superficial spreading melanoma.

But these criteria do not apply to nodular melanomas, which typically are round, elevated, red or pink, and uniform in color throughout. They also carry a poor prognosis because they are likely to be deeper when identified—and lesion depth correlates with outcome.

A review of all 3,353 reported cases of melanomas in the Edinburgh area over the past 24 years found that 447 were nodular, Dr. McCormack reported. Unlike previously reported incidence rates, women were more commonly affected, with the male:female ratio being 1:1.24. Breslow thickness was high, with 53.7% of cases being greater than 4 mm and only 1.8% being less than 1 mm. In 25% of the patients, the lesion was less than 10 mm in diameter; in another 24%, the lesion was 10–20 mm in diameter.

The most common sites were sun-exposed areas, such as the head, neck, and distal limbs.

“This is in contrast to the other types of melanoma, which in our district have been occurring more frequently on usually covered sites of the body,” Dr. McCormack wrote in a poster session at the annual meeting of the British Association of Dermatologists.

The mean age of patients tended to rise over time, from 54.7 years in the first 6 years of the survey to 65.9 years in the most recent cohort.

“Thus, over the years the typical nodular melanoma patient has come to be older, less frequently male,” with a relatively small lesion that has a high Breslow thickness on the head and neck or distal limbs, she wrote, adding that these factors should be borne in mind when targeted melanoma education programs are designed in the future.

This difference in lesion distribution raises the question as to whether nodular melanomas are biologically different from other types of melanoma, as some have suggested.

Nodular melanoma, unlike superficial spreading melanoma, is typically round, elevated, red or pink, and uniform in color. Courtesy Dr. Sally McCormack

GLASGOW, SCOTLAND — The success in recent years of public- and professional-relations efforts to spread awareness of early signs of melanoma has had one unfortunate downside: The common checklists that identify worrisome features of skin lesions do not apply to the highly lethal nodular form of the disease, according to Sally McCormack, M.B., and her colleagues at the department of dermatology, Royal Infirmary of Edinburgh in Scotland.

Educational efforts aimed at increasing the early recognition of melanoma during the past 20 years have been beneficial, with many more early, thin lesions being identified and removed. Mnemonics like “ABCD”—asymmetry, border irregularity, color variation, and diameter exceeding 6 mm—are helpful tip-offs for the more common forms of the disease, such as superficial spreading melanoma.

But these criteria do not apply to nodular melanomas, which typically are round, elevated, red or pink, and uniform in color throughout. They also carry a poor prognosis because they are likely to be deeper when identified—and lesion depth correlates with outcome.

A review of all 3,353 reported cases of melanomas in the Edinburgh area over the past 24 years found that 447 were nodular, Dr. McCormack reported. Unlike previously reported incidence rates, women were more commonly affected, with the male:female ratio being 1:1.24. Breslow thickness was high, with 53.7% of cases being greater than 4 mm and only 1.8% being less than 1 mm. In 25% of the patients, the lesion was less than 10 mm in diameter; in another 24%, the lesion was 10–20 mm in diameter.

The most common sites were sun-exposed areas, such as the head, neck, and distal limbs.

“This is in contrast to the other types of melanoma, which in our district have been occurring more frequently on usually covered sites of the body,” Dr. McCormack wrote in a poster session at the annual meeting of the British Association of Dermatologists.

The mean age of patients tended to rise over time, from 54.7 years in the first 6 years of the survey to 65.9 years in the most recent cohort.

“Thus, over the years the typical nodular melanoma patient has come to be older, less frequently male,” with a relatively small lesion that has a high Breslow thickness on the head and neck or distal limbs, she wrote, adding that these factors should be borne in mind when targeted melanoma education programs are designed in the future.

This difference in lesion distribution raises the question as to whether nodular melanomas are biologically different from other types of melanoma, as some have suggested.

Nodular melanoma, unlike superficial spreading melanoma, is typically round, elevated, red or pink, and uniform in color. Courtesy Dr. Sally McCormack

GLASGOW, SCOTLAND — The success in recent years of public- and professional-relations efforts to spread awareness of early signs of melanoma has had one unfortunate downside: The common checklists that identify worrisome features of skin lesions do not apply to the highly lethal nodular form of the disease, according to Sally McCormack, M.B., and her colleagues at the department of dermatology, Royal Infirmary of Edinburgh in Scotland.

Educational efforts aimed at increasing the early recognition of melanoma during the past 20 years have been beneficial, with many more early, thin lesions being identified and removed. Mnemonics like “ABCD”—asymmetry, border irregularity, color variation, and diameter exceeding 6 mm—are helpful tip-offs for the more common forms of the disease, such as superficial spreading melanoma.

But these criteria do not apply to nodular melanomas, which typically are round, elevated, red or pink, and uniform in color throughout. They also carry a poor prognosis because they are likely to be deeper when identified—and lesion depth correlates with outcome.

A review of all 3,353 reported cases of melanomas in the Edinburgh area over the past 24 years found that 447 were nodular, Dr. McCormack reported. Unlike previously reported incidence rates, women were more commonly affected, with the male:female ratio being 1:1.24. Breslow thickness was high, with 53.7% of cases being greater than 4 mm and only 1.8% being less than 1 mm. In 25% of the patients, the lesion was less than 10 mm in diameter; in another 24%, the lesion was 10–20 mm in diameter.

The most common sites were sun-exposed areas, such as the head, neck, and distal limbs.

“This is in contrast to the other types of melanoma, which in our district have been occurring more frequently on usually covered sites of the body,” Dr. McCormack wrote in a poster session at the annual meeting of the British Association of Dermatologists.

The mean age of patients tended to rise over time, from 54.7 years in the first 6 years of the survey to 65.9 years in the most recent cohort.

“Thus, over the years the typical nodular melanoma patient has come to be older, less frequently male,” with a relatively small lesion that has a high Breslow thickness on the head and neck or distal limbs, she wrote, adding that these factors should be borne in mind when targeted melanoma education programs are designed in the future.

This difference in lesion distribution raises the question as to whether nodular melanomas are biologically different from other types of melanoma, as some have suggested.

GLASGOW, SCOTLAND — A rational approach to the treatment of atopic dermatitis is to use calcineurin inhibitors and topical corticosteroids in different therapeutic niches, based on a scientific understanding of the effects of the drugs on the stratum corneum and a recognition of the associated genetic-environmental interplay, Michael J. Cork, M.B., said at the annual meeting of the British Association of Dermatologists.

Topical corticosteroids, particularly the potent ones, have profound thinning effects on not only the dermis, but also the epidermis, including the stratum corneum.

In areas such as the face where the stratum corneum is normally thinner than on other body sites, corticosteroid-induced thinning of the skin can result in a low barrier reserve, leaving the skin vulnerable to insult such as from allergens and irritants, Dr. Cork said.

“Pimecrolimus appears to have no effect on the skin barrier. We have not yet looked at tacrolimus but we think it is a class effect,” he said. The two drugs have similar molecular weights, but pimecrolimus is more lipophilic, appears to have a higher affinity to skin, and tends to remain trapped in the stratum corneum. With tacrolimus, the penetration through the stratum corneum and into the other layers of the skin into systemic circulation is greater than with pimecrolimus, but it still is low, said Dr. Cork, head of the academic dermatology group in the division of genomic medicine at the University of Sheffield (England).

These drug effects occur in normal as well as in abnormal skin, but in atopic dermatitis various other factors further contribute to skin vulnerability.

“Atopic eczema is a classic example of a gene-environment interaction, involving multiple genetic changes and multiple environmental factors,” Dr. Cork said.

One of the primary genetic determinants in atopic dermatitis appears to be a change in the 3′ untranslated region of the stratum corneum chymotryptic enzyme (SCCE) gene, which regulates protease activity

“We did a case-control study in our clinic and found a strong association with atopic eczema with the rare allele of the protease gene,” he said (J. Invest. Dermatol. 2004;123:62–6).

Proteases are necessary for the shedding of corneocytes from the upper layers of skin, a process that is achieved by cleavage of an adhesion protein within corneodesmosomes with SCCE.

This process, which is held in check by protease inhibitors, must be tightly regulated to prevent the skin barrier from breaking down.

The rare allele of the protease gene, which contains a repeat AACC, is likely to increase the expression of messenger RNA for the SCCE gene. The result is an increase in production of protease leading to an excessive breakdown of the corneodesmosomes and the skin barrier.

Application of topical corticosteroids to even normal skin induces the expression of protease SCCE mRNA and increases the production of SCCE protein. In atopic eczema the preexisting increase in SCCE can be further exacerbated by topical corticosteroids, inducing SCCE production, he said.

Exposure to environmental factors such as soap and detergent, which raise the pH of the skin from 5.5 to 7.5, can further contribute to skin breakdown, as proteases are pH sensitive, he said.

Further complicating the picture in the case of flare is the presence of secondary proteases from the inflammatory infiltrate.

This is the circumstance in which topical corticosteroids can be most useful and beneficial for protecting the skin barrier function. “Use of a topical steroid to suppress these high levels of secondary proteases during a flare has an overall positive, restorative effect on the skin barrier,” Dr. Cork said.

But for milder, chronic use, corticosteroids can negatively affect the skin barrier, so pimecrolimus could reduce the number of flares and prevent their progression.

And there is very little systemic absorption, potentially about 0.2% of a dose, he said.

For patients with more severe eczema, who otherwise would need greater amounts of topical corticosteroids, rotating the steroid with tacrolimus can control the symptoms and minimize exposure to potent steroids.

“So, based on our understanding of the skin barrier and how topical corticosteroids and calcineurin inhibitors interact with the skin barrier, we can begin to carve out different niches where their benefits will be greater than the adverse effects,” he said.

Dr. Cork disclosed that he has received research grants from Novartis and that he is on the company's advisory board.

GLASGOW, SCOTLAND — A rational approach to the treatment of atopic dermatitis is to use calcineurin inhibitors and topical corticosteroids in different therapeutic niches, based on a scientific understanding of the effects of the drugs on the stratum corneum and a recognition of the associated genetic-environmental interplay, Michael J. Cork, M.B., said at the annual meeting of the British Association of Dermatologists.

Topical corticosteroids, particularly the potent ones, have profound thinning effects on not only the dermis, but also the epidermis, including the stratum corneum.

In areas such as the face where the stratum corneum is normally thinner than on other body sites, corticosteroid-induced thinning of the skin can result in a low barrier reserve, leaving the skin vulnerable to insult such as from allergens and irritants, Dr. Cork said.

“Pimecrolimus appears to have no effect on the skin barrier. We have not yet looked at tacrolimus but we think it is a class effect,” he said. The two drugs have similar molecular weights, but pimecrolimus is more lipophilic, appears to have a higher affinity to skin, and tends to remain trapped in the stratum corneum. With tacrolimus, the penetration through the stratum corneum and into the other layers of the skin into systemic circulation is greater than with pimecrolimus, but it still is low, said Dr. Cork, head of the academic dermatology group in the division of genomic medicine at the University of Sheffield (England).

These drug effects occur in normal as well as in abnormal skin, but in atopic dermatitis various other factors further contribute to skin vulnerability.

“Atopic eczema is a classic example of a gene-environment interaction, involving multiple genetic changes and multiple environmental factors,” Dr. Cork said.

One of the primary genetic determinants in atopic dermatitis appears to be a change in the 3′ untranslated region of the stratum corneum chymotryptic enzyme (SCCE) gene, which regulates protease activity

“We did a case-control study in our clinic and found a strong association with atopic eczema with the rare allele of the protease gene,” he said (J. Invest. Dermatol. 2004;123:62–6).

Proteases are necessary for the shedding of corneocytes from the upper layers of skin, a process that is achieved by cleavage of an adhesion protein within corneodesmosomes with SCCE.

This process, which is held in check by protease inhibitors, must be tightly regulated to prevent the skin barrier from breaking down.

The rare allele of the protease gene, which contains a repeat AACC, is likely to increase the expression of messenger RNA for the SCCE gene. The result is an increase in production of protease leading to an excessive breakdown of the corneodesmosomes and the skin barrier.

Application of topical corticosteroids to even normal skin induces the expression of protease SCCE mRNA and increases the production of SCCE protein. In atopic eczema the preexisting increase in SCCE can be further exacerbated by topical corticosteroids, inducing SCCE production, he said.

Exposure to environmental factors such as soap and detergent, which raise the pH of the skin from 5.5 to 7.5, can further contribute to skin breakdown, as proteases are pH sensitive, he said.

Further complicating the picture in the case of flare is the presence of secondary proteases from the inflammatory infiltrate.

This is the circumstance in which topical corticosteroids can be most useful and beneficial for protecting the skin barrier function. “Use of a topical steroid to suppress these high levels of secondary proteases during a flare has an overall positive, restorative effect on the skin barrier,” Dr. Cork said.

But for milder, chronic use, corticosteroids can negatively affect the skin barrier, so pimecrolimus could reduce the number of flares and prevent their progression.

And there is very little systemic absorption, potentially about 0.2% of a dose, he said.

For patients with more severe eczema, who otherwise would need greater amounts of topical corticosteroids, rotating the steroid with tacrolimus can control the symptoms and minimize exposure to potent steroids.

“So, based on our understanding of the skin barrier and how topical corticosteroids and calcineurin inhibitors interact with the skin barrier, we can begin to carve out different niches where their benefits will be greater than the adverse effects,” he said.

Dr. Cork disclosed that he has received research grants from Novartis and that he is on the company's advisory board.

GLASGOW, SCOTLAND — A rational approach to the treatment of atopic dermatitis is to use calcineurin inhibitors and topical corticosteroids in different therapeutic niches, based on a scientific understanding of the effects of the drugs on the stratum corneum and a recognition of the associated genetic-environmental interplay, Michael J. Cork, M.B., said at the annual meeting of the British Association of Dermatologists.

Topical corticosteroids, particularly the potent ones, have profound thinning effects on not only the dermis, but also the epidermis, including the stratum corneum.

In areas such as the face where the stratum corneum is normally thinner than on other body sites, corticosteroid-induced thinning of the skin can result in a low barrier reserve, leaving the skin vulnerable to insult such as from allergens and irritants, Dr. Cork said.

“Pimecrolimus appears to have no effect on the skin barrier. We have not yet looked at tacrolimus but we think it is a class effect,” he said. The two drugs have similar molecular weights, but pimecrolimus is more lipophilic, appears to have a higher affinity to skin, and tends to remain trapped in the stratum corneum. With tacrolimus, the penetration through the stratum corneum and into the other layers of the skin into systemic circulation is greater than with pimecrolimus, but it still is low, said Dr. Cork, head of the academic dermatology group in the division of genomic medicine at the University of Sheffield (England).

These drug effects occur in normal as well as in abnormal skin, but in atopic dermatitis various other factors further contribute to skin vulnerability.

“Atopic eczema is a classic example of a gene-environment interaction, involving multiple genetic changes and multiple environmental factors,” Dr. Cork said.

One of the primary genetic determinants in atopic dermatitis appears to be a change in the 3′ untranslated region of the stratum corneum chymotryptic enzyme (SCCE) gene, which regulates protease activity

“We did a case-control study in our clinic and found a strong association with atopic eczema with the rare allele of the protease gene,” he said (J. Invest. Dermatol. 2004;123:62–6).

Proteases are necessary for the shedding of corneocytes from the upper layers of skin, a process that is achieved by cleavage of an adhesion protein within corneodesmosomes with SCCE.

This process, which is held in check by protease inhibitors, must be tightly regulated to prevent the skin barrier from breaking down.

The rare allele of the protease gene, which contains a repeat AACC, is likely to increase the expression of messenger RNA for the SCCE gene. The result is an increase in production of protease leading to an excessive breakdown of the corneodesmosomes and the skin barrier.

Application of topical corticosteroids to even normal skin induces the expression of protease SCCE mRNA and increases the production of SCCE protein. In atopic eczema the preexisting increase in SCCE can be further exacerbated by topical corticosteroids, inducing SCCE production, he said.

Exposure to environmental factors such as soap and detergent, which raise the pH of the skin from 5.5 to 7.5, can further contribute to skin breakdown, as proteases are pH sensitive, he said.

Further complicating the picture in the case of flare is the presence of secondary proteases from the inflammatory infiltrate.

This is the circumstance in which topical corticosteroids can be most useful and beneficial for protecting the skin barrier function. “Use of a topical steroid to suppress these high levels of secondary proteases during a flare has an overall positive, restorative effect on the skin barrier,” Dr. Cork said.

But for milder, chronic use, corticosteroids can negatively affect the skin barrier, so pimecrolimus could reduce the number of flares and prevent their progression.

And there is very little systemic absorption, potentially about 0.2% of a dose, he said.

For patients with more severe eczema, who otherwise would need greater amounts of topical corticosteroids, rotating the steroid with tacrolimus can control the symptoms and minimize exposure to potent steroids.

“So, based on our understanding of the skin barrier and how topical corticosteroids and calcineurin inhibitors interact with the skin barrier, we can begin to carve out different niches where their benefits will be greater than the adverse effects,” he said.

Dr. Cork disclosed that he has received research grants from Novartis and that he is on the company's advisory board.

NEW YORK – Racial disparities in access to health care will disappear only when adequate and representative samples of patients of color participate in clinical trials, Winston Price, M.D., said at the annual meeting of the National Medical Association.

That disparities in delivery of health care exist is not in question. The Institute of Medicine report “Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare” revealed the extent of the problem, showing that disparities remain even after adjustment for factors such as insurance coverage and socioeconomics.

But a widespread mistrust of the U.S. health care system among people of African descent–not least because of past abuses such as the Tuskegee Syphilis Study, in which black patients went untreated for many years despite the availability of effective therapy–has led to an unwillingness among African Americans to participate in clinical trials that might directly benefit their own health.

An increasing understanding of genetic differences and racial differences in response to medications now makes it imperative that people of color be included and their needs addressed in the drug development process, said Dr. Price of the State University of New York Health Science Center, Brooklyn.

The experience with BiDil, a fixed-dose combination of isosorbide dinitrate and hydralazine approved specifically for the treatment of heart failure in black patients, shows it can be done (August 2005, page 74).

“You had 1,050 African Americans who enrolled in the study, and the attrition rate was zero,” Dr. Price, who is also president of the NMA, said in a press briefing. “Every single one stayed with that study until completion. The drug was approved by the Food and Drug Administration on June 23, not because it was the right thing to do but because it was pure science and evidence based. All we're asking for is parity.”

Other model programs also are demonstrating that blacks can be recruited successfully, Christopher L. Edwards, Ph.D., said at the briefing.

Programs that are successful tend to be well entrenched in the community; they have significant outreach and education and strong, ongoing relationships with local organizations such as churches and fraternities, Dr. Edwards said.

They do not pressure potential study participants, but rather provide information and allow patients to process the information at home and respond to the investigators when they are ready, he said.

Successful investigators are available to the community not only when recruiting; they are able to articulate the tangible benefits of participation, not only for patients themselves but also for future generations. Dr. Edwards' program in the department of psychiatry at Duke University Medical Center, Durham, N.C., is an example.

“We make ourselves available for interviews on television, religious radio, and pop radio. In one creative marketing plan, we placed advertisements for one of our genetic studies on the side of 20 city buses, and have seen a significant number of patients responding.” he said.

The overall strategy of information dissemination is to go where the patients are, and not to rely on them to come to us, he said. “With the bus advertisements, the demographic we were recruiting was reliant on public transportation,” he added. And the advertisements provided phone numbers, not e-mail addresses or Web sites because these would not be particularly helpful for a population that doesn't own computers.

In the Duke program, the relevant stakeholders are at the table when recruiting programs are being designed. “If we are recruiting college students, we had students who sat on review panels and advisory boards to give us guidance as to what they would respond to, how, and in what setting,” Dr. Edwards said.

Another panel member, Rahn K. Bailey, M.D., said that throughout his career he has been interested in issues such as differences in drug metabolism between African Americans and other patients. For example, about 40% of black patients are slow or intermediate metabolizers of many psychiatric medications, said Dr. Bailey of the department of psychiatry and human behavior, University of Texas, Houston, and chair of the NMA psychiatry and behavioral sciences section.

Because of this, black patients tend to experience more toxicity, and efficacy may be compromised, he said. “It's not surprising to me now that many of my patients over the years have had great difficulty getting better, relapsed a lot quicker, come back to the hospital frequently, and ended up in the legal system because of clinical issues that were not addressed medically,” Dr. Bailey said.

“In psychiatry, it's as if we did all our studies on inpatients and none on outpatients, or in suburban communities rather than inner cities. The distinctions are apparent and actually affect medical decision making, he said, adding that these issues also are relevant in cardiovascular medicine, neurology, ob.gyn., and other areas of medicine. Audience member William Lawson, M.D., brought up the work of Surgeon General David Satcher, M.D., Ph.D., in his 1999 report “Mental Health: A Report of the Surgeon General.” One of the points made in this report was that virtually all U.S. psychiatric studies included primarily white males, so almost all the available psychiatric drugs had less than 1% African American representation, said Dr. Lawson, chair of psychiatry, Howard University, Washington.

“And the consequences have been awful. For example, once the second-generation antipsychotic medications came on the market it became clear that the risk of obesity, diabetes, and metabolic syndrome was much more of a problem for African Americans and Hispanics than for whites. We don't want to improve the mental health of our patients at the expense of giving them complications that can be lethal,” Dr. Lawson said.

NEW YORK – Racial disparities in access to health care will disappear only when adequate and representative samples of patients of color participate in clinical trials, Winston Price, M.D., said at the annual meeting of the National Medical Association.

That disparities in delivery of health care exist is not in question. The Institute of Medicine report “Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare” revealed the extent of the problem, showing that disparities remain even after adjustment for factors such as insurance coverage and socioeconomics.

But a widespread mistrust of the U.S. health care system among people of African descent–not least because of past abuses such as the Tuskegee Syphilis Study, in which black patients went untreated for many years despite the availability of effective therapy–has led to an unwillingness among African Americans to participate in clinical trials that might directly benefit their own health.

An increasing understanding of genetic differences and racial differences in response to medications now makes it imperative that people of color be included and their needs addressed in the drug development process, said Dr. Price of the State University of New York Health Science Center, Brooklyn.

The experience with BiDil, a fixed-dose combination of isosorbide dinitrate and hydralazine approved specifically for the treatment of heart failure in black patients, shows it can be done (August 2005, page 74).

“You had 1,050 African Americans who enrolled in the study, and the attrition rate was zero,” Dr. Price, who is also president of the NMA, said in a press briefing. “Every single one stayed with that study until completion. The drug was approved by the Food and Drug Administration on June 23, not because it was the right thing to do but because it was pure science and evidence based. All we're asking for is parity.”

Other model programs also are demonstrating that blacks can be recruited successfully, Christopher L. Edwards, Ph.D., said at the briefing.

Programs that are successful tend to be well entrenched in the community; they have significant outreach and education and strong, ongoing relationships with local organizations such as churches and fraternities, Dr. Edwards said.

They do not pressure potential study participants, but rather provide information and allow patients to process the information at home and respond to the investigators when they are ready, he said.

Successful investigators are available to the community not only when recruiting; they are able to articulate the tangible benefits of participation, not only for patients themselves but also for future generations. Dr. Edwards' program in the department of psychiatry at Duke University Medical Center, Durham, N.C., is an example.

“We make ourselves available for interviews on television, religious radio, and pop radio. In one creative marketing plan, we placed advertisements for one of our genetic studies on the side of 20 city buses, and have seen a significant number of patients responding.” he said.

The overall strategy of information dissemination is to go where the patients are, and not to rely on them to come to us, he said. “With the bus advertisements, the demographic we were recruiting was reliant on public transportation,” he added. And the advertisements provided phone numbers, not e-mail addresses or Web sites because these would not be particularly helpful for a population that doesn't own computers.

In the Duke program, the relevant stakeholders are at the table when recruiting programs are being designed. “If we are recruiting college students, we had students who sat on review panels and advisory boards to give us guidance as to what they would respond to, how, and in what setting,” Dr. Edwards said.

Another panel member, Rahn K. Bailey, M.D., said that throughout his career he has been interested in issues such as differences in drug metabolism between African Americans and other patients. For example, about 40% of black patients are slow or intermediate metabolizers of many psychiatric medications, said Dr. Bailey of the department of psychiatry and human behavior, University of Texas, Houston, and chair of the NMA psychiatry and behavioral sciences section.

Because of this, black patients tend to experience more toxicity, and efficacy may be compromised, he said. “It's not surprising to me now that many of my patients over the years have had great difficulty getting better, relapsed a lot quicker, come back to the hospital frequently, and ended up in the legal system because of clinical issues that were not addressed medically,” Dr. Bailey said.

“In psychiatry, it's as if we did all our studies on inpatients and none on outpatients, or in suburban communities rather than inner cities. The distinctions are apparent and actually affect medical decision making, he said, adding that these issues also are relevant in cardiovascular medicine, neurology, ob.gyn., and other areas of medicine. Audience member William Lawson, M.D., brought up the work of Surgeon General David Satcher, M.D., Ph.D., in his 1999 report “Mental Health: A Report of the Surgeon General.” One of the points made in this report was that virtually all U.S. psychiatric studies included primarily white males, so almost all the available psychiatric drugs had less than 1% African American representation, said Dr. Lawson, chair of psychiatry, Howard University, Washington.

“And the consequences have been awful. For example, once the second-generation antipsychotic medications came on the market it became clear that the risk of obesity, diabetes, and metabolic syndrome was much more of a problem for African Americans and Hispanics than for whites. We don't want to improve the mental health of our patients at the expense of giving them complications that can be lethal,” Dr. Lawson said.

NEW YORK – Racial disparities in access to health care will disappear only when adequate and representative samples of patients of color participate in clinical trials, Winston Price, M.D., said at the annual meeting of the National Medical Association.

That disparities in delivery of health care exist is not in question. The Institute of Medicine report “Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare” revealed the extent of the problem, showing that disparities remain even after adjustment for factors such as insurance coverage and socioeconomics.

But a widespread mistrust of the U.S. health care system among people of African descent–not least because of past abuses such as the Tuskegee Syphilis Study, in which black patients went untreated for many years despite the availability of effective therapy–has led to an unwillingness among African Americans to participate in clinical trials that might directly benefit their own health.

An increasing understanding of genetic differences and racial differences in response to medications now makes it imperative that people of color be included and their needs addressed in the drug development process, said Dr. Price of the State University of New York Health Science Center, Brooklyn.

The experience with BiDil, a fixed-dose combination of isosorbide dinitrate and hydralazine approved specifically for the treatment of heart failure in black patients, shows it can be done (August 2005, page 74).

“You had 1,050 African Americans who enrolled in the study, and the attrition rate was zero,” Dr. Price, who is also president of the NMA, said in a press briefing. “Every single one stayed with that study until completion. The drug was approved by the Food and Drug Administration on June 23, not because it was the right thing to do but because it was pure science and evidence based. All we're asking for is parity.”

Other model programs also are demonstrating that blacks can be recruited successfully, Christopher L. Edwards, Ph.D., said at the briefing.

Programs that are successful tend to be well entrenched in the community; they have significant outreach and education and strong, ongoing relationships with local organizations such as churches and fraternities, Dr. Edwards said.

They do not pressure potential study participants, but rather provide information and allow patients to process the information at home and respond to the investigators when they are ready, he said.

Successful investigators are available to the community not only when recruiting; they are able to articulate the tangible benefits of participation, not only for patients themselves but also for future generations. Dr. Edwards' program in the department of psychiatry at Duke University Medical Center, Durham, N.C., is an example.

“We make ourselves available for interviews on television, religious radio, and pop radio. In one creative marketing plan, we placed advertisements for one of our genetic studies on the side of 20 city buses, and have seen a significant number of patients responding.” he said.

The overall strategy of information dissemination is to go where the patients are, and not to rely on them to come to us, he said. “With the bus advertisements, the demographic we were recruiting was reliant on public transportation,” he added. And the advertisements provided phone numbers, not e-mail addresses or Web sites because these would not be particularly helpful for a population that doesn't own computers.

In the Duke program, the relevant stakeholders are at the table when recruiting programs are being designed. “If we are recruiting college students, we had students who sat on review panels and advisory boards to give us guidance as to what they would respond to, how, and in what setting,” Dr. Edwards said.

Another panel member, Rahn K. Bailey, M.D., said that throughout his career he has been interested in issues such as differences in drug metabolism between African Americans and other patients. For example, about 40% of black patients are slow or intermediate metabolizers of many psychiatric medications, said Dr. Bailey of the department of psychiatry and human behavior, University of Texas, Houston, and chair of the NMA psychiatry and behavioral sciences section.

Because of this, black patients tend to experience more toxicity, and efficacy may be compromised, he said. “It's not surprising to me now that many of my patients over the years have had great difficulty getting better, relapsed a lot quicker, come back to the hospital frequently, and ended up in the legal system because of clinical issues that were not addressed medically,” Dr. Bailey said.

“In psychiatry, it's as if we did all our studies on inpatients and none on outpatients, or in suburban communities rather than inner cities. The distinctions are apparent and actually affect medical decision making, he said, adding that these issues also are relevant in cardiovascular medicine, neurology, ob.gyn., and other areas of medicine. Audience member William Lawson, M.D., brought up the work of Surgeon General David Satcher, M.D., Ph.D., in his 1999 report “Mental Health: A Report of the Surgeon General.” One of the points made in this report was that virtually all U.S. psychiatric studies included primarily white males, so almost all the available psychiatric drugs had less than 1% African American representation, said Dr. Lawson, chair of psychiatry, Howard University, Washington.

“And the consequences have been awful. For example, once the second-generation antipsychotic medications came on the market it became clear that the risk of obesity, diabetes, and metabolic syndrome was much more of a problem for African Americans and Hispanics than for whites. We don't want to improve the mental health of our patients at the expense of giving them complications that can be lethal,” Dr. Lawson said.

NEW YORK — Racial disparities in access to health care will disappear only when adequate and representative samples of minorities participate in clinical trials, Winston Price, M.D., said at the annual meeting of the National Medical Association.

That disparities in delivery of health care exist is not in question. The Institute of Medicine report “Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare” revealed the extent of the problem, showing that disparities remain even after adjustment for factors such as insurance coverage and socioeconomic status.

But a widespread mistrust of the U.S. health care system among minorities—not least because of past abuses such as the Tuskegee Syphilis Study, in which blacks went untreated for many years despite the availability of effective therapy—has led to an unwillingness among African Americans to participate in the clinical trials that might directly benefit their own health.

An increasing understanding of genetic and racial differences in response to medications makes it imperative that minorities be included and their needs addressed in the drug development process, said Dr. Price of the State University of New York Health Science Center, Brooklyn.

The experience with BiDil, a fixed-dose combination of isosorbide dinitrate and hydralazine approved specifically for the treatment of heart failure in black patients, shows it can be done.

“You had 1,050 African Americans who enrolled in the study, and the attrition rate was zero,” Dr. Price, who is also president of the NMA, said in a press briefing. “Every single one stayed with that study until completion. The drug was approved by the Food and Drug Administration on June 23, not because it was the right thing to do but because it was pure science and evidence based.” Other models also are demonstrating blacks can be recruited successfully, Christopher L. Edwards, Ph.D., said.

Programs that are successful tend to be well entrenched in the community; they have good outreach and education and relationships with local organizations such as churches and fraternities, Dr. Edwards said.

They do not pressure potential participants, but provide information and allow patients to process it at home and respond when they are ready, he said.

Successful investigators are available to the community not only when recruiting; they are able to articulate the tangible benefits of participation, not only for patients themselves but also for future generations. Dr. Edwards' program in the department of psychiatry at Duke University Medical Center, Durham, N.C., is an example.

“We make ourselves available for interviews on television, religious radio, and pop radio. In one creative marketing plan, we placed advertisements for one of our genetic studies on the side of 20 city buses, and have seen a significant number of patients responding.” he said.

The strategy of information dissemination is to go where the patients are, and not to rely on them to come to us, he said. “With the bus advertisements, the demographic we were recruiting was reliant on public transportation,” he added. And the ads provided phone numbers, not e-mail addresses or Web sites because those would not be helpful for any potential participant who did not own a computer.

In the Duke program, the relevant stakeholders are at the table when recruiting programs are being designed. “If we are recruiting college students, we had students who sat on review panels and advisory boards to give us guidance as to what they would respond to, how, and in what setting,” Dr. Edwards said.

Another panel member, Rahn K. Bailey, M.D., said throughout his career he has been interested in issues such as differences in drug metabolism between African Americans and other patients. For example, about 40% of black patients are slow or intermediate metabolizers of many psychiatric medications, said Dr. Bailey of the department of psychiatry and human behavior, University of Texas, Houston, and chair of the NMA psychiatry and behavioral sciences section. As a result, black patients tend to experience more toxicity, and efficacy may be compromised.

“It's not surprising to me now that many of my patients over the years have had great difficulty getting better, relapsed a lot quicker, come back to the hospital frequently, and ended up in the legal system because of clinical issues that were not addressed medically,” Dr. Bailey said.

Audience member William Lawson, M.D., brought up the work of Surgeon General David Satcher, M.D., Ph.D., in his 1999 report “Mental Health: A Report of the Surgeon General.” One of the points made was that virtually all U.S. psychiatric studies included primarily white males, so almost all psychiatric drugs had less than 1% African American representation, said Dr. Lawson, chair of psychiatry, Howard University, Washington. “And the consequences have been awful.”

NEW YORK — Racial disparities in access to health care will disappear only when adequate and representative samples of minorities participate in clinical trials, Winston Price, M.D., said at the annual meeting of the National Medical Association.

That disparities in delivery of health care exist is not in question. The Institute of Medicine report “Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare” revealed the extent of the problem, showing that disparities remain even after adjustment for factors such as insurance coverage and socioeconomic status.

But a widespread mistrust of the U.S. health care system among minorities—not least because of past abuses such as the Tuskegee Syphilis Study, in which blacks went untreated for many years despite the availability of effective therapy—has led to an unwillingness among African Americans to participate in the clinical trials that might directly benefit their own health.

An increasing understanding of genetic and racial differences in response to medications makes it imperative that minorities be included and their needs addressed in the drug development process, said Dr. Price of the State University of New York Health Science Center, Brooklyn.

The experience with BiDil, a fixed-dose combination of isosorbide dinitrate and hydralazine approved specifically for the treatment of heart failure in black patients, shows it can be done.

“You had 1,050 African Americans who enrolled in the study, and the attrition rate was zero,” Dr. Price, who is also president of the NMA, said in a press briefing. “Every single one stayed with that study until completion. The drug was approved by the Food and Drug Administration on June 23, not because it was the right thing to do but because it was pure science and evidence based.” Other models also are demonstrating blacks can be recruited successfully, Christopher L. Edwards, Ph.D., said.

Programs that are successful tend to be well entrenched in the community; they have good outreach and education and relationships with local organizations such as churches and fraternities, Dr. Edwards said.

They do not pressure potential participants, but provide information and allow patients to process it at home and respond when they are ready, he said.

Successful investigators are available to the community not only when recruiting; they are able to articulate the tangible benefits of participation, not only for patients themselves but also for future generations. Dr. Edwards' program in the department of psychiatry at Duke University Medical Center, Durham, N.C., is an example.

“We make ourselves available for interviews on television, religious radio, and pop radio. In one creative marketing plan, we placed advertisements for one of our genetic studies on the side of 20 city buses, and have seen a significant number of patients responding.” he said.

The strategy of information dissemination is to go where the patients are, and not to rely on them to come to us, he said. “With the bus advertisements, the demographic we were recruiting was reliant on public transportation,” he added. And the ads provided phone numbers, not e-mail addresses or Web sites because those would not be helpful for any potential participant who did not own a computer.

In the Duke program, the relevant stakeholders are at the table when recruiting programs are being designed. “If we are recruiting college students, we had students who sat on review panels and advisory boards to give us guidance as to what they would respond to, how, and in what setting,” Dr. Edwards said.

Another panel member, Rahn K. Bailey, M.D., said throughout his career he has been interested in issues such as differences in drug metabolism between African Americans and other patients. For example, about 40% of black patients are slow or intermediate metabolizers of many psychiatric medications, said Dr. Bailey of the department of psychiatry and human behavior, University of Texas, Houston, and chair of the NMA psychiatry and behavioral sciences section. As a result, black patients tend to experience more toxicity, and efficacy may be compromised.

“It's not surprising to me now that many of my patients over the years have had great difficulty getting better, relapsed a lot quicker, come back to the hospital frequently, and ended up in the legal system because of clinical issues that were not addressed medically,” Dr. Bailey said.

Audience member William Lawson, M.D., brought up the work of Surgeon General David Satcher, M.D., Ph.D., in his 1999 report “Mental Health: A Report of the Surgeon General.” One of the points made was that virtually all U.S. psychiatric studies included primarily white males, so almost all psychiatric drugs had less than 1% African American representation, said Dr. Lawson, chair of psychiatry, Howard University, Washington. “And the consequences have been awful.”

NEW YORK — Racial disparities in access to health care will disappear only when adequate and representative samples of minorities participate in clinical trials, Winston Price, M.D., said at the annual meeting of the National Medical Association.

That disparities in delivery of health care exist is not in question. The Institute of Medicine report “Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare” revealed the extent of the problem, showing that disparities remain even after adjustment for factors such as insurance coverage and socioeconomic status.

But a widespread mistrust of the U.S. health care system among minorities—not least because of past abuses such as the Tuskegee Syphilis Study, in which blacks went untreated for many years despite the availability of effective therapy—has led to an unwillingness among African Americans to participate in the clinical trials that might directly benefit their own health.

An increasing understanding of genetic and racial differences in response to medications makes it imperative that minorities be included and their needs addressed in the drug development process, said Dr. Price of the State University of New York Health Science Center, Brooklyn.

The experience with BiDil, a fixed-dose combination of isosorbide dinitrate and hydralazine approved specifically for the treatment of heart failure in black patients, shows it can be done.

“You had 1,050 African Americans who enrolled in the study, and the attrition rate was zero,” Dr. Price, who is also president of the NMA, said in a press briefing. “Every single one stayed with that study until completion. The drug was approved by the Food and Drug Administration on June 23, not because it was the right thing to do but because it was pure science and evidence based.” Other models also are demonstrating blacks can be recruited successfully, Christopher L. Edwards, Ph.D., said.

Programs that are successful tend to be well entrenched in the community; they have good outreach and education and relationships with local organizations such as churches and fraternities, Dr. Edwards said.

They do not pressure potential participants, but provide information and allow patients to process it at home and respond when they are ready, he said.

Successful investigators are available to the community not only when recruiting; they are able to articulate the tangible benefits of participation, not only for patients themselves but also for future generations. Dr. Edwards' program in the department of psychiatry at Duke University Medical Center, Durham, N.C., is an example.

“We make ourselves available for interviews on television, religious radio, and pop radio. In one creative marketing plan, we placed advertisements for one of our genetic studies on the side of 20 city buses, and have seen a significant number of patients responding.” he said.

The strategy of information dissemination is to go where the patients are, and not to rely on them to come to us, he said. “With the bus advertisements, the demographic we were recruiting was reliant on public transportation,” he added. And the ads provided phone numbers, not e-mail addresses or Web sites because those would not be helpful for any potential participant who did not own a computer.

In the Duke program, the relevant stakeholders are at the table when recruiting programs are being designed. “If we are recruiting college students, we had students who sat on review panels and advisory boards to give us guidance as to what they would respond to, how, and in what setting,” Dr. Edwards said.

Another panel member, Rahn K. Bailey, M.D., said throughout his career he has been interested in issues such as differences in drug metabolism between African Americans and other patients. For example, about 40% of black patients are slow or intermediate metabolizers of many psychiatric medications, said Dr. Bailey of the department of psychiatry and human behavior, University of Texas, Houston, and chair of the NMA psychiatry and behavioral sciences section. As a result, black patients tend to experience more toxicity, and efficacy may be compromised.

“It's not surprising to me now that many of my patients over the years have had great difficulty getting better, relapsed a lot quicker, come back to the hospital frequently, and ended up in the legal system because of clinical issues that were not addressed medically,” Dr. Bailey said.

Audience member William Lawson, M.D., brought up the work of Surgeon General David Satcher, M.D., Ph.D., in his 1999 report “Mental Health: A Report of the Surgeon General.” One of the points made was that virtually all U.S. psychiatric studies included primarily white males, so almost all psychiatric drugs had less than 1% African American representation, said Dr. Lawson, chair of psychiatry, Howard University, Washington. “And the consequences have been awful.”

NEW YORK — The mantra for the new world order is “It is not if, but when,” and physicians must be prepared to care for victims of radiation injury resulting from terrorist events, Lt. Col. Norvell V. Coots, MC, USA, said at the annual meeting of the National Medical Association.

Radiation injury can result from dirty bombs, which are devices that contain radioactive material along with conventional explosives, or small thermonuclear “suitcase” bombs, which proliferated in the former Soviet Union. It is thought that some have not been accounted for, Dr. Coots said. Additionally, explosives could be planted near a factory or hospital that uses significant amounts of radioactive material, in essence creating the same results.

Cutaneous injuries can result from the direct effects of radiation, especially on the basal layer, which is the most radiosensitive. Flash burns, which are caused by heat, can be particularly injurious if the victim is wearing dark clothing that will absorb the heat or even burst into flame, he said. Contaminants left on the skin can cause further injury.

The cutaneous damage from radiation injury may manifest as ecchymoses, petechiae, bullae, epidermal sloughing, ulceration, hair loss, hyperkeratosis, and stochastic radiation reactions with long-term carcinogenesis.

In treatment of these patients, the first concern is decontamination, which consists of removal of clothing and washing the body with soap and water. “Soap does exactly what it is supposed to do—it breaks the electrostatic and protein bonds that cause contaminants and dirt to adhere to the skin,” Dr. Coots said.

The wound should then be debrided and treated with topical antimicrobials. Because there may be damage to the vasculature and a lack of oxygenation in the area, hyperbaric oxygen may be beneficial for healing.

Aside from the cutaneous injury, acute radiation syndromes affect the hematopoietic, cardiovascular, gastrointestinal, and central nervous systems, beginning with a prodromal phase that typically consists of nausea, vomiting, and diarrhea. This is followed by a latent subclinical phase and then acute radiation illness, with effects ranging from moderate leukopenia to pneumonia, purpura, hemorrhage, and convulsions. The damage is progressive and dose dependent, said Dr. Coots, who is the commander of the Andrew Rader U.S. Army Health Clinic, Fort Myer, Va., and a staff dermatologist at Walter Reed Army Medical Center, Washington.

Treatment also must include control of sepsis and pain, as well as surgical repair as needed. Flaps are used rather than grafts because with radiation injury the skin is devascularized and a graft would fail, he said.

Care of the victim will also require consultation with many colleagues—both specialist physicians and mental health care providers. “Fear is one of the biggest things we have to deal with any time we deal with a terrorist event, but particularly with radiation because its invisibility is particularly threatening,” he said.

“The purpose of terrorism is simple: It's a psychological weapon aimed at the civilian population rather than the military population, and it is designed to force a nation to surrender when their military forces never would,” Dr. Coots said.

“We're a big country but we're a vulnerable country,” he said. The United States has thousands of miles of coastline and porous borders in both the north and south. Millions of people travel to or from the United States each year through hundreds of international airports.

Additionally, hundreds of ships dockhere annually, depositing millions of containers that can be distributed across the country within hours or days, he said.

The federal government maintains three main information sites on on dealing with ionizing radiation injuries:

▸ Radiation Emergency Assistance Center/Training Site (REAC/TS), www.orau.gov/reacts/default.htm

▸ Centers for Disease Control and Prevention, www.bt.cdc.gov/radiation/pdf/MassCasualtiesGuidelines.pdf

▸ Armed Forces Radiobiology Research Institute, www.afrri.usuhs.mil

NEW YORK — The mantra for the new world order is “It is not if, but when,” and physicians must be prepared to care for victims of radiation injury resulting from terrorist events, Lt. Col. Norvell V. Coots, MC, USA, said at the annual meeting of the National Medical Association.

Radiation injury can result from dirty bombs, which are devices that contain radioactive material along with conventional explosives, or small thermonuclear “suitcase” bombs, which proliferated in the former Soviet Union. It is thought that some have not been accounted for, Dr. Coots said. Additionally, explosives could be planted near a factory or hospital that uses significant amounts of radioactive material, in essence creating the same results.

Cutaneous injuries can result from the direct effects of radiation, especially on the basal layer, which is the most radiosensitive. Flash burns, which are caused by heat, can be particularly injurious if the victim is wearing dark clothing that will absorb the heat or even burst into flame, he said. Contaminants left on the skin can cause further injury.

The cutaneous damage from radiation injury may manifest as ecchymoses, petechiae, bullae, epidermal sloughing, ulceration, hair loss, hyperkeratosis, and stochastic radiation reactions with long-term carcinogenesis.

In treatment of these patients, the first concern is decontamination, which consists of removal of clothing and washing the body with soap and water. “Soap does exactly what it is supposed to do—it breaks the electrostatic and protein bonds that cause contaminants and dirt to adhere to the skin,” Dr. Coots said.

The wound should then be debrided and treated with topical antimicrobials. Because there may be damage to the vasculature and a lack of oxygenation in the area, hyperbaric oxygen may be beneficial for healing.

Aside from the cutaneous injury, acute radiation syndromes affect the hematopoietic, cardiovascular, gastrointestinal, and central nervous systems, beginning with a prodromal phase that typically consists of nausea, vomiting, and diarrhea. This is followed by a latent subclinical phase and then acute radiation illness, with effects ranging from moderate leukopenia to pneumonia, purpura, hemorrhage, and convulsions. The damage is progressive and dose dependent, said Dr. Coots, who is the commander of the Andrew Rader U.S. Army Health Clinic, Fort Myer, Va., and a staff dermatologist at Walter Reed Army Medical Center, Washington.

Treatment also must include control of sepsis and pain, as well as surgical repair as needed. Flaps are used rather than grafts because with radiation injury the skin is devascularized and a graft would fail, he said.

Care of the victim will also require consultation with many colleagues—both specialist physicians and mental health care providers. “Fear is one of the biggest things we have to deal with any time we deal with a terrorist event, but particularly with radiation because its invisibility is particularly threatening,” he said.

“The purpose of terrorism is simple: It's a psychological weapon aimed at the civilian population rather than the military population, and it is designed to force a nation to surrender when their military forces never would,” Dr. Coots said.

“We're a big country but we're a vulnerable country,” he said. The United States has thousands of miles of coastline and porous borders in both the north and south. Millions of people travel to or from the United States each year through hundreds of international airports.

Additionally, hundreds of ships dockhere annually, depositing millions of containers that can be distributed across the country within hours or days, he said.

The federal government maintains three main information sites on on dealing with ionizing radiation injuries:

▸ Radiation Emergency Assistance Center/Training Site (REAC/TS), www.orau.gov/reacts/default.htm

▸ Centers for Disease Control and Prevention, www.bt.cdc.gov/radiation/pdf/MassCasualtiesGuidelines.pdf

▸ Armed Forces Radiobiology Research Institute, www.afrri.usuhs.mil

NEW YORK — The mantra for the new world order is “It is not if, but when,” and physicians must be prepared to care for victims of radiation injury resulting from terrorist events, Lt. Col. Norvell V. Coots, MC, USA, said at the annual meeting of the National Medical Association.

Radiation injury can result from dirty bombs, which are devices that contain radioactive material along with conventional explosives, or small thermonuclear “suitcase” bombs, which proliferated in the former Soviet Union. It is thought that some have not been accounted for, Dr. Coots said. Additionally, explosives could be planted near a factory or hospital that uses significant amounts of radioactive material, in essence creating the same results.

Cutaneous injuries can result from the direct effects of radiation, especially on the basal layer, which is the most radiosensitive. Flash burns, which are caused by heat, can be particularly injurious if the victim is wearing dark clothing that will absorb the heat or even burst into flame, he said. Contaminants left on the skin can cause further injury.

The cutaneous damage from radiation injury may manifest as ecchymoses, petechiae, bullae, epidermal sloughing, ulceration, hair loss, hyperkeratosis, and stochastic radiation reactions with long-term carcinogenesis.

In treatment of these patients, the first concern is decontamination, which consists of removal of clothing and washing the body with soap and water. “Soap does exactly what it is supposed to do—it breaks the electrostatic and protein bonds that cause contaminants and dirt to adhere to the skin,” Dr. Coots said.

The wound should then be debrided and treated with topical antimicrobials. Because there may be damage to the vasculature and a lack of oxygenation in the area, hyperbaric oxygen may be beneficial for healing.

Aside from the cutaneous injury, acute radiation syndromes affect the hematopoietic, cardiovascular, gastrointestinal, and central nervous systems, beginning with a prodromal phase that typically consists of nausea, vomiting, and diarrhea. This is followed by a latent subclinical phase and then acute radiation illness, with effects ranging from moderate leukopenia to pneumonia, purpura, hemorrhage, and convulsions. The damage is progressive and dose dependent, said Dr. Coots, who is the commander of the Andrew Rader U.S. Army Health Clinic, Fort Myer, Va., and a staff dermatologist at Walter Reed Army Medical Center, Washington.

Treatment also must include control of sepsis and pain, as well as surgical repair as needed. Flaps are used rather than grafts because with radiation injury the skin is devascularized and a graft would fail, he said.

Care of the victim will also require consultation with many colleagues—both specialist physicians and mental health care providers. “Fear is one of the biggest things we have to deal with any time we deal with a terrorist event, but particularly with radiation because its invisibility is particularly threatening,” he said.

“The purpose of terrorism is simple: It's a psychological weapon aimed at the civilian population rather than the military population, and it is designed to force a nation to surrender when their military forces never would,” Dr. Coots said.

“We're a big country but we're a vulnerable country,” he said. The United States has thousands of miles of coastline and porous borders in both the north and south. Millions of people travel to or from the United States each year through hundreds of international airports.

Additionally, hundreds of ships dockhere annually, depositing millions of containers that can be distributed across the country within hours or days, he said.

The federal government maintains three main information sites on on dealing with ionizing radiation injuries:

▸ Radiation Emergency Assistance Center/Training Site (REAC/TS), www.orau.gov/reacts/default.htm

▸ Centers for Disease Control and Prevention, www.bt.cdc.gov/radiation/pdf/MassCasualtiesGuidelines.pdf

▸ Armed Forces Radiobiology Research Institute, www.afrri.usuhs.mil

NEW YORK — Racial disparities in access to health care will disappear only when adequate and representative samples of minorities participate in clinical trials, Winston Price, M.D., said at the annual meeting of the National Medical Association.

That disparities in delivery of health care exist is not in question. The Institute of Medicine report “Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare” revealed the extent of the problem, showing that disparities remain even after adjustment for factors such as insurance coverage and socioeconomic status.

But a widespread mistrust of the U.S. health care system among minorities—not least because of past abuses such as the Tuskegee Syphilis Study, in which blacks went untreated for many years despite the availability of effective therapy— has led to an unwillingness among African Americans to participate in the clinical trials that might directly benefit their own health.

An increasing understanding of genetic differences and racial differences in response to medications now makes it imperative that minorities be included and their needs addressed in the drug development process, said Dr. Price of the State University of New York Health Science Center, Brooklyn.

The experience with BiDil, a fixed-dose combination of isosorbide dinitrate and hydralazine approved specifically for the treatment of heart failure in black patients, shows it can be done (July 2005, page 1).

“You had 1,050 African Americans who enrolled in the study, and the attrition rate was zero,” Dr. Price, who is also president of the NMA, said in a press briefing. “Every single one stayed with that study until completion. The drug was approved by the Food and Drug Administration on June 23, not because it was the right thing to do but because it was pure science and evidence based. All we're asking for is parity.”

Other model programs also are demonstrating that blacks can be recruited successfully, Christopher L. Edwards, Ph.D., said at the briefing.

Programs that are successful tend to be well entrenched in the community; they have significant outreach and education and strong, ongoing relationships with local organizations such as churches and fraternities, Dr. Edwards said.

They do not pressure potential study participants, but rather provide information and allow patients to process the information at home and respond to the investigators when they are ready, he said.

Successful investigators are available to the community not only when recruiting; they are able to articulate the tangible benefits of participation, not only for patients themselves but also for future generations. Dr. Edwards' program in the department of psychiatry at Duke University Medical Center, Durham, N.C., is an example.

“We make ourselves available for interviews on television, religious radio, and pop radio. In one creative marketing plan, we placed advertisements for one of our genetic studies on the side of 20 city buses, and have seen a significant number of patients responding.” he said.

The overall strategy of information dissemination is to go where the patients are, and not to rely on them to come to us, he said. “With the bus advertisements, the demographic we were recruiting was reliant on public transportation,” he added. And the advertisements provided phone numbers, not e-mail addresses or Web sites because these would not be helpful for a population that doesn't own computers.

In the Duke program, the relevant stakeholders are at the table when recruiting programs are being designed. “If we are recruiting college students, we had students who sat on review panels and advisory boards to give us guidance as to what they would respond to, how, and in what setting,” Dr. Edwards said.

NEW YORK — Racial disparities in access to health care will disappear only when adequate and representative samples of minorities participate in clinical trials, Winston Price, M.D., said at the annual meeting of the National Medical Association.

That disparities in delivery of health care exist is not in question. The Institute of Medicine report “Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare” revealed the extent of the problem, showing that disparities remain even after adjustment for factors such as insurance coverage and socioeconomic status.

But a widespread mistrust of the U.S. health care system among minorities—not least because of past abuses such as the Tuskegee Syphilis Study, in which blacks went untreated for many years despite the availability of effective therapy— has led to an unwillingness among African Americans to participate in the clinical trials that might directly benefit their own health.

An increasing understanding of genetic differences and racial differences in response to medications now makes it imperative that minorities be included and their needs addressed in the drug development process, said Dr. Price of the State University of New York Health Science Center, Brooklyn.

The experience with BiDil, a fixed-dose combination of isosorbide dinitrate and hydralazine approved specifically for the treatment of heart failure in black patients, shows it can be done (July 2005, page 1).

“You had 1,050 African Americans who enrolled in the study, and the attrition rate was zero,” Dr. Price, who is also president of the NMA, said in a press briefing. “Every single one stayed with that study until completion. The drug was approved by the Food and Drug Administration on June 23, not because it was the right thing to do but because it was pure science and evidence based. All we're asking for is parity.”

Other model programs also are demonstrating that blacks can be recruited successfully, Christopher L. Edwards, Ph.D., said at the briefing.

Programs that are successful tend to be well entrenched in the community; they have significant outreach and education and strong, ongoing relationships with local organizations such as churches and fraternities, Dr. Edwards said.

They do not pressure potential study participants, but rather provide information and allow patients to process the information at home and respond to the investigators when they are ready, he said.

Successful investigators are available to the community not only when recruiting; they are able to articulate the tangible benefits of participation, not only for patients themselves but also for future generations. Dr. Edwards' program in the department of psychiatry at Duke University Medical Center, Durham, N.C., is an example.

“We make ourselves available for interviews on television, religious radio, and pop radio. In one creative marketing plan, we placed advertisements for one of our genetic studies on the side of 20 city buses, and have seen a significant number of patients responding.” he said.

The overall strategy of information dissemination is to go where the patients are, and not to rely on them to come to us, he said. “With the bus advertisements, the demographic we were recruiting was reliant on public transportation,” he added. And the advertisements provided phone numbers, not e-mail addresses or Web sites because these would not be helpful for a population that doesn't own computers.

In the Duke program, the relevant stakeholders are at the table when recruiting programs are being designed. “If we are recruiting college students, we had students who sat on review panels and advisory boards to give us guidance as to what they would respond to, how, and in what setting,” Dr. Edwards said.

NEW YORK — Racial disparities in access to health care will disappear only when adequate and representative samples of minorities participate in clinical trials, Winston Price, M.D., said at the annual meeting of the National Medical Association.

That disparities in delivery of health care exist is not in question. The Institute of Medicine report “Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare” revealed the extent of the problem, showing that disparities remain even after adjustment for factors such as insurance coverage and socioeconomic status.

But a widespread mistrust of the U.S. health care system among minorities—not least because of past abuses such as the Tuskegee Syphilis Study, in which blacks went untreated for many years despite the availability of effective therapy— has led to an unwillingness among African Americans to participate in the clinical trials that might directly benefit their own health.

An increasing understanding of genetic differences and racial differences in response to medications now makes it imperative that minorities be included and their needs addressed in the drug development process, said Dr. Price of the State University of New York Health Science Center, Brooklyn.

The experience with BiDil, a fixed-dose combination of isosorbide dinitrate and hydralazine approved specifically for the treatment of heart failure in black patients, shows it can be done (July 2005, page 1).

“You had 1,050 African Americans who enrolled in the study, and the attrition rate was zero,” Dr. Price, who is also president of the NMA, said in a press briefing. “Every single one stayed with that study until completion. The drug was approved by the Food and Drug Administration on June 23, not because it was the right thing to do but because it was pure science and evidence based. All we're asking for is parity.”

Other model programs also are demonstrating that blacks can be recruited successfully, Christopher L. Edwards, Ph.D., said at the briefing.

Programs that are successful tend to be well entrenched in the community; they have significant outreach and education and strong, ongoing relationships with local organizations such as churches and fraternities, Dr. Edwards said.

They do not pressure potential study participants, but rather provide information and allow patients to process the information at home and respond to the investigators when they are ready, he said.

Successful investigators are available to the community not only when recruiting; they are able to articulate the tangible benefits of participation, not only for patients themselves but also for future generations. Dr. Edwards' program in the department of psychiatry at Duke University Medical Center, Durham, N.C., is an example.

“We make ourselves available for interviews on television, religious radio, and pop radio. In one creative marketing plan, we placed advertisements for one of our genetic studies on the side of 20 city buses, and have seen a significant number of patients responding.” he said.

The overall strategy of information dissemination is to go where the patients are, and not to rely on them to come to us, he said. “With the bus advertisements, the demographic we were recruiting was reliant on public transportation,” he added. And the advertisements provided phone numbers, not e-mail addresses or Web sites because these would not be helpful for a population that doesn't own computers.

In the Duke program, the relevant stakeholders are at the table when recruiting programs are being designed. “If we are recruiting college students, we had students who sat on review panels and advisory boards to give us guidance as to what they would respond to, how, and in what setting,” Dr. Edwards said.

VIENNA — The prognosis for children with mixed connective tissue disease is highly variable, with some progressing to scleroderma and others developing systemic lupus erythematosus, but in a significant number of cases, the autoimmune disorder improves over the long term, Thomas J.A. Lehman, M.D., said at the annual European congress of rheumatology.

This condition was first described by G.C. Sharp and colleagues in 1972 as a syndrome that included severe myositis, pulmonary hypertension, Raynaud's phenomenon, and esophageal hypomotility. It was felt to be a variant of lupus because patients were antinuclear antibody positive, but many also had features that were not typical of lupus, such as nailfold capillary abnormalities, Gottron's papules, hypergammaglobulinemia, and synovitis. Renal findings almost never included diffuse proliferative glomerular nephritis, although membranous nephritis sometimes was present.

Subsequently, other groups have attempted to refine Sharp's criteria. But even today, precisely what constitutes mixed connective tissue disease remains controversial—there are no official, definitive criteria—and some textbooks categorize the condition as an undifferentiated connective tissue disease or an overlap syndrome.

“Whatever you choose to call it, this is a relatively distinct group that diverges strongly over time, and we don't yet know how to tell who is going to diverge in which direction,” he said at the meeting, which was sponsored by the European League Against Rheumatism.

Most patients are strongly antinuclear antibody positive, ribonucleoprotein antibody positive, and Small antibody negative. C3 and C4 are usually normal, and tests for antidouble-stranded DNA most often are negative. Some 20%–50% of patients also have thrombocytopenia.

Careful monitoring can help determine the direction in which the condition will evolve. Urinalysis, for example, can reveal if a patient has become Smith positive and is developing classic lupus. Signs of progressive respiratory compromise may suggest progression to scleroderma, which tends to have the worst outcomes for the patients.

“But in my experience, the most common outcome has been for them to get better,” said Dr. Lehman, chief of the division of pediatric rheumatology at the Hospital for Special Surgery in New York City, who cares for many of these children.

This good outcome, however, requires close monitoring for potentially serious—or lethal—events, such as sudden, overwhelming sepsis, he said.

“These patients are functionally asplenic, so if the child develops a fever and signs of infection are present, start antibiotics and worry about false alarms later,” he said.

And cough, shortness of breath, or other respiratory problems can signal pulmonary hypertension, so it's wise to suggest an echocardiogram and high-resolution CT, said Dr. Lehman, who is also professor of clinical pediatrics, Weill Medical College of Cornell University, New York City.

The key is treating the individual's symptoms, and this can include the use of low-dose corticosteroids, hydroxychloroquine, and methotrexate, with calcium channel blockers for Raynaud's phenomenon.

“Monitoring the levels of IgG and hemoglobin, as well as the erythrocyte sedimentation rate, will tell you whether your treatment is adequately controlling the disease process,” he said at the meeting, which was sponsored by the European League Against Rheumatism.

“I've never had to use any of the immunosuppressive agents, such as cyclophosphamide or mycophenylate mofetil, at least in the early stages before the disease more fully delineates itself,” he said.

VIENNA — The prognosis for children with mixed connective tissue disease is highly variable, with some progressing to scleroderma and others developing systemic lupus erythematosus, but in a significant number of cases, the autoimmune disorder improves over the long term, Thomas J.A. Lehman, M.D., said at the annual European congress of rheumatology.

This condition was first described by G.C. Sharp and colleagues in 1972 as a syndrome that included severe myositis, pulmonary hypertension, Raynaud's phenomenon, and esophageal hypomotility. It was felt to be a variant of lupus because patients were antinuclear antibody positive, but many also had features that were not typical of lupus, such as nailfold capillary abnormalities, Gottron's papules, hypergammaglobulinemia, and synovitis. Renal findings almost never included diffuse proliferative glomerular nephritis, although membranous nephritis sometimes was present.

Subsequently, other groups have attempted to refine Sharp's criteria. But even today, precisely what constitutes mixed connective tissue disease remains controversial—there are no official, definitive criteria—and some textbooks categorize the condition as an undifferentiated connective tissue disease or an overlap syndrome.

“Whatever you choose to call it, this is a relatively distinct group that diverges strongly over time, and we don't yet know how to tell who is going to diverge in which direction,” he said at the meeting, which was sponsored by the European League Against Rheumatism.

Most patients are strongly antinuclear antibody positive, ribonucleoprotein antibody positive, and Small antibody negative. C3 and C4 are usually normal, and tests for antidouble-stranded DNA most often are negative. Some 20%–50% of patients also have thrombocytopenia.

Careful monitoring can help determine the direction in which the condition will evolve. Urinalysis, for example, can reveal if a patient has become Smith positive and is developing classic lupus. Signs of progressive respiratory compromise may suggest progression to scleroderma, which tends to have the worst outcomes for the patients.

“But in my experience, the most common outcome has been for them to get better,” said Dr. Lehman, chief of the division of pediatric rheumatology at the Hospital for Special Surgery in New York City, who cares for many of these children.

This good outcome, however, requires close monitoring for potentially serious—or lethal—events, such as sudden, overwhelming sepsis, he said.

“These patients are functionally asplenic, so if the child develops a fever and signs of infection are present, start antibiotics and worry about false alarms later,” he said.

And cough, shortness of breath, or other respiratory problems can signal pulmonary hypertension, so it's wise to suggest an echocardiogram and high-resolution CT, said Dr. Lehman, who is also professor of clinical pediatrics, Weill Medical College of Cornell University, New York City.

The key is treating the individual's symptoms, and this can include the use of low-dose corticosteroids, hydroxychloroquine, and methotrexate, with calcium channel blockers for Raynaud's phenomenon.

“Monitoring the levels of IgG and hemoglobin, as well as the erythrocyte sedimentation rate, will tell you whether your treatment is adequately controlling the disease process,” he said at the meeting, which was sponsored by the European League Against Rheumatism.

“I've never had to use any of the immunosuppressive agents, such as cyclophosphamide or mycophenylate mofetil, at least in the early stages before the disease more fully delineates itself,” he said.

VIENNA — The prognosis for children with mixed connective tissue disease is highly variable, with some progressing to scleroderma and others developing systemic lupus erythematosus, but in a significant number of cases, the autoimmune disorder improves over the long term, Thomas J.A. Lehman, M.D., said at the annual European congress of rheumatology.

This condition was first described by G.C. Sharp and colleagues in 1972 as a syndrome that included severe myositis, pulmonary hypertension, Raynaud's phenomenon, and esophageal hypomotility. It was felt to be a variant of lupus because patients were antinuclear antibody positive, but many also had features that were not typical of lupus, such as nailfold capillary abnormalities, Gottron's papules, hypergammaglobulinemia, and synovitis. Renal findings almost never included diffuse proliferative glomerular nephritis, although membranous nephritis sometimes was present.

Subsequently, other groups have attempted to refine Sharp's criteria. But even today, precisely what constitutes mixed connective tissue disease remains controversial—there are no official, definitive criteria—and some textbooks categorize the condition as an undifferentiated connective tissue disease or an overlap syndrome.

“Whatever you choose to call it, this is a relatively distinct group that diverges strongly over time, and we don't yet know how to tell who is going to diverge in which direction,” he said at the meeting, which was sponsored by the European League Against Rheumatism.

Most patients are strongly antinuclear antibody positive, ribonucleoprotein antibody positive, and Small antibody negative. C3 and C4 are usually normal, and tests for antidouble-stranded DNA most often are negative. Some 20%–50% of patients also have thrombocytopenia.

Careful monitoring can help determine the direction in which the condition will evolve. Urinalysis, for example, can reveal if a patient has become Smith positive and is developing classic lupus. Signs of progressive respiratory compromise may suggest progression to scleroderma, which tends to have the worst outcomes for the patients.

“But in my experience, the most common outcome has been for them to get better,” said Dr. Lehman, chief of the division of pediatric rheumatology at the Hospital for Special Surgery in New York City, who cares for many of these children.

This good outcome, however, requires close monitoring for potentially serious—or lethal—events, such as sudden, overwhelming sepsis, he said.

“These patients are functionally asplenic, so if the child develops a fever and signs of infection are present, start antibiotics and worry about false alarms later,” he said.

And cough, shortness of breath, or other respiratory problems can signal pulmonary hypertension, so it's wise to suggest an echocardiogram and high-resolution CT, said Dr. Lehman, who is also professor of clinical pediatrics, Weill Medical College of Cornell University, New York City.

The key is treating the individual's symptoms, and this can include the use of low-dose corticosteroids, hydroxychloroquine, and methotrexate, with calcium channel blockers for Raynaud's phenomenon.

“Monitoring the levels of IgG and hemoglobin, as well as the erythrocyte sedimentation rate, will tell you whether your treatment is adequately controlling the disease process,” he said at the meeting, which was sponsored by the European League Against Rheumatism.

“I've never had to use any of the immunosuppressive agents, such as cyclophosphamide or mycophenylate mofetil, at least in the early stages before the disease more fully delineates itself,” he said.

VIENNA — Response rates to biologic agents are high among patients with rheumatoid arthritis, but remission rates remain disappointingly low, Mikkel Ostergaard, M.D., said at the annual European congress of rheumatology.

According to the Danish Database for Biological Therapies in Rheumatology (DANBIO), two-thirds of patients on tumor necrosis factor-α blockers have persistently inadequate inflammatory control.

A total of 417 patients in Denmark receiving these drugs have been enrolled in DANBIO since October 2000—378 on infliximab and 39 on etanercept. Disease activity was measured at baseline and six times during the following year.

At baseline, the median disease duration was 9 years, swollen joint count was 10, tender joint count was 11, serum C-reactive protein was 27 mcg/mL, and DAS-28 was 5.9.

The median number of disease-modifying antirheumatic drugs taken previously was four.

There were no differences in baseline data or clinical response between patients receiving infliximab and those receiving etanercept.

From week 6 on, 15%–20% of patients were in clinical remission and another 10%–15% had low disease activity. Thus, approximately 70% of patients had moderate or high disease activity, said Dr. Ostergaard of Copenhagen University Hospitals.

Despite this less than optimal response in many patients, the median time they remained on the same drug exceeded 2 years, he said at the congress, sponsored by the European League Against Rheumatism.

This illustrates that continuous close monitoring of each patient with careful consideration of therapeutic adjustments is needed in daily clinical practice to achieve the goal of disease control in RA patients treated with biologics, he said.

Dr. Ostergaard disclosed that he has received financial support from Schering-Plough and Wyeth Pharmaceuticals.

VIENNA — Response rates to biologic agents are high among patients with rheumatoid arthritis, but remission rates remain disappointingly low, Mikkel Ostergaard, M.D., said at the annual European congress of rheumatology.

According to the Danish Database for Biological Therapies in Rheumatology (DANBIO), two-thirds of patients on tumor necrosis factor-α blockers have persistently inadequate inflammatory control.

A total of 417 patients in Denmark receiving these drugs have been enrolled in DANBIO since October 2000—378 on infliximab and 39 on etanercept. Disease activity was measured at baseline and six times during the following year.

At baseline, the median disease duration was 9 years, swollen joint count was 10, tender joint count was 11, serum C-reactive protein was 27 mcg/mL, and DAS-28 was 5.9.

The median number of disease-modifying antirheumatic drugs taken previously was four.

There were no differences in baseline data or clinical response between patients receiving infliximab and those receiving etanercept.

From week 6 on, 15%–20% of patients were in clinical remission and another 10%–15% had low disease activity. Thus, approximately 70% of patients had moderate or high disease activity, said Dr. Ostergaard of Copenhagen University Hospitals.

Despite this less than optimal response in many patients, the median time they remained on the same drug exceeded 2 years, he said at the congress, sponsored by the European League Against Rheumatism.

This illustrates that continuous close monitoring of each patient with careful consideration of therapeutic adjustments is needed in daily clinical practice to achieve the goal of disease control in RA patients treated with biologics, he said.

Dr. Ostergaard disclosed that he has received financial support from Schering-Plough and Wyeth Pharmaceuticals.

VIENNA — Response rates to biologic agents are high among patients with rheumatoid arthritis, but remission rates remain disappointingly low, Mikkel Ostergaard, M.D., said at the annual European congress of rheumatology.

According to the Danish Database for Biological Therapies in Rheumatology (DANBIO), two-thirds of patients on tumor necrosis factor-α blockers have persistently inadequate inflammatory control.

A total of 417 patients in Denmark receiving these drugs have been enrolled in DANBIO since October 2000—378 on infliximab and 39 on etanercept. Disease activity was measured at baseline and six times during the following year.

At baseline, the median disease duration was 9 years, swollen joint count was 10, tender joint count was 11, serum C-reactive protein was 27 mcg/mL, and DAS-28 was 5.9.

The median number of disease-modifying antirheumatic drugs taken previously was four.

There were no differences in baseline data or clinical response between patients receiving infliximab and those receiving etanercept.

From week 6 on, 15%–20% of patients were in clinical remission and another 10%–15% had low disease activity. Thus, approximately 70% of patients had moderate or high disease activity, said Dr. Ostergaard of Copenhagen University Hospitals.

Despite this less than optimal response in many patients, the median time they remained on the same drug exceeded 2 years, he said at the congress, sponsored by the European League Against Rheumatism.

This illustrates that continuous close monitoring of each patient with careful consideration of therapeutic adjustments is needed in daily clinical practice to achieve the goal of disease control in RA patients treated with biologics, he said.

Dr. Ostergaard disclosed that he has received financial support from Schering-Plough and Wyeth Pharmaceuticals.

VIENNA — A new approach to forefoot reconstruction in patients with rheumatoid arthritis has shown superior results with regard to pain, deformity, and function compared with conventional techniques, according to Takeshi Mitsuka, M.D., of the department of orthopedic surgery, Chiba Tokushukai Hospital, Funabashi, Japan.

Reconstruction of the lateral toes is done by means of a metatarsal oblique osteotomy. For the great toe, either a Swanson implant or a metatarsal osteotomy can be done, depending on the condition of the joint, and the result is the preservation of the function of the metatarsophalangeal joints, Dr. Mitsuka wrote in a poster presented at the annual European congress of rheumatology.

“I have been performing this procedure since 1998 for almost all rheumatoid [arthritis] patients with forefoot deformities. The outcome is better than with resection arthroplasty of the MTP [metatarsophalangeal] joints or arthrodesis of the big toe for stability and mobility of the joint, length of toe, gait, and cosmetic result,” he told this newspaper.

A total of 53 forefoot reconstructions in 31 patients have been done to date. Mean age at time of surgery was 60 years, and the mean duration of rheumatoid arthritis until time of operation was 18 years.

At their latest follow-up, patients were evaluated clinically using the American Orthopedic Foot and Ankle Society (AOFAS) score. Hallux valgus angle and intermetatarsal angle were examined radiologically.

Two patients died of causes unrelated to surgery, and in one foot the Swanson implant was removed 11 months after placement because of reactive synovitis.

Among the remaining 48 feet, with a mean follow-up of 40 months, the AOFAS score for the great toe improved from an average of 36 points preoperatively to 89 points (out of 100). For the lateral toes, the average score improved from 27 points to 87 points.

The hallux valgus angle improved from an average of 45 degrees preoperatively to 19 degrees at the latest evaluation, Dr. Mitsuka noted at the meeting, which was sponsored by the European League Against Rheumatism.

Intermetatarsal angle also improved, from an average of 16 degrees before surgery to 13 degrees.

Reconstruction of the great toe of 44 feet in 25 patients involved arthroplasty with a Swanson implant, and was done with a Mitchell's osteotomy in the remaining 9 feet in 6 patients. In the lateral toes, an oblique osteotomy was performed at the metatarsal neck, starting proximally on the dorsum and proceeding distally and plantarward at an angle of 45 degrees. This was then resected at a width of 5–15 mm.

The metatarsal head subsequently was freed from its plantar aspect, and the dislocated base of the proximal phalanx was corrected. The osteotomized bones were then transfixed longitudinally by Kirschner wires from the distal phalanx to the metatarsal base.

A 53-year-old RA patient with forefoot deformities is shown prior to surgery.

Lateral toe reconstruction was performed by means of a metatarsal oblique osteotomy. Photos courtesy Dr. Takeshi Mitsuka

VIENNA — A new approach to forefoot reconstruction in patients with rheumatoid arthritis has shown superior results with regard to pain, deformity, and function compared with conventional techniques, according to Takeshi Mitsuka, M.D., of the department of orthopedic surgery, Chiba Tokushukai Hospital, Funabashi, Japan.

Reconstruction of the lateral toes is done by means of a metatarsal oblique osteotomy. For the great toe, either a Swanson implant or a metatarsal osteotomy can be done, depending on the condition of the joint, and the result is the preservation of the function of the metatarsophalangeal joints, Dr. Mitsuka wrote in a poster presented at the annual European congress of rheumatology.

“I have been performing this procedure since 1998 for almost all rheumatoid [arthritis] patients with forefoot deformities. The outcome is better than with resection arthroplasty of the MTP [metatarsophalangeal] joints or arthrodesis of the big toe for stability and mobility of the joint, length of toe, gait, and cosmetic result,” he told this newspaper.

A total of 53 forefoot reconstructions in 31 patients have been done to date. Mean age at time of surgery was 60 years, and the mean duration of rheumatoid arthritis until time of operation was 18 years.

At their latest follow-up, patients were evaluated clinically using the American Orthopedic Foot and Ankle Society (AOFAS) score. Hallux valgus angle and intermetatarsal angle were examined radiologically.

Two patients died of causes unrelated to surgery, and in one foot the Swanson implant was removed 11 months after placement because of reactive synovitis.

Among the remaining 48 feet, with a mean follow-up of 40 months, the AOFAS score for the great toe improved from an average of 36 points preoperatively to 89 points (out of 100). For the lateral toes, the average score improved from 27 points to 87 points.

The hallux valgus angle improved from an average of 45 degrees preoperatively to 19 degrees at the latest evaluation, Dr. Mitsuka noted at the meeting, which was sponsored by the European League Against Rheumatism.

Intermetatarsal angle also improved, from an average of 16 degrees before surgery to 13 degrees.

Reconstruction of the great toe of 44 feet in 25 patients involved arthroplasty with a Swanson implant, and was done with a Mitchell's osteotomy in the remaining 9 feet in 6 patients. In the lateral toes, an oblique osteotomy was performed at the metatarsal neck, starting proximally on the dorsum and proceeding distally and plantarward at an angle of 45 degrees. This was then resected at a width of 5–15 mm.

The metatarsal head subsequently was freed from its plantar aspect, and the dislocated base of the proximal phalanx was corrected. The osteotomized bones were then transfixed longitudinally by Kirschner wires from the distal phalanx to the metatarsal base.

A 53-year-old RA patient with forefoot deformities is shown prior to surgery.

Lateral toe reconstruction was performed by means of a metatarsal oblique osteotomy. Photos courtesy Dr. Takeshi Mitsuka

VIENNA — A new approach to forefoot reconstruction in patients with rheumatoid arthritis has shown superior results with regard to pain, deformity, and function compared with conventional techniques, according to Takeshi Mitsuka, M.D., of the department of orthopedic surgery, Chiba Tokushukai Hospital, Funabashi, Japan.

Reconstruction of the lateral toes is done by means of a metatarsal oblique osteotomy. For the great toe, either a Swanson implant or a metatarsal osteotomy can be done, depending on the condition of the joint, and the result is the preservation of the function of the metatarsophalangeal joints, Dr. Mitsuka wrote in a poster presented at the annual European congress of rheumatology.

“I have been performing this procedure since 1998 for almost all rheumatoid [arthritis] patients with forefoot deformities. The outcome is better than with resection arthroplasty of the MTP [metatarsophalangeal] joints or arthrodesis of the big toe for stability and mobility of the joint, length of toe, gait, and cosmetic result,” he told this newspaper.

A total of 53 forefoot reconstructions in 31 patients have been done to date. Mean age at time of surgery was 60 years, and the mean duration of rheumatoid arthritis until time of operation was 18 years.

At their latest follow-up, patients were evaluated clinically using the American Orthopedic Foot and Ankle Society (AOFAS) score. Hallux valgus angle and intermetatarsal angle were examined radiologically.

Two patients died of causes unrelated to surgery, and in one foot the Swanson implant was removed 11 months after placement because of reactive synovitis.

Among the remaining 48 feet, with a mean follow-up of 40 months, the AOFAS score for the great toe improved from an average of 36 points preoperatively to 89 points (out of 100). For the lateral toes, the average score improved from 27 points to 87 points.

The hallux valgus angle improved from an average of 45 degrees preoperatively to 19 degrees at the latest evaluation, Dr. Mitsuka noted at the meeting, which was sponsored by the European League Against Rheumatism.

Intermetatarsal angle also improved, from an average of 16 degrees before surgery to 13 degrees.

Reconstruction of the great toe of 44 feet in 25 patients involved arthroplasty with a Swanson implant, and was done with a Mitchell's osteotomy in the remaining 9 feet in 6 patients. In the lateral toes, an oblique osteotomy was performed at the metatarsal neck, starting proximally on the dorsum and proceeding distally and plantarward at an angle of 45 degrees. This was then resected at a width of 5–15 mm.

The metatarsal head subsequently was freed from its plantar aspect, and the dislocated base of the proximal phalanx was corrected. The osteotomized bones were then transfixed longitudinally by Kirschner wires from the distal phalanx to the metatarsal base.

A 53-year-old RA patient with forefoot deformities is shown prior to surgery.

Lateral toe reconstruction was performed by means of a metatarsal oblique osteotomy. Photos courtesy Dr. Takeshi Mitsuka