Timothy F. Kirn

VANCOUVER, B.C. — According to an informal poll, most melanoma experts would want a sentinel node biopsy if they had melanoma, despite the fact that sentinel node biopsy results have now been followed out for 5 years, and were not shown to increase long-term survival.

The poll was taken by Merrick Ross, M.D., at the Sixth World Congress on Melanoma, following a presentation of the 5-year results of the 1,973-subject, Multicenter Selective Lymphadenectomy Trial.

The Multicenter Selective Lymphadenectomy Trial found no statistically significant difference in 5-year survival rates between those who had sentinel node biopsy and those who did not (87% vs. 86%), the primary end point of the trial, said Donald L. Morton, M.D., the originator of the procedure. Dr. Morton is the chief of science and medicine at the John Wayne Cancer Institute, Santa Monica, Calif.

However, subanalysis of the data from the trial suggested enough benefit that if sentinel node biopsy were considered a new drug, it would warrant Food and Drug Administration approval, Dr. Morton asserted.

One of the commentators, John Thompson, M.D., said he agreed. Assessment of the sentinel node for evidence of migrating melanoma cells “is likely to be appropriate and important for the foreseeable future,” said Prof. Thompson, executive director of the Sydney Melanoma Unit at the Royal Prince Alfred Hospital, Camperdown, Australia, and another principal investigator in the trial.

The other commentator, however, disagreed strongly. The trial was designed to look for a difference in survival, and it failed to show one, said J. Meirion Thomas, M.D., of the sarcoma unit of the Royal Marsden Hospital, London. “We must stop burying our head in the sand,” Dr. Thomas said. “At the present time, this procedure offers patients no benefit.”

Dr. Ross, chief of the melanoma section at the M.D. Anderson Cancer Center, Houston, and an advocate of the procedure, asked the approximately 200 melanoma experts present in the room: “If you had melanoma, would you want a sentinel node procedure?” About 90% of the audience raised their hands, indicating they would.

The Multicenter Selective Lymphadenectomy Trial looked at patients who had melanomas with greater than a 1.0-mm Breslow thickness. It randomized about 60% of the patients to wide local excision with a sentinel node biopsy, which was followed by regional lymphadenectomy if a positive sentinel node was found. About 40% of the patients were randomized to a watch-and-wait group, in which they received a wide local excision only, and were followed. If the followed patients developed a palpable node, they then underwent regional lymphadenectomy. The median time of follow-up of the patients was 59 months.

Although there was no difference in overall survival, there was a difference in disease-free survival (78% vs. 73%), Dr. Morton said.

The analysis also showed that there was a similar rate of positive nodes in both groups (16%); that node positive patients overall had lower survival at 5 years (71% vs. 88%); and that when patients needed regional lymphadenectomy, those in the sentinel node biopsy group had fewer positive nodes at lymphadenectomy than did those in the watch-and-wait group (an average 1.6 vs. 3.4), among other findings.

Moreover, 5-year survival among those with positive nodes was significantly higher in those patients with a positive sentinel node and immediate lymph node dissection than it was among the patients who had a delayed complete dissection (71% vs. 55%).

Taking the data all together, no evidence suggested that the sentinel node biopsy was inaccurate, or that it was unsafe in any way. The data further suggested that there were some patients whose disease was caught while it was still limited to the sentinel node, and that these patients were cured, Dr. Morton said.

“There is a very short window of opportunity here where in fact there is a small, but definite subset of patients who have their disease limited to the sentinel node, and their removal aborts the blood-borne and distant metastasis,” he said.

Sentinel node biopsy is important also because it removes uncertainty for many patients, and it allows for more accurate cancer staging of patients, which is critical information for conducting clinical trials, he added.

The reason the trial may have shown no effect on overall survival may be because it enrolled too few patients to make a clear difference, Prof. Thompson suggested.

Dr. Morton agreed. The $90-million trial has had far fewer deaths (13%) than were expected when the trial was designed over a decade ago, when the only information they had to go on to decide how many patients might be needed was the historical rate at the John Wayne Cancer Institute, he said.

The real issue is the accuracy of sentinel node biopsy, given that it has shown no benefit, Dr. Thomas said. The false- negative rate has been shown to be about 13%. The false-positive rate is not known, but by extrapolating from various data sources, it can be estimated to be anywhere from 12% to 22%, and those patients are getting unnecessary lymphadenectomies.

“There is no survival advantage, and they shouldn't be looking at those other measures,” he said.

Dr. Ross, on the other hand, said he was not dismayed by the lack of a survival advantage in the trial.

“Overall it is a better way to treat patients because you are identifying and removing disease early,” he added.

VANCOUVER, B.C. — According to an informal poll, most melanoma experts would want a sentinel node biopsy if they had melanoma, despite the fact that sentinel node biopsy results have now been followed out for 5 years, and were not shown to increase long-term survival.

The poll was taken by Merrick Ross, M.D., at the Sixth World Congress on Melanoma, following a presentation of the 5-year results of the 1,973-subject, Multicenter Selective Lymphadenectomy Trial.

The Multicenter Selective Lymphadenectomy Trial found no statistically significant difference in 5-year survival rates between those who had sentinel node biopsy and those who did not (87% vs. 86%), the primary end point of the trial, said Donald L. Morton, M.D., the originator of the procedure. Dr. Morton is the chief of science and medicine at the John Wayne Cancer Institute, Santa Monica, Calif.

However, subanalysis of the data from the trial suggested enough benefit that if sentinel node biopsy were considered a new drug, it would warrant Food and Drug Administration approval, Dr. Morton asserted.

One of the commentators, John Thompson, M.D., said he agreed. Assessment of the sentinel node for evidence of migrating melanoma cells “is likely to be appropriate and important for the foreseeable future,” said Prof. Thompson, executive director of the Sydney Melanoma Unit at the Royal Prince Alfred Hospital, Camperdown, Australia, and another principal investigator in the trial.

The other commentator, however, disagreed strongly. The trial was designed to look for a difference in survival, and it failed to show one, said J. Meirion Thomas, M.D., of the sarcoma unit of the Royal Marsden Hospital, London. “We must stop burying our head in the sand,” Dr. Thomas said. “At the present time, this procedure offers patients no benefit.”

Dr. Ross, chief of the melanoma section at the M.D. Anderson Cancer Center, Houston, and an advocate of the procedure, asked the approximately 200 melanoma experts present in the room: “If you had melanoma, would you want a sentinel node procedure?” About 90% of the audience raised their hands, indicating they would.

The Multicenter Selective Lymphadenectomy Trial looked at patients who had melanomas with greater than a 1.0-mm Breslow thickness. It randomized about 60% of the patients to wide local excision with a sentinel node biopsy, which was followed by regional lymphadenectomy if a positive sentinel node was found. About 40% of the patients were randomized to a watch-and-wait group, in which they received a wide local excision only, and were followed. If the followed patients developed a palpable node, they then underwent regional lymphadenectomy. The median time of follow-up of the patients was 59 months.

Although there was no difference in overall survival, there was a difference in disease-free survival (78% vs. 73%), Dr. Morton said.

The analysis also showed that there was a similar rate of positive nodes in both groups (16%); that node positive patients overall had lower survival at 5 years (71% vs. 88%); and that when patients needed regional lymphadenectomy, those in the sentinel node biopsy group had fewer positive nodes at lymphadenectomy than did those in the watch-and-wait group (an average 1.6 vs. 3.4), among other findings.

Moreover, 5-year survival among those with positive nodes was significantly higher in those patients with a positive sentinel node and immediate lymph node dissection than it was among the patients who had a delayed complete dissection (71% vs. 55%).

Taking the data all together, no evidence suggested that the sentinel node biopsy was inaccurate, or that it was unsafe in any way. The data further suggested that there were some patients whose disease was caught while it was still limited to the sentinel node, and that these patients were cured, Dr. Morton said.

“There is a very short window of opportunity here where in fact there is a small, but definite subset of patients who have their disease limited to the sentinel node, and their removal aborts the blood-borne and distant metastasis,” he said.

Sentinel node biopsy is important also because it removes uncertainty for many patients, and it allows for more accurate cancer staging of patients, which is critical information for conducting clinical trials, he added.

The reason the trial may have shown no effect on overall survival may be because it enrolled too few patients to make a clear difference, Prof. Thompson suggested.

Dr. Morton agreed. The $90-million trial has had far fewer deaths (13%) than were expected when the trial was designed over a decade ago, when the only information they had to go on to decide how many patients might be needed was the historical rate at the John Wayne Cancer Institute, he said.

The real issue is the accuracy of sentinel node biopsy, given that it has shown no benefit, Dr. Thomas said. The false- negative rate has been shown to be about 13%. The false-positive rate is not known, but by extrapolating from various data sources, it can be estimated to be anywhere from 12% to 22%, and those patients are getting unnecessary lymphadenectomies.

“There is no survival advantage, and they shouldn't be looking at those other measures,” he said.

Dr. Ross, on the other hand, said he was not dismayed by the lack of a survival advantage in the trial.

“Overall it is a better way to treat patients because you are identifying and removing disease early,” he added.

VANCOUVER, B.C. — According to an informal poll, most melanoma experts would want a sentinel node biopsy if they had melanoma, despite the fact that sentinel node biopsy results have now been followed out for 5 years, and were not shown to increase long-term survival.

The poll was taken by Merrick Ross, M.D., at the Sixth World Congress on Melanoma, following a presentation of the 5-year results of the 1,973-subject, Multicenter Selective Lymphadenectomy Trial.

The Multicenter Selective Lymphadenectomy Trial found no statistically significant difference in 5-year survival rates between those who had sentinel node biopsy and those who did not (87% vs. 86%), the primary end point of the trial, said Donald L. Morton, M.D., the originator of the procedure. Dr. Morton is the chief of science and medicine at the John Wayne Cancer Institute, Santa Monica, Calif.

However, subanalysis of the data from the trial suggested enough benefit that if sentinel node biopsy were considered a new drug, it would warrant Food and Drug Administration approval, Dr. Morton asserted.

One of the commentators, John Thompson, M.D., said he agreed. Assessment of the sentinel node for evidence of migrating melanoma cells “is likely to be appropriate and important for the foreseeable future,” said Prof. Thompson, executive director of the Sydney Melanoma Unit at the Royal Prince Alfred Hospital, Camperdown, Australia, and another principal investigator in the trial.

The other commentator, however, disagreed strongly. The trial was designed to look for a difference in survival, and it failed to show one, said J. Meirion Thomas, M.D., of the sarcoma unit of the Royal Marsden Hospital, London. “We must stop burying our head in the sand,” Dr. Thomas said. “At the present time, this procedure offers patients no benefit.”

Dr. Ross, chief of the melanoma section at the M.D. Anderson Cancer Center, Houston, and an advocate of the procedure, asked the approximately 200 melanoma experts present in the room: “If you had melanoma, would you want a sentinel node procedure?” About 90% of the audience raised their hands, indicating they would.

The Multicenter Selective Lymphadenectomy Trial looked at patients who had melanomas with greater than a 1.0-mm Breslow thickness. It randomized about 60% of the patients to wide local excision with a sentinel node biopsy, which was followed by regional lymphadenectomy if a positive sentinel node was found. About 40% of the patients were randomized to a watch-and-wait group, in which they received a wide local excision only, and were followed. If the followed patients developed a palpable node, they then underwent regional lymphadenectomy. The median time of follow-up of the patients was 59 months.

Although there was no difference in overall survival, there was a difference in disease-free survival (78% vs. 73%), Dr. Morton said.

The analysis also showed that there was a similar rate of positive nodes in both groups (16%); that node positive patients overall had lower survival at 5 years (71% vs. 88%); and that when patients needed regional lymphadenectomy, those in the sentinel node biopsy group had fewer positive nodes at lymphadenectomy than did those in the watch-and-wait group (an average 1.6 vs. 3.4), among other findings.

Moreover, 5-year survival among those with positive nodes was significantly higher in those patients with a positive sentinel node and immediate lymph node dissection than it was among the patients who had a delayed complete dissection (71% vs. 55%).

Taking the data all together, no evidence suggested that the sentinel node biopsy was inaccurate, or that it was unsafe in any way. The data further suggested that there were some patients whose disease was caught while it was still limited to the sentinel node, and that these patients were cured, Dr. Morton said.

“There is a very short window of opportunity here where in fact there is a small, but definite subset of patients who have their disease limited to the sentinel node, and their removal aborts the blood-borne and distant metastasis,” he said.

Sentinel node biopsy is important also because it removes uncertainty for many patients, and it allows for more accurate cancer staging of patients, which is critical information for conducting clinical trials, he added.

The reason the trial may have shown no effect on overall survival may be because it enrolled too few patients to make a clear difference, Prof. Thompson suggested.

Dr. Morton agreed. The $90-million trial has had far fewer deaths (13%) than were expected when the trial was designed over a decade ago, when the only information they had to go on to decide how many patients might be needed was the historical rate at the John Wayne Cancer Institute, he said.

The real issue is the accuracy of sentinel node biopsy, given that it has shown no benefit, Dr. Thomas said. The false- negative rate has been shown to be about 13%. The false-positive rate is not known, but by extrapolating from various data sources, it can be estimated to be anywhere from 12% to 22%, and those patients are getting unnecessary lymphadenectomies.

“There is no survival advantage, and they shouldn't be looking at those other measures,” he said.

Dr. Ross, on the other hand, said he was not dismayed by the lack of a survival advantage in the trial.

“Overall it is a better way to treat patients because you are identifying and removing disease early,” he added.

SAN FRANCISCO — A pack of chewing gum can save laparoscopic abdominal surgery patients over $500 in hospitalization costs?

That's what a randomized study of postoperative ileus and “sham feeding” found.

Estimates are that half of inpatient abdominal and pelvic surgery patients do not have a return of bowel function for 4 days, and 25% have not had a return by 6 days. The cost of postoperative ileus nationally is estimated to be $750 million to $1 billion a year.

A number of investigators have begun to explore the use of sham feeding—that is, chewing without swallowing food—to see whether it can cause cholinergic stimulation of the gut and speed the return to normal bowel function following abdominal surgery.

This study took that concept to the next level, James T. McCormick, D.O., said at the annual clinical congress of the American College of Surgeons. It found that laparoscopic colectomy patients randomized to chewing four sticks of gum a day had their first defecation and were discharged from the hospital almost a day earlier than other patients.

The study, which enrolled 102 patients undergoing elective colectomy, included both open colectomy and laparoscopic colectomy patients. However, the benefits were seen only in the patients who had a laparoscopic procedure, said Dr. McCormick of the Western Pennsylvania Hospital, Pittsburgh.

In the laparoscopic patients, the 42 patients who chewed gum had an average time to first bowel movement of 2.9 days, compared with an average of 3.5 days in the 20-patient, clear-liquid control group, and were released from the hospital in 4.4 days, compared with 5.2 days.

Patients in the study began to receive solid food when it was deemed that they could tolerate it, and there was no difference between the groups in hunger or vomiting. The patients who chewed gum were given the gum at mealtimes and one time in the evening to simulate a snack. By protocol, they chewed for 15 minutes.

“Is more chewing better? I don't know,” Dr. McCormick said.

SAN FRANCISCO — A pack of chewing gum can save laparoscopic abdominal surgery patients over $500 in hospitalization costs?

That's what a randomized study of postoperative ileus and “sham feeding” found.

Estimates are that half of inpatient abdominal and pelvic surgery patients do not have a return of bowel function for 4 days, and 25% have not had a return by 6 days. The cost of postoperative ileus nationally is estimated to be $750 million to $1 billion a year.

A number of investigators have begun to explore the use of sham feeding—that is, chewing without swallowing food—to see whether it can cause cholinergic stimulation of the gut and speed the return to normal bowel function following abdominal surgery.

This study took that concept to the next level, James T. McCormick, D.O., said at the annual clinical congress of the American College of Surgeons. It found that laparoscopic colectomy patients randomized to chewing four sticks of gum a day had their first defecation and were discharged from the hospital almost a day earlier than other patients.

The study, which enrolled 102 patients undergoing elective colectomy, included both open colectomy and laparoscopic colectomy patients. However, the benefits were seen only in the patients who had a laparoscopic procedure, said Dr. McCormick of the Western Pennsylvania Hospital, Pittsburgh.

In the laparoscopic patients, the 42 patients who chewed gum had an average time to first bowel movement of 2.9 days, compared with an average of 3.5 days in the 20-patient, clear-liquid control group, and were released from the hospital in 4.4 days, compared with 5.2 days.

Patients in the study began to receive solid food when it was deemed that they could tolerate it, and there was no difference between the groups in hunger or vomiting. The patients who chewed gum were given the gum at mealtimes and one time in the evening to simulate a snack. By protocol, they chewed for 15 minutes.

“Is more chewing better? I don't know,” Dr. McCormick said.

SAN FRANCISCO — A pack of chewing gum can save laparoscopic abdominal surgery patients over $500 in hospitalization costs?

That's what a randomized study of postoperative ileus and “sham feeding” found.

Estimates are that half of inpatient abdominal and pelvic surgery patients do not have a return of bowel function for 4 days, and 25% have not had a return by 6 days. The cost of postoperative ileus nationally is estimated to be $750 million to $1 billion a year.

A number of investigators have begun to explore the use of sham feeding—that is, chewing without swallowing food—to see whether it can cause cholinergic stimulation of the gut and speed the return to normal bowel function following abdominal surgery.

This study took that concept to the next level, James T. McCormick, D.O., said at the annual clinical congress of the American College of Surgeons. It found that laparoscopic colectomy patients randomized to chewing four sticks of gum a day had their first defecation and were discharged from the hospital almost a day earlier than other patients.

The study, which enrolled 102 patients undergoing elective colectomy, included both open colectomy and laparoscopic colectomy patients. However, the benefits were seen only in the patients who had a laparoscopic procedure, said Dr. McCormick of the Western Pennsylvania Hospital, Pittsburgh.

In the laparoscopic patients, the 42 patients who chewed gum had an average time to first bowel movement of 2.9 days, compared with an average of 3.5 days in the 20-patient, clear-liquid control group, and were released from the hospital in 4.4 days, compared with 5.2 days.

Patients in the study began to receive solid food when it was deemed that they could tolerate it, and there was no difference between the groups in hunger or vomiting. The patients who chewed gum were given the gum at mealtimes and one time in the evening to simulate a snack. By protocol, they chewed for 15 minutes.

“Is more chewing better? I don't know,” Dr. McCormick said.

JACKSON HOLE, WYO. — Faced with the need for acute treatment of status epilepticus, emergency physicians need to remember that treatment practice is more empiric than evidence-based—and when lorazepam and fosphenytoin fail to stop the seizures, the next step is unknown, Eelco F.M. Wijdicks, M.D., said at a meeting on high-risk emergency medicine sponsored by the Mayo Clinic. Clinical trials, and even case series, with an appreciable number of patients are rare in status epilepticus.

Data from the two existing trials have established fairly clearly that lorazepam is the first-line drug of choice, said Dr. Wijdicks, director of the division of critical care neurology at the Mayo Clinic, Rochester, Minn.

The earlier of the two trials compared treatment with lorazepam, phenytoin, phenobarbital, and diazepam followed by phenytoin (N. Engl. J. Med. 1998;339:792–8)—regimens that, except for lorazepam, have largely fallen from first-line use today, Dr. Wijdicks noted. The second trial compared intravenous lorazepam or diazepam with placebo, delivered in an ambulance (N. Engl. J. Med. 2001;345:631–7).

In both studies, lorazepam was the most effective agent, terminating seizures in about 60% of patients.

Fosphenytoin is generally considered the second-line treatment, and it was the next most effective agent in the first clinical trial. Fosphenytoin is safer than phenytoin, Dr. Wijdicks said, but still can cause heart arrhythmias.

Absolutely no data indicate how long treatment should be continued, he cautioned.

With lorazepam and fosphenytoin, the practice at the Mayo Clinic is not to continue treatment for longer than 6–8 hours if seizures are controlled.

Dosages are titrated back at 10% an hour, unless seizures reappear. If that occurs, Mayo physicians go back to the dosage that achieved control and try again.

Likewise, no data suggest what agent should be used next in refractory cases. Surveys indicate that many physicians report using midazolam or propofol. For a treatment of last resort, physicians list their options to include lidocaine, ketamine, and barbiturates.

Dr. Wijdicks said he prefers intravenous valproate because it does not affect blood pressure and carries less risk than barbiturates.

The dosage is a bolus of 25 mg/kg, followed by an infusion of 1 mg/kg per hour.

Barbiturates are very effective, and the surveys suggest that about half of experts would use a barbiturate as a third-line agent.

These drugs are very tricky, however, said Dr. Wijdicks. If the patient should go into a barbiturate coma, it would mean weeks in intensive care and on mechanical ventilation, he said.

Although many status epilepticus patients become acidotic, treatment with bicarbonates is generally not necessary or advisable, Dr. Wijdicks said.

In many cases, the patient's pH does not change enough to warrant treatment, given the risk that making a patient alkaline may perpetuate seizures.

Dr. Wijdicks touched on two other subjects as well: psychogenic status epilepticus and outcomes.

Psychogenic status is a serious matter, he cautioned. When it is not recognized, patients can be subjected to the wrong interventions and suffer iatrogenic injury or death.

There is one key to recognizing psychogenic status even before an EEG: Patients will have their eyes open during their convulsions.

The outcome of status epilepticus is not universally dismal, Dr. Wijdicks said. Studies have shown that when patients come out of status epilepticus in less than an hour and have no structural brain lesion, most will return to functional independence.

JACKSON HOLE, WYO. — Faced with the need for acute treatment of status epilepticus, emergency physicians need to remember that treatment practice is more empiric than evidence-based—and when lorazepam and fosphenytoin fail to stop the seizures, the next step is unknown, Eelco F.M. Wijdicks, M.D., said at a meeting on high-risk emergency medicine sponsored by the Mayo Clinic. Clinical trials, and even case series, with an appreciable number of patients are rare in status epilepticus.

Data from the two existing trials have established fairly clearly that lorazepam is the first-line drug of choice, said Dr. Wijdicks, director of the division of critical care neurology at the Mayo Clinic, Rochester, Minn.

The earlier of the two trials compared treatment with lorazepam, phenytoin, phenobarbital, and diazepam followed by phenytoin (N. Engl. J. Med. 1998;339:792–8)—regimens that, except for lorazepam, have largely fallen from first-line use today, Dr. Wijdicks noted. The second trial compared intravenous lorazepam or diazepam with placebo, delivered in an ambulance (N. Engl. J. Med. 2001;345:631–7).

In both studies, lorazepam was the most effective agent, terminating seizures in about 60% of patients.

Fosphenytoin is generally considered the second-line treatment, and it was the next most effective agent in the first clinical trial. Fosphenytoin is safer than phenytoin, Dr. Wijdicks said, but still can cause heart arrhythmias.

Absolutely no data indicate how long treatment should be continued, he cautioned.

With lorazepam and fosphenytoin, the practice at the Mayo Clinic is not to continue treatment for longer than 6–8 hours if seizures are controlled.

Dosages are titrated back at 10% an hour, unless seizures reappear. If that occurs, Mayo physicians go back to the dosage that achieved control and try again.

Likewise, no data suggest what agent should be used next in refractory cases. Surveys indicate that many physicians report using midazolam or propofol. For a treatment of last resort, physicians list their options to include lidocaine, ketamine, and barbiturates.

Dr. Wijdicks said he prefers intravenous valproate because it does not affect blood pressure and carries less risk than barbiturates.

The dosage is a bolus of 25 mg/kg, followed by an infusion of 1 mg/kg per hour.

Barbiturates are very effective, and the surveys suggest that about half of experts would use a barbiturate as a third-line agent.

These drugs are very tricky, however, said Dr. Wijdicks. If the patient should go into a barbiturate coma, it would mean weeks in intensive care and on mechanical ventilation, he said.

Although many status epilepticus patients become acidotic, treatment with bicarbonates is generally not necessary or advisable, Dr. Wijdicks said.

In many cases, the patient's pH does not change enough to warrant treatment, given the risk that making a patient alkaline may perpetuate seizures.

Dr. Wijdicks touched on two other subjects as well: psychogenic status epilepticus and outcomes.

Psychogenic status is a serious matter, he cautioned. When it is not recognized, patients can be subjected to the wrong interventions and suffer iatrogenic injury or death.

There is one key to recognizing psychogenic status even before an EEG: Patients will have their eyes open during their convulsions.

The outcome of status epilepticus is not universally dismal, Dr. Wijdicks said. Studies have shown that when patients come out of status epilepticus in less than an hour and have no structural brain lesion, most will return to functional independence.

JACKSON HOLE, WYO. — Faced with the need for acute treatment of status epilepticus, emergency physicians need to remember that treatment practice is more empiric than evidence-based—and when lorazepam and fosphenytoin fail to stop the seizures, the next step is unknown, Eelco F.M. Wijdicks, M.D., said at a meeting on high-risk emergency medicine sponsored by the Mayo Clinic. Clinical trials, and even case series, with an appreciable number of patients are rare in status epilepticus.

Data from the two existing trials have established fairly clearly that lorazepam is the first-line drug of choice, said Dr. Wijdicks, director of the division of critical care neurology at the Mayo Clinic, Rochester, Minn.

The earlier of the two trials compared treatment with lorazepam, phenytoin, phenobarbital, and diazepam followed by phenytoin (N. Engl. J. Med. 1998;339:792–8)—regimens that, except for lorazepam, have largely fallen from first-line use today, Dr. Wijdicks noted. The second trial compared intravenous lorazepam or diazepam with placebo, delivered in an ambulance (N. Engl. J. Med. 2001;345:631–7).

In both studies, lorazepam was the most effective agent, terminating seizures in about 60% of patients.

Fosphenytoin is generally considered the second-line treatment, and it was the next most effective agent in the first clinical trial. Fosphenytoin is safer than phenytoin, Dr. Wijdicks said, but still can cause heart arrhythmias.

Absolutely no data indicate how long treatment should be continued, he cautioned.

With lorazepam and fosphenytoin, the practice at the Mayo Clinic is not to continue treatment for longer than 6–8 hours if seizures are controlled.

Dosages are titrated back at 10% an hour, unless seizures reappear. If that occurs, Mayo physicians go back to the dosage that achieved control and try again.

Likewise, no data suggest what agent should be used next in refractory cases. Surveys indicate that many physicians report using midazolam or propofol. For a treatment of last resort, physicians list their options to include lidocaine, ketamine, and barbiturates.

Dr. Wijdicks said he prefers intravenous valproate because it does not affect blood pressure and carries less risk than barbiturates.

The dosage is a bolus of 25 mg/kg, followed by an infusion of 1 mg/kg per hour.

Barbiturates are very effective, and the surveys suggest that about half of experts would use a barbiturate as a third-line agent.

These drugs are very tricky, however, said Dr. Wijdicks. If the patient should go into a barbiturate coma, it would mean weeks in intensive care and on mechanical ventilation, he said.

Although many status epilepticus patients become acidotic, treatment with bicarbonates is generally not necessary or advisable, Dr. Wijdicks said.

In many cases, the patient's pH does not change enough to warrant treatment, given the risk that making a patient alkaline may perpetuate seizures.

Dr. Wijdicks touched on two other subjects as well: psychogenic status epilepticus and outcomes.

Psychogenic status is a serious matter, he cautioned. When it is not recognized, patients can be subjected to the wrong interventions and suffer iatrogenic injury or death.

There is one key to recognizing psychogenic status even before an EEG: Patients will have their eyes open during their convulsions.

The outcome of status epilepticus is not universally dismal, Dr. Wijdicks said. Studies have shown that when patients come out of status epilepticus in less than an hour and have no structural brain lesion, most will return to functional independence.

CHICAGO — Many individuals diagnosed with irritable bowel syndrome could actually have pelvic floor dysfunction, a condition that can be much more remediable, according to a study conducted at the Mayo Clinic.

Considerable overlap exists in the symptoms of pelvic floor dysfunction and irritable bowel syndrome (IBS), particularly constipation-predominant irritable bowel syndrome, even though the Rome diagnostic criteria for functional bowel disorders considers the two distinctly separate entities, Christopher N. Andrews, M.D., the main investigator of the study, said in a poster presentation at the annual Digestive Disease Week.

The study showed that few patients who present with symptoms of straining, lumpy or hard stools, or a sensation of incomplete evacuation get a pelvic floor work-up as they should, because those with pelvic floor dysfunction probably could be helped by biofeedback training of the pelvic floor muscles, Dr. Andrews said in an interview.

The study included 450 patients being seen at the Mayo Clinic, Rochester; 77% of participants were women. The patients either had diagnosed IBS or were undergoing a scintigraphic GI transit study.

The patients filled out a symptom questionnaire to help the investigators determine whether they had symptoms the Rome criteria listed in conjunction with pelvic floor dysfunction. Study investigators reviewed the patients' medical records to see if the subjects had been given any anorectal defecation testing.

A total of 194 of the patients had at least two symptoms of pelvic floor dysfunction as outlined by the Rome criteria. But only 50 patients (11%) had undergone pelvic floor dysfunction testing, usually balloon-expulsion manometry. Of those 50 patients, 13 (26%) had an abnormal test result.

Patients with constipation-predominant IBS were more likely to get testing, but they were also more likely to have overlapping symptoms and an abnormal test result.

Of the 78 patients with constipation-predominant IBS, 76 had at least two symptoms of pelvic floor dysfunction. Of those patients, 24 (32%) underwent testing, and among those tested, 8 (33%) had an abnormal test result.

Anorectal defecation testing of patients with IBS-type symptoms is thought to have become more common at highly specialized centers in recent years, Dr. Andrews said in the interview. But if the rate of testing is so low at the Mayo Clinic, then it is probably not done often enough anywhere.

One problem that may discourage testing is that there are different tests but no real standards concerning which to use, he added.

The Rome criteria symptoms used to define pelvic floor dysfunction include straining when defecating more than 25% of the time, lumpy or hard stools more than 25% of the time, incomplete evacuation more than 25% of the time, sensation of anorectal blocking more than 25% of the time, manual maneuvers to facilitate defecation more than 25% of the time, or one or fewer defecations per week.

CHICAGO — Many individuals diagnosed with irritable bowel syndrome could actually have pelvic floor dysfunction, a condition that can be much more remediable, according to a study conducted at the Mayo Clinic.

Considerable overlap exists in the symptoms of pelvic floor dysfunction and irritable bowel syndrome (IBS), particularly constipation-predominant irritable bowel syndrome, even though the Rome diagnostic criteria for functional bowel disorders considers the two distinctly separate entities, Christopher N. Andrews, M.D., the main investigator of the study, said in a poster presentation at the annual Digestive Disease Week.

The study showed that few patients who present with symptoms of straining, lumpy or hard stools, or a sensation of incomplete evacuation get a pelvic floor work-up as they should, because those with pelvic floor dysfunction probably could be helped by biofeedback training of the pelvic floor muscles, Dr. Andrews said in an interview.

The study included 450 patients being seen at the Mayo Clinic, Rochester; 77% of participants were women. The patients either had diagnosed IBS or were undergoing a scintigraphic GI transit study.

The patients filled out a symptom questionnaire to help the investigators determine whether they had symptoms the Rome criteria listed in conjunction with pelvic floor dysfunction. Study investigators reviewed the patients' medical records to see if the subjects had been given any anorectal defecation testing.

A total of 194 of the patients had at least two symptoms of pelvic floor dysfunction as outlined by the Rome criteria. But only 50 patients (11%) had undergone pelvic floor dysfunction testing, usually balloon-expulsion manometry. Of those 50 patients, 13 (26%) had an abnormal test result.

Patients with constipation-predominant IBS were more likely to get testing, but they were also more likely to have overlapping symptoms and an abnormal test result.

Of the 78 patients with constipation-predominant IBS, 76 had at least two symptoms of pelvic floor dysfunction. Of those patients, 24 (32%) underwent testing, and among those tested, 8 (33%) had an abnormal test result.

Anorectal defecation testing of patients with IBS-type symptoms is thought to have become more common at highly specialized centers in recent years, Dr. Andrews said in the interview. But if the rate of testing is so low at the Mayo Clinic, then it is probably not done often enough anywhere.

One problem that may discourage testing is that there are different tests but no real standards concerning which to use, he added.

The Rome criteria symptoms used to define pelvic floor dysfunction include straining when defecating more than 25% of the time, lumpy or hard stools more than 25% of the time, incomplete evacuation more than 25% of the time, sensation of anorectal blocking more than 25% of the time, manual maneuvers to facilitate defecation more than 25% of the time, or one or fewer defecations per week.

CHICAGO — Many individuals diagnosed with irritable bowel syndrome could actually have pelvic floor dysfunction, a condition that can be much more remediable, according to a study conducted at the Mayo Clinic.

Considerable overlap exists in the symptoms of pelvic floor dysfunction and irritable bowel syndrome (IBS), particularly constipation-predominant irritable bowel syndrome, even though the Rome diagnostic criteria for functional bowel disorders considers the two distinctly separate entities, Christopher N. Andrews, M.D., the main investigator of the study, said in a poster presentation at the annual Digestive Disease Week.

The study showed that few patients who present with symptoms of straining, lumpy or hard stools, or a sensation of incomplete evacuation get a pelvic floor work-up as they should, because those with pelvic floor dysfunction probably could be helped by biofeedback training of the pelvic floor muscles, Dr. Andrews said in an interview.

The study included 450 patients being seen at the Mayo Clinic, Rochester; 77% of participants were women. The patients either had diagnosed IBS or were undergoing a scintigraphic GI transit study.

The patients filled out a symptom questionnaire to help the investigators determine whether they had symptoms the Rome criteria listed in conjunction with pelvic floor dysfunction. Study investigators reviewed the patients' medical records to see if the subjects had been given any anorectal defecation testing.

A total of 194 of the patients had at least two symptoms of pelvic floor dysfunction as outlined by the Rome criteria. But only 50 patients (11%) had undergone pelvic floor dysfunction testing, usually balloon-expulsion manometry. Of those 50 patients, 13 (26%) had an abnormal test result.

Patients with constipation-predominant IBS were more likely to get testing, but they were also more likely to have overlapping symptoms and an abnormal test result.

Of the 78 patients with constipation-predominant IBS, 76 had at least two symptoms of pelvic floor dysfunction. Of those patients, 24 (32%) underwent testing, and among those tested, 8 (33%) had an abnormal test result.

Anorectal defecation testing of patients with IBS-type symptoms is thought to have become more common at highly specialized centers in recent years, Dr. Andrews said in the interview. But if the rate of testing is so low at the Mayo Clinic, then it is probably not done often enough anywhere.

One problem that may discourage testing is that there are different tests but no real standards concerning which to use, he added.

The Rome criteria symptoms used to define pelvic floor dysfunction include straining when defecating more than 25% of the time, lumpy or hard stools more than 25% of the time, incomplete evacuation more than 25% of the time, sensation of anorectal blocking more than 25% of the time, manual maneuvers to facilitate defecation more than 25% of the time, or one or fewer defecations per week.

VANCOUVER, B.C. — Genetic studies suggest that certain people are susceptible to melanomas caused by early, minimal sun exposure, according to speakers at the Sixth World Congress on Melanoma.

The problem with explaining melanoma risk solely by sunlight exposure has always been that, while it is true that melanoma rates in fair-skinned people increase the closer they live to the equator, it is also true that indoor workers get more melanomas than do outdoor workers, said David Whiteman, M.D., chair of the population and clinical sciences division at the Queensland (Australia) Institute for Medical Research.

And every physician knows that younger patients have more melanomas on the trunk than on the perpetually sun-exposed areas of the head and neck, he added. The theory that intermittent exposure is worse for melanoma than is constant exposure has been only partially satisfactory.

On the basis of evidence that younger people tend to get melanomas more frequently on unexposed sites, and older people get melanomas on exposed sites, Dr. Whiteman and his colleagues investigated a group of 306 melanoma patients. They compared those with head and neck melanomas with those with trunk melanomas.

The results showed that the individuals with head and neck melanomas were more likely to report high levels of sun exposure, often occupational. These patients also were more likely to have previous skin cancers or actinic keratoses; low nevus counts; and, in melanomas examined histologically by the investigators, a low probability of nevi remnants.

The individuals with trunk melanomas tended to show the opposite: They had mostly recreational sun exposure, high nevus counts, and a high likelihood of nevi remnants in their melanomas.

The data strongly suggest that there are two types of persons who get melanoma: those without a genetic susceptibility who need high sun exposure, and those with a genetic susceptibility, Dr. Whiteman said.

“This is just a hypothesis, and like all hypotheses, it needs to be tested,” he said.

BRAF mutations might be central to sun and melanoma risk, said Janet Maldonado, M.D., a second-year dermatology resident at the University of California, San Francisco. BRAF is a gene involved in the Ras pathway, which, among other things, mediates cellular proliferation.

In a study she conducted, Dr. Maldonado looked at BRAF mutations in 126 cases of melanoma, and found that the mutation was common when the melanoma was on skin without much sun damage (56%), but uncommon in melanomas from sun-damaged skin (11%).

Other investigations also have shown that true congenital nevi rarely have a BRAF mutation, whereas nevi that arise early in young children and could be confused with congenital nevi often do. This finding suggests that sunlight is necessary for creating BRAF mutations and that certain people are susceptible.

Other research has shown that melanomas that arise on skin without sun damage tend to have BRAF mutations, and melanomas on sun-damaged skin tend to have increased copies of the cyclin D gene, located on chromosome 11, Dr. Maldonado said.

This new information on sun risk, genetics, and melanoma may lead to new targeted treatments, and maybe a susceptibility test, commented Martin Weinstock, M.D., a professor of dermatology at Brown University, Providence, R.I.

Although the association between mutation and melanoma suggests certain individuals are at greater risk from sun exposure than others, it does not mean doctors should stop warning people about too much sun since sunlight is implicated in both types of melanoma identified.

The finding also reinforces the need for public education about the importance of skin self-examination.

VANCOUVER, B.C. — Genetic studies suggest that certain people are susceptible to melanomas caused by early, minimal sun exposure, according to speakers at the Sixth World Congress on Melanoma.

The problem with explaining melanoma risk solely by sunlight exposure has always been that, while it is true that melanoma rates in fair-skinned people increase the closer they live to the equator, it is also true that indoor workers get more melanomas than do outdoor workers, said David Whiteman, M.D., chair of the population and clinical sciences division at the Queensland (Australia) Institute for Medical Research.

And every physician knows that younger patients have more melanomas on the trunk than on the perpetually sun-exposed areas of the head and neck, he added. The theory that intermittent exposure is worse for melanoma than is constant exposure has been only partially satisfactory.

On the basis of evidence that younger people tend to get melanomas more frequently on unexposed sites, and older people get melanomas on exposed sites, Dr. Whiteman and his colleagues investigated a group of 306 melanoma patients. They compared those with head and neck melanomas with those with trunk melanomas.

The results showed that the individuals with head and neck melanomas were more likely to report high levels of sun exposure, often occupational. These patients also were more likely to have previous skin cancers or actinic keratoses; low nevus counts; and, in melanomas examined histologically by the investigators, a low probability of nevi remnants.

The individuals with trunk melanomas tended to show the opposite: They had mostly recreational sun exposure, high nevus counts, and a high likelihood of nevi remnants in their melanomas.

The data strongly suggest that there are two types of persons who get melanoma: those without a genetic susceptibility who need high sun exposure, and those with a genetic susceptibility, Dr. Whiteman said.

“This is just a hypothesis, and like all hypotheses, it needs to be tested,” he said.

BRAF mutations might be central to sun and melanoma risk, said Janet Maldonado, M.D., a second-year dermatology resident at the University of California, San Francisco. BRAF is a gene involved in the Ras pathway, which, among other things, mediates cellular proliferation.

In a study she conducted, Dr. Maldonado looked at BRAF mutations in 126 cases of melanoma, and found that the mutation was common when the melanoma was on skin without much sun damage (56%), but uncommon in melanomas from sun-damaged skin (11%).

Other investigations also have shown that true congenital nevi rarely have a BRAF mutation, whereas nevi that arise early in young children and could be confused with congenital nevi often do. This finding suggests that sunlight is necessary for creating BRAF mutations and that certain people are susceptible.

Other research has shown that melanomas that arise on skin without sun damage tend to have BRAF mutations, and melanomas on sun-damaged skin tend to have increased copies of the cyclin D gene, located on chromosome 11, Dr. Maldonado said.

This new information on sun risk, genetics, and melanoma may lead to new targeted treatments, and maybe a susceptibility test, commented Martin Weinstock, M.D., a professor of dermatology at Brown University, Providence, R.I.

Although the association between mutation and melanoma suggests certain individuals are at greater risk from sun exposure than others, it does not mean doctors should stop warning people about too much sun since sunlight is implicated in both types of melanoma identified.

The finding also reinforces the need for public education about the importance of skin self-examination.

VANCOUVER, B.C. — Genetic studies suggest that certain people are susceptible to melanomas caused by early, minimal sun exposure, according to speakers at the Sixth World Congress on Melanoma.

The problem with explaining melanoma risk solely by sunlight exposure has always been that, while it is true that melanoma rates in fair-skinned people increase the closer they live to the equator, it is also true that indoor workers get more melanomas than do outdoor workers, said David Whiteman, M.D., chair of the population and clinical sciences division at the Queensland (Australia) Institute for Medical Research.

And every physician knows that younger patients have more melanomas on the trunk than on the perpetually sun-exposed areas of the head and neck, he added. The theory that intermittent exposure is worse for melanoma than is constant exposure has been only partially satisfactory.

On the basis of evidence that younger people tend to get melanomas more frequently on unexposed sites, and older people get melanomas on exposed sites, Dr. Whiteman and his colleagues investigated a group of 306 melanoma patients. They compared those with head and neck melanomas with those with trunk melanomas.

The results showed that the individuals with head and neck melanomas were more likely to report high levels of sun exposure, often occupational. These patients also were more likely to have previous skin cancers or actinic keratoses; low nevus counts; and, in melanomas examined histologically by the investigators, a low probability of nevi remnants.

The individuals with trunk melanomas tended to show the opposite: They had mostly recreational sun exposure, high nevus counts, and a high likelihood of nevi remnants in their melanomas.

The data strongly suggest that there are two types of persons who get melanoma: those without a genetic susceptibility who need high sun exposure, and those with a genetic susceptibility, Dr. Whiteman said.

“This is just a hypothesis, and like all hypotheses, it needs to be tested,” he said.

BRAF mutations might be central to sun and melanoma risk, said Janet Maldonado, M.D., a second-year dermatology resident at the University of California, San Francisco. BRAF is a gene involved in the Ras pathway, which, among other things, mediates cellular proliferation.

In a study she conducted, Dr. Maldonado looked at BRAF mutations in 126 cases of melanoma, and found that the mutation was common when the melanoma was on skin without much sun damage (56%), but uncommon in melanomas from sun-damaged skin (11%).

Other investigations also have shown that true congenital nevi rarely have a BRAF mutation, whereas nevi that arise early in young children and could be confused with congenital nevi often do. This finding suggests that sunlight is necessary for creating BRAF mutations and that certain people are susceptible.

Other research has shown that melanomas that arise on skin without sun damage tend to have BRAF mutations, and melanomas on sun-damaged skin tend to have increased copies of the cyclin D gene, located on chromosome 11, Dr. Maldonado said.

This new information on sun risk, genetics, and melanoma may lead to new targeted treatments, and maybe a susceptibility test, commented Martin Weinstock, M.D., a professor of dermatology at Brown University, Providence, R.I.

Although the association between mutation and melanoma suggests certain individuals are at greater risk from sun exposure than others, it does not mean doctors should stop warning people about too much sun since sunlight is implicated in both types of melanoma identified.

The finding also reinforces the need for public education about the importance of skin self-examination.

SAN FRANCISCO – Screening for the four common problems of old age that constitute geriatric syndrome–cognitive loss, falls, incontinence, and depression–offers a holistic way to meet the needs of elderly patients, William J. Hall, M.D., said at the annual meeting of the American College of Physicians.

These problems affect the patient's quality of life and compliance with treatment for other medical conditions, noted Dr. Hall, director of the Center for Healthy Aging at the University of Rochester (N.Y.).

“The fact is, when elderly people are depressed, they don't take their ACE inhibitors,” he said. “It's as simple as that.”

A good way to address geriatric syndrome during office visits, Dr. Hall said, is to focus on one the following components at each visit:

▸ Cognitive loss. The Mini-Mental State Examination (MMSE) is a good screen for cognitive loss. But a new mental status exam that is even more practical appears to be highly sensitive.

The exam includes a category fluency test (in 1 minute, the patient names as many things as possible in a category such as animals or cities) and a phonemic fluency test (in 1 minute, the patient names as many words as possible that start with a given letter). When a cutoff of 15 words is used for the category fluency test, it appears to pick up about 90% of cases of dementia–even mild dementia (Neurology 2004;62:556–62).

This test's flexibility means that it can be made culturally or intellectually appropriate for the patient. It may also provide differential information, because patients with vascular dementia have more impairment in the phonemic test than the category test, Dr. Hall said.

Treatments for cognitive impairment seem to have “reached the end of the line” with the cholinesterase inhibitors and memantine, at least for now, he said. Other strategies, such as antioxidant or anti-inflammatory approaches, and estrogen, vitamins, and statins, have not panned out. Much of the initial enthusiasm about the cholinesterase inhibitors has turned to skepticism recently. Donepezil (Aricept) was shown in one influential study to double the time it took for patients to enter a nursing home, but that study has not yet been replicated. In general, there is a dearth of independent studies of cholinesterase inhibitors not sponsored by drug manufacturers.

“I would have a very hard time not trying Aricept in dementia,” he said. “There is so little hope otherwise.”

▸ Falls. European geriatricians studying the stance and movement of elderly people who have serious falls have identified a “psychomotor disadaptation syndrome.” The characteristic features include a stance with trunk bent forward, toes clenched, and knee flexion, or the presence of reactional hypertonia.

In the office setting, the “get-up-and-go” test offers a practical way to identify patients at risk of falling, Dr. Hall said. The patient is directed to rise from a chair, walk 10 feet, turn around, return to the chair, and sit down. The tester rates the patient's stability.

Muscle weakness appears to be the most important predictor of falls. “It trumps everything else by a substantial order of magnitude,” including factors such as dementia or age over 80 years, Dr. Hall said.

Even minimal strength training can reap benefits, and several exercises can be used that do not require expensive equipment or supervision.

▸ Urinary incontinence. After age 65 years, 15%–30% of women have urinary incontinence, and 50% of all elderly patients living in institutions have it.

Even though urinary incontinence can greatly limit their activities, fewer than half of patients seek medical help without prompting. When patients do seek help, the average time from the beginning of a serious problem to the appointment is 41 months. Thus, physicians must be proactive in looking for the problem, he said.

The cough stress test is “really good” at picking up urinary incontinence. Leakage with a cough may signal either stress incontinence or overactive bladder. With stress incontinence, the leakage occurs immediately. With overactive bladder, it takes a few seconds, Dr. Hall explained.

Kegel exercises are highly effective for stress incontinence. A recent major review of the evidence suggested that women who did pelvic floor muscle training were 23 times more likely to have cure or improvement in their incontinence, without the need for other treatments such as biofeedback or electrical stimulation.

▸ Depression. Few elderly people develop full-blown depression that would meet diagnostic criteria. Rather, the elderly are prone to subclinical depression that can almost be described as a “failure to thrive,” Dr. Hall said.

According to a Cochrane Collaboration review not yet published, effective screening for depression–even mild depression–can be done with two questions: “Have you been bothered in the past month by low interest in pleasure or doing things?” and “Have you been feeling down, depressed, or hopeless in the past month?”

SAN FRANCISCO – Screening for the four common problems of old age that constitute geriatric syndrome–cognitive loss, falls, incontinence, and depression–offers a holistic way to meet the needs of elderly patients, William J. Hall, M.D., said at the annual meeting of the American College of Physicians.

These problems affect the patient's quality of life and compliance with treatment for other medical conditions, noted Dr. Hall, director of the Center for Healthy Aging at the University of Rochester (N.Y.).

“The fact is, when elderly people are depressed, they don't take their ACE inhibitors,” he said. “It's as simple as that.”

A good way to address geriatric syndrome during office visits, Dr. Hall said, is to focus on one the following components at each visit:

▸ Cognitive loss. The Mini-Mental State Examination (MMSE) is a good screen for cognitive loss. But a new mental status exam that is even more practical appears to be highly sensitive.

The exam includes a category fluency test (in 1 minute, the patient names as many things as possible in a category such as animals or cities) and a phonemic fluency test (in 1 minute, the patient names as many words as possible that start with a given letter). When a cutoff of 15 words is used for the category fluency test, it appears to pick up about 90% of cases of dementia–even mild dementia (Neurology 2004;62:556–62).

This test's flexibility means that it can be made culturally or intellectually appropriate for the patient. It may also provide differential information, because patients with vascular dementia have more impairment in the phonemic test than the category test, Dr. Hall said.

Treatments for cognitive impairment seem to have “reached the end of the line” with the cholinesterase inhibitors and memantine, at least for now, he said. Other strategies, such as antioxidant or anti-inflammatory approaches, and estrogen, vitamins, and statins, have not panned out. Much of the initial enthusiasm about the cholinesterase inhibitors has turned to skepticism recently. Donepezil (Aricept) was shown in one influential study to double the time it took for patients to enter a nursing home, but that study has not yet been replicated. In general, there is a dearth of independent studies of cholinesterase inhibitors not sponsored by drug manufacturers.

“I would have a very hard time not trying Aricept in dementia,” he said. “There is so little hope otherwise.”

▸ Falls. European geriatricians studying the stance and movement of elderly people who have serious falls have identified a “psychomotor disadaptation syndrome.” The characteristic features include a stance with trunk bent forward, toes clenched, and knee flexion, or the presence of reactional hypertonia.

In the office setting, the “get-up-and-go” test offers a practical way to identify patients at risk of falling, Dr. Hall said. The patient is directed to rise from a chair, walk 10 feet, turn around, return to the chair, and sit down. The tester rates the patient's stability.

Muscle weakness appears to be the most important predictor of falls. “It trumps everything else by a substantial order of magnitude,” including factors such as dementia or age over 80 years, Dr. Hall said.

Even minimal strength training can reap benefits, and several exercises can be used that do not require expensive equipment or supervision.

▸ Urinary incontinence. After age 65 years, 15%–30% of women have urinary incontinence, and 50% of all elderly patients living in institutions have it.

Even though urinary incontinence can greatly limit their activities, fewer than half of patients seek medical help without prompting. When patients do seek help, the average time from the beginning of a serious problem to the appointment is 41 months. Thus, physicians must be proactive in looking for the problem, he said.

The cough stress test is “really good” at picking up urinary incontinence. Leakage with a cough may signal either stress incontinence or overactive bladder. With stress incontinence, the leakage occurs immediately. With overactive bladder, it takes a few seconds, Dr. Hall explained.

Kegel exercises are highly effective for stress incontinence. A recent major review of the evidence suggested that women who did pelvic floor muscle training were 23 times more likely to have cure or improvement in their incontinence, without the need for other treatments such as biofeedback or electrical stimulation.

▸ Depression. Few elderly people develop full-blown depression that would meet diagnostic criteria. Rather, the elderly are prone to subclinical depression that can almost be described as a “failure to thrive,” Dr. Hall said.

According to a Cochrane Collaboration review not yet published, effective screening for depression–even mild depression–can be done with two questions: “Have you been bothered in the past month by low interest in pleasure or doing things?” and “Have you been feeling down, depressed, or hopeless in the past month?”

SAN FRANCISCO – Screening for the four common problems of old age that constitute geriatric syndrome–cognitive loss, falls, incontinence, and depression–offers a holistic way to meet the needs of elderly patients, William J. Hall, M.D., said at the annual meeting of the American College of Physicians.

These problems affect the patient's quality of life and compliance with treatment for other medical conditions, noted Dr. Hall, director of the Center for Healthy Aging at the University of Rochester (N.Y.).

“The fact is, when elderly people are depressed, they don't take their ACE inhibitors,” he said. “It's as simple as that.”

A good way to address geriatric syndrome during office visits, Dr. Hall said, is to focus on one the following components at each visit:

▸ Cognitive loss. The Mini-Mental State Examination (MMSE) is a good screen for cognitive loss. But a new mental status exam that is even more practical appears to be highly sensitive.

The exam includes a category fluency test (in 1 minute, the patient names as many things as possible in a category such as animals or cities) and a phonemic fluency test (in 1 minute, the patient names as many words as possible that start with a given letter). When a cutoff of 15 words is used for the category fluency test, it appears to pick up about 90% of cases of dementia–even mild dementia (Neurology 2004;62:556–62).

This test's flexibility means that it can be made culturally or intellectually appropriate for the patient. It may also provide differential information, because patients with vascular dementia have more impairment in the phonemic test than the category test, Dr. Hall said.

Treatments for cognitive impairment seem to have “reached the end of the line” with the cholinesterase inhibitors and memantine, at least for now, he said. Other strategies, such as antioxidant or anti-inflammatory approaches, and estrogen, vitamins, and statins, have not panned out. Much of the initial enthusiasm about the cholinesterase inhibitors has turned to skepticism recently. Donepezil (Aricept) was shown in one influential study to double the time it took for patients to enter a nursing home, but that study has not yet been replicated. In general, there is a dearth of independent studies of cholinesterase inhibitors not sponsored by drug manufacturers.

“I would have a very hard time not trying Aricept in dementia,” he said. “There is so little hope otherwise.”

▸ Falls. European geriatricians studying the stance and movement of elderly people who have serious falls have identified a “psychomotor disadaptation syndrome.” The characteristic features include a stance with trunk bent forward, toes clenched, and knee flexion, or the presence of reactional hypertonia.

In the office setting, the “get-up-and-go” test offers a practical way to identify patients at risk of falling, Dr. Hall said. The patient is directed to rise from a chair, walk 10 feet, turn around, return to the chair, and sit down. The tester rates the patient's stability.

Muscle weakness appears to be the most important predictor of falls. “It trumps everything else by a substantial order of magnitude,” including factors such as dementia or age over 80 years, Dr. Hall said.

Even minimal strength training can reap benefits, and several exercises can be used that do not require expensive equipment or supervision.

▸ Urinary incontinence. After age 65 years, 15%–30% of women have urinary incontinence, and 50% of all elderly patients living in institutions have it.

Even though urinary incontinence can greatly limit their activities, fewer than half of patients seek medical help without prompting. When patients do seek help, the average time from the beginning of a serious problem to the appointment is 41 months. Thus, physicians must be proactive in looking for the problem, he said.

The cough stress test is “really good” at picking up urinary incontinence. Leakage with a cough may signal either stress incontinence or overactive bladder. With stress incontinence, the leakage occurs immediately. With overactive bladder, it takes a few seconds, Dr. Hall explained.

Kegel exercises are highly effective for stress incontinence. A recent major review of the evidence suggested that women who did pelvic floor muscle training were 23 times more likely to have cure or improvement in their incontinence, without the need for other treatments such as biofeedback or electrical stimulation.

▸ Depression. Few elderly people develop full-blown depression that would meet diagnostic criteria. Rather, the elderly are prone to subclinical depression that can almost be described as a “failure to thrive,” Dr. Hall said.

According to a Cochrane Collaboration review not yet published, effective screening for depression–even mild depression–can be done with two questions: “Have you been bothered in the past month by low interest in pleasure or doing things?” and “Have you been feeling down, depressed, or hopeless in the past month?”

LOS ANGELES – Adolescents who have experienced a significant, life-threatening illness can develop posttraumatic stress disorder, according to a study of 104 transplant patients.

The study found that 1 year after a transplant procedure, 16% of the patients met all criteria for a posttraumatic stress disorder (PTSD) diagnosis, and 14% met two of the three criteria, said Margaret L. Stuber, M.D., at the annual meeting of the Society for Adolescent Medicine.

Other studies have documented PTSD responses to childhood cancer, diabetes, and burns, said Dr. Stuber, professor of psychiatry at the University of California, Los Angeles.

The purpose of the current study was to try to tease out what specific factors lead to PTSD. Hence, the study included and compared kidney, heart, and liver transplant patients–that is, patients with conditions with very different courses and prognoses.

The study found the patients had similar risk factors for PTSD, regardless of the type of transplant the patients had had. The factors associated with an adolescent developing PTSD were medical complications and the experience of an acute illness (rather than a chronic one), meaning it is uncertainty, anxiety, and what Dr. Stuber called “disruption of expectations” that triggers the PTSD reaction.

Demographics did not seem to play a significant role in determining risk for PTSD, he noted.

Other studies have found that PTSD can have a negative impact on a patient's compliance with his or her medical regimen. One report describing six noncompliant patients with PTSD indicated that treating them for PTSD improved their adherence to medical therapy.

Overall, the work in this field also suggests general anxiety level is an important predictor of the risk that an adolescent will develop PTSD. Dr. Stuber thus recommended focusing on general anxiety level as a risk factor for PTSD. “[It] is essential we find out what the patient's subjective experience is,” he said. “I would screen for anxiety.”

Symptoms of PTSD include recurrent and distressing recollections of the traumatic event, avoidance, and increased arousal.

Avoidance may entail efforts to stay away from reminders of the event but can also manifest as an inability to recall important aspects of the event, diminished interest in activities, feelings of detachment from others, and a restricted range of affect. Features of increased arousal can be sleep problems, irritability, a lack of concentration, hypervigilance, and an exaggerated startle response.

LOS ANGELES – Adolescents who have experienced a significant, life-threatening illness can develop posttraumatic stress disorder, according to a study of 104 transplant patients.

The study found that 1 year after a transplant procedure, 16% of the patients met all criteria for a posttraumatic stress disorder (PTSD) diagnosis, and 14% met two of the three criteria, said Margaret L. Stuber, M.D., at the annual meeting of the Society for Adolescent Medicine.

Other studies have documented PTSD responses to childhood cancer, diabetes, and burns, said Dr. Stuber, professor of psychiatry at the University of California, Los Angeles.

The purpose of the current study was to try to tease out what specific factors lead to PTSD. Hence, the study included and compared kidney, heart, and liver transplant patients–that is, patients with conditions with very different courses and prognoses.

The study found the patients had similar risk factors for PTSD, regardless of the type of transplant the patients had had. The factors associated with an adolescent developing PTSD were medical complications and the experience of an acute illness (rather than a chronic one), meaning it is uncertainty, anxiety, and what Dr. Stuber called “disruption of expectations” that triggers the PTSD reaction.

Demographics did not seem to play a significant role in determining risk for PTSD, he noted.

Other studies have found that PTSD can have a negative impact on a patient's compliance with his or her medical regimen. One report describing six noncompliant patients with PTSD indicated that treating them for PTSD improved their adherence to medical therapy.

Overall, the work in this field also suggests general anxiety level is an important predictor of the risk that an adolescent will develop PTSD. Dr. Stuber thus recommended focusing on general anxiety level as a risk factor for PTSD. “[It] is essential we find out what the patient's subjective experience is,” he said. “I would screen for anxiety.”

Symptoms of PTSD include recurrent and distressing recollections of the traumatic event, avoidance, and increased arousal.

Avoidance may entail efforts to stay away from reminders of the event but can also manifest as an inability to recall important aspects of the event, diminished interest in activities, feelings of detachment from others, and a restricted range of affect. Features of increased arousal can be sleep problems, irritability, a lack of concentration, hypervigilance, and an exaggerated startle response.

LOS ANGELES – Adolescents who have experienced a significant, life-threatening illness can develop posttraumatic stress disorder, according to a study of 104 transplant patients.

The study found that 1 year after a transplant procedure, 16% of the patients met all criteria for a posttraumatic stress disorder (PTSD) diagnosis, and 14% met two of the three criteria, said Margaret L. Stuber, M.D., at the annual meeting of the Society for Adolescent Medicine.

Other studies have documented PTSD responses to childhood cancer, diabetes, and burns, said Dr. Stuber, professor of psychiatry at the University of California, Los Angeles.

The purpose of the current study was to try to tease out what specific factors lead to PTSD. Hence, the study included and compared kidney, heart, and liver transplant patients–that is, patients with conditions with very different courses and prognoses.

The study found the patients had similar risk factors for PTSD, regardless of the type of transplant the patients had had. The factors associated with an adolescent developing PTSD were medical complications and the experience of an acute illness (rather than a chronic one), meaning it is uncertainty, anxiety, and what Dr. Stuber called “disruption of expectations” that triggers the PTSD reaction.

Demographics did not seem to play a significant role in determining risk for PTSD, he noted.

Other studies have found that PTSD can have a negative impact on a patient's compliance with his or her medical regimen. One report describing six noncompliant patients with PTSD indicated that treating them for PTSD improved their adherence to medical therapy.

Overall, the work in this field also suggests general anxiety level is an important predictor of the risk that an adolescent will develop PTSD. Dr. Stuber thus recommended focusing on general anxiety level as a risk factor for PTSD. “[It] is essential we find out what the patient's subjective experience is,” he said. “I would screen for anxiety.”

Symptoms of PTSD include recurrent and distressing recollections of the traumatic event, avoidance, and increased arousal.

Avoidance may entail efforts to stay away from reminders of the event but can also manifest as an inability to recall important aspects of the event, diminished interest in activities, feelings of detachment from others, and a restricted range of affect. Features of increased arousal can be sleep problems, irritability, a lack of concentration, hypervigilance, and an exaggerated startle response.

Open surgical repair of pararenal abdominal aneurysms can be performed with a 30-day mortality rate of only 2%, according to a patient series from the Mayo Clinic.

Between 1993 and 2003, a total of 3,058 open surgical repairs of abdominal aortic aneurysms (AAAs) were performed. Of those, 246 were pararenal AAAs, reported Charles A. West, M.D., of the Mayo Clinic, Rochester, Minn.

The most common complication was postoperative renal insufficiency, which occurred in 21% of the patients and was associated with increased mesenteric ischemia time, left-renal vein division, and renal-artery bypass.

The mean renal ischemia time was 23 minutes, according to Dr. West, who first reported the information at this year's Midwestern Vascular Surgery Society annual meeting, in Chicago.

Pulmonary complications occurred in 16% of patients and were associated with advanced age, suprarenal aneurysm repair, and increased mesenteric ischemia time.

The investigators were unable to identify any specific factors associated with the five deaths that occurred within 30 days of the procedures.

The purpose of their review of the cases treated at the Mayo Clinic was to provide a baseline comparison that could be used now that so many AAA repairs are being done through an endovascular procedure. In the future, it will probably be possible to perform endovascular branch-graft repairs.

Open surgical repair of pararenal abdominal aneurysms can be performed with a 30-day mortality rate of only 2%, according to a patient series from the Mayo Clinic.

Between 1993 and 2003, a total of 3,058 open surgical repairs of abdominal aortic aneurysms (AAAs) were performed. Of those, 246 were pararenal AAAs, reported Charles A. West, M.D., of the Mayo Clinic, Rochester, Minn.

The most common complication was postoperative renal insufficiency, which occurred in 21% of the patients and was associated with increased mesenteric ischemia time, left-renal vein division, and renal-artery bypass.

The mean renal ischemia time was 23 minutes, according to Dr. West, who first reported the information at this year's Midwestern Vascular Surgery Society annual meeting, in Chicago.

Pulmonary complications occurred in 16% of patients and were associated with advanced age, suprarenal aneurysm repair, and increased mesenteric ischemia time.

The investigators were unable to identify any specific factors associated with the five deaths that occurred within 30 days of the procedures.

The purpose of their review of the cases treated at the Mayo Clinic was to provide a baseline comparison that could be used now that so many AAA repairs are being done through an endovascular procedure. In the future, it will probably be possible to perform endovascular branch-graft repairs.

Open surgical repair of pararenal abdominal aneurysms can be performed with a 30-day mortality rate of only 2%, according to a patient series from the Mayo Clinic.

Between 1993 and 2003, a total of 3,058 open surgical repairs of abdominal aortic aneurysms (AAAs) were performed. Of those, 246 were pararenal AAAs, reported Charles A. West, M.D., of the Mayo Clinic, Rochester, Minn.

The most common complication was postoperative renal insufficiency, which occurred in 21% of the patients and was associated with increased mesenteric ischemia time, left-renal vein division, and renal-artery bypass.

The mean renal ischemia time was 23 minutes, according to Dr. West, who first reported the information at this year's Midwestern Vascular Surgery Society annual meeting, in Chicago.

Pulmonary complications occurred in 16% of patients and were associated with advanced age, suprarenal aneurysm repair, and increased mesenteric ischemia time.

The investigators were unable to identify any specific factors associated with the five deaths that occurred within 30 days of the procedures.

The purpose of their review of the cases treated at the Mayo Clinic was to provide a baseline comparison that could be used now that so many AAA repairs are being done through an endovascular procedure. In the future, it will probably be possible to perform endovascular branch-graft repairs.

The absence of a recommendation to screen women for abdominal aortic aneurysm in the recent U.S. Preventive Services Task Force statement could mean that as many as one-quarter to one-third of individuals will be missed, according to a new study.

The study reviewed the results of a large public screening program conducted in 40 states between 2002 and 2004. Among the 7,841 persons screened, of whom 60% were women, 183 abdominal aortic aneurysms (AAAs) were found. An AAA was detected in 143 (5%) of the men and 40 (1%) of the women, said the study's principal investigator, William R. Flinn, M.D., head of vascular surgery at the University of Maryland Medical Center.

Therefore, 22% of the AAAs detected were in women.

Moreover, 40% of the women with an AAA were found to be hypertensive, a risk factor for rupture, according to Dr. Flinn, who first reported the information at this year's Midwestern Vascular Surgery Society annual meeting, in Chicago.

The U.S. Preventive Services Task Force statement, issued this year, recommends one-time ultrasound screening for men aged 65–75 who have ever smoked. The statement does not recommend routine screening for men who have never smoked, nor does it recommend it for women.

The rationale for not recommending screening for women is that there is fair evidence that the harms would outweigh the benefits, according to the statement.

The prevalence of large AAAs in women is low. The majority of deaths from ruptured AAAs in women occur in those older than 80 years. At the same time, the operative mortality for surgical repair is between 2% and 6%, and about a third of surgeries have complications.

One large screening study with control subjects found no difference in mortality with screening among women followed for 10 years, the statement notes.

That data could be outdated, however, according to Dr. Flinn. In his study, the ratio of men to women with an AAA was 4:1 for those over 80 years of age, but 3:1 for those in their 70s, and about 2:1 for those in their 60s.

This may reflect the fact that women have now taken on many of the risk factors of men and that the prevalence is changing, Dr. Flinn reported.

In an interview, Dr. Flinn said the evidence of a rising prevalence is rather preliminary and not based on large numbers of women. Therefore, it is less-than-definitive information.

What he is certain of, however, is that screening for women is justified. The previous studies might not have found any improvement in mortality with screening because not enough of the women who screened positive did anything about their aneurysms, he proposed. That is not atypical behavior, particularly for women.

He also noted that in his program women account for at least 60% of those who take the time to come in for screening, and that until investigators really started to look more closely, medicine underestimated the impact of coronary artery disease on women.

“I would bet all the money I have that any screening for aneurysm will have a positive impact on mortality,” he said.

The absence of a recommendation to screen women for abdominal aortic aneurysm in the recent U.S. Preventive Services Task Force statement could mean that as many as one-quarter to one-third of individuals will be missed, according to a new study.

The study reviewed the results of a large public screening program conducted in 40 states between 2002 and 2004. Among the 7,841 persons screened, of whom 60% were women, 183 abdominal aortic aneurysms (AAAs) were found. An AAA was detected in 143 (5%) of the men and 40 (1%) of the women, said the study's principal investigator, William R. Flinn, M.D., head of vascular surgery at the University of Maryland Medical Center.

Therefore, 22% of the AAAs detected were in women.

Moreover, 40% of the women with an AAA were found to be hypertensive, a risk factor for rupture, according to Dr. Flinn, who first reported the information at this year's Midwestern Vascular Surgery Society annual meeting, in Chicago.

The U.S. Preventive Services Task Force statement, issued this year, recommends one-time ultrasound screening for men aged 65–75 who have ever smoked. The statement does not recommend routine screening for men who have never smoked, nor does it recommend it for women.

The rationale for not recommending screening for women is that there is fair evidence that the harms would outweigh the benefits, according to the statement.

The prevalence of large AAAs in women is low. The majority of deaths from ruptured AAAs in women occur in those older than 80 years. At the same time, the operative mortality for surgical repair is between 2% and 6%, and about a third of surgeries have complications.

One large screening study with control subjects found no difference in mortality with screening among women followed for 10 years, the statement notes.

That data could be outdated, however, according to Dr. Flinn. In his study, the ratio of men to women with an AAA was 4:1 for those over 80 years of age, but 3:1 for those in their 70s, and about 2:1 for those in their 60s.

This may reflect the fact that women have now taken on many of the risk factors of men and that the prevalence is changing, Dr. Flinn reported.

In an interview, Dr. Flinn said the evidence of a rising prevalence is rather preliminary and not based on large numbers of women. Therefore, it is less-than-definitive information.

What he is certain of, however, is that screening for women is justified. The previous studies might not have found any improvement in mortality with screening because not enough of the women who screened positive did anything about their aneurysms, he proposed. That is not atypical behavior, particularly for women.

He also noted that in his program women account for at least 60% of those who take the time to come in for screening, and that until investigators really started to look more closely, medicine underestimated the impact of coronary artery disease on women.

“I would bet all the money I have that any screening for aneurysm will have a positive impact on mortality,” he said.

The absence of a recommendation to screen women for abdominal aortic aneurysm in the recent U.S. Preventive Services Task Force statement could mean that as many as one-quarter to one-third of individuals will be missed, according to a new study.

The study reviewed the results of a large public screening program conducted in 40 states between 2002 and 2004. Among the 7,841 persons screened, of whom 60% were women, 183 abdominal aortic aneurysms (AAAs) were found. An AAA was detected in 143 (5%) of the men and 40 (1%) of the women, said the study's principal investigator, William R. Flinn, M.D., head of vascular surgery at the University of Maryland Medical Center.

Therefore, 22% of the AAAs detected were in women.

Moreover, 40% of the women with an AAA were found to be hypertensive, a risk factor for rupture, according to Dr. Flinn, who first reported the information at this year's Midwestern Vascular Surgery Society annual meeting, in Chicago.

The U.S. Preventive Services Task Force statement, issued this year, recommends one-time ultrasound screening for men aged 65–75 who have ever smoked. The statement does not recommend routine screening for men who have never smoked, nor does it recommend it for women.

The rationale for not recommending screening for women is that there is fair evidence that the harms would outweigh the benefits, according to the statement.

The prevalence of large AAAs in women is low. The majority of deaths from ruptured AAAs in women occur in those older than 80 years. At the same time, the operative mortality for surgical repair is between 2% and 6%, and about a third of surgeries have complications.

One large screening study with control subjects found no difference in mortality with screening among women followed for 10 years, the statement notes.

That data could be outdated, however, according to Dr. Flinn. In his study, the ratio of men to women with an AAA was 4:1 for those over 80 years of age, but 3:1 for those in their 70s, and about 2:1 for those in their 60s.

This may reflect the fact that women have now taken on many of the risk factors of men and that the prevalence is changing, Dr. Flinn reported.

In an interview, Dr. Flinn said the evidence of a rising prevalence is rather preliminary and not based on large numbers of women. Therefore, it is less-than-definitive information.

What he is certain of, however, is that screening for women is justified. The previous studies might not have found any improvement in mortality with screening because not enough of the women who screened positive did anything about their aneurysms, he proposed. That is not atypical behavior, particularly for women.

He also noted that in his program women account for at least 60% of those who take the time to come in for screening, and that until investigators really started to look more closely, medicine underestimated the impact of coronary artery disease on women.

“I would bet all the money I have that any screening for aneurysm will have a positive impact on mortality,” he said.

VANCOUVER, B.C. — Is it time to let the sun shine in? That was a major topic of discussion by the experts at the recent Sixth World Congress on Melanoma.

The specific subjects ranged from evidence that vitamin D might have a role in protecting against cancer, to evidence that genetic susceptibility might play a previously underappreciated role in melanoma risk, to the fact that messages about sunburn avoidance and use of sunscreen are having little impact on behavior and so could be the wrong strategy for reducing mortality.

New evidence strongly suggests that people who have had more sun exposure have better survival from melanoma than those who have had less, said Marianne Berwick, Ph.D., who is an epidemiologist at the University of New Mexico Cancer Research and Treatment Center in Albuquerque.

She and her colleagues recently found that patients who reported ever having been sunburned had half the mortality of those who had never been sunburned. The study looked at 528 individuals with melanomas who were followed until death or to 5 years. They also found similar increases in survival likelihood related to overall sun exposure and to the presence of marked solar elastosis (J. Natl. Cancer Inst. 2005;97:195–9).

The same observations have been noted in previous research, conducted by others as well as by her, Dr. Berwick said.

More recently, Dr. Berwick and her colleagues examined data they collected from the multinational Genes, Environment and Melanoma Study. They compared melanoma cases from Australia, where melanoma incidence is high, with those from Canada, where sun exposure is low.

Most of the cases (60%) were thin melanomas (0.76 mm or less Breslow thickness).

Although there was no difference in median thickness between cases from the two countries, there was a difference in the presence of solar elastosis and the percentage of tumors that showed evidence of being in a vertical growth phase, the investigation found.

Solar elastosis was present in 60% of the Canadian patients, and 64% of the melanomas were in a vertical growth phase when they were removed. Solar elastosis was present in 75% of the Australians, but only 45% of the melanomas were in a vertical growth phase, Dr. Berwick said.

Though this evidence may help explain why survival might be better in areas where melanoma incidence is highest, and why incidence is rising but not mortality, the question of mechanism remains, Dr. Berwick said.

The popular hypothesis is that this might be due to the effects of vitamin D, she noted. But the epidemiologic evidence that vitamin D is chemoprotective in people who might otherwise be at risk of melanoma is slim. No one knows what the optimal level of vitamin D is, and there are different ways to measure levels. Moreover, studies that have tried to correlate vitamin D level with cancer cases have had conflicting results.

Alternative possible explanations for reduced mortality include the idea that the more aggressive types of melanoma are not the types associated with UV light damage, or that the collagen deposits and other skin changes that come with solar elastosis form a barrier to invasiveness and/or metastasis.

So is there a safe level of sun exposure, one that perhaps should be recommended to the public?

Some experts are beginning to think there is, Bruce Armstrong, M.D., head of the school of public health at the University of Sydney, pointed out at the meeting.

Reviewing the history of the evidence, Dr. Armstrong said it is fairly clear that sun exposure attenuates cancer risks, and that melanoma is not the sole malignancy to have a relationship to lack of sun.

The observation that sunlight may protect against cancer was first made in 1941 by investigators exploring the idea that people who got skin cancer did not get other cancers; since then, low sun exposure has been correlated with a high risk of prostate, breast, ovarian, and colon cancers and, most recently, non-Hodgkin's lymphoma.

As with melanoma, data have suggested that sun exposure might attenuate the mortality of some of these cancers, Dr. Armstrong said.

In 1983 in Australia, his group documented an association between increased melanoma survival and sun exposure. More recently, another group has shown, using a large database, that in Europe melanoma diagnosis and mortality has a seasonal variation that may relate to sun exposure (Eur. J. Cancer 2005;41:126–32).

Though it is not proven that vitamin D is the mechanism of the cancer effects seen, there is some evidence that even in sunny climates, vitamin D deficiency may be common, Dr. Armstrong said.

One recent survey of Australian populations found that even at the end of summer, 30% of Australian boys were marginally vitamin D deficient, as was a much higher percentage of the elderly, particularly those with dark skin.

It also must be noted that sun exposure has a number of other health benefits, including promoting bone health and even just creating a sense of well-being, Dr. Armstrong added.

It has been suggested that receiving the equivalent of one minimal erythema dose to the hands and face per week is sufficient for vitamin D synthesis, Dr. Armstrong said. That amount of exposure, Dr. Berwick said, would translate into about 5–10 minutes per day spent in sunshine, two to three times per week.

On the other hand, no melanoma experts appear to be recommending that campaigns to warn about the dangers of too much sun exposure should be abandoned.

Addressing that question directly in two separate lectures, Martin A. Weinstock, M.D., noted that sun education campaigns appear to have made little difference in behavior.

He said that regular self-performed skin examination appears to be the more important melanoma strategy because studies show that it can be encouraged and that it significantly affects mortality.

But both approaches are still needed, said Dr. Weinstock, a professor of dermatology at Brown University, Providence, R.I. Evidence still implicates sun exposure in the genesis of melanoma, and primary prevention will always be important, he said.

“Obviously, there are new hypotheses out there, but a lot remains to be elucidated,” he said. “People still need to take measures for both prevention and early detection.”

VANCOUVER, B.C. — Is it time to let the sun shine in? That was a major topic of discussion by the experts at the recent Sixth World Congress on Melanoma.

The specific subjects ranged from evidence that vitamin D might have a role in protecting against cancer, to evidence that genetic susceptibility might play a previously underappreciated role in melanoma risk, to the fact that messages about sunburn avoidance and use of sunscreen are having little impact on behavior and so could be the wrong strategy for reducing mortality.

New evidence strongly suggests that people who have had more sun exposure have better survival from melanoma than those who have had less, said Marianne Berwick, Ph.D., who is an epidemiologist at the University of New Mexico Cancer Research and Treatment Center in Albuquerque.

She and her colleagues recently found that patients who reported ever having been sunburned had half the mortality of those who had never been sunburned. The study looked at 528 individuals with melanomas who were followed until death or to 5 years. They also found similar increases in survival likelihood related to overall sun exposure and to the presence of marked solar elastosis (J. Natl. Cancer Inst. 2005;97:195–9).

The same observations have been noted in previous research, conducted by others as well as by her, Dr. Berwick said.

More recently, Dr. Berwick and her colleagues examined data they collected from the multinational Genes, Environment and Melanoma Study. They compared melanoma cases from Australia, where melanoma incidence is high, with those from Canada, where sun exposure is low.

Most of the cases (60%) were thin melanomas (0.76 mm or less Breslow thickness).

Although there was no difference in median thickness between cases from the two countries, there was a difference in the presence of solar elastosis and the percentage of tumors that showed evidence of being in a vertical growth phase, the investigation found.

Solar elastosis was present in 60% of the Canadian patients, and 64% of the melanomas were in a vertical growth phase when they were removed. Solar elastosis was present in 75% of the Australians, but only 45% of the melanomas were in a vertical growth phase, Dr. Berwick said.

Though this evidence may help explain why survival might be better in areas where melanoma incidence is highest, and why incidence is rising but not mortality, the question of mechanism remains, Dr. Berwick said.

The popular hypothesis is that this might be due to the effects of vitamin D, she noted. But the epidemiologic evidence that vitamin D is chemoprotective in people who might otherwise be at risk of melanoma is slim. No one knows what the optimal level of vitamin D is, and there are different ways to measure levels. Moreover, studies that have tried to correlate vitamin D level with cancer cases have had conflicting results.

Alternative possible explanations for reduced mortality include the idea that the more aggressive types of melanoma are not the types associated with UV light damage, or that the collagen deposits and other skin changes that come with solar elastosis form a barrier to invasiveness and/or metastasis.

So is there a safe level of sun exposure, one that perhaps should be recommended to the public?

Some experts are beginning to think there is, Bruce Armstrong, M.D., head of the school of public health at the University of Sydney, pointed out at the meeting.

Reviewing the history of the evidence, Dr. Armstrong said it is fairly clear that sun exposure attenuates cancer risks, and that melanoma is not the sole malignancy to have a relationship to lack of sun.

The observation that sunlight may protect against cancer was first made in 1941 by investigators exploring the idea that people who got skin cancer did not get other cancers; since then, low sun exposure has been correlated with a high risk of prostate, breast, ovarian, and colon cancers and, most recently, non-Hodgkin's lymphoma.

As with melanoma, data have suggested that sun exposure might attenuate the mortality of some of these cancers, Dr. Armstrong said.

In 1983 in Australia, his group documented an association between increased melanoma survival and sun exposure. More recently, another group has shown, using a large database, that in Europe melanoma diagnosis and mortality has a seasonal variation that may relate to sun exposure (Eur. J. Cancer 2005;41:126–32).

Though it is not proven that vitamin D is the mechanism of the cancer effects seen, there is some evidence that even in sunny climates, vitamin D deficiency may be common, Dr. Armstrong said.

One recent survey of Australian populations found that even at the end of summer, 30% of Australian boys were marginally vitamin D deficient, as was a much higher percentage of the elderly, particularly those with dark skin.

It also must be noted that sun exposure has a number of other health benefits, including promoting bone health and even just creating a sense of well-being, Dr. Armstrong added.

It has been suggested that receiving the equivalent of one minimal erythema dose to the hands and face per week is sufficient for vitamin D synthesis, Dr. Armstrong said. That amount of exposure, Dr. Berwick said, would translate into about 5–10 minutes per day spent in sunshine, two to three times per week.

On the other hand, no melanoma experts appear to be recommending that campaigns to warn about the dangers of too much sun exposure should be abandoned.

Addressing that question directly in two separate lectures, Martin A. Weinstock, M.D., noted that sun education campaigns appear to have made little difference in behavior.

He said that regular self-performed skin examination appears to be the more important melanoma strategy because studies show that it can be encouraged and that it significantly affects mortality.

But both approaches are still needed, said Dr. Weinstock, a professor of dermatology at Brown University, Providence, R.I. Evidence still implicates sun exposure in the genesis of melanoma, and primary prevention will always be important, he said.

“Obviously, there are new hypotheses out there, but a lot remains to be elucidated,” he said. “People still need to take measures for both prevention and early detection.”

VANCOUVER, B.C. — Is it time to let the sun shine in? That was a major topic of discussion by the experts at the recent Sixth World Congress on Melanoma.

The specific subjects ranged from evidence that vitamin D might have a role in protecting against cancer, to evidence that genetic susceptibility might play a previously underappreciated role in melanoma risk, to the fact that messages about sunburn avoidance and use of sunscreen are having little impact on behavior and so could be the wrong strategy for reducing mortality.

New evidence strongly suggests that people who have had more sun exposure have better survival from melanoma than those who have had less, said Marianne Berwick, Ph.D., who is an epidemiologist at the University of New Mexico Cancer Research and Treatment Center in Albuquerque.

She and her colleagues recently found that patients who reported ever having been sunburned had half the mortality of those who had never been sunburned. The study looked at 528 individuals with melanomas who were followed until death or to 5 years. They also found similar increases in survival likelihood related to overall sun exposure and to the presence of marked solar elastosis (J. Natl. Cancer Inst. 2005;97:195–9).

The same observations have been noted in previous research, conducted by others as well as by her, Dr. Berwick said.

More recently, Dr. Berwick and her colleagues examined data they collected from the multinational Genes, Environment and Melanoma Study. They compared melanoma cases from Australia, where melanoma incidence is high, with those from Canada, where sun exposure is low.

Most of the cases (60%) were thin melanomas (0.76 mm or less Breslow thickness).

Although there was no difference in median thickness between cases from the two countries, there was a difference in the presence of solar elastosis and the percentage of tumors that showed evidence of being in a vertical growth phase, the investigation found.

Solar elastosis was present in 60% of the Canadian patients, and 64% of the melanomas were in a vertical growth phase when they were removed. Solar elastosis was present in 75% of the Australians, but only 45% of the melanomas were in a vertical growth phase, Dr. Berwick said.

Though this evidence may help explain why survival might be better in areas where melanoma incidence is highest, and why incidence is rising but not mortality, the question of mechanism remains, Dr. Berwick said.

The popular hypothesis is that this might be due to the effects of vitamin D, she noted. But the epidemiologic evidence that vitamin D is chemoprotective in people who might otherwise be at risk of melanoma is slim. No one knows what the optimal level of vitamin D is, and there are different ways to measure levels. Moreover, studies that have tried to correlate vitamin D level with cancer cases have had conflicting results.

Alternative possible explanations for reduced mortality include the idea that the more aggressive types of melanoma are not the types associated with UV light damage, or that the collagen deposits and other skin changes that come with solar elastosis form a barrier to invasiveness and/or metastasis.

So is there a safe level of sun exposure, one that perhaps should be recommended to the public?

Some experts are beginning to think there is, Bruce Armstrong, M.D., head of the school of public health at the University of Sydney, pointed out at the meeting.

Reviewing the history of the evidence, Dr. Armstrong said it is fairly clear that sun exposure attenuates cancer risks, and that melanoma is not the sole malignancy to have a relationship to lack of sun.

The observation that sunlight may protect against cancer was first made in 1941 by investigators exploring the idea that people who got skin cancer did not get other cancers; since then, low sun exposure has been correlated with a high risk of prostate, breast, ovarian, and colon cancers and, most recently, non-Hodgkin's lymphoma.

As with melanoma, data have suggested that sun exposure might attenuate the mortality of some of these cancers, Dr. Armstrong said.

In 1983 in Australia, his group documented an association between increased melanoma survival and sun exposure. More recently, another group has shown, using a large database, that in Europe melanoma diagnosis and mortality has a seasonal variation that may relate to sun exposure (Eur. J. Cancer 2005;41:126–32).

Though it is not proven that vitamin D is the mechanism of the cancer effects seen, there is some evidence that even in sunny climates, vitamin D deficiency may be common, Dr. Armstrong said.

One recent survey of Australian populations found that even at the end of summer, 30% of Australian boys were marginally vitamin D deficient, as was a much higher percentage of the elderly, particularly those with dark skin.

It also must be noted that sun exposure has a number of other health benefits, including promoting bone health and even just creating a sense of well-being, Dr. Armstrong added.

It has been suggested that receiving the equivalent of one minimal erythema dose to the hands and face per week is sufficient for vitamin D synthesis, Dr. Armstrong said. That amount of exposure, Dr. Berwick said, would translate into about 5–10 minutes per day spent in sunshine, two to three times per week.

On the other hand, no melanoma experts appear to be recommending that campaigns to warn about the dangers of too much sun exposure should be abandoned.

Addressing that question directly in two separate lectures, Martin A. Weinstock, M.D., noted that sun education campaigns appear to have made little difference in behavior.

He said that regular self-performed skin examination appears to be the more important melanoma strategy because studies show that it can be encouraged and that it significantly affects mortality.

But both approaches are still needed, said Dr. Weinstock, a professor of dermatology at Brown University, Providence, R.I. Evidence still implicates sun exposure in the genesis of melanoma, and primary prevention will always be important, he said.

“Obviously, there are new hypotheses out there, but a lot remains to be elucidated,” he said. “People still need to take measures for both prevention and early detection.”