Kate Johnson

MIAMI BEACH — Although prophylactic cholecystectomy is recommended by some surgeons for patients undergoing bariatric surgery, pharmacologic prophylaxis for cholelithiasis is adequate, according to Daniele Matera, M.D.

“Our study confirms the doubt of the strict necessity of prophylactic cholecystectomy in obesity surgery,” he said at a congress on laparoscopy and minimally invasive surgery.

Morbid obesity is one of the major risk factors for gallbladder disease, and the risk is even greater following rapid weight loss—the goal of biliopancreatic diversion, explained Dr. Matera of the department of surgery at Catholic University of the Sacred Heart, Rome.

The literature contains evidence both for and against prophylactic cholecystectomy prior to biliopancreatic diversion, but there are operative risks that can be avoided with pharmacologic prophylaxis, Dr. Matera said at the congress, sponsored by the Society of Laparoendoscopic Surgeons.

The goal of the study was to evaluate the incidence of cholelithiasis and the role of medical prophylaxis in obese patients undergoing laparoscopic biliopancreatic diversion.

A total of 68 obese patients with negative preoperative hepatic ultrasonography were randomized to receive either laparoscopic biliopancreatic diversion with prophylactic cholecystectomy, or laparoscopic biliopancreatic diversion with postoperative medical prophylaxis consisting of ursodeoxycholic acid (600 mg) orally twice a day for 2 years.

Patients in the medical prophylaxis group were followed for 2 years with periodic gallbladder ultrasound examinations. Symptomatic gallstones requiring cholecystectomy developed in only one (3%) patient during this period.

At 6 months, gallstones were present in three patients (8%), and gallbladder sludge was detected in two patients (6%).

At 12 months, gallstones were present in four patients (11%), and gallbladder sludge was detected in one patient (3%).

And at 24 months, gallstones were present in six patients (17%), and gallbladder sludge was detected in two patients (6%).

The study suggests that the operative risks of prophylactic cholecystectomy can be avoided with the use of medical prophylaxis, Dr. Matera said.

MIAMI BEACH — Although prophylactic cholecystectomy is recommended by some surgeons for patients undergoing bariatric surgery, pharmacologic prophylaxis for cholelithiasis is adequate, according to Daniele Matera, M.D.

“Our study confirms the doubt of the strict necessity of prophylactic cholecystectomy in obesity surgery,” he said at a congress on laparoscopy and minimally invasive surgery.

Morbid obesity is one of the major risk factors for gallbladder disease, and the risk is even greater following rapid weight loss—the goal of biliopancreatic diversion, explained Dr. Matera of the department of surgery at Catholic University of the Sacred Heart, Rome.

The literature contains evidence both for and against prophylactic cholecystectomy prior to biliopancreatic diversion, but there are operative risks that can be avoided with pharmacologic prophylaxis, Dr. Matera said at the congress, sponsored by the Society of Laparoendoscopic Surgeons.

The goal of the study was to evaluate the incidence of cholelithiasis and the role of medical prophylaxis in obese patients undergoing laparoscopic biliopancreatic diversion.

A total of 68 obese patients with negative preoperative hepatic ultrasonography were randomized to receive either laparoscopic biliopancreatic diversion with prophylactic cholecystectomy, or laparoscopic biliopancreatic diversion with postoperative medical prophylaxis consisting of ursodeoxycholic acid (600 mg) orally twice a day for 2 years.

Patients in the medical prophylaxis group were followed for 2 years with periodic gallbladder ultrasound examinations. Symptomatic gallstones requiring cholecystectomy developed in only one (3%) patient during this period.

At 6 months, gallstones were present in three patients (8%), and gallbladder sludge was detected in two patients (6%).

At 12 months, gallstones were present in four patients (11%), and gallbladder sludge was detected in one patient (3%).

And at 24 months, gallstones were present in six patients (17%), and gallbladder sludge was detected in two patients (6%).

The study suggests that the operative risks of prophylactic cholecystectomy can be avoided with the use of medical prophylaxis, Dr. Matera said.

MIAMI BEACH — Although prophylactic cholecystectomy is recommended by some surgeons for patients undergoing bariatric surgery, pharmacologic prophylaxis for cholelithiasis is adequate, according to Daniele Matera, M.D.

“Our study confirms the doubt of the strict necessity of prophylactic cholecystectomy in obesity surgery,” he said at a congress on laparoscopy and minimally invasive surgery.

Morbid obesity is one of the major risk factors for gallbladder disease, and the risk is even greater following rapid weight loss—the goal of biliopancreatic diversion, explained Dr. Matera of the department of surgery at Catholic University of the Sacred Heart, Rome.

The literature contains evidence both for and against prophylactic cholecystectomy prior to biliopancreatic diversion, but there are operative risks that can be avoided with pharmacologic prophylaxis, Dr. Matera said at the congress, sponsored by the Society of Laparoendoscopic Surgeons.

The goal of the study was to evaluate the incidence of cholelithiasis and the role of medical prophylaxis in obese patients undergoing laparoscopic biliopancreatic diversion.

A total of 68 obese patients with negative preoperative hepatic ultrasonography were randomized to receive either laparoscopic biliopancreatic diversion with prophylactic cholecystectomy, or laparoscopic biliopancreatic diversion with postoperative medical prophylaxis consisting of ursodeoxycholic acid (600 mg) orally twice a day for 2 years.

Patients in the medical prophylaxis group were followed for 2 years with periodic gallbladder ultrasound examinations. Symptomatic gallstones requiring cholecystectomy developed in only one (3%) patient during this period.

At 6 months, gallstones were present in three patients (8%), and gallbladder sludge was detected in two patients (6%).

At 12 months, gallstones were present in four patients (11%), and gallbladder sludge was detected in one patient (3%).

And at 24 months, gallstones were present in six patients (17%), and gallbladder sludge was detected in two patients (6%).

The study suggests that the operative risks of prophylactic cholecystectomy can be avoided with the use of medical prophylaxis, Dr. Matera said.

Prolonged use of bisphosphonate therapy can lead to osteonecrosis of the jaw—a previously unrecognized and potentially serious complication that can often be avoided, according to Salvatore Ruggiero, M.D., D.M.D.

Patients on intravenous therapy face the highest risk whether they are taking the medication for cancer or for osteoporosis; the risk is lower, although not absent, in those taking oral bisphosphonates, said Dr. Ruggiero, who is chief of oral and maxillofacial surgery at Long Island Jewish Medical Center in New Hyde Park, NY.

“The push is to alert physicians that this is a potential problem, so that before they start a patient on bisphosphonates, they send them to a dentist to extract any teeth that are nonrestorable,” he told this newspaper. “Prevention and early detection are important for preserving the jawbone.”

In his experience, most cases have been associated with infections after dental surgeries such as tooth extractions. However, necrosis has also occurred spontaneously in a significant number of patients, he said.

For this reason, he recommends that all patients on long-term bisphosphonate therapy have two or three preventive dental visits per year, and that physicians be alert for early signs of necrosis.

Patients should be alert to “things like tooth pain, swelling, numbness of the lip and chin, or pain within the jaw. This is not a very difficult diagnosis to make. You basically have to look in the mouth, and if you see exposed bone it is very clear,” he said.

Dr. Ruggiero's published research (J. Oral Maxillofac. Surg. 2004;62:527-34) has prompted warnings from the Food and Drug Administration, as well as from Novartis, which manufactures the intravenous bisphosphonates pamidronate disodium (Aredia) and zoledronic acid (Zometa).

Novartis has also changed its package inserts to reflect this information. Labeling for oral bisphosphonates has not changed.

His study identified 63 patients with osteonecrosis of the jaw (ONJ), all of whom had received bisphosphonate therapy for extended periods (6-48 months). Overall, 56 of the patients had used intravenous bisphosphonates for cancer chemotherapy, and the remaining 7 for osteoporosis.

Until these cases were identified, ONJ had been a rare clinical scenario, Dr. Ruggiero noted.

The typical presenting symptoms were pain and nonhealing exposed bone at the site of a previous tooth extraction. However, nine patients (14%) had no history of a recent dentoalveolar procedure and presented with spontaneous exposure and necrosis of the alveolar bone. Biopsies of the lesions showed no evidence of metastatic disease.

The lesions had been refractory to conservative debridement procedures and antibiotic therapy. Most patients required surgical procedures to remove all of the involved bone, which included 45 sequestrectomies, 4 marginal mandibular resections, 6 segmental mandibular resections, 5 partial maxillectomies, and 1 complete maxillectomy.

Despite these surgical procedures, five patients had persistent bone necrosis and developed new regions of exposed bone even after they stopped bisphosphonate therapy.

Dr. Ruggiero speculates that the impaired bone wound healing may result from a compromised vascular supply caused by the antiangiogenic effects of bisphosphonates. The lack of bone problems elsewhere in the body may be due to the unique environment created by oral microflora.

Spontaneous osteonecrosis can occur in patients on bisphosphonates long term.

More typically, osteonecrosis of the jaw occurs after tooth extraction or surgery. Photos courtesy Salvatore Ruggiero, M.D., D.M.D./Long Island Jewish Medical Center

Prolonged use of bisphosphonate therapy can lead to osteonecrosis of the jaw—a previously unrecognized and potentially serious complication that can often be avoided, according to Salvatore Ruggiero, M.D., D.M.D.

Patients on intravenous therapy face the highest risk whether they are taking the medication for cancer or for osteoporosis; the risk is lower, although not absent, in those taking oral bisphosphonates, said Dr. Ruggiero, who is chief of oral and maxillofacial surgery at Long Island Jewish Medical Center in New Hyde Park, NY.

“The push is to alert physicians that this is a potential problem, so that before they start a patient on bisphosphonates, they send them to a dentist to extract any teeth that are nonrestorable,” he told this newspaper. “Prevention and early detection are important for preserving the jawbone.”

In his experience, most cases have been associated with infections after dental surgeries such as tooth extractions. However, necrosis has also occurred spontaneously in a significant number of patients, he said.

For this reason, he recommends that all patients on long-term bisphosphonate therapy have two or three preventive dental visits per year, and that physicians be alert for early signs of necrosis.

Patients should be alert to “things like tooth pain, swelling, numbness of the lip and chin, or pain within the jaw. This is not a very difficult diagnosis to make. You basically have to look in the mouth, and if you see exposed bone it is very clear,” he said.

Dr. Ruggiero's published research (J. Oral Maxillofac. Surg. 2004;62:527-34) has prompted warnings from the Food and Drug Administration, as well as from Novartis, which manufactures the intravenous bisphosphonates pamidronate disodium (Aredia) and zoledronic acid (Zometa).

Novartis has also changed its package inserts to reflect this information. Labeling for oral bisphosphonates has not changed.

His study identified 63 patients with osteonecrosis of the jaw (ONJ), all of whom had received bisphosphonate therapy for extended periods (6-48 months). Overall, 56 of the patients had used intravenous bisphosphonates for cancer chemotherapy, and the remaining 7 for osteoporosis.

Until these cases were identified, ONJ had been a rare clinical scenario, Dr. Ruggiero noted.

The typical presenting symptoms were pain and nonhealing exposed bone at the site of a previous tooth extraction. However, nine patients (14%) had no history of a recent dentoalveolar procedure and presented with spontaneous exposure and necrosis of the alveolar bone. Biopsies of the lesions showed no evidence of metastatic disease.

The lesions had been refractory to conservative debridement procedures and antibiotic therapy. Most patients required surgical procedures to remove all of the involved bone, which included 45 sequestrectomies, 4 marginal mandibular resections, 6 segmental mandibular resections, 5 partial maxillectomies, and 1 complete maxillectomy.

Despite these surgical procedures, five patients had persistent bone necrosis and developed new regions of exposed bone even after they stopped bisphosphonate therapy.

Dr. Ruggiero speculates that the impaired bone wound healing may result from a compromised vascular supply caused by the antiangiogenic effects of bisphosphonates. The lack of bone problems elsewhere in the body may be due to the unique environment created by oral microflora.

Spontaneous osteonecrosis can occur in patients on bisphosphonates long term.

More typically, osteonecrosis of the jaw occurs after tooth extraction or surgery. Photos courtesy Salvatore Ruggiero, M.D., D.M.D./Long Island Jewish Medical Center

Prolonged use of bisphosphonate therapy can lead to osteonecrosis of the jaw—a previously unrecognized and potentially serious complication that can often be avoided, according to Salvatore Ruggiero, M.D., D.M.D.

Patients on intravenous therapy face the highest risk whether they are taking the medication for cancer or for osteoporosis; the risk is lower, although not absent, in those taking oral bisphosphonates, said Dr. Ruggiero, who is chief of oral and maxillofacial surgery at Long Island Jewish Medical Center in New Hyde Park, NY.

“The push is to alert physicians that this is a potential problem, so that before they start a patient on bisphosphonates, they send them to a dentist to extract any teeth that are nonrestorable,” he told this newspaper. “Prevention and early detection are important for preserving the jawbone.”

In his experience, most cases have been associated with infections after dental surgeries such as tooth extractions. However, necrosis has also occurred spontaneously in a significant number of patients, he said.

For this reason, he recommends that all patients on long-term bisphosphonate therapy have two or three preventive dental visits per year, and that physicians be alert for early signs of necrosis.

Patients should be alert to “things like tooth pain, swelling, numbness of the lip and chin, or pain within the jaw. This is not a very difficult diagnosis to make. You basically have to look in the mouth, and if you see exposed bone it is very clear,” he said.

Dr. Ruggiero's published research (J. Oral Maxillofac. Surg. 2004;62:527-34) has prompted warnings from the Food and Drug Administration, as well as from Novartis, which manufactures the intravenous bisphosphonates pamidronate disodium (Aredia) and zoledronic acid (Zometa).

Novartis has also changed its package inserts to reflect this information. Labeling for oral bisphosphonates has not changed.

His study identified 63 patients with osteonecrosis of the jaw (ONJ), all of whom had received bisphosphonate therapy for extended periods (6-48 months). Overall, 56 of the patients had used intravenous bisphosphonates for cancer chemotherapy, and the remaining 7 for osteoporosis.

Until these cases were identified, ONJ had been a rare clinical scenario, Dr. Ruggiero noted.

The typical presenting symptoms were pain and nonhealing exposed bone at the site of a previous tooth extraction. However, nine patients (14%) had no history of a recent dentoalveolar procedure and presented with spontaneous exposure and necrosis of the alveolar bone. Biopsies of the lesions showed no evidence of metastatic disease.

The lesions had been refractory to conservative debridement procedures and antibiotic therapy. Most patients required surgical procedures to remove all of the involved bone, which included 45 sequestrectomies, 4 marginal mandibular resections, 6 segmental mandibular resections, 5 partial maxillectomies, and 1 complete maxillectomy.

Despite these surgical procedures, five patients had persistent bone necrosis and developed new regions of exposed bone even after they stopped bisphosphonate therapy.

Dr. Ruggiero speculates that the impaired bone wound healing may result from a compromised vascular supply caused by the antiangiogenic effects of bisphosphonates. The lack of bone problems elsewhere in the body may be due to the unique environment created by oral microflora.

Spontaneous osteonecrosis can occur in patients on bisphosphonates long term.

More typically, osteonecrosis of the jaw occurs after tooth extraction or surgery. Photos courtesy Salvatore Ruggiero, M.D., D.M.D./Long Island Jewish Medical Center

SNOWMASS, COLO. — Physicians diagnosing epidermolysis bullosa in a newborn have few initial clues about which type of the disease their patient has, or the course it will take, until they do electron microscopy and immunofluorescence testing, according to Anne Lucky, M.D.

“At the very beginning the different forms of epidermolysis bullosa (EB) all look virtually the same. We tell parents we don't know if it's going to be a severe or mild form until the testing is done.” In other words, the child may have a normal lifespan or may die in the first year of life, she told this newspaper.

Speaking at a clinical dermatology seminar sponsored by Medicis, Dr. Lucky, professor of dermatology and pediatrics at the University of Cincinnati and the Cincinnati Children's Hospital Medical Center said that electron microscopy, immunofluorescence mapping of the basement membrane, and genetic investigation for specific proteins, can help distinguish between epidermolysis bullosasimplex (EBS), junctional epidermolysis bullosa (JEB), and dystrophic epidermolysis bullosa (DEB).

EBS is caused by keratin and plectin mutations, while JEB is caused by mutations of basement membrane proteins, and DEB is caused by mutations of type VII collagen, she explained.

Although all forms of EB cause severe blistering and skin erosions, blister formation in EBS is within the epidermis, while it is seen within the basement membrane zone in JEB, and within the upper dermis in DEB.

Correct identification of the type of EB is important for giving parents a realistic outlook about the prognosis, she explained. While all types of EB have variations in severity, certain subtypes of JEB (Herlitz) probably carry the worst prognosis, often associated with pyloric atresia, as well as severe, generalized granulation tissue around the trachea. Forms of DEB can be accompanied by esophageal strictures, as well pseudosyndactyly, and an increased risk for squamous cell carcinoma, among other things, she said.

Wound care plays an essential role in the management of all types of EB.

“Extensive aplasia cutis is usually fatal in the first weeks of life. It is really like handling a burn patient—they are very susceptible to infection,” she said, adding that new silicone-based bandages (manufactured by Mölnlycke) have made great improvements because they minimize skin trauma.

“They stick well to the surface of the skin, but with no adhesive—it's more like a suction,” said Dr. Lucky, who has no financial association with any company that makes products for treatment of EB.

In addition, biologically active dressings and grafts, such as Apligraf, a semi-permeable living skin graft, not only cover the wound, but promote healing. Wrapping is also important for protection and for avoidance of progressive syndactyly or fusion of digits as a result of extensive erosions.

Although esophageal strictures are common in certain forms of EB, Dr. Lucky says routine investigation for them is not necessary. If symptoms are present, barium swallows must start above the clavicle otherwise the stricture will generally be missed, she added. When indicated, esophageal dilation can be performed with hydrostatic balloon insertion and dilation, and the effects of this procedure can be expected to persist for at least 1 year.

Esophageal strictures and a gradual reduction in a child's ability to fully open his or her mouth can lead to poor nutrition, osteopenia, and dental problems. For these reasons, feeding gastrostomies should be considered, and prophylactic dental hygiene should be stressed, she said.

Hand surgery to separate webbed fingers is also an “untapped area,” she said. “Some surgeons do it, but with variable success. The future may lie in physical and occupational therapy.”

Pain management and psychiatric support are also important—and often go hand-in-hand because of the potential for drug addiction.

Dr. Lucky said many physicians have never heard of EB, and their first encounter may be overwhelming. The Cincinnati Children's Hospital Medical Center has an interdisciplinary EB team offering a full range of resources (www.cincinnatichildrens.org/eb-center

“Pseudosyndactyly” can occur in epidermolysis bullosa. This 4-year-old patient has a moderate case.

Wrapping is important for protection and for avoidance of fusion of digits as a result of extensive erosions. Photos courtesy Dr. Anne Lucky

SNOWMASS, COLO. — Physicians diagnosing epidermolysis bullosa in a newborn have few initial clues about which type of the disease their patient has, or the course it will take, until they do electron microscopy and immunofluorescence testing, according to Anne Lucky, M.D.

“At the very beginning the different forms of epidermolysis bullosa (EB) all look virtually the same. We tell parents we don't know if it's going to be a severe or mild form until the testing is done.” In other words, the child may have a normal lifespan or may die in the first year of life, she told this newspaper.

Speaking at a clinical dermatology seminar sponsored by Medicis, Dr. Lucky, professor of dermatology and pediatrics at the University of Cincinnati and the Cincinnati Children's Hospital Medical Center said that electron microscopy, immunofluorescence mapping of the basement membrane, and genetic investigation for specific proteins, can help distinguish between epidermolysis bullosasimplex (EBS), junctional epidermolysis bullosa (JEB), and dystrophic epidermolysis bullosa (DEB).

EBS is caused by keratin and plectin mutations, while JEB is caused by mutations of basement membrane proteins, and DEB is caused by mutations of type VII collagen, she explained.

Although all forms of EB cause severe blistering and skin erosions, blister formation in EBS is within the epidermis, while it is seen within the basement membrane zone in JEB, and within the upper dermis in DEB.

Correct identification of the type of EB is important for giving parents a realistic outlook about the prognosis, she explained. While all types of EB have variations in severity, certain subtypes of JEB (Herlitz) probably carry the worst prognosis, often associated with pyloric atresia, as well as severe, generalized granulation tissue around the trachea. Forms of DEB can be accompanied by esophageal strictures, as well pseudosyndactyly, and an increased risk for squamous cell carcinoma, among other things, she said.

Wound care plays an essential role in the management of all types of EB.

“Extensive aplasia cutis is usually fatal in the first weeks of life. It is really like handling a burn patient—they are very susceptible to infection,” she said, adding that new silicone-based bandages (manufactured by Mölnlycke) have made great improvements because they minimize skin trauma.

“They stick well to the surface of the skin, but with no adhesive—it's more like a suction,” said Dr. Lucky, who has no financial association with any company that makes products for treatment of EB.

In addition, biologically active dressings and grafts, such as Apligraf, a semi-permeable living skin graft, not only cover the wound, but promote healing. Wrapping is also important for protection and for avoidance of progressive syndactyly or fusion of digits as a result of extensive erosions.

Although esophageal strictures are common in certain forms of EB, Dr. Lucky says routine investigation for them is not necessary. If symptoms are present, barium swallows must start above the clavicle otherwise the stricture will generally be missed, she added. When indicated, esophageal dilation can be performed with hydrostatic balloon insertion and dilation, and the effects of this procedure can be expected to persist for at least 1 year.

Esophageal strictures and a gradual reduction in a child's ability to fully open his or her mouth can lead to poor nutrition, osteopenia, and dental problems. For these reasons, feeding gastrostomies should be considered, and prophylactic dental hygiene should be stressed, she said.

Hand surgery to separate webbed fingers is also an “untapped area,” she said. “Some surgeons do it, but with variable success. The future may lie in physical and occupational therapy.”

Pain management and psychiatric support are also important—and often go hand-in-hand because of the potential for drug addiction.

Dr. Lucky said many physicians have never heard of EB, and their first encounter may be overwhelming. The Cincinnati Children's Hospital Medical Center has an interdisciplinary EB team offering a full range of resources (www.cincinnatichildrens.org/eb-center

“Pseudosyndactyly” can occur in epidermolysis bullosa. This 4-year-old patient has a moderate case.

Wrapping is important for protection and for avoidance of fusion of digits as a result of extensive erosions. Photos courtesy Dr. Anne Lucky

SNOWMASS, COLO. — Physicians diagnosing epidermolysis bullosa in a newborn have few initial clues about which type of the disease their patient has, or the course it will take, until they do electron microscopy and immunofluorescence testing, according to Anne Lucky, M.D.

“At the very beginning the different forms of epidermolysis bullosa (EB) all look virtually the same. We tell parents we don't know if it's going to be a severe or mild form until the testing is done.” In other words, the child may have a normal lifespan or may die in the first year of life, she told this newspaper.

Speaking at a clinical dermatology seminar sponsored by Medicis, Dr. Lucky, professor of dermatology and pediatrics at the University of Cincinnati and the Cincinnati Children's Hospital Medical Center said that electron microscopy, immunofluorescence mapping of the basement membrane, and genetic investigation for specific proteins, can help distinguish between epidermolysis bullosasimplex (EBS), junctional epidermolysis bullosa (JEB), and dystrophic epidermolysis bullosa (DEB).

EBS is caused by keratin and plectin mutations, while JEB is caused by mutations of basement membrane proteins, and DEB is caused by mutations of type VII collagen, she explained.

Although all forms of EB cause severe blistering and skin erosions, blister formation in EBS is within the epidermis, while it is seen within the basement membrane zone in JEB, and within the upper dermis in DEB.

Correct identification of the type of EB is important for giving parents a realistic outlook about the prognosis, she explained. While all types of EB have variations in severity, certain subtypes of JEB (Herlitz) probably carry the worst prognosis, often associated with pyloric atresia, as well as severe, generalized granulation tissue around the trachea. Forms of DEB can be accompanied by esophageal strictures, as well pseudosyndactyly, and an increased risk for squamous cell carcinoma, among other things, she said.

Wound care plays an essential role in the management of all types of EB.

“Extensive aplasia cutis is usually fatal in the first weeks of life. It is really like handling a burn patient—they are very susceptible to infection,” she said, adding that new silicone-based bandages (manufactured by Mölnlycke) have made great improvements because they minimize skin trauma.

“They stick well to the surface of the skin, but with no adhesive—it's more like a suction,” said Dr. Lucky, who has no financial association with any company that makes products for treatment of EB.

In addition, biologically active dressings and grafts, such as Apligraf, a semi-permeable living skin graft, not only cover the wound, but promote healing. Wrapping is also important for protection and for avoidance of progressive syndactyly or fusion of digits as a result of extensive erosions.

Although esophageal strictures are common in certain forms of EB, Dr. Lucky says routine investigation for them is not necessary. If symptoms are present, barium swallows must start above the clavicle otherwise the stricture will generally be missed, she added. When indicated, esophageal dilation can be performed with hydrostatic balloon insertion and dilation, and the effects of this procedure can be expected to persist for at least 1 year.

Esophageal strictures and a gradual reduction in a child's ability to fully open his or her mouth can lead to poor nutrition, osteopenia, and dental problems. For these reasons, feeding gastrostomies should be considered, and prophylactic dental hygiene should be stressed, she said.

Hand surgery to separate webbed fingers is also an “untapped area,” she said. “Some surgeons do it, but with variable success. The future may lie in physical and occupational therapy.”

Pain management and psychiatric support are also important—and often go hand-in-hand because of the potential for drug addiction.

Dr. Lucky said many physicians have never heard of EB, and their first encounter may be overwhelming. The Cincinnati Children's Hospital Medical Center has an interdisciplinary EB team offering a full range of resources (www.cincinnatichildrens.org/eb-center

“Pseudosyndactyly” can occur in epidermolysis bullosa. This 4-year-old patient has a moderate case.

Wrapping is important for protection and for avoidance of fusion of digits as a result of extensive erosions. Photos courtesy Dr. Anne Lucky

MIAMI BEACH — Physicians investigating a patient's persistent infertility should not underestimate the value of combined laparoscopy and hysteroscopy for allowing the most thorough work-up, according to Liselotte Mettler, Prof. Dr. Med.

Other common methods of investigating tubal patency, such as hysterosalpingogram (HSG), are valuable in that they are minimally invasive and can be performed in the office. But none of these methods offers as revealing a view of the ovaries and uterus as the combination of laparoscopy and hysteroscopy, according to Dr. Mettler, who is professor of obstetrics and gynecology and the head of gynecology, endocrinology and reproductive medicine at the University of Kiel, (Germany).

Speaking at a congress on laparoscopy and minimally invasive surgery, Dr. Mettler outlined her study of 120 patients investigated for tubal patency over a 2-year period.

The patients were examined using one of six available methods: hysterosalpingogram, hysterosalpingo contrast sonography (HyCoSy), laparoscopy with chromopertubation and hysteroscopy, transvaginal hydrolaparoscopy, air-contrast sonohysterography, or CO₂ pertubation.

In assessing each of these approaches, Dr. Mettler explained that all six proved safe and were associated with only minor side effects.

The cheapest method is air-contrast sonohysterography, which is performed in much the same way as regular sonohysterography, except that a balloon catheter is used.

In this procedure, as well as in CO₂ pertubation, contrast dye is forced into the fallopian tubes and can be painful when used in women with occlusions, she said.

HsCoSy is the second least expensive investigation. In this procedure, a transcervical balloon catheter is passed through the internal cervical os and inflated, and then a transvaginal probe is used to visualize the uterine cavity.

This maneuver is made possible with the injection of contrast solution, which allows the physician to evaluate tubal flow.

The main drawback of this and many of the other investigations is that no treatment can be performed at the time pathology is diagnosed, she said during the meeting, which was sponsored by the Society of Laparoendoscopic Surgeons.

With HSG, although tubal patency can be tested, no pelvic pathology can be assessed.

Although transvaginal hydrolaparoscopy can be used to evaluate tubal patency, it is quite traumatic and can assess only a small part of the lower pelvis, she said.

In laparoscopy the entire pelvis can be assessed, and—with the addition of chromopertubation—tubal patency can be evaluated at the same time. Adding hysteroscopy to this procedure allows assessment of the internal uterus, and if immediate therapy is necessary, it can be easily done while the patient is still under anesthesia, she said.

“When we see patients, they have been through many, many work-ups already, so we don't hesitate to go straight to laparoscopy,” Dr. Mettler told this newspaper.

“It is important to distinguish between outpatients and hospital patients. In our case, we are in a hospital and have access to operative techniques,” Dr. Mettler noted.

She said physicians who are not in a position to offer this type of investigation to patients with persistent infertility should refer them immediately to someone who can.

“After a certain amount of time, there is no point in confirming tubal patency by HSG in a woman only to find out 2 years later at laparoscopy that she has extensive adhesions. Tubal patency alone is not the only important factor,” she said.

MIAMI BEACH — Physicians investigating a patient's persistent infertility should not underestimate the value of combined laparoscopy and hysteroscopy for allowing the most thorough work-up, according to Liselotte Mettler, Prof. Dr. Med.

Other common methods of investigating tubal patency, such as hysterosalpingogram (HSG), are valuable in that they are minimally invasive and can be performed in the office. But none of these methods offers as revealing a view of the ovaries and uterus as the combination of laparoscopy and hysteroscopy, according to Dr. Mettler, who is professor of obstetrics and gynecology and the head of gynecology, endocrinology and reproductive medicine at the University of Kiel, (Germany).

Speaking at a congress on laparoscopy and minimally invasive surgery, Dr. Mettler outlined her study of 120 patients investigated for tubal patency over a 2-year period.

The patients were examined using one of six available methods: hysterosalpingogram, hysterosalpingo contrast sonography (HyCoSy), laparoscopy with chromopertubation and hysteroscopy, transvaginal hydrolaparoscopy, air-contrast sonohysterography, or CO₂ pertubation.

In assessing each of these approaches, Dr. Mettler explained that all six proved safe and were associated with only minor side effects.

The cheapest method is air-contrast sonohysterography, which is performed in much the same way as regular sonohysterography, except that a balloon catheter is used.

In this procedure, as well as in CO₂ pertubation, contrast dye is forced into the fallopian tubes and can be painful when used in women with occlusions, she said.

HsCoSy is the second least expensive investigation. In this procedure, a transcervical balloon catheter is passed through the internal cervical os and inflated, and then a transvaginal probe is used to visualize the uterine cavity.

This maneuver is made possible with the injection of contrast solution, which allows the physician to evaluate tubal flow.

The main drawback of this and many of the other investigations is that no treatment can be performed at the time pathology is diagnosed, she said during the meeting, which was sponsored by the Society of Laparoendoscopic Surgeons.

With HSG, although tubal patency can be tested, no pelvic pathology can be assessed.

Although transvaginal hydrolaparoscopy can be used to evaluate tubal patency, it is quite traumatic and can assess only a small part of the lower pelvis, she said.

In laparoscopy the entire pelvis can be assessed, and—with the addition of chromopertubation—tubal patency can be evaluated at the same time. Adding hysteroscopy to this procedure allows assessment of the internal uterus, and if immediate therapy is necessary, it can be easily done while the patient is still under anesthesia, she said.

“When we see patients, they have been through many, many work-ups already, so we don't hesitate to go straight to laparoscopy,” Dr. Mettler told this newspaper.

“It is important to distinguish between outpatients and hospital patients. In our case, we are in a hospital and have access to operative techniques,” Dr. Mettler noted.

She said physicians who are not in a position to offer this type of investigation to patients with persistent infertility should refer them immediately to someone who can.

“After a certain amount of time, there is no point in confirming tubal patency by HSG in a woman only to find out 2 years later at laparoscopy that she has extensive adhesions. Tubal patency alone is not the only important factor,” she said.

MIAMI BEACH — Physicians investigating a patient's persistent infertility should not underestimate the value of combined laparoscopy and hysteroscopy for allowing the most thorough work-up, according to Liselotte Mettler, Prof. Dr. Med.

Other common methods of investigating tubal patency, such as hysterosalpingogram (HSG), are valuable in that they are minimally invasive and can be performed in the office. But none of these methods offers as revealing a view of the ovaries and uterus as the combination of laparoscopy and hysteroscopy, according to Dr. Mettler, who is professor of obstetrics and gynecology and the head of gynecology, endocrinology and reproductive medicine at the University of Kiel, (Germany).

Speaking at a congress on laparoscopy and minimally invasive surgery, Dr. Mettler outlined her study of 120 patients investigated for tubal patency over a 2-year period.

The patients were examined using one of six available methods: hysterosalpingogram, hysterosalpingo contrast sonography (HyCoSy), laparoscopy with chromopertubation and hysteroscopy, transvaginal hydrolaparoscopy, air-contrast sonohysterography, or CO₂ pertubation.

In assessing each of these approaches, Dr. Mettler explained that all six proved safe and were associated with only minor side effects.

The cheapest method is air-contrast sonohysterography, which is performed in much the same way as regular sonohysterography, except that a balloon catheter is used.

In this procedure, as well as in CO₂ pertubation, contrast dye is forced into the fallopian tubes and can be painful when used in women with occlusions, she said.

HsCoSy is the second least expensive investigation. In this procedure, a transcervical balloon catheter is passed through the internal cervical os and inflated, and then a transvaginal probe is used to visualize the uterine cavity.

This maneuver is made possible with the injection of contrast solution, which allows the physician to evaluate tubal flow.

The main drawback of this and many of the other investigations is that no treatment can be performed at the time pathology is diagnosed, she said during the meeting, which was sponsored by the Society of Laparoendoscopic Surgeons.

With HSG, although tubal patency can be tested, no pelvic pathology can be assessed.

Although transvaginal hydrolaparoscopy can be used to evaluate tubal patency, it is quite traumatic and can assess only a small part of the lower pelvis, she said.

In laparoscopy the entire pelvis can be assessed, and—with the addition of chromopertubation—tubal patency can be evaluated at the same time. Adding hysteroscopy to this procedure allows assessment of the internal uterus, and if immediate therapy is necessary, it can be easily done while the patient is still under anesthesia, she said.

“When we see patients, they have been through many, many work-ups already, so we don't hesitate to go straight to laparoscopy,” Dr. Mettler told this newspaper.

“It is important to distinguish between outpatients and hospital patients. In our case, we are in a hospital and have access to operative techniques,” Dr. Mettler noted.

She said physicians who are not in a position to offer this type of investigation to patients with persistent infertility should refer them immediately to someone who can.

“After a certain amount of time, there is no point in confirming tubal patency by HSG in a woman only to find out 2 years later at laparoscopy that she has extensive adhesions. Tubal patency alone is not the only important factor,” she said.

About two-thirds of Americans support the use of genetic testing of embryos during in vitro fertilization to avoid the birth of a child with a fatal disease, but fewer than 30% support its hypothetical use for selecting intelligence or strength, according to a report from the Genetics and Public Policy Center in Washington.

A “majority of Americans think that testing for health-related purposes is an appropriate use of reproductive genetic testing, but only a minority support its use for trait selection,” noted the report entitled “Reproductive Genetic Testing: What America Thinks.”

The report touches on the more textured differences and similarities in opinion concerning these issues among the American public. It describes the political debate over reproductive genetic testing as framed by two polarized views, whereas the views of most Americans “are more nuanced and elastic, reflecting the tensions among hopes, values, and personal experience.”

“Public debate and media coverage of reproductive genetic technologies hide a surprising level of concordance among Americans for using genetic testing to identify risks of disease,” observed Kathy Hudson, director of the center, in a written statement.

The research included 21 focus groups, 62 in-depth interviews, surveys of more than 6,000 people, and both in-person and online town hall meetings.

The study authors noted that respondents' awareness about preimplantation genetic diagnosis (PGD) was very low.

“While most participants had heard of genetic testing at some level, the pace of technology in this field rapidly has outstripped public awareness,” the report noted. When asked whether they had heard of various technologies before that day, only 40% of participants had heard of PGD. A total of 83% said they were aware of prenatal testing, 90% had heard of in vitro fertilization (IVF), and 97% had heard of cloning.

When asked about the statement “Reproductive genetic technology will inevitably lead to genetic enhancement and designer babies,” 75% of participants said they agreed.

Yet, the participants were clear that it is not the technologies themselves that they fear, but rather that “unrestrained human selfishness and vanity will drive people to use reproductive genetic testing inappropriately,” noted the authors. “They believed that the technology is being developed for good purposes, but human vices will result in consumer demand for capricious uses.”

The study reports that 84% of participants were concerned about reproductive technologies being unregulated; however, 70% also were concerned “about government regulators invading private reproductive decisions.”

A companion report entitled “Reproductive Genetic Testing: Issues and Options for Policymakers” explores various options for overseeing the use, cost, access, and safety of reproductive genetic testing.

Both reports are available atwww.dnapolicy.org

About two-thirds of Americans support the use of genetic testing of embryos during in vitro fertilization to avoid the birth of a child with a fatal disease, but fewer than 30% support its hypothetical use for selecting intelligence or strength, according to a report from the Genetics and Public Policy Center in Washington.

A “majority of Americans think that testing for health-related purposes is an appropriate use of reproductive genetic testing, but only a minority support its use for trait selection,” noted the report entitled “Reproductive Genetic Testing: What America Thinks.”

The report touches on the more textured differences and similarities in opinion concerning these issues among the American public. It describes the political debate over reproductive genetic testing as framed by two polarized views, whereas the views of most Americans “are more nuanced and elastic, reflecting the tensions among hopes, values, and personal experience.”

“Public debate and media coverage of reproductive genetic technologies hide a surprising level of concordance among Americans for using genetic testing to identify risks of disease,” observed Kathy Hudson, director of the center, in a written statement.

The research included 21 focus groups, 62 in-depth interviews, surveys of more than 6,000 people, and both in-person and online town hall meetings.

The study authors noted that respondents' awareness about preimplantation genetic diagnosis (PGD) was very low.

“While most participants had heard of genetic testing at some level, the pace of technology in this field rapidly has outstripped public awareness,” the report noted. When asked whether they had heard of various technologies before that day, only 40% of participants had heard of PGD. A total of 83% said they were aware of prenatal testing, 90% had heard of in vitro fertilization (IVF), and 97% had heard of cloning.

When asked about the statement “Reproductive genetic technology will inevitably lead to genetic enhancement and designer babies,” 75% of participants said they agreed.

Yet, the participants were clear that it is not the technologies themselves that they fear, but rather that “unrestrained human selfishness and vanity will drive people to use reproductive genetic testing inappropriately,” noted the authors. “They believed that the technology is being developed for good purposes, but human vices will result in consumer demand for capricious uses.”

The study reports that 84% of participants were concerned about reproductive technologies being unregulated; however, 70% also were concerned “about government regulators invading private reproductive decisions.”

A companion report entitled “Reproductive Genetic Testing: Issues and Options for Policymakers” explores various options for overseeing the use, cost, access, and safety of reproductive genetic testing.

Both reports are available atwww.dnapolicy.org

About two-thirds of Americans support the use of genetic testing of embryos during in vitro fertilization to avoid the birth of a child with a fatal disease, but fewer than 30% support its hypothetical use for selecting intelligence or strength, according to a report from the Genetics and Public Policy Center in Washington.

A “majority of Americans think that testing for health-related purposes is an appropriate use of reproductive genetic testing, but only a minority support its use for trait selection,” noted the report entitled “Reproductive Genetic Testing: What America Thinks.”

The report touches on the more textured differences and similarities in opinion concerning these issues among the American public. It describes the political debate over reproductive genetic testing as framed by two polarized views, whereas the views of most Americans “are more nuanced and elastic, reflecting the tensions among hopes, values, and personal experience.”

“Public debate and media coverage of reproductive genetic technologies hide a surprising level of concordance among Americans for using genetic testing to identify risks of disease,” observed Kathy Hudson, director of the center, in a written statement.

The research included 21 focus groups, 62 in-depth interviews, surveys of more than 6,000 people, and both in-person and online town hall meetings.

The study authors noted that respondents' awareness about preimplantation genetic diagnosis (PGD) was very low.

“While most participants had heard of genetic testing at some level, the pace of technology in this field rapidly has outstripped public awareness,” the report noted. When asked whether they had heard of various technologies before that day, only 40% of participants had heard of PGD. A total of 83% said they were aware of prenatal testing, 90% had heard of in vitro fertilization (IVF), and 97% had heard of cloning.

When asked about the statement “Reproductive genetic technology will inevitably lead to genetic enhancement and designer babies,” 75% of participants said they agreed.

Yet, the participants were clear that it is not the technologies themselves that they fear, but rather that “unrestrained human selfishness and vanity will drive people to use reproductive genetic testing inappropriately,” noted the authors. “They believed that the technology is being developed for good purposes, but human vices will result in consumer demand for capricious uses.”

The study reports that 84% of participants were concerned about reproductive technologies being unregulated; however, 70% also were concerned “about government regulators invading private reproductive decisions.”

A companion report entitled “Reproductive Genetic Testing: Issues and Options for Policymakers” explores various options for overseeing the use, cost, access, and safety of reproductive genetic testing.

Both reports are available atwww.dnapolicy.org

PHILADELPHIA — Discontinuation of hormonal contraceptives should be the first-line approach in addressing sexual dysfunction in women using these agents.

Susan Sarajari, M.D., outlined her study of 20 women who experienced improved sexual function and testosterone levels after discontinuing hormonal contraception. “This is the first trial that correlates serum androgen changes with specific domains of sexual function,” she said at the annual meeting of the American Society for Reproductive Medicine.

About 15% of hormonal contraceptive users report sexual dysfunction in the form of low libido, vaginal dryness, impaired orgasm, and decreased arousal. “This may be the result of changes in serum androgens,” said Dr. Sarajari, a fellow in reproductive endocrinology and infertility at the University of California, Los Angeles, Medical Center.

Her study measured baseline total testosterone, free testosterone, and sex hormone-binding globulin (SHBG) in premenopausal women (mean age 34 years) who had been using hormonal contraceptives for at least 6 months. Most women had been taking oral contraceptives, but one had been using a contraceptive patch and one had been using a contraceptive vaginal ring.

The serum levels were assessed again 4 months after the women discontinued contraception. Patients also completed questionnaires at baseline and at the end of the study, which assessed sexual function, distress associated with sexual dysfunction, and sexual desire and energy.

Mean total and free testosterone levels increased, while SHBG decreased significantly after contraceptive discontinuation. These changes coincided with a significant increase in sexual energy, decrease in sexual distress, and an improvement in global sexual function scores. “There was significant improvement in arousal, lubrication, orgasm, and satisfaction,” she said, noting that the “antiandrogenic” profiles of hormonal contraceptives that are promoted by drug companies are not entirely beneficial.

PHILADELPHIA — Discontinuation of hormonal contraceptives should be the first-line approach in addressing sexual dysfunction in women using these agents.

Susan Sarajari, M.D., outlined her study of 20 women who experienced improved sexual function and testosterone levels after discontinuing hormonal contraception. “This is the first trial that correlates serum androgen changes with specific domains of sexual function,” she said at the annual meeting of the American Society for Reproductive Medicine.

About 15% of hormonal contraceptive users report sexual dysfunction in the form of low libido, vaginal dryness, impaired orgasm, and decreased arousal. “This may be the result of changes in serum androgens,” said Dr. Sarajari, a fellow in reproductive endocrinology and infertility at the University of California, Los Angeles, Medical Center.

Her study measured baseline total testosterone, free testosterone, and sex hormone-binding globulin (SHBG) in premenopausal women (mean age 34 years) who had been using hormonal contraceptives for at least 6 months. Most women had been taking oral contraceptives, but one had been using a contraceptive patch and one had been using a contraceptive vaginal ring.

The serum levels were assessed again 4 months after the women discontinued contraception. Patients also completed questionnaires at baseline and at the end of the study, which assessed sexual function, distress associated with sexual dysfunction, and sexual desire and energy.

Mean total and free testosterone levels increased, while SHBG decreased significantly after contraceptive discontinuation. These changes coincided with a significant increase in sexual energy, decrease in sexual distress, and an improvement in global sexual function scores. “There was significant improvement in arousal, lubrication, orgasm, and satisfaction,” she said, noting that the “antiandrogenic” profiles of hormonal contraceptives that are promoted by drug companies are not entirely beneficial.

PHILADELPHIA — Discontinuation of hormonal contraceptives should be the first-line approach in addressing sexual dysfunction in women using these agents.

Susan Sarajari, M.D., outlined her study of 20 women who experienced improved sexual function and testosterone levels after discontinuing hormonal contraception. “This is the first trial that correlates serum androgen changes with specific domains of sexual function,” she said at the annual meeting of the American Society for Reproductive Medicine.

About 15% of hormonal contraceptive users report sexual dysfunction in the form of low libido, vaginal dryness, impaired orgasm, and decreased arousal. “This may be the result of changes in serum androgens,” said Dr. Sarajari, a fellow in reproductive endocrinology and infertility at the University of California, Los Angeles, Medical Center.

Her study measured baseline total testosterone, free testosterone, and sex hormone-binding globulin (SHBG) in premenopausal women (mean age 34 years) who had been using hormonal contraceptives for at least 6 months. Most women had been taking oral contraceptives, but one had been using a contraceptive patch and one had been using a contraceptive vaginal ring.

The serum levels were assessed again 4 months after the women discontinued contraception. Patients also completed questionnaires at baseline and at the end of the study, which assessed sexual function, distress associated with sexual dysfunction, and sexual desire and energy.

Mean total and free testosterone levels increased, while SHBG decreased significantly after contraceptive discontinuation. These changes coincided with a significant increase in sexual energy, decrease in sexual distress, and an improvement in global sexual function scores. “There was significant improvement in arousal, lubrication, orgasm, and satisfaction,” she said, noting that the “antiandrogenic” profiles of hormonal contraceptives that are promoted by drug companies are not entirely beneficial.

PHILADELPHIA — Surgically menopausal women under the age of 50 deserve special attention with regard to sexual desire disorder, results of a new study suggest.

“Physicians should routinely inquire about sexual function both pre- and postsurgery in these women,” said Sandra Leiblum, Ph.D., principal investigator in the study and professor of psychiatry at Robert Wood Johnson Medical School in Piscataway, N.J.

“Surgical menopause plays havoc for women in terms of sexual desire, and when this is compromised, so are other aspects of their sexuality such as arousal, orgasm, and pleasure,” she said at the annual meeting of the American Society for Reproductive Medicine.

In the study, sponsored by Procter & Gamble Pharmaceuticals, more than 1,200 women were surveyed about sexual activity and desire, relationship issues, and distress levels in association with these issues.

Dr. Leiblum and her associates compared responses of pre-menopausal women under the age of 50 years with those of naturally menopausal women aged 50 to 70 years and surgically menopausal women in two age ranges—20-49 years and 50-70 years.

The young surgically menopausal women had significantly less desire, more personal stress, and higher rates of hypoactive sexual desire disorder (HSDD) than any of the other groups. Dr. Leiblum said roughly one-third of all U.S. women report low sexual interest, but not necessarily HSDD.

In the study, HSDD was present in one-quarter of the young, surgically menopausal women but only one in six premenopausal women of the same age and older surgically menopausal women. Naturally menopausal women had the lowest rate of HSDD at 1 in 10.

“Compared with women who do not have HSDD, women with this condition are 11 times more likely to be dissatisfied with their sex lives and 21/2 times more likely to be dissatisfied with their relationship,” Dr. Leiblum said.

PHILADELPHIA — Surgically menopausal women under the age of 50 deserve special attention with regard to sexual desire disorder, results of a new study suggest.

“Physicians should routinely inquire about sexual function both pre- and postsurgery in these women,” said Sandra Leiblum, Ph.D., principal investigator in the study and professor of psychiatry at Robert Wood Johnson Medical School in Piscataway, N.J.

“Surgical menopause plays havoc for women in terms of sexual desire, and when this is compromised, so are other aspects of their sexuality such as arousal, orgasm, and pleasure,” she said at the annual meeting of the American Society for Reproductive Medicine.

In the study, sponsored by Procter & Gamble Pharmaceuticals, more than 1,200 women were surveyed about sexual activity and desire, relationship issues, and distress levels in association with these issues.

Dr. Leiblum and her associates compared responses of pre-menopausal women under the age of 50 years with those of naturally menopausal women aged 50 to 70 years and surgically menopausal women in two age ranges—20-49 years and 50-70 years.

The young surgically menopausal women had significantly less desire, more personal stress, and higher rates of hypoactive sexual desire disorder (HSDD) than any of the other groups. Dr. Leiblum said roughly one-third of all U.S. women report low sexual interest, but not necessarily HSDD.

In the study, HSDD was present in one-quarter of the young, surgically menopausal women but only one in six premenopausal women of the same age and older surgically menopausal women. Naturally menopausal women had the lowest rate of HSDD at 1 in 10.

“Compared with women who do not have HSDD, women with this condition are 11 times more likely to be dissatisfied with their sex lives and 21/2 times more likely to be dissatisfied with their relationship,” Dr. Leiblum said.

PHILADELPHIA — Surgically menopausal women under the age of 50 deserve special attention with regard to sexual desire disorder, results of a new study suggest.

“Physicians should routinely inquire about sexual function both pre- and postsurgery in these women,” said Sandra Leiblum, Ph.D., principal investigator in the study and professor of psychiatry at Robert Wood Johnson Medical School in Piscataway, N.J.

“Surgical menopause plays havoc for women in terms of sexual desire, and when this is compromised, so are other aspects of their sexuality such as arousal, orgasm, and pleasure,” she said at the annual meeting of the American Society for Reproductive Medicine.

In the study, sponsored by Procter & Gamble Pharmaceuticals, more than 1,200 women were surveyed about sexual activity and desire, relationship issues, and distress levels in association with these issues.

Dr. Leiblum and her associates compared responses of pre-menopausal women under the age of 50 years with those of naturally menopausal women aged 50 to 70 years and surgically menopausal women in two age ranges—20-49 years and 50-70 years.

The young surgically menopausal women had significantly less desire, more personal stress, and higher rates of hypoactive sexual desire disorder (HSDD) than any of the other groups. Dr. Leiblum said roughly one-third of all U.S. women report low sexual interest, but not necessarily HSDD.

In the study, HSDD was present in one-quarter of the young, surgically menopausal women but only one in six premenopausal women of the same age and older surgically menopausal women. Naturally menopausal women had the lowest rate of HSDD at 1 in 10.

“Compared with women who do not have HSDD, women with this condition are 11 times more likely to be dissatisfied with their sex lives and 21/2 times more likely to be dissatisfied with their relationship,” Dr. Leiblum said.

CHICAGO — Physicians can now use data to help them personalize a smoker's risk of developing lung cancer, and advise smokers about whether to undergo annual low-dose CT screening for the disease.

The International Early Lung Cancer Action Program (I-ELCAP) collected the diagnostic and prognostic data from the baseline CT screening and follow-up of almost 28,000 smokers, lead investigator Claudia I. Henschke, M.D., reported at the annual meeting of the Radiological Society of North America.

“Based on our data, we can now predict—by age, and by how much has been smoked or when a smoker has quit—what is the likelihood of [their] developing lung cancer,” she said at a press briefing.

Whether to undertake the expense of lung CT screening (around $300) is a patient's personal decision, one that should be reconsidered each year, based on the previous year's results, she said. There are now enough data to guide physicians on whether to recommend annual screening for an individual patient, she added.

The study findings suggest that the probability of an early lung cancer being detected with annual CT screening is about 80%—and with early diagnosis of early disease there is a 95% probability of a cure.

“Annual CT screening identifies a high percentage of stage I diagnoses of lung cancer, the most curable form of lung cancer,” said Dr. Henschke, professor of radiology and division chief of chest imaging at New York Hospital-Cornell Medical Center in New York. “Our study found that deaths from stage I lung cancer were surprisingly low … if treatment was pursued.”

Without screening, there is a 5-10% chance of a cancer being cured (because it would usually be discovered at a late stage) compared to a 76-78% chance of a cure with screening and early treatment, she said.

The study found that a delay in treatment of more than 6 months resulted in increased tumor size and often a higher stage of disease. And if a cancer was detected after a 2-year gap in screening, it tended to be eight times larger than a cancer detected on annual screening, with more chance of lymph node metastasis, she said.

The I-ELCAP data will soon be widely available to help physicians personalize lung cancer risk and screening issues for a wide range of patient ages and smoking histories, Dr. Henschke said.

She gave the example of a 45-year-old with a smoking history of less than 30 pack-years. The data show that this smoker's risk of developing lung cancer is 0.2%, that there would be an 80% likelihood that an early cancer could be detected with annual screening, and a 95% chance of a cure, she said.

The study also found that age has as much of an impact on the likelihood of former and current smokers developing cancer as does the number of cigarettes smoked. It found that lung cancer develops in twice as many smokers aged 50-74 years (15 per 1,000), compared with smokers under age 50 (6 per 1,000).

In addition, regardless of a patient's age or smoking history, cancer risk does not decline appreciably until 20 years after smoking cessation. “It starts decreasing slowly when they quit, and drops to half by 20 years,” she said.

Although the U.S. Preventive Services Task Force does not recommend annual lung cancer screening, even for smokers, it has switched from a negative to a more neutral position on the subject, Dr. Henschke said.

Still, most insurance companies do not cover lung CT when it is done for screening purposes alone.

CHICAGO — Physicians can now use data to help them personalize a smoker's risk of developing lung cancer, and advise smokers about whether to undergo annual low-dose CT screening for the disease.

The International Early Lung Cancer Action Program (I-ELCAP) collected the diagnostic and prognostic data from the baseline CT screening and follow-up of almost 28,000 smokers, lead investigator Claudia I. Henschke, M.D., reported at the annual meeting of the Radiological Society of North America.

“Based on our data, we can now predict—by age, and by how much has been smoked or when a smoker has quit—what is the likelihood of [their] developing lung cancer,” she said at a press briefing.

Whether to undertake the expense of lung CT screening (around $300) is a patient's personal decision, one that should be reconsidered each year, based on the previous year's results, she said. There are now enough data to guide physicians on whether to recommend annual screening for an individual patient, she added.

The study findings suggest that the probability of an early lung cancer being detected with annual CT screening is about 80%—and with early diagnosis of early disease there is a 95% probability of a cure.

“Annual CT screening identifies a high percentage of stage I diagnoses of lung cancer, the most curable form of lung cancer,” said Dr. Henschke, professor of radiology and division chief of chest imaging at New York Hospital-Cornell Medical Center in New York. “Our study found that deaths from stage I lung cancer were surprisingly low … if treatment was pursued.”

Without screening, there is a 5-10% chance of a cancer being cured (because it would usually be discovered at a late stage) compared to a 76-78% chance of a cure with screening and early treatment, she said.

The study found that a delay in treatment of more than 6 months resulted in increased tumor size and often a higher stage of disease. And if a cancer was detected after a 2-year gap in screening, it tended to be eight times larger than a cancer detected on annual screening, with more chance of lymph node metastasis, she said.

The I-ELCAP data will soon be widely available to help physicians personalize lung cancer risk and screening issues for a wide range of patient ages and smoking histories, Dr. Henschke said.

She gave the example of a 45-year-old with a smoking history of less than 30 pack-years. The data show that this smoker's risk of developing lung cancer is 0.2%, that there would be an 80% likelihood that an early cancer could be detected with annual screening, and a 95% chance of a cure, she said.

The study also found that age has as much of an impact on the likelihood of former and current smokers developing cancer as does the number of cigarettes smoked. It found that lung cancer develops in twice as many smokers aged 50-74 years (15 per 1,000), compared with smokers under age 50 (6 per 1,000).

In addition, regardless of a patient's age or smoking history, cancer risk does not decline appreciably until 20 years after smoking cessation. “It starts decreasing slowly when they quit, and drops to half by 20 years,” she said.

Although the U.S. Preventive Services Task Force does not recommend annual lung cancer screening, even for smokers, it has switched from a negative to a more neutral position on the subject, Dr. Henschke said.

Still, most insurance companies do not cover lung CT when it is done for screening purposes alone.

CHICAGO — Physicians can now use data to help them personalize a smoker's risk of developing lung cancer, and advise smokers about whether to undergo annual low-dose CT screening for the disease.

The International Early Lung Cancer Action Program (I-ELCAP) collected the diagnostic and prognostic data from the baseline CT screening and follow-up of almost 28,000 smokers, lead investigator Claudia I. Henschke, M.D., reported at the annual meeting of the Radiological Society of North America.

“Based on our data, we can now predict—by age, and by how much has been smoked or when a smoker has quit—what is the likelihood of [their] developing lung cancer,” she said at a press briefing.

Whether to undertake the expense of lung CT screening (around $300) is a patient's personal decision, one that should be reconsidered each year, based on the previous year's results, she said. There are now enough data to guide physicians on whether to recommend annual screening for an individual patient, she added.

The study findings suggest that the probability of an early lung cancer being detected with annual CT screening is about 80%—and with early diagnosis of early disease there is a 95% probability of a cure.

“Annual CT screening identifies a high percentage of stage I diagnoses of lung cancer, the most curable form of lung cancer,” said Dr. Henschke, professor of radiology and division chief of chest imaging at New York Hospital-Cornell Medical Center in New York. “Our study found that deaths from stage I lung cancer were surprisingly low … if treatment was pursued.”

Without screening, there is a 5-10% chance of a cancer being cured (because it would usually be discovered at a late stage) compared to a 76-78% chance of a cure with screening and early treatment, she said.

The study found that a delay in treatment of more than 6 months resulted in increased tumor size and often a higher stage of disease. And if a cancer was detected after a 2-year gap in screening, it tended to be eight times larger than a cancer detected on annual screening, with more chance of lymph node metastasis, she said.

The I-ELCAP data will soon be widely available to help physicians personalize lung cancer risk and screening issues for a wide range of patient ages and smoking histories, Dr. Henschke said.

She gave the example of a 45-year-old with a smoking history of less than 30 pack-years. The data show that this smoker's risk of developing lung cancer is 0.2%, that there would be an 80% likelihood that an early cancer could be detected with annual screening, and a 95% chance of a cure, she said.

The study also found that age has as much of an impact on the likelihood of former and current smokers developing cancer as does the number of cigarettes smoked. It found that lung cancer develops in twice as many smokers aged 50-74 years (15 per 1,000), compared with smokers under age 50 (6 per 1,000).

In addition, regardless of a patient's age or smoking history, cancer risk does not decline appreciably until 20 years after smoking cessation. “It starts decreasing slowly when they quit, and drops to half by 20 years,” she said.

Although the U.S. Preventive Services Task Force does not recommend annual lung cancer screening, even for smokers, it has switched from a negative to a more neutral position on the subject, Dr. Henschke said.

Still, most insurance companies do not cover lung CT when it is done for screening purposes alone.

The provision of chlamydia or gonorrhea treatment directly to patients' sexual partners, without requiring the partners to visit a physician, significantly improved infection control in patients, researchers at the University of Washington in Seattle reported.

“We believe that the inadequacies of current approaches to partner notification and the persistence of unacceptably high levels of morbidity from sexually transmitted infections in the United States should motivate both clinicians and public health authorities to incorporate patient-delivered partner therapy and other approaches to expedited care of partners into clinical and public health policies,” wrote Matthew R. Golden, M.D., the study's lead investigator (N. Engl. J. Med. 2005; 352:676-85).

The study randomized 2,751 patients recently treated for chlamydia and/or gonorrhea infections to either expedited treatment or standard referral for their partners.

The 1,376 patients in the expedited treatment group were offered medication to give to as many as three partners. An additional 1,375 patients in the standard referral group were advised to tell their partners to seek care, available at no cost at the public health department's sexually transmitted diseases (STD) clinic.

The medication for partners in the expedited treatment group was distributed to patients in three ways; at the STD clinic, by direct mail, or through participating pharmacies. It consisted of either a single 400-mg dose of cefixime and a 1-g sachet of azithromycin for partners of patients with gonorrhea or azithromycin only for partners of patients with chlamydia.

Warnings and information about the medication, condoms, and STD prevention also were included in the packets.

A total of 1,860 patients (67%) completed the study and were interviewed and retested 10-18 weeks after their initial diagnosis and treatment.

More patients in the expedited treatment group reported that their partners were likely to have been treated, or to have tested negative for STDs—making persistent or recurrent infection with either gonorrhea or chlamydia significantly less common in this group (10%), compared with the standard referral group (13%), for a relative risk of 0.76.

Expedited treatment was more effective in reducing gonorrhea (73%) than chlamydia (15%)—a finding that might be partially explained by chlamydia treatment failure, the authors suggested.

The findings represent “a major advance for the control and prevention of STDs,” reported Emily J. Erbelding, M.D., and Jonathan M. Zenilman, M.D., of Johns Hopkins University, Baltimore, in an accompanying editorial (N. Engl. J. Med. 2005;352:720-1).

“We can conclude that the use of expedited approaches designed to circumvent traditional evaluation by a clinician increases the chance of an exposed partner's receiving proper therapy and, most important, reduces the original patient's risk of reinfection,” Dr. Erbelding and Dr. Zenilman wrote.

The study authors noted several weaknesses in their model of patient-delivered partner therapy. These included legal barriers in many states, the uncertain availability of cefixime, potential adverse effects of treating partners without a clinical evaluation, and the missed opportunity for educating partners as well as treating them for other STDs.

The provision of chlamydia or gonorrhea treatment directly to patients' sexual partners, without requiring the partners to visit a physician, significantly improved infection control in patients, researchers at the University of Washington in Seattle reported.

“We believe that the inadequacies of current approaches to partner notification and the persistence of unacceptably high levels of morbidity from sexually transmitted infections in the United States should motivate both clinicians and public health authorities to incorporate patient-delivered partner therapy and other approaches to expedited care of partners into clinical and public health policies,” wrote Matthew R. Golden, M.D., the study's lead investigator (N. Engl. J. Med. 2005; 352:676-85).

The study randomized 2,751 patients recently treated for chlamydia and/or gonorrhea infections to either expedited treatment or standard referral for their partners.

The 1,376 patients in the expedited treatment group were offered medication to give to as many as three partners. An additional 1,375 patients in the standard referral group were advised to tell their partners to seek care, available at no cost at the public health department's sexually transmitted diseases (STD) clinic.

The medication for partners in the expedited treatment group was distributed to patients in three ways; at the STD clinic, by direct mail, or through participating pharmacies. It consisted of either a single 400-mg dose of cefixime and a 1-g sachet of azithromycin for partners of patients with gonorrhea or azithromycin only for partners of patients with chlamydia.

Warnings and information about the medication, condoms, and STD prevention also were included in the packets.

A total of 1,860 patients (67%) completed the study and were interviewed and retested 10-18 weeks after their initial diagnosis and treatment.

More patients in the expedited treatment group reported that their partners were likely to have been treated, or to have tested negative for STDs—making persistent or recurrent infection with either gonorrhea or chlamydia significantly less common in this group (10%), compared with the standard referral group (13%), for a relative risk of 0.76.

Expedited treatment was more effective in reducing gonorrhea (73%) than chlamydia (15%)—a finding that might be partially explained by chlamydia treatment failure, the authors suggested.

The findings represent “a major advance for the control and prevention of STDs,” reported Emily J. Erbelding, M.D., and Jonathan M. Zenilman, M.D., of Johns Hopkins University, Baltimore, in an accompanying editorial (N. Engl. J. Med. 2005;352:720-1).

“We can conclude that the use of expedited approaches designed to circumvent traditional evaluation by a clinician increases the chance of an exposed partner's receiving proper therapy and, most important, reduces the original patient's risk of reinfection,” Dr. Erbelding and Dr. Zenilman wrote.

The study authors noted several weaknesses in their model of patient-delivered partner therapy. These included legal barriers in many states, the uncertain availability of cefixime, potential adverse effects of treating partners without a clinical evaluation, and the missed opportunity for educating partners as well as treating them for other STDs.

The provision of chlamydia or gonorrhea treatment directly to patients' sexual partners, without requiring the partners to visit a physician, significantly improved infection control in patients, researchers at the University of Washington in Seattle reported.

“We believe that the inadequacies of current approaches to partner notification and the persistence of unacceptably high levels of morbidity from sexually transmitted infections in the United States should motivate both clinicians and public health authorities to incorporate patient-delivered partner therapy and other approaches to expedited care of partners into clinical and public health policies,” wrote Matthew R. Golden, M.D., the study's lead investigator (N. Engl. J. Med. 2005; 352:676-85).

The study randomized 2,751 patients recently treated for chlamydia and/or gonorrhea infections to either expedited treatment or standard referral for their partners.

The 1,376 patients in the expedited treatment group were offered medication to give to as many as three partners. An additional 1,375 patients in the standard referral group were advised to tell their partners to seek care, available at no cost at the public health department's sexually transmitted diseases (STD) clinic.

The medication for partners in the expedited treatment group was distributed to patients in three ways; at the STD clinic, by direct mail, or through participating pharmacies. It consisted of either a single 400-mg dose of cefixime and a 1-g sachet of azithromycin for partners of patients with gonorrhea or azithromycin only for partners of patients with chlamydia.

Warnings and information about the medication, condoms, and STD prevention also were included in the packets.

A total of 1,860 patients (67%) completed the study and were interviewed and retested 10-18 weeks after their initial diagnosis and treatment.

More patients in the expedited treatment group reported that their partners were likely to have been treated, or to have tested negative for STDs—making persistent or recurrent infection with either gonorrhea or chlamydia significantly less common in this group (10%), compared with the standard referral group (13%), for a relative risk of 0.76.

Expedited treatment was more effective in reducing gonorrhea (73%) than chlamydia (15%)—a finding that might be partially explained by chlamydia treatment failure, the authors suggested.

The findings represent “a major advance for the control and prevention of STDs,” reported Emily J. Erbelding, M.D., and Jonathan M. Zenilman, M.D., of Johns Hopkins University, Baltimore, in an accompanying editorial (N. Engl. J. Med. 2005;352:720-1).

“We can conclude that the use of expedited approaches designed to circumvent traditional evaluation by a clinician increases the chance of an exposed partner's receiving proper therapy and, most important, reduces the original patient's risk of reinfection,” Dr. Erbelding and Dr. Zenilman wrote.

The study authors noted several weaknesses in their model of patient-delivered partner therapy. These included legal barriers in many states, the uncertain availability of cefixime, potential adverse effects of treating partners without a clinical evaluation, and the missed opportunity for educating partners as well as treating them for other STDs.

QUEBEC CITY — One-third of menopausal women with diabetes do not receive annual screening mammography, according to results of a large study.

“Even though they had more frequent visits to physicians, compared with healthy women, women with diabetes have a 32% lower likelihood of getting mammograms,” said Lorraine Lipscombe, M.D., a research fellow at the Institute for Clinical Evaluative Sciences, Toronto.

The retrospective study included about 69,000 women with diabetes, aged between 50 and 69 years, and compared them with about 663,000 controls of the same age, she reported at the joint annual meeting of the Canadian Diabetes Association and the Canadian Society of Endocrinology and Metabolism.

The medical records were taken from a provincial database as well as the Ontario Diabetes Database and tracked for 2 years, starting from their first physician visit to determine whether they had a screening mammogram, said Dr. Lipscombe, also of Sunnybrook and Women's College Health Sciences Centre, Toronto.

Compared with healthy women, those with diabetes had more physician visits per year (9 vs. 7) and were more likely to see a specialist (29% vs. 11%). However, significantly fewer diabetic women had at least one screening mammogram during the study period (38% vs. 47%, odds ratio 0.68).

This finding is of particular concern in light of evidence that suggests there may be an increased risk of breast cancer in women with diabetes, Dr. Lipscombe told FAMILY PRACTICE NEWS.

The mechanism for this increased risk may be a higher rate of obesity in this population, which can predispose women to breast cancer. It may also be related to insulin exposure, she said.

“Not just treatment with insulin, but possibly also the fact that there is a state of insulin resistance for many years before the onset of diabetes. This means that the body makes more insulin than normal, and because insulin is a growth factor it can increase the risk of breast cancer.”

The study results suggest that primary preventive care may be suboptimal in diabetes patients, and physicians should consider ways to ensure that patients get regular mammography reminders, according to Dr. Lipscombe.

QUEBEC CITY — One-third of menopausal women with diabetes do not receive annual screening mammography, according to results of a large study.

“Even though they had more frequent visits to physicians, compared with healthy women, women with diabetes have a 32% lower likelihood of getting mammograms,” said Lorraine Lipscombe, M.D., a research fellow at the Institute for Clinical Evaluative Sciences, Toronto.

The retrospective study included about 69,000 women with diabetes, aged between 50 and 69 years, and compared them with about 663,000 controls of the same age, she reported at the joint annual meeting of the Canadian Diabetes Association and the Canadian Society of Endocrinology and Metabolism.

The medical records were taken from a provincial database as well as the Ontario Diabetes Database and tracked for 2 years, starting from their first physician visit to determine whether they had a screening mammogram, said Dr. Lipscombe, also of Sunnybrook and Women's College Health Sciences Centre, Toronto.

Compared with healthy women, those with diabetes had more physician visits per year (9 vs. 7) and were more likely to see a specialist (29% vs. 11%). However, significantly fewer diabetic women had at least one screening mammogram during the study period (38% vs. 47%, odds ratio 0.68).

This finding is of particular concern in light of evidence that suggests there may be an increased risk of breast cancer in women with diabetes, Dr. Lipscombe told FAMILY PRACTICE NEWS.

The mechanism for this increased risk may be a higher rate of obesity in this population, which can predispose women to breast cancer. It may also be related to insulin exposure, she said.

“Not just treatment with insulin, but possibly also the fact that there is a state of insulin resistance for many years before the onset of diabetes. This means that the body makes more insulin than normal, and because insulin is a growth factor it can increase the risk of breast cancer.”

The study results suggest that primary preventive care may be suboptimal in diabetes patients, and physicians should consider ways to ensure that patients get regular mammography reminders, according to Dr. Lipscombe.

QUEBEC CITY — One-third of menopausal women with diabetes do not receive annual screening mammography, according to results of a large study.

“Even though they had more frequent visits to physicians, compared with healthy women, women with diabetes have a 32% lower likelihood of getting mammograms,” said Lorraine Lipscombe, M.D., a research fellow at the Institute for Clinical Evaluative Sciences, Toronto.

The retrospective study included about 69,000 women with diabetes, aged between 50 and 69 years, and compared them with about 663,000 controls of the same age, she reported at the joint annual meeting of the Canadian Diabetes Association and the Canadian Society of Endocrinology and Metabolism.

The medical records were taken from a provincial database as well as the Ontario Diabetes Database and tracked for 2 years, starting from their first physician visit to determine whether they had a screening mammogram, said Dr. Lipscombe, also of Sunnybrook and Women's College Health Sciences Centre, Toronto.

Compared with healthy women, those with diabetes had more physician visits per year (9 vs. 7) and were more likely to see a specialist (29% vs. 11%). However, significantly fewer diabetic women had at least one screening mammogram during the study period (38% vs. 47%, odds ratio 0.68).

This finding is of particular concern in light of evidence that suggests there may be an increased risk of breast cancer in women with diabetes, Dr. Lipscombe told FAMILY PRACTICE NEWS.

The mechanism for this increased risk may be a higher rate of obesity in this population, which can predispose women to breast cancer. It may also be related to insulin exposure, she said.

“Not just treatment with insulin, but possibly also the fact that there is a state of insulin resistance for many years before the onset of diabetes. This means that the body makes more insulin than normal, and because insulin is a growth factor it can increase the risk of breast cancer.”

The study results suggest that primary preventive care may be suboptimal in diabetes patients, and physicians should consider ways to ensure that patients get regular mammography reminders, according to Dr. Lipscombe.