Consensus Panel Recommendations Research Articles

Cardiovascular pre‐participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol

The 1996 American Heart Association consensus panel recommendations stated that pre-participation cardiovascular screening for young competitive athletes is justifiable and compelling on ethical, legal, and medical grounds. The present article represents the consensus statement of the Study Group on Sports Cardiology of the Working Group on Cardiac Rehabilitation and Exercise Physiology and the Working Group on Myocardial and Pericardial diseases of the European Society of Cardiology, which comprises cardiovascular specialists and other physicians from different European countries with extensive clinical experience with young competitive athletes, as well as with pathological substrates of sudden death. The document takes note of the 25-year Italian experience on systematic pre-participation screening of competitive athletes and focuses on relevant issues, mostly regarding the relative risk, causes, and prevalence of sudden death in athletes; the efficacy, feasibility, and cost-effectiveness of population-based pre-participation cardiovascular screening; the key role of 12-lead ECG for identification of cardiovascular diseases such as cardiomyopathies and channelopathies at risk of sudden death during sports; and the potential of preventing fatal events. The main purpose of the consensus document is to reinforce the principle of the need for pre-participation medical clearance of all young athletes involved in organized sports programmes, on the basis of (i) the proven efficacy of systematic screening by 12-lead ECG (in addition to history and physical examination) to identify hypertrophic cardiomyopathy—the leading cause of sports-related sudden death—and to prevent athletic field fatalities; (ii) the potential screening ability in detecting other lethal cardiovascular diseases presenting with ECG abnormalities. The consensus document recommends the implementation of a common European screening protocol essentially based on 12-lead ECG.

Role of nicotinic acid in raising high-density lipoprotein cholesterol (HDL-C) to reduce cardiovascular risk: an Asian/Pacific consensus

ardiovascular disease is a leading cause of morbidity and mortality in Asia, and the burden of disease is expected to rise further in the 21st century. As in Western populations, dyslipidaemia is an important cardiovascular risk factor in Asian people. International guidelines focus on reduction of low-density lipoprotein cholesterol (LDL-C) for prevention and treatment of coronary heart disease (CHD). However, increasing body mass index and prevalence of type 2 diabetes and metabolic syndrome in Asia have highlighted the importance of low levels of high-density lipoprotein cholesterol (HDL-C) as a coronary risk factor. Therapeutic lifestyle changes and pharmacological intervention aimed at raising HDL-C, should benefit such patients. Weight loss and physical However, to achieve target HDL-C levels exercise are important interventions for raising HDL-C. pharmacological intervention is usually necessary. Current treatment options include statins, fibrates and nicotinic acid, either as monotherapy or in combination. Statins are generally regarded as the foundation of lipid-modifying therapy. Mainly via reduction of LDL-C. Both fibrates and nicotinic acidare effective in raising HDL-C levels, and reducing triglyceride-rich lipoproteins. The efficacy and safety profile of nicotinic acid demonstrated in Western populations indicates the clinical benefits of this therapy either alone or in combination with a statin. Based on the available evidence, the Pan-Asian Consensus Panel recommends that HDL-C levels should be raised to at least 1.0 mmol/L (40 mg/dL) in Asian patients with CHD or with a high level of risk for premature vascular disease, including patients at high risk with type 2 diabetes or the metabolic syndrome.

Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol

The 1996 American Heart Association consensus panel recommendations stated that pre-participation cardiovascular screening for young competitive athletes is justifiable and compelling on ethical, legal, and medical grounds. The present article represents the consensus statement of the Study Group on Sports Cardiology of the Working Group on Cardiac Rehabilitation and Exercise Physiology and the Working Group on Myocardial and Pericardial diseases of the European Society of Cardiology, which comprises cardiovascular specialists and other physicians from different European countries with extensive clinical experience with young competitive athletes, as well as with pathological substrates of sudden death. The document takes note of the 25-year Italian experience on systematic pre-participation screening of competitive athletes and focuses on relevant issues, mostly regarding the relative risk, causes, and prevalence of sudden death in athletes; the efficacy, feasibility, and cost-effectiveness of population-based pre-participation cardiovascular screening; the key role of 12-lead ECG for identification of cardiovascular diseases such as cardiomyopathies and channelopathies at risk of sudden death during sports; and the potential of preventing fatal events. The main purpose of the consensus document is to reinforce the principle of the need for pre-participation medical clearance of all young athletes involved in organized sports programmes, on the basis of (i) the proven efficacy of systematic screening by 12-lead ECG (in addition to history and physical examination) to identify hypertrophic cardiomyopathy-the leading cause of sports-related sudden death-and to prevent athletic field fatalities; (ii) the potential screening ability in detecting other lethal cardiovascular diseases presenting with ECG abnormalities. The consensus document recommends the implementation of a common European screening protocol essentially based on 12-lead ECG.

Expanded-spectrum β-lactamase producing Klebsiella pneumoniae-related peritonitis in a patient on peritoneal dialysis

While hospitalized for pneumonia with ventilator-dependent respiratory failure, a 45-year-old man on continuous ambulatory peritoneal dialysis (CAPD) had nosocomial peritonitis secondary to infection by expanded spectrum beta-lactamase producing Klebsiella pneumoniae (ESBL-Kp). He was treated successfully with a 3-week course of intraperitoneal (IP) flomoxef therapy without subsequent relapse, loss of peritoneal catheter, ultrafiltration failure, or dialysis inadequacy. The International Consensus Panel recommends IP ceftazidime as the treatment of choice for CAPD patients suffering Klebsiella species-related peritonitis. However, the most appropriate form of IP antibiotic therapy and the outcomes for expanded-spectrum beta-lactamase (ESBL)-producing bacteria-related peritonitis for CAPD patients have not been established yet. Further, the ability to correctly report minimal inhibitory concentrations (MICs) of ceftazidime for ESBL bacteria in the resistant range varies between laboratories, making the diagnosis of ESBL-Kp-related CAPD peritonitis more complex and difficult. Thus, it appears reasonable to suggest that its incidence is probably underestimated and its significance ignored. The authors suggest that a 3-week IP treatment with flomoxef, a synthesized oxacephem, with loading and maintenance doses of 250 and 125 mg/L, respectively, is effective and safe for ESBL-Kp-related peritonitis in these patients. ESBL producing bacterial infection should be considered as a possible cause of overt CAPD-related peritonitis. Early detection of ESBLB pathogens and institution of effective antibiotic treatment may improve the prognosis.

Clinical indications for cardiovascular magnetic resonance (CMR): Consensus Panel report?

This paper was guest edited by Dr. E. Fleck. Deutsches Herzzentrum Berlin, Germany Cardiovascular magnetic resonance (CMR) is established in clinical practice for the diagnosis and management of diseases of the cardiovascular system. However, current guidelines for when this technique should be employed in clinical practice have not been revised since a Task Force report of 1998.1 Considerable technical and practice advances have been made in the intervening years and the level of interest from clinicians in this field is at an unprecedented level. Therefore the aim of this report from a Consensus Panel of established experts in the field of CMR is to update these guidelines. As CMR is a multi-disciplinary technique with international interest, the Consensus Panel was composed of European and American cardiologists and radiologists with major input from members with additional established expertise in paediatric cardiology, nuclear cardiology, magnetic resonance physics and spectroscopy, as well as health economics. The Consensus Panel was originated, approved and funded in its activities by the Working Group on CMR of the European Society of Cardiology and the Society for Cardiovascular Magnetic Resonance. The Consensus Panel recommendations are based on evidence compiled from the literature and expert experience. If there is insufficient evidence in the literature, this is indicated in the report but usually no recommendations are made under these circumstances. The appropriateness of using CMR is described for the frequent disease entities where imaging information may be warranted. The diagnostic use of CMR will be described in the context of other, competing imaging techniques, with particular emphasis on the differential indications with respect to echocardiography. The usefulness of CMR in specific diseases is summarized by means of the following classification:

The 'effectiveness' scale--therapeutic outcome of pharmacologic therapies for ED: an international consensus panel report.

Despite availability of outcome measures and scales for assessing erectile dysfunction (ED) treatment efficacy, guidelines are not available for assessing broader therapeutic outcomes or defining treatment failure in ED. An International Consensus Advisory Panel was convened to develop guidelines, definitions and a new algorithm for evaluating treatment effectiveness in ED. These new guidelines are recommended for use in both research and clinical practice. A multidisciplinary, international panel, consisting of 11 senior researchers and clinicians, was convened to address pertinent issues concerning therapeutic outcome assessment for ED. The panel utilized a modified Delphi method of consensus development and proposed a new model for outcomes assessment. This model is inherently testable, using existing instruments and current methods of assessment. Following a comprehensive literature review and discussion, the Panel recommended adoption of a new treatment effectiveness conceptual framework or theoretical model for assessing therapeutic outcomes in ED. Treatment effectiveness is presumed to be a combined function of two other factors, treatment response and treatment satisfaction. Treatment response is based on the combined assessment of efficacy and tolerability, and treatment satisfaction on the combined assessment of patient and partner satisfaction. Taken together, these two domains define an overall domain of treatment effectiveness. This therapeutic index would be derived by independently assessing treatment efficacy and satisfaction by means of event logs, questionnaires or the more typical patient interview methods. In conclusion, the Ad Hoc Advisory Consensus Panel recommends adoption of a new framework or conceptual model for conducting ED outcome trials or clinical research. The concept of 'treatment effectiveness' is proposed as a new 'umbrella concept' or distal outcome to be evaluated.

Management of postoperative vomiting in pediatric patients

Postoperative vomiting remains a common complication of general anesthesia and occurs more frequently in children than adults. Prophylactic antiemetics have limited efficacy and have a potential for side effects. The new 5 HT3 antagonists are effective but expensive, while the older less expensive drugs such as droperidol have come under disrepute because of the potential for serious, life-threatening, cardiac arrhythmias. This review examines the literature to aid practicing anesthesiologists in the choice of patient who will benefit from prophylactic antiemetics. In this review we discuss the factors associated with postoperative vomiting that are and are not under the control of the anesthesiologist. The Consensus Panel recommendations for reducing the risks of postoperative vomiting and for the rational use of prophylactic antiemetics in selected cases are reviewed. The controversy over the 'black box warning' on the use of droperidol is discussed. Finally, the evidence supports the importance of choosing a drug from another class for rescue therapy when prophylaxis with one drug has failed. Anesthesiologists should practice evidence-based medicine in reducing the common anesthetic complication of postoperative vomiting by an individualized approach that balances the choice of drugs with the expected risk of postoperative vomiting for cost-effective management.

Clinical Management of Primary Hyperparathyroidism and Thresholds for Surgical Referral: A National Study Examining Concordance Between Practice Patterns and Consensus Panel Recommendations

To determine whether 1990 guidelines established by the National Institutes of Health (NIH) for the optimal management (surgical versus nonsurgical) of patients with asymptomatic primary hyperparathyroidism (PHPT) are known and followed by endocrinologists. We surveyed endocrinologists in the United States who were randomly selected in 1998 from two endocrine societies. Endocrinologists were asked about management of asymptomatic patients with PHPT, awareness of NIH recommendations, practice demographics, and annual PHPT case volume. We classified endocrinologists into either low-volume (<12 cases of PHPT per year) or high-volume (> or = 12 cases per year) physicians. Of 374 eligible physicians, 146 (39%) responded to our survey. In comparison with nonrespondents, respondents were of similar age, sex, years in practice, and geographic location profiles; this finding suggested minimal nonresponse bias. More high-volume physicians than low-volume physicians were aware of the NIH guidelines (75% versus 50%; P<0.01). Management of asymptomatic patients was similar between volume groups; overall, 39% of patients were referred for surgical treatment. Nevertheless, considerable variation in management existed; 7% of all physicians referred > or = 90% of their asymptomatic patients for surgical treatment, whereas 31% referred < or = 10%. Adherence to monitoring guidelines for nonsurgically managed patients ranged widely, depending on the specific recommendation (from 6% of physicians obtaining creatinine clearance assessments every 6 months to 78% of physicians ordering serum calcium measurements every 6 months). Surgical referral practices also varied substantially, with 25% of all physicians referring a 40-year-old patient with PHPT when hypercalcemia was mild (< or = 1 mg/dL above normal), 39% when hypercalcemia was moderate, and 31% when hypercalcemia was severe (>1.5 mg/dL above normal). Of the responding physicians, 4% reported that hypercalcemia alone was not sufficient justification to refer a patient for surgical intervention. Higher PHPT case volume was not associated with differences in surgical referral. Suboptimal awareness of the 1990 NIH panel recommendations and the substantial variation in clinical management of PHPT indicate that newer NIH guidelines developed in 2002 must be more widely disseminated and strongly recommended if practice patterns are to be influenced and clinical outcomes improved.

Treatment recommendations in Waldenstrom's macroglobulinemia: Consensus Panel Recommendations from the Second International Workshop on Waldenstrom's Macroglobulinemia

This presentation represents consensus recommendations for the treatment of patients with Waldenstrom's macroglobulinemia (WM), which were prepared in conjunction with the second International Workshop held in Athens, Greece during September 2002. The faculty adopted the following statements for the management of patients with Waldenstrom's macroglobulinemia: (1) Alkylating agents, nucleoside analogues, and rituximab are reasonable choices for first line therapy of WM. (2) Both cladribine and fludarabine are reasonable choices for the therapy of WM. (3) Combinations of alkylating agents, nucleoside analogues, or rituximab should at this time be encouraged in the context of a clinical trial. (4) In WM, rituximab can cause a sudden rise in serum IgM and viscosity levels in certain patients, which may lead to complications, therefore close monitoring of these parameters and symptoms of hyperviscosity is recommended for WM patients undergoing rituximab therapy. (5) For relapsed disease, it is reasonable to use an alternate first line agent or re-use of the same agent; however, since autologous stem cell transplantation may have a role in treating patients with relapsed disease it is recommended that for patients in whom autologous transplantation is seriously being considered, exposure to alkylator or nucleoside analogue drugs should be limited. (6) Combination chemotherapy for patients who can tolerate myelotoxic therapy, thalidomide alone or with dexamethasone, can reasonably be considered to have relapsed. (7) Autologous stem cell transplantation may be considered for patients with refractory or relapsing disease. (8) Allogeneic transplantation should only be undertaken in the context of a clinical trial. (9) Plasmapheresis should be considered as interim therapy until definitive therapy can be initiated. (10) Rituximab should be considered for patients with IgM-related neuropathies. (11) Corticosteroids may be useful in the treatment of symptomatic mixed cryoglobulinemia. (12) Splenectomy is rarely indicated but has been used to manage painful splenomegaly and hypersplenism. Semin Oncol 30:121-126. © 2003 Elsevier Inc. All rights reserved.

Prognostic markers and criteria to initiate therapy in Waldenstrom's macroglobulinemia: Consensus Panel Recommendations from the Second International Workshop on Waldenstrom's Macroglobulinemia

This presentation represents consensus recommendations on prognostic markers and criteria to initiate therapy in patients with Waldenstrom's macroglobulinemia (WM), which were prepared in conjunction with the Second International Workshop held in Athens, Greece during September 2002. The panel recommended that initiation of therapy should not be based on the IgM level per se since this may not correlate with the clinical manifestations of WM. The consensus panel agreed that initiation of therapy was appropriate for patients with constitutional symptoms such as recurrent fever, night sweats, fatigue due to anemia, or weight loss. The presence of progressive, symptomatic lymphadenopathy or splenomegaly provide additional reasons to begin therapy. The presence of anemia with a hemoglobin value of ≤ 10 g/dL or a platelet count < 100 × 10 9/L due to marrow infiltration also justifies treatment. Certain complications such as hyperviscosity syndrome, symptomatic sensorimotor peripheral neuropathy, systemic amyloidosis, renal insufficiency, or symptomatic cryoglobulinemia may also be indications for therapy. Recommendations for follow-up of watch-and-wait patients are that those with monoclonal gammopathy of undetermined significance (MGUS) should have serum protein electrophoresis repeated each year. Patients with asymptomatic (smoldering) macroglobulinemia should be evaluated every 6 months. Regarding prognostic markers, hemoglobin and β 2-microglobulin levels at diagnosis are important prognostic markers in WM: they influence the timing of treatment and survival. Age is a consistently important prognostic factor for survival. However, the panel felt that current data are inadequate to support the use of any prognostic marker to select the timing and type of therapy, and called for studies on the application of prognostic markers in WM. Semin Oncol 30:116-120. © 2003 Elsevier Inc. All rights reserved.

Uniform response criteria in Waldenstrom's macroglobulinemia: Consensus Panel Recommendations from the Second International Workshop on Waldenstrom's Macroglobulinemia

Waldenstrom's macroglobulinemia (WM) is a malignant disorder of lymphoplasmacytic cells that produce a monoclonal immunoglobulin M (IgM). Since the original description by Jan Waldenström of three patients with symptoms of hyperviscosity due to circulating monoclonal IgM, the definition of WM has been controversial. Standardized criteria for diagnosis have now been proposed, including the presence of any IgM monoclonal protein and marrow and/or nodal lymphoplasmacytic cells. Although previous response criteria have generally incorporated parameters for monoclonal protein reduction and/or improvement of marrow/nodal involvement, specific and uniform response criteria are needed to facilitate comparisons of response, remission duration, progression-free survival, and overall survival in clinical trials similar to those previously established for other diseases such as chronic lymphocytic leukemia, lymphoma, and myeloma. This is of particular importance as new agents are developed and evaluated. This presentation represents consensus recommendations for uniform response criteria for use in assessing responses to treatment for patients with WM, which were prepared in conjunction with the Second International Workshop held in Athens, Greece during September 2002. Semin Oncol 30:127-131. © 2003 Elsevier Inc. All rights reserved.

Clinicopathological definition of Waldenstrom's macroglobulinemia: Consensus Panel Recommendations from the Second International Workshop on Waldenstrom's Macroglobulinemia

This presentation represents consensus recommendations for the clinicopathological definition of Waldenstrom's macroglobulinemia (WM), which were prepared in conjunction with the Second International Workshop held in Athens, Greece during September 2002. WM is an uncommon lymphoproliferative disorder characterized primarily by bone marrow infiltration and IgM monoclonal gammopathy. It should be considered a distinct clinicopathological entity rather than a clinical syndrome secondary to IgM secretion. The underlying pathological diagnosis in WM is lymphoplasmacytic lymphoma as defined by the World Health Organization (WHO) and Revised European-American Lymphoma (REAL) classification criteria. The concentration of monoclonal IgM can vary widely in WM and it is not possible to define a concentration that reliably distinguishes WM from monoclonal gammopathy of undetermined significance (MGUS) and other lymphoproliferative disorders. A diagnosis of WM can therefore be made irrespective of IgM concentration if there is evidence on a bone marrow trephine biopsy of bone marrow infiltration by lymphoplasmacytic lymphoma with predominantly an intertrabecular pattern, supported by appropriate immunophenotypic studies. Simple criteria to distinguish patients with symptomatic WM who require therapy from those with asymptomatic WM and MGUS were also proposed. Patients with clinical features attributable to IgM monoclonal gammopathy but no overt evidence of lymphoma are considered to constitute a distinct clinical group and the term “IgM-related disorders” is proposed. Semin Oncol 30:110-115. © 2003 Elsevier Inc. All rights reserved.

Variation in administrators' and clinicians' attitudes toward critical elements of an infection control program and the role of the infection control practitioner in New South Wales, Australia

Background: Debate remains over the core activities of infection control (IC) programs. Differences in stakeholder opinions must be considered if consensus panel guidelines and recommendations are to be broadly applied. This article describes a survey of administrators and clinicians employed in hospitals in New South Wales, Australia. Respondents self-reported their levels of agreement with affirmative statements regarding the role of the infection control practitioner (ICP) and the essential requirements and infrastructure of IC programs. Method: The study population included administrators and clinicians in each public, private, and freestanding day hospital in New South Wales. Respondents reported the intensity of their agreement with 16 affirmative statements relating to IC program infrastructure and resources and the ICP's role and responsibilities. Results: The overall response rate was 62.1% (587/945). Clinicians (349/587) and administrators (238/587) accounted for 59.5% and 40.5% of the response rate, respectively. Overall, administrators and clinicians reported greatest levels of agreement for those elements not requiring additional resources. Conclusion: The extent of divergence between administrators and clinicians is not so great that it can not be resolved. Our findings demonstrate the degree of administrator support that clinicians can expect for each element. We advocate better communication between clinicians and administrators in conjunction with objective strategic planning. Our findings provide a guide for ICPs to either establish or negotiate the core components of their IC program. (Am J Infect Control 2001;29:262-70)

Medication management of stimulants in pediatric practice settings: a national perspective.

Using a nationally representative sample of office-based physicians, the management practices of pediatricians, psychiatrists, and family practice physicians were investigated. The major aims were to determine (1) what types of services these physicians were providing to children who received stimulants, (2) what factors predicted receipt of stimulants, and (3) whether these practices were concordant or discordant with professional consensus on diagnosis and treatment of attention-deficit hyperactivity disorders (ADHD). Prescribing and management practice data from the 1995 National Ambulatory Medical Care Survey (NAMCS) were analyzed for children ages 0 to 17 years who were seen for psychiatric problems and received stimulant medication. Results indicated that 2 million visits by children were made in 1995 to psychiatrists, pediatricians, or family practitioners in which psychotropic medications were prescribed. In pediatric visits where stimulant medication was prescribed, mental health counseling was provided 47.3% of the time and psychotherapy 21.6%. Follow-up arrangements were made in 79.1% of the visits. Psychiatrists were significantly more likely to provide psychotherapy and to specify follow-up visits than were pediatricians, but less likely to provide other health counseling. Controlling for demographic and physician effects, the factors with the most significant effect on the probability of receiving stimulants were geographic region (living in the South), race (being white), receiving mental health counseling, not receiving psychotherapy, and having health insurance. Less than 50% of pediatric visits for psychiatric reasons involving stimulant medications included any form of psychosocial intervention. In 21% of these visits, no recommendations were made for follow-up care. These practices diverge from National Institutes of Health (NIH) consensus panel recommendations and association-issued practice parameters.

CF Carrier testing in a high risk population: Anxiety, risk perceptions, and reproductive plans of carrier by “non-carrier” couples

PurposeThe risk perceptions, psychological status and reproductive plans of 52 carrier by “noncarrier” (mutation screen negative) couples is the subject of this report. MethodsCystic fibrosis (CF) carrier testing was offered to relatives of individuals with CF. ResultsIn this population testing was not associated with any significant adverse psychological effects, reproductive uncertainty, or inaccurate risk perceptions. ConclusionsThe results of this study have important implications in light of the recent NIH CF Consensus Panel recommendations that CF carrier testing be offered to all high risk adults and all couples planning a pregnancy or seeking prenatal testing. Genetics in Medicine, 1999:1(7):323-327.

Magnesium utilization survey in selected patients with diabetes

Patients with diabetes mellitus were surveyed to determine magnesium utilization and supplementation patterns and the extent to which these patterns correlate with American Diabetes Association (ADA) consensus panel recommendations. Participating ADA member physicians were asked to enroll five or more patients with insulin-dependent diabetes mellitus (IDDM, or type I diabetes) or non—insulin-dependent diabetes mellitus (NIDDM, or type II diabetes) who were not currently receiving magnesium supplementation and who they believed required or could benefit from oral magnesium chloride administration. Data were then collected regarding specific patient characteristics (ie, current diabetes therapy and glucose control); concomitant diseases and cardiovascular medications; baseline serum magnesium level, if measured before initiating magnesium chloride supplementation; and magnesium chloride dosage and duration. A total of 199 patients with diabetes began treatment with magnesium chloride supplementation after enrollment by a specialist. The mean baseline serum magnesium level for patients with IDDM was 1.48 mg/dL and for patients with NIDDM was 1.4 mg/dL (normal range, 1.80 to 2.40 mg/dL). No differences in mean serum magnesium levels were observed between men and women and between those with IDDM and those with NIDDM. Glucose control, as measured by glycosylated hemoglobin A 1c, did not correlate with magnesium serum levels. A concomitant cardiovascular disease was present in 70% of patients. In 78.3% of patients, supplementation was initiated because of low serum magnesium levels; in 21.7%, magnesium chloride therapy was initiated empirically. No correlation was found between serum magnesium levels and the prescribed dosage or the recommended duration of magnesium therapy. Patterns of magnesium utilization among survey respondents generally followed ADA consensus panel recommendations. A majority of diabetic patients who were given magnesium chloride supplementation had concomitant cardiovascular disease. Primary care physicians and cardiologists who treat large numbers of patients with diabetes and cardiovascular disease should be knowledgeable of the ADA consensus report because of the high prevalence of hypomagnesemia and because of the consequences of magnesium deficiency in these high-risk groups. To achieve successful long-term maintenance in these patients, additional physician education appears to be necessary regarding initial dosing strategies and recommended duration of supplementation.

Excision Margins for Melanoma in Awkward Places Like the Eyelid

To the Editor. —I read with interest a recently published National Institutes of Health (NIH) consensus statement that identified several clinical directions for future research on the diagnosis and treatment of early melanoma of the skin. 1 These included the determination of optimal margins for primary melanomas deeper than 1 mm and the investigation of alternative therapies for primary melanomas in which normal tissue conservation is critical. One of these (unmentioned) special locations is the eyelid, where consensus panel recommendations of excision margins (0.5 cm for melanoma in situ and 1 cm for thin invasive melanoma) represent radical sacrifices of eyelid tissue. From the few reported series in the ophthalmologic literature, 2 it appears that cutaneous melanoma of the eyelid is rare but carries a relatively favorable prognosis in comparison with cutaneous melanomas of other sites. These differences in prognosis and unique aspects of eyelid anatomy may have important treatment