Greg Muirhead

MAUI, HAWAII — Cat-scratch disease should be consided in any patient with fever of an unknown origin who has had contact with cats—especially kittens, according to Dr. Jay M. Lieberman.

He presented several cases of children with prolonged fevers who remained without a diagnosis, despite extensive evaluations, until the possibility of cat-scratch disease was entertained and a history of contact with kittens was obtained.

The diagnosis of cat-scratch disease often can be made from the history and physical examination, and serologies may not be reliable, Dr. Lieberman said at a meeting sponsored by the University Childrens Medical Group and the American Academy of Pediatrics.

Kittens are more likely to cause cat-scratch disease than are older cats.

The disease is caused by Bartonella henselae, and approximately 40% of cats are bacteremic with the organism, explained Dr. Lieberman, who is professor of clinical pediatrics at the University of California, Irvine.

Cat-scratch disease is transmitted to humans through scratches, licks, or bites from kittens, less often from older cats, and sometimes from dogs.

A primary papule may be seen 3-12 days after inoculation time, followed 7-60 days (average 12-14 days) later by regional lymphadenopathy that may suppurate or regress over 2-4 months.

Lymphadenopathy usually involves the nodes that drain the site of inoculation. Fever occurs in half of patients, and malaise, anorexia, and headache also may occur.

The area around the nodes may be noninflamed but can be warm, tender, and erythematous, Dr. Lieberman said at the meeting, which also was sponsored by California Chapter 2 of the AAP. As many as 30% of nodes will suppurate spontaneously.

Atypical presentations of cat-scratch disease included prolonged fever/fever of unknown origin, granulomatous hepatitis, conjunctivitis with preauricular adenopathy (Parinaud's oculoglandular syndrome), encephalopathy/encephalitis, osteomyelitis, and ocular disease.

Although patients may be treated with rifampin or gentamicin or trimethoprim-sulfamethoxazole (TMP/SMZ), or a combination of anti-infectives, Dr. Lieberman does not routinely recommend their use.

"In general, we have not treated our patients with antimicrobial therapy," he said. "Most patients do not require specific therapy, and the illness resolves on its own."

One prospective randomized trial of azithromycin vs. placebo found a significantly greater decrease in lymph node size in azithromycin-treated patients at 30 days, but there was no significant difference thereafter (Pediatr. Infect. Dis. J. 1998;17:447-52).

Dr. Lieberman then discussed other infections that can be acquired from pets:

▸ Dog and cat bite wound infections. Approximately 5%-15% of dog bites lead to infections, as do 20%-50% of cat bites.

Pasteurella species, short gram-negative coccobacilli that are part of the normal flora of cats and dogs, are isolated from 75% of infections from cat bites and 50% of infections from dog bites.

Pasteurella organisms are not susceptible to cephalexin or dicloxacillin, Dr. Lieberman said.

To help prevent infection from bites, wounds should be cleaned, debrided, and closed. Bite wounds should be reevaluated in 1-2 days. When indicated, there may be a need for tetanus and/or rabies prophylaxis.

Antibiotic prophylaxis is indicated for puncture wounds (including all cat bites), bites over tendons, joints, and bone; bites on the face and/or genitals; bites involving an immunocompromised person; and bites that cannot be well cleaned and debrided. Antibiotic prophylaxis, when indicated, may be used for 48-72 hours.

Amoxicillin-clavulanate is the antibiotic of choice for prevention or treatment of animal bite wound infections, he said. Alternatives include a combination of cephalexin or dicloxacillin and penicillin V or a combination of clindamycin and trimethoprim-sulfamethoxazole.

▸ Rat-bite fever. This is "caused by Streptobacillus moniliformis, an unusual gram-negative pleomorphic rod. It is normal oral flora in rats and can be excreted in rat urine. Humans are infected after a bite or scratch—or kiss—from an infected rat, or after handling a rat or ingesting food or water contaminated with rat excreta," explained Dr. Lieberman.

There is an incubation period of 2-10 days, followed by rapid onset of fever, chills, headache, and myalgia.

Rash may develop 2-4 days after the onset of fever. The rash usually is maculopapular, often including the palms of hands and soles of feet, and it may evolve into petechiae, purpura, and vesicles. About half of patients develop an asymmetric septic polyarthritis.

Dr. Lieberman described three children with rat-bite fever seen at his hospital over the past several years, all of whom presented with fevers, polyarthritis, and the characteristic rash, which was most prominent on the soles of the feet.

The treatment of choice is penicillin G. "These patients get better quickly," he said.

▸ Salmonellosis. About 3% of U.S. households have reptiles, most commonly lizards, snakes, turtles. Tortoises are chronic, intermittent shedders of Salmonella, and the Centers for Disease Control and Prevention estimates that more than 70,000 reptile-associated U.S. cases of salmonellosis occur each year, Dr. Lieberman said.

Rules for dealing with reptiles include washing hands thoroughly after handling them.

Also, reptiles should be kept out of child care centers and households in which there are children younger than 5 years or immunocompromised people living, he noted.

Dr. Lieberman disclosed that he is on a speakers' bureau for GlaxoSmithKline.

'Most patients do not require specific therapy, and the illness resolves on its own.' DR. LIEBERMAN

An 8-year-old girl with cat-scratch lymphadenopathy, which typically involves the nodes that drain the inoculation site, is shown. Courtesy Dr. Sherif Emil

MAUI, HAWAII — Cat-scratch disease should be consided in any patient with fever of an unknown origin who has had contact with cats—especially kittens, according to Dr. Jay M. Lieberman.

He presented several cases of children with prolonged fevers who remained without a diagnosis, despite extensive evaluations, until the possibility of cat-scratch disease was entertained and a history of contact with kittens was obtained.

The diagnosis of cat-scratch disease often can be made from the history and physical examination, and serologies may not be reliable, Dr. Lieberman said at a meeting sponsored by the University Childrens Medical Group and the American Academy of Pediatrics.

Kittens are more likely to cause cat-scratch disease than are older cats.

The disease is caused by Bartonella henselae, and approximately 40% of cats are bacteremic with the organism, explained Dr. Lieberman, who is professor of clinical pediatrics at the University of California, Irvine.

Cat-scratch disease is transmitted to humans through scratches, licks, or bites from kittens, less often from older cats, and sometimes from dogs.

A primary papule may be seen 3-12 days after inoculation time, followed 7-60 days (average 12-14 days) later by regional lymphadenopathy that may suppurate or regress over 2-4 months.

Lymphadenopathy usually involves the nodes that drain the site of inoculation. Fever occurs in half of patients, and malaise, anorexia, and headache also may occur.

The area around the nodes may be noninflamed but can be warm, tender, and erythematous, Dr. Lieberman said at the meeting, which also was sponsored by California Chapter 2 of the AAP. As many as 30% of nodes will suppurate spontaneously.

Atypical presentations of cat-scratch disease included prolonged fever/fever of unknown origin, granulomatous hepatitis, conjunctivitis with preauricular adenopathy (Parinaud's oculoglandular syndrome), encephalopathy/encephalitis, osteomyelitis, and ocular disease.

Although patients may be treated with rifampin or gentamicin or trimethoprim-sulfamethoxazole (TMP/SMZ), or a combination of anti-infectives, Dr. Lieberman does not routinely recommend their use.

"In general, we have not treated our patients with antimicrobial therapy," he said. "Most patients do not require specific therapy, and the illness resolves on its own."

One prospective randomized trial of azithromycin vs. placebo found a significantly greater decrease in lymph node size in azithromycin-treated patients at 30 days, but there was no significant difference thereafter (Pediatr. Infect. Dis. J. 1998;17:447-52).

Dr. Lieberman then discussed other infections that can be acquired from pets:

▸ Dog and cat bite wound infections. Approximately 5%-15% of dog bites lead to infections, as do 20%-50% of cat bites.

Pasteurella species, short gram-negative coccobacilli that are part of the normal flora of cats and dogs, are isolated from 75% of infections from cat bites and 50% of infections from dog bites.

Pasteurella organisms are not susceptible to cephalexin or dicloxacillin, Dr. Lieberman said.

To help prevent infection from bites, wounds should be cleaned, debrided, and closed. Bite wounds should be reevaluated in 1-2 days. When indicated, there may be a need for tetanus and/or rabies prophylaxis.

Antibiotic prophylaxis is indicated for puncture wounds (including all cat bites), bites over tendons, joints, and bone; bites on the face and/or genitals; bites involving an immunocompromised person; and bites that cannot be well cleaned and debrided. Antibiotic prophylaxis, when indicated, may be used for 48-72 hours.

Amoxicillin-clavulanate is the antibiotic of choice for prevention or treatment of animal bite wound infections, he said. Alternatives include a combination of cephalexin or dicloxacillin and penicillin V or a combination of clindamycin and trimethoprim-sulfamethoxazole.

▸ Rat-bite fever. This is "caused by Streptobacillus moniliformis, an unusual gram-negative pleomorphic rod. It is normal oral flora in rats and can be excreted in rat urine. Humans are infected after a bite or scratch—or kiss—from an infected rat, or after handling a rat or ingesting food or water contaminated with rat excreta," explained Dr. Lieberman.

There is an incubation period of 2-10 days, followed by rapid onset of fever, chills, headache, and myalgia.

Rash may develop 2-4 days after the onset of fever. The rash usually is maculopapular, often including the palms of hands and soles of feet, and it may evolve into petechiae, purpura, and vesicles. About half of patients develop an asymmetric septic polyarthritis.

Dr. Lieberman described three children with rat-bite fever seen at his hospital over the past several years, all of whom presented with fevers, polyarthritis, and the characteristic rash, which was most prominent on the soles of the feet.

The treatment of choice is penicillin G. "These patients get better quickly," he said.

▸ Salmonellosis. About 3% of U.S. households have reptiles, most commonly lizards, snakes, turtles. Tortoises are chronic, intermittent shedders of Salmonella, and the Centers for Disease Control and Prevention estimates that more than 70,000 reptile-associated U.S. cases of salmonellosis occur each year, Dr. Lieberman said.

Rules for dealing with reptiles include washing hands thoroughly after handling them.

Also, reptiles should be kept out of child care centers and households in which there are children younger than 5 years or immunocompromised people living, he noted.

Dr. Lieberman disclosed that he is on a speakers' bureau for GlaxoSmithKline.

'Most patients do not require specific therapy, and the illness resolves on its own.' DR. LIEBERMAN

An 8-year-old girl with cat-scratch lymphadenopathy, which typically involves the nodes that drain the inoculation site, is shown. Courtesy Dr. Sherif Emil

MAUI, HAWAII — Cat-scratch disease should be consided in any patient with fever of an unknown origin who has had contact with cats—especially kittens, according to Dr. Jay M. Lieberman.

He presented several cases of children with prolonged fevers who remained without a diagnosis, despite extensive evaluations, until the possibility of cat-scratch disease was entertained and a history of contact with kittens was obtained.

The diagnosis of cat-scratch disease often can be made from the history and physical examination, and serologies may not be reliable, Dr. Lieberman said at a meeting sponsored by the University Childrens Medical Group and the American Academy of Pediatrics.

Kittens are more likely to cause cat-scratch disease than are older cats.

The disease is caused by Bartonella henselae, and approximately 40% of cats are bacteremic with the organism, explained Dr. Lieberman, who is professor of clinical pediatrics at the University of California, Irvine.

Cat-scratch disease is transmitted to humans through scratches, licks, or bites from kittens, less often from older cats, and sometimes from dogs.

A primary papule may be seen 3-12 days after inoculation time, followed 7-60 days (average 12-14 days) later by regional lymphadenopathy that may suppurate or regress over 2-4 months.

Lymphadenopathy usually involves the nodes that drain the site of inoculation. Fever occurs in half of patients, and malaise, anorexia, and headache also may occur.

The area around the nodes may be noninflamed but can be warm, tender, and erythematous, Dr. Lieberman said at the meeting, which also was sponsored by California Chapter 2 of the AAP. As many as 30% of nodes will suppurate spontaneously.

Atypical presentations of cat-scratch disease included prolonged fever/fever of unknown origin, granulomatous hepatitis, conjunctivitis with preauricular adenopathy (Parinaud's oculoglandular syndrome), encephalopathy/encephalitis, osteomyelitis, and ocular disease.

Although patients may be treated with rifampin or gentamicin or trimethoprim-sulfamethoxazole (TMP/SMZ), or a combination of anti-infectives, Dr. Lieberman does not routinely recommend their use.

"In general, we have not treated our patients with antimicrobial therapy," he said. "Most patients do not require specific therapy, and the illness resolves on its own."

One prospective randomized trial of azithromycin vs. placebo found a significantly greater decrease in lymph node size in azithromycin-treated patients at 30 days, but there was no significant difference thereafter (Pediatr. Infect. Dis. J. 1998;17:447-52).

Dr. Lieberman then discussed other infections that can be acquired from pets:

▸ Dog and cat bite wound infections. Approximately 5%-15% of dog bites lead to infections, as do 20%-50% of cat bites.

Pasteurella species, short gram-negative coccobacilli that are part of the normal flora of cats and dogs, are isolated from 75% of infections from cat bites and 50% of infections from dog bites.

Pasteurella organisms are not susceptible to cephalexin or dicloxacillin, Dr. Lieberman said.

To help prevent infection from bites, wounds should be cleaned, debrided, and closed. Bite wounds should be reevaluated in 1-2 days. When indicated, there may be a need for tetanus and/or rabies prophylaxis.

Antibiotic prophylaxis is indicated for puncture wounds (including all cat bites), bites over tendons, joints, and bone; bites on the face and/or genitals; bites involving an immunocompromised person; and bites that cannot be well cleaned and debrided. Antibiotic prophylaxis, when indicated, may be used for 48-72 hours.

Amoxicillin-clavulanate is the antibiotic of choice for prevention or treatment of animal bite wound infections, he said. Alternatives include a combination of cephalexin or dicloxacillin and penicillin V or a combination of clindamycin and trimethoprim-sulfamethoxazole.

▸ Rat-bite fever. This is "caused by Streptobacillus moniliformis, an unusual gram-negative pleomorphic rod. It is normal oral flora in rats and can be excreted in rat urine. Humans are infected after a bite or scratch—or kiss—from an infected rat, or after handling a rat or ingesting food or water contaminated with rat excreta," explained Dr. Lieberman.

There is an incubation period of 2-10 days, followed by rapid onset of fever, chills, headache, and myalgia.

Rash may develop 2-4 days after the onset of fever. The rash usually is maculopapular, often including the palms of hands and soles of feet, and it may evolve into petechiae, purpura, and vesicles. About half of patients develop an asymmetric septic polyarthritis.

Dr. Lieberman described three children with rat-bite fever seen at his hospital over the past several years, all of whom presented with fevers, polyarthritis, and the characteristic rash, which was most prominent on the soles of the feet.

The treatment of choice is penicillin G. "These patients get better quickly," he said.

▸ Salmonellosis. About 3% of U.S. households have reptiles, most commonly lizards, snakes, turtles. Tortoises are chronic, intermittent shedders of Salmonella, and the Centers for Disease Control and Prevention estimates that more than 70,000 reptile-associated U.S. cases of salmonellosis occur each year, Dr. Lieberman said.

Rules for dealing with reptiles include washing hands thoroughly after handling them.

Also, reptiles should be kept out of child care centers and households in which there are children younger than 5 years or immunocompromised people living, he noted.

Dr. Lieberman disclosed that he is on a speakers' bureau for GlaxoSmithKline.

'Most patients do not require specific therapy, and the illness resolves on its own.' DR. LIEBERMAN

An 8-year-old girl with cat-scratch lymphadenopathy, which typically involves the nodes that drain the inoculation site, is shown. Courtesy Dr. Sherif Emil

MAUI, HAWAII — All that appears to be croup is not, said Dr. Seth M. Pransky.

The conditions mimicking croup range from anatomical problems to gastroesophageal reflux disease (GERD) to an infection contracted at birth, said Dr. Pransky, director of pediatric otolaryngology at Rady Children's Hospital, San Diego. They include the following:

▸ Subglottic hemangioma. These patients “present with 'croup' at about 6 weeks of age, but they have no fever, they have a good cry, and up until that point they've been eating pretty well,” he said at a meeting sponsored by the University Childrens Medical Group and the American Academy of Pediatrics. “But they come in with some respiratory difficulty.”

These patients have a submucosal mass, located beneath the vocal cords, most likely in the left posterolateral wall, he explained. Females are more likely to have it than are males, by a ratio of 3.5:1.

Management options include the use of steroids, GERD therapy, and—in life-threatening cases only—vincristine, he said. Surgery is usually necessary and often is done endoscopically. Open surgical excision also can be performed. Rarely, tracheostomy is necessary.

▸ Postintubation glottic and subglottic lesions. These may be caused by either long or quick intubations, he said at the meeting, which was also sponsored by California Chapter 2 of the AAP.

In the subglottis, mucous glands abraded by intubation become obstructed and secrete heavily, creating a thick-walled cyst, especially when the patient has a cold; this causes airway obstruction.

“These patients present with stridor, typically when they have a cold,” he said. The situation usually resolves with the abatement of the cold. A history will reveal the prior intubation that caused the situation, and there are surgical options for treatment.

▸ Congenital airway abnormalities. These include glottic webs, which tend to be thick and to extend to the subglottis. They include the 22q deletion syndrome, which is associated with a variety of abnormalities, including speech abnormalities. It's a form of laryngeal atresia, an abnormality in the pharynx. There are surgical options for treatment.

▸ Laryngeal clefts. These are associated with recurrent cough and aspiration problems, he explained. “Clefts [classified as Veau I or II] can be treated endoscopically. Clefts [classified as Veau III] go into the trachea itself and require open surgical intervention.”

▸ Recurrent respiratory papillomatosis (RRP). The patient may have a history of “asthma” or recurrent croup, but the correct diagnosis is usually identified at about age 3 years, although this infection has been found in neonates. Ask about maternal vaginal condylomata, Dr. Pransky recommended. In preadolescent patients, especially girls, think about the possibility of sexual abuse, because this disease is caused by the human papillomavirus (HPV). If the child was infected by the mother during delivery, keep in mind that the infection may clear from women within 2 years, and therefore may be absent from the mother by the time the physician finds the infection in the child.

The goals of treatment are to maintain the airway and voice and to prevent the disease from spreading to the lungs, where it can convert to a malignancy. Tracheostomy is avoided because the site of incision is where the virus is likely to go.

A drug that may be helpful in patients with RRP from HPV infection is cidofovir, which is approved for treatment of cytomegalovirus retinitis in HIV patients. Several studies have found “lasting remission in pediatric patients about 50% of the time,” he said. “Lasting remission is 5 years without disease,” he added.

But the most important measure to take in preventing RRP is vaccination for HPV, he emphasized.

▸ Gastroesophageal reflux disease (GERD). The occurrence of nocturnal cough is the most important piece of clinical information suggesting GERD. Ear-nose-throat manifestations of and associations with GERD include rhinitis of infancy, recurrent otitis, chronic sinusitis, stridor, hoarseness, chronic cough (especially nocturnal), halitosis, laryngospasm/apnea, severe laryngomalacia, recurrent croup, subglottic stenosis, recurrent bronchitis, and asthma.

▸ Eosinophilic esophagitis (EE). The symptoms of this disorder are similar to GERD but often do not respond to GERD therapy. Adolescents who do not have a history of a tracheoesophageal fistula but who gag on food or have swallowing problems may have EE, he said, “unless proven otherwise.”

“It's very hard to treat; right now, the only treatment is swallowed steroids,” he noted. He predicted that there would be a patented product available for EE treatment within a year.

▸ Foreign body. A history may reveal this problem, along with x-rays and the presence of a transient wheeze. The use of a double-headed stethoscope allows the physician to listen to both sides of the lungs at the same time and to check for subtle differences suggestive of a foreign body. “The critical issue for tracheal or airway foreign bodies is history, history, history,” said Dr. Pransky who disclosed that he is on the speakers' bureau for Merck & Co.; he also conducts research with ArthroCare Corp. and Medtronic Inc.

MAUI, HAWAII — All that appears to be croup is not, said Dr. Seth M. Pransky.

The conditions mimicking croup range from anatomical problems to gastroesophageal reflux disease (GERD) to an infection contracted at birth, said Dr. Pransky, director of pediatric otolaryngology at Rady Children's Hospital, San Diego. They include the following:

▸ Subglottic hemangioma. These patients “present with 'croup' at about 6 weeks of age, but they have no fever, they have a good cry, and up until that point they've been eating pretty well,” he said at a meeting sponsored by the University Childrens Medical Group and the American Academy of Pediatrics. “But they come in with some respiratory difficulty.”

These patients have a submucosal mass, located beneath the vocal cords, most likely in the left posterolateral wall, he explained. Females are more likely to have it than are males, by a ratio of 3.5:1.

Management options include the use of steroids, GERD therapy, and—in life-threatening cases only—vincristine, he said. Surgery is usually necessary and often is done endoscopically. Open surgical excision also can be performed. Rarely, tracheostomy is necessary.

▸ Postintubation glottic and subglottic lesions. These may be caused by either long or quick intubations, he said at the meeting, which was also sponsored by California Chapter 2 of the AAP.

In the subglottis, mucous glands abraded by intubation become obstructed and secrete heavily, creating a thick-walled cyst, especially when the patient has a cold; this causes airway obstruction.

“These patients present with stridor, typically when they have a cold,” he said. The situation usually resolves with the abatement of the cold. A history will reveal the prior intubation that caused the situation, and there are surgical options for treatment.

▸ Congenital airway abnormalities. These include glottic webs, which tend to be thick and to extend to the subglottis. They include the 22q deletion syndrome, which is associated with a variety of abnormalities, including speech abnormalities. It's a form of laryngeal atresia, an abnormality in the pharynx. There are surgical options for treatment.

▸ Laryngeal clefts. These are associated with recurrent cough and aspiration problems, he explained. “Clefts [classified as Veau I or II] can be treated endoscopically. Clefts [classified as Veau III] go into the trachea itself and require open surgical intervention.”

▸ Recurrent respiratory papillomatosis (RRP). The patient may have a history of “asthma” or recurrent croup, but the correct diagnosis is usually identified at about age 3 years, although this infection has been found in neonates. Ask about maternal vaginal condylomata, Dr. Pransky recommended. In preadolescent patients, especially girls, think about the possibility of sexual abuse, because this disease is caused by the human papillomavirus (HPV). If the child was infected by the mother during delivery, keep in mind that the infection may clear from women within 2 years, and therefore may be absent from the mother by the time the physician finds the infection in the child.

The goals of treatment are to maintain the airway and voice and to prevent the disease from spreading to the lungs, where it can convert to a malignancy. Tracheostomy is avoided because the site of incision is where the virus is likely to go.

A drug that may be helpful in patients with RRP from HPV infection is cidofovir, which is approved for treatment of cytomegalovirus retinitis in HIV patients. Several studies have found “lasting remission in pediatric patients about 50% of the time,” he said. “Lasting remission is 5 years without disease,” he added.

But the most important measure to take in preventing RRP is vaccination for HPV, he emphasized.

▸ Gastroesophageal reflux disease (GERD). The occurrence of nocturnal cough is the most important piece of clinical information suggesting GERD. Ear-nose-throat manifestations of and associations with GERD include rhinitis of infancy, recurrent otitis, chronic sinusitis, stridor, hoarseness, chronic cough (especially nocturnal), halitosis, laryngospasm/apnea, severe laryngomalacia, recurrent croup, subglottic stenosis, recurrent bronchitis, and asthma.

▸ Eosinophilic esophagitis (EE). The symptoms of this disorder are similar to GERD but often do not respond to GERD therapy. Adolescents who do not have a history of a tracheoesophageal fistula but who gag on food or have swallowing problems may have EE, he said, “unless proven otherwise.”

“It's very hard to treat; right now, the only treatment is swallowed steroids,” he noted. He predicted that there would be a patented product available for EE treatment within a year.

▸ Foreign body. A history may reveal this problem, along with x-rays and the presence of a transient wheeze. The use of a double-headed stethoscope allows the physician to listen to both sides of the lungs at the same time and to check for subtle differences suggestive of a foreign body. “The critical issue for tracheal or airway foreign bodies is history, history, history,” said Dr. Pransky who disclosed that he is on the speakers' bureau for Merck & Co.; he also conducts research with ArthroCare Corp. and Medtronic Inc.

MAUI, HAWAII — All that appears to be croup is not, said Dr. Seth M. Pransky.

The conditions mimicking croup range from anatomical problems to gastroesophageal reflux disease (GERD) to an infection contracted at birth, said Dr. Pransky, director of pediatric otolaryngology at Rady Children's Hospital, San Diego. They include the following:

▸ Subglottic hemangioma. These patients “present with 'croup' at about 6 weeks of age, but they have no fever, they have a good cry, and up until that point they've been eating pretty well,” he said at a meeting sponsored by the University Childrens Medical Group and the American Academy of Pediatrics. “But they come in with some respiratory difficulty.”

These patients have a submucosal mass, located beneath the vocal cords, most likely in the left posterolateral wall, he explained. Females are more likely to have it than are males, by a ratio of 3.5:1.

Management options include the use of steroids, GERD therapy, and—in life-threatening cases only—vincristine, he said. Surgery is usually necessary and often is done endoscopically. Open surgical excision also can be performed. Rarely, tracheostomy is necessary.

▸ Postintubation glottic and subglottic lesions. These may be caused by either long or quick intubations, he said at the meeting, which was also sponsored by California Chapter 2 of the AAP.

In the subglottis, mucous glands abraded by intubation become obstructed and secrete heavily, creating a thick-walled cyst, especially when the patient has a cold; this causes airway obstruction.

“These patients present with stridor, typically when they have a cold,” he said. The situation usually resolves with the abatement of the cold. A history will reveal the prior intubation that caused the situation, and there are surgical options for treatment.

▸ Congenital airway abnormalities. These include glottic webs, which tend to be thick and to extend to the subglottis. They include the 22q deletion syndrome, which is associated with a variety of abnormalities, including speech abnormalities. It's a form of laryngeal atresia, an abnormality in the pharynx. There are surgical options for treatment.

▸ Laryngeal clefts. These are associated with recurrent cough and aspiration problems, he explained. “Clefts [classified as Veau I or II] can be treated endoscopically. Clefts [classified as Veau III] go into the trachea itself and require open surgical intervention.”

▸ Recurrent respiratory papillomatosis (RRP). The patient may have a history of “asthma” or recurrent croup, but the correct diagnosis is usually identified at about age 3 years, although this infection has been found in neonates. Ask about maternal vaginal condylomata, Dr. Pransky recommended. In preadolescent patients, especially girls, think about the possibility of sexual abuse, because this disease is caused by the human papillomavirus (HPV). If the child was infected by the mother during delivery, keep in mind that the infection may clear from women within 2 years, and therefore may be absent from the mother by the time the physician finds the infection in the child.

The goals of treatment are to maintain the airway and voice and to prevent the disease from spreading to the lungs, where it can convert to a malignancy. Tracheostomy is avoided because the site of incision is where the virus is likely to go.

A drug that may be helpful in patients with RRP from HPV infection is cidofovir, which is approved for treatment of cytomegalovirus retinitis in HIV patients. Several studies have found “lasting remission in pediatric patients about 50% of the time,” he said. “Lasting remission is 5 years without disease,” he added.

But the most important measure to take in preventing RRP is vaccination for HPV, he emphasized.

▸ Gastroesophageal reflux disease (GERD). The occurrence of nocturnal cough is the most important piece of clinical information suggesting GERD. Ear-nose-throat manifestations of and associations with GERD include rhinitis of infancy, recurrent otitis, chronic sinusitis, stridor, hoarseness, chronic cough (especially nocturnal), halitosis, laryngospasm/apnea, severe laryngomalacia, recurrent croup, subglottic stenosis, recurrent bronchitis, and asthma.

▸ Eosinophilic esophagitis (EE). The symptoms of this disorder are similar to GERD but often do not respond to GERD therapy. Adolescents who do not have a history of a tracheoesophageal fistula but who gag on food or have swallowing problems may have EE, he said, “unless proven otherwise.”

“It's very hard to treat; right now, the only treatment is swallowed steroids,” he noted. He predicted that there would be a patented product available for EE treatment within a year.

▸ Foreign body. A history may reveal this problem, along with x-rays and the presence of a transient wheeze. The use of a double-headed stethoscope allows the physician to listen to both sides of the lungs at the same time and to check for subtle differences suggestive of a foreign body. “The critical issue for tracheal or airway foreign bodies is history, history, history,” said Dr. Pransky who disclosed that he is on the speakers' bureau for Merck & Co.; he also conducts research with ArthroCare Corp. and Medtronic Inc.

MAUI, HAWAII — A number of studies have examined the association of botulinum toxin type A treatment with reduced symptoms of depression, but the connection is still unexplained, Dr. Frederick C. Beddingfield III said at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation.

Depressive symptoms commonly occur in patients who have a negative perception about their appearance, and effective treatment often is accompanied by improved psychosocial function, but the limitations and mixed results of the studies that have been conducted leave open the question of how botulinum toxin type A (Botox) is associated with improved psychosocial function, said Dr. Beddingfield of the University of California, Los Angeles. He also is vice president and therapeutic area head of dermatology clinical research at Allergan, which manufactures Botox.

A study of botulinum toxin type A for the treatment of glabellar frown lines in 10 patients with major depressive disorder (MDD) found that 9 patients no longer had MDD after 2 months of treatment (Dermatol. Surg. 2006;32:645–50). But since the study had a small number of patients and was not randomized, blinded, or placebo controlled, the results are interesting but inconclusive, he said.

He also discussed a 4-week study of botulinum toxin type A for focal hyperhidrosis in 70 outpatients (43 female, 27 male). Reductions in depression, anxiety, and social phobia were statistically significant but clinically insignificant because patients were within normal limits at baseline. There was a statistically and clinically significant improvement in "social insecurity" scores (Br. J. Dermatol. 2005;152:342–5).

A study of 289 patients (101 men, 188 women) treated with botulinum toxin type A for cervical dystonia found that treatment was associated with less depression and anxiety, along with an improved quality of life (J. Neurol. Neurosurg. Psychiatry 2002;72:608–14).

A 4-week study of 89 patients with blepharospasm and 131 patients with cervical dystonia (CD) treated with botulinum toxin type A found improvements in clinical symptoms for both blepharospasm and CD patients, accompanied by reduced depression in CD patients (correlated with reduced neck pain) but not in blepharospasm patients, Dr. Beddingfield said.

Quality of life improved minimally for CD patients and not at all for blepharospasm patients (J. Neurol. 2002;249:842–6).

In a study of 51 outpatients (32 female, 19 male) treated for blepharospasm with botulinum toxin type A for 1–7 years, investigators found that all but 1 patient had a positive outcome from treatment (Acta Neurol. Scand. 2001;103:49–52). Twenty-nine patients felt depressed, 19 expressed fear of recurrence of blepharospasm symptoms, 27 expressed fear of increasing doses of botulinum toxin type A, 37 found widespread work improvements from therapy, and 34 said they felt more independent of other people, he said.

Of 32 patients treated for spasmodic dysphonia (SD) in another study, with follow-up for 22 patients after week 1 and 13 after 2 months, those who were depressed before treatment had significant improvements in depression and anxiety measures by 1 week following treatment. But depression and anxiety measures did not improve significantly between week 1 and month 2 after treatment (Arch. Otolaryngol. 1994;120:310–6).

There were statistically significant improvements in measures of depression, anxiety, quality of life, and somatization after 1 month in a different study of 10 patients treated with botulinum toxin type A for SD (Gen. Hosp. Psychiatry 1998;20:255–9).

A study of 26 patients (5 male, 21 female) treated for torticollis found improvements in torticollis symptoms accompanied by a statistically significant improvement in mood and reduced depression (J. Neurol. Neurosurg. Psychiatry 1992;55:229–31).

Investigators who treated 16 patients with botulinum toxin type A for idiopathic torticollis found no significant improvement in patients' or physicians' assessments of head position through five follow-up visits (Mov. Disord. 1995;10:398). There were, however, significant improvements in patients' symptoms of depression, perceived disfigurement, interference with daily activities, experience of pain, and overall impression of their torticollis, he said.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

MAUI, HAWAII — A number of studies have examined the association of botulinum toxin type A treatment with reduced symptoms of depression, but the connection is still unexplained, Dr. Frederick C. Beddingfield III said at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation.

Depressive symptoms commonly occur in patients who have a negative perception about their appearance, and effective treatment often is accompanied by improved psychosocial function, but the limitations and mixed results of the studies that have been conducted leave open the question of how botulinum toxin type A (Botox) is associated with improved psychosocial function, said Dr. Beddingfield of the University of California, Los Angeles. He also is vice president and therapeutic area head of dermatology clinical research at Allergan, which manufactures Botox.

A study of botulinum toxin type A for the treatment of glabellar frown lines in 10 patients with major depressive disorder (MDD) found that 9 patients no longer had MDD after 2 months of treatment (Dermatol. Surg. 2006;32:645–50). But since the study had a small number of patients and was not randomized, blinded, or placebo controlled, the results are interesting but inconclusive, he said.

He also discussed a 4-week study of botulinum toxin type A for focal hyperhidrosis in 70 outpatients (43 female, 27 male). Reductions in depression, anxiety, and social phobia were statistically significant but clinically insignificant because patients were within normal limits at baseline. There was a statistically and clinically significant improvement in "social insecurity" scores (Br. J. Dermatol. 2005;152:342–5).

A study of 289 patients (101 men, 188 women) treated with botulinum toxin type A for cervical dystonia found that treatment was associated with less depression and anxiety, along with an improved quality of life (J. Neurol. Neurosurg. Psychiatry 2002;72:608–14).

A 4-week study of 89 patients with blepharospasm and 131 patients with cervical dystonia (CD) treated with botulinum toxin type A found improvements in clinical symptoms for both blepharospasm and CD patients, accompanied by reduced depression in CD patients (correlated with reduced neck pain) but not in blepharospasm patients, Dr. Beddingfield said.

Quality of life improved minimally for CD patients and not at all for blepharospasm patients (J. Neurol. 2002;249:842–6).

In a study of 51 outpatients (32 female, 19 male) treated for blepharospasm with botulinum toxin type A for 1–7 years, investigators found that all but 1 patient had a positive outcome from treatment (Acta Neurol. Scand. 2001;103:49–52). Twenty-nine patients felt depressed, 19 expressed fear of recurrence of blepharospasm symptoms, 27 expressed fear of increasing doses of botulinum toxin type A, 37 found widespread work improvements from therapy, and 34 said they felt more independent of other people, he said.

Of 32 patients treated for spasmodic dysphonia (SD) in another study, with follow-up for 22 patients after week 1 and 13 after 2 months, those who were depressed before treatment had significant improvements in depression and anxiety measures by 1 week following treatment. But depression and anxiety measures did not improve significantly between week 1 and month 2 after treatment (Arch. Otolaryngol. 1994;120:310–6).

There were statistically significant improvements in measures of depression, anxiety, quality of life, and somatization after 1 month in a different study of 10 patients treated with botulinum toxin type A for SD (Gen. Hosp. Psychiatry 1998;20:255–9).

A study of 26 patients (5 male, 21 female) treated for torticollis found improvements in torticollis symptoms accompanied by a statistically significant improvement in mood and reduced depression (J. Neurol. Neurosurg. Psychiatry 1992;55:229–31).

Investigators who treated 16 patients with botulinum toxin type A for idiopathic torticollis found no significant improvement in patients' or physicians' assessments of head position through five follow-up visits (Mov. Disord. 1995;10:398). There were, however, significant improvements in patients' symptoms of depression, perceived disfigurement, interference with daily activities, experience of pain, and overall impression of their torticollis, he said.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

MAUI, HAWAII — A number of studies have examined the association of botulinum toxin type A treatment with reduced symptoms of depression, but the connection is still unexplained, Dr. Frederick C. Beddingfield III said at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation.

Depressive symptoms commonly occur in patients who have a negative perception about their appearance, and effective treatment often is accompanied by improved psychosocial function, but the limitations and mixed results of the studies that have been conducted leave open the question of how botulinum toxin type A (Botox) is associated with improved psychosocial function, said Dr. Beddingfield of the University of California, Los Angeles. He also is vice president and therapeutic area head of dermatology clinical research at Allergan, which manufactures Botox.

A study of botulinum toxin type A for the treatment of glabellar frown lines in 10 patients with major depressive disorder (MDD) found that 9 patients no longer had MDD after 2 months of treatment (Dermatol. Surg. 2006;32:645–50). But since the study had a small number of patients and was not randomized, blinded, or placebo controlled, the results are interesting but inconclusive, he said.

He also discussed a 4-week study of botulinum toxin type A for focal hyperhidrosis in 70 outpatients (43 female, 27 male). Reductions in depression, anxiety, and social phobia were statistically significant but clinically insignificant because patients were within normal limits at baseline. There was a statistically and clinically significant improvement in "social insecurity" scores (Br. J. Dermatol. 2005;152:342–5).

A study of 289 patients (101 men, 188 women) treated with botulinum toxin type A for cervical dystonia found that treatment was associated with less depression and anxiety, along with an improved quality of life (J. Neurol. Neurosurg. Psychiatry 2002;72:608–14).

A 4-week study of 89 patients with blepharospasm and 131 patients with cervical dystonia (CD) treated with botulinum toxin type A found improvements in clinical symptoms for both blepharospasm and CD patients, accompanied by reduced depression in CD patients (correlated with reduced neck pain) but not in blepharospasm patients, Dr. Beddingfield said.

Quality of life improved minimally for CD patients and not at all for blepharospasm patients (J. Neurol. 2002;249:842–6).

In a study of 51 outpatients (32 female, 19 male) treated for blepharospasm with botulinum toxin type A for 1–7 years, investigators found that all but 1 patient had a positive outcome from treatment (Acta Neurol. Scand. 2001;103:49–52). Twenty-nine patients felt depressed, 19 expressed fear of recurrence of blepharospasm symptoms, 27 expressed fear of increasing doses of botulinum toxin type A, 37 found widespread work improvements from therapy, and 34 said they felt more independent of other people, he said.

Of 32 patients treated for spasmodic dysphonia (SD) in another study, with follow-up for 22 patients after week 1 and 13 after 2 months, those who were depressed before treatment had significant improvements in depression and anxiety measures by 1 week following treatment. But depression and anxiety measures did not improve significantly between week 1 and month 2 after treatment (Arch. Otolaryngol. 1994;120:310–6).

There were statistically significant improvements in measures of depression, anxiety, quality of life, and somatization after 1 month in a different study of 10 patients treated with botulinum toxin type A for SD (Gen. Hosp. Psychiatry 1998;20:255–9).

A study of 26 patients (5 male, 21 female) treated for torticollis found improvements in torticollis symptoms accompanied by a statistically significant improvement in mood and reduced depression (J. Neurol. Neurosurg. Psychiatry 1992;55:229–31).

Investigators who treated 16 patients with botulinum toxin type A for idiopathic torticollis found no significant improvement in patients' or physicians' assessments of head position through five follow-up visits (Mov. Disord. 1995;10:398). There were, however, significant improvements in patients' symptoms of depression, perceived disfigurement, interference with daily activities, experience of pain, and overall impression of their torticollis, he said.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

MAUI, HAWAII — An online digital photography management service may improve dermatologists' use of patient photos, Dr. Ashish C. Bhatia said at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation.

To make good use of photos taken of patients, software is needed that allows for easy cataloging, rapid retrieval, and viewing features such as the ability to zoom in for a close-up examination.

Both local software, which is used only on an office computer, and software accessed through an application service provider (ASP) can do this, but there are disadvantages to local software, said Dr. Bhatia of Northwestern University, Chicago.

Drawbacks of local software include up-front costs, the need to update it periodically, and the vulnerability of the photo database to computer crashes. With an ASP, services are provided for a monthly payment, eliminating higher up-front costs.

Since the provider is responsible for continuously upgrading the software, "you don't have to worry about all that," he said. The database is accessible anywhere there is Internet access, and is safer. "If your computer crashes, all your data are not on your local computer," he said.

Secure transactions can be conducted over the Internet, he said. The photos can be shared more readily with referring physicians while complying with HIPAA.

ASPs can also be limited by the Internet. Access may be temporarily lost because of server downtime or power outages, he said, though, "this can happen even with your regular office solutions." Plus, the photo database is stored outside the office, so "they have your data. But most ASPs will send you a hard copy of all your data or send it on a DVD," he said.

There have been significant improvements in ASPs. In the past, it was difficult to access ASP systems from offices with electronic medical record systems or practice management software, "but now most of these companies are making communications conduits to interface with those," Dr. Bhatia said. With his current system, the log-in is done with user names and passwords, which allow different access levels for various people. Dr. Bhatia said that his ASP has enabled him to show before and after pictures to referring physicians by sending them links by e-mail. Access is secured through an encrypted link. The photos cannot be copied or downloaded.

Dr. Bhatia disclosed his meeting expenses were reimbursed by Through the Lens Inc. He is an unpaid consultant to several digital imaging hardware and software companies.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

Photography Tips

Dr. Bhatia offered these tips to better use photography.

Take consistent photographs.

Make sure positioning is consistent to compare photos over time and confirm the results of procedures. Teach staff how to position a patient. Basic views include:

▸ Frontal view.

▸ Oblique (45 degree) view. Put dots on the wall and instruct the patient to stare straight at the different dots for positioning.

▸ Full lateral view, from the top of the head to the collarbone.

Backgrounds are important. Try a portable background or a black or blue box painted on a wall. Distractions should be eliminated by covering up clothing, necklaces, etc. Use a room with no window or a shade.

To maintain a consistent distance, "we actually have markings on the floor for where the patient is supposed to sit," he said. Marks also show the photographer where to stand.

Catalog the photos.

List the patient's name, date, location, and diagnosis for easy retrieval.

Share with patients and referring physicians.

"Before and after" shots may be set up at kiosks. Label these clearly, explaining the procedure.

MAUI, HAWAII — An online digital photography management service may improve dermatologists' use of patient photos, Dr. Ashish C. Bhatia said at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation.

To make good use of photos taken of patients, software is needed that allows for easy cataloging, rapid retrieval, and viewing features such as the ability to zoom in for a close-up examination.

Both local software, which is used only on an office computer, and software accessed through an application service provider (ASP) can do this, but there are disadvantages to local software, said Dr. Bhatia of Northwestern University, Chicago.

Drawbacks of local software include up-front costs, the need to update it periodically, and the vulnerability of the photo database to computer crashes. With an ASP, services are provided for a monthly payment, eliminating higher up-front costs.

Since the provider is responsible for continuously upgrading the software, "you don't have to worry about all that," he said. The database is accessible anywhere there is Internet access, and is safer. "If your computer crashes, all your data are not on your local computer," he said.

Secure transactions can be conducted over the Internet, he said. The photos can be shared more readily with referring physicians while complying with HIPAA.

ASPs can also be limited by the Internet. Access may be temporarily lost because of server downtime or power outages, he said, though, "this can happen even with your regular office solutions." Plus, the photo database is stored outside the office, so "they have your data. But most ASPs will send you a hard copy of all your data or send it on a DVD," he said.

There have been significant improvements in ASPs. In the past, it was difficult to access ASP systems from offices with electronic medical record systems or practice management software, "but now most of these companies are making communications conduits to interface with those," Dr. Bhatia said. With his current system, the log-in is done with user names and passwords, which allow different access levels for various people. Dr. Bhatia said that his ASP has enabled him to show before and after pictures to referring physicians by sending them links by e-mail. Access is secured through an encrypted link. The photos cannot be copied or downloaded.

Dr. Bhatia disclosed his meeting expenses were reimbursed by Through the Lens Inc. He is an unpaid consultant to several digital imaging hardware and software companies.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

Photography Tips

Dr. Bhatia offered these tips to better use photography.

Take consistent photographs.

Make sure positioning is consistent to compare photos over time and confirm the results of procedures. Teach staff how to position a patient. Basic views include:

▸ Frontal view.

▸ Oblique (45 degree) view. Put dots on the wall and instruct the patient to stare straight at the different dots for positioning.

▸ Full lateral view, from the top of the head to the collarbone.

Backgrounds are important. Try a portable background or a black or blue box painted on a wall. Distractions should be eliminated by covering up clothing, necklaces, etc. Use a room with no window or a shade.

To maintain a consistent distance, "we actually have markings on the floor for where the patient is supposed to sit," he said. Marks also show the photographer where to stand.

Catalog the photos.

List the patient's name, date, location, and diagnosis for easy retrieval.

Share with patients and referring physicians.

"Before and after" shots may be set up at kiosks. Label these clearly, explaining the procedure.

MAUI, HAWAII — An online digital photography management service may improve dermatologists' use of patient photos, Dr. Ashish C. Bhatia said at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation.

To make good use of photos taken of patients, software is needed that allows for easy cataloging, rapid retrieval, and viewing features such as the ability to zoom in for a close-up examination.

Both local software, which is used only on an office computer, and software accessed through an application service provider (ASP) can do this, but there are disadvantages to local software, said Dr. Bhatia of Northwestern University, Chicago.

Drawbacks of local software include up-front costs, the need to update it periodically, and the vulnerability of the photo database to computer crashes. With an ASP, services are provided for a monthly payment, eliminating higher up-front costs.

Since the provider is responsible for continuously upgrading the software, "you don't have to worry about all that," he said. The database is accessible anywhere there is Internet access, and is safer. "If your computer crashes, all your data are not on your local computer," he said.

Secure transactions can be conducted over the Internet, he said. The photos can be shared more readily with referring physicians while complying with HIPAA.

ASPs can also be limited by the Internet. Access may be temporarily lost because of server downtime or power outages, he said, though, "this can happen even with your regular office solutions." Plus, the photo database is stored outside the office, so "they have your data. But most ASPs will send you a hard copy of all your data or send it on a DVD," he said.

There have been significant improvements in ASPs. In the past, it was difficult to access ASP systems from offices with electronic medical record systems or practice management software, "but now most of these companies are making communications conduits to interface with those," Dr. Bhatia said. With his current system, the log-in is done with user names and passwords, which allow different access levels for various people. Dr. Bhatia said that his ASP has enabled him to show before and after pictures to referring physicians by sending them links by e-mail. Access is secured through an encrypted link. The photos cannot be copied or downloaded.

Dr. Bhatia disclosed his meeting expenses were reimbursed by Through the Lens Inc. He is an unpaid consultant to several digital imaging hardware and software companies.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

Photography Tips

Dr. Bhatia offered these tips to better use photography.

Take consistent photographs.

Make sure positioning is consistent to compare photos over time and confirm the results of procedures. Teach staff how to position a patient. Basic views include:

▸ Frontal view.

▸ Oblique (45 degree) view. Put dots on the wall and instruct the patient to stare straight at the different dots for positioning.

▸ Full lateral view, from the top of the head to the collarbone.

Backgrounds are important. Try a portable background or a black or blue box painted on a wall. Distractions should be eliminated by covering up clothing, necklaces, etc. Use a room with no window or a shade.

To maintain a consistent distance, "we actually have markings on the floor for where the patient is supposed to sit," he said. Marks also show the photographer where to stand.

Catalog the photos.

List the patient's name, date, location, and diagnosis for easy retrieval.

Share with patients and referring physicians.

"Before and after" shots may be set up at kiosks. Label these clearly, explaining the procedure.

MAUI, HAWAII — A large international study showed aspirin plus dipyridamole worked better than aspirin alone in preventing a major vascular event following a transient ischemic attack or a minor stroke of arterial origin, Dr. Gregory W. Albers said at a symposium on emergency medicine sponsored by Stanford School of Medicine.

The recent European/Australasian Stroke Prevention in Reversible Ischaemia Trial (ESPRIT) was a randomized, open-label study of 2,739 patients who had experienced nondisabling cerebral ischemia of presumed arterial origin, said Dr. Albers, who is professor of neurology and neurological sciences and director of the Stanford Stroke Center, Stanford (Calif.) University Medical Center.

The ESPRIT designers wanted to know whether a combination of aspirin (30–325 mg) plus dipyridamole (200 mg b.i.d.) was better than aspirin (30–325 mg) alone at preventing the primary outcome of stroke, myocardial infarction, major bleeding events, or death from vascular causes (Lancet 2006;367:1665–73). Average patient follow-up was 3.5 years.

There was a statistically significant 20% risk reduction for the combination therapy, he said. “Not only were there fewer strokes, but there were fewer cardiac events,” he said.

“For whatever reason, bleeding doesn't seem to be such an issue, probably because dipyridamole is not much of an antiplatelet agent,” he added. “You don't get the same long-term bleeding effects with dipyridamole and aspirin as you get with clopidogrel and aspirin.”

The Netherlands-based study was a secondary stroke prevention trial not funded by a drug company.

MAUI, HAWAII — A large international study showed aspirin plus dipyridamole worked better than aspirin alone in preventing a major vascular event following a transient ischemic attack or a minor stroke of arterial origin, Dr. Gregory W. Albers said at a symposium on emergency medicine sponsored by Stanford School of Medicine.

The recent European/Australasian Stroke Prevention in Reversible Ischaemia Trial (ESPRIT) was a randomized, open-label study of 2,739 patients who had experienced nondisabling cerebral ischemia of presumed arterial origin, said Dr. Albers, who is professor of neurology and neurological sciences and director of the Stanford Stroke Center, Stanford (Calif.) University Medical Center.

The ESPRIT designers wanted to know whether a combination of aspirin (30–325 mg) plus dipyridamole (200 mg b.i.d.) was better than aspirin (30–325 mg) alone at preventing the primary outcome of stroke, myocardial infarction, major bleeding events, or death from vascular causes (Lancet 2006;367:1665–73). Average patient follow-up was 3.5 years.

There was a statistically significant 20% risk reduction for the combination therapy, he said. “Not only were there fewer strokes, but there were fewer cardiac events,” he said.

“For whatever reason, bleeding doesn't seem to be such an issue, probably because dipyridamole is not much of an antiplatelet agent,” he added. “You don't get the same long-term bleeding effects with dipyridamole and aspirin as you get with clopidogrel and aspirin.”

The Netherlands-based study was a secondary stroke prevention trial not funded by a drug company.

MAUI, HAWAII — A large international study showed aspirin plus dipyridamole worked better than aspirin alone in preventing a major vascular event following a transient ischemic attack or a minor stroke of arterial origin, Dr. Gregory W. Albers said at a symposium on emergency medicine sponsored by Stanford School of Medicine.

The recent European/Australasian Stroke Prevention in Reversible Ischaemia Trial (ESPRIT) was a randomized, open-label study of 2,739 patients who had experienced nondisabling cerebral ischemia of presumed arterial origin, said Dr. Albers, who is professor of neurology and neurological sciences and director of the Stanford Stroke Center, Stanford (Calif.) University Medical Center.

The ESPRIT designers wanted to know whether a combination of aspirin (30–325 mg) plus dipyridamole (200 mg b.i.d.) was better than aspirin (30–325 mg) alone at preventing the primary outcome of stroke, myocardial infarction, major bleeding events, or death from vascular causes (Lancet 2006;367:1665–73). Average patient follow-up was 3.5 years.

There was a statistically significant 20% risk reduction for the combination therapy, he said. “Not only were there fewer strokes, but there were fewer cardiac events,” he said.

“For whatever reason, bleeding doesn't seem to be such an issue, probably because dipyridamole is not much of an antiplatelet agent,” he added. “You don't get the same long-term bleeding effects with dipyridamole and aspirin as you get with clopidogrel and aspirin.”

The Netherlands-based study was a secondary stroke prevention trial not funded by a drug company.

MAUI, HAWAII — Common practices in wound treatment, such as wearing sterile gloves and using saline instead of tap water for irrigation to prevent infection, are not supported by evidence from clinical studies but are continued from fear of lawsuits, Dr. Adam Singer observed at a conference sponsored by the American College of Emergency Physicians.

Dr. Singer examined several common wound treatment practices:

▸ Sterile vs. nonsterile gloves. A multicenter, single-blind, randomized controlled trial had 816 patients (of 9,000 patients) randomized to be treated with either sterile gloves (408) or without sterile gloves (408) (Ann. Emerg. Med. 2004;43:362–70). There was a 97% follow-up rate after 1 week. Infection rates were 6.1% for those patients treated with sterile gloves, compared with 4.4% for those treated without sterile gloves. “Look at how many patients were screened, 9,000, while only 816 were entered,” he said, adding that this suggests a selection bias. Nevertheless, the differences between groups were not statistically significant. “So, there's no difference whether you use sterile gloves or you do not use sterile gloves,” remarked Dr. Singer, professor and vice chairman for research in the department of emergency medicine at the State University of New York at Stony Brook. But given concerns about potential lawsuits, he added, “I just put on the gloves—for a dollar, it's not worth the hassle.”

▸ Wound irrigation in children: saline or tap water? A randomized, controlled trial compared outcomes of wounds irrigated with saline in 271 children with outcomes of wounds irrigated with tap water in 259 children (Ann. Emerg. Med. 2003;41:609–16). In the tap water group, there were more hand wounds, which increased the risk of infection. But the infection rate was 2.8% for saline-irrigated wounds, compared with 2.9% for tap water-irrigated wounds. “The infection rates were almost identical,” Dr. Singer observed. But he doesn't use tap water in practice, he added—for the same reason that he uses sterile gloves.

▸ Effect of cap and mask on infection rates. A study compared infection rates for 442 lacerations (IMJ Ill. Med. J. 1984; 165:397–9). A total of 239 lacerations were repaired while the physician wore a cap and mask, while 203 were repaired without the physician wearing a cap and mask. Infections developed in 2.5% of the patients in the cap-and-mask group, compared with 3.9% of the patients in the non-cap-and-mask group. “These differences are not statistically significant or clinically significant,” Dr. Singer said, “so I don't use caps and masks.”

The goals of wound management have shifted beyond concerns about infections, he indicated.

“The goals of wound management—whether a laceration, abrasion, or any type of burn—are to close the wound early and prevent wound infection,” noted Dr. Singer. “But more and more, we're paying attention to cosmetic outcomes as well as functional outcomes, because infection rates are actually quite rare.” In the emergency department, the infection rate is about 3%–5% he added.

A 1998 study examined treatment outcomes of 1,923 facial and scalp lacerations, of which 1,090 were irrigated and 833 were not irrigated (Ann. Emerg. Med. 1998;31:73–7). The infection rate was 0.9% for irrigated lacerations, compared with 1.4% for nonirrigated lacerations. Optimal cosmesis outcomes were achieved in 76% of irrigated lacerations, compared with 82% of nonirrigated lacerations.

The differences, he observed, were not statistically significant or clinically significant. But the favorable cosmetic outcomes of not using irrigation appeared to approach significance. The conclusion? “You need to use judgment, as always,” Dr. Singer said.

The conference was jointly sponsored by the Institute for Emergency Medical Education.

MAUI, HAWAII — Common practices in wound treatment, such as wearing sterile gloves and using saline instead of tap water for irrigation to prevent infection, are not supported by evidence from clinical studies but are continued from fear of lawsuits, Dr. Adam Singer observed at a conference sponsored by the American College of Emergency Physicians.

Dr. Singer examined several common wound treatment practices:

▸ Sterile vs. nonsterile gloves. A multicenter, single-blind, randomized controlled trial had 816 patients (of 9,000 patients) randomized to be treated with either sterile gloves (408) or without sterile gloves (408) (Ann. Emerg. Med. 2004;43:362–70). There was a 97% follow-up rate after 1 week. Infection rates were 6.1% for those patients treated with sterile gloves, compared with 4.4% for those treated without sterile gloves. “Look at how many patients were screened, 9,000, while only 816 were entered,” he said, adding that this suggests a selection bias. Nevertheless, the differences between groups were not statistically significant. “So, there's no difference whether you use sterile gloves or you do not use sterile gloves,” remarked Dr. Singer, professor and vice chairman for research in the department of emergency medicine at the State University of New York at Stony Brook. But given concerns about potential lawsuits, he added, “I just put on the gloves—for a dollar, it's not worth the hassle.”

▸ Wound irrigation in children: saline or tap water? A randomized, controlled trial compared outcomes of wounds irrigated with saline in 271 children with outcomes of wounds irrigated with tap water in 259 children (Ann. Emerg. Med. 2003;41:609–16). In the tap water group, there were more hand wounds, which increased the risk of infection. But the infection rate was 2.8% for saline-irrigated wounds, compared with 2.9% for tap water-irrigated wounds. “The infection rates were almost identical,” Dr. Singer observed. But he doesn't use tap water in practice, he added—for the same reason that he uses sterile gloves.

▸ Effect of cap and mask on infection rates. A study compared infection rates for 442 lacerations (IMJ Ill. Med. J. 1984; 165:397–9). A total of 239 lacerations were repaired while the physician wore a cap and mask, while 203 were repaired without the physician wearing a cap and mask. Infections developed in 2.5% of the patients in the cap-and-mask group, compared with 3.9% of the patients in the non-cap-and-mask group. “These differences are not statistically significant or clinically significant,” Dr. Singer said, “so I don't use caps and masks.”

The goals of wound management have shifted beyond concerns about infections, he indicated.

“The goals of wound management—whether a laceration, abrasion, or any type of burn—are to close the wound early and prevent wound infection,” noted Dr. Singer. “But more and more, we're paying attention to cosmetic outcomes as well as functional outcomes, because infection rates are actually quite rare.” In the emergency department, the infection rate is about 3%–5% he added.

A 1998 study examined treatment outcomes of 1,923 facial and scalp lacerations, of which 1,090 were irrigated and 833 were not irrigated (Ann. Emerg. Med. 1998;31:73–7). The infection rate was 0.9% for irrigated lacerations, compared with 1.4% for nonirrigated lacerations. Optimal cosmesis outcomes were achieved in 76% of irrigated lacerations, compared with 82% of nonirrigated lacerations.

The differences, he observed, were not statistically significant or clinically significant. But the favorable cosmetic outcomes of not using irrigation appeared to approach significance. The conclusion? “You need to use judgment, as always,” Dr. Singer said.

The conference was jointly sponsored by the Institute for Emergency Medical Education.

MAUI, HAWAII — Common practices in wound treatment, such as wearing sterile gloves and using saline instead of tap water for irrigation to prevent infection, are not supported by evidence from clinical studies but are continued from fear of lawsuits, Dr. Adam Singer observed at a conference sponsored by the American College of Emergency Physicians.

Dr. Singer examined several common wound treatment practices:

▸ Sterile vs. nonsterile gloves. A multicenter, single-blind, randomized controlled trial had 816 patients (of 9,000 patients) randomized to be treated with either sterile gloves (408) or without sterile gloves (408) (Ann. Emerg. Med. 2004;43:362–70). There was a 97% follow-up rate after 1 week. Infection rates were 6.1% for those patients treated with sterile gloves, compared with 4.4% for those treated without sterile gloves. “Look at how many patients were screened, 9,000, while only 816 were entered,” he said, adding that this suggests a selection bias. Nevertheless, the differences between groups were not statistically significant. “So, there's no difference whether you use sterile gloves or you do not use sterile gloves,” remarked Dr. Singer, professor and vice chairman for research in the department of emergency medicine at the State University of New York at Stony Brook. But given concerns about potential lawsuits, he added, “I just put on the gloves—for a dollar, it's not worth the hassle.”

▸ Wound irrigation in children: saline or tap water? A randomized, controlled trial compared outcomes of wounds irrigated with saline in 271 children with outcomes of wounds irrigated with tap water in 259 children (Ann. Emerg. Med. 2003;41:609–16). In the tap water group, there were more hand wounds, which increased the risk of infection. But the infection rate was 2.8% for saline-irrigated wounds, compared with 2.9% for tap water-irrigated wounds. “The infection rates were almost identical,” Dr. Singer observed. But he doesn't use tap water in practice, he added—for the same reason that he uses sterile gloves.

▸ Effect of cap and mask on infection rates. A study compared infection rates for 442 lacerations (IMJ Ill. Med. J. 1984; 165:397–9). A total of 239 lacerations were repaired while the physician wore a cap and mask, while 203 were repaired without the physician wearing a cap and mask. Infections developed in 2.5% of the patients in the cap-and-mask group, compared with 3.9% of the patients in the non-cap-and-mask group. “These differences are not statistically significant or clinically significant,” Dr. Singer said, “so I don't use caps and masks.”

The goals of wound management have shifted beyond concerns about infections, he indicated.

“The goals of wound management—whether a laceration, abrasion, or any type of burn—are to close the wound early and prevent wound infection,” noted Dr. Singer. “But more and more, we're paying attention to cosmetic outcomes as well as functional outcomes, because infection rates are actually quite rare.” In the emergency department, the infection rate is about 3%–5% he added.

A 1998 study examined treatment outcomes of 1,923 facial and scalp lacerations, of which 1,090 were irrigated and 833 were not irrigated (Ann. Emerg. Med. 1998;31:73–7). The infection rate was 0.9% for irrigated lacerations, compared with 1.4% for nonirrigated lacerations. Optimal cosmesis outcomes were achieved in 76% of irrigated lacerations, compared with 82% of nonirrigated lacerations.

The differences, he observed, were not statistically significant or clinically significant. But the favorable cosmetic outcomes of not using irrigation appeared to approach significance. The conclusion? “You need to use judgment, as always,” Dr. Singer said.

The conference was jointly sponsored by the Institute for Emergency Medical Education.