Patrice Wendling

CHICAGO – Two commonly used dyes produced mixed results in sentinel lymph node mapping of early stage breast cancer in what was described as the highest-powered study to date.

The average number of sentinel lymph nodes identified per person was significantly higher with 1% methylene blue dye than with 1% lymphazurin (2.89 vs. 2.22; P less than .001).

Although there is extensive support for methylene blue as a safe and efficacious alternative to lymphazurin, this finding on the number of sentinel nodes identified is not replicated in any other study, Dr. Vaishali Patel said at the annual clinical congress of the American College of Surgeons. The study was conducted at the McLaren Flint (Mich.) Medical Center. Dr. Sukamal Saha was principal investigator.

On the other hand, lymphazurin identified significantly more additional lymph nodes than methylene blue (mean 4.48 vs. 2.84; P less than .001).

Nodal positivity was also significantly higher with lymphazurin than methylene blue (14.93% vs. 8.85%; P less than .001), which also has not been reported in other trials.

“We think this does offer a true comparison between the two dyes,” Dr. Patel of Detroit Medical Center Sinai-Grace Hospital said. “The volume of dye and technique were consistent for all 651 patients. … with one surgeon performing the injections and one surgeon performing the procedures.” The 651 consecutive patients were randomly assigned based on agent availability to a preoperative injection of lymphazurin (half intraparenchymal and half subareolar in the upper outer quadrant) or an intraoperative injection of methylene blue over 5 minutes (3 ccs intraparenchymal, 1 cc subareolar, and 1 cc intradermal).

The lymphazurin and methylene blue groups were also similar in number (298 patients vs. 353 patients), age (mean 61.6 years vs. 63.5 years), and T stage (in situ 12% vs. 17.8%; T1 64% vs. 65%; T2 23% vs. 17.5%).

In contrast, three smaller, well-established studies that came to different conclusions used four different surgeons and novel techniques to inject their radiocolloid and supervised residents for lymphatic mapping, she noted.

The radiocolloid lymphazurin first demonstrated superiority over methylene blue in 1990, but alternatives continue to be investigated due to frequent nonavailability and a host of adverse events including blue hives, blue discoloration or tattooing, and anaphylaxis.

Lymphazurin also costs 10-12 times more than methylene blue, which was reflected in the study in an average per patient cost of $815 vs. $75 for methylene blue, Dr. Patel said.

The American Society of Breast Surgeons, however, recommends dual-agent mapping using blue dye and a radioisotope in breast cancer to further improve the success in identifying the sentinel lymph nodes. The improvement is likely because of the dual mechanism at play: radiocolloids become entrapped within the lymph node, whereas certain blue dyes bind to interstitial albumin and are taken up by lymphatics, she explained.

The higher number of sentinel lymph nodes in the methylene blue group may be due to its particle size, which is smaller, weighs less, and diffused faster, Dr. Patel suggested.

The higher number of additional lymph nodes captured with lymphazurin may be because of the higher frequency of nodal dissection in this group than in the methylene blue group (25% vs. 16%).

The finding of greater nodal positivity in the lymphazurin group may be related to mechanism of action or the high percentage of patients with T1 disease enrolled in the study. Still, nodal positivity was higher with lymphazurin than methylene blue regardless of T stage, she said.

The lymphazurin group had higher rates than the methylene blue group of pseudohypoxemia (10% vs. 0%; P less than .0001), but blue hives (1.34% vs. 0%; P = .043) and anaphylaxis (.67% vs. 0%; P = .20) were kept in check. Patients were premedicated and early in the series, the surgeon began excising the area of injected blue skin during the primary surgery, Dr. Patel observed.

Despite being diluted, methylene blue was associated with higher rates of seroma (3.4% vs. 1.7%; P = .005) and skin necrosis (2.55% vs. 9%; P = .005).

Discussant Dr. Alyssa Throckmorton of Baptist Memorial Health Care in Memphis pointed out that more recent data show radiocolloid mapping alone is comparable to dual-agent mapping, suggesting that blue dye may not be needed. That said, there have been national shortages of methylene blue as well as lymphazurin.

“I think in surgeons who are going to use blue dye, with the way drug shortages have become in the last few years, you are going to have to be facile and familiar with both types of dye if you are going to use that as part of your clinical practice,” she said.

[email protected]

CHICAGO – Two commonly used dyes produced mixed results in sentinel lymph node mapping of early stage breast cancer in what was described as the highest-powered study to date.

The average number of sentinel lymph nodes identified per person was significantly higher with 1% methylene blue dye than with 1% lymphazurin (2.89 vs. 2.22; P less than .001).

Although there is extensive support for methylene blue as a safe and efficacious alternative to lymphazurin, this finding on the number of sentinel nodes identified is not replicated in any other study, Dr. Vaishali Patel said at the annual clinical congress of the American College of Surgeons. The study was conducted at the McLaren Flint (Mich.) Medical Center. Dr. Sukamal Saha was principal investigator.

On the other hand, lymphazurin identified significantly more additional lymph nodes than methylene blue (mean 4.48 vs. 2.84; P less than .001).

Nodal positivity was also significantly higher with lymphazurin than methylene blue (14.93% vs. 8.85%; P less than .001), which also has not been reported in other trials.

“We think this does offer a true comparison between the two dyes,” Dr. Patel of Detroit Medical Center Sinai-Grace Hospital said. “The volume of dye and technique were consistent for all 651 patients. … with one surgeon performing the injections and one surgeon performing the procedures.” The 651 consecutive patients were randomly assigned based on agent availability to a preoperative injection of lymphazurin (half intraparenchymal and half subareolar in the upper outer quadrant) or an intraoperative injection of methylene blue over 5 minutes (3 ccs intraparenchymal, 1 cc subareolar, and 1 cc intradermal).

The lymphazurin and methylene blue groups were also similar in number (298 patients vs. 353 patients), age (mean 61.6 years vs. 63.5 years), and T stage (in situ 12% vs. 17.8%; T1 64% vs. 65%; T2 23% vs. 17.5%).

In contrast, three smaller, well-established studies that came to different conclusions used four different surgeons and novel techniques to inject their radiocolloid and supervised residents for lymphatic mapping, she noted.

The radiocolloid lymphazurin first demonstrated superiority over methylene blue in 1990, but alternatives continue to be investigated due to frequent nonavailability and a host of adverse events including blue hives, blue discoloration or tattooing, and anaphylaxis.

Lymphazurin also costs 10-12 times more than methylene blue, which was reflected in the study in an average per patient cost of $815 vs. $75 for methylene blue, Dr. Patel said.

The American Society of Breast Surgeons, however, recommends dual-agent mapping using blue dye and a radioisotope in breast cancer to further improve the success in identifying the sentinel lymph nodes. The improvement is likely because of the dual mechanism at play: radiocolloids become entrapped within the lymph node, whereas certain blue dyes bind to interstitial albumin and are taken up by lymphatics, she explained.

The higher number of sentinel lymph nodes in the methylene blue group may be due to its particle size, which is smaller, weighs less, and diffused faster, Dr. Patel suggested.

The higher number of additional lymph nodes captured with lymphazurin may be because of the higher frequency of nodal dissection in this group than in the methylene blue group (25% vs. 16%).

The finding of greater nodal positivity in the lymphazurin group may be related to mechanism of action or the high percentage of patients with T1 disease enrolled in the study. Still, nodal positivity was higher with lymphazurin than methylene blue regardless of T stage, she said.

The lymphazurin group had higher rates than the methylene blue group of pseudohypoxemia (10% vs. 0%; P less than .0001), but blue hives (1.34% vs. 0%; P = .043) and anaphylaxis (.67% vs. 0%; P = .20) were kept in check. Patients were premedicated and early in the series, the surgeon began excising the area of injected blue skin during the primary surgery, Dr. Patel observed.

Despite being diluted, methylene blue was associated with higher rates of seroma (3.4% vs. 1.7%; P = .005) and skin necrosis (2.55% vs. 9%; P = .005).

Discussant Dr. Alyssa Throckmorton of Baptist Memorial Health Care in Memphis pointed out that more recent data show radiocolloid mapping alone is comparable to dual-agent mapping, suggesting that blue dye may not be needed. That said, there have been national shortages of methylene blue as well as lymphazurin.

“I think in surgeons who are going to use blue dye, with the way drug shortages have become in the last few years, you are going to have to be facile and familiar with both types of dye if you are going to use that as part of your clinical practice,” she said.

[email protected]

CHICAGO – Two commonly used dyes produced mixed results in sentinel lymph node mapping of early stage breast cancer in what was described as the highest-powered study to date.

The average number of sentinel lymph nodes identified per person was significantly higher with 1% methylene blue dye than with 1% lymphazurin (2.89 vs. 2.22; P less than .001).

Although there is extensive support for methylene blue as a safe and efficacious alternative to lymphazurin, this finding on the number of sentinel nodes identified is not replicated in any other study, Dr. Vaishali Patel said at the annual clinical congress of the American College of Surgeons. The study was conducted at the McLaren Flint (Mich.) Medical Center. Dr. Sukamal Saha was principal investigator.

On the other hand, lymphazurin identified significantly more additional lymph nodes than methylene blue (mean 4.48 vs. 2.84; P less than .001).

Nodal positivity was also significantly higher with lymphazurin than methylene blue (14.93% vs. 8.85%; P less than .001), which also has not been reported in other trials.

“We think this does offer a true comparison between the two dyes,” Dr. Patel of Detroit Medical Center Sinai-Grace Hospital said. “The volume of dye and technique were consistent for all 651 patients. … with one surgeon performing the injections and one surgeon performing the procedures.” The 651 consecutive patients were randomly assigned based on agent availability to a preoperative injection of lymphazurin (half intraparenchymal and half subareolar in the upper outer quadrant) or an intraoperative injection of methylene blue over 5 minutes (3 ccs intraparenchymal, 1 cc subareolar, and 1 cc intradermal).

The lymphazurin and methylene blue groups were also similar in number (298 patients vs. 353 patients), age (mean 61.6 years vs. 63.5 years), and T stage (in situ 12% vs. 17.8%; T1 64% vs. 65%; T2 23% vs. 17.5%).

In contrast, three smaller, well-established studies that came to different conclusions used four different surgeons and novel techniques to inject their radiocolloid and supervised residents for lymphatic mapping, she noted.

The radiocolloid lymphazurin first demonstrated superiority over methylene blue in 1990, but alternatives continue to be investigated due to frequent nonavailability and a host of adverse events including blue hives, blue discoloration or tattooing, and anaphylaxis.

Lymphazurin also costs 10-12 times more than methylene blue, which was reflected in the study in an average per patient cost of $815 vs. $75 for methylene blue, Dr. Patel said.

The American Society of Breast Surgeons, however, recommends dual-agent mapping using blue dye and a radioisotope in breast cancer to further improve the success in identifying the sentinel lymph nodes. The improvement is likely because of the dual mechanism at play: radiocolloids become entrapped within the lymph node, whereas certain blue dyes bind to interstitial albumin and are taken up by lymphatics, she explained.

The higher number of sentinel lymph nodes in the methylene blue group may be due to its particle size, which is smaller, weighs less, and diffused faster, Dr. Patel suggested.

The higher number of additional lymph nodes captured with lymphazurin may be because of the higher frequency of nodal dissection in this group than in the methylene blue group (25% vs. 16%).

The finding of greater nodal positivity in the lymphazurin group may be related to mechanism of action or the high percentage of patients with T1 disease enrolled in the study. Still, nodal positivity was higher with lymphazurin than methylene blue regardless of T stage, she said.

The lymphazurin group had higher rates than the methylene blue group of pseudohypoxemia (10% vs. 0%; P less than .0001), but blue hives (1.34% vs. 0%; P = .043) and anaphylaxis (.67% vs. 0%; P = .20) were kept in check. Patients were premedicated and early in the series, the surgeon began excising the area of injected blue skin during the primary surgery, Dr. Patel observed.

Despite being diluted, methylene blue was associated with higher rates of seroma (3.4% vs. 1.7%; P = .005) and skin necrosis (2.55% vs. 9%; P = .005).

Discussant Dr. Alyssa Throckmorton of Baptist Memorial Health Care in Memphis pointed out that more recent data show radiocolloid mapping alone is comparable to dual-agent mapping, suggesting that blue dye may not be needed. That said, there have been national shortages of methylene blue as well as lymphazurin.

“I think in surgeons who are going to use blue dye, with the way drug shortages have become in the last few years, you are going to have to be facile and familiar with both types of dye if you are going to use that as part of your clinical practice,” she said.

[email protected]

CHICAGO – Treating tattoos through a transparent perfluorodecalin-infused gel patch may cut down on the number of laser treatments needed to remove unwanted tattoos, results of a small pilot study suggest.

In 11 of 17 patients, tattoos treated through the perfluorodecalin (PFD) patch showed more rapid clearance of their tattoos compared with conventional treatment with the same 755-nm Q-switched alexandrite laser, Dr. Brian Biesman said at the annual meeting of the American Society for Dermatologic Surgery.

Courtesy ON Light Sciences

There were, however, a wide variety of responses, likely reflecting the heterogeneity of the tattoos themselves, ranging from no difference after many treatment sessions to more than 80% clearance after only two sessions, said Dr. Biesman, who is in private practice in Nashville, Tenn. Perfluorodecalin, a fluorocarbon that enhances oxygen delivery, reduces the epidermal whitening that typically limits Q-switched laser tattoo removal to a single pass. Use of the PFD patch in a prior study resolved whitening within an average of 5 seconds, allowing for three to four laser passes in less than 5 minutes (Lasers Surg Med. 2013 Feb;45[2]:76-80).

The DeScribe Transparent PFD Patch (ON Light Sciences) was approved in the United States in April 2015 for use as an accessory to laser tattoo removal procedures using a 755-nm Q-switched alexandrite laser in Fitzpatrick skin type I-III patients.

Anecdotal evidence presented by Dr. Biesman from his own patients suggests that the PFD patch may also speed tattoo clearance when used with different pulse durations and wavelengths, including 5-nanosecond (1,064 nm, 532 nm, and 650 nm) and picosecond (755 nm, 532 nm, and 1,064 nm) lasers.

Courtesy ON Light Sciences

“It does appear that this patch is efficacious with other Q-switched lasers, both nanosecond and picosecond,” he said, adding that this work is preliminary and under careful study.

The pilot study involved 17 patients with Fitzpatrick skin types I-III and black or blue tattoos treated with a conventional Q-switched alexandrite laser at the maximum tolerable fluence through the PFD patch on one side for three to four passes and with one pass through the air on the other side.

The patch allowed a factor of 1.5-times to 1.8-times higher fluence than control, Dr. Biesman said. In no case did the control side tattoo fade faster than the PFD patch side.

The study was sufficiently powered to qualitatively answer the question of whether the patch could enhance the clearance rate relative to control, but the quantitative rate could not be measured because of the small patient numbers, he noted.

Predictive factors were not identifiable because of the large number of variables, such as tattoo ink, tattoo location, and patient age.

There were no unanticipated adverse events with up to a year of follow-up. Three patients reported three areas of skin hypopigmentation that fully resolved, Dr. Biesman said.

The majority of patients in the pilot study, as well as in a 30-patient pivotal study, reported higher satisfaction with the patch treatment. This seemed to be from a combination of factors, including less discomfort during and after treatment, easier posttreatment recovery, and faster resolution, he said in an interview.

“In our practice, the patch has become the standard of care,” he added. “My nursing staff is highly protective of our patients and will not permit treatment of our patients without the patch. Based on our patients’ objective and subjective experience, I concur.”

Further studies to formally evaluate the performance of the patch in the treatment of benign pigmented lesions and with other Q-switched lasers, using a variety of wavelengths and pulse durations, are currently under consideration.

[email protected]

CHICAGO – Treating tattoos through a transparent perfluorodecalin-infused gel patch may cut down on the number of laser treatments needed to remove unwanted tattoos, results of a small pilot study suggest.

In 11 of 17 patients, tattoos treated through the perfluorodecalin (PFD) patch showed more rapid clearance of their tattoos compared with conventional treatment with the same 755-nm Q-switched alexandrite laser, Dr. Brian Biesman said at the annual meeting of the American Society for Dermatologic Surgery.

Courtesy ON Light Sciences

There were, however, a wide variety of responses, likely reflecting the heterogeneity of the tattoos themselves, ranging from no difference after many treatment sessions to more than 80% clearance after only two sessions, said Dr. Biesman, who is in private practice in Nashville, Tenn. Perfluorodecalin, a fluorocarbon that enhances oxygen delivery, reduces the epidermal whitening that typically limits Q-switched laser tattoo removal to a single pass. Use of the PFD patch in a prior study resolved whitening within an average of 5 seconds, allowing for three to four laser passes in less than 5 minutes (Lasers Surg Med. 2013 Feb;45[2]:76-80).

The DeScribe Transparent PFD Patch (ON Light Sciences) was approved in the United States in April 2015 for use as an accessory to laser tattoo removal procedures using a 755-nm Q-switched alexandrite laser in Fitzpatrick skin type I-III patients.

Anecdotal evidence presented by Dr. Biesman from his own patients suggests that the PFD patch may also speed tattoo clearance when used with different pulse durations and wavelengths, including 5-nanosecond (1,064 nm, 532 nm, and 650 nm) and picosecond (755 nm, 532 nm, and 1,064 nm) lasers.

Courtesy ON Light Sciences

“It does appear that this patch is efficacious with other Q-switched lasers, both nanosecond and picosecond,” he said, adding that this work is preliminary and under careful study.

The pilot study involved 17 patients with Fitzpatrick skin types I-III and black or blue tattoos treated with a conventional Q-switched alexandrite laser at the maximum tolerable fluence through the PFD patch on one side for three to four passes and with one pass through the air on the other side.

The patch allowed a factor of 1.5-times to 1.8-times higher fluence than control, Dr. Biesman said. In no case did the control side tattoo fade faster than the PFD patch side.

The study was sufficiently powered to qualitatively answer the question of whether the patch could enhance the clearance rate relative to control, but the quantitative rate could not be measured because of the small patient numbers, he noted.

Predictive factors were not identifiable because of the large number of variables, such as tattoo ink, tattoo location, and patient age.

There were no unanticipated adverse events with up to a year of follow-up. Three patients reported three areas of skin hypopigmentation that fully resolved, Dr. Biesman said.

The majority of patients in the pilot study, as well as in a 30-patient pivotal study, reported higher satisfaction with the patch treatment. This seemed to be from a combination of factors, including less discomfort during and after treatment, easier posttreatment recovery, and faster resolution, he said in an interview.

“In our practice, the patch has become the standard of care,” he added. “My nursing staff is highly protective of our patients and will not permit treatment of our patients without the patch. Based on our patients’ objective and subjective experience, I concur.”

Further studies to formally evaluate the performance of the patch in the treatment of benign pigmented lesions and with other Q-switched lasers, using a variety of wavelengths and pulse durations, are currently under consideration.

[email protected]

CHICAGO – Treating tattoos through a transparent perfluorodecalin-infused gel patch may cut down on the number of laser treatments needed to remove unwanted tattoos, results of a small pilot study suggest.

In 11 of 17 patients, tattoos treated through the perfluorodecalin (PFD) patch showed more rapid clearance of their tattoos compared with conventional treatment with the same 755-nm Q-switched alexandrite laser, Dr. Brian Biesman said at the annual meeting of the American Society for Dermatologic Surgery.

Courtesy ON Light Sciences

There were, however, a wide variety of responses, likely reflecting the heterogeneity of the tattoos themselves, ranging from no difference after many treatment sessions to more than 80% clearance after only two sessions, said Dr. Biesman, who is in private practice in Nashville, Tenn. Perfluorodecalin, a fluorocarbon that enhances oxygen delivery, reduces the epidermal whitening that typically limits Q-switched laser tattoo removal to a single pass. Use of the PFD patch in a prior study resolved whitening within an average of 5 seconds, allowing for three to four laser passes in less than 5 minutes (Lasers Surg Med. 2013 Feb;45[2]:76-80).

The DeScribe Transparent PFD Patch (ON Light Sciences) was approved in the United States in April 2015 for use as an accessory to laser tattoo removal procedures using a 755-nm Q-switched alexandrite laser in Fitzpatrick skin type I-III patients.

Anecdotal evidence presented by Dr. Biesman from his own patients suggests that the PFD patch may also speed tattoo clearance when used with different pulse durations and wavelengths, including 5-nanosecond (1,064 nm, 532 nm, and 650 nm) and picosecond (755 nm, 532 nm, and 1,064 nm) lasers.

Courtesy ON Light Sciences

“It does appear that this patch is efficacious with other Q-switched lasers, both nanosecond and picosecond,” he said, adding that this work is preliminary and under careful study.

The pilot study involved 17 patients with Fitzpatrick skin types I-III and black or blue tattoos treated with a conventional Q-switched alexandrite laser at the maximum tolerable fluence through the PFD patch on one side for three to four passes and with one pass through the air on the other side.

The patch allowed a factor of 1.5-times to 1.8-times higher fluence than control, Dr. Biesman said. In no case did the control side tattoo fade faster than the PFD patch side.

The study was sufficiently powered to qualitatively answer the question of whether the patch could enhance the clearance rate relative to control, but the quantitative rate could not be measured because of the small patient numbers, he noted.

Predictive factors were not identifiable because of the large number of variables, such as tattoo ink, tattoo location, and patient age.

There were no unanticipated adverse events with up to a year of follow-up. Three patients reported three areas of skin hypopigmentation that fully resolved, Dr. Biesman said.

The majority of patients in the pilot study, as well as in a 30-patient pivotal study, reported higher satisfaction with the patch treatment. This seemed to be from a combination of factors, including less discomfort during and after treatment, easier posttreatment recovery, and faster resolution, he said in an interview.

“In our practice, the patch has become the standard of care,” he added. “My nursing staff is highly protective of our patients and will not permit treatment of our patients without the patch. Based on our patients’ objective and subjective experience, I concur.”

Further studies to formally evaluate the performance of the patch in the treatment of benign pigmented lesions and with other Q-switched lasers, using a variety of wavelengths and pulse durations, are currently under consideration.

[email protected]

LOS ANGELES – A mobile phone–based intervention targeting both maternal and child behavior significantly cut sugar-sweetened drink consumption in preschoolers and prompted modest weight loss in Moms.

After just 3 months, the children reduced their daily intake of sugar-sweetened beverages (SSB) by 10 fluid ounces, compared with 3.2 ounces for controls, while their mothers lost 2.6% of their body weight vs. a gain of 1.4% for controls.

Patrice Wendling/Frontline Medical News

Both outcomes were statistically significant in regression analysis, after adjusting for child age and baseline SSB intake (P = .02) and for maternal age and race (P = .003).

On the surface, 10 fluid ounces may not sound like a lot, but at study entry these 3- to 5-year-old North Carolinian preschoolers were already consuming at least 12 ounces per day of SSBs such as 100% fruit juice, fruit drinks, sweetened tea, flavored milks, sports/energy drinks, and sodas.

“Sugar-sweetened beverages really stand out as one of the drivers of excessive weight gain in early childhood and 10 ounces is a lot for kids,” study author Ms. Brooke Nezami of the University of North Carolina in Chapel Hill, said in an interview at Obesity Week 2015. “The American Academy of Pediatrics says a serving of 100 percent fruit juice is 4 to 6 ounces, so that’s over 2 servings a day.”

Targeting mothers as the agent of change to improve child dietary behaviors may help them make healthy choices and lose weight, but getting busy moms to participate has been a huge hurdle for traditional interventions.

The Smart Moms intervention sought to reduce child SSB intake to one serving per day using 12 weekly and six bi-weekly website lessons, developed based on social cognitive theory. Children’s consumption of SSBs and mothers’ caloric beverages, high-calorie “red” foods from the Traffic Light Diet, and weight were monitored daily, with totals submitted weekly via text, Ms. Nezami, of the University of North Carolina at Chapel Hill, reported.

The mothers, who had a body mass index (BMI) of 25 kg/m² to 50 kg/m² at enrollment, were asked to reduce their intake of caloric beverages to less than 8 ounces per day, reduce intake of “red” foods, and to weigh themselves daily. They attended only one group meeting and then received text messages three to four times per week with tips, motivational messages, and self-monitoring prompts and 12 weekly and 6 biweekly emails with personalized feedback on their progress.

The 51 mothers and 51 children, recruited from the community, also completed in-person and on-line assessments at baseline, 3 months, and 6 months. The 6-month data are to be reported at a meeting next year.

At baseline, children in the Smart Moms intervention and wait-list control groups had an average age of 4.5 years; 40.7% vs. 58.3%, respectively, were boys; 18.5% vs. 29.2% were overweight or obese; and they consumed 15.3 ounces vs. 12.5 ounces of SSBs per day.

Mothers in the intervention and control groups had an average age of 36 years; average BMI of 33.1 kg/m² vs. 32 kg/m^2, respectively; 74% vs. 65% had an annual income of more than $75,000; and 92.6% vs. 87.5% were married.

At 3 months, daily calories from beverages declined from 252 to 131.5 among women using the intervention and rose from 169.5 to 216.7 among controls, Ms. Nezami reported in the award-winning poster.

Moms using the intervention cut their total daily calories from 1,865 to 1,569 at 3 months, compared with a small increase from 1,750 to 1,805 for controls. The differences for both outcomes were not statistically significant.

Child BMI-z scores declined from 0.30 to 0.27 with the intervention and from 0.49 to 0.45 among controls, but the difference was not significant.

Adherence to the mobile intervention remained strong at 3 months, with an average of 11 of 12 weekly self-monitoring reports and 11 of 12 weekly goal progress assessments completed, Ms. Nezami said.

“This low-burden, mobile-delivered intervention has the potential for widespread dissemination and could be an effective way to change weight-related behaviors in preschool-age children and their parents,” she concluded at the meeting, presented by the Obesity Society and American Society for Metabolic and Bariatric Surgery.

That said, some mothers may need additional encouragement from health care providers to recognize that early childhood is an opportune time to promote healthy eating habits and to reduce SSB intake.

“Most moms in the study when I presented them with the information on the risk of sugar-sweetened beverages and the calories their child was consuming from beverages were like, ‘Wow, this is something I need to change,’ ” she said. “But some participants didn’t necessarily feel at the end of it all that changing their child’s diet was as important as changing their own because they feel they’re young, they’ve still got time to create healthy diets of their own.”

The study was funded by the Gillings Dissertation Award from the University of North Carolina at Chapel Hill. Ms. Nezami reported having no conflicts of interest.

[email protected]

LOS ANGELES – A mobile phone–based intervention targeting both maternal and child behavior significantly cut sugar-sweetened drink consumption in preschoolers and prompted modest weight loss in Moms.

After just 3 months, the children reduced their daily intake of sugar-sweetened beverages (SSB) by 10 fluid ounces, compared with 3.2 ounces for controls, while their mothers lost 2.6% of their body weight vs. a gain of 1.4% for controls.

Patrice Wendling/Frontline Medical News

Both outcomes were statistically significant in regression analysis, after adjusting for child age and baseline SSB intake (P = .02) and for maternal age and race (P = .003).

On the surface, 10 fluid ounces may not sound like a lot, but at study entry these 3- to 5-year-old North Carolinian preschoolers were already consuming at least 12 ounces per day of SSBs such as 100% fruit juice, fruit drinks, sweetened tea, flavored milks, sports/energy drinks, and sodas.

“Sugar-sweetened beverages really stand out as one of the drivers of excessive weight gain in early childhood and 10 ounces is a lot for kids,” study author Ms. Brooke Nezami of the University of North Carolina in Chapel Hill, said in an interview at Obesity Week 2015. “The American Academy of Pediatrics says a serving of 100 percent fruit juice is 4 to 6 ounces, so that’s over 2 servings a day.”

Targeting mothers as the agent of change to improve child dietary behaviors may help them make healthy choices and lose weight, but getting busy moms to participate has been a huge hurdle for traditional interventions.

The Smart Moms intervention sought to reduce child SSB intake to one serving per day using 12 weekly and six bi-weekly website lessons, developed based on social cognitive theory. Children’s consumption of SSBs and mothers’ caloric beverages, high-calorie “red” foods from the Traffic Light Diet, and weight were monitored daily, with totals submitted weekly via text, Ms. Nezami, of the University of North Carolina at Chapel Hill, reported.

The mothers, who had a body mass index (BMI) of 25 kg/m² to 50 kg/m² at enrollment, were asked to reduce their intake of caloric beverages to less than 8 ounces per day, reduce intake of “red” foods, and to weigh themselves daily. They attended only one group meeting and then received text messages three to four times per week with tips, motivational messages, and self-monitoring prompts and 12 weekly and 6 biweekly emails with personalized feedback on their progress.

The 51 mothers and 51 children, recruited from the community, also completed in-person and on-line assessments at baseline, 3 months, and 6 months. The 6-month data are to be reported at a meeting next year.

At baseline, children in the Smart Moms intervention and wait-list control groups had an average age of 4.5 years; 40.7% vs. 58.3%, respectively, were boys; 18.5% vs. 29.2% were overweight or obese; and they consumed 15.3 ounces vs. 12.5 ounces of SSBs per day.

Mothers in the intervention and control groups had an average age of 36 years; average BMI of 33.1 kg/m² vs. 32 kg/m^2, respectively; 74% vs. 65% had an annual income of more than $75,000; and 92.6% vs. 87.5% were married.

At 3 months, daily calories from beverages declined from 252 to 131.5 among women using the intervention and rose from 169.5 to 216.7 among controls, Ms. Nezami reported in the award-winning poster.

Moms using the intervention cut their total daily calories from 1,865 to 1,569 at 3 months, compared with a small increase from 1,750 to 1,805 for controls. The differences for both outcomes were not statistically significant.

Child BMI-z scores declined from 0.30 to 0.27 with the intervention and from 0.49 to 0.45 among controls, but the difference was not significant.

Adherence to the mobile intervention remained strong at 3 months, with an average of 11 of 12 weekly self-monitoring reports and 11 of 12 weekly goal progress assessments completed, Ms. Nezami said.

“This low-burden, mobile-delivered intervention has the potential for widespread dissemination and could be an effective way to change weight-related behaviors in preschool-age children and their parents,” she concluded at the meeting, presented by the Obesity Society and American Society for Metabolic and Bariatric Surgery.

That said, some mothers may need additional encouragement from health care providers to recognize that early childhood is an opportune time to promote healthy eating habits and to reduce SSB intake.

“Most moms in the study when I presented them with the information on the risk of sugar-sweetened beverages and the calories their child was consuming from beverages were like, ‘Wow, this is something I need to change,’ ” she said. “But some participants didn’t necessarily feel at the end of it all that changing their child’s diet was as important as changing their own because they feel they’re young, they’ve still got time to create healthy diets of their own.”

The study was funded by the Gillings Dissertation Award from the University of North Carolina at Chapel Hill. Ms. Nezami reported having no conflicts of interest.

[email protected]

LOS ANGELES – A mobile phone–based intervention targeting both maternal and child behavior significantly cut sugar-sweetened drink consumption in preschoolers and prompted modest weight loss in Moms.

After just 3 months, the children reduced their daily intake of sugar-sweetened beverages (SSB) by 10 fluid ounces, compared with 3.2 ounces for controls, while their mothers lost 2.6% of their body weight vs. a gain of 1.4% for controls.

Patrice Wendling/Frontline Medical News

Both outcomes were statistically significant in regression analysis, after adjusting for child age and baseline SSB intake (P = .02) and for maternal age and race (P = .003).

On the surface, 10 fluid ounces may not sound like a lot, but at study entry these 3- to 5-year-old North Carolinian preschoolers were already consuming at least 12 ounces per day of SSBs such as 100% fruit juice, fruit drinks, sweetened tea, flavored milks, sports/energy drinks, and sodas.

“Sugar-sweetened beverages really stand out as one of the drivers of excessive weight gain in early childhood and 10 ounces is a lot for kids,” study author Ms. Brooke Nezami of the University of North Carolina in Chapel Hill, said in an interview at Obesity Week 2015. “The American Academy of Pediatrics says a serving of 100 percent fruit juice is 4 to 6 ounces, so that’s over 2 servings a day.”

Targeting mothers as the agent of change to improve child dietary behaviors may help them make healthy choices and lose weight, but getting busy moms to participate has been a huge hurdle for traditional interventions.

The Smart Moms intervention sought to reduce child SSB intake to one serving per day using 12 weekly and six bi-weekly website lessons, developed based on social cognitive theory. Children’s consumption of SSBs and mothers’ caloric beverages, high-calorie “red” foods from the Traffic Light Diet, and weight were monitored daily, with totals submitted weekly via text, Ms. Nezami, of the University of North Carolina at Chapel Hill, reported.

The mothers, who had a body mass index (BMI) of 25 kg/m² to 50 kg/m² at enrollment, were asked to reduce their intake of caloric beverages to less than 8 ounces per day, reduce intake of “red” foods, and to weigh themselves daily. They attended only one group meeting and then received text messages three to four times per week with tips, motivational messages, and self-monitoring prompts and 12 weekly and 6 biweekly emails with personalized feedback on their progress.

The 51 mothers and 51 children, recruited from the community, also completed in-person and on-line assessments at baseline, 3 months, and 6 months. The 6-month data are to be reported at a meeting next year.

At baseline, children in the Smart Moms intervention and wait-list control groups had an average age of 4.5 years; 40.7% vs. 58.3%, respectively, were boys; 18.5% vs. 29.2% were overweight or obese; and they consumed 15.3 ounces vs. 12.5 ounces of SSBs per day.

Mothers in the intervention and control groups had an average age of 36 years; average BMI of 33.1 kg/m² vs. 32 kg/m^2, respectively; 74% vs. 65% had an annual income of more than $75,000; and 92.6% vs. 87.5% were married.

At 3 months, daily calories from beverages declined from 252 to 131.5 among women using the intervention and rose from 169.5 to 216.7 among controls, Ms. Nezami reported in the award-winning poster.

Moms using the intervention cut their total daily calories from 1,865 to 1,569 at 3 months, compared with a small increase from 1,750 to 1,805 for controls. The differences for both outcomes were not statistically significant.

Child BMI-z scores declined from 0.30 to 0.27 with the intervention and from 0.49 to 0.45 among controls, but the difference was not significant.

Adherence to the mobile intervention remained strong at 3 months, with an average of 11 of 12 weekly self-monitoring reports and 11 of 12 weekly goal progress assessments completed, Ms. Nezami said.

“This low-burden, mobile-delivered intervention has the potential for widespread dissemination and could be an effective way to change weight-related behaviors in preschool-age children and their parents,” she concluded at the meeting, presented by the Obesity Society and American Society for Metabolic and Bariatric Surgery.

That said, some mothers may need additional encouragement from health care providers to recognize that early childhood is an opportune time to promote healthy eating habits and to reduce SSB intake.

“Most moms in the study when I presented them with the information on the risk of sugar-sweetened beverages and the calories their child was consuming from beverages were like, ‘Wow, this is something I need to change,’ ” she said. “But some participants didn’t necessarily feel at the end of it all that changing their child’s diet was as important as changing their own because they feel they’re young, they’ve still got time to create healthy diets of their own.”

The study was funded by the Gillings Dissertation Award from the University of North Carolina at Chapel Hill. Ms. Nezami reported having no conflicts of interest.

[email protected]

CHICAGO – Significant variance exists in management of primary cutaneous melanoma, according to a national survey of 510 dermatologists.

Most dermatologists (36%) preferred a shave biopsy for lesions suspected of being melanoma, despite guidelines from the American Academy of Dermatology (AAD) and National Comprehensive Cancer Network (NCCN) guidelines that recommend narrow excision biopsy.

©The National Cancer Institute

In all, 31% of dermatologists used a narrow local excision (less than 5 mm margin), 13% saucerization/scoop shave biopsy, 11%, punch biopsy, 3% wide local excision, and 7% other.

“The guidelines and academy are all very clear that one of the goals of the biopsy is to obtain tumor depth, so we were surprised that a significant number of providers use shave biopsy or other methods that may leave a risk of not getting the correct depth,” study co-author Dr. Aaron S. Farberg, a melanoma clinical research fellow at the National Society for Cutaneous Medicine in New York City, said in an interview.

Notably, dermatologists in academic and dermatology-based group practices were significantly less likely than those in multispecialty or solo practice to use narrow excision (23% vs. 42%; P < .001).

Although treatment for melanoma evolves continuously, the authors observed that dermatologists remain at the forefront of melanoma management and play a critical role in patient decision making.

“This study suggests that a knowledge gap may exist representing an educational opportunity to more effectively disseminate and implement recommended approaches,” Dr. Farberg and Dr. Darrell Rigel, of New York University School of Medicine, reported in a poster presentation at the annual meeting of the American Society for Dermatologic Surgery.

The survey also revealed that dermatologists are going beyond suggested surgical margins when excising melanoma.

For malignant melanoma in situ (MMIS), 62% used a 5 mm or less margin, 36% a 6 mm to 10 mm margin, and 2% a 1.1 cm to 1.9 cm margin. For these lesions, the AAD recommends a 0.5 cm-1 cm (5 mm-10 mm) margin and the NCCN a 0.5 cm margin, Drs. Farber and Rigel reported.

Academic dermatologists were significantly more likely than all other practice types to refer patients with MMIS out for excision (18% vs. 10%; P < .05).

For invasive melanoma less than 1 mm in depth, both the AAD and NCCN recommend a 1 cm margin (10 mm). In all, 61% of dermatologists reported using 6 mm to 10 mm margins, with 34% opting for 1.1 cm to 1.9 cm margins, 3% at least 2 cm margins, and 2% no more than 5 mm margins.

No significant difference was found across provider types for treatment of melanomas less than 1 mm in depth.

For invasive melanoma greater than 1 mm in depth, 54% of respondents used 1.1 cm to 1.9 cm margins, with most (67%) referring the patient to another provider. Both national guidelines recommend 1 cm to 2 cm margins for melanomas 1 mm to 2 mm in depth and 2 cm margins for melanoma greater than 2 mm in depth.

Academic dermatologists were significantly more likely than other dermatologists to treat these lesions rather than to refer the patient out (51% vs. 30%; P < .001).

“This is exciting new data that suggests that there still is a variance in early melanoma management,” Dr. Rigel, past president of AAD and ASDS, said in an interview. “The data suggest more studies need to be done to better access why this is occurring.”

Dr. Hensin Tsao, who served on the 2011 AAD guideline working group and is co-chairing the AAD’s pending guideline update, said in an interview that, “Dr. Rigel is well respected in the field and the project will undoubtedly be submitted for publication and subject to further review. It is worthwhile to wait on the final published results and conclusions.”

He agreed, however, with the authors’ suggestion that there is significant variation in practice. Regarding the finding that 36% of respondents use a shave biopsy for suspicious lesions, the AAD guidelines recommend that the entire lesion be removed with a 1 mm to 3 mm margin, which can be accomplished by an elliptical or punch excision with sutures or shave removal to a depth below the anticipated plane of the lesion, Dr. Tsao, of Massachusetts General Hospital in Boston, said.

“It is quite possible that some of the respondents to the questionnaire interpreted ‘shave biopsy’ as a full shave disk excision,” he said. “That said, intentional and routine partial sampling of suspected melanomas would be at odds with the guidelines.”

It is not inappropriate to remove a suspicious lesion, if small enough, with a punch biopsy, Dr. Tsao said, adding, “Perhaps again, the respondents failed to distinguish between partial punch biopsy and punch excision.”

On occasion, the AAD guidelines also make accommodations for an incisional biopsy “of the clinically or dermatoscopically most atypical portion of the lesion.” In this situation, a smaller incisional punch biopsy may be performed of the highly suspicious area.

“There are certainly areas that the investigators have identified which could represent potential knowledge gaps,” Dr. Tsao said. “For instance, 14% of the respondents used a 0.6 cm to 1.0 cm (6 mm-10 mm) margin for melanoma greater than 1 mm.”

Dermatologists’ surveillance of patients in the survey was somewhat less divergent. The most recommended follow-up interval for patients diagnosed within the last 5 years, was 6 months (49%), followed by a 3-month interval (25%), and other (24%). Follow-up was extended to yearly by 63% of dermatologists for patients diagnosed more than five years earlier, Dr. Farberg and Dr. Rigel reported.

Both the AAD and NCCN recommend follow-up every 3 to 12 months for those diagnosed with melanoma within the previous 5 years, while for those diagnosed more than 5 years prior, the AAD recommends follow-up every 3 to 12 months and the NCCN every 12 months.

“Adherence to evidence-based guidelines should lead to improved patient outcomes and quality of care. However, newer studies and emerging data may also justify deviations from existing guidelines, suggesting review of those guidelines may be indicated,” Dr. Farberg and Dr. Rigel concluded.

For example, a prospective series examining surgical margins in 1,072 patients with 1,120 malignant melanoma in situs showed that only 86% were successfully excised with a 6-mm margin, significantly less than the 98.9% clearance achieved with a 9-mm margin, Dr. Farberg told this publication.

That said, a 9-mm margin may not be appropriate for all lesions, such as those on the face, he observed.

The investigators said they hope the survey results will spur on revision of the guidelines, last updated in 2011.

Limitations of the survey include a lack of information on clinical factors such as patient history or anatomic site, the survey may have led to generalized answers, and access to care and reimbursement also may have impacted management, the authors noted.

The response rate to the survey was also low at 8%, with 6,177 practicing U.S. dermatologists surveyed. The demographics of the respondents, however, strongly reflected the full AAD membership, Dr. Farberg said. No significant geographical differences were observed.

[email protected]

CHICAGO – Significant variance exists in management of primary cutaneous melanoma, according to a national survey of 510 dermatologists.

Most dermatologists (36%) preferred a shave biopsy for lesions suspected of being melanoma, despite guidelines from the American Academy of Dermatology (AAD) and National Comprehensive Cancer Network (NCCN) guidelines that recommend narrow excision biopsy.

©The National Cancer Institute

In all, 31% of dermatologists used a narrow local excision (less than 5 mm margin), 13% saucerization/scoop shave biopsy, 11%, punch biopsy, 3% wide local excision, and 7% other.

“The guidelines and academy are all very clear that one of the goals of the biopsy is to obtain tumor depth, so we were surprised that a significant number of providers use shave biopsy or other methods that may leave a risk of not getting the correct depth,” study co-author Dr. Aaron S. Farberg, a melanoma clinical research fellow at the National Society for Cutaneous Medicine in New York City, said in an interview.

Notably, dermatologists in academic and dermatology-based group practices were significantly less likely than those in multispecialty or solo practice to use narrow excision (23% vs. 42%; P < .001).

Although treatment for melanoma evolves continuously, the authors observed that dermatologists remain at the forefront of melanoma management and play a critical role in patient decision making.

“This study suggests that a knowledge gap may exist representing an educational opportunity to more effectively disseminate and implement recommended approaches,” Dr. Farberg and Dr. Darrell Rigel, of New York University School of Medicine, reported in a poster presentation at the annual meeting of the American Society for Dermatologic Surgery.

The survey also revealed that dermatologists are going beyond suggested surgical margins when excising melanoma.

For malignant melanoma in situ (MMIS), 62% used a 5 mm or less margin, 36% a 6 mm to 10 mm margin, and 2% a 1.1 cm to 1.9 cm margin. For these lesions, the AAD recommends a 0.5 cm-1 cm (5 mm-10 mm) margin and the NCCN a 0.5 cm margin, Drs. Farber and Rigel reported.

Academic dermatologists were significantly more likely than all other practice types to refer patients with MMIS out for excision (18% vs. 10%; P < .05).

For invasive melanoma less than 1 mm in depth, both the AAD and NCCN recommend a 1 cm margin (10 mm). In all, 61% of dermatologists reported using 6 mm to 10 mm margins, with 34% opting for 1.1 cm to 1.9 cm margins, 3% at least 2 cm margins, and 2% no more than 5 mm margins.

No significant difference was found across provider types for treatment of melanomas less than 1 mm in depth.

For invasive melanoma greater than 1 mm in depth, 54% of respondents used 1.1 cm to 1.9 cm margins, with most (67%) referring the patient to another provider. Both national guidelines recommend 1 cm to 2 cm margins for melanomas 1 mm to 2 mm in depth and 2 cm margins for melanoma greater than 2 mm in depth.

Academic dermatologists were significantly more likely than other dermatologists to treat these lesions rather than to refer the patient out (51% vs. 30%; P < .001).

“This is exciting new data that suggests that there still is a variance in early melanoma management,” Dr. Rigel, past president of AAD and ASDS, said in an interview. “The data suggest more studies need to be done to better access why this is occurring.”

Dr. Hensin Tsao, who served on the 2011 AAD guideline working group and is co-chairing the AAD’s pending guideline update, said in an interview that, “Dr. Rigel is well respected in the field and the project will undoubtedly be submitted for publication and subject to further review. It is worthwhile to wait on the final published results and conclusions.”

He agreed, however, with the authors’ suggestion that there is significant variation in practice. Regarding the finding that 36% of respondents use a shave biopsy for suspicious lesions, the AAD guidelines recommend that the entire lesion be removed with a 1 mm to 3 mm margin, which can be accomplished by an elliptical or punch excision with sutures or shave removal to a depth below the anticipated plane of the lesion, Dr. Tsao, of Massachusetts General Hospital in Boston, said.

“It is quite possible that some of the respondents to the questionnaire interpreted ‘shave biopsy’ as a full shave disk excision,” he said. “That said, intentional and routine partial sampling of suspected melanomas would be at odds with the guidelines.”

It is not inappropriate to remove a suspicious lesion, if small enough, with a punch biopsy, Dr. Tsao said, adding, “Perhaps again, the respondents failed to distinguish between partial punch biopsy and punch excision.”

On occasion, the AAD guidelines also make accommodations for an incisional biopsy “of the clinically or dermatoscopically most atypical portion of the lesion.” In this situation, a smaller incisional punch biopsy may be performed of the highly suspicious area.

“There are certainly areas that the investigators have identified which could represent potential knowledge gaps,” Dr. Tsao said. “For instance, 14% of the respondents used a 0.6 cm to 1.0 cm (6 mm-10 mm) margin for melanoma greater than 1 mm.”

Dermatologists’ surveillance of patients in the survey was somewhat less divergent. The most recommended follow-up interval for patients diagnosed within the last 5 years, was 6 months (49%), followed by a 3-month interval (25%), and other (24%). Follow-up was extended to yearly by 63% of dermatologists for patients diagnosed more than five years earlier, Dr. Farberg and Dr. Rigel reported.

Both the AAD and NCCN recommend follow-up every 3 to 12 months for those diagnosed with melanoma within the previous 5 years, while for those diagnosed more than 5 years prior, the AAD recommends follow-up every 3 to 12 months and the NCCN every 12 months.

“Adherence to evidence-based guidelines should lead to improved patient outcomes and quality of care. However, newer studies and emerging data may also justify deviations from existing guidelines, suggesting review of those guidelines may be indicated,” Dr. Farberg and Dr. Rigel concluded.

For example, a prospective series examining surgical margins in 1,072 patients with 1,120 malignant melanoma in situs showed that only 86% were successfully excised with a 6-mm margin, significantly less than the 98.9% clearance achieved with a 9-mm margin, Dr. Farberg told this publication.

That said, a 9-mm margin may not be appropriate for all lesions, such as those on the face, he observed.

The investigators said they hope the survey results will spur on revision of the guidelines, last updated in 2011.

Limitations of the survey include a lack of information on clinical factors such as patient history or anatomic site, the survey may have led to generalized answers, and access to care and reimbursement also may have impacted management, the authors noted.

The response rate to the survey was also low at 8%, with 6,177 practicing U.S. dermatologists surveyed. The demographics of the respondents, however, strongly reflected the full AAD membership, Dr. Farberg said. No significant geographical differences were observed.

[email protected]

CHICAGO – Significant variance exists in management of primary cutaneous melanoma, according to a national survey of 510 dermatologists.

Most dermatologists (36%) preferred a shave biopsy for lesions suspected of being melanoma, despite guidelines from the American Academy of Dermatology (AAD) and National Comprehensive Cancer Network (NCCN) guidelines that recommend narrow excision biopsy.

©The National Cancer Institute

In all, 31% of dermatologists used a narrow local excision (less than 5 mm margin), 13% saucerization/scoop shave biopsy, 11%, punch biopsy, 3% wide local excision, and 7% other.

“The guidelines and academy are all very clear that one of the goals of the biopsy is to obtain tumor depth, so we were surprised that a significant number of providers use shave biopsy or other methods that may leave a risk of not getting the correct depth,” study co-author Dr. Aaron S. Farberg, a melanoma clinical research fellow at the National Society for Cutaneous Medicine in New York City, said in an interview.

Notably, dermatologists in academic and dermatology-based group practices were significantly less likely than those in multispecialty or solo practice to use narrow excision (23% vs. 42%; P < .001).

Although treatment for melanoma evolves continuously, the authors observed that dermatologists remain at the forefront of melanoma management and play a critical role in patient decision making.

“This study suggests that a knowledge gap may exist representing an educational opportunity to more effectively disseminate and implement recommended approaches,” Dr. Farberg and Dr. Darrell Rigel, of New York University School of Medicine, reported in a poster presentation at the annual meeting of the American Society for Dermatologic Surgery.

The survey also revealed that dermatologists are going beyond suggested surgical margins when excising melanoma.

For malignant melanoma in situ (MMIS), 62% used a 5 mm or less margin, 36% a 6 mm to 10 mm margin, and 2% a 1.1 cm to 1.9 cm margin. For these lesions, the AAD recommends a 0.5 cm-1 cm (5 mm-10 mm) margin and the NCCN a 0.5 cm margin, Drs. Farber and Rigel reported.

Academic dermatologists were significantly more likely than all other practice types to refer patients with MMIS out for excision (18% vs. 10%; P < .05).

For invasive melanoma less than 1 mm in depth, both the AAD and NCCN recommend a 1 cm margin (10 mm). In all, 61% of dermatologists reported using 6 mm to 10 mm margins, with 34% opting for 1.1 cm to 1.9 cm margins, 3% at least 2 cm margins, and 2% no more than 5 mm margins.

No significant difference was found across provider types for treatment of melanomas less than 1 mm in depth.

For invasive melanoma greater than 1 mm in depth, 54% of respondents used 1.1 cm to 1.9 cm margins, with most (67%) referring the patient to another provider. Both national guidelines recommend 1 cm to 2 cm margins for melanomas 1 mm to 2 mm in depth and 2 cm margins for melanoma greater than 2 mm in depth.

Academic dermatologists were significantly more likely than other dermatologists to treat these lesions rather than to refer the patient out (51% vs. 30%; P < .001).

“This is exciting new data that suggests that there still is a variance in early melanoma management,” Dr. Rigel, past president of AAD and ASDS, said in an interview. “The data suggest more studies need to be done to better access why this is occurring.”

Dr. Hensin Tsao, who served on the 2011 AAD guideline working group and is co-chairing the AAD’s pending guideline update, said in an interview that, “Dr. Rigel is well respected in the field and the project will undoubtedly be submitted for publication and subject to further review. It is worthwhile to wait on the final published results and conclusions.”

He agreed, however, with the authors’ suggestion that there is significant variation in practice. Regarding the finding that 36% of respondents use a shave biopsy for suspicious lesions, the AAD guidelines recommend that the entire lesion be removed with a 1 mm to 3 mm margin, which can be accomplished by an elliptical or punch excision with sutures or shave removal to a depth below the anticipated plane of the lesion, Dr. Tsao, of Massachusetts General Hospital in Boston, said.

“It is quite possible that some of the respondents to the questionnaire interpreted ‘shave biopsy’ as a full shave disk excision,” he said. “That said, intentional and routine partial sampling of suspected melanomas would be at odds with the guidelines.”

It is not inappropriate to remove a suspicious lesion, if small enough, with a punch biopsy, Dr. Tsao said, adding, “Perhaps again, the respondents failed to distinguish between partial punch biopsy and punch excision.”

On occasion, the AAD guidelines also make accommodations for an incisional biopsy “of the clinically or dermatoscopically most atypical portion of the lesion.” In this situation, a smaller incisional punch biopsy may be performed of the highly suspicious area.

“There are certainly areas that the investigators have identified which could represent potential knowledge gaps,” Dr. Tsao said. “For instance, 14% of the respondents used a 0.6 cm to 1.0 cm (6 mm-10 mm) margin for melanoma greater than 1 mm.”

Dermatologists’ surveillance of patients in the survey was somewhat less divergent. The most recommended follow-up interval for patients diagnosed within the last 5 years, was 6 months (49%), followed by a 3-month interval (25%), and other (24%). Follow-up was extended to yearly by 63% of dermatologists for patients diagnosed more than five years earlier, Dr. Farberg and Dr. Rigel reported.

Both the AAD and NCCN recommend follow-up every 3 to 12 months for those diagnosed with melanoma within the previous 5 years, while for those diagnosed more than 5 years prior, the AAD recommends follow-up every 3 to 12 months and the NCCN every 12 months.

“Adherence to evidence-based guidelines should lead to improved patient outcomes and quality of care. However, newer studies and emerging data may also justify deviations from existing guidelines, suggesting review of those guidelines may be indicated,” Dr. Farberg and Dr. Rigel concluded.

For example, a prospective series examining surgical margins in 1,072 patients with 1,120 malignant melanoma in situs showed that only 86% were successfully excised with a 6-mm margin, significantly less than the 98.9% clearance achieved with a 9-mm margin, Dr. Farberg told this publication.

That said, a 9-mm margin may not be appropriate for all lesions, such as those on the face, he observed.

The investigators said they hope the survey results will spur on revision of the guidelines, last updated in 2011.

Limitations of the survey include a lack of information on clinical factors such as patient history or anatomic site, the survey may have led to generalized answers, and access to care and reimbursement also may have impacted management, the authors noted.

The response rate to the survey was also low at 8%, with 6,177 practicing U.S. dermatologists surveyed. The demographics of the respondents, however, strongly reflected the full AAD membership, Dr. Farberg said. No significant geographical differences were observed.

[email protected]

LOS ANGELES – One in five adolescents report poor mental health 2 years after gastric bypass surgery, a Swedish study shows.

“There is an unmet need for psychiatric and psychological treatment in adolescents, and 20% is a much higher figure than you find in adults,” Kajsa Järvholm of Lund University, Sweden, said at Obesity Week 2015.

Notably, weight loss did not differ during follow-up between adolescents with poor mental health (PMH) and those with average or good mental health.

Girls were more likely than were boys to report PMH (14 vs. 2; P = .053), but no significant age difference was found.

Prior research has shown that adolescents seeking bariatric surgery have impaired mental health compared with population norms, but most adolescents experience an improvement after surgery.

A recent systematic review of psychological and social outcomes in adolescents undergoing bariatric surgery found overall quality of life improved after surgery, regardless of the surgical type, with peak improvement at months 6 to 12 (Clin Obes. 2015 Nov. 6. doi: 10.1111/cob.12119).

The current study involved 82 adolescents who were part of the larger Adolescent Morbid Obesity Surgery (AMOS) study cohort. At the time of surgery, the average age of the patients was 16.8 years and the average body mass index was 45.4 kg/m². Two-thirds (67%) were girls.

The adolescents were assessed by self-report questionnaires at baseline, 1 year, and 2 years after laparoscopic bariatric surgery. Standardized cutoffs on two different variables, depression and obesity-related problems, were used to classify adolescents as having a PMH or average and good mental health 2 years after surgery.

Adolescents with PMH at 2 years post surgery reported significantly more symptoms of anxiety (P = .004) and depression (P = .028) already before surgery, Ms. Järvholm said.

One year after surgery, more differences were observed. Adolescents with PMH, in addition to reporting more symptoms of anxiety (P less than .0001) and depression (P = .003), also reported more anger (P = .005) and obesity-related problems (P = .006) than did adolescents with an average or good mental health.

No differences were seen at this time in self-concept or disruptive behavior, she said.

Two years after surgery, all measured aspects of mental health were worse in adolescents with PMH (all P values less than .0001), Ms. Järvholm said.

“Preoperative identification is difficult since most variables do not differ between groups, but we should take extra care with adolescents with more anxiety and more depression already before surgery,” she said at the meeting, presented by the Obesity Society and American Society for Metabolic and Bariatric Surgery.

[email protected]

LOS ANGELES – One in five adolescents report poor mental health 2 years after gastric bypass surgery, a Swedish study shows.

“There is an unmet need for psychiatric and psychological treatment in adolescents, and 20% is a much higher figure than you find in adults,” Kajsa Järvholm of Lund University, Sweden, said at Obesity Week 2015.

Notably, weight loss did not differ during follow-up between adolescents with poor mental health (PMH) and those with average or good mental health.

Girls were more likely than were boys to report PMH (14 vs. 2; P = .053), but no significant age difference was found.

Prior research has shown that adolescents seeking bariatric surgery have impaired mental health compared with population norms, but most adolescents experience an improvement after surgery.

A recent systematic review of psychological and social outcomes in adolescents undergoing bariatric surgery found overall quality of life improved after surgery, regardless of the surgical type, with peak improvement at months 6 to 12 (Clin Obes. 2015 Nov. 6. doi: 10.1111/cob.12119).

The current study involved 82 adolescents who were part of the larger Adolescent Morbid Obesity Surgery (AMOS) study cohort. At the time of surgery, the average age of the patients was 16.8 years and the average body mass index was 45.4 kg/m². Two-thirds (67%) were girls.

The adolescents were assessed by self-report questionnaires at baseline, 1 year, and 2 years after laparoscopic bariatric surgery. Standardized cutoffs on two different variables, depression and obesity-related problems, were used to classify adolescents as having a PMH or average and good mental health 2 years after surgery.

Adolescents with PMH at 2 years post surgery reported significantly more symptoms of anxiety (P = .004) and depression (P = .028) already before surgery, Ms. Järvholm said.

One year after surgery, more differences were observed. Adolescents with PMH, in addition to reporting more symptoms of anxiety (P less than .0001) and depression (P = .003), also reported more anger (P = .005) and obesity-related problems (P = .006) than did adolescents with an average or good mental health.

No differences were seen at this time in self-concept or disruptive behavior, she said.

Two years after surgery, all measured aspects of mental health were worse in adolescents with PMH (all P values less than .0001), Ms. Järvholm said.

“Preoperative identification is difficult since most variables do not differ between groups, but we should take extra care with adolescents with more anxiety and more depression already before surgery,” she said at the meeting, presented by the Obesity Society and American Society for Metabolic and Bariatric Surgery.

[email protected]

LOS ANGELES – One in five adolescents report poor mental health 2 years after gastric bypass surgery, a Swedish study shows.

“There is an unmet need for psychiatric and psychological treatment in adolescents, and 20% is a much higher figure than you find in adults,” Kajsa Järvholm of Lund University, Sweden, said at Obesity Week 2015.

Notably, weight loss did not differ during follow-up between adolescents with poor mental health (PMH) and those with average or good mental health.

Girls were more likely than were boys to report PMH (14 vs. 2; P = .053), but no significant age difference was found.

Prior research has shown that adolescents seeking bariatric surgery have impaired mental health compared with population norms, but most adolescents experience an improvement after surgery.

A recent systematic review of psychological and social outcomes in adolescents undergoing bariatric surgery found overall quality of life improved after surgery, regardless of the surgical type, with peak improvement at months 6 to 12 (Clin Obes. 2015 Nov. 6. doi: 10.1111/cob.12119).

The current study involved 82 adolescents who were part of the larger Adolescent Morbid Obesity Surgery (AMOS) study cohort. At the time of surgery, the average age of the patients was 16.8 years and the average body mass index was 45.4 kg/m². Two-thirds (67%) were girls.

The adolescents were assessed by self-report questionnaires at baseline, 1 year, and 2 years after laparoscopic bariatric surgery. Standardized cutoffs on two different variables, depression and obesity-related problems, were used to classify adolescents as having a PMH or average and good mental health 2 years after surgery.

Adolescents with PMH at 2 years post surgery reported significantly more symptoms of anxiety (P = .004) and depression (P = .028) already before surgery, Ms. Järvholm said.

One year after surgery, more differences were observed. Adolescents with PMH, in addition to reporting more symptoms of anxiety (P less than .0001) and depression (P = .003), also reported more anger (P = .005) and obesity-related problems (P = .006) than did adolescents with an average or good mental health.

No differences were seen at this time in self-concept or disruptive behavior, she said.

Two years after surgery, all measured aspects of mental health were worse in adolescents with PMH (all P values less than .0001), Ms. Järvholm said.

“Preoperative identification is difficult since most variables do not differ between groups, but we should take extra care with adolescents with more anxiety and more depression already before surgery,” she said at the meeting, presented by the Obesity Society and American Society for Metabolic and Bariatric Surgery.

[email protected]

CHICAGO – Patients undergoing Roux-en-Y gastric bypass are twice as likely to need a reoperation as those having sleeve gastrectomy, according to ACS NSQIP data.

Reoperation among Roux-en-Y patients was associated with a 10-fold increase in mortality over sleeve gastrectomy (1.2% vs. 0.1%; P less than .01) and a 3-fold increase in length of stay (6 days vs. 2 days; P less than .01), Dr. Matthew Whealon reported at the American College of Surgeons Clinical Congress

The results are consistent with prior contemporary analyses using ACS National Surgical Quality Improvement Program (NSQIP) data reporting reoperation rates of 2.5%-5.1% for Roux-en-Y gastric bypass (RYGB) and 1.6%-3% for sleeve gastrectomy. Those analyses, however, did not include the reasons for reoperation, as these data were not available until the 2012 database release, he said.

Patrice Wendling/Frontline Medical News

With these data now in hand, lead author Dr. Mark Hanna and his fellow investigators at the University of California, Irvine, identified 36,757 adults in the 2012-2013 database who underwent RYGB (n = 19,597) or sleeve gastrectomy (n = 17,160) for morbid obesity and performed multivariate regression analyses to identify risk factors associated with reoperation.

In all, 518 RYGB patients and 231 sleeve gastrectomy patients required an unplanned return to the operating room (2.6% vs. 1.3%), Dr. Whealon said. The mean time from the index procedure to reoperation was 7.6 days and 7.1 days, respectively.

Obstruction was the biggest driver of reoperation following RYGB, accounting for 28% of reoperations. Other causes were bleeding (14.5%), leak (13%), and other unspecified reasons (18.5%), with data missing in 12%.

Bleeding was the most common indication for reoperation after sleeve gastrectomy (25.5%), followed by other unspecified reasons(24.6%), missing data (13%), leak (12.55%), and obstruction (11.2%), he said.

In adjusted multivariate analyses, factors that significantly increased the risk for reoperation were heart failure (adjusted odds ratio, 2.3), dependent functional status (aOR, 2.1), RYGB (aOR, 1.94), chronic obstructive pulmonary disease (aOR, 1.7), open operation (aOR, 1.6), and male sex (aOR, 1.1). The P values were less than .05 for all comparisons.

Factors not significant for reoperation included body mass index, age, smoking status, bleeding disorder, steroid use, dialysis, hypertension, diabetes, preoperative sepsis, emergent admission, elective operation, and preoperative weight loss.

While bariatric surgery remains a safe operation with low mortality and reoperation rates, additional studies are needed, because of the increased mortality associated with reoperation, to identify ways to mitigate these complications, Dr. Whealon said.

Limitations of the study were that ICD-9 codes for postoperative hemorrhage could not differentiate between intra-abdominal and gastrointestinal bleeding, the database is subject to coding errors, and missing data may have introduced bias into the study, he noted.

Discussant Dr. Matthew Goldblatt of the Medical College of Wisconsin in Milwaukee commented that use of the ACS MBSAQIP (Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program) database would have avoided some of the coding errors for reoperation.

He also questioned whether the average 7-day return to surgery interval reflects the use of endoscopy, as few surgeons would wait that long if, as the analysis suggests, a primary reason for reoperation was postoperative bleeding.

Endoscopy was included in the reoperations, Dr. Whealon said, but he could not speak to the exact percentage it comprised.

Finally, Dr. Goldblatt said, “the patients that you identified as being the highest risk for complication, as is often the case in these reviews, are really the ones most likely to gain the most from the procedure. … So how can people avoid operating on these patients when they are the ones that can get the most out of it?”

Dr. Whealon agreed that high-risk patients have the most to gain and suggested that “optimizing their comorbid conditions before operation will help reduce their risk.”

The authors reported having no conflicts of interest.

[email protected]

CHICAGO – Patients undergoing Roux-en-Y gastric bypass are twice as likely to need a reoperation as those having sleeve gastrectomy, according to ACS NSQIP data.

Reoperation among Roux-en-Y patients was associated with a 10-fold increase in mortality over sleeve gastrectomy (1.2% vs. 0.1%; P less than .01) and a 3-fold increase in length of stay (6 days vs. 2 days; P less than .01), Dr. Matthew Whealon reported at the American College of Surgeons Clinical Congress

The results are consistent with prior contemporary analyses using ACS National Surgical Quality Improvement Program (NSQIP) data reporting reoperation rates of 2.5%-5.1% for Roux-en-Y gastric bypass (RYGB) and 1.6%-3% for sleeve gastrectomy. Those analyses, however, did not include the reasons for reoperation, as these data were not available until the 2012 database release, he said.

Patrice Wendling/Frontline Medical News

With these data now in hand, lead author Dr. Mark Hanna and his fellow investigators at the University of California, Irvine, identified 36,757 adults in the 2012-2013 database who underwent RYGB (n = 19,597) or sleeve gastrectomy (n = 17,160) for morbid obesity and performed multivariate regression analyses to identify risk factors associated with reoperation.

In all, 518 RYGB patients and 231 sleeve gastrectomy patients required an unplanned return to the operating room (2.6% vs. 1.3%), Dr. Whealon said. The mean time from the index procedure to reoperation was 7.6 days and 7.1 days, respectively.

Obstruction was the biggest driver of reoperation following RYGB, accounting for 28% of reoperations. Other causes were bleeding (14.5%), leak (13%), and other unspecified reasons (18.5%), with data missing in 12%.

Bleeding was the most common indication for reoperation after sleeve gastrectomy (25.5%), followed by other unspecified reasons(24.6%), missing data (13%), leak (12.55%), and obstruction (11.2%), he said.

In adjusted multivariate analyses, factors that significantly increased the risk for reoperation were heart failure (adjusted odds ratio, 2.3), dependent functional status (aOR, 2.1), RYGB (aOR, 1.94), chronic obstructive pulmonary disease (aOR, 1.7), open operation (aOR, 1.6), and male sex (aOR, 1.1). The P values were less than .05 for all comparisons.

Factors not significant for reoperation included body mass index, age, smoking status, bleeding disorder, steroid use, dialysis, hypertension, diabetes, preoperative sepsis, emergent admission, elective operation, and preoperative weight loss.

While bariatric surgery remains a safe operation with low mortality and reoperation rates, additional studies are needed, because of the increased mortality associated with reoperation, to identify ways to mitigate these complications, Dr. Whealon said.

Limitations of the study were that ICD-9 codes for postoperative hemorrhage could not differentiate between intra-abdominal and gastrointestinal bleeding, the database is subject to coding errors, and missing data may have introduced bias into the study, he noted.

Discussant Dr. Matthew Goldblatt of the Medical College of Wisconsin in Milwaukee commented that use of the ACS MBSAQIP (Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program) database would have avoided some of the coding errors for reoperation.

He also questioned whether the average 7-day return to surgery interval reflects the use of endoscopy, as few surgeons would wait that long if, as the analysis suggests, a primary reason for reoperation was postoperative bleeding.

Endoscopy was included in the reoperations, Dr. Whealon said, but he could not speak to the exact percentage it comprised.

Finally, Dr. Goldblatt said, “the patients that you identified as being the highest risk for complication, as is often the case in these reviews, are really the ones most likely to gain the most from the procedure. … So how can people avoid operating on these patients when they are the ones that can get the most out of it?”

Dr. Whealon agreed that high-risk patients have the most to gain and suggested that “optimizing their comorbid conditions before operation will help reduce their risk.”

The authors reported having no conflicts of interest.

[email protected]

CHICAGO – Patients undergoing Roux-en-Y gastric bypass are twice as likely to need a reoperation as those having sleeve gastrectomy, according to ACS NSQIP data.

Reoperation among Roux-en-Y patients was associated with a 10-fold increase in mortality over sleeve gastrectomy (1.2% vs. 0.1%; P less than .01) and a 3-fold increase in length of stay (6 days vs. 2 days; P less than .01), Dr. Matthew Whealon reported at the American College of Surgeons Clinical Congress

The results are consistent with prior contemporary analyses using ACS National Surgical Quality Improvement Program (NSQIP) data reporting reoperation rates of 2.5%-5.1% for Roux-en-Y gastric bypass (RYGB) and 1.6%-3% for sleeve gastrectomy. Those analyses, however, did not include the reasons for reoperation, as these data were not available until the 2012 database release, he said.

Patrice Wendling/Frontline Medical News

With these data now in hand, lead author Dr. Mark Hanna and his fellow investigators at the University of California, Irvine, identified 36,757 adults in the 2012-2013 database who underwent RYGB (n = 19,597) or sleeve gastrectomy (n = 17,160) for morbid obesity and performed multivariate regression analyses to identify risk factors associated with reoperation.

In all, 518 RYGB patients and 231 sleeve gastrectomy patients required an unplanned return to the operating room (2.6% vs. 1.3%), Dr. Whealon said. The mean time from the index procedure to reoperation was 7.6 days and 7.1 days, respectively.

Obstruction was the biggest driver of reoperation following RYGB, accounting for 28% of reoperations. Other causes were bleeding (14.5%), leak (13%), and other unspecified reasons (18.5%), with data missing in 12%.

Bleeding was the most common indication for reoperation after sleeve gastrectomy (25.5%), followed by other unspecified reasons(24.6%), missing data (13%), leak (12.55%), and obstruction (11.2%), he said.

In adjusted multivariate analyses, factors that significantly increased the risk for reoperation were heart failure (adjusted odds ratio, 2.3), dependent functional status (aOR, 2.1), RYGB (aOR, 1.94), chronic obstructive pulmonary disease (aOR, 1.7), open operation (aOR, 1.6), and male sex (aOR, 1.1). The P values were less than .05 for all comparisons.

Factors not significant for reoperation included body mass index, age, smoking status, bleeding disorder, steroid use, dialysis, hypertension, diabetes, preoperative sepsis, emergent admission, elective operation, and preoperative weight loss.

While bariatric surgery remains a safe operation with low mortality and reoperation rates, additional studies are needed, because of the increased mortality associated with reoperation, to identify ways to mitigate these complications, Dr. Whealon said.

Limitations of the study were that ICD-9 codes for postoperative hemorrhage could not differentiate between intra-abdominal and gastrointestinal bleeding, the database is subject to coding errors, and missing data may have introduced bias into the study, he noted.

Discussant Dr. Matthew Goldblatt of the Medical College of Wisconsin in Milwaukee commented that use of the ACS MBSAQIP (Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program) database would have avoided some of the coding errors for reoperation.

He also questioned whether the average 7-day return to surgery interval reflects the use of endoscopy, as few surgeons would wait that long if, as the analysis suggests, a primary reason for reoperation was postoperative bleeding.

Endoscopy was included in the reoperations, Dr. Whealon said, but he could not speak to the exact percentage it comprised.

Finally, Dr. Goldblatt said, “the patients that you identified as being the highest risk for complication, as is often the case in these reviews, are really the ones most likely to gain the most from the procedure. … So how can people avoid operating on these patients when they are the ones that can get the most out of it?”

Dr. Whealon agreed that high-risk patients have the most to gain and suggested that “optimizing their comorbid conditions before operation will help reduce their risk.”

The authors reported having no conflicts of interest.

[email protected]