Kate Johnson

HOUSTON — Biopsy should be considered more frequently for pigmented lesions that appear on the vulva, compared with elsewhere on the body, because in this location they are particularly tricky to identify by appearance alone, Dr. Libby Edwards said at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital.

“It is not that pigmented lesions are likely to be more dangerous on the vulva—they are not. It's just that their appearance is less specific,” Dr. Edwards said in an interview.

“Whereas the importance of pigmented lesions on other areas can usually be gauged relatively well by their appearance, on the vulva, very abnormal-looking lesions may be unimportant and vice versa,” commented Dr. Edwards, a dermatologist who runs a private practice in Charlotte, N.C.

For example, vulvar melanosis—patchy, irregular hyperpigmentation—is a benign condition that can appear indistinguishable from vulvar melanoma.

“You have to biopsy this, it is the only way you can rule out melanoma or pigmented vulvar intraepithelial neoplasia,” she said.

In addition, vulvar melanosis can occur as postinflammatory change associated with lichen sclerosus. “You need to treat any underlying disease, but otherwise there is no treatment for vulvar melanosis,” said Dr. Edwards.

HOUSTON — Biopsy should be considered more frequently for pigmented lesions that appear on the vulva, compared with elsewhere on the body, because in this location they are particularly tricky to identify by appearance alone, Dr. Libby Edwards said at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital.

“It is not that pigmented lesions are likely to be more dangerous on the vulva—they are not. It's just that their appearance is less specific,” Dr. Edwards said in an interview.

“Whereas the importance of pigmented lesions on other areas can usually be gauged relatively well by their appearance, on the vulva, very abnormal-looking lesions may be unimportant and vice versa,” commented Dr. Edwards, a dermatologist who runs a private practice in Charlotte, N.C.

For example, vulvar melanosis—patchy, irregular hyperpigmentation—is a benign condition that can appear indistinguishable from vulvar melanoma.

“You have to biopsy this, it is the only way you can rule out melanoma or pigmented vulvar intraepithelial neoplasia,” she said.

In addition, vulvar melanosis can occur as postinflammatory change associated with lichen sclerosus. “You need to treat any underlying disease, but otherwise there is no treatment for vulvar melanosis,” said Dr. Edwards.

HOUSTON — Biopsy should be considered more frequently for pigmented lesions that appear on the vulva, compared with elsewhere on the body, because in this location they are particularly tricky to identify by appearance alone, Dr. Libby Edwards said at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital.

“It is not that pigmented lesions are likely to be more dangerous on the vulva—they are not. It's just that their appearance is less specific,” Dr. Edwards said in an interview.

“Whereas the importance of pigmented lesions on other areas can usually be gauged relatively well by their appearance, on the vulva, very abnormal-looking lesions may be unimportant and vice versa,” commented Dr. Edwards, a dermatologist who runs a private practice in Charlotte, N.C.

For example, vulvar melanosis—patchy, irregular hyperpigmentation—is a benign condition that can appear indistinguishable from vulvar melanoma.

“You have to biopsy this, it is the only way you can rule out melanoma or pigmented vulvar intraepithelial neoplasia,” she said.

In addition, vulvar melanosis can occur as postinflammatory change associated with lichen sclerosus. “You need to treat any underlying disease, but otherwise there is no treatment for vulvar melanosis,” said Dr. Edwards.

HOUSTON — Although most clinicians treat all anogenital human papillomavirus infections, nontreatment is something to consider in certain cases, Dr. Peter J. Lynch said at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital.

“Treatment is painful, and it's costly,” said Dr. Lynch, professor and chairman of the dermatology department at the University of California, Davis.

“Spontaneous regression is likely in a young woman. In such a patient, I would biopsy one or two of the warts. If there is no dysplasia and if she is in a monogamous relationship and her partner is willing, I would be open to waiting several months to see if regression might occur without treatment,” he said in an interview.

Most, but not all, human papillomavirus (HPV) infections resolve spontaneously, he said. Those in older individuals and those caused by high-risk types resolve more slowly and occasionally persist indefinitely.

The argument for treatment is that it can reduce the degree of contagion; however, asymptomatic shedding still occurs. “In latency, the HPV DNA remains at the site of the lesion and may reactivate at any time,” he said.

In the case of a woman in a monogamous heterosexual relationship (she may have been infected many years previously or even at birth), the risk this presents to her partner is minimal.

“Biologically, the infection behaves quite differently in men than in women,” he said. “The male equivalent of vulvar intraepdithelial neoplasia is extremely unlikely to progress to invasive disease. As such, infection with high-risk HPV is of trivial importance to the man but is of appreciable importance to a female sexual partner if spread to her cervix or vulva should occur.”

Although treating female infection also may reduce the risk of subsequent malignant progression in patients with high-risk HPV types, absence of dysplasia on biopsy signals a low cancer risk in the first place, said Dr. Lynch.

And not all lesions need biopsy. For example, filiform warts, common warts, and small nodular warts are unlikely to show high-risk HPV or dysplasia. However, flat-topped, pigmented, or large nodular warts could be dysplastic and therefore need to be biopsied, he said.

“If you took a poll, probably 98% of gynecologists and 85% of dermatologists would treat all HPV. But there is an option out there, and we shouldn't just blindly say every infection has to be treated.”

HOUSTON — Although most clinicians treat all anogenital human papillomavirus infections, nontreatment is something to consider in certain cases, Dr. Peter J. Lynch said at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital.

“Treatment is painful, and it's costly,” said Dr. Lynch, professor and chairman of the dermatology department at the University of California, Davis.

“Spontaneous regression is likely in a young woman. In such a patient, I would biopsy one or two of the warts. If there is no dysplasia and if she is in a monogamous relationship and her partner is willing, I would be open to waiting several months to see if regression might occur without treatment,” he said in an interview.

Most, but not all, human papillomavirus (HPV) infections resolve spontaneously, he said. Those in older individuals and those caused by high-risk types resolve more slowly and occasionally persist indefinitely.

The argument for treatment is that it can reduce the degree of contagion; however, asymptomatic shedding still occurs. “In latency, the HPV DNA remains at the site of the lesion and may reactivate at any time,” he said.

In the case of a woman in a monogamous heterosexual relationship (she may have been infected many years previously or even at birth), the risk this presents to her partner is minimal.

“Biologically, the infection behaves quite differently in men than in women,” he said. “The male equivalent of vulvar intraepdithelial neoplasia is extremely unlikely to progress to invasive disease. As such, infection with high-risk HPV is of trivial importance to the man but is of appreciable importance to a female sexual partner if spread to her cervix or vulva should occur.”

Although treating female infection also may reduce the risk of subsequent malignant progression in patients with high-risk HPV types, absence of dysplasia on biopsy signals a low cancer risk in the first place, said Dr. Lynch.

And not all lesions need biopsy. For example, filiform warts, common warts, and small nodular warts are unlikely to show high-risk HPV or dysplasia. However, flat-topped, pigmented, or large nodular warts could be dysplastic and therefore need to be biopsied, he said.

“If you took a poll, probably 98% of gynecologists and 85% of dermatologists would treat all HPV. But there is an option out there, and we shouldn't just blindly say every infection has to be treated.”

HOUSTON — Although most clinicians treat all anogenital human papillomavirus infections, nontreatment is something to consider in certain cases, Dr. Peter J. Lynch said at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital.

“Treatment is painful, and it's costly,” said Dr. Lynch, professor and chairman of the dermatology department at the University of California, Davis.

“Spontaneous regression is likely in a young woman. In such a patient, I would biopsy one or two of the warts. If there is no dysplasia and if she is in a monogamous relationship and her partner is willing, I would be open to waiting several months to see if regression might occur without treatment,” he said in an interview.

Most, but not all, human papillomavirus (HPV) infections resolve spontaneously, he said. Those in older individuals and those caused by high-risk types resolve more slowly and occasionally persist indefinitely.

The argument for treatment is that it can reduce the degree of contagion; however, asymptomatic shedding still occurs. “In latency, the HPV DNA remains at the site of the lesion and may reactivate at any time,” he said.

In the case of a woman in a monogamous heterosexual relationship (she may have been infected many years previously or even at birth), the risk this presents to her partner is minimal.

“Biologically, the infection behaves quite differently in men than in women,” he said. “The male equivalent of vulvar intraepdithelial neoplasia is extremely unlikely to progress to invasive disease. As such, infection with high-risk HPV is of trivial importance to the man but is of appreciable importance to a female sexual partner if spread to her cervix or vulva should occur.”

Although treating female infection also may reduce the risk of subsequent malignant progression in patients with high-risk HPV types, absence of dysplasia on biopsy signals a low cancer risk in the first place, said Dr. Lynch.

And not all lesions need biopsy. For example, filiform warts, common warts, and small nodular warts are unlikely to show high-risk HPV or dysplasia. However, flat-topped, pigmented, or large nodular warts could be dysplastic and therefore need to be biopsied, he said.

“If you took a poll, probably 98% of gynecologists and 85% of dermatologists would treat all HPV. But there is an option out there, and we shouldn't just blindly say every infection has to be treated.”

MONTREAL — A product that dehydrates, rather than poisons, head lice should be available soon in the United States to fill a gap widened by parental concerns about the toxicity of existing treatments, Dr. Ian Landells, said at Dermatology Update 2007.

The treatment, which was launched in Britain 2 years ago as Full Marks solution (SSL International) and in Canada last fall as Resultz (Altana Pharma Inc.), contains 50% isopropyl myristate as its active ingredient and works by dissolving the waxy exoskeleton of lice and causing dehydration.

“This is the first clinically proven toxin-free treatment that has a mechanical mode of action,” said Dr. Landells of Memorial University, St. John's, Nfld. “It's a really nice alternative and the only treatment I am going to be recommending from now on.”

The product is currently in phase III trials in the United States and is expected to be marketed here by Piedmont Pharma in the next few years, noted Dr. Landells, who has served on the advisory board for Altana.

An increasing number of parents are expressing reluctance about using currently available pediculocides on their children because of concerns about neurotoxicity and lack of efficacy.

Company data on a Canadian efficacy and safety trial showed that treatment with Resultz eliminated 100% of live lice at 24 hours, resulting in an overall 96.5% cure rate. A second treatment 1 week after the first is very important to catch any new lice that may have hatched from remaining nits, Dr. Landells said.

In addition, he presented data from a company-sponsored phase II trial comparing Resultz with a pyrethrin plus piperonyl butoxide product (Rid) and a phase III trial comparing it with a permethrin 1% product (Nix/Lyclear). The cure rates in the first study, which involved 52 patients, were 63% for Resultz and 23% for Rid. In the second study (94 patients), the cure rates were 78% for Resultz and 20% for Nix/Lyclear, he said.

Adverse events for Resultz were mild and less frequent than for permethrin 1% (11% vs. 29%). They included rash, tingling, burning and dry scalp, and stinging eyes, and resolved within 24 hours. “It's a harmless surfactant found in products like soaps that we use on kids all the time,” he concluded, noting that because it is toxin free, there are no safety concerns about repeated treatments.

Isopropyl myristate is used to dissolve the waxy exoskeletons of head lice, causing them to die of dehydration. CDC/Dr. Dennis D. Juranek

ELSEVIER GLOBAL MEDICAL NEWS

MONTREAL — A product that dehydrates, rather than poisons, head lice should be available soon in the United States to fill a gap widened by parental concerns about the toxicity of existing treatments, Dr. Ian Landells, said at Dermatology Update 2007.

The treatment, which was launched in Britain 2 years ago as Full Marks solution (SSL International) and in Canada last fall as Resultz (Altana Pharma Inc.), contains 50% isopropyl myristate as its active ingredient and works by dissolving the waxy exoskeleton of lice and causing dehydration.

“This is the first clinically proven toxin-free treatment that has a mechanical mode of action,” said Dr. Landells of Memorial University, St. John's, Nfld. “It's a really nice alternative and the only treatment I am going to be recommending from now on.”

The product is currently in phase III trials in the United States and is expected to be marketed here by Piedmont Pharma in the next few years, noted Dr. Landells, who has served on the advisory board for Altana.

An increasing number of parents are expressing reluctance about using currently available pediculocides on their children because of concerns about neurotoxicity and lack of efficacy.

Company data on a Canadian efficacy and safety trial showed that treatment with Resultz eliminated 100% of live lice at 24 hours, resulting in an overall 96.5% cure rate. A second treatment 1 week after the first is very important to catch any new lice that may have hatched from remaining nits, Dr. Landells said.

In addition, he presented data from a company-sponsored phase II trial comparing Resultz with a pyrethrin plus piperonyl butoxide product (Rid) and a phase III trial comparing it with a permethrin 1% product (Nix/Lyclear). The cure rates in the first study, which involved 52 patients, were 63% for Resultz and 23% for Rid. In the second study (94 patients), the cure rates were 78% for Resultz and 20% for Nix/Lyclear, he said.

Adverse events for Resultz were mild and less frequent than for permethrin 1% (11% vs. 29%). They included rash, tingling, burning and dry scalp, and stinging eyes, and resolved within 24 hours. “It's a harmless surfactant found in products like soaps that we use on kids all the time,” he concluded, noting that because it is toxin free, there are no safety concerns about repeated treatments.

Isopropyl myristate is used to dissolve the waxy exoskeletons of head lice, causing them to die of dehydration. CDC/Dr. Dennis D. Juranek

ELSEVIER GLOBAL MEDICAL NEWS

MONTREAL — A product that dehydrates, rather than poisons, head lice should be available soon in the United States to fill a gap widened by parental concerns about the toxicity of existing treatments, Dr. Ian Landells, said at Dermatology Update 2007.

The treatment, which was launched in Britain 2 years ago as Full Marks solution (SSL International) and in Canada last fall as Resultz (Altana Pharma Inc.), contains 50% isopropyl myristate as its active ingredient and works by dissolving the waxy exoskeleton of lice and causing dehydration.

“This is the first clinically proven toxin-free treatment that has a mechanical mode of action,” said Dr. Landells of Memorial University, St. John's, Nfld. “It's a really nice alternative and the only treatment I am going to be recommending from now on.”

The product is currently in phase III trials in the United States and is expected to be marketed here by Piedmont Pharma in the next few years, noted Dr. Landells, who has served on the advisory board for Altana.

An increasing number of parents are expressing reluctance about using currently available pediculocides on their children because of concerns about neurotoxicity and lack of efficacy.

Company data on a Canadian efficacy and safety trial showed that treatment with Resultz eliminated 100% of live lice at 24 hours, resulting in an overall 96.5% cure rate. A second treatment 1 week after the first is very important to catch any new lice that may have hatched from remaining nits, Dr. Landells said.

In addition, he presented data from a company-sponsored phase II trial comparing Resultz with a pyrethrin plus piperonyl butoxide product (Rid) and a phase III trial comparing it with a permethrin 1% product (Nix/Lyclear). The cure rates in the first study, which involved 52 patients, were 63% for Resultz and 23% for Rid. In the second study (94 patients), the cure rates were 78% for Resultz and 20% for Nix/Lyclear, he said.

Adverse events for Resultz were mild and less frequent than for permethrin 1% (11% vs. 29%). They included rash, tingling, burning and dry scalp, and stinging eyes, and resolved within 24 hours. “It's a harmless surfactant found in products like soaps that we use on kids all the time,” he concluded, noting that because it is toxin free, there are no safety concerns about repeated treatments.

Isopropyl myristate is used to dissolve the waxy exoskeletons of head lice, causing them to die of dehydration. CDC/Dr. Dennis D. Juranek

ELSEVIER GLOBAL MEDICAL NEWS

A national quality improvement initiative significantly improved several aspects of care for diabetes, asthma, and hypertension at community health centers, but had no impact on intermediate outcomes, according to a study published in the New England Journal of Medicine.

"The substantial room for improvement in the postintervention period suggests the need for continued refinement of these methods," wrote Dr. Bruce E. Landon from Harvard Medical School, Boston, and his colleagues (N. Engl. J. Med. 2007;356:921–34).

"There is still much to learn about the tools and methods for quality improvement and their potential effectiveness," they added.

The study compared the quality of care at 44 community health centers before and after their participation in the quality-improvement Health Disparities Collaboratives.

This initiative, sponsored by the Health Resources and Services Administration, the Agency for Healthcare Research and Quality, and the Commonwealth Fund, was designed to improve care at community health centers, a particularly relevant target because of their "prominent role in providing care for members of minority groups and other disadvantaged populations," Dr. Landon and his associates said.

Since 1998, about two-thirds of community health centers (645) have participated in the collaboratives, but to date there has been no evaluation of their effect, they wrote.

The 44 intervention centers enrolled in the quality-improvement collaborative were matched with 20 control centers which had never participated in a quality-improvement collaborative.

In addition, 40 of the 44 intervention centers also served as internal controls. Sequential, random samples of patients with diabetes, asthma, or hypertension were selected during the 1-year period before the intervention and the 1-year period after its completion.

In all, 9,658 patients with one of the three conditions were selected: 3,392 with asthma, 2,904 with diabetes, and 3,362 with hypertension. Percentage scores for overall quality of care and composite scores for prevention and screening; disease monitoring and treatment; and outcomes were then calculated.

The study found that overall, when considering all three conditions, the intervention centers improved their care 4.9% above internal controls and 4.5% above external controls.

In the composite score for prevention and screening, intervention centers also improved 6.2% more than internal controls and 4.5% more than external controls.

And intervention centers also improved significantly more than controls in the composite score for disease monitoring and treatment (5.9% over external controls and 5.5% over internal ones).

When results were divided according to the three conditions, the overall trend was evident in centers focusing on asthma and diabetes, but not in those focusing on hypertension.

With regard to specific measures within the centers, the percentage of patients receiving anti-inflammatory medication for persistent asthma, the percentage of patients with an asthma management plan, the percentage of diabetes patients with two or more assessments of glycated hemoglobin levels, and the percentage of patients advised about smoking all increased more in the intervention centers, compared with the control centers.

The authors offered several explanations for the lack of effect with respect to intermediate outcomes, including that many of the processes of care that were studied are linked to longer-term outcomes.

In addition, "intermediate outcomes may require more intensive interventions in order to overcome environmental factors that pose particular challenges for patients treated at community health centers," they noted.

A national quality improvement initiative significantly improved several aspects of care for diabetes, asthma, and hypertension at community health centers, but had no impact on intermediate outcomes, according to a study published in the New England Journal of Medicine.

"The substantial room for improvement in the postintervention period suggests the need for continued refinement of these methods," wrote Dr. Bruce E. Landon from Harvard Medical School, Boston, and his colleagues (N. Engl. J. Med. 2007;356:921–34).

"There is still much to learn about the tools and methods for quality improvement and their potential effectiveness," they added.

The study compared the quality of care at 44 community health centers before and after their participation in the quality-improvement Health Disparities Collaboratives.

This initiative, sponsored by the Health Resources and Services Administration, the Agency for Healthcare Research and Quality, and the Commonwealth Fund, was designed to improve care at community health centers, a particularly relevant target because of their "prominent role in providing care for members of minority groups and other disadvantaged populations," Dr. Landon and his associates said.

Since 1998, about two-thirds of community health centers (645) have participated in the collaboratives, but to date there has been no evaluation of their effect, they wrote.

The 44 intervention centers enrolled in the quality-improvement collaborative were matched with 20 control centers which had never participated in a quality-improvement collaborative.

In addition, 40 of the 44 intervention centers also served as internal controls. Sequential, random samples of patients with diabetes, asthma, or hypertension were selected during the 1-year period before the intervention and the 1-year period after its completion.

In all, 9,658 patients with one of the three conditions were selected: 3,392 with asthma, 2,904 with diabetes, and 3,362 with hypertension. Percentage scores for overall quality of care and composite scores for prevention and screening; disease monitoring and treatment; and outcomes were then calculated.

The study found that overall, when considering all three conditions, the intervention centers improved their care 4.9% above internal controls and 4.5% above external controls.

In the composite score for prevention and screening, intervention centers also improved 6.2% more than internal controls and 4.5% more than external controls.

And intervention centers also improved significantly more than controls in the composite score for disease monitoring and treatment (5.9% over external controls and 5.5% over internal ones).

When results were divided according to the three conditions, the overall trend was evident in centers focusing on asthma and diabetes, but not in those focusing on hypertension.

With regard to specific measures within the centers, the percentage of patients receiving anti-inflammatory medication for persistent asthma, the percentage of patients with an asthma management plan, the percentage of diabetes patients with two or more assessments of glycated hemoglobin levels, and the percentage of patients advised about smoking all increased more in the intervention centers, compared with the control centers.

The authors offered several explanations for the lack of effect with respect to intermediate outcomes, including that many of the processes of care that were studied are linked to longer-term outcomes.

In addition, "intermediate outcomes may require more intensive interventions in order to overcome environmental factors that pose particular challenges for patients treated at community health centers," they noted.

A national quality improvement initiative significantly improved several aspects of care for diabetes, asthma, and hypertension at community health centers, but had no impact on intermediate outcomes, according to a study published in the New England Journal of Medicine.

"The substantial room for improvement in the postintervention period suggests the need for continued refinement of these methods," wrote Dr. Bruce E. Landon from Harvard Medical School, Boston, and his colleagues (N. Engl. J. Med. 2007;356:921–34).

"There is still much to learn about the tools and methods for quality improvement and their potential effectiveness," they added.

The study compared the quality of care at 44 community health centers before and after their participation in the quality-improvement Health Disparities Collaboratives.

This initiative, sponsored by the Health Resources and Services Administration, the Agency for Healthcare Research and Quality, and the Commonwealth Fund, was designed to improve care at community health centers, a particularly relevant target because of their "prominent role in providing care for members of minority groups and other disadvantaged populations," Dr. Landon and his associates said.

Since 1998, about two-thirds of community health centers (645) have participated in the collaboratives, but to date there has been no evaluation of their effect, they wrote.

The 44 intervention centers enrolled in the quality-improvement collaborative were matched with 20 control centers which had never participated in a quality-improvement collaborative.

In addition, 40 of the 44 intervention centers also served as internal controls. Sequential, random samples of patients with diabetes, asthma, or hypertension were selected during the 1-year period before the intervention and the 1-year period after its completion.

In all, 9,658 patients with one of the three conditions were selected: 3,392 with asthma, 2,904 with diabetes, and 3,362 with hypertension. Percentage scores for overall quality of care and composite scores for prevention and screening; disease monitoring and treatment; and outcomes were then calculated.

The study found that overall, when considering all three conditions, the intervention centers improved their care 4.9% above internal controls and 4.5% above external controls.

In the composite score for prevention and screening, intervention centers also improved 6.2% more than internal controls and 4.5% more than external controls.

And intervention centers also improved significantly more than controls in the composite score for disease monitoring and treatment (5.9% over external controls and 5.5% over internal ones).

When results were divided according to the three conditions, the overall trend was evident in centers focusing on asthma and diabetes, but not in those focusing on hypertension.

With regard to specific measures within the centers, the percentage of patients receiving anti-inflammatory medication for persistent asthma, the percentage of patients with an asthma management plan, the percentage of diabetes patients with two or more assessments of glycated hemoglobin levels, and the percentage of patients advised about smoking all increased more in the intervention centers, compared with the control centers.

The authors offered several explanations for the lack of effect with respect to intermediate outcomes, including that many of the processes of care that were studied are linked to longer-term outcomes.

In addition, "intermediate outcomes may require more intensive interventions in order to overcome environmental factors that pose particular challenges for patients treated at community health centers," they noted.

HOUSTON — Biopsy should be considered more frequently for pigmented lesions that appear on the vulva, compared with elsewhere on the body, because in this location they are particularly tricky to identify by appearance alone, Dr. Libby Edwards said at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital.

“It is not that pigmented lesions are likely to be more dangerous on the vulva—they are not. It's just that their appearance is less specific,” she said in an interview.

“Whereas the importance of pigmented lesions on other areas can usually be gauged relatively well by their appearance, on the vulva very abnormal-looking lesions may be unimportant and vice versa,” said Dr. Edwards, a dermatologist in private practice in Charlotte, N.C.

For example, vulvar melanosis—patchy, irregular hyperpigmentation—is a benign condition that can appear indistinguishable from vulvar melanoma.

“You have to biopsy this, it is the only way you can rule out melanoma or pigmented vulvar intraepithelial neoplasia,” she said.

Additionally, vulvar melanosis can occur as postinflammatory change associated with lichen sclerosus. “You need to treat any underlying disease, but otherwise there is no treatment for vulvar melanosis.

HOUSTON — Biopsy should be considered more frequently for pigmented lesions that appear on the vulva, compared with elsewhere on the body, because in this location they are particularly tricky to identify by appearance alone, Dr. Libby Edwards said at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital.

“It is not that pigmented lesions are likely to be more dangerous on the vulva—they are not. It's just that their appearance is less specific,” she said in an interview.

“Whereas the importance of pigmented lesions on other areas can usually be gauged relatively well by their appearance, on the vulva very abnormal-looking lesions may be unimportant and vice versa,” said Dr. Edwards, a dermatologist in private practice in Charlotte, N.C.

For example, vulvar melanosis—patchy, irregular hyperpigmentation—is a benign condition that can appear indistinguishable from vulvar melanoma.

“You have to biopsy this, it is the only way you can rule out melanoma or pigmented vulvar intraepithelial neoplasia,” she said.

Additionally, vulvar melanosis can occur as postinflammatory change associated with lichen sclerosus. “You need to treat any underlying disease, but otherwise there is no treatment for vulvar melanosis.

HOUSTON — Biopsy should be considered more frequently for pigmented lesions that appear on the vulva, compared with elsewhere on the body, because in this location they are particularly tricky to identify by appearance alone, Dr. Libby Edwards said at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital.

“It is not that pigmented lesions are likely to be more dangerous on the vulva—they are not. It's just that their appearance is less specific,” she said in an interview.

“Whereas the importance of pigmented lesions on other areas can usually be gauged relatively well by their appearance, on the vulva very abnormal-looking lesions may be unimportant and vice versa,” said Dr. Edwards, a dermatologist in private practice in Charlotte, N.C.

For example, vulvar melanosis—patchy, irregular hyperpigmentation—is a benign condition that can appear indistinguishable from vulvar melanoma.

“You have to biopsy this, it is the only way you can rule out melanoma or pigmented vulvar intraepithelial neoplasia,” she said.

Additionally, vulvar melanosis can occur as postinflammatory change associated with lichen sclerosus. “You need to treat any underlying disease, but otherwise there is no treatment for vulvar melanosis.

HOUSTON — Although most clinicians treat all anogenital human papillomavirus infections, nontreatment is something to consider in certain cases, Dr. Peter J. Lynch said at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital.

“Treatment is painful, and it's costly,” said Dr. Lynch, professor and chairman of the dermatology department at the University of California, Davis.

“Spontaneous regression is likely in a young woman. In such a patient, I would biopsy one or two of the warts. If there is no dysplasia and if she is in a monogamous relationship and her partner is willing, I would be open to waiting several months to see if regression might occur without treatment,” he said in an interview.

Most, but not all, human papillomavirus (HPV) infections resolve spontaneously, he explained. Those in older individuals and those caused by high-risk types resolve more slowly and occasionally persist indefinitely.

The argument for treatment is that it can reduce the degree of contagion; however, asymptomatic shedding still occurs. “In latency, the HPV DNA remains at the site of the lesion and may reactivate at any time,” Dr. Lynch said.

In the case of a woman in a monogamous heterosexual relationship (she may have been infected many years previously or even at birth), the risk this presents to her partner is minimal. “Biologically, the infection behaves quite differently in men than in women,” he said. “The male equivalent of vulvar intraepithelial neoplasia is extremely unlikely to progress to invasive disease. As such, infection with high-risk HPV is of trivial importance to the man but is of appreciable importance to a female sexual partner if spread to her cervix or vulva should occur.”

Although treating female infection also may reduce the risk of subsequent malignant progression in patients with high-risk HPV types, absence of dysplasia on biopsy signals a low cancer risk in the first place, said Dr. Lynch. And not all lesions need biopsy. For example, filiform warts, common warts, and small nodular warts are unlikely to show high-risk HPV or dysplasia. However, flat-topped, pigmented, or large nodular warts could be dysplastic and therefore need to be biopsied, he said.

“If you took a poll, probably 98% of gynecologists and 85% of dermatologists would treat all HPV. But there is an option out there, and we shouldn't just blindly say every infection has to be treated.”

HOUSTON — Although most clinicians treat all anogenital human papillomavirus infections, nontreatment is something to consider in certain cases, Dr. Peter J. Lynch said at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital.

“Treatment is painful, and it's costly,” said Dr. Lynch, professor and chairman of the dermatology department at the University of California, Davis.

“Spontaneous regression is likely in a young woman. In such a patient, I would biopsy one or two of the warts. If there is no dysplasia and if she is in a monogamous relationship and her partner is willing, I would be open to waiting several months to see if regression might occur without treatment,” he said in an interview.

Most, but not all, human papillomavirus (HPV) infections resolve spontaneously, he explained. Those in older individuals and those caused by high-risk types resolve more slowly and occasionally persist indefinitely.

The argument for treatment is that it can reduce the degree of contagion; however, asymptomatic shedding still occurs. “In latency, the HPV DNA remains at the site of the lesion and may reactivate at any time,” Dr. Lynch said.

In the case of a woman in a monogamous heterosexual relationship (she may have been infected many years previously or even at birth), the risk this presents to her partner is minimal. “Biologically, the infection behaves quite differently in men than in women,” he said. “The male equivalent of vulvar intraepithelial neoplasia is extremely unlikely to progress to invasive disease. As such, infection with high-risk HPV is of trivial importance to the man but is of appreciable importance to a female sexual partner if spread to her cervix or vulva should occur.”

Although treating female infection also may reduce the risk of subsequent malignant progression in patients with high-risk HPV types, absence of dysplasia on biopsy signals a low cancer risk in the first place, said Dr. Lynch. And not all lesions need biopsy. For example, filiform warts, common warts, and small nodular warts are unlikely to show high-risk HPV or dysplasia. However, flat-topped, pigmented, or large nodular warts could be dysplastic and therefore need to be biopsied, he said.

“If you took a poll, probably 98% of gynecologists and 85% of dermatologists would treat all HPV. But there is an option out there, and we shouldn't just blindly say every infection has to be treated.”

HOUSTON — Although most clinicians treat all anogenital human papillomavirus infections, nontreatment is something to consider in certain cases, Dr. Peter J. Lynch said at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital.

“Treatment is painful, and it's costly,” said Dr. Lynch, professor and chairman of the dermatology department at the University of California, Davis.

“Spontaneous regression is likely in a young woman. In such a patient, I would biopsy one or two of the warts. If there is no dysplasia and if she is in a monogamous relationship and her partner is willing, I would be open to waiting several months to see if regression might occur without treatment,” he said in an interview.

Most, but not all, human papillomavirus (HPV) infections resolve spontaneously, he explained. Those in older individuals and those caused by high-risk types resolve more slowly and occasionally persist indefinitely.

The argument for treatment is that it can reduce the degree of contagion; however, asymptomatic shedding still occurs. “In latency, the HPV DNA remains at the site of the lesion and may reactivate at any time,” Dr. Lynch said.

In the case of a woman in a monogamous heterosexual relationship (she may have been infected many years previously or even at birth), the risk this presents to her partner is minimal. “Biologically, the infection behaves quite differently in men than in women,” he said. “The male equivalent of vulvar intraepithelial neoplasia is extremely unlikely to progress to invasive disease. As such, infection with high-risk HPV is of trivial importance to the man but is of appreciable importance to a female sexual partner if spread to her cervix or vulva should occur.”

Although treating female infection also may reduce the risk of subsequent malignant progression in patients with high-risk HPV types, absence of dysplasia on biopsy signals a low cancer risk in the first place, said Dr. Lynch. And not all lesions need biopsy. For example, filiform warts, common warts, and small nodular warts are unlikely to show high-risk HPV or dysplasia. However, flat-topped, pigmented, or large nodular warts could be dysplastic and therefore need to be biopsied, he said.

“If you took a poll, probably 98% of gynecologists and 85% of dermatologists would treat all HPV. But there is an option out there, and we shouldn't just blindly say every infection has to be treated.”

NEW YORK — Although symptomatic celiac disease is a clear indication for treatment with a gluten-free diet, there was lively debate about the necessity of diagnosing and treating asymptomatic disease among delegates at an international symposium on celiac disease.

“If we are going to diagnose this disease [in asymptomatic people], then we have to be certain it will be of benefit,” said Dr. Richard Logan of the University of Nottingham (England).

Experts believe that diagnosed, symptomatic celiac disease represents only the tip of the iceberg of gluten sensitivity, and that below the waterline there is a spectrum of asymptomatic disease that includes people with positive serology and histology (silent disease), as well as those with positive serology but negative histology (latent disease).

Such asymptomatic patients are often diagnosed during family screening, because it is now recognized that genetic predisposition plays an important role in the development of the disorder; almost all celiac patients carry the DQ2 or DQ8 genes.

But the uncertain clinical benefit of labeling asymptomatic individuals and prescribing them a lifelong gluten-free diet should be carefully weighed against the potential psychological and economic risks, warned several experts at the meeting, cosponsored by the AGA Institute.

A gluten-free diet can dramatically reduce or eliminate symptoms and has also been considered protective against the increased risks of malignancy and osteoporosis that have been associated with celiac disease, even its asymptomatic form. However, new findings suggest that these long-term risks might be lower than was previously believed, said Dr. Joe West of the University of Nottingham (England).

His study of almost 5,000 treated celiac patients and of more than 23,000 controls revealed a 30% increase in overall malignancies among the celiac patients (BMJ 2004;329:716–9), but a closer analysis revealed a detection bias in that most cancers were diagnosed in the first year after the celiac diagnosis.

After controlling for this phenomenon, the difference in overall cancer rate between the two groups was no longer significant. However, further analysis of individual cancers revealed a fivefold increase in non-Hodgkin's lymphoma among the celiac patients, and a 40-fold increase in small bowel lymphoma (Aliment. Pharmacol. Ther. 2004;20:769–75). Of note was that breast cancers were 70% less common in the celiac population, a finding for which Dr. West said he has no explanation.

His research also found a 30% increase in osteoporosis among celiac patients, with a twofold increase in hip fracture; however, the absolute risk remained small. These results were restricted to diagnosed celiac patients who were being treated with a gluten-free diet, and therefore their relevance for undiagnosed, untreated individuals is not clear, he said.

Another argument for screening and treating asymptomatic celiac disease comes from evidence that it might progress to overt disease with continued gluten exposure, other experts said. Early treatment with a gluten-free diet could halt the progression from latent to silent and then to symptomatic disease, they suggested.

But the psychological price of a lifelong gluten-free diet is often underappreciated by physicians who prescribe it, Dr. Logan said. A recent survey of patients diagnosed with celiac disease revealed that one-third felt the gluten-free diet greatly reduced their enjoyment of food, and a quarter were not entirely pleased to have been diagnosed, he said.

Despite experiencing relief of symptoms, many celiac patients (particularly women) on a gluten-free diet report a reduced quality of life, said Dr. Claes Hallert of Linköping (Sweden) University. “Many patients react psychologically to the restrictive diet—there are social problems, societal problems, problems at work, problems with travel—and this may lead to depression,” he said in an interview.

In a study of 40 celiac patients, his research group identified 195 situational dilemmas faced by patients dealing with a gluten-free diet. Specific emotions that were identified included isolation, shame, fear of gluten, and worry about inconveniencing others. Patients also reported unwanted visibility, neglect, disclosure avoidance, and risk-taking (J. Hum. Nutr. Diet. 2005;18:171–80).

NEW YORK — Although symptomatic celiac disease is a clear indication for treatment with a gluten-free diet, there was lively debate about the necessity of diagnosing and treating asymptomatic disease among delegates at an international symposium on celiac disease.

“If we are going to diagnose this disease [in asymptomatic people], then we have to be certain it will be of benefit,” said Dr. Richard Logan of the University of Nottingham (England).

Experts believe that diagnosed, symptomatic celiac disease represents only the tip of the iceberg of gluten sensitivity, and that below the waterline there is a spectrum of asymptomatic disease that includes people with positive serology and histology (silent disease), as well as those with positive serology but negative histology (latent disease).

Such asymptomatic patients are often diagnosed during family screening, because it is now recognized that genetic predisposition plays an important role in the development of the disorder; almost all celiac patients carry the DQ2 or DQ8 genes.

But the uncertain clinical benefit of labeling asymptomatic individuals and prescribing them a lifelong gluten-free diet should be carefully weighed against the potential psychological and economic risks, warned several experts at the meeting, cosponsored by the AGA Institute.

A gluten-free diet can dramatically reduce or eliminate symptoms and has also been considered protective against the increased risks of malignancy and osteoporosis that have been associated with celiac disease, even its asymptomatic form. However, new findings suggest that these long-term risks might be lower than was previously believed, said Dr. Joe West of the University of Nottingham (England).

His study of almost 5,000 treated celiac patients and of more than 23,000 controls revealed a 30% increase in overall malignancies among the celiac patients (BMJ 2004;329:716–9), but a closer analysis revealed a detection bias in that most cancers were diagnosed in the first year after the celiac diagnosis.

After controlling for this phenomenon, the difference in overall cancer rate between the two groups was no longer significant. However, further analysis of individual cancers revealed a fivefold increase in non-Hodgkin's lymphoma among the celiac patients, and a 40-fold increase in small bowel lymphoma (Aliment. Pharmacol. Ther. 2004;20:769–75). Of note was that breast cancers were 70% less common in the celiac population, a finding for which Dr. West said he has no explanation.

His research also found a 30% increase in osteoporosis among celiac patients, with a twofold increase in hip fracture; however, the absolute risk remained small. These results were restricted to diagnosed celiac patients who were being treated with a gluten-free diet, and therefore their relevance for undiagnosed, untreated individuals is not clear, he said.

Another argument for screening and treating asymptomatic celiac disease comes from evidence that it might progress to overt disease with continued gluten exposure, other experts said. Early treatment with a gluten-free diet could halt the progression from latent to silent and then to symptomatic disease, they suggested.

But the psychological price of a lifelong gluten-free diet is often underappreciated by physicians who prescribe it, Dr. Logan said. A recent survey of patients diagnosed with celiac disease revealed that one-third felt the gluten-free diet greatly reduced their enjoyment of food, and a quarter were not entirely pleased to have been diagnosed, he said.

Despite experiencing relief of symptoms, many celiac patients (particularly women) on a gluten-free diet report a reduced quality of life, said Dr. Claes Hallert of Linköping (Sweden) University. “Many patients react psychologically to the restrictive diet—there are social problems, societal problems, problems at work, problems with travel—and this may lead to depression,” he said in an interview.

In a study of 40 celiac patients, his research group identified 195 situational dilemmas faced by patients dealing with a gluten-free diet. Specific emotions that were identified included isolation, shame, fear of gluten, and worry about inconveniencing others. Patients also reported unwanted visibility, neglect, disclosure avoidance, and risk-taking (J. Hum. Nutr. Diet. 2005;18:171–80).

NEW YORK — Although symptomatic celiac disease is a clear indication for treatment with a gluten-free diet, there was lively debate about the necessity of diagnosing and treating asymptomatic disease among delegates at an international symposium on celiac disease.

“If we are going to diagnose this disease [in asymptomatic people], then we have to be certain it will be of benefit,” said Dr. Richard Logan of the University of Nottingham (England).

Experts believe that diagnosed, symptomatic celiac disease represents only the tip of the iceberg of gluten sensitivity, and that below the waterline there is a spectrum of asymptomatic disease that includes people with positive serology and histology (silent disease), as well as those with positive serology but negative histology (latent disease).

Such asymptomatic patients are often diagnosed during family screening, because it is now recognized that genetic predisposition plays an important role in the development of the disorder; almost all celiac patients carry the DQ2 or DQ8 genes.

But the uncertain clinical benefit of labeling asymptomatic individuals and prescribing them a lifelong gluten-free diet should be carefully weighed against the potential psychological and economic risks, warned several experts at the meeting, cosponsored by the AGA Institute.

A gluten-free diet can dramatically reduce or eliminate symptoms and has also been considered protective against the increased risks of malignancy and osteoporosis that have been associated with celiac disease, even its asymptomatic form. However, new findings suggest that these long-term risks might be lower than was previously believed, said Dr. Joe West of the University of Nottingham (England).

His study of almost 5,000 treated celiac patients and of more than 23,000 controls revealed a 30% increase in overall malignancies among the celiac patients (BMJ 2004;329:716–9), but a closer analysis revealed a detection bias in that most cancers were diagnosed in the first year after the celiac diagnosis.

After controlling for this phenomenon, the difference in overall cancer rate between the two groups was no longer significant. However, further analysis of individual cancers revealed a fivefold increase in non-Hodgkin's lymphoma among the celiac patients, and a 40-fold increase in small bowel lymphoma (Aliment. Pharmacol. Ther. 2004;20:769–75). Of note was that breast cancers were 70% less common in the celiac population, a finding for which Dr. West said he has no explanation.

His research also found a 30% increase in osteoporosis among celiac patients, with a twofold increase in hip fracture; however, the absolute risk remained small. These results were restricted to diagnosed celiac patients who were being treated with a gluten-free diet, and therefore their relevance for undiagnosed, untreated individuals is not clear, he said.

Another argument for screening and treating asymptomatic celiac disease comes from evidence that it might progress to overt disease with continued gluten exposure, other experts said. Early treatment with a gluten-free diet could halt the progression from latent to silent and then to symptomatic disease, they suggested.

But the psychological price of a lifelong gluten-free diet is often underappreciated by physicians who prescribe it, Dr. Logan said. A recent survey of patients diagnosed with celiac disease revealed that one-third felt the gluten-free diet greatly reduced their enjoyment of food, and a quarter were not entirely pleased to have been diagnosed, he said.

Despite experiencing relief of symptoms, many celiac patients (particularly women) on a gluten-free diet report a reduced quality of life, said Dr. Claes Hallert of Linköping (Sweden) University. “Many patients react psychologically to the restrictive diet—there are social problems, societal problems, problems at work, problems with travel—and this may lead to depression,” he said in an interview.

In a study of 40 celiac patients, his research group identified 195 situational dilemmas faced by patients dealing with a gluten-free diet. Specific emotions that were identified included isolation, shame, fear of gluten, and worry about inconveniencing others. Patients also reported unwanted visibility, neglect, disclosure avoidance, and risk-taking (J. Hum. Nutr. Diet. 2005;18:171–80).

The first rapid test for viral meningitis has been cleared for marketing by the Food and Drug Administration.

The Xpert EV test (Cepheid)—which was released in Europe last summer—can help identify viral meningitis within 2.5 hours instead of the current 3–7 days, thus helping physicians to distinguish quickly between the viral and bacterial forms of the infection, according to the FDA.

“Since bacterial meningitis can be deadly within as little as 2 days, patients who have viral meningitis are frequently treated with antibiotics as a safeguard,” said Dr. Daniel G. Schultz, director of the FDA's Center for Devices and Radiological Health, in a written statement. By using the rapid test, physicians can reduce this unnecessary antibiotic treatment, he noted.

The Xpert EV test uses reverse-transcription real-time polymerase chain reaction to detect enterovirus, which is responsible for 85%–95% of viral meningitis, in cerebrospinal fluid (CSF). However, the test should not be used in isolation, Dr. Steven Gutman, director of the FDA's Office of In Vitro Diagnostics, said in an interview. “It is not intended that this test would be the sole determinant. It is an adjunctive test used in conjunction with other factors such as history, physical, and other lab tests.”

Indeed, according to the company, the test is designed to be used in conjunction “with standard CSF tests [such as] bacterial gram stain, bacterial culture, CSF glucose, CSF-blood glucose ratio, CSF protein concentrations, and CSF leukocyte counts.” It “fills a clinical testing void,” because it is a fully automated test, thereby allowing “round-the-clock” testing, Cepheid said a written statement.

In a six-site study conducted by the company that included 255 patient samples, the test had a sensitivity of 96% and a specificity of 97%, Dr. Gutman said.

The first rapid test for viral meningitis has been cleared for marketing by the Food and Drug Administration.

The Xpert EV test (Cepheid)—which was released in Europe last summer—can help identify viral meningitis within 2.5 hours instead of the current 3–7 days, thus helping physicians to distinguish quickly between the viral and bacterial forms of the infection, according to the FDA.

“Since bacterial meningitis can be deadly within as little as 2 days, patients who have viral meningitis are frequently treated with antibiotics as a safeguard,” said Dr. Daniel G. Schultz, director of the FDA's Center for Devices and Radiological Health, in a written statement. By using the rapid test, physicians can reduce this unnecessary antibiotic treatment, he noted.

The Xpert EV test uses reverse-transcription real-time polymerase chain reaction to detect enterovirus, which is responsible for 85%–95% of viral meningitis, in cerebrospinal fluid (CSF). However, the test should not be used in isolation, Dr. Steven Gutman, director of the FDA's Office of In Vitro Diagnostics, said in an interview. “It is not intended that this test would be the sole determinant. It is an adjunctive test used in conjunction with other factors such as history, physical, and other lab tests.”

Indeed, according to the company, the test is designed to be used in conjunction “with standard CSF tests [such as] bacterial gram stain, bacterial culture, CSF glucose, CSF-blood glucose ratio, CSF protein concentrations, and CSF leukocyte counts.” It “fills a clinical testing void,” because it is a fully automated test, thereby allowing “round-the-clock” testing, Cepheid said a written statement.

In a six-site study conducted by the company that included 255 patient samples, the test had a sensitivity of 96% and a specificity of 97%, Dr. Gutman said.

The first rapid test for viral meningitis has been cleared for marketing by the Food and Drug Administration.

The Xpert EV test (Cepheid)—which was released in Europe last summer—can help identify viral meningitis within 2.5 hours instead of the current 3–7 days, thus helping physicians to distinguish quickly between the viral and bacterial forms of the infection, according to the FDA.

“Since bacterial meningitis can be deadly within as little as 2 days, patients who have viral meningitis are frequently treated with antibiotics as a safeguard,” said Dr. Daniel G. Schultz, director of the FDA's Center for Devices and Radiological Health, in a written statement. By using the rapid test, physicians can reduce this unnecessary antibiotic treatment, he noted.

The Xpert EV test uses reverse-transcription real-time polymerase chain reaction to detect enterovirus, which is responsible for 85%–95% of viral meningitis, in cerebrospinal fluid (CSF). However, the test should not be used in isolation, Dr. Steven Gutman, director of the FDA's Office of In Vitro Diagnostics, said in an interview. “It is not intended that this test would be the sole determinant. It is an adjunctive test used in conjunction with other factors such as history, physical, and other lab tests.”

Indeed, according to the company, the test is designed to be used in conjunction “with standard CSF tests [such as] bacterial gram stain, bacterial culture, CSF glucose, CSF-blood glucose ratio, CSF protein concentrations, and CSF leukocyte counts.” It “fills a clinical testing void,” because it is a fully automated test, thereby allowing “round-the-clock” testing, Cepheid said a written statement.

In a six-site study conducted by the company that included 255 patient samples, the test had a sensitivity of 96% and a specificity of 97%, Dr. Gutman said.

A national quality improvement initiative significantly improved several aspects of care for diabetes, asthma, and hypertension at community health centers, but had no impact on intermediate outcomes, according to a recent study.

“The substantial room for improvement in the postintervention period suggests the need for continued refinement of these methods,” wrote Dr. Bruce E. Landon of Harvard Medical School, Boston, and colleagues (N. Engl. J. Med. 2007;356:921–34). “There is still much to learn about the tools and methods for quality improvement and their potential effectiveness.”

The study compared the quality of care at 44 community health centers before and after their participation in the quality-improvement Health Disparities Collaboratives. This initiative, sponsored by the Health Resources and Services Administration, the Agency for Healthcare Research and Quality, and the Commonwealth Fund, was designed to improve care at community health centers, a particularly relevant target because of their “prominent role in providing care for members of minority groups and other disadvantaged populations,” the authors noted. Since 1998, about two-thirds of community health centers (645) have participated in the collaboratives, but to date there has been no evaluation of their effect, they wrote.

The 44 intervention centers enrolled in the quality-improvement collaborative were matched with 20 control centers which had never participated in a quality-improvement collaborative. In addition, 40 of the 44 intervention centers also served as internal controls. Sequential, random samples of patients with diabetes, asthma, or hypertension were selected during the 1-year period before the intervention and the 1-year period after its completion. A total of 9,658 patients with one of the three conditions were selected: 3,392 with asthma; 2,904 with diabetes; and 3,362 with hypertension. Percentage scores for overall quality of care and composite scores for prevention and screening, disease monitoring and treatment, and outcomes were then calculated.

The study found that overall, when considering all three conditions, the intervention centers improved their care 4.9% above internal controls and 4.5% above external controls. In the composite score for prevention and screening, intervention centers also improved 6.2% more than internal controls and 4.5% more than external controls. And intervention centers also improved significantly more than controls in the composite score for disease monitoring and treatment (5.9% over external controls and 5.5% over internal ones).

When results were divided according to the three conditions, the overall trend was evident in centers focusing on asthma and diabetes, but not in those focusing on hypertension.

With regard to specific measures within the centers, the percentage of patients receiving antiinflammatory medication for persistent asthma, the percentage of patients with an asthma management plan, the percentage of diabetes patients with two or more assessments of glycated hemoglobin levels, and the percentage of patients advised about smoking all increased more in the intervention centers, compared with the control centers.

The authors offered several explanations for the lack of effect with respect to intermediate outcomes, including that many of the processes of care that were studied are linked to longer-term outcomes. In addition, “intermediate outcomes may require more intensive interventions in order to overcome environmental factors that pose particular challenges for patients treated at community health centers,” they noted.

A national quality improvement initiative significantly improved several aspects of care for diabetes, asthma, and hypertension at community health centers, but had no impact on intermediate outcomes, according to a recent study.

“The substantial room for improvement in the postintervention period suggests the need for continued refinement of these methods,” wrote Dr. Bruce E. Landon of Harvard Medical School, Boston, and colleagues (N. Engl. J. Med. 2007;356:921–34). “There is still much to learn about the tools and methods for quality improvement and their potential effectiveness.”

The study compared the quality of care at 44 community health centers before and after their participation in the quality-improvement Health Disparities Collaboratives. This initiative, sponsored by the Health Resources and Services Administration, the Agency for Healthcare Research and Quality, and the Commonwealth Fund, was designed to improve care at community health centers, a particularly relevant target because of their “prominent role in providing care for members of minority groups and other disadvantaged populations,” the authors noted. Since 1998, about two-thirds of community health centers (645) have participated in the collaboratives, but to date there has been no evaluation of their effect, they wrote.

The 44 intervention centers enrolled in the quality-improvement collaborative were matched with 20 control centers which had never participated in a quality-improvement collaborative. In addition, 40 of the 44 intervention centers also served as internal controls. Sequential, random samples of patients with diabetes, asthma, or hypertension were selected during the 1-year period before the intervention and the 1-year period after its completion. A total of 9,658 patients with one of the three conditions were selected: 3,392 with asthma; 2,904 with diabetes; and 3,362 with hypertension. Percentage scores for overall quality of care and composite scores for prevention and screening, disease monitoring and treatment, and outcomes were then calculated.

The study found that overall, when considering all three conditions, the intervention centers improved their care 4.9% above internal controls and 4.5% above external controls. In the composite score for prevention and screening, intervention centers also improved 6.2% more than internal controls and 4.5% more than external controls. And intervention centers also improved significantly more than controls in the composite score for disease monitoring and treatment (5.9% over external controls and 5.5% over internal ones).

When results were divided according to the three conditions, the overall trend was evident in centers focusing on asthma and diabetes, but not in those focusing on hypertension.

With regard to specific measures within the centers, the percentage of patients receiving antiinflammatory medication for persistent asthma, the percentage of patients with an asthma management plan, the percentage of diabetes patients with two or more assessments of glycated hemoglobin levels, and the percentage of patients advised about smoking all increased more in the intervention centers, compared with the control centers.

The authors offered several explanations for the lack of effect with respect to intermediate outcomes, including that many of the processes of care that were studied are linked to longer-term outcomes. In addition, “intermediate outcomes may require more intensive interventions in order to overcome environmental factors that pose particular challenges for patients treated at community health centers,” they noted.

A national quality improvement initiative significantly improved several aspects of care for diabetes, asthma, and hypertension at community health centers, but had no impact on intermediate outcomes, according to a recent study.

“The substantial room for improvement in the postintervention period suggests the need for continued refinement of these methods,” wrote Dr. Bruce E. Landon of Harvard Medical School, Boston, and colleagues (N. Engl. J. Med. 2007;356:921–34). “There is still much to learn about the tools and methods for quality improvement and their potential effectiveness.”

The study compared the quality of care at 44 community health centers before and after their participation in the quality-improvement Health Disparities Collaboratives. This initiative, sponsored by the Health Resources and Services Administration, the Agency for Healthcare Research and Quality, and the Commonwealth Fund, was designed to improve care at community health centers, a particularly relevant target because of their “prominent role in providing care for members of minority groups and other disadvantaged populations,” the authors noted. Since 1998, about two-thirds of community health centers (645) have participated in the collaboratives, but to date there has been no evaluation of their effect, they wrote.

The 44 intervention centers enrolled in the quality-improvement collaborative were matched with 20 control centers which had never participated in a quality-improvement collaborative. In addition, 40 of the 44 intervention centers also served as internal controls. Sequential, random samples of patients with diabetes, asthma, or hypertension were selected during the 1-year period before the intervention and the 1-year period after its completion. A total of 9,658 patients with one of the three conditions were selected: 3,392 with asthma; 2,904 with diabetes; and 3,362 with hypertension. Percentage scores for overall quality of care and composite scores for prevention and screening, disease monitoring and treatment, and outcomes were then calculated.

The study found that overall, when considering all three conditions, the intervention centers improved their care 4.9% above internal controls and 4.5% above external controls. In the composite score for prevention and screening, intervention centers also improved 6.2% more than internal controls and 4.5% more than external controls. And intervention centers also improved significantly more than controls in the composite score for disease monitoring and treatment (5.9% over external controls and 5.5% over internal ones).

When results were divided according to the three conditions, the overall trend was evident in centers focusing on asthma and diabetes, but not in those focusing on hypertension.

With regard to specific measures within the centers, the percentage of patients receiving antiinflammatory medication for persistent asthma, the percentage of patients with an asthma management plan, the percentage of diabetes patients with two or more assessments of glycated hemoglobin levels, and the percentage of patients advised about smoking all increased more in the intervention centers, compared with the control centers.

The authors offered several explanations for the lack of effect with respect to intermediate outcomes, including that many of the processes of care that were studied are linked to longer-term outcomes. In addition, “intermediate outcomes may require more intensive interventions in order to overcome environmental factors that pose particular challenges for patients treated at community health centers,” they noted.

HOUSTON — Labial agglutination resolves spontaneously at puberty in up to 80% of girls and has a 40% recurrence rate after treatment, whether medical or surgical, making nontreatment the best option when patients are asymptomatic, according to Dr. Abbey B. Berenson, professor of obstetrics and gynecology at the University of Texas at Galveston.

“There is only one case report of this leading to urinary retention,” she said at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital. “That's why I don't start treatment when they're asymptomatic. You could end up taking them to the OR just so they look normal, and you don't want to do that.”

Extensive labial agglutination is present in 5% of prepubertal girls and up to 10% of girls aged 12 months or under, she said. Patients are usually referred with the chief complaint of “absent vagina” because there may be only a small opening visible below the clitoris. Although the majority of patients are asymptomatic, some may have urinary symptoms. “The vagina can form a sort of pocket in which urine gathers and then dribbles out. These are the ones you want to treat because you don't want to see kidney damage due to repeat urinary tract infections or urethritis,” she said.

Dr. Berenson recommends topical estrogen cream as first-line treatment.

“I really think it's important to try and avoid surgery,” she said in an interview. “It is such a big deal to take these children to the operating room, and so often the problem recurs anyway.”

The success rates for estrogen medical therapy range from 50% to 100%, she said. “This works for thin adhesions but not thick or recurrent ones.” Parents should be instructed to use a finger to apply the estrogen cream over the gray fusion line using some pressure. This should be done twice a day for 2–4 weeks but stopped if breast budding occurs.

The risk of recurrence can be lowered with good hygiene and reduced irritation, because the condition is believed to develop as a result of low estrogen levels and local irritation, which injures tissue and results in adherence of the labia minora.

Surgical treatment should be reserved for those who fail medical therapy, Dr. Berenson said.

It's important to try and avoid surgery. It is such a big deal to take these children to the OR. DR. BERENSON

HOUSTON — Labial agglutination resolves spontaneously at puberty in up to 80% of girls and has a 40% recurrence rate after treatment, whether medical or surgical, making nontreatment the best option when patients are asymptomatic, according to Dr. Abbey B. Berenson, professor of obstetrics and gynecology at the University of Texas at Galveston.

“There is only one case report of this leading to urinary retention,” she said at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital. “That's why I don't start treatment when they're asymptomatic. You could end up taking them to the OR just so they look normal, and you don't want to do that.”

Extensive labial agglutination is present in 5% of prepubertal girls and up to 10% of girls aged 12 months or under, she said. Patients are usually referred with the chief complaint of “absent vagina” because there may be only a small opening visible below the clitoris. Although the majority of patients are asymptomatic, some may have urinary symptoms. “The vagina can form a sort of pocket in which urine gathers and then dribbles out. These are the ones you want to treat because you don't want to see kidney damage due to repeat urinary tract infections or urethritis,” she said.

Dr. Berenson recommends topical estrogen cream as first-line treatment.

“I really think it's important to try and avoid surgery,” she said in an interview. “It is such a big deal to take these children to the operating room, and so often the problem recurs anyway.”

The success rates for estrogen medical therapy range from 50% to 100%, she said. “This works for thin adhesions but not thick or recurrent ones.” Parents should be instructed to use a finger to apply the estrogen cream over the gray fusion line using some pressure. This should be done twice a day for 2–4 weeks but stopped if breast budding occurs.

The risk of recurrence can be lowered with good hygiene and reduced irritation, because the condition is believed to develop as a result of low estrogen levels and local irritation, which injures tissue and results in adherence of the labia minora.

Surgical treatment should be reserved for those who fail medical therapy, Dr. Berenson said.

It's important to try and avoid surgery. It is such a big deal to take these children to the OR. DR. BERENSON

HOUSTON — Labial agglutination resolves spontaneously at puberty in up to 80% of girls and has a 40% recurrence rate after treatment, whether medical or surgical, making nontreatment the best option when patients are asymptomatic, according to Dr. Abbey B. Berenson, professor of obstetrics and gynecology at the University of Texas at Galveston.

“There is only one case report of this leading to urinary retention,” she said at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital. “That's why I don't start treatment when they're asymptomatic. You could end up taking them to the OR just so they look normal, and you don't want to do that.”

Extensive labial agglutination is present in 5% of prepubertal girls and up to 10% of girls aged 12 months or under, she said. Patients are usually referred with the chief complaint of “absent vagina” because there may be only a small opening visible below the clitoris. Although the majority of patients are asymptomatic, some may have urinary symptoms. “The vagina can form a sort of pocket in which urine gathers and then dribbles out. These are the ones you want to treat because you don't want to see kidney damage due to repeat urinary tract infections or urethritis,” she said.

Dr. Berenson recommends topical estrogen cream as first-line treatment.

“I really think it's important to try and avoid surgery,” she said in an interview. “It is such a big deal to take these children to the operating room, and so often the problem recurs anyway.”

The success rates for estrogen medical therapy range from 50% to 100%, she said. “This works for thin adhesions but not thick or recurrent ones.” Parents should be instructed to use a finger to apply the estrogen cream over the gray fusion line using some pressure. This should be done twice a day for 2–4 weeks but stopped if breast budding occurs.

The risk of recurrence can be lowered with good hygiene and reduced irritation, because the condition is believed to develop as a result of low estrogen levels and local irritation, which injures tissue and results in adherence of the labia minora.

Surgical treatment should be reserved for those who fail medical therapy, Dr. Berenson said.

It's important to try and avoid surgery. It is such a big deal to take these children to the OR. DR. BERENSON