Damian McNamara

CHAMPIONSGATE, FLA. — Transobturator tape procedures are as likely to result in complications as retropubic tape procedures, but the complications are different, according to Austrian registry data presented at the annual meeting of the Society of Gynecologic Surgeons.

In 2003, transobturator tape became available for correction of stress urinary incontinence in Austria. In 2004, researchers established a registry to track complications and outcomes. They compared performance against retropubic tape data collected in a previous registry.

“Of the intraoperative problems reported to us, increased bleeding was the most common,” said Dr. Karl Tamussino, attending obstetrician and gynecologist at the Medical University of Graz (Austria).

Increased bleeding was reported with 3.5% of the 2,436 operations performed at 47 centers.

The surgeons in Austria used a variety of transobturator tape products, including the TVT-Obturator (Gynecare), Monarc (AMS), and Obtape (Mentor-Porges). A meeting attendee asked if there were any significant differences among products. “Bleeding was pretty much the same,” Dr. Tamussino replied.

Centers were asked to voluntarily complete a one-page, 15-item questionnaire with each procedure. “The registry is very simple. That is the key to amassing numbers,” said Dr. Tamussino, who presented the findings on behalf of the Austrian Urogynecology Working Group. Disclosures for the working group researchers include AMS, Contura, Lilly/Boehringer, and Gynecare.

Other intraoperative complications included 11 bladder perforations, 10 vaginal perforations, and 2 urethral perforations. “Bladder and urethral perforations were more common with systems inserted from the outside,” Dr. Tamussino said at the meeting, which was jointly sponsored by the American College of Surgeons.

A total of 51 patients had a tape-related reoperation. Voiding dysfunction was the most common reason; the tape was loosened or cut for 27 patients. An inability to void completely postoperatively “seems to be very similar to what is seen with conventional TVT [tension-free vaginal tape],” Dr. Tamussino said.

Vaginal tape erosions in nine patients required reoperations, as did a hematoma in one patient at 14 days postoperatively. In addition, seven patients experienced erosions and/or abscesses. Of these, four occurred with Obtape, which is no longer available in Austria, Dr. Tamussino said. The others occurred with the Monarc, TVT-Obturator, and intravaginal slingplasty systems.

“What we did not expect is these can occur months later,” he said.

A meeting attendee asked why erosion and abscesses were reported together. “There were 0.4% erosions alone, and we will separate these out in the [future] randomized trial,” Dr. Tamussino said.

Another unexpected postoperative complication was groin pain, with about a 1% incidence, Dr. Tamussino said.

“Unfortunately, we were not expecting the pain issue. We did not have this on the sheet, so we are probably underreporting.”

Vaginal erosions, abscesses, and pain may be more common with transobturator than retropubic tape procedures, the authors concluded. “Complications seem more related to the tape materials and not the technique,” Dr. Tamussino said.

“These are very important complication data on a very large number of procedures,” said study discussant Dr. R. Edward Varner of the department of obstetrics and gynecology at the University of Alabama, Birmingham. “Transobturator tapes seem to be relatively safe, especially in experienced hands.”

The registry was voluntary, a potential limitation, Dr. Tamussino said. “We just invited people to participate, we did not motivate them.” Dr. Varner agreed that the “reporting of data relies on patients with varying amounts of compulsiveness.”

CHAMPIONSGATE, FLA. — Transobturator tape procedures are as likely to result in complications as retropubic tape procedures, but the complications are different, according to Austrian registry data presented at the annual meeting of the Society of Gynecologic Surgeons.

In 2003, transobturator tape became available for correction of stress urinary incontinence in Austria. In 2004, researchers established a registry to track complications and outcomes. They compared performance against retropubic tape data collected in a previous registry.

“Of the intraoperative problems reported to us, increased bleeding was the most common,” said Dr. Karl Tamussino, attending obstetrician and gynecologist at the Medical University of Graz (Austria).

Increased bleeding was reported with 3.5% of the 2,436 operations performed at 47 centers.

The surgeons in Austria used a variety of transobturator tape products, including the TVT-Obturator (Gynecare), Monarc (AMS), and Obtape (Mentor-Porges). A meeting attendee asked if there were any significant differences among products. “Bleeding was pretty much the same,” Dr. Tamussino replied.

Centers were asked to voluntarily complete a one-page, 15-item questionnaire with each procedure. “The registry is very simple. That is the key to amassing numbers,” said Dr. Tamussino, who presented the findings on behalf of the Austrian Urogynecology Working Group. Disclosures for the working group researchers include AMS, Contura, Lilly/Boehringer, and Gynecare.

Other intraoperative complications included 11 bladder perforations, 10 vaginal perforations, and 2 urethral perforations. “Bladder and urethral perforations were more common with systems inserted from the outside,” Dr. Tamussino said at the meeting, which was jointly sponsored by the American College of Surgeons.

A total of 51 patients had a tape-related reoperation. Voiding dysfunction was the most common reason; the tape was loosened or cut for 27 patients. An inability to void completely postoperatively “seems to be very similar to what is seen with conventional TVT [tension-free vaginal tape],” Dr. Tamussino said.

Vaginal tape erosions in nine patients required reoperations, as did a hematoma in one patient at 14 days postoperatively. In addition, seven patients experienced erosions and/or abscesses. Of these, four occurred with Obtape, which is no longer available in Austria, Dr. Tamussino said. The others occurred with the Monarc, TVT-Obturator, and intravaginal slingplasty systems.

“What we did not expect is these can occur months later,” he said.

A meeting attendee asked why erosion and abscesses were reported together. “There were 0.4% erosions alone, and we will separate these out in the [future] randomized trial,” Dr. Tamussino said.

Another unexpected postoperative complication was groin pain, with about a 1% incidence, Dr. Tamussino said.

“Unfortunately, we were not expecting the pain issue. We did not have this on the sheet, so we are probably underreporting.”

Vaginal erosions, abscesses, and pain may be more common with transobturator than retropubic tape procedures, the authors concluded. “Complications seem more related to the tape materials and not the technique,” Dr. Tamussino said.

“These are very important complication data on a very large number of procedures,” said study discussant Dr. R. Edward Varner of the department of obstetrics and gynecology at the University of Alabama, Birmingham. “Transobturator tapes seem to be relatively safe, especially in experienced hands.”

The registry was voluntary, a potential limitation, Dr. Tamussino said. “We just invited people to participate, we did not motivate them.” Dr. Varner agreed that the “reporting of data relies on patients with varying amounts of compulsiveness.”

CHAMPIONSGATE, FLA. — Transobturator tape procedures are as likely to result in complications as retropubic tape procedures, but the complications are different, according to Austrian registry data presented at the annual meeting of the Society of Gynecologic Surgeons.

In 2003, transobturator tape became available for correction of stress urinary incontinence in Austria. In 2004, researchers established a registry to track complications and outcomes. They compared performance against retropubic tape data collected in a previous registry.

“Of the intraoperative problems reported to us, increased bleeding was the most common,” said Dr. Karl Tamussino, attending obstetrician and gynecologist at the Medical University of Graz (Austria).

Increased bleeding was reported with 3.5% of the 2,436 operations performed at 47 centers.

The surgeons in Austria used a variety of transobturator tape products, including the TVT-Obturator (Gynecare), Monarc (AMS), and Obtape (Mentor-Porges). A meeting attendee asked if there were any significant differences among products. “Bleeding was pretty much the same,” Dr. Tamussino replied.

Centers were asked to voluntarily complete a one-page, 15-item questionnaire with each procedure. “The registry is very simple. That is the key to amassing numbers,” said Dr. Tamussino, who presented the findings on behalf of the Austrian Urogynecology Working Group. Disclosures for the working group researchers include AMS, Contura, Lilly/Boehringer, and Gynecare.

Other intraoperative complications included 11 bladder perforations, 10 vaginal perforations, and 2 urethral perforations. “Bladder and urethral perforations were more common with systems inserted from the outside,” Dr. Tamussino said at the meeting, which was jointly sponsored by the American College of Surgeons.

A total of 51 patients had a tape-related reoperation. Voiding dysfunction was the most common reason; the tape was loosened or cut for 27 patients. An inability to void completely postoperatively “seems to be very similar to what is seen with conventional TVT [tension-free vaginal tape],” Dr. Tamussino said.

Vaginal tape erosions in nine patients required reoperations, as did a hematoma in one patient at 14 days postoperatively. In addition, seven patients experienced erosions and/or abscesses. Of these, four occurred with Obtape, which is no longer available in Austria, Dr. Tamussino said. The others occurred with the Monarc, TVT-Obturator, and intravaginal slingplasty systems.

“What we did not expect is these can occur months later,” he said.

A meeting attendee asked why erosion and abscesses were reported together. “There were 0.4% erosions alone, and we will separate these out in the [future] randomized trial,” Dr. Tamussino said.

Another unexpected postoperative complication was groin pain, with about a 1% incidence, Dr. Tamussino said.

“Unfortunately, we were not expecting the pain issue. We did not have this on the sheet, so we are probably underreporting.”

Vaginal erosions, abscesses, and pain may be more common with transobturator than retropubic tape procedures, the authors concluded. “Complications seem more related to the tape materials and not the technique,” Dr. Tamussino said.

“These are very important complication data on a very large number of procedures,” said study discussant Dr. R. Edward Varner of the department of obstetrics and gynecology at the University of Alabama, Birmingham. “Transobturator tapes seem to be relatively safe, especially in experienced hands.”

The registry was voluntary, a potential limitation, Dr. Tamussino said. “We just invited people to participate, we did not motivate them.” Dr. Varner agreed that the “reporting of data relies on patients with varying amounts of compulsiveness.”

BIRMINGHAM, ENGLAND — Metabolic changes in the basal ganglia that can be detected with magnetic resonance spectroscopy may precede irreversible changes from neuropsychiatric lupus, according to a pilot study.

“Why look at basal ganglia? They are highly prone to hypoxic damage and have recently been linked with the frontal lobe regarding cognitive function,” Dr. Pamela L. Peterson said at the annual meeting of the British Society for Rheumatology. In Parkinson disease “and other diseases, there is increasing recognition of the role of basal ganglia.”

There are at least four circuits that link the basal ganglia to the cerebral cortex. Although less common, movement disorders are a well-accepted complication of neuropsychiatric systemic lupus erythematosus (NPSLE) and may be mediated by the basal ganglia, said Dr. Peterson, a rheumatology fellow at St. George's Hospital, London.

Clinicians more commonly order MRIs to detect abnormalities in the periventricular region and subcortical white matter of patients with NPSLE. However, magnetic resonance spectroscopy of the basal ganglia might prove useful for earlier clinical intervention,

“Magnetic resonance spectroscopy is noninvasive, cheap, and easily added to an MRI protocol,” Dr. Peterson said.

Preliminary findings of the study are based on 24 patients with NPSLE, 8 patients with active lupus but without neurologic symptoms, and 4 healthy controls. Participants are recruited for the ongoing study from St. George's University of London; St. Thomas' Hospital, London; and University College London. The age range is 17–54 years.

Blood tests indicated absolute concentrations of N-acetylaspartate (NAA), choline, creatine, and myoinositol. The metabolite NAA is a marker for neuronal loss or dysfunction, Dr. Peterson said. Participants had an MRI, magnetic resonance spectroscopy, and diffusion tensor imaging, plus an interview, clinical assessment, and psychometric testing.

The researchers found a statistically significant correlation between decreases in NAA in the basal ganglia and frontal white matter. Also, levels were significantly lower in these regions, compared with healthy controls. “There was a step-wise deterioration in NAA with worsening neurologic effects,” Dr. Peterson said.

Participants with non-neuropsychiatric lupus also had decreases in the metabolite, but the reductions were not significantly different, compared with controls.

“This correlation may simply indicate a global reduction of NAA in patients with NPSLE or it may reflect abnormalities in the circuits connecting the frontal white matter with the basal ganglia,” the researchers noted. NPSLE may alter the cortical striatal fibers that connect basal ganglia and frontal lobe, Dr. Peterson added.

Although the pilot data from the study included only magnetic resonance spectroscopy findings, Dr. Peterson said changes in myoinositol in these two regions also appear to be correlated. In addition, initial psychometry results suggest “a possible relationship between NAA reduction in the basal ganglia and processing speed.”

“My results are tentative. This is a small data set,” Dr. Peterson said. “We want bigger numbers in the future.”

BIRMINGHAM, ENGLAND — Metabolic changes in the basal ganglia that can be detected with magnetic resonance spectroscopy may precede irreversible changes from neuropsychiatric lupus, according to a pilot study.

“Why look at basal ganglia? They are highly prone to hypoxic damage and have recently been linked with the frontal lobe regarding cognitive function,” Dr. Pamela L. Peterson said at the annual meeting of the British Society for Rheumatology. In Parkinson disease “and other diseases, there is increasing recognition of the role of basal ganglia.”

There are at least four circuits that link the basal ganglia to the cerebral cortex. Although less common, movement disorders are a well-accepted complication of neuropsychiatric systemic lupus erythematosus (NPSLE) and may be mediated by the basal ganglia, said Dr. Peterson, a rheumatology fellow at St. George's Hospital, London.

Clinicians more commonly order MRIs to detect abnormalities in the periventricular region and subcortical white matter of patients with NPSLE. However, magnetic resonance spectroscopy of the basal ganglia might prove useful for earlier clinical intervention,

“Magnetic resonance spectroscopy is noninvasive, cheap, and easily added to an MRI protocol,” Dr. Peterson said.

Preliminary findings of the study are based on 24 patients with NPSLE, 8 patients with active lupus but without neurologic symptoms, and 4 healthy controls. Participants are recruited for the ongoing study from St. George's University of London; St. Thomas' Hospital, London; and University College London. The age range is 17–54 years.

Blood tests indicated absolute concentrations of N-acetylaspartate (NAA), choline, creatine, and myoinositol. The metabolite NAA is a marker for neuronal loss or dysfunction, Dr. Peterson said. Participants had an MRI, magnetic resonance spectroscopy, and diffusion tensor imaging, plus an interview, clinical assessment, and psychometric testing.

The researchers found a statistically significant correlation between decreases in NAA in the basal ganglia and frontal white matter. Also, levels were significantly lower in these regions, compared with healthy controls. “There was a step-wise deterioration in NAA with worsening neurologic effects,” Dr. Peterson said.

Participants with non-neuropsychiatric lupus also had decreases in the metabolite, but the reductions were not significantly different, compared with controls.

“This correlation may simply indicate a global reduction of NAA in patients with NPSLE or it may reflect abnormalities in the circuits connecting the frontal white matter with the basal ganglia,” the researchers noted. NPSLE may alter the cortical striatal fibers that connect basal ganglia and frontal lobe, Dr. Peterson added.

Although the pilot data from the study included only magnetic resonance spectroscopy findings, Dr. Peterson said changes in myoinositol in these two regions also appear to be correlated. In addition, initial psychometry results suggest “a possible relationship between NAA reduction in the basal ganglia and processing speed.”

“My results are tentative. This is a small data set,” Dr. Peterson said. “We want bigger numbers in the future.”

BIRMINGHAM, ENGLAND — Metabolic changes in the basal ganglia that can be detected with magnetic resonance spectroscopy may precede irreversible changes from neuropsychiatric lupus, according to a pilot study.

“Why look at basal ganglia? They are highly prone to hypoxic damage and have recently been linked with the frontal lobe regarding cognitive function,” Dr. Pamela L. Peterson said at the annual meeting of the British Society for Rheumatology. In Parkinson disease “and other diseases, there is increasing recognition of the role of basal ganglia.”

There are at least four circuits that link the basal ganglia to the cerebral cortex. Although less common, movement disorders are a well-accepted complication of neuropsychiatric systemic lupus erythematosus (NPSLE) and may be mediated by the basal ganglia, said Dr. Peterson, a rheumatology fellow at St. George's Hospital, London.

Clinicians more commonly order MRIs to detect abnormalities in the periventricular region and subcortical white matter of patients with NPSLE. However, magnetic resonance spectroscopy of the basal ganglia might prove useful for earlier clinical intervention,

“Magnetic resonance spectroscopy is noninvasive, cheap, and easily added to an MRI protocol,” Dr. Peterson said.

Preliminary findings of the study are based on 24 patients with NPSLE, 8 patients with active lupus but without neurologic symptoms, and 4 healthy controls. Participants are recruited for the ongoing study from St. George's University of London; St. Thomas' Hospital, London; and University College London. The age range is 17–54 years.

Blood tests indicated absolute concentrations of N-acetylaspartate (NAA), choline, creatine, and myoinositol. The metabolite NAA is a marker for neuronal loss or dysfunction, Dr. Peterson said. Participants had an MRI, magnetic resonance spectroscopy, and diffusion tensor imaging, plus an interview, clinical assessment, and psychometric testing.

The researchers found a statistically significant correlation between decreases in NAA in the basal ganglia and frontal white matter. Also, levels were significantly lower in these regions, compared with healthy controls. “There was a step-wise deterioration in NAA with worsening neurologic effects,” Dr. Peterson said.

Participants with non-neuropsychiatric lupus also had decreases in the metabolite, but the reductions were not significantly different, compared with controls.

“This correlation may simply indicate a global reduction of NAA in patients with NPSLE or it may reflect abnormalities in the circuits connecting the frontal white matter with the basal ganglia,” the researchers noted. NPSLE may alter the cortical striatal fibers that connect basal ganglia and frontal lobe, Dr. Peterson added.

Although the pilot data from the study included only magnetic resonance spectroscopy findings, Dr. Peterson said changes in myoinositol in these two regions also appear to be correlated. In addition, initial psychometry results suggest “a possible relationship between NAA reduction in the basal ganglia and processing speed.”

“My results are tentative. This is a small data set,” Dr. Peterson said. “We want bigger numbers in the future.”

TORONTO — The presentation of vasculitis in a child may be complicated when the patient has coexisting strep A infection. Taking time to sniff carefully can lead to the correct diagnosis and treatment, Dr. Miriam Weinstein said at the annual conference of the Canadian Dermatology Association.

She described the case of an otherwise healthy 10-year-old boy who presents with an urticaria-like skin eruption of edematous plaques over his entire body and face. Each lesion persists for more than 24 hours and then resolves completely. He also has fever, abdominal pain, and vasculitis of the small to medium arteries. He has had 10 episodes, each lasting approximately 10 days, in the last 3 years. Differential diagnosis included leukocytoclastic vasculitis, but that condition is rare, with no clear reports in the literature. Poly-arteritis nodosa was another consideration, although this patient did not have the painful, tender nodules that are often associated with this condition.

The cutaneous form of poly-arteritis nodosa (cPAN) primarily affects the skin without systemic involvement such as vasculitis. Microscopic PAN (mPAN), in contrast, often affects small arteries and veins and can feature lung and kidney involvement. “These are different conditions, but they may be part of a spectrum—from mPAN to PAN,” said Dr. Weinstein, medical director of the pediatric dermatology fellowship program at the Hospital for Sick Children in Toronto.

A skin biopsy in this case indicated neutrophilic vasculitis with inflammation.

“Group A strep was cultured from his throat when I saw him on the tenth eruption,” Dr. Weinstein said. His throat swab findings were negative between episodes.

Determination of the precise diagnosis was challenging. “He had a recurrent strep infection. This case involved urticarial eruption, which is uncommon with strep. He also had some features consistent with mPAN … vasculitis of small to medium arteries,” Dr. Weinstein said.

The final diagnosis was group A β-hemolytic streptococci-induced mPAN with urticarial lesions.

Group A strep infection is often mistaken for Candida, irritant contact dermatitis, or seborrheic dermatitis. It is often treated but persists, Dr. Weinstein said. Frequently there is an odor with group A strep infection that is not present with Candida.

“Don't forget perianal strep. It is more common than reported and often missed,” she said. This usually affects patients younger than 10 years. If asked, these kids will have a history of painful bowel movements and perianal itch.

“Often the parents don't know about this. It is the first time it's asked,” Dr. Weinstein commented.

Both Candida and group A strep can induce psoriasis. Strep is a well-known inducer of psoriasis and psoriasislike conditions. Psoriasiform infectious disease features widespread, acute, well-demarcated, and erythematous plaques with scale. “There are no reports of this in the literature, but many pediatric dermatologists see this,” she said.

Throat swabs were negative between eruptions of a recurrent group A strep infection with vasculitis.

The child's recurrent group A streptococcus infection with vasculitis was diagnosed on histology findings (above). Photos courtesy Dr. Miriam Weinstein

TORONTO — The presentation of vasculitis in a child may be complicated when the patient has coexisting strep A infection. Taking time to sniff carefully can lead to the correct diagnosis and treatment, Dr. Miriam Weinstein said at the annual conference of the Canadian Dermatology Association.

She described the case of an otherwise healthy 10-year-old boy who presents with an urticaria-like skin eruption of edematous plaques over his entire body and face. Each lesion persists for more than 24 hours and then resolves completely. He also has fever, abdominal pain, and vasculitis of the small to medium arteries. He has had 10 episodes, each lasting approximately 10 days, in the last 3 years. Differential diagnosis included leukocytoclastic vasculitis, but that condition is rare, with no clear reports in the literature. Poly-arteritis nodosa was another consideration, although this patient did not have the painful, tender nodules that are often associated with this condition.

The cutaneous form of poly-arteritis nodosa (cPAN) primarily affects the skin without systemic involvement such as vasculitis. Microscopic PAN (mPAN), in contrast, often affects small arteries and veins and can feature lung and kidney involvement. “These are different conditions, but they may be part of a spectrum—from mPAN to PAN,” said Dr. Weinstein, medical director of the pediatric dermatology fellowship program at the Hospital for Sick Children in Toronto.

A skin biopsy in this case indicated neutrophilic vasculitis with inflammation.

“Group A strep was cultured from his throat when I saw him on the tenth eruption,” Dr. Weinstein said. His throat swab findings were negative between episodes.

Determination of the precise diagnosis was challenging. “He had a recurrent strep infection. This case involved urticarial eruption, which is uncommon with strep. He also had some features consistent with mPAN … vasculitis of small to medium arteries,” Dr. Weinstein said.

The final diagnosis was group A β-hemolytic streptococci-induced mPAN with urticarial lesions.

Group A strep infection is often mistaken for Candida, irritant contact dermatitis, or seborrheic dermatitis. It is often treated but persists, Dr. Weinstein said. Frequently there is an odor with group A strep infection that is not present with Candida.

“Don't forget perianal strep. It is more common than reported and often missed,” she said. This usually affects patients younger than 10 years. If asked, these kids will have a history of painful bowel movements and perianal itch.

“Often the parents don't know about this. It is the first time it's asked,” Dr. Weinstein commented.

Both Candida and group A strep can induce psoriasis. Strep is a well-known inducer of psoriasis and psoriasislike conditions. Psoriasiform infectious disease features widespread, acute, well-demarcated, and erythematous plaques with scale. “There are no reports of this in the literature, but many pediatric dermatologists see this,” she said.

Throat swabs were negative between eruptions of a recurrent group A strep infection with vasculitis.

The child's recurrent group A streptococcus infection with vasculitis was diagnosed on histology findings (above). Photos courtesy Dr. Miriam Weinstein

TORONTO — The presentation of vasculitis in a child may be complicated when the patient has coexisting strep A infection. Taking time to sniff carefully can lead to the correct diagnosis and treatment, Dr. Miriam Weinstein said at the annual conference of the Canadian Dermatology Association.

She described the case of an otherwise healthy 10-year-old boy who presents with an urticaria-like skin eruption of edematous plaques over his entire body and face. Each lesion persists for more than 24 hours and then resolves completely. He also has fever, abdominal pain, and vasculitis of the small to medium arteries. He has had 10 episodes, each lasting approximately 10 days, in the last 3 years. Differential diagnosis included leukocytoclastic vasculitis, but that condition is rare, with no clear reports in the literature. Poly-arteritis nodosa was another consideration, although this patient did not have the painful, tender nodules that are often associated with this condition.

The cutaneous form of poly-arteritis nodosa (cPAN) primarily affects the skin without systemic involvement such as vasculitis. Microscopic PAN (mPAN), in contrast, often affects small arteries and veins and can feature lung and kidney involvement. “These are different conditions, but they may be part of a spectrum—from mPAN to PAN,” said Dr. Weinstein, medical director of the pediatric dermatology fellowship program at the Hospital for Sick Children in Toronto.

A skin biopsy in this case indicated neutrophilic vasculitis with inflammation.

“Group A strep was cultured from his throat when I saw him on the tenth eruption,” Dr. Weinstein said. His throat swab findings were negative between episodes.

Determination of the precise diagnosis was challenging. “He had a recurrent strep infection. This case involved urticarial eruption, which is uncommon with strep. He also had some features consistent with mPAN … vasculitis of small to medium arteries,” Dr. Weinstein said.

The final diagnosis was group A β-hemolytic streptococci-induced mPAN with urticarial lesions.

Group A strep infection is often mistaken for Candida, irritant contact dermatitis, or seborrheic dermatitis. It is often treated but persists, Dr. Weinstein said. Frequently there is an odor with group A strep infection that is not present with Candida.

“Don't forget perianal strep. It is more common than reported and often missed,” she said. This usually affects patients younger than 10 years. If asked, these kids will have a history of painful bowel movements and perianal itch.

“Often the parents don't know about this. It is the first time it's asked,” Dr. Weinstein commented.

Both Candida and group A strep can induce psoriasis. Strep is a well-known inducer of psoriasis and psoriasislike conditions. Psoriasiform infectious disease features widespread, acute, well-demarcated, and erythematous plaques with scale. “There are no reports of this in the literature, but many pediatric dermatologists see this,” she said.

Throat swabs were negative between eruptions of a recurrent group A strep infection with vasculitis.

The child's recurrent group A streptococcus infection with vasculitis was diagnosed on histology findings (above). Photos courtesy Dr. Miriam Weinstein

BIRMINGHAM, ENGLAND — Pulsed cyclophosphamide is as effective as daily oral administration for patients with systemic vasculitis and is associated with fewer side effects, according to initial results of a study presented at the annual meeting of the British Society for Rheumatology.

Six previous randomized, controlled trials demonstrate the efficacy of cyclophosphamide for induction and maintenance of remission of generalized vasculitis in a majority of patients up to 6 months, Dr. David Carruthers said. However, the optimal dosing regimen remains unknown.

“A common question is: Does the route of cyclophosphamide administration make a difference?” said Dr. Carruthers, a consultant rheumatologist at City Hospital, Birmingham (England).

In unpublished data from the completed CYCLOPS (Daily Oral Versus Pulsed Cyclophosphamide for Renal Vasculitis) study, researchers compared remission rates at 3 and 6 months for 160 patients randomized to intermittent pulse therapy or daily oral therapy.

The rate of remission at 3 months was 70% in the pulse regimen group and 65% in the conventional daily oral regimen group. At 6 months, 92% of the pulse therapy group achieved remission, compared with 86% of the daily oral group.

“This seems to indicate pulse is as effective,” Dr. Carruthers explained. “There was no difference in patient survival either.”

The researchers found a higher rate of infection—including severe and life-threatening leukopenia—with continuous oral therapy, compared with pulse cyclophosphamide, Dr. Carruthers said. Pulse therapy has a potential for higher long-term remission rates, compared with daily therapy, “but that remains to be seen,” he said.

Cyclophosphamide appears to cause equal rates of induction of remission compared with methotrexate in other studies, Dr. Carruthers said, however, methotrexate remission takes longer to achieve.

In addition, there was a 70% relapse rate at 1 year with methotrexate, compared with 45% with continuous oral cyclophosphamide, among 100 participants in the NORAM (Methotrexate Versus Cyclophosphamide for “Early Systemic” Disease) study (Arthritis Rheum. 2005;52:2461-9). “Most relapses occurred when patients were off all therapy, including steroids,” Dr. Carruthers said.

Mean time to relapse was 13.5 months in the NORAM study. Dr. Carruthers said, “It does seem that prolonged therapy is necessary beyond 12 months.”

In response to a question from an audience member on the use of azathioprine for induction of remission, Dr. Carruthers said: “Cyclophosphamide use in a targeted manner is more predictable than use of azathioprine for induction of remission.”

Although Dr. Carruthers recommended cyclophosphamide as initial therapy, he said it might not be necessary for the maintenance phase. “It appears unnecessary to keep patients on cyclophosphamide once remission is achieved. They can be given azathioprine for up to 18 months.” For example, findings from the CYCAZERAM (Cyclophosphamide Versus Azathioprine as Remission Maintenance Therapy for ANCA [antineutrophil cytoplasmic antibody]-associated Vasculitis) study demonstrated no increase in relapse when azathioprine was substituted for cyclophosphamide after remission was achieved (N. Engl. J. Med. 2003;349:36-44).

“Tapering the dose of oral steroids is probably needed for all,” Dr. Carruthers said. “But it is not clear if steroid maintenance is needed after 18 months or not.” A meeting attendee asked if any randomized, controlled trial compared prednisone and cyclophosphamide for remission induction. “No,” Dr. Carruthers said. “The early studies were retrospective reviews. I don't think now we can ethically do studies where we put patients on steroids only versus cyclophosphamide.”

The British Society for Rheumatology, in conjunction with the British Health Professionals in Rheumatology, expects to release guidelines for the management of adults with ANCA-associated vasculitis soon, Dr. Carruthers said. The recommendations will be available on their Web site (www.rheumatology.org.ukwww.vasculitis.org

BIRMINGHAM, ENGLAND — Pulsed cyclophosphamide is as effective as daily oral administration for patients with systemic vasculitis and is associated with fewer side effects, according to initial results of a study presented at the annual meeting of the British Society for Rheumatology.

Six previous randomized, controlled trials demonstrate the efficacy of cyclophosphamide for induction and maintenance of remission of generalized vasculitis in a majority of patients up to 6 months, Dr. David Carruthers said. However, the optimal dosing regimen remains unknown.

“A common question is: Does the route of cyclophosphamide administration make a difference?” said Dr. Carruthers, a consultant rheumatologist at City Hospital, Birmingham (England).

In unpublished data from the completed CYCLOPS (Daily Oral Versus Pulsed Cyclophosphamide for Renal Vasculitis) study, researchers compared remission rates at 3 and 6 months for 160 patients randomized to intermittent pulse therapy or daily oral therapy.

The rate of remission at 3 months was 70% in the pulse regimen group and 65% in the conventional daily oral regimen group. At 6 months, 92% of the pulse therapy group achieved remission, compared with 86% of the daily oral group.

“This seems to indicate pulse is as effective,” Dr. Carruthers explained. “There was no difference in patient survival either.”

The researchers found a higher rate of infection—including severe and life-threatening leukopenia—with continuous oral therapy, compared with pulse cyclophosphamide, Dr. Carruthers said. Pulse therapy has a potential for higher long-term remission rates, compared with daily therapy, “but that remains to be seen,” he said.

Cyclophosphamide appears to cause equal rates of induction of remission compared with methotrexate in other studies, Dr. Carruthers said, however, methotrexate remission takes longer to achieve.

In addition, there was a 70% relapse rate at 1 year with methotrexate, compared with 45% with continuous oral cyclophosphamide, among 100 participants in the NORAM (Methotrexate Versus Cyclophosphamide for “Early Systemic” Disease) study (Arthritis Rheum. 2005;52:2461-9). “Most relapses occurred when patients were off all therapy, including steroids,” Dr. Carruthers said.

Mean time to relapse was 13.5 months in the NORAM study. Dr. Carruthers said, “It does seem that prolonged therapy is necessary beyond 12 months.”

In response to a question from an audience member on the use of azathioprine for induction of remission, Dr. Carruthers said: “Cyclophosphamide use in a targeted manner is more predictable than use of azathioprine for induction of remission.”

Although Dr. Carruthers recommended cyclophosphamide as initial therapy, he said it might not be necessary for the maintenance phase. “It appears unnecessary to keep patients on cyclophosphamide once remission is achieved. They can be given azathioprine for up to 18 months.” For example, findings from the CYCAZERAM (Cyclophosphamide Versus Azathioprine as Remission Maintenance Therapy for ANCA [antineutrophil cytoplasmic antibody]-associated Vasculitis) study demonstrated no increase in relapse when azathioprine was substituted for cyclophosphamide after remission was achieved (N. Engl. J. Med. 2003;349:36-44).

“Tapering the dose of oral steroids is probably needed for all,” Dr. Carruthers said. “But it is not clear if steroid maintenance is needed after 18 months or not.” A meeting attendee asked if any randomized, controlled trial compared prednisone and cyclophosphamide for remission induction. “No,” Dr. Carruthers said. “The early studies were retrospective reviews. I don't think now we can ethically do studies where we put patients on steroids only versus cyclophosphamide.”

The British Society for Rheumatology, in conjunction with the British Health Professionals in Rheumatology, expects to release guidelines for the management of adults with ANCA-associated vasculitis soon, Dr. Carruthers said. The recommendations will be available on their Web site (www.rheumatology.org.ukwww.vasculitis.org

BIRMINGHAM, ENGLAND — Pulsed cyclophosphamide is as effective as daily oral administration for patients with systemic vasculitis and is associated with fewer side effects, according to initial results of a study presented at the annual meeting of the British Society for Rheumatology.

Six previous randomized, controlled trials demonstrate the efficacy of cyclophosphamide for induction and maintenance of remission of generalized vasculitis in a majority of patients up to 6 months, Dr. David Carruthers said. However, the optimal dosing regimen remains unknown.

“A common question is: Does the route of cyclophosphamide administration make a difference?” said Dr. Carruthers, a consultant rheumatologist at City Hospital, Birmingham (England).

In unpublished data from the completed CYCLOPS (Daily Oral Versus Pulsed Cyclophosphamide for Renal Vasculitis) study, researchers compared remission rates at 3 and 6 months for 160 patients randomized to intermittent pulse therapy or daily oral therapy.

The rate of remission at 3 months was 70% in the pulse regimen group and 65% in the conventional daily oral regimen group. At 6 months, 92% of the pulse therapy group achieved remission, compared with 86% of the daily oral group.

“This seems to indicate pulse is as effective,” Dr. Carruthers explained. “There was no difference in patient survival either.”

The researchers found a higher rate of infection—including severe and life-threatening leukopenia—with continuous oral therapy, compared with pulse cyclophosphamide, Dr. Carruthers said. Pulse therapy has a potential for higher long-term remission rates, compared with daily therapy, “but that remains to be seen,” he said.

Cyclophosphamide appears to cause equal rates of induction of remission compared with methotrexate in other studies, Dr. Carruthers said, however, methotrexate remission takes longer to achieve.

In addition, there was a 70% relapse rate at 1 year with methotrexate, compared with 45% with continuous oral cyclophosphamide, among 100 participants in the NORAM (Methotrexate Versus Cyclophosphamide for “Early Systemic” Disease) study (Arthritis Rheum. 2005;52:2461-9). “Most relapses occurred when patients were off all therapy, including steroids,” Dr. Carruthers said.

Mean time to relapse was 13.5 months in the NORAM study. Dr. Carruthers said, “It does seem that prolonged therapy is necessary beyond 12 months.”

In response to a question from an audience member on the use of azathioprine for induction of remission, Dr. Carruthers said: “Cyclophosphamide use in a targeted manner is more predictable than use of azathioprine for induction of remission.”

Although Dr. Carruthers recommended cyclophosphamide as initial therapy, he said it might not be necessary for the maintenance phase. “It appears unnecessary to keep patients on cyclophosphamide once remission is achieved. They can be given azathioprine for up to 18 months.” For example, findings from the CYCAZERAM (Cyclophosphamide Versus Azathioprine as Remission Maintenance Therapy for ANCA [antineutrophil cytoplasmic antibody]-associated Vasculitis) study demonstrated no increase in relapse when azathioprine was substituted for cyclophosphamide after remission was achieved (N. Engl. J. Med. 2003;349:36-44).

“Tapering the dose of oral steroids is probably needed for all,” Dr. Carruthers said. “But it is not clear if steroid maintenance is needed after 18 months or not.” A meeting attendee asked if any randomized, controlled trial compared prednisone and cyclophosphamide for remission induction. “No,” Dr. Carruthers said. “The early studies were retrospective reviews. I don't think now we can ethically do studies where we put patients on steroids only versus cyclophosphamide.”

The British Society for Rheumatology, in conjunction with the British Health Professionals in Rheumatology, expects to release guidelines for the management of adults with ANCA-associated vasculitis soon, Dr. Carruthers said. The recommendations will be available on their Web site (www.rheumatology.org.ukwww.vasculitis.org

MIAMI — Intervene to prevent marijuana use in children as young as 8 years, a National Institute on Drug Abuse researcher suggested at the annual conference of the American Society for Addiction Medicine.

“Addiction is a developmental disease—it starts in adolescence and childhood with tobacco, THC [tetrahydrocannabinol], and alcohol,” Jag H. Khalsa, Ph.D., said.

Physicians first can help children and their parents overcome the common misperception that marijuana carries much lower health risks, compared with other substances, Dr. Khalsa said. “Young people think this drug is innocuous and does not do much harm. Drug use goes up with this perception and down with the perception that it is dangerous.”

Almost 20% of high school seniors smoke marijuana. Overall, 15 million Americans 12 years and older have used marijuana at least once in their lifetime, and there are 2–3 million new users each year, said Dr. Khalsa. He is chief of the medical consequences branch, division of pharmacotherapies and medical consequences of drug abuse, National Institute on Drug Abuse, Bethesda, Md.“Marijuana continues to remain the third most commonly used drug mentioned in the ER—so the consequences are significant,” Dr. Khalsa said.

Among the most important adverse effects of marijuana use are the cognitive effects: impairment in cognition, short-term memory loss, and executive dysfunction. These deficits can be dose related and can persist up to 15 days, according to a NIDA-funded study (Neurology 2002;59:1337-43). College students who abused marijuana showed impairment in cognitive function and ability to remember simple tasks at baseline. Effects were still observed after 7 days and 15 days of abstinence, but deficits were no longer seen at day 28. “This suggests people recovered from the chronic effects of marijuana.”

Chronic marijuana use also may be associated with major depression, attention-deficit/hyperactivity disorder, and aggressive behaviors in drug-dependent adolescents. Acute increases in heart rate, increased blood pressure, and cardiac output alterations are among the cardiovascular effects. Endocrine effects in humans include lower testosterone levels, decreased luteinizing hormone levels, infertility, and gynecomastia. “There are inconsistent reports, however, in the literature” regarding endocrine alterations, Dr. Khalsa said.

In addition, the immune effects are significant, he said. THC suppresses macro-phages, natural killer cells, and T lymphocytes, mediated through CB2 receptors on leukocytes. “Suppression of antitumor activity makes a person more susceptible to cancer. Squamous cell carcinomas have been reported in the mouths of marijuana users,” he noted.

Marijuana smoke contains approximately 50% more carcinogenic compounds than tobacco smoke. However, “sometimes it is difficult to tease out effects between the people who smoke both tobacco and marijuana over the long term,” Dr. Khalsa said.

THC also can cause modest short-term bronchodilation. In addition, regular marijuana smoking leads to chronic cough and increased sputum production, he said.

For more information on the clinical effects of marijuana and research developments, visit www.nida.nih.gov

MIAMI — Intervene to prevent marijuana use in children as young as 8 years, a National Institute on Drug Abuse researcher suggested at the annual conference of the American Society for Addiction Medicine.

“Addiction is a developmental disease—it starts in adolescence and childhood with tobacco, THC [tetrahydrocannabinol], and alcohol,” Jag H. Khalsa, Ph.D., said.

Physicians first can help children and their parents overcome the common misperception that marijuana carries much lower health risks, compared with other substances, Dr. Khalsa said. “Young people think this drug is innocuous and does not do much harm. Drug use goes up with this perception and down with the perception that it is dangerous.”

Almost 20% of high school seniors smoke marijuana. Overall, 15 million Americans 12 years and older have used marijuana at least once in their lifetime, and there are 2–3 million new users each year, said Dr. Khalsa. He is chief of the medical consequences branch, division of pharmacotherapies and medical consequences of drug abuse, National Institute on Drug Abuse, Bethesda, Md.“Marijuana continues to remain the third most commonly used drug mentioned in the ER—so the consequences are significant,” Dr. Khalsa said.

Among the most important adverse effects of marijuana use are the cognitive effects: impairment in cognition, short-term memory loss, and executive dysfunction. These deficits can be dose related and can persist up to 15 days, according to a NIDA-funded study (Neurology 2002;59:1337-43). College students who abused marijuana showed impairment in cognitive function and ability to remember simple tasks at baseline. Effects were still observed after 7 days and 15 days of abstinence, but deficits were no longer seen at day 28. “This suggests people recovered from the chronic effects of marijuana.”

Chronic marijuana use also may be associated with major depression, attention-deficit/hyperactivity disorder, and aggressive behaviors in drug-dependent adolescents. Acute increases in heart rate, increased blood pressure, and cardiac output alterations are among the cardiovascular effects. Endocrine effects in humans include lower testosterone levels, decreased luteinizing hormone levels, infertility, and gynecomastia. “There are inconsistent reports, however, in the literature” regarding endocrine alterations, Dr. Khalsa said.

In addition, the immune effects are significant, he said. THC suppresses macro-phages, natural killer cells, and T lymphocytes, mediated through CB2 receptors on leukocytes. “Suppression of antitumor activity makes a person more susceptible to cancer. Squamous cell carcinomas have been reported in the mouths of marijuana users,” he noted.

Marijuana smoke contains approximately 50% more carcinogenic compounds than tobacco smoke. However, “sometimes it is difficult to tease out effects between the people who smoke both tobacco and marijuana over the long term,” Dr. Khalsa said.

THC also can cause modest short-term bronchodilation. In addition, regular marijuana smoking leads to chronic cough and increased sputum production, he said.

For more information on the clinical effects of marijuana and research developments, visit www.nida.nih.gov

MIAMI — Intervene to prevent marijuana use in children as young as 8 years, a National Institute on Drug Abuse researcher suggested at the annual conference of the American Society for Addiction Medicine.

“Addiction is a developmental disease—it starts in adolescence and childhood with tobacco, THC [tetrahydrocannabinol], and alcohol,” Jag H. Khalsa, Ph.D., said.

Physicians first can help children and their parents overcome the common misperception that marijuana carries much lower health risks, compared with other substances, Dr. Khalsa said. “Young people think this drug is innocuous and does not do much harm. Drug use goes up with this perception and down with the perception that it is dangerous.”

Almost 20% of high school seniors smoke marijuana. Overall, 15 million Americans 12 years and older have used marijuana at least once in their lifetime, and there are 2–3 million new users each year, said Dr. Khalsa. He is chief of the medical consequences branch, division of pharmacotherapies and medical consequences of drug abuse, National Institute on Drug Abuse, Bethesda, Md.“Marijuana continues to remain the third most commonly used drug mentioned in the ER—so the consequences are significant,” Dr. Khalsa said.

Among the most important adverse effects of marijuana use are the cognitive effects: impairment in cognition, short-term memory loss, and executive dysfunction. These deficits can be dose related and can persist up to 15 days, according to a NIDA-funded study (Neurology 2002;59:1337-43). College students who abused marijuana showed impairment in cognitive function and ability to remember simple tasks at baseline. Effects were still observed after 7 days and 15 days of abstinence, but deficits were no longer seen at day 28. “This suggests people recovered from the chronic effects of marijuana.”

Chronic marijuana use also may be associated with major depression, attention-deficit/hyperactivity disorder, and aggressive behaviors in drug-dependent adolescents. Acute increases in heart rate, increased blood pressure, and cardiac output alterations are among the cardiovascular effects. Endocrine effects in humans include lower testosterone levels, decreased luteinizing hormone levels, infertility, and gynecomastia. “There are inconsistent reports, however, in the literature” regarding endocrine alterations, Dr. Khalsa said.

In addition, the immune effects are significant, he said. THC suppresses macro-phages, natural killer cells, and T lymphocytes, mediated through CB2 receptors on leukocytes. “Suppression of antitumor activity makes a person more susceptible to cancer. Squamous cell carcinomas have been reported in the mouths of marijuana users,” he noted.

Marijuana smoke contains approximately 50% more carcinogenic compounds than tobacco smoke. However, “sometimes it is difficult to tease out effects between the people who smoke both tobacco and marijuana over the long term,” Dr. Khalsa said.

THC also can cause modest short-term bronchodilation. In addition, regular marijuana smoking leads to chronic cough and increased sputum production, he said.

For more information on the clinical effects of marijuana and research developments, visit www.nida.nih.gov

MIAMI – Women with problematic substance use during pregnancy prefer integrated treatment over separate obstetric and substance use care, according to a presentation at the annual conference of the American Society of Addiction Medicine.

The investigators found that women attending one of two integrated programs reported feeling less stigmatization about their substance abuse. They also liked the care they received from consistent providers. In contrast, those who received isolated substance abuse treatment at a traditional center and obstetric care at a general hospital reported harsh and punitive treatment from hospital staff that made them feel marginalized, Dr. Lisa G. Lefebvre said during an interview at a poster session.

“Patients tour the maternity ward in advance, and everyone on the staff is trained to be sensitive to their substance use,” said Dr. Lefebvre, who is an addiction medicine consultant with the department of family and community medicine, University of Toronto. “The women like this [integrated] model,” she said. “They have one doctor who treats pregnancy and everything you'd do for addiction.”

In 2005, researchers used focus groups in Toronto to assess satisfaction among women attending one of two integrated programs–the Toronto Center for Substance Use in Pregnancy or the Herzl Family Practice Centre. Transcripts of these sessions were coded for recurring themes.

The researchers compared the subjects' satisfaction with that of women recruited from the obstetrics department at a general hospital in 1995. Women in the latter group also attended a community substance use treatment center.

Women who attended separate programs were less likely to report a good birth experience. “Is it possible that the stigma of substance use was worse in 1995? “Even in 2005, when they ended up in another facility, they felt stigma,” she said.

MIAMI – Women with problematic substance use during pregnancy prefer integrated treatment over separate obstetric and substance use care, according to a presentation at the annual conference of the American Society of Addiction Medicine.

The investigators found that women attending one of two integrated programs reported feeling less stigmatization about their substance abuse. They also liked the care they received from consistent providers. In contrast, those who received isolated substance abuse treatment at a traditional center and obstetric care at a general hospital reported harsh and punitive treatment from hospital staff that made them feel marginalized, Dr. Lisa G. Lefebvre said during an interview at a poster session.

“Patients tour the maternity ward in advance, and everyone on the staff is trained to be sensitive to their substance use,” said Dr. Lefebvre, who is an addiction medicine consultant with the department of family and community medicine, University of Toronto. “The women like this [integrated] model,” she said. “They have one doctor who treats pregnancy and everything you'd do for addiction.”

In 2005, researchers used focus groups in Toronto to assess satisfaction among women attending one of two integrated programs–the Toronto Center for Substance Use in Pregnancy or the Herzl Family Practice Centre. Transcripts of these sessions were coded for recurring themes.

The researchers compared the subjects' satisfaction with that of women recruited from the obstetrics department at a general hospital in 1995. Women in the latter group also attended a community substance use treatment center.

Women who attended separate programs were less likely to report a good birth experience. “Is it possible that the stigma of substance use was worse in 1995? “Even in 2005, when they ended up in another facility, they felt stigma,” she said.

MIAMI – Women with problematic substance use during pregnancy prefer integrated treatment over separate obstetric and substance use care, according to a presentation at the annual conference of the American Society of Addiction Medicine.

The investigators found that women attending one of two integrated programs reported feeling less stigmatization about their substance abuse. They also liked the care they received from consistent providers. In contrast, those who received isolated substance abuse treatment at a traditional center and obstetric care at a general hospital reported harsh and punitive treatment from hospital staff that made them feel marginalized, Dr. Lisa G. Lefebvre said during an interview at a poster session.

“Patients tour the maternity ward in advance, and everyone on the staff is trained to be sensitive to their substance use,” said Dr. Lefebvre, who is an addiction medicine consultant with the department of family and community medicine, University of Toronto. “The women like this [integrated] model,” she said. “They have one doctor who treats pregnancy and everything you'd do for addiction.”

In 2005, researchers used focus groups in Toronto to assess satisfaction among women attending one of two integrated programs–the Toronto Center for Substance Use in Pregnancy or the Herzl Family Practice Centre. Transcripts of these sessions were coded for recurring themes.

The researchers compared the subjects' satisfaction with that of women recruited from the obstetrics department at a general hospital in 1995. Women in the latter group also attended a community substance use treatment center.

Women who attended separate programs were less likely to report a good birth experience. “Is it possible that the stigma of substance use was worse in 1995? “Even in 2005, when they ended up in another facility, they felt stigma,” she said.

MIAMI – Limited access and availability of behavioral therapies aimed at helping cannabis-dependent patients support the search for effective pharmacologic treatments, Dr. Ahmed M. Elkashef said at the annual conference of the American Society of Addiction Medicine.

“We will have better outcomes once we have medications available,” Dr. Elkashef said. Several agents are in development and might be best used in combination with behavioral therapies. In the meantime, varying degrees of success are reported with off-label use of existing medications, said Dr. Elkashef, chief of clinical trials at the division of pharmacotherapies and medical consequences of drug abuse, National Institute on Drug Abuse, Rockville, Md.

For example, a pilot study of buspirone showed nearly a 50% decrease in marijuana use, as well as subjective reports of improvement, after 12 weeks, compared with baseline (Am. J. Addict. 2006;15:404). Investigators did a larger follow-up study and found “buspirone gave a significant reduction in positive urines, so it's promising,” Dr. Elkashef said.

A secondary analysis of a fluoxetine (Prozac) study included 22 depressed, alcoholic, marijuana users (Addict. Behav. 1999;24:111–4). Participants took 20–40 mg fluoxetine daily or placebo for 12 weeks. “The Prozac group had about 20 times less marijuana cigarettes smoked versus placebo,” Dr. Elkashef said. “Now a larger study is funded by NIDA.”

Early indications for a drug in development for weight loss, rimonabant (Zimulti), show possible efficacy blocking the “high” of smoked cannabis as well, Dr. Elkashef said.

“You may want to think about it like naltrexone for alcohol abuse when it gets to the market.” (Sanofi Aventis, maker of Zimulti, withdrew its application for the drug after a Food and Drug Administration panel voted against recommending it for approval because of concerns about the drug's psychiatric and neurologic side effects.)

Researchers assessing naltrexone for cannabis dependence found that 50 mg increased the toxic effects of tetrahydrocannabinol (THC), the primary active component of marijuana. “So we don't think this will be useful as a treatment,” according to Dr. Elkashef.

Subsequently, however, researchers found that 12 mg naltrexone did not potentiate the intoxicating effect of THC.

“It is the heavy users who tend to benefit,” he added. “All we can say about naltrexone at this point is, avoid the 50 mg and use 12 mg.

“Ask patients about patterns of use, and if they are heavy users, naltrexone might be useful for them.”

Bupropion SR for marijuana withdrawal made participants feel worse in another study, Dr. Elkashef said. Individuals reported increased irritability, restlessness, and depression, as well as difficulty with sleeping (Psychopharmacology [Berl.] 2001;155:171–9).

“Apparently, you don't want to use anything that is a stimulant during withdrawal from marijuana.”

In another study, nefazodone (Serzone) improved marijuana withdrawal anxiety and muscle pain, but did not improve other symptoms; patients were “irritable,” “miserable,” or had decreased sleep quality (Psychopharmacology [Berl.] 2003;165:157–65).

Other researchers found divalproex (Depakote) actually worsened mood and cognitive performance during marijuana abstinence (Neuropsychopharmacology 2004;29:158–70).

Regarding the future, selegiline (Emsam), corticotrophin-releasing hormone antagonists, citicoline, clozapine (Clozaril), risperidone (Risperdal), and lofexidine (Britlofex) are among the agents currently being studied with NIDA funding.

Researchers hope these agents will provide greater efficacy to reduce marijuana use or ease symptoms of withdrawal among heavy users.

MIAMI – Limited access and availability of behavioral therapies aimed at helping cannabis-dependent patients support the search for effective pharmacologic treatments, Dr. Ahmed M. Elkashef said at the annual conference of the American Society of Addiction Medicine.

“We will have better outcomes once we have medications available,” Dr. Elkashef said. Several agents are in development and might be best used in combination with behavioral therapies. In the meantime, varying degrees of success are reported with off-label use of existing medications, said Dr. Elkashef, chief of clinical trials at the division of pharmacotherapies and medical consequences of drug abuse, National Institute on Drug Abuse, Rockville, Md.

For example, a pilot study of buspirone showed nearly a 50% decrease in marijuana use, as well as subjective reports of improvement, after 12 weeks, compared with baseline (Am. J. Addict. 2006;15:404). Investigators did a larger follow-up study and found “buspirone gave a significant reduction in positive urines, so it's promising,” Dr. Elkashef said.

A secondary analysis of a fluoxetine (Prozac) study included 22 depressed, alcoholic, marijuana users (Addict. Behav. 1999;24:111–4). Participants took 20–40 mg fluoxetine daily or placebo for 12 weeks. “The Prozac group had about 20 times less marijuana cigarettes smoked versus placebo,” Dr. Elkashef said. “Now a larger study is funded by NIDA.”

Early indications for a drug in development for weight loss, rimonabant (Zimulti), show possible efficacy blocking the “high” of smoked cannabis as well, Dr. Elkashef said.

“You may want to think about it like naltrexone for alcohol abuse when it gets to the market.” (Sanofi Aventis, maker of Zimulti, withdrew its application for the drug after a Food and Drug Administration panel voted against recommending it for approval because of concerns about the drug's psychiatric and neurologic side effects.)

Researchers assessing naltrexone for cannabis dependence found that 50 mg increased the toxic effects of tetrahydrocannabinol (THC), the primary active component of marijuana. “So we don't think this will be useful as a treatment,” according to Dr. Elkashef.

Subsequently, however, researchers found that 12 mg naltrexone did not potentiate the intoxicating effect of THC.

“It is the heavy users who tend to benefit,” he added. “All we can say about naltrexone at this point is, avoid the 50 mg and use 12 mg.

“Ask patients about patterns of use, and if they are heavy users, naltrexone might be useful for them.”

Bupropion SR for marijuana withdrawal made participants feel worse in another study, Dr. Elkashef said. Individuals reported increased irritability, restlessness, and depression, as well as difficulty with sleeping (Psychopharmacology [Berl.] 2001;155:171–9).

“Apparently, you don't want to use anything that is a stimulant during withdrawal from marijuana.”

In another study, nefazodone (Serzone) improved marijuana withdrawal anxiety and muscle pain, but did not improve other symptoms; patients were “irritable,” “miserable,” or had decreased sleep quality (Psychopharmacology [Berl.] 2003;165:157–65).

Other researchers found divalproex (Depakote) actually worsened mood and cognitive performance during marijuana abstinence (Neuropsychopharmacology 2004;29:158–70).

Regarding the future, selegiline (Emsam), corticotrophin-releasing hormone antagonists, citicoline, clozapine (Clozaril), risperidone (Risperdal), and lofexidine (Britlofex) are among the agents currently being studied with NIDA funding.

Researchers hope these agents will provide greater efficacy to reduce marijuana use or ease symptoms of withdrawal among heavy users.

MIAMI – Limited access and availability of behavioral therapies aimed at helping cannabis-dependent patients support the search for effective pharmacologic treatments, Dr. Ahmed M. Elkashef said at the annual conference of the American Society of Addiction Medicine.

“We will have better outcomes once we have medications available,” Dr. Elkashef said. Several agents are in development and might be best used in combination with behavioral therapies. In the meantime, varying degrees of success are reported with off-label use of existing medications, said Dr. Elkashef, chief of clinical trials at the division of pharmacotherapies and medical consequences of drug abuse, National Institute on Drug Abuse, Rockville, Md.

For example, a pilot study of buspirone showed nearly a 50% decrease in marijuana use, as well as subjective reports of improvement, after 12 weeks, compared with baseline (Am. J. Addict. 2006;15:404). Investigators did a larger follow-up study and found “buspirone gave a significant reduction in positive urines, so it's promising,” Dr. Elkashef said.

A secondary analysis of a fluoxetine (Prozac) study included 22 depressed, alcoholic, marijuana users (Addict. Behav. 1999;24:111–4). Participants took 20–40 mg fluoxetine daily or placebo for 12 weeks. “The Prozac group had about 20 times less marijuana cigarettes smoked versus placebo,” Dr. Elkashef said. “Now a larger study is funded by NIDA.”

Early indications for a drug in development for weight loss, rimonabant (Zimulti), show possible efficacy blocking the “high” of smoked cannabis as well, Dr. Elkashef said.

“You may want to think about it like naltrexone for alcohol abuse when it gets to the market.” (Sanofi Aventis, maker of Zimulti, withdrew its application for the drug after a Food and Drug Administration panel voted against recommending it for approval because of concerns about the drug's psychiatric and neurologic side effects.)

Researchers assessing naltrexone for cannabis dependence found that 50 mg increased the toxic effects of tetrahydrocannabinol (THC), the primary active component of marijuana. “So we don't think this will be useful as a treatment,” according to Dr. Elkashef.

Subsequently, however, researchers found that 12 mg naltrexone did not potentiate the intoxicating effect of THC.

“It is the heavy users who tend to benefit,” he added. “All we can say about naltrexone at this point is, avoid the 50 mg and use 12 mg.

“Ask patients about patterns of use, and if they are heavy users, naltrexone might be useful for them.”

Bupropion SR for marijuana withdrawal made participants feel worse in another study, Dr. Elkashef said. Individuals reported increased irritability, restlessness, and depression, as well as difficulty with sleeping (Psychopharmacology [Berl.] 2001;155:171–9).

“Apparently, you don't want to use anything that is a stimulant during withdrawal from marijuana.”

In another study, nefazodone (Serzone) improved marijuana withdrawal anxiety and muscle pain, but did not improve other symptoms; patients were “irritable,” “miserable,” or had decreased sleep quality (Psychopharmacology [Berl.] 2003;165:157–65).

Other researchers found divalproex (Depakote) actually worsened mood and cognitive performance during marijuana abstinence (Neuropsychopharmacology 2004;29:158–70).

Regarding the future, selegiline (Emsam), corticotrophin-releasing hormone antagonists, citicoline, clozapine (Clozaril), risperidone (Risperdal), and lofexidine (Britlofex) are among the agents currently being studied with NIDA funding.

Researchers hope these agents will provide greater efficacy to reduce marijuana use or ease symptoms of withdrawal among heavy users.

Diagnosis:Recurrent Group A Streptococcus Infection With Vasculitis

TORONTO — The differential diagnosis included leukocytoclastic vasculitis, but that condition is rare, with no clear reports in the literature. Polyarteritis nodosa was also considered, although this patient did not have the painful, tender nodules that are often associated with this condition.

The cutaneous form of polyarteritis nodosa (cPAN) primarily affects the skin without systemic involvement such as vasculitis. Microscopic PAN (mPAN), in contrast, often affects small arteries and veins and can feature lung and kidney involvement. "These are different conditions, but they may be part of a spectrum—from mPAN to PAN," Dr. Miriam Weinstein said at the annual conference of the Canadian Dermatology Association.

A skin biopsy in this case indicated neutrophilic vasculitis with inflammation.

"Group A strep was cultured from his throat when I saw him on the tenth eruption," Dr. Weinstein said. His throat swab findings were negative between episodes.

Can group A strep be seen with vasculitis? "The answer is 'yes'," said Dr. Wein-stein, medical director of the pediatric dermatology fellowship program at the Hospital for Sick Children in Toronto.

Of the different PAN subtypes, cPAN is the only one consistently linked with group A streptococci infection in the literature (Int. J. Dermatol. 1998;37:664-6; Arch. Dis. Child. 1996;74:367; and Ann. Rheum. Dis. 1995;54:134-6).

Determination of the precise diagnosis was challenging. "He had a recurrent strep infection. This case involved urticarial eruption, which is uncommon with strep. He also had some features consistent with mPAN … vasculitis of small to medium arteries," Dr. Weinstein said.

The final diagnosis was group A β-hemolytic streptococci-induced mPAN with urticarial lesions.

Recurrent strep infections also can affect younger children, although the presentation can differ. "If you see persistent erythematous folds, particularly in infants and babies, think group A strep and swab," she suggested.

Group A strep infection is often mistaken for Candida, irritant contact dermatitis, or seborrheic dermatitis. It is often treated but persists, Dr. Weinstein said. Frequently there is an odor with group A strep infection that is not present with Candida. "Don't forget perianal strep. It is more common than reported and often missed," she said. This usually affects patients younger than 10 years. If asked, these kids will have a history of painful bowel movements and perianal itch. "Often the parents don't know about this. It is the first time it's asked," she noted.

Both Candida and group A strep can induce psoriasis. Psoriasiform infectious disease features widespread, acute, well-demarcated, and erythematous plaques with scale. "There are no reports of this in the literature, but many pediatric dermatologists see this," Dr. Weinstein said.

The child had an occurrence of urticarial eruptions, which is uncommon with strep. Courtesy Dr. Miriam Weinstein

Diagnosis:Recurrent Group A Streptococcus Infection With Vasculitis

TORONTO — The differential diagnosis included leukocytoclastic vasculitis, but that condition is rare, with no clear reports in the literature. Polyarteritis nodosa was also considered, although this patient did not have the painful, tender nodules that are often associated with this condition.

The cutaneous form of polyarteritis nodosa (cPAN) primarily affects the skin without systemic involvement such as vasculitis. Microscopic PAN (mPAN), in contrast, often affects small arteries and veins and can feature lung and kidney involvement. "These are different conditions, but they may be part of a spectrum—from mPAN to PAN," Dr. Miriam Weinstein said at the annual conference of the Canadian Dermatology Association.

A skin biopsy in this case indicated neutrophilic vasculitis with inflammation.

"Group A strep was cultured from his throat when I saw him on the tenth eruption," Dr. Weinstein said. His throat swab findings were negative between episodes.

Can group A strep be seen with vasculitis? "The answer is 'yes'," said Dr. Wein-stein, medical director of the pediatric dermatology fellowship program at the Hospital for Sick Children in Toronto.

Of the different PAN subtypes, cPAN is the only one consistently linked with group A streptococci infection in the literature (Int. J. Dermatol. 1998;37:664-6; Arch. Dis. Child. 1996;74:367; and Ann. Rheum. Dis. 1995;54:134-6).

Determination of the precise diagnosis was challenging. "He had a recurrent strep infection. This case involved urticarial eruption, which is uncommon with strep. He also had some features consistent with mPAN … vasculitis of small to medium arteries," Dr. Weinstein said.

The final diagnosis was group A β-hemolytic streptococci-induced mPAN with urticarial lesions.

Recurrent strep infections also can affect younger children, although the presentation can differ. "If you see persistent erythematous folds, particularly in infants and babies, think group A strep and swab," she suggested.

Group A strep infection is often mistaken for Candida, irritant contact dermatitis, or seborrheic dermatitis. It is often treated but persists, Dr. Weinstein said. Frequently there is an odor with group A strep infection that is not present with Candida. "Don't forget perianal strep. It is more common than reported and often missed," she said. This usually affects patients younger than 10 years. If asked, these kids will have a history of painful bowel movements and perianal itch. "Often the parents don't know about this. It is the first time it's asked," she noted.

Both Candida and group A strep can induce psoriasis. Psoriasiform infectious disease features widespread, acute, well-demarcated, and erythematous plaques with scale. "There are no reports of this in the literature, but many pediatric dermatologists see this," Dr. Weinstein said.

The child had an occurrence of urticarial eruptions, which is uncommon with strep. Courtesy Dr. Miriam Weinstein

Diagnosis:Recurrent Group A Streptococcus Infection With Vasculitis

TORONTO — The differential diagnosis included leukocytoclastic vasculitis, but that condition is rare, with no clear reports in the literature. Polyarteritis nodosa was also considered, although this patient did not have the painful, tender nodules that are often associated with this condition.

The cutaneous form of polyarteritis nodosa (cPAN) primarily affects the skin without systemic involvement such as vasculitis. Microscopic PAN (mPAN), in contrast, often affects small arteries and veins and can feature lung and kidney involvement. "These are different conditions, but they may be part of a spectrum—from mPAN to PAN," Dr. Miriam Weinstein said at the annual conference of the Canadian Dermatology Association.

A skin biopsy in this case indicated neutrophilic vasculitis with inflammation.

"Group A strep was cultured from his throat when I saw him on the tenth eruption," Dr. Weinstein said. His throat swab findings were negative between episodes.

Can group A strep be seen with vasculitis? "The answer is 'yes'," said Dr. Wein-stein, medical director of the pediatric dermatology fellowship program at the Hospital for Sick Children in Toronto.

Of the different PAN subtypes, cPAN is the only one consistently linked with group A streptococci infection in the literature (Int. J. Dermatol. 1998;37:664-6; Arch. Dis. Child. 1996;74:367; and Ann. Rheum. Dis. 1995;54:134-6).

Determination of the precise diagnosis was challenging. "He had a recurrent strep infection. This case involved urticarial eruption, which is uncommon with strep. He also had some features consistent with mPAN … vasculitis of small to medium arteries," Dr. Weinstein said.

The final diagnosis was group A β-hemolytic streptococci-induced mPAN with urticarial lesions.

Recurrent strep infections also can affect younger children, although the presentation can differ. "If you see persistent erythematous folds, particularly in infants and babies, think group A strep and swab," she suggested.

Group A strep infection is often mistaken for Candida, irritant contact dermatitis, or seborrheic dermatitis. It is often treated but persists, Dr. Weinstein said. Frequently there is an odor with group A strep infection that is not present with Candida. "Don't forget perianal strep. It is more common than reported and often missed," she said. This usually affects patients younger than 10 years. If asked, these kids will have a history of painful bowel movements and perianal itch. "Often the parents don't know about this. It is the first time it's asked," she noted.

Both Candida and group A strep can induce psoriasis. Psoriasiform infectious disease features widespread, acute, well-demarcated, and erythematous plaques with scale. "There are no reports of this in the literature, but many pediatric dermatologists see this," Dr. Weinstein said.

The child had an occurrence of urticarial eruptions, which is uncommon with strep. Courtesy Dr. Miriam Weinstein

PALM BEACH, FLA. — Technical tips to optimize use of injectable facial fillers and botulinum toxin were offered during a live patient demonstration at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

A natural-looking result is the goal. "We want to return patients to what they looked like when they were younger. That is what our patients want," Dr. Mark S. Nestor said. "Really, the idea is combining [products], such as Botox and some of these fillers, to get optimal results."

An initial patient assessment should include realistic expectations. Know what fillers can and cannot achieve. "What you see as a physician may be different than what a patient is concerned about. When you have done this for a while, it's interesting to look at why something bothers patients," said Dr. Nestor of Aventura, Fla.

Along with Dr. James M. Spencer and Dr. Joely Kaufman, Dr. Nestor treated a series of volunteers at the meeting with combined treatments of injectable fillers and botulinum toxin.

Treatment was halted for one person who experienced an adverse reaction. She was tilted back in the chair while ice was applied to her forehead. "She is having a vasovagal response, which is not that uncommon," Dr. Nestor said. "This happened in South Beach [at a meeting in February 2007]. Patients need to be laid back, and they will come out of it quickly."

The newest filler option is Perlane (hyaluronic acid, Medicis), which was approved by the Food and Drug Administration in May for correction of moderate to severe facial folds and wrinkles. Perlane's nonimmunogenic, stabilized hyaluronic acid gel particles are similar to Restylane (hyaluronic acid, Medicis) but larger. Perlane adds volume to restore surface contour in facial wrinkles and folds, including the nasolabial fold. The product should be injected into the deep dermis up to the superficial layer of the subcutis.

Dr. Nestor injected Perlane with a 27-G needle. "You can actually feel the filler going in. What you are seeing right away is the significant lift you get because this product is really robust."

After injecting the nasolabial folds, he massaged inside and outside of the mouth to get an even distribution, noting that "Perlane smooths out very, very nicely." The next step involved superficial injections of Restylane on top of the same area. He finished the treatment with botulinum toxin injections to the crow's feet area.

Perlane can also be injected to accentuate areas below the mouth, said Dr. Nestor, who disclosed a relationship with Medicis.

While treating another volunteer, he noted that Perlane can replace significant volume loss in the midcheek for an extended period. "It doesn't roll off. Studies have shown it can remain there 5 or 6 years."

In contrast, Dr. Nestor advised undercorrection of volume loss when using Juvederm Ultra (hyaluronic acid gel, Allergan). "The idea here is that you can always inject more. You don't want to inject too much to begin with." He typically injects the filler as he withdraws the syringe. "You can feel it going into the deeper aspect of the dermis."

Dr. Kaufman injected another volunteer with Juvederm. Another option would be Sculptra (poly-L-lactic acid, Sanofi-Aventis). "By using Sculptra, you would need less hyaluronic acid in the nasolabial folds," said Dr. Kaufman of the University of Miami. The direction of product flow can make a big difference. For marionette lines, for example, she injects downward toward the center of the face below a patient's mouth. In addition, one little bolus of hyaluronic acid right under the vermilion border on either side of the mouth "really turns the lip up," she said.

Another combination approach uses injection of Radiesse (calcium hydroxylapatite, BioForm Medical) to restore facial volume and botulinum toxin to lift the corners of the mouth, said Dr. Spencer, who has a skin cancer and cosmetic dermatology practice in St. Petersburg, Fla.

Dr. Spencer used a 27-G needle and a 1.3-cc syringe during the demonstration. Radiesse is "more viscous, so it takes a little more effort to inject," he said. Threading or serial puncture down are the two technique options. "I always see them back in a week to make sure everything is okay." He estimated that the volume enhancement with Radiesse will last 1-2 years.

Dr. Kaufman and Dr. Spencer had no relevant disclosures regarding the products used in the demonstration.

PALM BEACH, FLA. — Technical tips to optimize use of injectable facial fillers and botulinum toxin were offered during a live patient demonstration at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

A natural-looking result is the goal. "We want to return patients to what they looked like when they were younger. That is what our patients want," Dr. Mark S. Nestor said. "Really, the idea is combining [products], such as Botox and some of these fillers, to get optimal results."

An initial patient assessment should include realistic expectations. Know what fillers can and cannot achieve. "What you see as a physician may be different than what a patient is concerned about. When you have done this for a while, it's interesting to look at why something bothers patients," said Dr. Nestor of Aventura, Fla.

Along with Dr. James M. Spencer and Dr. Joely Kaufman, Dr. Nestor treated a series of volunteers at the meeting with combined treatments of injectable fillers and botulinum toxin.

Treatment was halted for one person who experienced an adverse reaction. She was tilted back in the chair while ice was applied to her forehead. "She is having a vasovagal response, which is not that uncommon," Dr. Nestor said. "This happened in South Beach [at a meeting in February 2007]. Patients need to be laid back, and they will come out of it quickly."

The newest filler option is Perlane (hyaluronic acid, Medicis), which was approved by the Food and Drug Administration in May for correction of moderate to severe facial folds and wrinkles. Perlane's nonimmunogenic, stabilized hyaluronic acid gel particles are similar to Restylane (hyaluronic acid, Medicis) but larger. Perlane adds volume to restore surface contour in facial wrinkles and folds, including the nasolabial fold. The product should be injected into the deep dermis up to the superficial layer of the subcutis.

Dr. Nestor injected Perlane with a 27-G needle. "You can actually feel the filler going in. What you are seeing right away is the significant lift you get because this product is really robust."

After injecting the nasolabial folds, he massaged inside and outside of the mouth to get an even distribution, noting that "Perlane smooths out very, very nicely." The next step involved superficial injections of Restylane on top of the same area. He finished the treatment with botulinum toxin injections to the crow's feet area.

Perlane can also be injected to accentuate areas below the mouth, said Dr. Nestor, who disclosed a relationship with Medicis.

While treating another volunteer, he noted that Perlane can replace significant volume loss in the midcheek for an extended period. "It doesn't roll off. Studies have shown it can remain there 5 or 6 years."

In contrast, Dr. Nestor advised undercorrection of volume loss when using Juvederm Ultra (hyaluronic acid gel, Allergan). "The idea here is that you can always inject more. You don't want to inject too much to begin with." He typically injects the filler as he withdraws the syringe. "You can feel it going into the deeper aspect of the dermis."

Dr. Kaufman injected another volunteer with Juvederm. Another option would be Sculptra (poly-L-lactic acid, Sanofi-Aventis). "By using Sculptra, you would need less hyaluronic acid in the nasolabial folds," said Dr. Kaufman of the University of Miami. The direction of product flow can make a big difference. For marionette lines, for example, she injects downward toward the center of the face below a patient's mouth. In addition, one little bolus of hyaluronic acid right under the vermilion border on either side of the mouth "really turns the lip up," she said.

Another combination approach uses injection of Radiesse (calcium hydroxylapatite, BioForm Medical) to restore facial volume and botulinum toxin to lift the corners of the mouth, said Dr. Spencer, who has a skin cancer and cosmetic dermatology practice in St. Petersburg, Fla.

Dr. Spencer used a 27-G needle and a 1.3-cc syringe during the demonstration. Radiesse is "more viscous, so it takes a little more effort to inject," he said. Threading or serial puncture down are the two technique options. "I always see them back in a week to make sure everything is okay." He estimated that the volume enhancement with Radiesse will last 1-2 years.

Dr. Kaufman and Dr. Spencer had no relevant disclosures regarding the products used in the demonstration.

PALM BEACH, FLA. — Technical tips to optimize use of injectable facial fillers and botulinum toxin were offered during a live patient demonstration at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

A natural-looking result is the goal. "We want to return patients to what they looked like when they were younger. That is what our patients want," Dr. Mark S. Nestor said. "Really, the idea is combining [products], such as Botox and some of these fillers, to get optimal results."

An initial patient assessment should include realistic expectations. Know what fillers can and cannot achieve. "What you see as a physician may be different than what a patient is concerned about. When you have done this for a while, it's interesting to look at why something bothers patients," said Dr. Nestor of Aventura, Fla.

Along with Dr. James M. Spencer and Dr. Joely Kaufman, Dr. Nestor treated a series of volunteers at the meeting with combined treatments of injectable fillers and botulinum toxin.

Treatment was halted for one person who experienced an adverse reaction. She was tilted back in the chair while ice was applied to her forehead. "She is having a vasovagal response, which is not that uncommon," Dr. Nestor said. "This happened in South Beach [at a meeting in February 2007]. Patients need to be laid back, and they will come out of it quickly."

The newest filler option is Perlane (hyaluronic acid, Medicis), which was approved by the Food and Drug Administration in May for correction of moderate to severe facial folds and wrinkles. Perlane's nonimmunogenic, stabilized hyaluronic acid gel particles are similar to Restylane (hyaluronic acid, Medicis) but larger. Perlane adds volume to restore surface contour in facial wrinkles and folds, including the nasolabial fold. The product should be injected into the deep dermis up to the superficial layer of the subcutis.

Dr. Nestor injected Perlane with a 27-G needle. "You can actually feel the filler going in. What you are seeing right away is the significant lift you get because this product is really robust."

After injecting the nasolabial folds, he massaged inside and outside of the mouth to get an even distribution, noting that "Perlane smooths out very, very nicely." The next step involved superficial injections of Restylane on top of the same area. He finished the treatment with botulinum toxin injections to the crow's feet area.

Perlane can also be injected to accentuate areas below the mouth, said Dr. Nestor, who disclosed a relationship with Medicis.

While treating another volunteer, he noted that Perlane can replace significant volume loss in the midcheek for an extended period. "It doesn't roll off. Studies have shown it can remain there 5 or 6 years."

In contrast, Dr. Nestor advised undercorrection of volume loss when using Juvederm Ultra (hyaluronic acid gel, Allergan). "The idea here is that you can always inject more. You don't want to inject too much to begin with." He typically injects the filler as he withdraws the syringe. "You can feel it going into the deeper aspect of the dermis."

Dr. Kaufman injected another volunteer with Juvederm. Another option would be Sculptra (poly-L-lactic acid, Sanofi-Aventis). "By using Sculptra, you would need less hyaluronic acid in the nasolabial folds," said Dr. Kaufman of the University of Miami. The direction of product flow can make a big difference. For marionette lines, for example, she injects downward toward the center of the face below a patient's mouth. In addition, one little bolus of hyaluronic acid right under the vermilion border on either side of the mouth "really turns the lip up," she said.

Another combination approach uses injection of Radiesse (calcium hydroxylapatite, BioForm Medical) to restore facial volume and botulinum toxin to lift the corners of the mouth, said Dr. Spencer, who has a skin cancer and cosmetic dermatology practice in St. Petersburg, Fla.

Dr. Spencer used a 27-G needle and a 1.3-cc syringe during the demonstration. Radiesse is "more viscous, so it takes a little more effort to inject," he said. Threading or serial puncture down are the two technique options. "I always see them back in a week to make sure everything is okay." He estimated that the volume enhancement with Radiesse will last 1-2 years.

Dr. Kaufman and Dr. Spencer had no relevant disclosures regarding the products used in the demonstration.

BIRMINGHAM, ENGLAND — Surgery can be an effective pain-relieving strategy for children with hip or knee joints severely disabled by juvenile idiopathic arthritis.

Total hip replacement is a good pain-relieving operation, and sometimes is indicated even in young patients, Dr. Johan Witt said at the annual meeting of the British Society for Rheumatology.

“Younger patients are better off getting a hip replacement while they still have bone to put this into,” said Dr. Witt, a consultant orthopedic surgeon at the University College of London Hospitals.

Joint replacements have the potential to last a long time, but close monitoring of the patients is warranted.

Synovectomy is an option that can help some patients with juvenile idiopathic arthritis (JIA), but it is used less and less frequently. “I've probably done one in the past year,” he said. “This requires intensive rehab to get anything out of it.”

Another option for a subgroup of patients is hip resurfacing. “There has been a push from patients over time, including a group of JIA patients,” he said. This procedure is indicated only for slightly older patients in whom the disease has largely resolved. “Some patients have an unrealistic view of what resurfacing can do. With some of the marketing around this, patients get confused.”

Another choice, osteotomy, rarely is indicated for patients with JIA. In this population, the joint is too stiff and severely involved, and the bone too osteopenic.

Hip involvement is the most common cause of limited mobility in JIA, affecting 30%–60% of patients. The ultimate results of nontreatment include a fixed flexion deformity, adduction, and greater internal than external hip rotation. Other potential consequences of hip deformity are excessive lumbar lordosis, fixed flexion deformity of the knees, genu valgum, and external tibial torsion.

Therefore, early identification of JIA is essential. “The younger you are when arthritis starts, the more likely it is to lead to persistent disability in later life,” he said.

Consider preoperative disease activity, upper limb involvement, and adjacent joint involvement, which can be important considerations for rehabilitation. Assess range of motion when a patient is under anesthesia.

In arthritic knees, Dr. Witt said that intra-articular steroids in combination with physiotherapy and rehabilitation are the front-line protocol. Surgery is a second-line option if the first interventions do not yield significant improvements.

Leg length discrepancies are common in children with knee involvement. A discrepancy or a valgus deformity can be corrected with epiphysiodesis.

“Remember this option,” Dr. Witt said. “It is a painless way of correcting this condition. It takes advantage of growth potential.”

Fixed flexion deformity (FFD) in combination with a valgus is a common presentation of an arthritic knee. “We are generally good at correcting the FFD. If it's a severe deformity, such as a 60-degree FFD, it may require some soft-tissue release in addition to knee replacement,” Dr. Witt commented.

In addition, “extreme osteoporosis is associated with active disease and is the enemy,” he said. “Many of these patients have been immobile for a long time, and immobility is bad for the skeleton.”

Total knee replacement studies in children with JIA all have had short follow-up. Studies of long-term outcomes of knee replacement are needed, Dr. Witt said.

BIRMINGHAM, ENGLAND — Surgery can be an effective pain-relieving strategy for children with hip or knee joints severely disabled by juvenile idiopathic arthritis.

Total hip replacement is a good pain-relieving operation, and sometimes is indicated even in young patients, Dr. Johan Witt said at the annual meeting of the British Society for Rheumatology.

“Younger patients are better off getting a hip replacement while they still have bone to put this into,” said Dr. Witt, a consultant orthopedic surgeon at the University College of London Hospitals.

Joint replacements have the potential to last a long time, but close monitoring of the patients is warranted.

Synovectomy is an option that can help some patients with juvenile idiopathic arthritis (JIA), but it is used less and less frequently. “I've probably done one in the past year,” he said. “This requires intensive rehab to get anything out of it.”

Another option for a subgroup of patients is hip resurfacing. “There has been a push from patients over time, including a group of JIA patients,” he said. This procedure is indicated only for slightly older patients in whom the disease has largely resolved. “Some patients have an unrealistic view of what resurfacing can do. With some of the marketing around this, patients get confused.”

Another choice, osteotomy, rarely is indicated for patients with JIA. In this population, the joint is too stiff and severely involved, and the bone too osteopenic.

Hip involvement is the most common cause of limited mobility in JIA, affecting 30%–60% of patients. The ultimate results of nontreatment include a fixed flexion deformity, adduction, and greater internal than external hip rotation. Other potential consequences of hip deformity are excessive lumbar lordosis, fixed flexion deformity of the knees, genu valgum, and external tibial torsion.

Therefore, early identification of JIA is essential. “The younger you are when arthritis starts, the more likely it is to lead to persistent disability in later life,” he said.

Consider preoperative disease activity, upper limb involvement, and adjacent joint involvement, which can be important considerations for rehabilitation. Assess range of motion when a patient is under anesthesia.

In arthritic knees, Dr. Witt said that intra-articular steroids in combination with physiotherapy and rehabilitation are the front-line protocol. Surgery is a second-line option if the first interventions do not yield significant improvements.

Leg length discrepancies are common in children with knee involvement. A discrepancy or a valgus deformity can be corrected with epiphysiodesis.

“Remember this option,” Dr. Witt said. “It is a painless way of correcting this condition. It takes advantage of growth potential.”

Fixed flexion deformity (FFD) in combination with a valgus is a common presentation of an arthritic knee. “We are generally good at correcting the FFD. If it's a severe deformity, such as a 60-degree FFD, it may require some soft-tissue release in addition to knee replacement,” Dr. Witt commented.

In addition, “extreme osteoporosis is associated with active disease and is the enemy,” he said. “Many of these patients have been immobile for a long time, and immobility is bad for the skeleton.”

Total knee replacement studies in children with JIA all have had short follow-up. Studies of long-term outcomes of knee replacement are needed, Dr. Witt said.

BIRMINGHAM, ENGLAND — Surgery can be an effective pain-relieving strategy for children with hip or knee joints severely disabled by juvenile idiopathic arthritis.

Total hip replacement is a good pain-relieving operation, and sometimes is indicated even in young patients, Dr. Johan Witt said at the annual meeting of the British Society for Rheumatology.

“Younger patients are better off getting a hip replacement while they still have bone to put this into,” said Dr. Witt, a consultant orthopedic surgeon at the University College of London Hospitals.

Joint replacements have the potential to last a long time, but close monitoring of the patients is warranted.

Synovectomy is an option that can help some patients with juvenile idiopathic arthritis (JIA), but it is used less and less frequently. “I've probably done one in the past year,” he said. “This requires intensive rehab to get anything out of it.”

Another option for a subgroup of patients is hip resurfacing. “There has been a push from patients over time, including a group of JIA patients,” he said. This procedure is indicated only for slightly older patients in whom the disease has largely resolved. “Some patients have an unrealistic view of what resurfacing can do. With some of the marketing around this, patients get confused.”

Another choice, osteotomy, rarely is indicated for patients with JIA. In this population, the joint is too stiff and severely involved, and the bone too osteopenic.

Hip involvement is the most common cause of limited mobility in JIA, affecting 30%–60% of patients. The ultimate results of nontreatment include a fixed flexion deformity, adduction, and greater internal than external hip rotation. Other potential consequences of hip deformity are excessive lumbar lordosis, fixed flexion deformity of the knees, genu valgum, and external tibial torsion.

Therefore, early identification of JIA is essential. “The younger you are when arthritis starts, the more likely it is to lead to persistent disability in later life,” he said.

Consider preoperative disease activity, upper limb involvement, and adjacent joint involvement, which can be important considerations for rehabilitation. Assess range of motion when a patient is under anesthesia.

In arthritic knees, Dr. Witt said that intra-articular steroids in combination with physiotherapy and rehabilitation are the front-line protocol. Surgery is a second-line option if the first interventions do not yield significant improvements.

Leg length discrepancies are common in children with knee involvement. A discrepancy or a valgus deformity can be corrected with epiphysiodesis.

“Remember this option,” Dr. Witt said. “It is a painless way of correcting this condition. It takes advantage of growth potential.”

Fixed flexion deformity (FFD) in combination with a valgus is a common presentation of an arthritic knee. “We are generally good at correcting the FFD. If it's a severe deformity, such as a 60-degree FFD, it may require some soft-tissue release in addition to knee replacement,” Dr. Witt commented.

In addition, “extreme osteoporosis is associated with active disease and is the enemy,” he said. “Many of these patients have been immobile for a long time, and immobility is bad for the skeleton.”

Total knee replacement studies in children with JIA all have had short follow-up. Studies of long-term outcomes of knee replacement are needed, Dr. Witt said.