Norra MacReady

NEWPORT BEACH, CALIF. — A foam-rubber pad with a hole in it helps many patients avoid surgery for chondrodermatitis nodularis chronica helicis, P. Haines Ely, M.D., said at the annual meeting of the Pacific Derma-tologic Association.

Chondrodermatitis nodularis chronica helicis (CNCH) is a painful pressure sore on the ear that occurs on actinically damaged skin. It is usually seen in middle-aged men, although rare cases have been reported in children who were paralyzed and always slept on the same side.

Traditionally, CNCH is removed by making a small slit in the skin with a scalpel and using curved scissors or a scalpel to snip out the damaged cartilage. The wound is then closed with sutures or with a drop of cyanoacrylate glue.

This approach is associated with a cure rate of about 80%, but there is also a recurrence rate of 10%–30%, said Dr. Ely, a dermatologist in private practice in Grass Valley, Calif.

He has had longer-term results with 1-inch-thick foam pads that he buys at a local surplus store in 8-foot sheets for about $10 a sheet. He cuts the sheets into smaller pieces approximately the size of a standard pillow, and then cuts a hole where the patient's ear will go. He instructs the patient to slip the foam between the pillowcase and the pillow, and to sleep with the ear resting in the depression formed by the hole.

If the CNCH does not resolve within 1 month, Dr. Ely has the patient come in for surgical excision. So far, virtually none of his patients have returned for surgery.

"I've actually ruined my surgical practice for chondrodermatitis because this almost always works," Dr. Ely said.

NEWPORT BEACH, CALIF. — A foam-rubber pad with a hole in it helps many patients avoid surgery for chondrodermatitis nodularis chronica helicis, P. Haines Ely, M.D., said at the annual meeting of the Pacific Derma-tologic Association.

Chondrodermatitis nodularis chronica helicis (CNCH) is a painful pressure sore on the ear that occurs on actinically damaged skin. It is usually seen in middle-aged men, although rare cases have been reported in children who were paralyzed and always slept on the same side.

Traditionally, CNCH is removed by making a small slit in the skin with a scalpel and using curved scissors or a scalpel to snip out the damaged cartilage. The wound is then closed with sutures or with a drop of cyanoacrylate glue.

This approach is associated with a cure rate of about 80%, but there is also a recurrence rate of 10%–30%, said Dr. Ely, a dermatologist in private practice in Grass Valley, Calif.

He has had longer-term results with 1-inch-thick foam pads that he buys at a local surplus store in 8-foot sheets for about $10 a sheet. He cuts the sheets into smaller pieces approximately the size of a standard pillow, and then cuts a hole where the patient's ear will go. He instructs the patient to slip the foam between the pillowcase and the pillow, and to sleep with the ear resting in the depression formed by the hole.

If the CNCH does not resolve within 1 month, Dr. Ely has the patient come in for surgical excision. So far, virtually none of his patients have returned for surgery.

"I've actually ruined my surgical practice for chondrodermatitis because this almost always works," Dr. Ely said.

NEWPORT BEACH, CALIF. — A foam-rubber pad with a hole in it helps many patients avoid surgery for chondrodermatitis nodularis chronica helicis, P. Haines Ely, M.D., said at the annual meeting of the Pacific Derma-tologic Association.

Chondrodermatitis nodularis chronica helicis (CNCH) is a painful pressure sore on the ear that occurs on actinically damaged skin. It is usually seen in middle-aged men, although rare cases have been reported in children who were paralyzed and always slept on the same side.

Traditionally, CNCH is removed by making a small slit in the skin with a scalpel and using curved scissors or a scalpel to snip out the damaged cartilage. The wound is then closed with sutures or with a drop of cyanoacrylate glue.

This approach is associated with a cure rate of about 80%, but there is also a recurrence rate of 10%–30%, said Dr. Ely, a dermatologist in private practice in Grass Valley, Calif.

He has had longer-term results with 1-inch-thick foam pads that he buys at a local surplus store in 8-foot sheets for about $10 a sheet. He cuts the sheets into smaller pieces approximately the size of a standard pillow, and then cuts a hole where the patient's ear will go. He instructs the patient to slip the foam between the pillowcase and the pillow, and to sleep with the ear resting in the depression formed by the hole.

If the CNCH does not resolve within 1 month, Dr. Ely has the patient come in for surgical excision. So far, virtually none of his patients have returned for surgery.

"I've actually ruined my surgical practice for chondrodermatitis because this almost always works," Dr. Ely said.

NEWPORT BEACH, CALIF. — Peri-oral injections of Botox may be a remedy when patients have lines radiating from the lips, a hollow appearance around the mouth, or an elongated upper lip often associated with aging, Joel Cohen, M.D., said at the annual meeting of the Pacific Dermatologic Association.

Injecting a total of 6–10 U of botulinum toxin type A into the orbicularis oris muscle can soften the lines and give the patient a more animated expression. The treatment also augments the upper lip in some patients, giving them a fuller lip without having to use fillers, said Dr. Cohen, a clinical assistant professor of dermatology at the University of Colorado, Denver.

Identify the injection sites by having the patient purse her lips. Inject the Botox superficially, into the peaks of the musculature. Treat the lower lip as well as the upper lip, "or it will look funny, and may accentuate any hyperfunctional musculature of the lower lip," he said.

Proper placement of the injections is important. Go too lateral, and you may weaken the lip elevators, which could result in a drooping lip and a risk of drooling. Injecting too medially or right at the midline could flatten the Cupid's bow.

Even under the best of circumstances, Botox treatments around the mouth may impair the patient's ability to purse her lips, whistle, drink from a straw, or pronounce the letters P and B. For those reasons, Dr. Cohen does not recommend this procedure to actors, singers, broadcast journalists, woodwind musicians, or scuba divers.

Moving farther down the face, Dr. Cohen said he has achieved good results injecting Botox into people with a dimpled, "golf-ball chin" that becomes especially prominent when they talk or chew. Feel along the chin for the bony margin, and inject 3–5 U into the belly of the mentalis muscle. With use of such small quantities, the treatment can be considered a "lunchtime" procedure.

Dr. Cohen offered a few pearls for maximizing cosmetic results and patient comfort during a lower-face procedure:

▸ Everyone has some naturally occurring lip asymmetry. Document this in photographs before the procedure, in case there's any question about it later. Some patients may benefit from a touch-up procedure a few weeks after the initial one.

▸ Makeup can obscure facial landmarks or small potential pitfalls such as vascular structures. Have the patient wipe it off before you administer the injections.

▸ Diluting the Botox makes the injections easier to perform, with no difference in cosmetic results as long as you're using an appropriate total dose. Dr. Cohen uses preserved saline, which decreases the pain.

▸ A 31-gauge syringe with a short hub also makes the procedure less painful.

NEWPORT BEACH, CALIF. — Peri-oral injections of Botox may be a remedy when patients have lines radiating from the lips, a hollow appearance around the mouth, or an elongated upper lip often associated with aging, Joel Cohen, M.D., said at the annual meeting of the Pacific Dermatologic Association.

Injecting a total of 6–10 U of botulinum toxin type A into the orbicularis oris muscle can soften the lines and give the patient a more animated expression. The treatment also augments the upper lip in some patients, giving them a fuller lip without having to use fillers, said Dr. Cohen, a clinical assistant professor of dermatology at the University of Colorado, Denver.

Identify the injection sites by having the patient purse her lips. Inject the Botox superficially, into the peaks of the musculature. Treat the lower lip as well as the upper lip, "or it will look funny, and may accentuate any hyperfunctional musculature of the lower lip," he said.

Proper placement of the injections is important. Go too lateral, and you may weaken the lip elevators, which could result in a drooping lip and a risk of drooling. Injecting too medially or right at the midline could flatten the Cupid's bow.

Even under the best of circumstances, Botox treatments around the mouth may impair the patient's ability to purse her lips, whistle, drink from a straw, or pronounce the letters P and B. For those reasons, Dr. Cohen does not recommend this procedure to actors, singers, broadcast journalists, woodwind musicians, or scuba divers.

Moving farther down the face, Dr. Cohen said he has achieved good results injecting Botox into people with a dimpled, "golf-ball chin" that becomes especially prominent when they talk or chew. Feel along the chin for the bony margin, and inject 3–5 U into the belly of the mentalis muscle. With use of such small quantities, the treatment can be considered a "lunchtime" procedure.

Dr. Cohen offered a few pearls for maximizing cosmetic results and patient comfort during a lower-face procedure:

▸ Everyone has some naturally occurring lip asymmetry. Document this in photographs before the procedure, in case there's any question about it later. Some patients may benefit from a touch-up procedure a few weeks after the initial one.

▸ Makeup can obscure facial landmarks or small potential pitfalls such as vascular structures. Have the patient wipe it off before you administer the injections.

▸ Diluting the Botox makes the injections easier to perform, with no difference in cosmetic results as long as you're using an appropriate total dose. Dr. Cohen uses preserved saline, which decreases the pain.

▸ A 31-gauge syringe with a short hub also makes the procedure less painful.

NEWPORT BEACH, CALIF. — Peri-oral injections of Botox may be a remedy when patients have lines radiating from the lips, a hollow appearance around the mouth, or an elongated upper lip often associated with aging, Joel Cohen, M.D., said at the annual meeting of the Pacific Dermatologic Association.

Injecting a total of 6–10 U of botulinum toxin type A into the orbicularis oris muscle can soften the lines and give the patient a more animated expression. The treatment also augments the upper lip in some patients, giving them a fuller lip without having to use fillers, said Dr. Cohen, a clinical assistant professor of dermatology at the University of Colorado, Denver.

Identify the injection sites by having the patient purse her lips. Inject the Botox superficially, into the peaks of the musculature. Treat the lower lip as well as the upper lip, "or it will look funny, and may accentuate any hyperfunctional musculature of the lower lip," he said.

Proper placement of the injections is important. Go too lateral, and you may weaken the lip elevators, which could result in a drooping lip and a risk of drooling. Injecting too medially or right at the midline could flatten the Cupid's bow.

Even under the best of circumstances, Botox treatments around the mouth may impair the patient's ability to purse her lips, whistle, drink from a straw, or pronounce the letters P and B. For those reasons, Dr. Cohen does not recommend this procedure to actors, singers, broadcast journalists, woodwind musicians, or scuba divers.

Moving farther down the face, Dr. Cohen said he has achieved good results injecting Botox into people with a dimpled, "golf-ball chin" that becomes especially prominent when they talk or chew. Feel along the chin for the bony margin, and inject 3–5 U into the belly of the mentalis muscle. With use of such small quantities, the treatment can be considered a "lunchtime" procedure.

Dr. Cohen offered a few pearls for maximizing cosmetic results and patient comfort during a lower-face procedure:

▸ Everyone has some naturally occurring lip asymmetry. Document this in photographs before the procedure, in case there's any question about it later. Some patients may benefit from a touch-up procedure a few weeks after the initial one.

▸ Makeup can obscure facial landmarks or small potential pitfalls such as vascular structures. Have the patient wipe it off before you administer the injections.

▸ Diluting the Botox makes the injections easier to perform, with no difference in cosmetic results as long as you're using an appropriate total dose. Dr. Cohen uses preserved saline, which decreases the pain.

▸ A 31-gauge syringe with a short hub also makes the procedure less painful.

LAS VEGAS — Daily teriparatide injections can lower a menopausal woman's risk of fractures, thanks to marked improvement in skeletal mass and structure, Robert Lindsay, M.D., said at the annual meeting of the American Geriatrics Society.

Teriparatide, a synthetic form of human parathyroid hormone, promotes bone remodeling and osteoblast activity. It also enhances calcium absorption during digestion. The end result is “a real increase in bone tissue mass,” said Dr. Lindsay, chief of internal medicine at Helen Hayes Hospital, West Haverstraw, N.Y.

The Food and Drug Administration approved teriparatide for treating osteoporosis in men and women in 2002. Eli Lilly & Co. markets the drug under the brand name Forteo. But the FDA gave teriparatide a black box warning because animal studies showed an association between long-term administration and an increased risk of osteosarcoma. The current recommendation is to limit clinical use of teriparatide to 2 years, although so far it has not been associated with any human cases of osteosarcoma, he said.

He recommended daily subcutaneous injections of 20 μg.

Serum markers of bone formation increase by about fourfold within 1 month of starting treatment with teriparatide, and reach peak levels within 6 months. Markers of bone resorption also rise, but more slowly. They start to increase within 6 months of starting teriparatide, and peak at about 12 months.

This is almost the direct converse of normal perimenopausal changes in bone metabolism, which are characterized by a rapid rise in resorption markers and a later, slower rise in markers of formation. Teriparatide may affect osteoblast activity directly, either through cellular recruitment or delayed apoptosis, he said.

Teriparatide exerts its effects more on trabecular bone than cortical bone, making the trabeculae thicker and rendering the bone stronger and more resistant to stress.

These salutary effects don't continue indefinitely. Bone remodeling activity peaks within about 1 year of starting teriparatide treatment and starts to decline until it returns to baseline levels after about 3 years. Longer treatment does not produce further gains.

Termination of teriparatide treatment before 3 years results in a rapid loss of bone mass—unless patients also take an antiresorptive agent, Dr. Lindsay said, citing findings from an observational follow-up study of women who participated in the placebo-controlled clinical trial that demonstrated the efficacy of teriparatide.

That study initially involved 1,637 subjects, of whom 1,093 took 20 μg or 40 μg teriparatide daily (N. Engl. J. Med. 2001;344:1434–41). The trial, which was planned to last 30 months, was terminated after 19 months because of the osteosarcoma finding in rats. At that point, the patients were free to seek treatment with other physicians, but 77% were available for follow-up examinations during the planned 30-month duration. Women who started taking bisphosphonates immediately maintained the benefits they had accrued with teriparatide; those who did not, promptly started losing bone mass.

Given this finding, plus the possible risk of osteosarcoma, patients should limit their use of teriparatide to 2 years and follow it with antiresorptive agents such as bisphosphonates, which can help maintain gains in bone mass, he said.

So far, teriparatide has not been associated with significant adverse effects. Mild hypercalcemia has been reported in rare cases. Dr. Lindsay said he regularly checks patients' serum and 24-hour urine calcium levels. Serum uric acid levels also increase 13%-25%. The clinical significance of this finding isn't clear, but Dr. Lindsay recommended measuring a patient's baseline uric acid levels before starting teriparatide.

All of the studies with teriparatide involved well-nourished individuals with adequate levels of calcium and vitamin D, he added. The findings may not apply to people with nutritional deficiencies.

LAS VEGAS — Daily teriparatide injections can lower a menopausal woman's risk of fractures, thanks to marked improvement in skeletal mass and structure, Robert Lindsay, M.D., said at the annual meeting of the American Geriatrics Society.

Teriparatide, a synthetic form of human parathyroid hormone, promotes bone remodeling and osteoblast activity. It also enhances calcium absorption during digestion. The end result is “a real increase in bone tissue mass,” said Dr. Lindsay, chief of internal medicine at Helen Hayes Hospital, West Haverstraw, N.Y.

The Food and Drug Administration approved teriparatide for treating osteoporosis in men and women in 2002. Eli Lilly & Co. markets the drug under the brand name Forteo. But the FDA gave teriparatide a black box warning because animal studies showed an association between long-term administration and an increased risk of osteosarcoma. The current recommendation is to limit clinical use of teriparatide to 2 years, although so far it has not been associated with any human cases of osteosarcoma, he said.

He recommended daily subcutaneous injections of 20 μg.

Serum markers of bone formation increase by about fourfold within 1 month of starting treatment with teriparatide, and reach peak levels within 6 months. Markers of bone resorption also rise, but more slowly. They start to increase within 6 months of starting teriparatide, and peak at about 12 months.

This is almost the direct converse of normal perimenopausal changes in bone metabolism, which are characterized by a rapid rise in resorption markers and a later, slower rise in markers of formation. Teriparatide may affect osteoblast activity directly, either through cellular recruitment or delayed apoptosis, he said.

Teriparatide exerts its effects more on trabecular bone than cortical bone, making the trabeculae thicker and rendering the bone stronger and more resistant to stress.

These salutary effects don't continue indefinitely. Bone remodeling activity peaks within about 1 year of starting teriparatide treatment and starts to decline until it returns to baseline levels after about 3 years. Longer treatment does not produce further gains.

Termination of teriparatide treatment before 3 years results in a rapid loss of bone mass—unless patients also take an antiresorptive agent, Dr. Lindsay said, citing findings from an observational follow-up study of women who participated in the placebo-controlled clinical trial that demonstrated the efficacy of teriparatide.

That study initially involved 1,637 subjects, of whom 1,093 took 20 μg or 40 μg teriparatide daily (N. Engl. J. Med. 2001;344:1434–41). The trial, which was planned to last 30 months, was terminated after 19 months because of the osteosarcoma finding in rats. At that point, the patients were free to seek treatment with other physicians, but 77% were available for follow-up examinations during the planned 30-month duration. Women who started taking bisphosphonates immediately maintained the benefits they had accrued with teriparatide; those who did not, promptly started losing bone mass.

Given this finding, plus the possible risk of osteosarcoma, patients should limit their use of teriparatide to 2 years and follow it with antiresorptive agents such as bisphosphonates, which can help maintain gains in bone mass, he said.

So far, teriparatide has not been associated with significant adverse effects. Mild hypercalcemia has been reported in rare cases. Dr. Lindsay said he regularly checks patients' serum and 24-hour urine calcium levels. Serum uric acid levels also increase 13%-25%. The clinical significance of this finding isn't clear, but Dr. Lindsay recommended measuring a patient's baseline uric acid levels before starting teriparatide.

All of the studies with teriparatide involved well-nourished individuals with adequate levels of calcium and vitamin D, he added. The findings may not apply to people with nutritional deficiencies.

LAS VEGAS — Daily teriparatide injections can lower a menopausal woman's risk of fractures, thanks to marked improvement in skeletal mass and structure, Robert Lindsay, M.D., said at the annual meeting of the American Geriatrics Society.

Teriparatide, a synthetic form of human parathyroid hormone, promotes bone remodeling and osteoblast activity. It also enhances calcium absorption during digestion. The end result is “a real increase in bone tissue mass,” said Dr. Lindsay, chief of internal medicine at Helen Hayes Hospital, West Haverstraw, N.Y.

The Food and Drug Administration approved teriparatide for treating osteoporosis in men and women in 2002. Eli Lilly & Co. markets the drug under the brand name Forteo. But the FDA gave teriparatide a black box warning because animal studies showed an association between long-term administration and an increased risk of osteosarcoma. The current recommendation is to limit clinical use of teriparatide to 2 years, although so far it has not been associated with any human cases of osteosarcoma, he said.

He recommended daily subcutaneous injections of 20 μg.

Serum markers of bone formation increase by about fourfold within 1 month of starting treatment with teriparatide, and reach peak levels within 6 months. Markers of bone resorption also rise, but more slowly. They start to increase within 6 months of starting teriparatide, and peak at about 12 months.

This is almost the direct converse of normal perimenopausal changes in bone metabolism, which are characterized by a rapid rise in resorption markers and a later, slower rise in markers of formation. Teriparatide may affect osteoblast activity directly, either through cellular recruitment or delayed apoptosis, he said.

Teriparatide exerts its effects more on trabecular bone than cortical bone, making the trabeculae thicker and rendering the bone stronger and more resistant to stress.

These salutary effects don't continue indefinitely. Bone remodeling activity peaks within about 1 year of starting teriparatide treatment and starts to decline until it returns to baseline levels after about 3 years. Longer treatment does not produce further gains.

Termination of teriparatide treatment before 3 years results in a rapid loss of bone mass—unless patients also take an antiresorptive agent, Dr. Lindsay said, citing findings from an observational follow-up study of women who participated in the placebo-controlled clinical trial that demonstrated the efficacy of teriparatide.

That study initially involved 1,637 subjects, of whom 1,093 took 20 μg or 40 μg teriparatide daily (N. Engl. J. Med. 2001;344:1434–41). The trial, which was planned to last 30 months, was terminated after 19 months because of the osteosarcoma finding in rats. At that point, the patients were free to seek treatment with other physicians, but 77% were available for follow-up examinations during the planned 30-month duration. Women who started taking bisphosphonates immediately maintained the benefits they had accrued with teriparatide; those who did not, promptly started losing bone mass.

Given this finding, plus the possible risk of osteosarcoma, patients should limit their use of teriparatide to 2 years and follow it with antiresorptive agents such as bisphosphonates, which can help maintain gains in bone mass, he said.

So far, teriparatide has not been associated with significant adverse effects. Mild hypercalcemia has been reported in rare cases. Dr. Lindsay said he regularly checks patients' serum and 24-hour urine calcium levels. Serum uric acid levels also increase 13%-25%. The clinical significance of this finding isn't clear, but Dr. Lindsay recommended measuring a patient's baseline uric acid levels before starting teriparatide.

All of the studies with teriparatide involved well-nourished individuals with adequate levels of calcium and vitamin D, he added. The findings may not apply to people with nutritional deficiencies.

LAS VEGAS — Elderly patients in long-term care have a real but underrecognized risk of minimal-trauma fractures, Violeta Galabova, M.D., warned at the annual meeting of the American Geriatrics Society.

Osteoporosis associated with disuse, although not extensively studied, is thought to be the primary mechanism behind the fractures, which often occur as the patient is being moved. “It's very important to teach nursing staff proper transfer techniques,” said Dr. Galabova, a fellow in geriatric medicine at the University of Pennsylvania, Philadelphia.

People who are confined to bed or wheelchair for 6 months or more are especially vulnerable, particularly if they've already sustained a previous fracture. Other risk factors include use of predisposing medications such as steroids, and poor nutritional status, as reflected in a body mass index less than 20 kg/m

She described three patients whose cases illustrate how these fractures may become apparent. The first was a 101-year-old woman who had been wheelchair bound for several years. During a routine examination 3 years ago, her doctor noted swelling of her left leg and diagnosed a spontaneous fracture of the left tibial-fibular segment, which occurred without any identifiable precipitating event. Over the next few years, the patient developed two more lower-extremity fractures.

The second patient was a 93-year-old bed-bound woman who had a history of a hip fracture and seizures. Since admission to a nursing home, she sustained a fracture of the right femur and the left humerus, both during routine transfers from a wheelchair to bed.

In the third case, a 79-year-old man with a history of Parkinson's disease and a right total hip arthroplasty was able to get around with a walker until he fell and sustained a subarachnoid hemorrhage that left him confined to bed. Six months after his fall, he complained of pain in his right thigh while being adjusted in bed by a member of the nursing home staff, and was diagnosed with a spiral periprosthetic fracture of the right femur.

It may be premature to recommend routine preventive measures for all nursing home patients, but people with risk factors for disuse fractures deserve close watching, Dr. Galabova said.

LAS VEGAS — Elderly patients in long-term care have a real but underrecognized risk of minimal-trauma fractures, Violeta Galabova, M.D., warned at the annual meeting of the American Geriatrics Society.

Osteoporosis associated with disuse, although not extensively studied, is thought to be the primary mechanism behind the fractures, which often occur as the patient is being moved. “It's very important to teach nursing staff proper transfer techniques,” said Dr. Galabova, a fellow in geriatric medicine at the University of Pennsylvania, Philadelphia.

People who are confined to bed or wheelchair for 6 months or more are especially vulnerable, particularly if they've already sustained a previous fracture. Other risk factors include use of predisposing medications such as steroids, and poor nutritional status, as reflected in a body mass index less than 20 kg/m

She described three patients whose cases illustrate how these fractures may become apparent. The first was a 101-year-old woman who had been wheelchair bound for several years. During a routine examination 3 years ago, her doctor noted swelling of her left leg and diagnosed a spontaneous fracture of the left tibial-fibular segment, which occurred without any identifiable precipitating event. Over the next few years, the patient developed two more lower-extremity fractures.

The second patient was a 93-year-old bed-bound woman who had a history of a hip fracture and seizures. Since admission to a nursing home, she sustained a fracture of the right femur and the left humerus, both during routine transfers from a wheelchair to bed.

In the third case, a 79-year-old man with a history of Parkinson's disease and a right total hip arthroplasty was able to get around with a walker until he fell and sustained a subarachnoid hemorrhage that left him confined to bed. Six months after his fall, he complained of pain in his right thigh while being adjusted in bed by a member of the nursing home staff, and was diagnosed with a spiral periprosthetic fracture of the right femur.

It may be premature to recommend routine preventive measures for all nursing home patients, but people with risk factors for disuse fractures deserve close watching, Dr. Galabova said.

LAS VEGAS — Elderly patients in long-term care have a real but underrecognized risk of minimal-trauma fractures, Violeta Galabova, M.D., warned at the annual meeting of the American Geriatrics Society.

Osteoporosis associated with disuse, although not extensively studied, is thought to be the primary mechanism behind the fractures, which often occur as the patient is being moved. “It's very important to teach nursing staff proper transfer techniques,” said Dr. Galabova, a fellow in geriatric medicine at the University of Pennsylvania, Philadelphia.

People who are confined to bed or wheelchair for 6 months or more are especially vulnerable, particularly if they've already sustained a previous fracture. Other risk factors include use of predisposing medications such as steroids, and poor nutritional status, as reflected in a body mass index less than 20 kg/m

She described three patients whose cases illustrate how these fractures may become apparent. The first was a 101-year-old woman who had been wheelchair bound for several years. During a routine examination 3 years ago, her doctor noted swelling of her left leg and diagnosed a spontaneous fracture of the left tibial-fibular segment, which occurred without any identifiable precipitating event. Over the next few years, the patient developed two more lower-extremity fractures.

The second patient was a 93-year-old bed-bound woman who had a history of a hip fracture and seizures. Since admission to a nursing home, she sustained a fracture of the right femur and the left humerus, both during routine transfers from a wheelchair to bed.

In the third case, a 79-year-old man with a history of Parkinson's disease and a right total hip arthroplasty was able to get around with a walker until he fell and sustained a subarachnoid hemorrhage that left him confined to bed. Six months after his fall, he complained of pain in his right thigh while being adjusted in bed by a member of the nursing home staff, and was diagnosed with a spiral periprosthetic fracture of the right femur.

It may be premature to recommend routine preventive measures for all nursing home patients, but people with risk factors for disuse fractures deserve close watching, Dr. Galabova said.

LOS ANGELES — Cancer patients call it “chemobrain”—a soggy mental state that seems to be a frequent side effect of chemotherapy.

It is rarely studied and poorly understood, but as the number of cancer survivors grows, the impact of chemotherapy on cognitive function will become an increasingly important concern, Curley Bonds, M.D., said at a review of psychiatry and psychopharmacology update sponsored by the University of California, Los Angeles.

Chemotherapy has been reported to affect several aspects of neuropsychological function. The components most commonly affected are focus and concentration, verbal and executive function, and motor activity, said Dr. Bonds of the university.

Several issues complicate research in this area. One is sorting out the impact of chemotherapy from the effect of the cancer itself and that of other forms of therapy. Fatigue, anxiety, and depression commonly accompany cancer and may have an independent effect on higher-order function.

Perhaps the most comprehensive analysis of chemotherapy and cognitive function is a metaanalysis of 30 studies of 29 populations comprising a total of 838 adult patients. The studies included three research designs that compared patients post treatment with control patients who had not undergone chemotherapy, with test scores obtained from normative controls, or with the patients' own baseline scores taken before starting treatment. The cognitive domains tested included attention, verbal and visuospatial memory, visuospatial skill, executive function, psychomotor skill, and information processing speed.

For each domain, the investigators calculated a weighted Cohen's d score, which measures effect size. The scores ranged from 0 (no effect) to +2 (improvement in function) or −2 (deterioration of function), with a score greater than .8 in either direction considered a significant effect. The patients who underwent chemotherapy showed the greatest treatment effects in executive function and verbal memory when compared with the normative controls, with scores of -.93 and -.91, respectively. A significant effect on motor function was also seen (J. Int. Neuropsychol. Soc. 2003;9:967-82).

In other controlled research, conducted mostly on women with breast cancer, the rate of cognitive impairment associated with chemotherapy has ranged from 16% to 50% and has persisted for as long as 10 years. Combination chemotherapy with methotrexate, cyclophosphamide, and 5-fluorouracil has been most frequently associated with cognitive problems. (See table.) On the other hand, anthracycline-based agents seem to be associated less frequently with neurotoxicity, Dr. Bonds said.

Cancer Drugs Carry Neurotoxic Effects

Chemotherapy Agents Associated With Neurotoxicity

Combination of methotrexate,* cyclophosphamide, and fluorouracil*

Vinca alkaloids

Cytarabine

Platinum analogues

Ifosfamide

Taxol

Taxotere

Fludarabine

Suramin

Agents Associated With Occasional Reports Of Cognitive or Motor Impairment

L-asparagine

Busulfan

Hexamethylmelamine

Procarbazine

Thiotepa

*Also associated with cognitive impairment individually

Source: Dr. Bonds

LOS ANGELES — Cancer patients call it “chemobrain”—a soggy mental state that seems to be a frequent side effect of chemotherapy.

It is rarely studied and poorly understood, but as the number of cancer survivors grows, the impact of chemotherapy on cognitive function will become an increasingly important concern, Curley Bonds, M.D., said at a review of psychiatry and psychopharmacology update sponsored by the University of California, Los Angeles.

Chemotherapy has been reported to affect several aspects of neuropsychological function. The components most commonly affected are focus and concentration, verbal and executive function, and motor activity, said Dr. Bonds of the university.

Several issues complicate research in this area. One is sorting out the impact of chemotherapy from the effect of the cancer itself and that of other forms of therapy. Fatigue, anxiety, and depression commonly accompany cancer and may have an independent effect on higher-order function.

Perhaps the most comprehensive analysis of chemotherapy and cognitive function is a metaanalysis of 30 studies of 29 populations comprising a total of 838 adult patients. The studies included three research designs that compared patients post treatment with control patients who had not undergone chemotherapy, with test scores obtained from normative controls, or with the patients' own baseline scores taken before starting treatment. The cognitive domains tested included attention, verbal and visuospatial memory, visuospatial skill, executive function, psychomotor skill, and information processing speed.

For each domain, the investigators calculated a weighted Cohen's d score, which measures effect size. The scores ranged from 0 (no effect) to +2 (improvement in function) or −2 (deterioration of function), with a score greater than .8 in either direction considered a significant effect. The patients who underwent chemotherapy showed the greatest treatment effects in executive function and verbal memory when compared with the normative controls, with scores of -.93 and -.91, respectively. A significant effect on motor function was also seen (J. Int. Neuropsychol. Soc. 2003;9:967-82).

In other controlled research, conducted mostly on women with breast cancer, the rate of cognitive impairment associated with chemotherapy has ranged from 16% to 50% and has persisted for as long as 10 years. Combination chemotherapy with methotrexate, cyclophosphamide, and 5-fluorouracil has been most frequently associated with cognitive problems. (See table.) On the other hand, anthracycline-based agents seem to be associated less frequently with neurotoxicity, Dr. Bonds said.

Cancer Drugs Carry Neurotoxic Effects

Chemotherapy Agents Associated With Neurotoxicity

Combination of methotrexate,* cyclophosphamide, and fluorouracil*

Vinca alkaloids

Cytarabine

Platinum analogues

Ifosfamide

Taxol

Taxotere

Fludarabine

Suramin

Agents Associated With Occasional Reports Of Cognitive or Motor Impairment

L-asparagine

Busulfan

Hexamethylmelamine

Procarbazine

Thiotepa

*Also associated with cognitive impairment individually

Source: Dr. Bonds

LOS ANGELES — Cancer patients call it “chemobrain”—a soggy mental state that seems to be a frequent side effect of chemotherapy.

It is rarely studied and poorly understood, but as the number of cancer survivors grows, the impact of chemotherapy on cognitive function will become an increasingly important concern, Curley Bonds, M.D., said at a review of psychiatry and psychopharmacology update sponsored by the University of California, Los Angeles.

Chemotherapy has been reported to affect several aspects of neuropsychological function. The components most commonly affected are focus and concentration, verbal and executive function, and motor activity, said Dr. Bonds of the university.

Several issues complicate research in this area. One is sorting out the impact of chemotherapy from the effect of the cancer itself and that of other forms of therapy. Fatigue, anxiety, and depression commonly accompany cancer and may have an independent effect on higher-order function.

Perhaps the most comprehensive analysis of chemotherapy and cognitive function is a metaanalysis of 30 studies of 29 populations comprising a total of 838 adult patients. The studies included three research designs that compared patients post treatment with control patients who had not undergone chemotherapy, with test scores obtained from normative controls, or with the patients' own baseline scores taken before starting treatment. The cognitive domains tested included attention, verbal and visuospatial memory, visuospatial skill, executive function, psychomotor skill, and information processing speed.

For each domain, the investigators calculated a weighted Cohen's d score, which measures effect size. The scores ranged from 0 (no effect) to +2 (improvement in function) or −2 (deterioration of function), with a score greater than .8 in either direction considered a significant effect. The patients who underwent chemotherapy showed the greatest treatment effects in executive function and verbal memory when compared with the normative controls, with scores of -.93 and -.91, respectively. A significant effect on motor function was also seen (J. Int. Neuropsychol. Soc. 2003;9:967-82).

In other controlled research, conducted mostly on women with breast cancer, the rate of cognitive impairment associated with chemotherapy has ranged from 16% to 50% and has persisted for as long as 10 years. Combination chemotherapy with methotrexate, cyclophosphamide, and 5-fluorouracil has been most frequently associated with cognitive problems. (See table.) On the other hand, anthracycline-based agents seem to be associated less frequently with neurotoxicity, Dr. Bonds said.

Cancer Drugs Carry Neurotoxic Effects

Chemotherapy Agents Associated With Neurotoxicity

Combination of methotrexate,* cyclophosphamide, and fluorouracil*

Vinca alkaloids

Cytarabine

Platinum analogues

Ifosfamide

Taxol

Taxotere

Fludarabine

Suramin

Agents Associated With Occasional Reports Of Cognitive or Motor Impairment

L-asparagine

Busulfan

Hexamethylmelamine

Procarbazine

Thiotepa

*Also associated with cognitive impairment individually

Source: Dr. Bonds