Damian McNamara

ORLANDO — Hunt for insomnia and fatigue after depression treatment because they are the most common residual symptoms, according to a presentation at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

An estimated 35%–45% of patients achieve remission with an antidepressant. “That means one-third of the time, you get lucky and they do very well,” Dr. Thomas L. Schwartz said. “That also means 55%–65% do not get fully better.”

Even if patients respond well, be consistent and systematic with follow-up. “Depression likes to come back” and about 80% relapse rate over 7 years, said Dr. Schwartz, director of Adult Outpatient Services, State University of New York in Syracuse.

With aggressive treatment of major depressive disorder, for example, many patients still experience three clusters of residual symptoms: insomnia; hypersomnia with fatigue and related symptoms; and problems with concentration, lack of interest, or a lack of mental energy. Multiple clusters are common in full treatment responders with major depressive order (J. Clin. Psychiatry 1999;60:221–5). After 8 weeks of treatment, 57% of 108 full responders to fluoxetine had two or more residual symptoms, 26% had one residual symptom, and only 17% had no residual symptom.

“If you leave people with three residual symptoms, they will be in trouble. Leave them with two and they will still be in trouble. Get them as well as you can,” said Dr. Schwartz, who is also director of the Depression and Anxiety Disorders Research Program at SUNY Upstate Medical University.

Sometimes, treating insomnia is very important, he said. It can lead to the other two main residual symptoms, fatigue and poor concentration. In one study, depression response was faster and more robust when patients took fluoxetine plus a sleep aid, eszopiclone (Lunesta), for 8 weeks, compared with fluoxetine plus placebo (Biol. Psychiatry 2006;59:1052–60). There were substantial sleep improvements in the dual treatment group as well.

Depressed mood, suicidal ideation, and psychomotor retardation are the least common residual symptoms of treatment of major depressive disorder.

For antidepressant treatment, “do the tried-and-true first, and treat aggressively,” Dr. Schwartz said. “The aim is to reduce all symptoms wherever possible.”

Psychotherapy with medication can also work well. If patients are depressed and have executive dysfunction, they may not be able to remember what they are told in therapy. “So treat with a medication first and then augment with psychotherapy.”

ORLANDO — Hunt for insomnia and fatigue after depression treatment because they are the most common residual symptoms, according to a presentation at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

An estimated 35%–45% of patients achieve remission with an antidepressant. “That means one-third of the time, you get lucky and they do very well,” Dr. Thomas L. Schwartz said. “That also means 55%–65% do not get fully better.”

Even if patients respond well, be consistent and systematic with follow-up. “Depression likes to come back” and about 80% relapse rate over 7 years, said Dr. Schwartz, director of Adult Outpatient Services, State University of New York in Syracuse.

With aggressive treatment of major depressive disorder, for example, many patients still experience three clusters of residual symptoms: insomnia; hypersomnia with fatigue and related symptoms; and problems with concentration, lack of interest, or a lack of mental energy. Multiple clusters are common in full treatment responders with major depressive order (J. Clin. Psychiatry 1999;60:221–5). After 8 weeks of treatment, 57% of 108 full responders to fluoxetine had two or more residual symptoms, 26% had one residual symptom, and only 17% had no residual symptom.

“If you leave people with three residual symptoms, they will be in trouble. Leave them with two and they will still be in trouble. Get them as well as you can,” said Dr. Schwartz, who is also director of the Depression and Anxiety Disorders Research Program at SUNY Upstate Medical University.

Sometimes, treating insomnia is very important, he said. It can lead to the other two main residual symptoms, fatigue and poor concentration. In one study, depression response was faster and more robust when patients took fluoxetine plus a sleep aid, eszopiclone (Lunesta), for 8 weeks, compared with fluoxetine plus placebo (Biol. Psychiatry 2006;59:1052–60). There were substantial sleep improvements in the dual treatment group as well.

Depressed mood, suicidal ideation, and psychomotor retardation are the least common residual symptoms of treatment of major depressive disorder.

For antidepressant treatment, “do the tried-and-true first, and treat aggressively,” Dr. Schwartz said. “The aim is to reduce all symptoms wherever possible.”

Psychotherapy with medication can also work well. If patients are depressed and have executive dysfunction, they may not be able to remember what they are told in therapy. “So treat with a medication first and then augment with psychotherapy.”

ORLANDO — Hunt for insomnia and fatigue after depression treatment because they are the most common residual symptoms, according to a presentation at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

An estimated 35%–45% of patients achieve remission with an antidepressant. “That means one-third of the time, you get lucky and they do very well,” Dr. Thomas L. Schwartz said. “That also means 55%–65% do not get fully better.”

Even if patients respond well, be consistent and systematic with follow-up. “Depression likes to come back” and about 80% relapse rate over 7 years, said Dr. Schwartz, director of Adult Outpatient Services, State University of New York in Syracuse.

With aggressive treatment of major depressive disorder, for example, many patients still experience three clusters of residual symptoms: insomnia; hypersomnia with fatigue and related symptoms; and problems with concentration, lack of interest, or a lack of mental energy. Multiple clusters are common in full treatment responders with major depressive order (J. Clin. Psychiatry 1999;60:221–5). After 8 weeks of treatment, 57% of 108 full responders to fluoxetine had two or more residual symptoms, 26% had one residual symptom, and only 17% had no residual symptom.

“If you leave people with three residual symptoms, they will be in trouble. Leave them with two and they will still be in trouble. Get them as well as you can,” said Dr. Schwartz, who is also director of the Depression and Anxiety Disorders Research Program at SUNY Upstate Medical University.

Sometimes, treating insomnia is very important, he said. It can lead to the other two main residual symptoms, fatigue and poor concentration. In one study, depression response was faster and more robust when patients took fluoxetine plus a sleep aid, eszopiclone (Lunesta), for 8 weeks, compared with fluoxetine plus placebo (Biol. Psychiatry 2006;59:1052–60). There were substantial sleep improvements in the dual treatment group as well.

Depressed mood, suicidal ideation, and psychomotor retardation are the least common residual symptoms of treatment of major depressive disorder.

For antidepressant treatment, “do the tried-and-true first, and treat aggressively,” Dr. Schwartz said. “The aim is to reduce all symptoms wherever possible.”

Psychotherapy with medication can also work well. If patients are depressed and have executive dysfunction, they may not be able to remember what they are told in therapy. “So treat with a medication first and then augment with psychotherapy.”

ORLANDO — Deficits in height, body mass index z scores, lean mass, and fat mass among children newly diagnosed with Crohn's disease carry implications for their long-term bone health, Dr. Meena Thayu reported at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

Treatment can improve some of these parameters, Dr. Thayu said.

Crohn's disease in children can cause chronic inflammation of the gastrointestinal tract, growth failure, and altered body composition. In addition, malabsorption can lead to nutritional deficiencies, including decreases in calcium and vitamin D, which may explain a higher risk of fractures in children and adults.

Other researchers found significant deficits in whole-body bone mineral content in 104 pediatric patients with Crohn's disease compared with 233 healthy controls (J. Bone Miner. Res. 2004;19:1961–8).

Another investigation in the same study population revealed lower height-for-age and BMI-for-age z scores among the children with Crohn's disease compared with controls (Am. J. Clin. Nutr. 2005;82:413–20).

“Crohn's disease subjects did not have the concomitant increases in lean mass with fat mass as the control children did,” said Dr. Thayu of the division of gastroenterology, hepatology and nutrition at the Children's Hospital of Philadelphia.

“These two cross-sectional studies … do not allow us to conclude the impact of the disease versus the impact of therapies,” Dr. Thayu said.

To address this, Dr. Thayu and associates studied 78 children within 2 weeks of diagnosis of Crohn's disease and 409 healthy controls. Participants were aged 5–21 years and did not have any chronic disease affecting growth.

The researchers assessed Tanner stage, disease characteristics, and body composition using whole-body dual-energy x-ray absorptiometry (DXA) scanning at baseline, 6 months, and 12 months after treatment initiated. “Although DXA is used widely clinically, it relies on two-dimensional data,” Dr. Thayu said. Therefore, they also performed peripheral quantitative CT on the tibia “which gives true trabecular bone mineral density and cortical dimensions, an indicator of bone strength.”

“Deficits in cortical dimension have a long-term impact on adult fracture risk,” Dr. Thayu said.

The Crohn's disease group had significantly lower Tanner scores, height, and BMI z scores than did controls. The affected group also had significant deficits in lean mass and trabecular bone mineral density versus the control group.

“Based on these findings, we were curious about any improvements after 12 months,” Dr. Thayu said. “So we launched a follow-up study.”

Preliminary results indicated changes in z scores for 29 children with Crohn's disease at a follow-up between 2.5 to 4 years after diagnosis.

“There is significant recovery in height and BMI. Interestingly, improvements in BMI are almost exclusively gains in fat mass.”

Modest improvements in lean mass were associated with improvements in trabecular density, Dr. Thayu said. In addition, those children with gains in lean mass were more likely to have improved clinical outcomes at follow-up.

ORLANDO — Deficits in height, body mass index z scores, lean mass, and fat mass among children newly diagnosed with Crohn's disease carry implications for their long-term bone health, Dr. Meena Thayu reported at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

Treatment can improve some of these parameters, Dr. Thayu said.

Crohn's disease in children can cause chronic inflammation of the gastrointestinal tract, growth failure, and altered body composition. In addition, malabsorption can lead to nutritional deficiencies, including decreases in calcium and vitamin D, which may explain a higher risk of fractures in children and adults.

Other researchers found significant deficits in whole-body bone mineral content in 104 pediatric patients with Crohn's disease compared with 233 healthy controls (J. Bone Miner. Res. 2004;19:1961–8).

Another investigation in the same study population revealed lower height-for-age and BMI-for-age z scores among the children with Crohn's disease compared with controls (Am. J. Clin. Nutr. 2005;82:413–20).

“Crohn's disease subjects did not have the concomitant increases in lean mass with fat mass as the control children did,” said Dr. Thayu of the division of gastroenterology, hepatology and nutrition at the Children's Hospital of Philadelphia.

“These two cross-sectional studies … do not allow us to conclude the impact of the disease versus the impact of therapies,” Dr. Thayu said.

To address this, Dr. Thayu and associates studied 78 children within 2 weeks of diagnosis of Crohn's disease and 409 healthy controls. Participants were aged 5–21 years and did not have any chronic disease affecting growth.

The researchers assessed Tanner stage, disease characteristics, and body composition using whole-body dual-energy x-ray absorptiometry (DXA) scanning at baseline, 6 months, and 12 months after treatment initiated. “Although DXA is used widely clinically, it relies on two-dimensional data,” Dr. Thayu said. Therefore, they also performed peripheral quantitative CT on the tibia “which gives true trabecular bone mineral density and cortical dimensions, an indicator of bone strength.”

“Deficits in cortical dimension have a long-term impact on adult fracture risk,” Dr. Thayu said.

The Crohn's disease group had significantly lower Tanner scores, height, and BMI z scores than did controls. The affected group also had significant deficits in lean mass and trabecular bone mineral density versus the control group.

“Based on these findings, we were curious about any improvements after 12 months,” Dr. Thayu said. “So we launched a follow-up study.”

Preliminary results indicated changes in z scores for 29 children with Crohn's disease at a follow-up between 2.5 to 4 years after diagnosis.

“There is significant recovery in height and BMI. Interestingly, improvements in BMI are almost exclusively gains in fat mass.”

Modest improvements in lean mass were associated with improvements in trabecular density, Dr. Thayu said. In addition, those children with gains in lean mass were more likely to have improved clinical outcomes at follow-up.

ORLANDO — Deficits in height, body mass index z scores, lean mass, and fat mass among children newly diagnosed with Crohn's disease carry implications for their long-term bone health, Dr. Meena Thayu reported at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

Treatment can improve some of these parameters, Dr. Thayu said.

Crohn's disease in children can cause chronic inflammation of the gastrointestinal tract, growth failure, and altered body composition. In addition, malabsorption can lead to nutritional deficiencies, including decreases in calcium and vitamin D, which may explain a higher risk of fractures in children and adults.

Other researchers found significant deficits in whole-body bone mineral content in 104 pediatric patients with Crohn's disease compared with 233 healthy controls (J. Bone Miner. Res. 2004;19:1961–8).

Another investigation in the same study population revealed lower height-for-age and BMI-for-age z scores among the children with Crohn's disease compared with controls (Am. J. Clin. Nutr. 2005;82:413–20).

“Crohn's disease subjects did not have the concomitant increases in lean mass with fat mass as the control children did,” said Dr. Thayu of the division of gastroenterology, hepatology and nutrition at the Children's Hospital of Philadelphia.

“These two cross-sectional studies … do not allow us to conclude the impact of the disease versus the impact of therapies,” Dr. Thayu said.

To address this, Dr. Thayu and associates studied 78 children within 2 weeks of diagnosis of Crohn's disease and 409 healthy controls. Participants were aged 5–21 years and did not have any chronic disease affecting growth.

The researchers assessed Tanner stage, disease characteristics, and body composition using whole-body dual-energy x-ray absorptiometry (DXA) scanning at baseline, 6 months, and 12 months after treatment initiated. “Although DXA is used widely clinically, it relies on two-dimensional data,” Dr. Thayu said. Therefore, they also performed peripheral quantitative CT on the tibia “which gives true trabecular bone mineral density and cortical dimensions, an indicator of bone strength.”

“Deficits in cortical dimension have a long-term impact on adult fracture risk,” Dr. Thayu said.

The Crohn's disease group had significantly lower Tanner scores, height, and BMI z scores than did controls. The affected group also had significant deficits in lean mass and trabecular bone mineral density versus the control group.

“Based on these findings, we were curious about any improvements after 12 months,” Dr. Thayu said. “So we launched a follow-up study.”

Preliminary results indicated changes in z scores for 29 children with Crohn's disease at a follow-up between 2.5 to 4 years after diagnosis.

“There is significant recovery in height and BMI. Interestingly, improvements in BMI are almost exclusively gains in fat mass.”

Modest improvements in lean mass were associated with improvements in trabecular density, Dr. Thayu said. In addition, those children with gains in lean mass were more likely to have improved clinical outcomes at follow-up.

MIAMI BEACH — The cervical injuries and vertebral insufficiency stress fractures that follow traumatic injury in elderly patients present special diagnostic challenges, Dr. Richard H. Daffner said at a symposium on emergency radiology sponsored by Baptist Health South Florida.

Decreased vision and hearing, diminished motor skills, slower reaction times, and multiple comorbidities disproportionately affect patients 65 years and older, he explained.

“What complicates this, particularly because falls are the biggest source of injury and trauma to the elderly, is fractures—which can contribute significantly to their ultimate demise,” said Dr. Daffner, director of musculoskeletal, trauma, and emergency radiology, Allegheny General Hospital, Pittsburgh.

Emergency physicians are most likely to encounter cervical fractures and vertebral insufficiency stress fractures in the elderly trauma patient. The majority of cervical fractures in the elderly tend to cluster at the C1 and C2 level, Dr. Daffner said. Hyperextension injury is the leading cause of a C2 fracture. “As you get older, your neck tends to be stiffer, but the C1-C2 region remains the most mobile,” he explained.

Dr. Daffner and his colleagues studied 231 elderly patients with a total of 274 cervical injuries. They found that 119 of these injuries (43%) were at C2. In contrast, among the 749 participants in the study who were younger than 65 years with a total of 870 cervical injuries, 221 injuries (25%) occurred at C2.

Dens fractures “can be quite subtle” on a radiograph, Dr. Daffner said. “You see it much better on computed tomography —a slight shift of bone forward around C2.”

A hyperextension injury is often devastating, Dr. Daffner said. “A wide vertebral disk space [on radiograph] is the hallmark sign, and it's never normal in the elderly population.” Patients with a wide disk space should undergo magnetic resonance imaging immediately to determine the extent of injury, he suggested. The injury can be associated with development of edema, osteophytes impinging on the spinal cord, and neurologic compromise.

Insufficiency stress fractures are common in the elderly and are very site-specific for a particular activity, Dr. Daffner said. The sacrum and pelvis are most commonly involved, but the fractures also occur at the femoral neck and tibial plateau. “The diagnosis is not often considered by the clinician—some of these seniors are very active.” Failure to identify these fractures early can lead to progressive disability, a longer healing time, and a fracture that becomes distracted.

An occult fracture can be detected with a bone scan if the injury is more than 24 hours old, Dr. Daffner said. On a bone scan, a butterfly pattern (which can also be described as resembling a Honda car logo) is highly suggestive of a sacral stress fracture.

Radiographs are less useful but sometimes show some osteopenia. Computed tomography is useful if there is an occult fracture in the spine. Computed tomography is also the procedure of choice for pelvic stress fractures.

However, magnetic resonance imaging is recommended for fractures in the peripheral skeleton. “A complete MR study is not needed—we often do coronal and axial images” in less than half an hour in most cases, he said. “MRI is very useful early on when a patient comes in right away complaining of pain.”

Many patients who have an insufficiency stress fracture have bone compromised by osteoporosis and/or a history of malignancy.

“One of the keys to differentiating a malignancy versus a stress fracture is a stress fracture tends to be linear and occurs in the vertical plane, up and down, whereas malignancies tend to be globular,” Dr. Daffner said.

MIAMI BEACH — The cervical injuries and vertebral insufficiency stress fractures that follow traumatic injury in elderly patients present special diagnostic challenges, Dr. Richard H. Daffner said at a symposium on emergency radiology sponsored by Baptist Health South Florida.

Decreased vision and hearing, diminished motor skills, slower reaction times, and multiple comorbidities disproportionately affect patients 65 years and older, he explained.

“What complicates this, particularly because falls are the biggest source of injury and trauma to the elderly, is fractures—which can contribute significantly to their ultimate demise,” said Dr. Daffner, director of musculoskeletal, trauma, and emergency radiology, Allegheny General Hospital, Pittsburgh.

Emergency physicians are most likely to encounter cervical fractures and vertebral insufficiency stress fractures in the elderly trauma patient. The majority of cervical fractures in the elderly tend to cluster at the C1 and C2 level, Dr. Daffner said. Hyperextension injury is the leading cause of a C2 fracture. “As you get older, your neck tends to be stiffer, but the C1-C2 region remains the most mobile,” he explained.

Dr. Daffner and his colleagues studied 231 elderly patients with a total of 274 cervical injuries. They found that 119 of these injuries (43%) were at C2. In contrast, among the 749 participants in the study who were younger than 65 years with a total of 870 cervical injuries, 221 injuries (25%) occurred at C2.

Dens fractures “can be quite subtle” on a radiograph, Dr. Daffner said. “You see it much better on computed tomography —a slight shift of bone forward around C2.”

A hyperextension injury is often devastating, Dr. Daffner said. “A wide vertebral disk space [on radiograph] is the hallmark sign, and it's never normal in the elderly population.” Patients with a wide disk space should undergo magnetic resonance imaging immediately to determine the extent of injury, he suggested. The injury can be associated with development of edema, osteophytes impinging on the spinal cord, and neurologic compromise.

Insufficiency stress fractures are common in the elderly and are very site-specific for a particular activity, Dr. Daffner said. The sacrum and pelvis are most commonly involved, but the fractures also occur at the femoral neck and tibial plateau. “The diagnosis is not often considered by the clinician—some of these seniors are very active.” Failure to identify these fractures early can lead to progressive disability, a longer healing time, and a fracture that becomes distracted.

An occult fracture can be detected with a bone scan if the injury is more than 24 hours old, Dr. Daffner said. On a bone scan, a butterfly pattern (which can also be described as resembling a Honda car logo) is highly suggestive of a sacral stress fracture.

Radiographs are less useful but sometimes show some osteopenia. Computed tomography is useful if there is an occult fracture in the spine. Computed tomography is also the procedure of choice for pelvic stress fractures.

However, magnetic resonance imaging is recommended for fractures in the peripheral skeleton. “A complete MR study is not needed—we often do coronal and axial images” in less than half an hour in most cases, he said. “MRI is very useful early on when a patient comes in right away complaining of pain.”

Many patients who have an insufficiency stress fracture have bone compromised by osteoporosis and/or a history of malignancy.

“One of the keys to differentiating a malignancy versus a stress fracture is a stress fracture tends to be linear and occurs in the vertical plane, up and down, whereas malignancies tend to be globular,” Dr. Daffner said.

MIAMI BEACH — The cervical injuries and vertebral insufficiency stress fractures that follow traumatic injury in elderly patients present special diagnostic challenges, Dr. Richard H. Daffner said at a symposium on emergency radiology sponsored by Baptist Health South Florida.

Decreased vision and hearing, diminished motor skills, slower reaction times, and multiple comorbidities disproportionately affect patients 65 years and older, he explained.

“What complicates this, particularly because falls are the biggest source of injury and trauma to the elderly, is fractures—which can contribute significantly to their ultimate demise,” said Dr. Daffner, director of musculoskeletal, trauma, and emergency radiology, Allegheny General Hospital, Pittsburgh.

Emergency physicians are most likely to encounter cervical fractures and vertebral insufficiency stress fractures in the elderly trauma patient. The majority of cervical fractures in the elderly tend to cluster at the C1 and C2 level, Dr. Daffner said. Hyperextension injury is the leading cause of a C2 fracture. “As you get older, your neck tends to be stiffer, but the C1-C2 region remains the most mobile,” he explained.

Dr. Daffner and his colleagues studied 231 elderly patients with a total of 274 cervical injuries. They found that 119 of these injuries (43%) were at C2. In contrast, among the 749 participants in the study who were younger than 65 years with a total of 870 cervical injuries, 221 injuries (25%) occurred at C2.

Dens fractures “can be quite subtle” on a radiograph, Dr. Daffner said. “You see it much better on computed tomography —a slight shift of bone forward around C2.”

A hyperextension injury is often devastating, Dr. Daffner said. “A wide vertebral disk space [on radiograph] is the hallmark sign, and it's never normal in the elderly population.” Patients with a wide disk space should undergo magnetic resonance imaging immediately to determine the extent of injury, he suggested. The injury can be associated with development of edema, osteophytes impinging on the spinal cord, and neurologic compromise.

Insufficiency stress fractures are common in the elderly and are very site-specific for a particular activity, Dr. Daffner said. The sacrum and pelvis are most commonly involved, but the fractures also occur at the femoral neck and tibial plateau. “The diagnosis is not often considered by the clinician—some of these seniors are very active.” Failure to identify these fractures early can lead to progressive disability, a longer healing time, and a fracture that becomes distracted.

An occult fracture can be detected with a bone scan if the injury is more than 24 hours old, Dr. Daffner said. On a bone scan, a butterfly pattern (which can also be described as resembling a Honda car logo) is highly suggestive of a sacral stress fracture.

Radiographs are less useful but sometimes show some osteopenia. Computed tomography is useful if there is an occult fracture in the spine. Computed tomography is also the procedure of choice for pelvic stress fractures.

However, magnetic resonance imaging is recommended for fractures in the peripheral skeleton. “A complete MR study is not needed—we often do coronal and axial images” in less than half an hour in most cases, he said. “MRI is very useful early on when a patient comes in right away complaining of pain.”

Many patients who have an insufficiency stress fracture have bone compromised by osteoporosis and/or a history of malignancy.

“One of the keys to differentiating a malignancy versus a stress fracture is a stress fracture tends to be linear and occurs in the vertical plane, up and down, whereas malignancies tend to be globular,” Dr. Daffner said.

MIAMI BEACH — Coronary CT angiography might improve detection of significant coronary risk in an emergency department and help physicians decide which chest pain patients can be discharged, according to a presentation at a symposium on emergency radiology sponsored by Baptist Health South Florida.

“In low-risk patients, we need a test with a high negative predictive value. Essentially we are screening for [those patients] we can send home. Many people think coronary CTA is that test,” Dr. Ella A. Kazerooni said.

Nonspecific chest pain is the second most common reason that people seek emergency department care, but only about 10%–15% of those patients have an acute coronary syndrome. “On the other hand, 2%–5% with acute coronary syndromes are mistakenly sent home. Often they do not meet risk criteria. And later they are admitted with a severe MI, or they die at home,” said Dr. Kazerooni, professor and director of the division of cardiothoracic radiology at the University of Michigan, Ann Arbor.

An estimated 5 million to 8 million Americans present to an emergency department with nonspecific chest pain each year, she said. The approximate cost for taking care of these patients is $10 billion.

Identification of which low-risk patients will progress to an acute coronary event has proved difficult, Dr. Kazerooni said. Other researchers performed a meta-analysis to determine potential risk factors (JAMA 1998;280:1256–63), but most likelihood ratios were not robust enough “to say 'send them home,'” said Dr. Kazerooni.

A total of 240 patients (12%) had a confirmed cardiac etiology among those presenting with chest pain during a 1-month study at the University of Michigan emergency department chest pain center. This finding supports what is in the literature, Dr. Kazerooni said. Annually, the mean length of stay is 21 hours, and the total room cost alone for this group of patients is close to $4 million.

“If you can do something to expedite triage, you can diagnose them earlier, at a lower cost, and use those rooms for other patients,” Dr. Kazerooni said.

What is the role of coronary CT angiography in the emergency department? Immediate coronary CT angiography can safely triage low-risk acute chest pain patients home if they have negative ECG/enzymes for ischemia/infarction, Dr. Kazerooni said. “Also, it can provide a significant reduction in length of stay and cost of care.”

In another study, 31 patients who presented to an emergency department with at least 30 minutes of chest pain had coronary CT angiography performed (Circ. J. 2005;69:1047–51). These patients “were already going to the cath lab, so it was not a low-risk population,” Dr. Kazerooni said. A total of 93% of the patients were men, and 71% had acute coronary syndrome. “Remember I told you in general 12%–15% of patients [have acute coronary syndrome] in other studies, so this was biased.” This was essentially a feasibility study that demonstrated coronary CT angiography can be performed in an emergency department, she added.

Some of the best data on coronary CT angiography in the emergency department came from another study that found 75% of 69 patients had no significant CT findings, Dr. Kazerooni said (Am. J. Roentgenol. 2005;185:553–40). About half the participants were men. Outside of the study, 45 patients would not have had a chest CT. A total of 19% patients had significant CT findings that explained their chest pain. There were two false negative CT findings because the images suffered from motion artifact, she said.

The 16-slice ECG-gated multidetector CT had a negative predictive value of 96% in this study. “They concluded this was a pilot study demonstrating feasibility, and that the greatest potential is for exclusion of significant coronary disease,” Dr. Kazerooni said.

A prospective, blinded study of 103 patients, 60% of whom were men, found CT angiography had a negative predictive value of 100% (Circulation 2006:114:2251–60).

Despite its impressive negative predictive value, the safety of screening nonspecific chest pain patients in the emergency department with coronary CT angiography still needs to be established, Dr. Kazerooni said.

The high negative predictive value of normal coronary CTangiograms like this one, in a 52-year-old woman presenting with chest pain, can expedite diagnosis. Courtesy Dr. Ella A. Kazerooni

MIAMI BEACH — Coronary CT angiography might improve detection of significant coronary risk in an emergency department and help physicians decide which chest pain patients can be discharged, according to a presentation at a symposium on emergency radiology sponsored by Baptist Health South Florida.

“In low-risk patients, we need a test with a high negative predictive value. Essentially we are screening for [those patients] we can send home. Many people think coronary CTA is that test,” Dr. Ella A. Kazerooni said.

Nonspecific chest pain is the second most common reason that people seek emergency department care, but only about 10%–15% of those patients have an acute coronary syndrome. “On the other hand, 2%–5% with acute coronary syndromes are mistakenly sent home. Often they do not meet risk criteria. And later they are admitted with a severe MI, or they die at home,” said Dr. Kazerooni, professor and director of the division of cardiothoracic radiology at the University of Michigan, Ann Arbor.

An estimated 5 million to 8 million Americans present to an emergency department with nonspecific chest pain each year, she said. The approximate cost for taking care of these patients is $10 billion.

Identification of which low-risk patients will progress to an acute coronary event has proved difficult, Dr. Kazerooni said. Other researchers performed a meta-analysis to determine potential risk factors (JAMA 1998;280:1256–63), but most likelihood ratios were not robust enough “to say 'send them home,'” said Dr. Kazerooni.

A total of 240 patients (12%) had a confirmed cardiac etiology among those presenting with chest pain during a 1-month study at the University of Michigan emergency department chest pain center. This finding supports what is in the literature, Dr. Kazerooni said. Annually, the mean length of stay is 21 hours, and the total room cost alone for this group of patients is close to $4 million.

“If you can do something to expedite triage, you can diagnose them earlier, at a lower cost, and use those rooms for other patients,” Dr. Kazerooni said.

What is the role of coronary CT angiography in the emergency department? Immediate coronary CT angiography can safely triage low-risk acute chest pain patients home if they have negative ECG/enzymes for ischemia/infarction, Dr. Kazerooni said. “Also, it can provide a significant reduction in length of stay and cost of care.”

In another study, 31 patients who presented to an emergency department with at least 30 minutes of chest pain had coronary CT angiography performed (Circ. J. 2005;69:1047–51). These patients “were already going to the cath lab, so it was not a low-risk population,” Dr. Kazerooni said. A total of 93% of the patients were men, and 71% had acute coronary syndrome. “Remember I told you in general 12%–15% of patients [have acute coronary syndrome] in other studies, so this was biased.” This was essentially a feasibility study that demonstrated coronary CT angiography can be performed in an emergency department, she added.

Some of the best data on coronary CT angiography in the emergency department came from another study that found 75% of 69 patients had no significant CT findings, Dr. Kazerooni said (Am. J. Roentgenol. 2005;185:553–40). About half the participants were men. Outside of the study, 45 patients would not have had a chest CT. A total of 19% patients had significant CT findings that explained their chest pain. There were two false negative CT findings because the images suffered from motion artifact, she said.

The 16-slice ECG-gated multidetector CT had a negative predictive value of 96% in this study. “They concluded this was a pilot study demonstrating feasibility, and that the greatest potential is for exclusion of significant coronary disease,” Dr. Kazerooni said.

A prospective, blinded study of 103 patients, 60% of whom were men, found CT angiography had a negative predictive value of 100% (Circulation 2006:114:2251–60).

Despite its impressive negative predictive value, the safety of screening nonspecific chest pain patients in the emergency department with coronary CT angiography still needs to be established, Dr. Kazerooni said.

The high negative predictive value of normal coronary CTangiograms like this one, in a 52-year-old woman presenting with chest pain, can expedite diagnosis. Courtesy Dr. Ella A. Kazerooni

MIAMI BEACH — Coronary CT angiography might improve detection of significant coronary risk in an emergency department and help physicians decide which chest pain patients can be discharged, according to a presentation at a symposium on emergency radiology sponsored by Baptist Health South Florida.

“In low-risk patients, we need a test with a high negative predictive value. Essentially we are screening for [those patients] we can send home. Many people think coronary CTA is that test,” Dr. Ella A. Kazerooni said.

Nonspecific chest pain is the second most common reason that people seek emergency department care, but only about 10%–15% of those patients have an acute coronary syndrome. “On the other hand, 2%–5% with acute coronary syndromes are mistakenly sent home. Often they do not meet risk criteria. And later they are admitted with a severe MI, or they die at home,” said Dr. Kazerooni, professor and director of the division of cardiothoracic radiology at the University of Michigan, Ann Arbor.

An estimated 5 million to 8 million Americans present to an emergency department with nonspecific chest pain each year, she said. The approximate cost for taking care of these patients is $10 billion.

Identification of which low-risk patients will progress to an acute coronary event has proved difficult, Dr. Kazerooni said. Other researchers performed a meta-analysis to determine potential risk factors (JAMA 1998;280:1256–63), but most likelihood ratios were not robust enough “to say 'send them home,'” said Dr. Kazerooni.

A total of 240 patients (12%) had a confirmed cardiac etiology among those presenting with chest pain during a 1-month study at the University of Michigan emergency department chest pain center. This finding supports what is in the literature, Dr. Kazerooni said. Annually, the mean length of stay is 21 hours, and the total room cost alone for this group of patients is close to $4 million.

“If you can do something to expedite triage, you can diagnose them earlier, at a lower cost, and use those rooms for other patients,” Dr. Kazerooni said.

What is the role of coronary CT angiography in the emergency department? Immediate coronary CT angiography can safely triage low-risk acute chest pain patients home if they have negative ECG/enzymes for ischemia/infarction, Dr. Kazerooni said. “Also, it can provide a significant reduction in length of stay and cost of care.”

In another study, 31 patients who presented to an emergency department with at least 30 minutes of chest pain had coronary CT angiography performed (Circ. J. 2005;69:1047–51). These patients “were already going to the cath lab, so it was not a low-risk population,” Dr. Kazerooni said. A total of 93% of the patients were men, and 71% had acute coronary syndrome. “Remember I told you in general 12%–15% of patients [have acute coronary syndrome] in other studies, so this was biased.” This was essentially a feasibility study that demonstrated coronary CT angiography can be performed in an emergency department, she added.

Some of the best data on coronary CT angiography in the emergency department came from another study that found 75% of 69 patients had no significant CT findings, Dr. Kazerooni said (Am. J. Roentgenol. 2005;185:553–40). About half the participants were men. Outside of the study, 45 patients would not have had a chest CT. A total of 19% patients had significant CT findings that explained their chest pain. There were two false negative CT findings because the images suffered from motion artifact, she said.

The 16-slice ECG-gated multidetector CT had a negative predictive value of 96% in this study. “They concluded this was a pilot study demonstrating feasibility, and that the greatest potential is for exclusion of significant coronary disease,” Dr. Kazerooni said.

A prospective, blinded study of 103 patients, 60% of whom were men, found CT angiography had a negative predictive value of 100% (Circulation 2006:114:2251–60).

Despite its impressive negative predictive value, the safety of screening nonspecific chest pain patients in the emergency department with coronary CT angiography still needs to be established, Dr. Kazerooni said.

The high negative predictive value of normal coronary CTangiograms like this one, in a 52-year-old woman presenting with chest pain, can expedite diagnosis. Courtesy Dr. Ella A. Kazerooni

FORT LAUDERDALE, FLA. – Adjunctive hyperbaric oxygen therapy significantly improves cognition for children with cerebral palsy, compared with standard therapy alone, according to an open, ongoing, observational study.

All participants significantly improved their physical, speech, and motor capabilities after 6 months, compared with baseline. Interim results for 84 children whose parents chose hyperbaric oxygen therapy (HBOT) and 20 children in a non-HBOT group were presented at a symposium on hyperbaric oxygen therapy.

Changes in cognition were distinctive. “Children receiving HBOT showed statistically significant improvements in cognitive-only parameters. This is interesting and what is driving us to go on with this treatment,” said Dr. Arun Mukherjee of Majeedia Hospital, New Delhi, India.

Researchers used a modified 49-item Gross Motor Function Measure to monitor clinical progress at 2-month intervals. In an attempt to assess the effects of hyperbaric oxygenation, researchers focused on 26 cognitive-only items, which are less dependent on therapist input. “This is the closest measure we can get to brain repair,” said Dr. Mukherjee, who is also director of the UDAAN Project for Cerebral Palsy at the Foundation for Spastic and Mentally Handicapped Persons in New Delhi. UDAAN is a Hindi word for flight (of freedom).

Hyperbaric therapy consisted of 100% oxygen delivered at 1.5 atmospheres. Not included in this interim analysis is a recently added third group of patients who receive a low-pressure HBOT option (ambient air delivered at 1.3 atmospheres).

Dr. Mukherjee and his associates launched the UDAAN HBOT-Based Multimode Long-Term Observational Study in 2001 to assess the benefits, if any, of adjunctive therapy for children with cerebral palsy. They tried nerve block with Botox and phenol, computer-assisted biofeedback, and pulsed magnetic field therapy. “We were not impressed with their cost-to-benefit ratio as per Indian prices. Hence, we have dropped them.”

Standard therapy consists of special education, occupational therapy, speech therapy, and physiotherapy totaling 2 hours daily. After 5 months of HBOT, clinicians administer 60 sessions of electroacupuncture using transcutaneous electrical nerve stimulation (TENS) specifically designed for cerebral palsy. This therapy reduces pain and discomfort of intensive exercises and helps the brain recognize pathways revived by HBOT, Dr. Mukherjee said at the symposium sponsored by the Ocean Hyperbaric Neurologic Center in Fort Lauderdale, Fla. “This alerts the brain that these circuits are now working,” he said.

Short-term treatment has limited other pediatric studies of hyperbaric oxygen for cerebral palsy, Dr. Mukherjee said. In the current investigation, it took 6 months before cognitive differences between groups reached statistical significance. This suggests the need for a long-term commitment to hyperbaric therapy for cerebral palsy.

FORT LAUDERDALE, FLA. – Adjunctive hyperbaric oxygen therapy significantly improves cognition for children with cerebral palsy, compared with standard therapy alone, according to an open, ongoing, observational study.

All participants significantly improved their physical, speech, and motor capabilities after 6 months, compared with baseline. Interim results for 84 children whose parents chose hyperbaric oxygen therapy (HBOT) and 20 children in a non-HBOT group were presented at a symposium on hyperbaric oxygen therapy.

Changes in cognition were distinctive. “Children receiving HBOT showed statistically significant improvements in cognitive-only parameters. This is interesting and what is driving us to go on with this treatment,” said Dr. Arun Mukherjee of Majeedia Hospital, New Delhi, India.

Researchers used a modified 49-item Gross Motor Function Measure to monitor clinical progress at 2-month intervals. In an attempt to assess the effects of hyperbaric oxygenation, researchers focused on 26 cognitive-only items, which are less dependent on therapist input. “This is the closest measure we can get to brain repair,” said Dr. Mukherjee, who is also director of the UDAAN Project for Cerebral Palsy at the Foundation for Spastic and Mentally Handicapped Persons in New Delhi. UDAAN is a Hindi word for flight (of freedom).

Hyperbaric therapy consisted of 100% oxygen delivered at 1.5 atmospheres. Not included in this interim analysis is a recently added third group of patients who receive a low-pressure HBOT option (ambient air delivered at 1.3 atmospheres).

Dr. Mukherjee and his associates launched the UDAAN HBOT-Based Multimode Long-Term Observational Study in 2001 to assess the benefits, if any, of adjunctive therapy for children with cerebral palsy. They tried nerve block with Botox and phenol, computer-assisted biofeedback, and pulsed magnetic field therapy. “We were not impressed with their cost-to-benefit ratio as per Indian prices. Hence, we have dropped them.”

Standard therapy consists of special education, occupational therapy, speech therapy, and physiotherapy totaling 2 hours daily. After 5 months of HBOT, clinicians administer 60 sessions of electroacupuncture using transcutaneous electrical nerve stimulation (TENS) specifically designed for cerebral palsy. This therapy reduces pain and discomfort of intensive exercises and helps the brain recognize pathways revived by HBOT, Dr. Mukherjee said at the symposium sponsored by the Ocean Hyperbaric Neurologic Center in Fort Lauderdale, Fla. “This alerts the brain that these circuits are now working,” he said.

Short-term treatment has limited other pediatric studies of hyperbaric oxygen for cerebral palsy, Dr. Mukherjee said. In the current investigation, it took 6 months before cognitive differences between groups reached statistical significance. This suggests the need for a long-term commitment to hyperbaric therapy for cerebral palsy.

FORT LAUDERDALE, FLA. – Adjunctive hyperbaric oxygen therapy significantly improves cognition for children with cerebral palsy, compared with standard therapy alone, according to an open, ongoing, observational study.

All participants significantly improved their physical, speech, and motor capabilities after 6 months, compared with baseline. Interim results for 84 children whose parents chose hyperbaric oxygen therapy (HBOT) and 20 children in a non-HBOT group were presented at a symposium on hyperbaric oxygen therapy.

Changes in cognition were distinctive. “Children receiving HBOT showed statistically significant improvements in cognitive-only parameters. This is interesting and what is driving us to go on with this treatment,” said Dr. Arun Mukherjee of Majeedia Hospital, New Delhi, India.

Researchers used a modified 49-item Gross Motor Function Measure to monitor clinical progress at 2-month intervals. In an attempt to assess the effects of hyperbaric oxygenation, researchers focused on 26 cognitive-only items, which are less dependent on therapist input. “This is the closest measure we can get to brain repair,” said Dr. Mukherjee, who is also director of the UDAAN Project for Cerebral Palsy at the Foundation for Spastic and Mentally Handicapped Persons in New Delhi. UDAAN is a Hindi word for flight (of freedom).

Hyperbaric therapy consisted of 100% oxygen delivered at 1.5 atmospheres. Not included in this interim analysis is a recently added third group of patients who receive a low-pressure HBOT option (ambient air delivered at 1.3 atmospheres).

Dr. Mukherjee and his associates launched the UDAAN HBOT-Based Multimode Long-Term Observational Study in 2001 to assess the benefits, if any, of adjunctive therapy for children with cerebral palsy. They tried nerve block with Botox and phenol, computer-assisted biofeedback, and pulsed magnetic field therapy. “We were not impressed with their cost-to-benefit ratio as per Indian prices. Hence, we have dropped them.”

Standard therapy consists of special education, occupational therapy, speech therapy, and physiotherapy totaling 2 hours daily. After 5 months of HBOT, clinicians administer 60 sessions of electroacupuncture using transcutaneous electrical nerve stimulation (TENS) specifically designed for cerebral palsy. This therapy reduces pain and discomfort of intensive exercises and helps the brain recognize pathways revived by HBOT, Dr. Mukherjee said at the symposium sponsored by the Ocean Hyperbaric Neurologic Center in Fort Lauderdale, Fla. “This alerts the brain that these circuits are now working,” he said.

Short-term treatment has limited other pediatric studies of hyperbaric oxygen for cerebral palsy, Dr. Mukherjee said. In the current investigation, it took 6 months before cognitive differences between groups reached statistical significance. This suggests the need for a long-term commitment to hyperbaric therapy for cerebral palsy.

FORT LAUDERDALE, FLA. – Hyperbaric oxygen therapy improves cognitive and social function in children with chronic brain injury, according to a study presented at a symposium on hyperbaric oxygen therapy.

Daily living, socialization, communication, and motor skills significantly improved for 21 children treated with hyperbaric oxygen therapy (HBOT), compared with 21 brain-injured patients who received standard therapy. Researchers included a third group of 21 healthy children to control for normal growth and development, reported Dr. Charles J. Golden at the symposium sponsored by the Ocean Hyperbaric Neurologic Center.

All participants were assessed more than 1 year after onset of their chronic brain injury. The majority had cerebral palsy. The average age of all participants was 4.5 years (range, 12 months to 18 years), said Dr. Golden, professor of psychology and director, Neuropsychology Assessment Center, Nova Southeastern University, Fort Lauderdale, Fla.

Average functioning level was close to two standard deviations below average–“so this was a very low functioning group,” he added.

Mild changes in some areas but no changes in the cerebellum were noted after 35 HBOT sessions, compared with baseline, Dr. Golden said. “This is not unexpected. These children had injuries high up in the brain.”

“Interestingly, you can predict reasonably well who will be a responder based on response over the first 35 treatments,” he said. “Some people are just nonresponders–you can give them 200 treatments, and they will not respond. Others are marvelous responders who respond well and right away.”

After a second round of 35 HBOT treatments, “there was a much greater effect on blood flow … so it seems to be a time-based effect,” Dr. Golden said.

The HBOT group made major changes in all areas that were greater than either the normal or standard therapy control groups.

“This is a group who is at the end–they have failed multiple therapies. And still we have about 70% who respond [to HBOT],” said Dr. Golden. “The plasticity of the brain may be much greater than we imagined. HBOT may stimulate ability of the brain to reorganize itself.”

Dr. Golden and his associates used the Vineland Adaptive Behavior Scales to rate basic adaptive, motor, and cognitive abilities “This can be used without a child having to perform for us, which is challenging with cerebral palsy,” he said.

They assessed blood flow changes with a series of three single-photon emission computed tomography (SPECT) scans before, during, and after HBOT treatment. They assessed the cerebellum, pons, right and left hemisphere subcortical areas, and the cortical region.

Families were highly motivated to see changes, a possible limitation of the study, Dr. Golden said. In addition, the study was not double-blind, and the sample was self-selected because “we cannot put children in hyperbaric chambers without parent permission.”

“Improvements in motor functions [from HBOT] allowed them to do things they could not do at the beginning of the study. The therapy allowed them to make a big jump in terms of their abilities.”

FORT LAUDERDALE, FLA. – Hyperbaric oxygen therapy improves cognitive and social function in children with chronic brain injury, according to a study presented at a symposium on hyperbaric oxygen therapy.

Daily living, socialization, communication, and motor skills significantly improved for 21 children treated with hyperbaric oxygen therapy (HBOT), compared with 21 brain-injured patients who received standard therapy. Researchers included a third group of 21 healthy children to control for normal growth and development, reported Dr. Charles J. Golden at the symposium sponsored by the Ocean Hyperbaric Neurologic Center.

All participants were assessed more than 1 year after onset of their chronic brain injury. The majority had cerebral palsy. The average age of all participants was 4.5 years (range, 12 months to 18 years), said Dr. Golden, professor of psychology and director, Neuropsychology Assessment Center, Nova Southeastern University, Fort Lauderdale, Fla.

Average functioning level was close to two standard deviations below average–“so this was a very low functioning group,” he added.

Mild changes in some areas but no changes in the cerebellum were noted after 35 HBOT sessions, compared with baseline, Dr. Golden said. “This is not unexpected. These children had injuries high up in the brain.”

“Interestingly, you can predict reasonably well who will be a responder based on response over the first 35 treatments,” he said. “Some people are just nonresponders–you can give them 200 treatments, and they will not respond. Others are marvelous responders who respond well and right away.”

After a second round of 35 HBOT treatments, “there was a much greater effect on blood flow … so it seems to be a time-based effect,” Dr. Golden said.

The HBOT group made major changes in all areas that were greater than either the normal or standard therapy control groups.

“This is a group who is at the end–they have failed multiple therapies. And still we have about 70% who respond [to HBOT],” said Dr. Golden. “The plasticity of the brain may be much greater than we imagined. HBOT may stimulate ability of the brain to reorganize itself.”

Dr. Golden and his associates used the Vineland Adaptive Behavior Scales to rate basic adaptive, motor, and cognitive abilities “This can be used without a child having to perform for us, which is challenging with cerebral palsy,” he said.

They assessed blood flow changes with a series of three single-photon emission computed tomography (SPECT) scans before, during, and after HBOT treatment. They assessed the cerebellum, pons, right and left hemisphere subcortical areas, and the cortical region.

Families were highly motivated to see changes, a possible limitation of the study, Dr. Golden said. In addition, the study was not double-blind, and the sample was self-selected because “we cannot put children in hyperbaric chambers without parent permission.”

“Improvements in motor functions [from HBOT] allowed them to do things they could not do at the beginning of the study. The therapy allowed them to make a big jump in terms of their abilities.”

FORT LAUDERDALE, FLA. – Hyperbaric oxygen therapy improves cognitive and social function in children with chronic brain injury, according to a study presented at a symposium on hyperbaric oxygen therapy.

Daily living, socialization, communication, and motor skills significantly improved for 21 children treated with hyperbaric oxygen therapy (HBOT), compared with 21 brain-injured patients who received standard therapy. Researchers included a third group of 21 healthy children to control for normal growth and development, reported Dr. Charles J. Golden at the symposium sponsored by the Ocean Hyperbaric Neurologic Center.

All participants were assessed more than 1 year after onset of their chronic brain injury. The majority had cerebral palsy. The average age of all participants was 4.5 years (range, 12 months to 18 years), said Dr. Golden, professor of psychology and director, Neuropsychology Assessment Center, Nova Southeastern University, Fort Lauderdale, Fla.

Average functioning level was close to two standard deviations below average–“so this was a very low functioning group,” he added.

Mild changes in some areas but no changes in the cerebellum were noted after 35 HBOT sessions, compared with baseline, Dr. Golden said. “This is not unexpected. These children had injuries high up in the brain.”

“Interestingly, you can predict reasonably well who will be a responder based on response over the first 35 treatments,” he said. “Some people are just nonresponders–you can give them 200 treatments, and they will not respond. Others are marvelous responders who respond well and right away.”

After a second round of 35 HBOT treatments, “there was a much greater effect on blood flow … so it seems to be a time-based effect,” Dr. Golden said.

The HBOT group made major changes in all areas that were greater than either the normal or standard therapy control groups.

“This is a group who is at the end–they have failed multiple therapies. And still we have about 70% who respond [to HBOT],” said Dr. Golden. “The plasticity of the brain may be much greater than we imagined. HBOT may stimulate ability of the brain to reorganize itself.”

Dr. Golden and his associates used the Vineland Adaptive Behavior Scales to rate basic adaptive, motor, and cognitive abilities “This can be used without a child having to perform for us, which is challenging with cerebral palsy,” he said.

They assessed blood flow changes with a series of three single-photon emission computed tomography (SPECT) scans before, during, and after HBOT treatment. They assessed the cerebellum, pons, right and left hemisphere subcortical areas, and the cortical region.

Families were highly motivated to see changes, a possible limitation of the study, Dr. Golden said. In addition, the study was not double-blind, and the sample was self-selected because “we cannot put children in hyperbaric chambers without parent permission.”

“Improvements in motor functions [from HBOT] allowed them to do things they could not do at the beginning of the study. The therapy allowed them to make a big jump in terms of their abilities.”

LAS VEGAS — Using three light forms to hit three targets effectively tightens skin and can add facial volume without fillers, Dr. Javier Ruiz-Esparza said at an international symposium on cosmetic and laser surgery.

"This is an entirely light-based procedure without any mechanical or medical improvement to heat multiple targets in multiple layers, with three energies in succession," Dr. Ruiz-Esparza said. "We call this approach 3-D rejuvenation."

The 3-D skin rejuvenation system from Cutera (Brisbane, Calif.) targets the deep dermis with infrared light for skin tightening; mid-dermal fibroblasts, melanin, and hemoglobin with a 1064-nm Nd:YAG laser to promote new collagen formation; and superficial melanin and hemoglobin with a 560-nm intense pulsed light to treat surface dyspigmentation.

This triple combination improves natural skin quality and fine wrinkles. "You can get quick improvement in a matter of 6 weeks without downtime and without pain," said Dr. Ruiz-Esparza of the University of California, San Diego. "So far, everything we have done with Nd:YAG has been aimed at improving planar, bidimensional signs of photodamage, such as solar lentigo and telangiectasias," said Dr. Ruiz-Esparza, who is a consultant for Cutera.

Now, this system—laser and pulsed light in combination with the Titan infrared light source—can also add volume. With this approach, new collagen forms and adds uniform volume to the face and neck "never seen before with any other technology," he said.

Maximum volume effects are observed at 3 months as the healing process promotes collagen creation. Some volume augmentation for lips might be possible too, although this is a work in progress, he said.

A meeting attendee asked about the end point for the Titan treatment. "I have found the last passes are the ones that count the most," Dr. Ruiz-Esparza said. There is more tightening after initial heating of the skin. "If you quit too soon, you will not get the same results," he noted.

Stop periodically and check for contracture of the skin. "You can continue treatment until it starts to hurt the patient. You don't want to go overboard and end up with erythema and edema," Dr. Ruiz-Esparza said.

For a patient who is skeptical about Titan treatment, treat one side and have the patient sit up and look in a mirror. The benefits of treatment will become even more pronounced when the patient smiles. "You can see it in every race—the dramatic difference between the treated and untreated sides," he said.

If patients remain unconvinced, send them home with just one side treated and tell them to come back if they see a difference, he said. This approach usually works because contraction on one side will persist and be visible for days or even weeks later.

The best tightening with Titan is often seen in what Dr. Ruiz-Esparza calls "area 1"—the cheek and either side of the mouth. "If I can get contraction in area 1, I can do a lot for the patient." Area 2 is the lateral aspects of the neck. Area 3—the forehead and temples—"is the one that gives me the least reliable result," he said.

Although dermatologists are well versed in the benefits of showing patient progress with photographs, Dr. Ruiz-Esparza said there are limitations. "We should stop trying to show results with still pictures. It's a pain in the neck because you need the same lighting, room, and expression." Instead, he proposed showing results with a postoperative video taken from every angle around the patient's face. "This hides nothing," he asserted.

Photos before (left) and after the procedure show some progress. But often, a postoperative video taken from different angles can show results more clearly. Photos courtesy Dr. Javier Ruiz-Esparza

LAS VEGAS — Using three light forms to hit three targets effectively tightens skin and can add facial volume without fillers, Dr. Javier Ruiz-Esparza said at an international symposium on cosmetic and laser surgery.

"This is an entirely light-based procedure without any mechanical or medical improvement to heat multiple targets in multiple layers, with three energies in succession," Dr. Ruiz-Esparza said. "We call this approach 3-D rejuvenation."

The 3-D skin rejuvenation system from Cutera (Brisbane, Calif.) targets the deep dermis with infrared light for skin tightening; mid-dermal fibroblasts, melanin, and hemoglobin with a 1064-nm Nd:YAG laser to promote new collagen formation; and superficial melanin and hemoglobin with a 560-nm intense pulsed light to treat surface dyspigmentation.

This triple combination improves natural skin quality and fine wrinkles. "You can get quick improvement in a matter of 6 weeks without downtime and without pain," said Dr. Ruiz-Esparza of the University of California, San Diego. "So far, everything we have done with Nd:YAG has been aimed at improving planar, bidimensional signs of photodamage, such as solar lentigo and telangiectasias," said Dr. Ruiz-Esparza, who is a consultant for Cutera.

Now, this system—laser and pulsed light in combination with the Titan infrared light source—can also add volume. With this approach, new collagen forms and adds uniform volume to the face and neck "never seen before with any other technology," he said.

Maximum volume effects are observed at 3 months as the healing process promotes collagen creation. Some volume augmentation for lips might be possible too, although this is a work in progress, he said.

A meeting attendee asked about the end point for the Titan treatment. "I have found the last passes are the ones that count the most," Dr. Ruiz-Esparza said. There is more tightening after initial heating of the skin. "If you quit too soon, you will not get the same results," he noted.

Stop periodically and check for contracture of the skin. "You can continue treatment until it starts to hurt the patient. You don't want to go overboard and end up with erythema and edema," Dr. Ruiz-Esparza said.

For a patient who is skeptical about Titan treatment, treat one side and have the patient sit up and look in a mirror. The benefits of treatment will become even more pronounced when the patient smiles. "You can see it in every race—the dramatic difference between the treated and untreated sides," he said.

If patients remain unconvinced, send them home with just one side treated and tell them to come back if they see a difference, he said. This approach usually works because contraction on one side will persist and be visible for days or even weeks later.

The best tightening with Titan is often seen in what Dr. Ruiz-Esparza calls "area 1"—the cheek and either side of the mouth. "If I can get contraction in area 1, I can do a lot for the patient." Area 2 is the lateral aspects of the neck. Area 3—the forehead and temples—"is the one that gives me the least reliable result," he said.

Although dermatologists are well versed in the benefits of showing patient progress with photographs, Dr. Ruiz-Esparza said there are limitations. "We should stop trying to show results with still pictures. It's a pain in the neck because you need the same lighting, room, and expression." Instead, he proposed showing results with a postoperative video taken from every angle around the patient's face. "This hides nothing," he asserted.

Photos before (left) and after the procedure show some progress. But often, a postoperative video taken from different angles can show results more clearly. Photos courtesy Dr. Javier Ruiz-Esparza

LAS VEGAS — Using three light forms to hit three targets effectively tightens skin and can add facial volume without fillers, Dr. Javier Ruiz-Esparza said at an international symposium on cosmetic and laser surgery.

"This is an entirely light-based procedure without any mechanical or medical improvement to heat multiple targets in multiple layers, with three energies in succession," Dr. Ruiz-Esparza said. "We call this approach 3-D rejuvenation."

The 3-D skin rejuvenation system from Cutera (Brisbane, Calif.) targets the deep dermis with infrared light for skin tightening; mid-dermal fibroblasts, melanin, and hemoglobin with a 1064-nm Nd:YAG laser to promote new collagen formation; and superficial melanin and hemoglobin with a 560-nm intense pulsed light to treat surface dyspigmentation.

This triple combination improves natural skin quality and fine wrinkles. "You can get quick improvement in a matter of 6 weeks without downtime and without pain," said Dr. Ruiz-Esparza of the University of California, San Diego. "So far, everything we have done with Nd:YAG has been aimed at improving planar, bidimensional signs of photodamage, such as solar lentigo and telangiectasias," said Dr. Ruiz-Esparza, who is a consultant for Cutera.

Now, this system—laser and pulsed light in combination with the Titan infrared light source—can also add volume. With this approach, new collagen forms and adds uniform volume to the face and neck "never seen before with any other technology," he said.

Maximum volume effects are observed at 3 months as the healing process promotes collagen creation. Some volume augmentation for lips might be possible too, although this is a work in progress, he said.

A meeting attendee asked about the end point for the Titan treatment. "I have found the last passes are the ones that count the most," Dr. Ruiz-Esparza said. There is more tightening after initial heating of the skin. "If you quit too soon, you will not get the same results," he noted.

Stop periodically and check for contracture of the skin. "You can continue treatment until it starts to hurt the patient. You don't want to go overboard and end up with erythema and edema," Dr. Ruiz-Esparza said.

For a patient who is skeptical about Titan treatment, treat one side and have the patient sit up and look in a mirror. The benefits of treatment will become even more pronounced when the patient smiles. "You can see it in every race—the dramatic difference between the treated and untreated sides," he said.

If patients remain unconvinced, send them home with just one side treated and tell them to come back if they see a difference, he said. This approach usually works because contraction on one side will persist and be visible for days or even weeks later.

The best tightening with Titan is often seen in what Dr. Ruiz-Esparza calls "area 1"—the cheek and either side of the mouth. "If I can get contraction in area 1, I can do a lot for the patient." Area 2 is the lateral aspects of the neck. Area 3—the forehead and temples—"is the one that gives me the least reliable result," he said.

Although dermatologists are well versed in the benefits of showing patient progress with photographs, Dr. Ruiz-Esparza said there are limitations. "We should stop trying to show results with still pictures. It's a pain in the neck because you need the same lighting, room, and expression." Instead, he proposed showing results with a postoperative video taken from every angle around the patient's face. "This hides nothing," he asserted.

Photos before (left) and after the procedure show some progress. But often, a postoperative video taken from different angles can show results more clearly. Photos courtesy Dr. Javier Ruiz-Esparza

LAS VEGAS —The filler poly-L-lactic acid is indicated for HIV facial atrophy, but in experienced hands it also is safe for volume replenishment of tear troughs and hands, Dr. Neil S. Sadick said at an international symposium on cosmetic and laser surgery.

Before the procedure, instruct patients not to take aspirin, ibuprofen, or platelet inhibitors. Apply a topical anesthetic, such as lidocaine, under occlusion for 30 minutes to the treatment area. "When the S-Caine peel is available, it will replace topical lidocaine," predicted Dr. Sadick, who is in private practice in New York.

Poly-L-lactic acid (Sculptra) is a synthetic filler that requires reconstitution at least 2 hours prior to treatment. Although the instructions for use indicate that the filler can sit reconstituted up to 2 weeks, "it can stay for a couple of months, according to several recent studies," Dr. Sadick said.

Proper dilution and technique are required. For tear troughs or hands, dilute the poly-L-lactic acid in 6 cc of sterile water and 2 cc of 1% lidocaine. For hands, 2 vials of poly-L-lactic acid and prepare eight 1-cc syringes (four for each hand) with 26-gauge half-inch needles. Have ice packs available.

"The most important factor is to tent the skin to minimize the bruising when injecting between each intraosseous space," said Dr. Sadick. "Always aspirate to make sure you are not in a blood vessel," he said.

Once the injections are finished, vigorously massage the area for 10 minutes and then apply ice packs for another 10 minutes. Repeat this regimen for three cycles to avoid the formation of nodules and to minimize pain, said Dr. Sadick, who is a consultant for Dermik Laboratories Inc., the manufacturer of Sculptra.

The volumetric effect goes away in the first few weeks, but collagen remodeling produces a late effect that lasts 6–9 months, Dr. Sadick said. Optimal results are seen after two or three treatment sessions at 3- to 4-week intervals.

Before and after images show the results of injecting a hand with poly-L-lactic acid (Sculptra), a filler approved for the treatment of HIV-associated lipoatrophy. Photos courtesy Dr. Neil S. Sadick

LAS VEGAS —The filler poly-L-lactic acid is indicated for HIV facial atrophy, but in experienced hands it also is safe for volume replenishment of tear troughs and hands, Dr. Neil S. Sadick said at an international symposium on cosmetic and laser surgery.

Before the procedure, instruct patients not to take aspirin, ibuprofen, or platelet inhibitors. Apply a topical anesthetic, such as lidocaine, under occlusion for 30 minutes to the treatment area. "When the S-Caine peel is available, it will replace topical lidocaine," predicted Dr. Sadick, who is in private practice in New York.

Poly-L-lactic acid (Sculptra) is a synthetic filler that requires reconstitution at least 2 hours prior to treatment. Although the instructions for use indicate that the filler can sit reconstituted up to 2 weeks, "it can stay for a couple of months, according to several recent studies," Dr. Sadick said.

Proper dilution and technique are required. For tear troughs or hands, dilute the poly-L-lactic acid in 6 cc of sterile water and 2 cc of 1% lidocaine. For hands, 2 vials of poly-L-lactic acid and prepare eight 1-cc syringes (four for each hand) with 26-gauge half-inch needles. Have ice packs available.

"The most important factor is to tent the skin to minimize the bruising when injecting between each intraosseous space," said Dr. Sadick. "Always aspirate to make sure you are not in a blood vessel," he said.

Once the injections are finished, vigorously massage the area for 10 minutes and then apply ice packs for another 10 minutes. Repeat this regimen for three cycles to avoid the formation of nodules and to minimize pain, said Dr. Sadick, who is a consultant for Dermik Laboratories Inc., the manufacturer of Sculptra.

The volumetric effect goes away in the first few weeks, but collagen remodeling produces a late effect that lasts 6–9 months, Dr. Sadick said. Optimal results are seen after two or three treatment sessions at 3- to 4-week intervals.

Before and after images show the results of injecting a hand with poly-L-lactic acid (Sculptra), a filler approved for the treatment of HIV-associated lipoatrophy. Photos courtesy Dr. Neil S. Sadick

LAS VEGAS —The filler poly-L-lactic acid is indicated for HIV facial atrophy, but in experienced hands it also is safe for volume replenishment of tear troughs and hands, Dr. Neil S. Sadick said at an international symposium on cosmetic and laser surgery.

Before the procedure, instruct patients not to take aspirin, ibuprofen, or platelet inhibitors. Apply a topical anesthetic, such as lidocaine, under occlusion for 30 minutes to the treatment area. "When the S-Caine peel is available, it will replace topical lidocaine," predicted Dr. Sadick, who is in private practice in New York.

Poly-L-lactic acid (Sculptra) is a synthetic filler that requires reconstitution at least 2 hours prior to treatment. Although the instructions for use indicate that the filler can sit reconstituted up to 2 weeks, "it can stay for a couple of months, according to several recent studies," Dr. Sadick said.

Proper dilution and technique are required. For tear troughs or hands, dilute the poly-L-lactic acid in 6 cc of sterile water and 2 cc of 1% lidocaine. For hands, 2 vials of poly-L-lactic acid and prepare eight 1-cc syringes (four for each hand) with 26-gauge half-inch needles. Have ice packs available.

"The most important factor is to tent the skin to minimize the bruising when injecting between each intraosseous space," said Dr. Sadick. "Always aspirate to make sure you are not in a blood vessel," he said.

Once the injections are finished, vigorously massage the area for 10 minutes and then apply ice packs for another 10 minutes. Repeat this regimen for three cycles to avoid the formation of nodules and to minimize pain, said Dr. Sadick, who is a consultant for Dermik Laboratories Inc., the manufacturer of Sculptra.

The volumetric effect goes away in the first few weeks, but collagen remodeling produces a late effect that lasts 6–9 months, Dr. Sadick said. Optimal results are seen after two or three treatment sessions at 3- to 4-week intervals.

Before and after images show the results of injecting a hand with poly-L-lactic acid (Sculptra), a filler approved for the treatment of HIV-associated lipoatrophy. Photos courtesy Dr. Neil S. Sadick

LAS VEGAS — Hair transplantation using follicular isolation is labor intensive and not for everyone, but the technique serves a subset of patients very well, Dr. Paul T. Rose said at an international symposium on cosmetic and laser surgery.

Unlike the more popular follicular unit extraction, in which hair follicles are extracted together from a donor hair strip, the isolation technique involves removal of individual follicles.

"What I am about to tell you some people would call a return to the 20th century. It's a retro method—we are going back to a punch biopsy, a 1-mm punch," Dr. Rose said.

Patients who are younger, want a scar revision, have limited donor hair, or are concerned about a linear scar from a donor strip are candidates. About 15% of Dr. Rose's hair transplantation patients fit one of these categories, he said.

"These days it is not enough to have a great result in the recipient area. The result in the donor area is becoming increasingly important," he noted. Some patients are "very concerned" after seeing donor site scar photos on the Internet, said Dr. Rose, who is in private practice in Tampa, Fla.

"In our practice, it's probably less than 5% of patients," Dr. Marc R. Avram said. The technique is usually reserved for patients who have a specific area with no hair, such as from multiple surgeries.

"Follicular extraction is not always easy," said Dr. Avram, who is in private practice in New York and is with the department of dermatology at New York-Presbyterian Hospital.

"I think this can help for scars, such as through an eyebrow or a beard," said Dr. Ken Washenik, medical director of Bosley and executive vice president of scientific and medical development at the Aderans Research Institute in Beverly Hills, Calif.

The isolation technique allows clinicians to extract donor hair from sites that might otherwise be unavailable. One example is body hair, although "I will tell patients that using body hair at this point is not proven," Dr. Rose said.

The different texture of body hair is one limitation. Dr. Washenik said that "body hair is single-unit extraction, so the number of donor hairs is more limited."

Altered pigmentation and scarring are potential disadvantages of the technique.

"Most of these punches heal wonderfully, but you can end up with hyper- or hypopigmentation," Dr. Rose said. Excessive harvesting in one area can yield a "moth-eaten" appearance and increase risk of scarring, so leave follicles immediately surrounding each graft, he suggested.

"It is an amazingly tedious process for the patient and surgeon," Dr. Rose said. Clinicians can transfer 500–700 grafts per day, compared with up to 2,000 grafts per day from a donor strip harvest. In addition, the isolation technique costs about twice as much as unit extraction.

Use of a modified slit lamp with a chin cushion can expedite the process. "The patient can sit up comfortably and I have better access to areas. I can harvest and place at the same time," Dr. Rose said.

Before the process begins, the hair should be cut down to 2–3 mm. Align the punch with the direction of the hair, which can change across the head. "Sometimes you have to do 10 or 15 of them, and adjust how you are doing. Check for hair transection," he said.

Partially enter the skin with the punch to form a circular rather than an oval defect. Enter to the level of the fat/dermal junction.

"Once you are confident of the level, set the punch depth because this varies from person to person," Dr. Rose said.

Remove the graft with appropriate forceps and free up any attachments. "Recognize that each patient is unique and there is variability with ease of extraction," Dr. Rose said. "A lot of time [the follicle] will just jump out at you, which is great. Sometimes you cannot get it out and you leave it behind."

The donor site is shown immediately after individual hair follicles were harvested with a punch.

One day after the procedure, healthy growth is seen in the hair follicles immediately surrounding the grafts.

Four days after the procedure, the donor site has resumed a normal appearance. Photos courtesy Dr. Paul T. Rose

LAS VEGAS — Hair transplantation using follicular isolation is labor intensive and not for everyone, but the technique serves a subset of patients very well, Dr. Paul T. Rose said at an international symposium on cosmetic and laser surgery.

Unlike the more popular follicular unit extraction, in which hair follicles are extracted together from a donor hair strip, the isolation technique involves removal of individual follicles.

"What I am about to tell you some people would call a return to the 20th century. It's a retro method—we are going back to a punch biopsy, a 1-mm punch," Dr. Rose said.

Patients who are younger, want a scar revision, have limited donor hair, or are concerned about a linear scar from a donor strip are candidates. About 15% of Dr. Rose's hair transplantation patients fit one of these categories, he said.

"These days it is not enough to have a great result in the recipient area. The result in the donor area is becoming increasingly important," he noted. Some patients are "very concerned" after seeing donor site scar photos on the Internet, said Dr. Rose, who is in private practice in Tampa, Fla.

"In our practice, it's probably less than 5% of patients," Dr. Marc R. Avram said. The technique is usually reserved for patients who have a specific area with no hair, such as from multiple surgeries.

"Follicular extraction is not always easy," said Dr. Avram, who is in private practice in New York and is with the department of dermatology at New York-Presbyterian Hospital.

"I think this can help for scars, such as through an eyebrow or a beard," said Dr. Ken Washenik, medical director of Bosley and executive vice president of scientific and medical development at the Aderans Research Institute in Beverly Hills, Calif.

The isolation technique allows clinicians to extract donor hair from sites that might otherwise be unavailable. One example is body hair, although "I will tell patients that using body hair at this point is not proven," Dr. Rose said.

The different texture of body hair is one limitation. Dr. Washenik said that "body hair is single-unit extraction, so the number of donor hairs is more limited."

Altered pigmentation and scarring are potential disadvantages of the technique.

"Most of these punches heal wonderfully, but you can end up with hyper- or hypopigmentation," Dr. Rose said. Excessive harvesting in one area can yield a "moth-eaten" appearance and increase risk of scarring, so leave follicles immediately surrounding each graft, he suggested.

"It is an amazingly tedious process for the patient and surgeon," Dr. Rose said. Clinicians can transfer 500–700 grafts per day, compared with up to 2,000 grafts per day from a donor strip harvest. In addition, the isolation technique costs about twice as much as unit extraction.

Use of a modified slit lamp with a chin cushion can expedite the process. "The patient can sit up comfortably and I have better access to areas. I can harvest and place at the same time," Dr. Rose said.

Before the process begins, the hair should be cut down to 2–3 mm. Align the punch with the direction of the hair, which can change across the head. "Sometimes you have to do 10 or 15 of them, and adjust how you are doing. Check for hair transection," he said.

Partially enter the skin with the punch to form a circular rather than an oval defect. Enter to the level of the fat/dermal junction.

"Once you are confident of the level, set the punch depth because this varies from person to person," Dr. Rose said.

Remove the graft with appropriate forceps and free up any attachments. "Recognize that each patient is unique and there is variability with ease of extraction," Dr. Rose said. "A lot of time [the follicle] will just jump out at you, which is great. Sometimes you cannot get it out and you leave it behind."

The donor site is shown immediately after individual hair follicles were harvested with a punch.

One day after the procedure, healthy growth is seen in the hair follicles immediately surrounding the grafts.

Four days after the procedure, the donor site has resumed a normal appearance. Photos courtesy Dr. Paul T. Rose

LAS VEGAS — Hair transplantation using follicular isolation is labor intensive and not for everyone, but the technique serves a subset of patients very well, Dr. Paul T. Rose said at an international symposium on cosmetic and laser surgery.

Unlike the more popular follicular unit extraction, in which hair follicles are extracted together from a donor hair strip, the isolation technique involves removal of individual follicles.

"What I am about to tell you some people would call a return to the 20th century. It's a retro method—we are going back to a punch biopsy, a 1-mm punch," Dr. Rose said.

Patients who are younger, want a scar revision, have limited donor hair, or are concerned about a linear scar from a donor strip are candidates. About 15% of Dr. Rose's hair transplantation patients fit one of these categories, he said.

"These days it is not enough to have a great result in the recipient area. The result in the donor area is becoming increasingly important," he noted. Some patients are "very concerned" after seeing donor site scar photos on the Internet, said Dr. Rose, who is in private practice in Tampa, Fla.

"In our practice, it's probably less than 5% of patients," Dr. Marc R. Avram said. The technique is usually reserved for patients who have a specific area with no hair, such as from multiple surgeries.

"Follicular extraction is not always easy," said Dr. Avram, who is in private practice in New York and is with the department of dermatology at New York-Presbyterian Hospital.

"I think this can help for scars, such as through an eyebrow or a beard," said Dr. Ken Washenik, medical director of Bosley and executive vice president of scientific and medical development at the Aderans Research Institute in Beverly Hills, Calif.

The isolation technique allows clinicians to extract donor hair from sites that might otherwise be unavailable. One example is body hair, although "I will tell patients that using body hair at this point is not proven," Dr. Rose said.

The different texture of body hair is one limitation. Dr. Washenik said that "body hair is single-unit extraction, so the number of donor hairs is more limited."

Altered pigmentation and scarring are potential disadvantages of the technique.

"Most of these punches heal wonderfully, but you can end up with hyper- or hypopigmentation," Dr. Rose said. Excessive harvesting in one area can yield a "moth-eaten" appearance and increase risk of scarring, so leave follicles immediately surrounding each graft, he suggested.

"It is an amazingly tedious process for the patient and surgeon," Dr. Rose said. Clinicians can transfer 500–700 grafts per day, compared with up to 2,000 grafts per day from a donor strip harvest. In addition, the isolation technique costs about twice as much as unit extraction.

Use of a modified slit lamp with a chin cushion can expedite the process. "The patient can sit up comfortably and I have better access to areas. I can harvest and place at the same time," Dr. Rose said.

Before the process begins, the hair should be cut down to 2–3 mm. Align the punch with the direction of the hair, which can change across the head. "Sometimes you have to do 10 or 15 of them, and adjust how you are doing. Check for hair transection," he said.

Partially enter the skin with the punch to form a circular rather than an oval defect. Enter to the level of the fat/dermal junction.

"Once you are confident of the level, set the punch depth because this varies from person to person," Dr. Rose said.

Remove the graft with appropriate forceps and free up any attachments. "Recognize that each patient is unique and there is variability with ease of extraction," Dr. Rose said. "A lot of time [the follicle] will just jump out at you, which is great. Sometimes you cannot get it out and you leave it behind."

The donor site is shown immediately after individual hair follicles were harvested with a punch.

One day after the procedure, healthy growth is seen in the hair follicles immediately surrounding the grafts.

Four days after the procedure, the donor site has resumed a normal appearance. Photos courtesy Dr. Paul T. Rose

LAS VEGAS — Liposuction can be an effective alternative to breast reduction surgery in select patients, according to a presentation at an international symposium on cosmetic and laser surgery.

Traditional breast reduction can require significant postoperative recovery and cause unnatural-looking breast lift, Dr. Cameron Rokhsar said. In addition, many patients are left with an inverted T scar. In contrast, liposuction with local anesthesia does not lift the breast and often leaves only small scars, said Dr. Rokhsar, a dermatologist in private practice in New York City.

Liposuction is a common cosmetic procedure in the United States. "The procedure has evolved from one under general anesthesia with massive blood loss to an outpatient procedure with minimal blood loss," Dr. Rokhsar said.

The fat removal technique became "extremely safe" with the advent of the tumescent technique, he added. For example, a survey of 66 physician members of the American Society of Dermatologic Surgery found that there were no deaths among 15,336 patients they treated with tumescent liposuction (Dermatol. Surg. 1995;21:459–62).

After baseline mammography, Dr. Rokhsar measures breast size through water displacement and makes radial markings. Cannulas are introduced through two tiny holes to remove the fat from the breast. The process can suction up to 50%–70% of breast fat. In an unpublished study of 30 of Dr. Rokhsar's patients, this procedure reduced breast size by an average of one cup size. A follow-up mammography is performed at 6 months as a new baseline reference.

"The patient can sit up afterward—it is a very simple procedure," said Dr. Rokhsar, who is also on the dermatology faculty at Albert Einstein College of Medicine in New York.

Liposuction is contraindicated for a breast composed primarily of glandular tissue versus fat, Dr. Rokhsar said.

Patients with nipple ptosis, a family history of breast cancer, or patients looking for significant breast lift are generally not candidates for breast liposuction, he added.

LAS VEGAS — Liposuction can be an effective alternative to breast reduction surgery in select patients, according to a presentation at an international symposium on cosmetic and laser surgery.

Traditional breast reduction can require significant postoperative recovery and cause unnatural-looking breast lift, Dr. Cameron Rokhsar said. In addition, many patients are left with an inverted T scar. In contrast, liposuction with local anesthesia does not lift the breast and often leaves only small scars, said Dr. Rokhsar, a dermatologist in private practice in New York City.

Liposuction is a common cosmetic procedure in the United States. "The procedure has evolved from one under general anesthesia with massive blood loss to an outpatient procedure with minimal blood loss," Dr. Rokhsar said.

The fat removal technique became "extremely safe" with the advent of the tumescent technique, he added. For example, a survey of 66 physician members of the American Society of Dermatologic Surgery found that there were no deaths among 15,336 patients they treated with tumescent liposuction (Dermatol. Surg. 1995;21:459–62).

After baseline mammography, Dr. Rokhsar measures breast size through water displacement and makes radial markings. Cannulas are introduced through two tiny holes to remove the fat from the breast. The process can suction up to 50%–70% of breast fat. In an unpublished study of 30 of Dr. Rokhsar's patients, this procedure reduced breast size by an average of one cup size. A follow-up mammography is performed at 6 months as a new baseline reference.

"The patient can sit up afterward—it is a very simple procedure," said Dr. Rokhsar, who is also on the dermatology faculty at Albert Einstein College of Medicine in New York.

Liposuction is contraindicated for a breast composed primarily of glandular tissue versus fat, Dr. Rokhsar said.

Patients with nipple ptosis, a family history of breast cancer, or patients looking for significant breast lift are generally not candidates for breast liposuction, he added.

LAS VEGAS — Liposuction can be an effective alternative to breast reduction surgery in select patients, according to a presentation at an international symposium on cosmetic and laser surgery.

Traditional breast reduction can require significant postoperative recovery and cause unnatural-looking breast lift, Dr. Cameron Rokhsar said. In addition, many patients are left with an inverted T scar. In contrast, liposuction with local anesthesia does not lift the breast and often leaves only small scars, said Dr. Rokhsar, a dermatologist in private practice in New York City.

Liposuction is a common cosmetic procedure in the United States. "The procedure has evolved from one under general anesthesia with massive blood loss to an outpatient procedure with minimal blood loss," Dr. Rokhsar said.

The fat removal technique became "extremely safe" with the advent of the tumescent technique, he added. For example, a survey of 66 physician members of the American Society of Dermatologic Surgery found that there were no deaths among 15,336 patients they treated with tumescent liposuction (Dermatol. Surg. 1995;21:459–62).

After baseline mammography, Dr. Rokhsar measures breast size through water displacement and makes radial markings. Cannulas are introduced through two tiny holes to remove the fat from the breast. The process can suction up to 50%–70% of breast fat. In an unpublished study of 30 of Dr. Rokhsar's patients, this procedure reduced breast size by an average of one cup size. A follow-up mammography is performed at 6 months as a new baseline reference.

"The patient can sit up afterward—it is a very simple procedure," said Dr. Rokhsar, who is also on the dermatology faculty at Albert Einstein College of Medicine in New York.

Liposuction is contraindicated for a breast composed primarily of glandular tissue versus fat, Dr. Rokhsar said.

Patients with nipple ptosis, a family history of breast cancer, or patients looking for significant breast lift are generally not candidates for breast liposuction, he added.