Damian McNamara

BIRMINGHAM, ENGLAND — Structural modification that could be achieved through mechanical, behavioral, and nutritional therapies may be a worthwhile goal in osteoarthritis treatment and a way to focus on therapy that involves more than just symptom relief, according to a presentation at the annual meeting of the British Society for Rheumatology.

A multitude of nonpharmacologic options for osteoarthritis can be pursued prior to drug treatment, Dr. Paul Dieppe said. For example, small studies support the theory that mechanically shifting the load off an affected lower-extremity joint modifies structure and alleviates symptoms of osteoarthritis.

Osteotomy, shoe wedging, and knee braces, as well as weight loss in the obese, are other options.

“If we kept thin, ate sensibly, maintained good muscle strength, avoided injuring our joints, and wore sensible shoes … there might not be as much osteoarthritis,” said Dr. Dieppe, professor of rheumatology and dean of the faculty of medicine, University of Bristol (England).

Dr. Dieppe says he is unhappy with the fact that people borrow the term “disease-modifying treatment” from the rheumatoid arthritis field and apply it to osteoarthritis.

“We go on pretending that osteoarthritis is related to rheumatoid arthritis, and just a bit different. What might disease-modifying treatment mean in osteoarthritis? We are talking about structure modification,” he said.

Structural changes can be achieved with Ilizarov frames—more commonly used by orthopedists to correct limb length discrepancies. The frames pull and increase the space between joints.

“Strangely, most of the data [so far have come] from the ankle joint,” Dr. Dieppe said. “The trials are small in numbers, but suggest very positive outcomes with recovery of the joint space in many cases, as well as symptom relief.”

Success with these frames provides proof of the concept that if the joint is unloaded, there is structure and symptom modification.

“It looks gruesome, but clearly, it can work,” Dr. Dieppe said.

Investigators should assess crepe shoes, shoe wedging, and other less invasive interventions, he added.

Osteoarthritis of the knee begins when a kinematic change occurs and shifts the load of the joint to a region unaccustomed to the new loading, according to a review article (Curr. Opin. Rheumatol. 2006;18:514–8). The authors state that the progression of osteoarthritis thereby is associated with the degree of this increased load during ambulation.

In terms of nutritional modification, trials are underway to assess any roles for vitamin C or vitamin D to slow the pathogenesis or progression of osteoarthritis, Dr. Dieppe said. Altering the course of osteoarthritis with certain dietary supplements does not work, he said, adding, “That chondroitin or glucosamine causes structural changes is a silly idea.”

“The relationship between symptom change and structural change requires further study,” he concluded.

BIRMINGHAM, ENGLAND — Structural modification that could be achieved through mechanical, behavioral, and nutritional therapies may be a worthwhile goal in osteoarthritis treatment and a way to focus on therapy that involves more than just symptom relief, according to a presentation at the annual meeting of the British Society for Rheumatology.

A multitude of nonpharmacologic options for osteoarthritis can be pursued prior to drug treatment, Dr. Paul Dieppe said. For example, small studies support the theory that mechanically shifting the load off an affected lower-extremity joint modifies structure and alleviates symptoms of osteoarthritis.

Osteotomy, shoe wedging, and knee braces, as well as weight loss in the obese, are other options.

“If we kept thin, ate sensibly, maintained good muscle strength, avoided injuring our joints, and wore sensible shoes … there might not be as much osteoarthritis,” said Dr. Dieppe, professor of rheumatology and dean of the faculty of medicine, University of Bristol (England).

Dr. Dieppe says he is unhappy with the fact that people borrow the term “disease-modifying treatment” from the rheumatoid arthritis field and apply it to osteoarthritis.

“We go on pretending that osteoarthritis is related to rheumatoid arthritis, and just a bit different. What might disease-modifying treatment mean in osteoarthritis? We are talking about structure modification,” he said.

Structural changes can be achieved with Ilizarov frames—more commonly used by orthopedists to correct limb length discrepancies. The frames pull and increase the space between joints.

“Strangely, most of the data [so far have come] from the ankle joint,” Dr. Dieppe said. “The trials are small in numbers, but suggest very positive outcomes with recovery of the joint space in many cases, as well as symptom relief.”

Success with these frames provides proof of the concept that if the joint is unloaded, there is structure and symptom modification.

“It looks gruesome, but clearly, it can work,” Dr. Dieppe said.

Investigators should assess crepe shoes, shoe wedging, and other less invasive interventions, he added.

Osteoarthritis of the knee begins when a kinematic change occurs and shifts the load of the joint to a region unaccustomed to the new loading, according to a review article (Curr. Opin. Rheumatol. 2006;18:514–8). The authors state that the progression of osteoarthritis thereby is associated with the degree of this increased load during ambulation.

In terms of nutritional modification, trials are underway to assess any roles for vitamin C or vitamin D to slow the pathogenesis or progression of osteoarthritis, Dr. Dieppe said. Altering the course of osteoarthritis with certain dietary supplements does not work, he said, adding, “That chondroitin or glucosamine causes structural changes is a silly idea.”

“The relationship between symptom change and structural change requires further study,” he concluded.

BIRMINGHAM, ENGLAND — Structural modification that could be achieved through mechanical, behavioral, and nutritional therapies may be a worthwhile goal in osteoarthritis treatment and a way to focus on therapy that involves more than just symptom relief, according to a presentation at the annual meeting of the British Society for Rheumatology.

A multitude of nonpharmacologic options for osteoarthritis can be pursued prior to drug treatment, Dr. Paul Dieppe said. For example, small studies support the theory that mechanically shifting the load off an affected lower-extremity joint modifies structure and alleviates symptoms of osteoarthritis.

Osteotomy, shoe wedging, and knee braces, as well as weight loss in the obese, are other options.

“If we kept thin, ate sensibly, maintained good muscle strength, avoided injuring our joints, and wore sensible shoes … there might not be as much osteoarthritis,” said Dr. Dieppe, professor of rheumatology and dean of the faculty of medicine, University of Bristol (England).

Dr. Dieppe says he is unhappy with the fact that people borrow the term “disease-modifying treatment” from the rheumatoid arthritis field and apply it to osteoarthritis.

“We go on pretending that osteoarthritis is related to rheumatoid arthritis, and just a bit different. What might disease-modifying treatment mean in osteoarthritis? We are talking about structure modification,” he said.

Structural changes can be achieved with Ilizarov frames—more commonly used by orthopedists to correct limb length discrepancies. The frames pull and increase the space between joints.

“Strangely, most of the data [so far have come] from the ankle joint,” Dr. Dieppe said. “The trials are small in numbers, but suggest very positive outcomes with recovery of the joint space in many cases, as well as symptom relief.”

Success with these frames provides proof of the concept that if the joint is unloaded, there is structure and symptom modification.

“It looks gruesome, but clearly, it can work,” Dr. Dieppe said.

Investigators should assess crepe shoes, shoe wedging, and other less invasive interventions, he added.

Osteoarthritis of the knee begins when a kinematic change occurs and shifts the load of the joint to a region unaccustomed to the new loading, according to a review article (Curr. Opin. Rheumatol. 2006;18:514–8). The authors state that the progression of osteoarthritis thereby is associated with the degree of this increased load during ambulation.

In terms of nutritional modification, trials are underway to assess any roles for vitamin C or vitamin D to slow the pathogenesis or progression of osteoarthritis, Dr. Dieppe said. Altering the course of osteoarthritis with certain dietary supplements does not work, he said, adding, “That chondroitin or glucosamine causes structural changes is a silly idea.”

“The relationship between symptom change and structural change requires further study,” he concluded.

BIRMINGHAM, ENGLAND – Structural modification for treatment of osteoarthritis maybe worthwhile because it offers more than just symptom relief, according to a presentation at the annual meeting of the British Society for Rheumatology.

A multitude of nonpharmacologic options for osteoarthritis which include mechanical, behavioral, and nutritional therapies, can be pursued prior to drug treatment, Dr. Paul Dieppe said.

For example, findings from small studies support the theory that mechanically shifting the load off an affected lower-extremity joint modifies structure and alleviates symptoms of osteoarthritis.

Osteotomy, shoe wedging, and knee braces, as well as weight loss in the obese, are other options. “If we kept thin, ate sensibly, maintained good muscle strength, avoided injuring our joints, and wore sensible shoes … there might not be as much osteoarthritis,” said Dr. Dieppe, professor of rheumatology and dean of the faculty of medicine, University of Bristol (England).

Dr. Dieppe says he is unhappy when people borrow the term “disease-modifying treatment” from the rheumatoid arthritis field and apply it to osteoarthritis. “We go on pretending that osteoarthritis is related to rheumatoid arthritis, and just a bit different. What might disease-modifying treatment mean in osteoarthritis? We are talking about structure modification.”

Structural changes can be achieved with Ilizarov frames–more commonly used by orthopedists to correct limb length discrepancies. The frames pull and increase the space between joints. “Most of the data [so far have come] from the ankle joint,” Dr. Dieppe said. “The trials are small in numbers, but suggest very positive outcomes with recovery of the joint space in many cases, as well as symptom relief.”

Success with these frames provides proof of the concept that if the joint is unloaded, there is structure and symptom modification. “It looks gruesome, but clearly, it can work.”

Investigators should assess crepe shoes, shoe wedging, and other less invasive interventions, he added.

Osteoarthritis of the knee begins when a kinematic change occurs and shifts the load of the joint to a region unaccustomed to the new loading, according to a review article (Curr. Opin. Rheumatol. 2006;18:514-8). The authors state that the progression of osteoarthritis thereby is associated with the degree of this increased load during ambulation.

In terms of nutritional modification, trials are underway to assess any roles for vitamin C or vitamin D to slow the pathogenesis or progression of osteoarthritis, Dr. Dieppe said. Altering the course of osteoarthritis with certain dietary supplements does not work, he said. “That chondroitin or glucosamine causes structural changes is a silly idea. The relationship between symptom change and structural change requires further study.”

BIRMINGHAM, ENGLAND – Structural modification for treatment of osteoarthritis maybe worthwhile because it offers more than just symptom relief, according to a presentation at the annual meeting of the British Society for Rheumatology.

A multitude of nonpharmacologic options for osteoarthritis which include mechanical, behavioral, and nutritional therapies, can be pursued prior to drug treatment, Dr. Paul Dieppe said.

For example, findings from small studies support the theory that mechanically shifting the load off an affected lower-extremity joint modifies structure and alleviates symptoms of osteoarthritis.

Osteotomy, shoe wedging, and knee braces, as well as weight loss in the obese, are other options. “If we kept thin, ate sensibly, maintained good muscle strength, avoided injuring our joints, and wore sensible shoes … there might not be as much osteoarthritis,” said Dr. Dieppe, professor of rheumatology and dean of the faculty of medicine, University of Bristol (England).

Dr. Dieppe says he is unhappy when people borrow the term “disease-modifying treatment” from the rheumatoid arthritis field and apply it to osteoarthritis. “We go on pretending that osteoarthritis is related to rheumatoid arthritis, and just a bit different. What might disease-modifying treatment mean in osteoarthritis? We are talking about structure modification.”

Structural changes can be achieved with Ilizarov frames–more commonly used by orthopedists to correct limb length discrepancies. The frames pull and increase the space between joints. “Most of the data [so far have come] from the ankle joint,” Dr. Dieppe said. “The trials are small in numbers, but suggest very positive outcomes with recovery of the joint space in many cases, as well as symptom relief.”

Success with these frames provides proof of the concept that if the joint is unloaded, there is structure and symptom modification. “It looks gruesome, but clearly, it can work.”

Investigators should assess crepe shoes, shoe wedging, and other less invasive interventions, he added.

Osteoarthritis of the knee begins when a kinematic change occurs and shifts the load of the joint to a region unaccustomed to the new loading, according to a review article (Curr. Opin. Rheumatol. 2006;18:514-8). The authors state that the progression of osteoarthritis thereby is associated with the degree of this increased load during ambulation.

In terms of nutritional modification, trials are underway to assess any roles for vitamin C or vitamin D to slow the pathogenesis or progression of osteoarthritis, Dr. Dieppe said. Altering the course of osteoarthritis with certain dietary supplements does not work, he said. “That chondroitin or glucosamine causes structural changes is a silly idea. The relationship between symptom change and structural change requires further study.”

BIRMINGHAM, ENGLAND – Structural modification for treatment of osteoarthritis maybe worthwhile because it offers more than just symptom relief, according to a presentation at the annual meeting of the British Society for Rheumatology.

A multitude of nonpharmacologic options for osteoarthritis which include mechanical, behavioral, and nutritional therapies, can be pursued prior to drug treatment, Dr. Paul Dieppe said.

For example, findings from small studies support the theory that mechanically shifting the load off an affected lower-extremity joint modifies structure and alleviates symptoms of osteoarthritis.

Osteotomy, shoe wedging, and knee braces, as well as weight loss in the obese, are other options. “If we kept thin, ate sensibly, maintained good muscle strength, avoided injuring our joints, and wore sensible shoes … there might not be as much osteoarthritis,” said Dr. Dieppe, professor of rheumatology and dean of the faculty of medicine, University of Bristol (England).

Dr. Dieppe says he is unhappy when people borrow the term “disease-modifying treatment” from the rheumatoid arthritis field and apply it to osteoarthritis. “We go on pretending that osteoarthritis is related to rheumatoid arthritis, and just a bit different. What might disease-modifying treatment mean in osteoarthritis? We are talking about structure modification.”

Structural changes can be achieved with Ilizarov frames–more commonly used by orthopedists to correct limb length discrepancies. The frames pull and increase the space between joints. “Most of the data [so far have come] from the ankle joint,” Dr. Dieppe said. “The trials are small in numbers, but suggest very positive outcomes with recovery of the joint space in many cases, as well as symptom relief.”

Success with these frames provides proof of the concept that if the joint is unloaded, there is structure and symptom modification. “It looks gruesome, but clearly, it can work.”

Investigators should assess crepe shoes, shoe wedging, and other less invasive interventions, he added.

Osteoarthritis of the knee begins when a kinematic change occurs and shifts the load of the joint to a region unaccustomed to the new loading, according to a review article (Curr. Opin. Rheumatol. 2006;18:514-8). The authors state that the progression of osteoarthritis thereby is associated with the degree of this increased load during ambulation.

In terms of nutritional modification, trials are underway to assess any roles for vitamin C or vitamin D to slow the pathogenesis or progression of osteoarthritis, Dr. Dieppe said. Altering the course of osteoarthritis with certain dietary supplements does not work, he said. “That chondroitin or glucosamine causes structural changes is a silly idea. The relationship between symptom change and structural change requires further study.”

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 often 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. “We need to get on top of these situations early,” he said. “The younger you are when arthritis starts, the more likely it is to lead to persistent disability in later life.”

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,” he said.

In addition, “extreme osteoporosis is associated with active disease and is the enemy,” Dr. Witt 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 warranted, 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 often 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. “We need to get on top of these situations early,” he said. “The younger you are when arthritis starts, the more likely it is to lead to persistent disability in later life.”

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,” he said.

In addition, “extreme osteoporosis is associated with active disease and is the enemy,” Dr. Witt 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 warranted, 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 often 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. “We need to get on top of these situations early,” he said. “The younger you are when arthritis starts, the more likely it is to lead to persistent disability in later life.”

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,” he said.

In addition, “extreme osteoporosis is associated with active disease and is the enemy,” Dr. Witt 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 warranted, Dr. Witt said.

PALM BEACH, FLA. — Cosmetic dermatology techniques can be used to improve postsurgical scarring, said Dr. Joel L. Cohen.

Cosmetic dermatology and dermatologic surgery share some common principles, including an appreciation for maintaining anatomy, symmetry, and aesthetic subunits, Dr. Cohen said. The increased risk of skin cancer among patients seeking treatment for signs of photodamage is another area of overlap. Dermatologists well versed in both realms will be particularly adept at improving postsurgical outcomes in their skin cancer patients, he said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

"It's nice for me to have lasers, fillers, and botulinum toxin in our armamentarium to help with scars," said Dr. Cohen, director of AboutSkin Dermatology and DermSurgery in Englewood, Colorado.

"Scars are clearly permanent but there are things we can do to minimize them or fine-tune their appearance," he said. For example, botulinum toxin can minimize the muscular tension vectors across a large and tight forehead closure from skin cancer by immobilizing the frontalis muscle.

Fillers can be used to improve depressed surgical scars after reconstruction. For example, after initial subcision, scars or contour changes on a patient's ear helical rim can be improved with fillers. The depth of the scar and the anatomic location can determine the choice of filler, he said.

Scar abrasion is another option for some patients. "Sometimes sanding devices are clearly needed and are helpful for textural changes," Dr. Cohen said. Diamond fraise dermabrasion is an example, as well as ablative and fractional resurfacing lasers. "Sometimes I even use a curet to sand a scar if there is a big concern about airborne infectious particles."

Residual erythema following skin cancer repairs can also be significantly improved with lasers. "Postoperative redness is a reality. We all see it, and sometimes intervening and using either a pulsed dye laser or even a pulsed light device can have dramatic results" said Dr. Cohen, who is also an assistant clinical professor of dermatology at the University of Colorado, Denver. Sometimes more than one modality is required to satisfy a patient. One young skin cancer patient wanted to quickly improve the bilobed flap scar on her nose in the few months before her wedding, for example. A combination of erbium laser and fractional resurfacing proved to be very helpful in helping to blend the scar line.

He tried several means to improve a hypopigmented full-thickness skin graft scar on the lower eyelid of a middle-aged woman after Mohs surgery. A combination of trichloroacetic acid peels and hydroquinone to the surrounding skin has provided the best results so far, he noted. "This is a great example of how sometimes the older and less expensive treatments are most effective."

"Once you are comfortable treating these types of surgical scars, this knowledge can be very helpful with other common dermatology patients, such as those with acne scars," Dr. Cohen said.

Dermatologists who want to offer aesthetic, surgical, and medical dermatology services may need to adjust their schedule, staff training, and office layout, Dr. Cohen said. Decide what percentage of each type of patient you want to treat on a typical day and cross-train your staff so they are comfortable explaining the different procedures.

Dr. Cohen is a consultant, speaker, clinical trial investigator, and instructor for Allergan (Botox); a consultant, speaker, clinical trial investigator, and instructor for Medicis (Restylane); a consultant and clinical trial investigator for BioForm (Radiesse); and was a consultant for Palomar (LUX1540 fractional laser).

The woman above is pictured immediately following Mohs surgery to remove a large morpheaform basal cell carcinoma.

After flap reconstruction, Botox is used to immobilize the frontalis muscle and prevent muscular contraction tension.

One week after Mohs surgery and reconstruction—at the time of suture removal—the forehead surgery site is healing well.

After 3 months, the surgery site is still healing well. Fractional laser therapy for the scar is discussed at this time. Photos courtesy Dr. Joel L. Cohen

PALM BEACH, FLA. — Cosmetic dermatology techniques can be used to improve postsurgical scarring, said Dr. Joel L. Cohen.

Cosmetic dermatology and dermatologic surgery share some common principles, including an appreciation for maintaining anatomy, symmetry, and aesthetic subunits, Dr. Cohen said. The increased risk of skin cancer among patients seeking treatment for signs of photodamage is another area of overlap. Dermatologists well versed in both realms will be particularly adept at improving postsurgical outcomes in their skin cancer patients, he said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

"It's nice for me to have lasers, fillers, and botulinum toxin in our armamentarium to help with scars," said Dr. Cohen, director of AboutSkin Dermatology and DermSurgery in Englewood, Colorado.

"Scars are clearly permanent but there are things we can do to minimize them or fine-tune their appearance," he said. For example, botulinum toxin can minimize the muscular tension vectors across a large and tight forehead closure from skin cancer by immobilizing the frontalis muscle.

Fillers can be used to improve depressed surgical scars after reconstruction. For example, after initial subcision, scars or contour changes on a patient's ear helical rim can be improved with fillers. The depth of the scar and the anatomic location can determine the choice of filler, he said.

Scar abrasion is another option for some patients. "Sometimes sanding devices are clearly needed and are helpful for textural changes," Dr. Cohen said. Diamond fraise dermabrasion is an example, as well as ablative and fractional resurfacing lasers. "Sometimes I even use a curet to sand a scar if there is a big concern about airborne infectious particles."

Residual erythema following skin cancer repairs can also be significantly improved with lasers. "Postoperative redness is a reality. We all see it, and sometimes intervening and using either a pulsed dye laser or even a pulsed light device can have dramatic results" said Dr. Cohen, who is also an assistant clinical professor of dermatology at the University of Colorado, Denver. Sometimes more than one modality is required to satisfy a patient. One young skin cancer patient wanted to quickly improve the bilobed flap scar on her nose in the few months before her wedding, for example. A combination of erbium laser and fractional resurfacing proved to be very helpful in helping to blend the scar line.

He tried several means to improve a hypopigmented full-thickness skin graft scar on the lower eyelid of a middle-aged woman after Mohs surgery. A combination of trichloroacetic acid peels and hydroquinone to the surrounding skin has provided the best results so far, he noted. "This is a great example of how sometimes the older and less expensive treatments are most effective."

"Once you are comfortable treating these types of surgical scars, this knowledge can be very helpful with other common dermatology patients, such as those with acne scars," Dr. Cohen said.

Dermatologists who want to offer aesthetic, surgical, and medical dermatology services may need to adjust their schedule, staff training, and office layout, Dr. Cohen said. Decide what percentage of each type of patient you want to treat on a typical day and cross-train your staff so they are comfortable explaining the different procedures.

Dr. Cohen is a consultant, speaker, clinical trial investigator, and instructor for Allergan (Botox); a consultant, speaker, clinical trial investigator, and instructor for Medicis (Restylane); a consultant and clinical trial investigator for BioForm (Radiesse); and was a consultant for Palomar (LUX1540 fractional laser).

The woman above is pictured immediately following Mohs surgery to remove a large morpheaform basal cell carcinoma.

After flap reconstruction, Botox is used to immobilize the frontalis muscle and prevent muscular contraction tension.

One week after Mohs surgery and reconstruction—at the time of suture removal—the forehead surgery site is healing well.

After 3 months, the surgery site is still healing well. Fractional laser therapy for the scar is discussed at this time. Photos courtesy Dr. Joel L. Cohen

PALM BEACH, FLA. — Cosmetic dermatology techniques can be used to improve postsurgical scarring, said Dr. Joel L. Cohen.

Cosmetic dermatology and dermatologic surgery share some common principles, including an appreciation for maintaining anatomy, symmetry, and aesthetic subunits, Dr. Cohen said. The increased risk of skin cancer among patients seeking treatment for signs of photodamage is another area of overlap. Dermatologists well versed in both realms will be particularly adept at improving postsurgical outcomes in their skin cancer patients, he said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

"It's nice for me to have lasers, fillers, and botulinum toxin in our armamentarium to help with scars," said Dr. Cohen, director of AboutSkin Dermatology and DermSurgery in Englewood, Colorado.

"Scars are clearly permanent but there are things we can do to minimize them or fine-tune their appearance," he said. For example, botulinum toxin can minimize the muscular tension vectors across a large and tight forehead closure from skin cancer by immobilizing the frontalis muscle.

Fillers can be used to improve depressed surgical scars after reconstruction. For example, after initial subcision, scars or contour changes on a patient's ear helical rim can be improved with fillers. The depth of the scar and the anatomic location can determine the choice of filler, he said.

Scar abrasion is another option for some patients. "Sometimes sanding devices are clearly needed and are helpful for textural changes," Dr. Cohen said. Diamond fraise dermabrasion is an example, as well as ablative and fractional resurfacing lasers. "Sometimes I even use a curet to sand a scar if there is a big concern about airborne infectious particles."

Residual erythema following skin cancer repairs can also be significantly improved with lasers. "Postoperative redness is a reality. We all see it, and sometimes intervening and using either a pulsed dye laser or even a pulsed light device can have dramatic results" said Dr. Cohen, who is also an assistant clinical professor of dermatology at the University of Colorado, Denver. Sometimes more than one modality is required to satisfy a patient. One young skin cancer patient wanted to quickly improve the bilobed flap scar on her nose in the few months before her wedding, for example. A combination of erbium laser and fractional resurfacing proved to be very helpful in helping to blend the scar line.

He tried several means to improve a hypopigmented full-thickness skin graft scar on the lower eyelid of a middle-aged woman after Mohs surgery. A combination of trichloroacetic acid peels and hydroquinone to the surrounding skin has provided the best results so far, he noted. "This is a great example of how sometimes the older and less expensive treatments are most effective."

"Once you are comfortable treating these types of surgical scars, this knowledge can be very helpful with other common dermatology patients, such as those with acne scars," Dr. Cohen said.

Dermatologists who want to offer aesthetic, surgical, and medical dermatology services may need to adjust their schedule, staff training, and office layout, Dr. Cohen said. Decide what percentage of each type of patient you want to treat on a typical day and cross-train your staff so they are comfortable explaining the different procedures.

Dr. Cohen is a consultant, speaker, clinical trial investigator, and instructor for Allergan (Botox); a consultant, speaker, clinical trial investigator, and instructor for Medicis (Restylane); a consultant and clinical trial investigator for BioForm (Radiesse); and was a consultant for Palomar (LUX1540 fractional laser).

The woman above is pictured immediately following Mohs surgery to remove a large morpheaform basal cell carcinoma.

After flap reconstruction, Botox is used to immobilize the frontalis muscle and prevent muscular contraction tension.

One week after Mohs surgery and reconstruction—at the time of suture removal—the forehead surgery site is healing well.

After 3 months, the surgery site is still healing well. Fractional laser therapy for the scar is discussed at this time. Photos courtesy Dr. Joel L. Cohen

MIAMI BEACH — Poly-L-lactic acid "is a little tricky to use, but with proper care it can be very effective," Dr. C. William Hanke III said at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

He and other experts shared their tips for dilution, reconstitution, administration, and follow-up to optimize aesthetic outcomes with the deep tissue filler poly-L-lactic acid (Sculptra).

"You can have dramatic, dramatic improvements in these patients with facial asymmetry. When people look at themselves in the mirror and start crying, you know it was worthwhile," said Dr. Marta I. Rendon of the University of Miami. "A lot of patients say, 'I don't want to look 20. I just want to look less tired,'" said Dr. Susan Weinkle of the University of South Florida, Tampa.

Dr. Rendon agreed: "You really want a natural and youthful appearance. You want harmony—someone who looks well, younger, well rested. You are complementing their natural attributes."

Assess patient goals before the procedure. Sometimes what patients want is not what's best for them. "You have to use common sense. We don't want to distort peoples' faces so they end up walking around looking like chipmunks," she said.

Restoration of facial volume loss in people with HIV is the approved indication for Sculptra. "These HIV lipoatrophy patients are the most appreciative I've ever met. They look sick to the world and this [treatment] makes a big difference," said Dr. Hanke of Indiana University, Indianapolis.

These three dermatologists offered clinical pearls on the following issues involved in the use of poly-L-lactic acid:

▸ Patient preparation. Both Dr. Hanke and Dr. Rendon mark injection spots on the cheek and outline the area to be filled with poly-L-lactic acid. "Always map the injection sites and take pictures," Dr. Rendon said. "I like to know for next time where I put the product and how the patient responded."

During an initial assessment, establish realistic expectations, agree on a treatment plan, and explain subjective and objective assessments of results, she said.

▸ Dilution. Dr. Hanke uses a 5-cc dilution per vial—3 cc of sterile water the night before, followed by 2 cc of Xylocaine (lidocaine) right before injection. Dr. Weinkle adds all 5 cc of water the night before and 2 cc of Xylocaine just before injection.

"When you add the Xylocaine with epinephrine, turn the bottle upside down and add it slowly. It won't get as foamy," Dr. Weinkle said. This tip should expedite the procedure.

▸ Reconstitution. A minimum of 2 hours for reconstitution is recommended. "We have patients pay a deposit so their bottle is ready the day before," Dr. Rendon said.

Keep the vial warm to maintain the product in solution, Dr. Weinkle said. You can place it in warm water or keep it near your body, she added.

Dr. Hanke and Dr. Rendon use a mixer to keep the product reconstituted during use. "It works better than hand mixing for me. You do not want to see white powder. You want to see it in full suspension," Dr. Hanke said.

If there is a white clump in the syringe or if the needle clogs during use, "pull it back, mix it a little, and keep going," Dr. Rendon said.

▸ Technique. Both doctors use a 3-cc syringe, but Dr. Hanke injects with a 25-G needle and Dr. Rendon prefers to use a 26-G needle.

Larger needles are easier to use, Dr. Weinkle said, and can spread the material with fewer injections, but be careful if you fan. "As you go back into a triangle area over and over, you may end up with a glob of material at the entry point."

Dr. Rendon said, "I just got used to using the shorter [half-inch] needle, and I don't do as much fanning with Sculptra as with the other products."

Seat the patient upright at a 30-degree angle. "Do a deep dermal injection with about 0.1–0.2 cc per injection site," Dr Rendon advised.

Although tunneling and depot are the two main injection techniques, "you will develop your own systems with experience and change your techniques accordingly," she added.

Poly-L-lactic acid is thicker than many other filler materials. Pressure must be maintained on the syringe plunger to maintain the flow. "This [product] flows easily with experience," Dr. Rendon commented.

Dr. Weinkle's assistant keeps track of the syringe count during the procedure "so I don't end up injecting all the product on one-half of the face," she said. If you do use more product on one side and know the patient is coming back, tell them: "I focused on the left side this time. Next time I will focus more on the right side," she said. Then make a note in the chart to do so.

Another pearl is to put cotton swabs in an open bottle of Drysol (aluminum chloride) to use during the procedure. Dr. Rendon uses this technique to promote coagulation and minimize point bleeding at injection sites.

▸ Postprocedure care. Have an assistant stay with the patient and massage the injected areas for 5–10 minutes. "Always massage, but don't overdo it," Dr. Rendon said. "If they are on Coumadin [warfarin] or aspirin, you will create bruising."

"Some advocate further massaging at home, but I think that is less important," Dr. Hanke said.

Both Dr. Rendon and Dr. Weinkle recommend follow-up massaging of the treated areas. Dr. Weinkle tells patients to follow the "rule of fives"—5 minutes five times a day "This compliance with postop care is associated with better outcomes," she said. Dr. Rendon advises 5 minutes of massage three times per day.

▸ Adverse events. Avoid injection of certain areas to minimize the risk of adverse events such as papules, nodules, or inflammatory granulomas. "You can use the product anywhere there is fat loss in the face, except the glabellar area and vermillion border," Dr. Rendon said.

"If you get close to the eye with injecting Sculptra, sometimes [patients] will not be able to close their eyes afterward," Dr. Weinkle said. "I had some Sculptra injected near my eye, and I was unable to close my eye for 3 hours. It freaked me out. Warn patients about this."

In addition, "do not inject this product into the lips. The skin is too thin—you'll get nodules," she said.

Caution is also advised regarding perioral injections in a heavy smoker.

"I got burned once with a woman who had an adverse effect," Dr. Weinkle recalled. "As they smoke and contract the muscles so strongly by pursing their lips, they move the product and get nodule formation."

▸ Long-term expectations. Most patients require three to four treatment sessions for maximal results with poly-L-lactic acid. "The timing of repeat injections is every 4–6 weeks until you get the desired effect," Dr. Rendon said. "It's not a product with immediate results. It's a slow, progressive improvement over 4–6 months."

Dr. Weinkle said, "Patients also need to be educated that time marches on and they may need to return for a Sculptra booster."

Dr. Weinkle is on the speakers' bureau for Dermik Laboratories, the manufacturer of Sculptra. Dr. Hanke and Dr. Rendon do not have disclosure statements regarding Sculptra or Dermik.

MIAMI BEACH — Poly-L-lactic acid "is a little tricky to use, but with proper care it can be very effective," Dr. C. William Hanke III said at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

He and other experts shared their tips for dilution, reconstitution, administration, and follow-up to optimize aesthetic outcomes with the deep tissue filler poly-L-lactic acid (Sculptra).

"You can have dramatic, dramatic improvements in these patients with facial asymmetry. When people look at themselves in the mirror and start crying, you know it was worthwhile," said Dr. Marta I. Rendon of the University of Miami. "A lot of patients say, 'I don't want to look 20. I just want to look less tired,'" said Dr. Susan Weinkle of the University of South Florida, Tampa.

Dr. Rendon agreed: "You really want a natural and youthful appearance. You want harmony—someone who looks well, younger, well rested. You are complementing their natural attributes."

Assess patient goals before the procedure. Sometimes what patients want is not what's best for them. "You have to use common sense. We don't want to distort peoples' faces so they end up walking around looking like chipmunks," she said.

Restoration of facial volume loss in people with HIV is the approved indication for Sculptra. "These HIV lipoatrophy patients are the most appreciative I've ever met. They look sick to the world and this [treatment] makes a big difference," said Dr. Hanke of Indiana University, Indianapolis.

These three dermatologists offered clinical pearls on the following issues involved in the use of poly-L-lactic acid:

▸ Patient preparation. Both Dr. Hanke and Dr. Rendon mark injection spots on the cheek and outline the area to be filled with poly-L-lactic acid. "Always map the injection sites and take pictures," Dr. Rendon said. "I like to know for next time where I put the product and how the patient responded."

During an initial assessment, establish realistic expectations, agree on a treatment plan, and explain subjective and objective assessments of results, she said.

▸ Dilution. Dr. Hanke uses a 5-cc dilution per vial—3 cc of sterile water the night before, followed by 2 cc of Xylocaine (lidocaine) right before injection. Dr. Weinkle adds all 5 cc of water the night before and 2 cc of Xylocaine just before injection.

"When you add the Xylocaine with epinephrine, turn the bottle upside down and add it slowly. It won't get as foamy," Dr. Weinkle said. This tip should expedite the procedure.

▸ Reconstitution. A minimum of 2 hours for reconstitution is recommended. "We have patients pay a deposit so their bottle is ready the day before," Dr. Rendon said.

Keep the vial warm to maintain the product in solution, Dr. Weinkle said. You can place it in warm water or keep it near your body, she added.

Dr. Hanke and Dr. Rendon use a mixer to keep the product reconstituted during use. "It works better than hand mixing for me. You do not want to see white powder. You want to see it in full suspension," Dr. Hanke said.

If there is a white clump in the syringe or if the needle clogs during use, "pull it back, mix it a little, and keep going," Dr. Rendon said.

▸ Technique. Both doctors use a 3-cc syringe, but Dr. Hanke injects with a 25-G needle and Dr. Rendon prefers to use a 26-G needle.

Larger needles are easier to use, Dr. Weinkle said, and can spread the material with fewer injections, but be careful if you fan. "As you go back into a triangle area over and over, you may end up with a glob of material at the entry point."

Dr. Rendon said, "I just got used to using the shorter [half-inch] needle, and I don't do as much fanning with Sculptra as with the other products."

Seat the patient upright at a 30-degree angle. "Do a deep dermal injection with about 0.1–0.2 cc per injection site," Dr Rendon advised.

Although tunneling and depot are the two main injection techniques, "you will develop your own systems with experience and change your techniques accordingly," she added.

Poly-L-lactic acid is thicker than many other filler materials. Pressure must be maintained on the syringe plunger to maintain the flow. "This [product] flows easily with experience," Dr. Rendon commented.

Dr. Weinkle's assistant keeps track of the syringe count during the procedure "so I don't end up injecting all the product on one-half of the face," she said. If you do use more product on one side and know the patient is coming back, tell them: "I focused on the left side this time. Next time I will focus more on the right side," she said. Then make a note in the chart to do so.

Another pearl is to put cotton swabs in an open bottle of Drysol (aluminum chloride) to use during the procedure. Dr. Rendon uses this technique to promote coagulation and minimize point bleeding at injection sites.

▸ Postprocedure care. Have an assistant stay with the patient and massage the injected areas for 5–10 minutes. "Always massage, but don't overdo it," Dr. Rendon said. "If they are on Coumadin [warfarin] or aspirin, you will create bruising."

"Some advocate further massaging at home, but I think that is less important," Dr. Hanke said.

Both Dr. Rendon and Dr. Weinkle recommend follow-up massaging of the treated areas. Dr. Weinkle tells patients to follow the "rule of fives"—5 minutes five times a day "This compliance with postop care is associated with better outcomes," she said. Dr. Rendon advises 5 minutes of massage three times per day.

▸ Adverse events. Avoid injection of certain areas to minimize the risk of adverse events such as papules, nodules, or inflammatory granulomas. "You can use the product anywhere there is fat loss in the face, except the glabellar area and vermillion border," Dr. Rendon said.

"If you get close to the eye with injecting Sculptra, sometimes [patients] will not be able to close their eyes afterward," Dr. Weinkle said. "I had some Sculptra injected near my eye, and I was unable to close my eye for 3 hours. It freaked me out. Warn patients about this."

In addition, "do not inject this product into the lips. The skin is too thin—you'll get nodules," she said.

Caution is also advised regarding perioral injections in a heavy smoker.

"I got burned once with a woman who had an adverse effect," Dr. Weinkle recalled. "As they smoke and contract the muscles so strongly by pursing their lips, they move the product and get nodule formation."

▸ Long-term expectations. Most patients require three to four treatment sessions for maximal results with poly-L-lactic acid. "The timing of repeat injections is every 4–6 weeks until you get the desired effect," Dr. Rendon said. "It's not a product with immediate results. It's a slow, progressive improvement over 4–6 months."

Dr. Weinkle said, "Patients also need to be educated that time marches on and they may need to return for a Sculptra booster."

Dr. Weinkle is on the speakers' bureau for Dermik Laboratories, the manufacturer of Sculptra. Dr. Hanke and Dr. Rendon do not have disclosure statements regarding Sculptra or Dermik.

MIAMI BEACH — Poly-L-lactic acid "is a little tricky to use, but with proper care it can be very effective," Dr. C. William Hanke III said at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

He and other experts shared their tips for dilution, reconstitution, administration, and follow-up to optimize aesthetic outcomes with the deep tissue filler poly-L-lactic acid (Sculptra).

"You can have dramatic, dramatic improvements in these patients with facial asymmetry. When people look at themselves in the mirror and start crying, you know it was worthwhile," said Dr. Marta I. Rendon of the University of Miami. "A lot of patients say, 'I don't want to look 20. I just want to look less tired,'" said Dr. Susan Weinkle of the University of South Florida, Tampa.

Dr. Rendon agreed: "You really want a natural and youthful appearance. You want harmony—someone who looks well, younger, well rested. You are complementing their natural attributes."

Assess patient goals before the procedure. Sometimes what patients want is not what's best for them. "You have to use common sense. We don't want to distort peoples' faces so they end up walking around looking like chipmunks," she said.

Restoration of facial volume loss in people with HIV is the approved indication for Sculptra. "These HIV lipoatrophy patients are the most appreciative I've ever met. They look sick to the world and this [treatment] makes a big difference," said Dr. Hanke of Indiana University, Indianapolis.

These three dermatologists offered clinical pearls on the following issues involved in the use of poly-L-lactic acid:

▸ Patient preparation. Both Dr. Hanke and Dr. Rendon mark injection spots on the cheek and outline the area to be filled with poly-L-lactic acid. "Always map the injection sites and take pictures," Dr. Rendon said. "I like to know for next time where I put the product and how the patient responded."

During an initial assessment, establish realistic expectations, agree on a treatment plan, and explain subjective and objective assessments of results, she said.

▸ Dilution. Dr. Hanke uses a 5-cc dilution per vial—3 cc of sterile water the night before, followed by 2 cc of Xylocaine (lidocaine) right before injection. Dr. Weinkle adds all 5 cc of water the night before and 2 cc of Xylocaine just before injection.

"When you add the Xylocaine with epinephrine, turn the bottle upside down and add it slowly. It won't get as foamy," Dr. Weinkle said. This tip should expedite the procedure.

▸ Reconstitution. A minimum of 2 hours for reconstitution is recommended. "We have patients pay a deposit so their bottle is ready the day before," Dr. Rendon said.

Keep the vial warm to maintain the product in solution, Dr. Weinkle said. You can place it in warm water or keep it near your body, she added.

Dr. Hanke and Dr. Rendon use a mixer to keep the product reconstituted during use. "It works better than hand mixing for me. You do not want to see white powder. You want to see it in full suspension," Dr. Hanke said.

If there is a white clump in the syringe or if the needle clogs during use, "pull it back, mix it a little, and keep going," Dr. Rendon said.

▸ Technique. Both doctors use a 3-cc syringe, but Dr. Hanke injects with a 25-G needle and Dr. Rendon prefers to use a 26-G needle.

Larger needles are easier to use, Dr. Weinkle said, and can spread the material with fewer injections, but be careful if you fan. "As you go back into a triangle area over and over, you may end up with a glob of material at the entry point."

Dr. Rendon said, "I just got used to using the shorter [half-inch] needle, and I don't do as much fanning with Sculptra as with the other products."

Seat the patient upright at a 30-degree angle. "Do a deep dermal injection with about 0.1–0.2 cc per injection site," Dr Rendon advised.

Although tunneling and depot are the two main injection techniques, "you will develop your own systems with experience and change your techniques accordingly," she added.

Poly-L-lactic acid is thicker than many other filler materials. Pressure must be maintained on the syringe plunger to maintain the flow. "This [product] flows easily with experience," Dr. Rendon commented.

Dr. Weinkle's assistant keeps track of the syringe count during the procedure "so I don't end up injecting all the product on one-half of the face," she said. If you do use more product on one side and know the patient is coming back, tell them: "I focused on the left side this time. Next time I will focus more on the right side," she said. Then make a note in the chart to do so.

Another pearl is to put cotton swabs in an open bottle of Drysol (aluminum chloride) to use during the procedure. Dr. Rendon uses this technique to promote coagulation and minimize point bleeding at injection sites.

▸ Postprocedure care. Have an assistant stay with the patient and massage the injected areas for 5–10 minutes. "Always massage, but don't overdo it," Dr. Rendon said. "If they are on Coumadin [warfarin] or aspirin, you will create bruising."

"Some advocate further massaging at home, but I think that is less important," Dr. Hanke said.

Both Dr. Rendon and Dr. Weinkle recommend follow-up massaging of the treated areas. Dr. Weinkle tells patients to follow the "rule of fives"—5 minutes five times a day "This compliance with postop care is associated with better outcomes," she said. Dr. Rendon advises 5 minutes of massage three times per day.

▸ Adverse events. Avoid injection of certain areas to minimize the risk of adverse events such as papules, nodules, or inflammatory granulomas. "You can use the product anywhere there is fat loss in the face, except the glabellar area and vermillion border," Dr. Rendon said.

"If you get close to the eye with injecting Sculptra, sometimes [patients] will not be able to close their eyes afterward," Dr. Weinkle said. "I had some Sculptra injected near my eye, and I was unable to close my eye for 3 hours. It freaked me out. Warn patients about this."

In addition, "do not inject this product into the lips. The skin is too thin—you'll get nodules," she said.

Caution is also advised regarding perioral injections in a heavy smoker.

"I got burned once with a woman who had an adverse effect," Dr. Weinkle recalled. "As they smoke and contract the muscles so strongly by pursing their lips, they move the product and get nodule formation."

▸ Long-term expectations. Most patients require three to four treatment sessions for maximal results with poly-L-lactic acid. "The timing of repeat injections is every 4–6 weeks until you get the desired effect," Dr. Rendon said. "It's not a product with immediate results. It's a slow, progressive improvement over 4–6 months."

Dr. Weinkle said, "Patients also need to be educated that time marches on and they may need to return for a Sculptra booster."

Dr. Weinkle is on the speakers' bureau for Dermik Laboratories, the manufacturer of Sculptra. Dr. Hanke and Dr. Rendon do not have disclosure statements regarding Sculptra or Dermik.

BIRMINGHAM, ENGLAND — An examination of the systemically unwell patient should include screening for generalized vasculitis, a rare but sometimes life-threatening condition, according to a presentation at the annual meeting of the British Society of Rheumatology.

“Systemic vasculitis is a challenging diagnosis. It may require rapid action, so exclude other diagnoses as quickly as possible,” Dr. Richard A. Watts said. “It may require treatment without a complete data set,” he added. Vasculitis with renal involvement, in particular, can progress very quickly.

Assess organ involvement and classify the type of vasculitis as accurately as possible, said Dr. Watts, of the Ipswich (England) Hospital. The spectrum of vasculitis is very broad, from a minor rash with no organ involvement to a fulminating, life-threatening disease. Although vasculitis is rare, “it must be considered in severe multisystem disease.” Dr. Watts cited a 45-year-old male teacher, unwell for 3 months, who presented to the emergency department with low-grade fever, myalgia, arthralgia, and recent weight loss. Physical exam revealed he was pyrexial with a temperature of 38° C (100° F), and an inconsistent faint systolic murmur. He was diagnosed with infective endocarditis and treated with antibiotics. Echocardiography was normal, indicating no significant structural abnormality. Blood cultures also were normal. The patient continued to worsen, so his antibiotics were changed. After 1 week in the hospital, the patient developed foot drop and red eye, and rheumatology was consulted.

The patient had nasal stuffiness, epistaxis, a lower-extremity rash, and poor vision in his left eye. A diagnosis of vasculitis was considered. The rheumatologist ordered a renal biopsy and a consultation with ophthalmology and neurology. The patient had a rapid response to prednisolone and cyclophosphamide, and a renal biopsy showed focal segmental necrotizing glomerulonephritis. He tested positive for antineutrophil cytoplasmic antibody (ANCA), ANCA with a cytoplasmic staining pattern (c-ANCA), and proteinase 3. Wegener's granulomatosis was the ultimate diagnosis. “He died last year after a relapse,” Dr. Watts said.

In a second case, a 38-year-old steel erector presented reporting 4 days of epigastric pain, shortness of breath, and vomiting. He also described recent weight loss and flulike symptoms that persisted for 3 weeks, including headache, malaise, and myalgia. The patient was admitted under the care of surgeons and given medications including amoxicillin and tramadol. He had an elevated alanine aminotransferase (ALT) level of 45 U/L. Abdominal ultrasound did not yield any specific findings. On days 4 and 5, he developed a macular and erythematous rash on the left palm and right buttock, as well as diarrhea.

Rheumatology was consulted on day 6. The rheumatologist noted a pruritic rash, malaise, sore throat, and conjunctivitis. Mouth ulcers, some joint pain, and headache were other symptoms. Renal function was normal. A CT scan of the patient's abdomen revealed a thickened bowel wall indicative of vasculitis, Dr. Watts said. A renal biopsy revealed acute interstitial nephritis. He developed hemoptysis after about 1 week. Vasculitis was seen in only one artery, however. The patient continued IV methylprednisolone and was transferred for plasmapheresis. His respiratory function then deteriorated. “He had a massive pulmonary hemorrhage and died. This case illustrates the need for rapid diagnosis,” Dr. Watts said.

“The key [to such cases] is to take a good history, asking for suggestive symptoms,” Dr. Watts said. Malaise, fever, weight loss, arthralgia, and myalgia are general symptoms. Dermatologic symptoms include purpura, ulcers, and infarctions of the skin. Otolaryngology signs include epistaxis, crusting, sinusitis, and deafness. Gastrointestinal symptoms include mouth ulcers, abdominal pain, and diarrhea. Sensory and/or motor impairment can also occur, he added.

The next step is to assess the level of inflammation, Dr. Watts said. Order a complete blood count and differential white cell count. Look beyond the neutrophil count for eosinophilia or lymphopenia, he suggested. An acute phase response will feature elevated erythrocyte sedimentation rate (ESR) and C-reactive protein levels. Also order a viral screen and a cryoglobulins assay, Dr. Watts said. “We are always worried about infection” in the differential diagnosis, and urinalysis is critical, Dr. Watts said. Hematuria or proteinuria can signal renal involvement, and renal dysfunction, as noted earlier, can progress very rapidly.

BIRMINGHAM, ENGLAND — An examination of the systemically unwell patient should include screening for generalized vasculitis, a rare but sometimes life-threatening condition, according to a presentation at the annual meeting of the British Society of Rheumatology.

“Systemic vasculitis is a challenging diagnosis. It may require rapid action, so exclude other diagnoses as quickly as possible,” Dr. Richard A. Watts said. “It may require treatment without a complete data set,” he added. Vasculitis with renal involvement, in particular, can progress very quickly.

Assess organ involvement and classify the type of vasculitis as accurately as possible, said Dr. Watts, of the Ipswich (England) Hospital. The spectrum of vasculitis is very broad, from a minor rash with no organ involvement to a fulminating, life-threatening disease. Although vasculitis is rare, “it must be considered in severe multisystem disease.” Dr. Watts cited a 45-year-old male teacher, unwell for 3 months, who presented to the emergency department with low-grade fever, myalgia, arthralgia, and recent weight loss. Physical exam revealed he was pyrexial with a temperature of 38° C (100° F), and an inconsistent faint systolic murmur. He was diagnosed with infective endocarditis and treated with antibiotics. Echocardiography was normal, indicating no significant structural abnormality. Blood cultures also were normal. The patient continued to worsen, so his antibiotics were changed. After 1 week in the hospital, the patient developed foot drop and red eye, and rheumatology was consulted.

The patient had nasal stuffiness, epistaxis, a lower-extremity rash, and poor vision in his left eye. A diagnosis of vasculitis was considered. The rheumatologist ordered a renal biopsy and a consultation with ophthalmology and neurology. The patient had a rapid response to prednisolone and cyclophosphamide, and a renal biopsy showed focal segmental necrotizing glomerulonephritis. He tested positive for antineutrophil cytoplasmic antibody (ANCA), ANCA with a cytoplasmic staining pattern (c-ANCA), and proteinase 3. Wegener's granulomatosis was the ultimate diagnosis. “He died last year after a relapse,” Dr. Watts said.

In a second case, a 38-year-old steel erector presented reporting 4 days of epigastric pain, shortness of breath, and vomiting. He also described recent weight loss and flulike symptoms that persisted for 3 weeks, including headache, malaise, and myalgia. The patient was admitted under the care of surgeons and given medications including amoxicillin and tramadol. He had an elevated alanine aminotransferase (ALT) level of 45 U/L. Abdominal ultrasound did not yield any specific findings. On days 4 and 5, he developed a macular and erythematous rash on the left palm and right buttock, as well as diarrhea.

Rheumatology was consulted on day 6. The rheumatologist noted a pruritic rash, malaise, sore throat, and conjunctivitis. Mouth ulcers, some joint pain, and headache were other symptoms. Renal function was normal. A CT scan of the patient's abdomen revealed a thickened bowel wall indicative of vasculitis, Dr. Watts said. A renal biopsy revealed acute interstitial nephritis. He developed hemoptysis after about 1 week. Vasculitis was seen in only one artery, however. The patient continued IV methylprednisolone and was transferred for plasmapheresis. His respiratory function then deteriorated. “He had a massive pulmonary hemorrhage and died. This case illustrates the need for rapid diagnosis,” Dr. Watts said.

“The key [to such cases] is to take a good history, asking for suggestive symptoms,” Dr. Watts said. Malaise, fever, weight loss, arthralgia, and myalgia are general symptoms. Dermatologic symptoms include purpura, ulcers, and infarctions of the skin. Otolaryngology signs include epistaxis, crusting, sinusitis, and deafness. Gastrointestinal symptoms include mouth ulcers, abdominal pain, and diarrhea. Sensory and/or motor impairment can also occur, he added.

The next step is to assess the level of inflammation, Dr. Watts said. Order a complete blood count and differential white cell count. Look beyond the neutrophil count for eosinophilia or lymphopenia, he suggested. An acute phase response will feature elevated erythrocyte sedimentation rate (ESR) and C-reactive protein levels. Also order a viral screen and a cryoglobulins assay, Dr. Watts said. “We are always worried about infection” in the differential diagnosis, and urinalysis is critical, Dr. Watts said. Hematuria or proteinuria can signal renal involvement, and renal dysfunction, as noted earlier, can progress very rapidly.

BIRMINGHAM, ENGLAND — An examination of the systemically unwell patient should include screening for generalized vasculitis, a rare but sometimes life-threatening condition, according to a presentation at the annual meeting of the British Society of Rheumatology.

“Systemic vasculitis is a challenging diagnosis. It may require rapid action, so exclude other diagnoses as quickly as possible,” Dr. Richard A. Watts said. “It may require treatment without a complete data set,” he added. Vasculitis with renal involvement, in particular, can progress very quickly.

Assess organ involvement and classify the type of vasculitis as accurately as possible, said Dr. Watts, of the Ipswich (England) Hospital. The spectrum of vasculitis is very broad, from a minor rash with no organ involvement to a fulminating, life-threatening disease. Although vasculitis is rare, “it must be considered in severe multisystem disease.” Dr. Watts cited a 45-year-old male teacher, unwell for 3 months, who presented to the emergency department with low-grade fever, myalgia, arthralgia, and recent weight loss. Physical exam revealed he was pyrexial with a temperature of 38° C (100° F), and an inconsistent faint systolic murmur. He was diagnosed with infective endocarditis and treated with antibiotics. Echocardiography was normal, indicating no significant structural abnormality. Blood cultures also were normal. The patient continued to worsen, so his antibiotics were changed. After 1 week in the hospital, the patient developed foot drop and red eye, and rheumatology was consulted.

The patient had nasal stuffiness, epistaxis, a lower-extremity rash, and poor vision in his left eye. A diagnosis of vasculitis was considered. The rheumatologist ordered a renal biopsy and a consultation with ophthalmology and neurology. The patient had a rapid response to prednisolone and cyclophosphamide, and a renal biopsy showed focal segmental necrotizing glomerulonephritis. He tested positive for antineutrophil cytoplasmic antibody (ANCA), ANCA with a cytoplasmic staining pattern (c-ANCA), and proteinase 3. Wegener's granulomatosis was the ultimate diagnosis. “He died last year after a relapse,” Dr. Watts said.

In a second case, a 38-year-old steel erector presented reporting 4 days of epigastric pain, shortness of breath, and vomiting. He also described recent weight loss and flulike symptoms that persisted for 3 weeks, including headache, malaise, and myalgia. The patient was admitted under the care of surgeons and given medications including amoxicillin and tramadol. He had an elevated alanine aminotransferase (ALT) level of 45 U/L. Abdominal ultrasound did not yield any specific findings. On days 4 and 5, he developed a macular and erythematous rash on the left palm and right buttock, as well as diarrhea.

Rheumatology was consulted on day 6. The rheumatologist noted a pruritic rash, malaise, sore throat, and conjunctivitis. Mouth ulcers, some joint pain, and headache were other symptoms. Renal function was normal. A CT scan of the patient's abdomen revealed a thickened bowel wall indicative of vasculitis, Dr. Watts said. A renal biopsy revealed acute interstitial nephritis. He developed hemoptysis after about 1 week. Vasculitis was seen in only one artery, however. The patient continued IV methylprednisolone and was transferred for plasmapheresis. His respiratory function then deteriorated. “He had a massive pulmonary hemorrhage and died. This case illustrates the need for rapid diagnosis,” Dr. Watts said.

“The key [to such cases] is to take a good history, asking for suggestive symptoms,” Dr. Watts said. Malaise, fever, weight loss, arthralgia, and myalgia are general symptoms. Dermatologic symptoms include purpura, ulcers, and infarctions of the skin. Otolaryngology signs include epistaxis, crusting, sinusitis, and deafness. Gastrointestinal symptoms include mouth ulcers, abdominal pain, and diarrhea. Sensory and/or motor impairment can also occur, he added.

The next step is to assess the level of inflammation, Dr. Watts said. Order a complete blood count and differential white cell count. Look beyond the neutrophil count for eosinophilia or lymphopenia, he suggested. An acute phase response will feature elevated erythrocyte sedimentation rate (ESR) and C-reactive protein levels. Also order a viral screen and a cryoglobulins assay, Dr. Watts said. “We are always worried about infection” in the differential diagnosis, and urinalysis is critical, Dr. Watts said. Hematuria or proteinuria can signal renal involvement, and renal dysfunction, as noted earlier, can progress very rapidly.

MIAMI BEACH — Human papillomavirus is often present in women who are HIV positive, but it remains unknown whether affected women are experiencing HPV reactivations, reinfections, or both, Dr. Matthew Pearson said at an ob.gyn. conference sponsored by the University of Miami.

Clinicians who treat women infected with HIV also are likely to see human papillomavirus (HPV) infection, including a higher prevalence of high-risk strains, compared with the general population. Progression and persistence of HPV are associated with poorer HIV infection status, indicated by either low CD4 counts and/or high viral loads in most studies.

An estimated 50 million people are infected with HIV worldwide, including more than 1 million in the United States, according to the Centers for Disease Control and Prevention. Also, there are an estimated 256 million people infected with HPV worldwide. In 1993, the CDC defined cervical cancer as an AIDS-defining illness.

“So is this a function of persistence or reinfection? Does the HPV go away and then the person gets reinfected?” asked Dr. Pearson, of the division of gynecologic oncology, University of Miami.

To try to answer this question, researchers looked at the natural history of coinfection in 2,362 women at a mean follow-up of 3 years (J. Natl. Cancer Inst. 2005;97:577–86). The participants included 1,848 HIV-positive and 514 HIV-negative women enrolled in the longitudinal Women's Interagency HIV Study in 1994 or 1995 (http://statepiaps.jhsph.edu/wihs

They found the rate of HPV clearance was lower among HIV-positive women (hazard ratio, 0.67), which suggested that persistence is a factor. However, the researchers also found that condom use decreased new HPV infections in women who had three or more partners. “This is consistent with the idea of reinfection from new partners,” Dr. Pearson said.

In 2001 and 2002, investigators for the Women's Interagency HIV Study enrolled an additional 1,144 women to assess the impact of highly active antiretroviral therapy (HAART). These additional participants included 406 HIV-negative women, 254 HIV-positive and HAART-naive women, and 484 HIV-positive HAART-treated women. An estimated 13% of women treated with HAART had regression of their cervical squamous intraepithelial lesions each year, compared with no regression in the non-HAART group (J. Natl. Cancer Inst. 2004;96:1070–6). After a median of 2.7 years, 45% had lesions that regressed to normal cytology in the HAART group, compared with 59% in HIV-negative women.

There is no consensus about whether routine testing for HPV should be done to screen for abnormalities, Dr. Pearson said. However, HPV screening can guide the frequency of subsequent cancer screening.

For example, when a new HIV-positive patient presents and HAART is prescribed, monitor the patient with a Pap test and HPV DNA analysis at 6 months and 1 year, Dr. Pearson suggested. If the Pap test results are negative and no high-risk HPV strain is detected, schedule an annual Pap/HPV test. If the patient is Pap negative but HPV positive for high-risk strains, schedule for a follow-up Pap test every 6 months.

If no HAART is prescribed and the CD4 count is greater than 500 cells per microliter, monitor the patient with a Pap test and HPV DNA analysis at 6 months and 1 year, Dr. Pearson suggested. However, if the patient has a CD4 count of 500 cells per microliter or below, schedule a follow-up Pap test every 6 months.

Each HPV type in the quadrivalent vaccine (Gardasil, Merck) is more prevalent among HIV-positive women than in the general population (J. Natl. Cancer Inst. 1999;91:226–36). These researchers concluded that prevalence of oncogenic HPV strains increases as CD4 counts decrease. Also, they found HIV-positive participants are more likely to be infected with multiple HPV strains; 23% of HIV-positive participants had two or more HPV types present.

Multiple HPV types also were more prevalent in HIV-positive women than in the general population (41% vs. 7%, odds ratio 9.3) in a meta-analysis of 20 studies with a total of 5,578 women (AIDS 2006;20:2337–44). These researchers also found multiple HPV types increasingly often as grade or abnormality on the Pap test increased. And, Dr. Pearson said, “HPV 16 nearly tripled from low-grade to high-grade Pap smears.”

“The question still remains if we should be vaccinating immunocompromised or HIV-positive women,” Dr. Pearson said. “The CDC thinks it is worthwhile.” Regarding the HPV vaccine, the CDC stated: “Immunocompromised females, either from disease or medication, can receive this vaccine; however, the immune response to vaccination and vaccine efficacy might be less than in immunocompetent females.” This view is shared by the Society of Gynecologic Oncology in their Statement on the Cervical Cancer Vaccine and the American College of Obstetricians and Gynecologists in their Committee Opinion #344, Dr. Pearson added.

“The types in the octavalent vaccine [Cervarix, GlaxoSmithKline] will be more appropriate in my population, HIV-positive women infected with multiple strains of HPV,” he said. Determining which one of these patients will benefit from vaccine prophylaxis is “a study we want to get started on here at the University of Miami.”

MIAMI BEACH — Human papillomavirus is often present in women who are HIV positive, but it remains unknown whether affected women are experiencing HPV reactivations, reinfections, or both, Dr. Matthew Pearson said at an ob.gyn. conference sponsored by the University of Miami.

Clinicians who treat women infected with HIV also are likely to see human papillomavirus (HPV) infection, including a higher prevalence of high-risk strains, compared with the general population. Progression and persistence of HPV are associated with poorer HIV infection status, indicated by either low CD4 counts and/or high viral loads in most studies.

An estimated 50 million people are infected with HIV worldwide, including more than 1 million in the United States, according to the Centers for Disease Control and Prevention. Also, there are an estimated 256 million people infected with HPV worldwide. In 1993, the CDC defined cervical cancer as an AIDS-defining illness.

“So is this a function of persistence or reinfection? Does the HPV go away and then the person gets reinfected?” asked Dr. Pearson, of the division of gynecologic oncology, University of Miami.

To try to answer this question, researchers looked at the natural history of coinfection in 2,362 women at a mean follow-up of 3 years (J. Natl. Cancer Inst. 2005;97:577–86). The participants included 1,848 HIV-positive and 514 HIV-negative women enrolled in the longitudinal Women's Interagency HIV Study in 1994 or 1995 (http://statepiaps.jhsph.edu/wihs

They found the rate of HPV clearance was lower among HIV-positive women (hazard ratio, 0.67), which suggested that persistence is a factor. However, the researchers also found that condom use decreased new HPV infections in women who had three or more partners. “This is consistent with the idea of reinfection from new partners,” Dr. Pearson said.

In 2001 and 2002, investigators for the Women's Interagency HIV Study enrolled an additional 1,144 women to assess the impact of highly active antiretroviral therapy (HAART). These additional participants included 406 HIV-negative women, 254 HIV-positive and HAART-naive women, and 484 HIV-positive HAART-treated women. An estimated 13% of women treated with HAART had regression of their cervical squamous intraepithelial lesions each year, compared with no regression in the non-HAART group (J. Natl. Cancer Inst. 2004;96:1070–6). After a median of 2.7 years, 45% had lesions that regressed to normal cytology in the HAART group, compared with 59% in HIV-negative women.

There is no consensus about whether routine testing for HPV should be done to screen for abnormalities, Dr. Pearson said. However, HPV screening can guide the frequency of subsequent cancer screening.

For example, when a new HIV-positive patient presents and HAART is prescribed, monitor the patient with a Pap test and HPV DNA analysis at 6 months and 1 year, Dr. Pearson suggested. If the Pap test results are negative and no high-risk HPV strain is detected, schedule an annual Pap/HPV test. If the patient is Pap negative but HPV positive for high-risk strains, schedule for a follow-up Pap test every 6 months.

If no HAART is prescribed and the CD4 count is greater than 500 cells per microliter, monitor the patient with a Pap test and HPV DNA analysis at 6 months and 1 year, Dr. Pearson suggested. However, if the patient has a CD4 count of 500 cells per microliter or below, schedule a follow-up Pap test every 6 months.

Each HPV type in the quadrivalent vaccine (Gardasil, Merck) is more prevalent among HIV-positive women than in the general population (J. Natl. Cancer Inst. 1999;91:226–36). These researchers concluded that prevalence of oncogenic HPV strains increases as CD4 counts decrease. Also, they found HIV-positive participants are more likely to be infected with multiple HPV strains; 23% of HIV-positive participants had two or more HPV types present.

Multiple HPV types also were more prevalent in HIV-positive women than in the general population (41% vs. 7%, odds ratio 9.3) in a meta-analysis of 20 studies with a total of 5,578 women (AIDS 2006;20:2337–44). These researchers also found multiple HPV types increasingly often as grade or abnormality on the Pap test increased. And, Dr. Pearson said, “HPV 16 nearly tripled from low-grade to high-grade Pap smears.”

“The question still remains if we should be vaccinating immunocompromised or HIV-positive women,” Dr. Pearson said. “The CDC thinks it is worthwhile.” Regarding the HPV vaccine, the CDC stated: “Immunocompromised females, either from disease or medication, can receive this vaccine; however, the immune response to vaccination and vaccine efficacy might be less than in immunocompetent females.” This view is shared by the Society of Gynecologic Oncology in their Statement on the Cervical Cancer Vaccine and the American College of Obstetricians and Gynecologists in their Committee Opinion #344, Dr. Pearson added.

“The types in the octavalent vaccine [Cervarix, GlaxoSmithKline] will be more appropriate in my population, HIV-positive women infected with multiple strains of HPV,” he said. Determining which one of these patients will benefit from vaccine prophylaxis is “a study we want to get started on here at the University of Miami.”

MIAMI BEACH — Human papillomavirus is often present in women who are HIV positive, but it remains unknown whether affected women are experiencing HPV reactivations, reinfections, or both, Dr. Matthew Pearson said at an ob.gyn. conference sponsored by the University of Miami.

Clinicians who treat women infected with HIV also are likely to see human papillomavirus (HPV) infection, including a higher prevalence of high-risk strains, compared with the general population. Progression and persistence of HPV are associated with poorer HIV infection status, indicated by either low CD4 counts and/or high viral loads in most studies.

An estimated 50 million people are infected with HIV worldwide, including more than 1 million in the United States, according to the Centers for Disease Control and Prevention. Also, there are an estimated 256 million people infected with HPV worldwide. In 1993, the CDC defined cervical cancer as an AIDS-defining illness.

“So is this a function of persistence or reinfection? Does the HPV go away and then the person gets reinfected?” asked Dr. Pearson, of the division of gynecologic oncology, University of Miami.

To try to answer this question, researchers looked at the natural history of coinfection in 2,362 women at a mean follow-up of 3 years (J. Natl. Cancer Inst. 2005;97:577–86). The participants included 1,848 HIV-positive and 514 HIV-negative women enrolled in the longitudinal Women's Interagency HIV Study in 1994 or 1995 (http://statepiaps.jhsph.edu/wihs

They found the rate of HPV clearance was lower among HIV-positive women (hazard ratio, 0.67), which suggested that persistence is a factor. However, the researchers also found that condom use decreased new HPV infections in women who had three or more partners. “This is consistent with the idea of reinfection from new partners,” Dr. Pearson said.

In 2001 and 2002, investigators for the Women's Interagency HIV Study enrolled an additional 1,144 women to assess the impact of highly active antiretroviral therapy (HAART). These additional participants included 406 HIV-negative women, 254 HIV-positive and HAART-naive women, and 484 HIV-positive HAART-treated women. An estimated 13% of women treated with HAART had regression of their cervical squamous intraepithelial lesions each year, compared with no regression in the non-HAART group (J. Natl. Cancer Inst. 2004;96:1070–6). After a median of 2.7 years, 45% had lesions that regressed to normal cytology in the HAART group, compared with 59% in HIV-negative women.

There is no consensus about whether routine testing for HPV should be done to screen for abnormalities, Dr. Pearson said. However, HPV screening can guide the frequency of subsequent cancer screening.

For example, when a new HIV-positive patient presents and HAART is prescribed, monitor the patient with a Pap test and HPV DNA analysis at 6 months and 1 year, Dr. Pearson suggested. If the Pap test results are negative and no high-risk HPV strain is detected, schedule an annual Pap/HPV test. If the patient is Pap negative but HPV positive for high-risk strains, schedule for a follow-up Pap test every 6 months.

If no HAART is prescribed and the CD4 count is greater than 500 cells per microliter, monitor the patient with a Pap test and HPV DNA analysis at 6 months and 1 year, Dr. Pearson suggested. However, if the patient has a CD4 count of 500 cells per microliter or below, schedule a follow-up Pap test every 6 months.

Each HPV type in the quadrivalent vaccine (Gardasil, Merck) is more prevalent among HIV-positive women than in the general population (J. Natl. Cancer Inst. 1999;91:226–36). These researchers concluded that prevalence of oncogenic HPV strains increases as CD4 counts decrease. Also, they found HIV-positive participants are more likely to be infected with multiple HPV strains; 23% of HIV-positive participants had two or more HPV types present.

Multiple HPV types also were more prevalent in HIV-positive women than in the general population (41% vs. 7%, odds ratio 9.3) in a meta-analysis of 20 studies with a total of 5,578 women (AIDS 2006;20:2337–44). These researchers also found multiple HPV types increasingly often as grade or abnormality on the Pap test increased. And, Dr. Pearson said, “HPV 16 nearly tripled from low-grade to high-grade Pap smears.”

“The question still remains if we should be vaccinating immunocompromised or HIV-positive women,” Dr. Pearson said. “The CDC thinks it is worthwhile.” Regarding the HPV vaccine, the CDC stated: “Immunocompromised females, either from disease or medication, can receive this vaccine; however, the immune response to vaccination and vaccine efficacy might be less than in immunocompetent females.” This view is shared by the Society of Gynecologic Oncology in their Statement on the Cervical Cancer Vaccine and the American College of Obstetricians and Gynecologists in their Committee Opinion #344, Dr. Pearson added.

“The types in the octavalent vaccine [Cervarix, GlaxoSmithKline] will be more appropriate in my population, HIV-positive women infected with multiple strains of HPV,” he said. Determining which one of these patients will benefit from vaccine prophylaxis is “a study we want to get started on here at the University of Miami.”

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 were less satisfied. Those women 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.

“Because our program is fairly new … we wanted to get an idea of what women thought,” said Dr. Lefebvre, an addiction medicine consultant with the department of family and community medicine, University of Toronto. Patients tour the maternity ward in advance, and everyone on the staff is trained to be sensitive to their substance use “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—the Centre for Addiction and Mental Health's addictions program in Toronto.

Women who attended separate programs were less likely to report a good birth experience or to know their obstetrician at delivery. “They had great addiction care but missed obstetric appointments,” Dr. Lefebvre said. 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.”

Clinicians in the integrated program encouraged the pregnant women to report themselves to child protection services. Surprisingly, many patients used the services as a resource, Dr. Lefebvre commented.

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 were less satisfied. Those women 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.

“Because our program is fairly new … we wanted to get an idea of what women thought,” said Dr. Lefebvre, an addiction medicine consultant with the department of family and community medicine, University of Toronto. Patients tour the maternity ward in advance, and everyone on the staff is trained to be sensitive to their substance use “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—the Centre for Addiction and Mental Health's addictions program in Toronto.

Women who attended separate programs were less likely to report a good birth experience or to know their obstetrician at delivery. “They had great addiction care but missed obstetric appointments,” Dr. Lefebvre said. 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.”

Clinicians in the integrated program encouraged the pregnant women to report themselves to child protection services. Surprisingly, many patients used the services as a resource, Dr. Lefebvre commented.

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 were less satisfied. Those women 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.

“Because our program is fairly new … we wanted to get an idea of what women thought,” said Dr. Lefebvre, an addiction medicine consultant with the department of family and community medicine, University of Toronto. Patients tour the maternity ward in advance, and everyone on the staff is trained to be sensitive to their substance use “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—the Centre for Addiction and Mental Health's addictions program in Toronto.

Women who attended separate programs were less likely to report a good birth experience or to know their obstetrician at delivery. “They had great addiction care but missed obstetric appointments,” Dr. Lefebvre said. 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.”

Clinicians in the integrated program encouraged the pregnant women to report themselves to child protection services. Surprisingly, many patients used the services as a resource, Dr. Lefebvre commented.

BIRMINGHAM, ENGLAND — Nearly half of all patients who initially failed therapy with anti-tumor necrosis factor-α agents benefited following a switch to a second or third drug in the class, according to a study presented at the annual meeting of the British Society for Rheumatology.

Dr. Jemma Pringle and associates studied 153 rheumatology patients who had a mean disease duration of 12 years upon entrance to a registry between 2001 and 2006. The patients' median initial disease activity score (DAS) was 7.55.

A cohort of 53 patients stopped their initial anti-TNF-α agent. Of these, 23 stopped due to an adverse event and 30 from loss of efficacy. Of the 33 who received a second anti-TNF-α agent, 22 responded and have remained on the drug for a median of 19 months at the time of her presentation, Dr. Pringle said.

The other 11 stopped anti-TNF-α therapy because of side effects and/or a lack of efficacy. Patients experienced a mean decrease in DAS of 32% from baseline to 4.15 after they undertook treatment with an alternative anti-TNF-α agent.

Of the seven participants who eventually switched to a third drug, four responded and continued to take the drug for a median of 6 months. There was a 44% mean decrease in baseline DAS among these patients.

“Nearly half of these are presently continuing their second or third agent with a clinically significant response,” said Dr. Pringle, a rheumatologist at Gartnavel General Hospital, Glasgow, Scotland.

Up to 40% of patients do not respond to their initial anti-TNF-α drug, commented Dr. Pringle.

However, because each of the different anti-TNF-α agents have different properties, Dr. Pringle advised sticking with the class before considering other therapies, despite the fact that switching patients to a second anti-TNF-α agent is not as cost effective (since second response rates are lower), as one meeting attendee pointed out.

BIRMINGHAM, ENGLAND — Nearly half of all patients who initially failed therapy with anti-tumor necrosis factor-α agents benefited following a switch to a second or third drug in the class, according to a study presented at the annual meeting of the British Society for Rheumatology.

Dr. Jemma Pringle and associates studied 153 rheumatology patients who had a mean disease duration of 12 years upon entrance to a registry between 2001 and 2006. The patients' median initial disease activity score (DAS) was 7.55.

A cohort of 53 patients stopped their initial anti-TNF-α agent. Of these, 23 stopped due to an adverse event and 30 from loss of efficacy. Of the 33 who received a second anti-TNF-α agent, 22 responded and have remained on the drug for a median of 19 months at the time of her presentation, Dr. Pringle said.

The other 11 stopped anti-TNF-α therapy because of side effects and/or a lack of efficacy. Patients experienced a mean decrease in DAS of 32% from baseline to 4.15 after they undertook treatment with an alternative anti-TNF-α agent.

Of the seven participants who eventually switched to a third drug, four responded and continued to take the drug for a median of 6 months. There was a 44% mean decrease in baseline DAS among these patients.

“Nearly half of these are presently continuing their second or third agent with a clinically significant response,” said Dr. Pringle, a rheumatologist at Gartnavel General Hospital, Glasgow, Scotland.

Up to 40% of patients do not respond to their initial anti-TNF-α drug, commented Dr. Pringle.

However, because each of the different anti-TNF-α agents have different properties, Dr. Pringle advised sticking with the class before considering other therapies, despite the fact that switching patients to a second anti-TNF-α agent is not as cost effective (since second response rates are lower), as one meeting attendee pointed out.

BIRMINGHAM, ENGLAND — Nearly half of all patients who initially failed therapy with anti-tumor necrosis factor-α agents benefited following a switch to a second or third drug in the class, according to a study presented at the annual meeting of the British Society for Rheumatology.

Dr. Jemma Pringle and associates studied 153 rheumatology patients who had a mean disease duration of 12 years upon entrance to a registry between 2001 and 2006. The patients' median initial disease activity score (DAS) was 7.55.

A cohort of 53 patients stopped their initial anti-TNF-α agent. Of these, 23 stopped due to an adverse event and 30 from loss of efficacy. Of the 33 who received a second anti-TNF-α agent, 22 responded and have remained on the drug for a median of 19 months at the time of her presentation, Dr. Pringle said.

The other 11 stopped anti-TNF-α therapy because of side effects and/or a lack of efficacy. Patients experienced a mean decrease in DAS of 32% from baseline to 4.15 after they undertook treatment with an alternative anti-TNF-α agent.

Of the seven participants who eventually switched to a third drug, four responded and continued to take the drug for a median of 6 months. There was a 44% mean decrease in baseline DAS among these patients.

“Nearly half of these are presently continuing their second or third agent with a clinically significant response,” said Dr. Pringle, a rheumatologist at Gartnavel General Hospital, Glasgow, Scotland.

Up to 40% of patients do not respond to their initial anti-TNF-α drug, commented Dr. Pringle.

However, because each of the different anti-TNF-α agents have different properties, Dr. Pringle advised sticking with the class before considering other therapies, despite the fact that switching patients to a second anti-TNF-α agent is not as cost effective (since second response rates are lower), as one meeting attendee pointed out.

BIRMINGHAM, ENGLAND — Adding adalimumab therapy to existing treatment of patients with rheumatoid arthritis might be a worthwhile step to drive some patients into remission, according to a large study presented at the annual meeting of the British Society for Rheumatology.

More than one-third of 6,610 long-term rheumatoid arthritis patients achieved remission at any point in the Research in Active Rheumatoid Arthritis (ReAct) study. Remission was achieved despite an average of three prior disease-modifying antirheumatic drugs and an average disease activity score (DAS) of 6.0 at baseline.

In contrast to a clinical trial that might exclude heavily pretreated patients or those with more severe disease, this open-label, multinational study was designed “to mimic day-to-day practices as best we could,” Dr. Paul Wordsworth said.

Participants received 40 mg adalimumab (Humira, Abbott) subcutaneously every other week for 12 weeks added to existing therapy with standard disease-modifying antirheumatic drugs, glucocorticoids and/or nonsteroidal anti-inflammatory drugs.

Patients could opt to continue the adjunctive therapy beyond 12 weeks. The mean duration of adalimumab treatment was 7 months. The mean age of participants was 54 years.

Overall, 81% of the participants in the study were female.

A subset of 1,251 patients continued adalimumab up to 52 weeks. At 1 year, 13% of patients were in remission for at least 6 months, defined as achievement of American College of Rheumatology 70% improvement criteria (ACR70).

The addition of adalimumab to standard therapy led to clinical remission defined as a DAS28 below 2.6 in 38% of all patients at any time during the study.

Remission was sustained at least 6 weeks by 21% of patients. A total of 20% achieved a DAS28 below 2.6 at week 12 and 25% at last observation, said Dr. Wordsworth, professor of clinical rheumatology, Nuffield Orthopaedic Centre, Oxford, England.

Researchers also assessed patients according to the simplified disease activity index (3.3 or less was considered remission), the clinical disease activity index, and the tender and swollen joint count.

Although it is difficult to conclude from this study if duration of therapy should go beyond 12 weeks, the percentage of patients who experienced clinical remission increased beyond this time point irrespective of the assessment method, Dr. Wordsworth said.

“There was a significant proportion of patients who had remission or significant improvement after 3 months,” he added.

Dr. Wordsworth disclosed that he is a consultant for Abbott, which makes adalimumab.

BIRMINGHAM, ENGLAND — Adding adalimumab therapy to existing treatment of patients with rheumatoid arthritis might be a worthwhile step to drive some patients into remission, according to a large study presented at the annual meeting of the British Society for Rheumatology.

More than one-third of 6,610 long-term rheumatoid arthritis patients achieved remission at any point in the Research in Active Rheumatoid Arthritis (ReAct) study. Remission was achieved despite an average of three prior disease-modifying antirheumatic drugs and an average disease activity score (DAS) of 6.0 at baseline.

In contrast to a clinical trial that might exclude heavily pretreated patients or those with more severe disease, this open-label, multinational study was designed “to mimic day-to-day practices as best we could,” Dr. Paul Wordsworth said.

Participants received 40 mg adalimumab (Humira, Abbott) subcutaneously every other week for 12 weeks added to existing therapy with standard disease-modifying antirheumatic drugs, glucocorticoids and/or nonsteroidal anti-inflammatory drugs.

Patients could opt to continue the adjunctive therapy beyond 12 weeks. The mean duration of adalimumab treatment was 7 months. The mean age of participants was 54 years.

Overall, 81% of the participants in the study were female.

A subset of 1,251 patients continued adalimumab up to 52 weeks. At 1 year, 13% of patients were in remission for at least 6 months, defined as achievement of American College of Rheumatology 70% improvement criteria (ACR70).

The addition of adalimumab to standard therapy led to clinical remission defined as a DAS28 below 2.6 in 38% of all patients at any time during the study.

Remission was sustained at least 6 weeks by 21% of patients. A total of 20% achieved a DAS28 below 2.6 at week 12 and 25% at last observation, said Dr. Wordsworth, professor of clinical rheumatology, Nuffield Orthopaedic Centre, Oxford, England.

Researchers also assessed patients according to the simplified disease activity index (3.3 or less was considered remission), the clinical disease activity index, and the tender and swollen joint count.

Although it is difficult to conclude from this study if duration of therapy should go beyond 12 weeks, the percentage of patients who experienced clinical remission increased beyond this time point irrespective of the assessment method, Dr. Wordsworth said.

“There was a significant proportion of patients who had remission or significant improvement after 3 months,” he added.

Dr. Wordsworth disclosed that he is a consultant for Abbott, which makes adalimumab.

BIRMINGHAM, ENGLAND — Adding adalimumab therapy to existing treatment of patients with rheumatoid arthritis might be a worthwhile step to drive some patients into remission, according to a large study presented at the annual meeting of the British Society for Rheumatology.

More than one-third of 6,610 long-term rheumatoid arthritis patients achieved remission at any point in the Research in Active Rheumatoid Arthritis (ReAct) study. Remission was achieved despite an average of three prior disease-modifying antirheumatic drugs and an average disease activity score (DAS) of 6.0 at baseline.

In contrast to a clinical trial that might exclude heavily pretreated patients or those with more severe disease, this open-label, multinational study was designed “to mimic day-to-day practices as best we could,” Dr. Paul Wordsworth said.

Participants received 40 mg adalimumab (Humira, Abbott) subcutaneously every other week for 12 weeks added to existing therapy with standard disease-modifying antirheumatic drugs, glucocorticoids and/or nonsteroidal anti-inflammatory drugs.

Patients could opt to continue the adjunctive therapy beyond 12 weeks. The mean duration of adalimumab treatment was 7 months. The mean age of participants was 54 years.

Overall, 81% of the participants in the study were female.

A subset of 1,251 patients continued adalimumab up to 52 weeks. At 1 year, 13% of patients were in remission for at least 6 months, defined as achievement of American College of Rheumatology 70% improvement criteria (ACR70).

The addition of adalimumab to standard therapy led to clinical remission defined as a DAS28 below 2.6 in 38% of all patients at any time during the study.

Remission was sustained at least 6 weeks by 21% of patients. A total of 20% achieved a DAS28 below 2.6 at week 12 and 25% at last observation, said Dr. Wordsworth, professor of clinical rheumatology, Nuffield Orthopaedic Centre, Oxford, England.

Researchers also assessed patients according to the simplified disease activity index (3.3 or less was considered remission), the clinical disease activity index, and the tender and swollen joint count.

Although it is difficult to conclude from this study if duration of therapy should go beyond 12 weeks, the percentage of patients who experienced clinical remission increased beyond this time point irrespective of the assessment method, Dr. Wordsworth said.

“There was a significant proportion of patients who had remission or significant improvement after 3 months,” he added.

Dr. Wordsworth disclosed that he is a consultant for Abbott, which makes adalimumab.