Damian McNamara

MIAMI BEACH — Eclamptic seizures are a rare but serious complication best treated according to a preestablished protocol, Dr. Baha Sibai said at an ob.gyn. conference sponsored by the University of Miami.

“Don't look for fetal heart rate first or think of the seizure. Don't stop to give meds to stop the seizure, and cover the fetal heart rate monitor,” he said. Instead, take care of the mother first, and “treat the patient according to her vital signs,” said Dr. Sibai, professor of obstetrics and gynecology at the University of Cincinnati.

He suggested the following seven steps for managing eclamptic seizure:

1. Prevent hypoxia by supporting maternal respiratory and cardiovascular functions.

2. Prevent maternal injury and aspiration.

3. Avoid the temptation to try to arrest the first seizure.

4. Prevent convulsions from recurring. This is accomplished chiefly with intravenous magnesium sulfate, administered slowly and never as an intravenous push, Dr. Sibai said. He suggested 6 g administered IV over 20 minutes, with 2 g IV per hour for maintenance. “When you give the loading dose, they feel terrible,” Dr. Sibai said. “I know this feels bad. I gave it to myself when I developed these protocols.” Talk to the patient to prevent magnesium toxicity. “If they are disoriented, they are approaching toxic levels,” Dr. Sibai said. “If a patient on magnesium shows abnormal behavior for any reason, for heaven's sake, stop it. No one has ever died from a lack of magnesium.”

5. Control severe hypertension to prevent cerebrovascular injury. “Most people don't know how to give antihypertension meds,” he said. “Call someone if you don't know, but not someone more ignorant than you. An IV bolus of 5 mg hydralazine, with another 10 mg IV bolus given 20-30 minutes later, can help control severe hypertension, he added. “Notice I haven't mentioned the fetal heart rate or baby yet,” Dr. Sibai said.

6. Manage complications such as disseminated intravascular coagulation and pulmonary edema.

7. Begin induction/delivery within 24 hours. “The worst thing you can do is everyone panics and rushes the woman to a C-section,” Dr. Sibai said. “Assess neurologic status. This is extremely important—do not take her for a C-section if unconscious.” Ask the patient to state her name, where she is, and the time of year.

Taking care of the mother first is important because “the baby will not do well if the mother is not doing well,” Dr. Sibai concluded.

MIAMI BEACH — Eclamptic seizures are a rare but serious complication best treated according to a preestablished protocol, Dr. Baha Sibai said at an ob.gyn. conference sponsored by the University of Miami.

“Don't look for fetal heart rate first or think of the seizure. Don't stop to give meds to stop the seizure, and cover the fetal heart rate monitor,” he said. Instead, take care of the mother first, and “treat the patient according to her vital signs,” said Dr. Sibai, professor of obstetrics and gynecology at the University of Cincinnati.

He suggested the following seven steps for managing eclamptic seizure:

1. Prevent hypoxia by supporting maternal respiratory and cardiovascular functions.

2. Prevent maternal injury and aspiration.

3. Avoid the temptation to try to arrest the first seizure.

4. Prevent convulsions from recurring. This is accomplished chiefly with intravenous magnesium sulfate, administered slowly and never as an intravenous push, Dr. Sibai said. He suggested 6 g administered IV over 20 minutes, with 2 g IV per hour for maintenance. “When you give the loading dose, they feel terrible,” Dr. Sibai said. “I know this feels bad. I gave it to myself when I developed these protocols.” Talk to the patient to prevent magnesium toxicity. “If they are disoriented, they are approaching toxic levels,” Dr. Sibai said. “If a patient on magnesium shows abnormal behavior for any reason, for heaven's sake, stop it. No one has ever died from a lack of magnesium.”

5. Control severe hypertension to prevent cerebrovascular injury. “Most people don't know how to give antihypertension meds,” he said. “Call someone if you don't know, but not someone more ignorant than you. An IV bolus of 5 mg hydralazine, with another 10 mg IV bolus given 20-30 minutes later, can help control severe hypertension, he added. “Notice I haven't mentioned the fetal heart rate or baby yet,” Dr. Sibai said.

6. Manage complications such as disseminated intravascular coagulation and pulmonary edema.

7. Begin induction/delivery within 24 hours. “The worst thing you can do is everyone panics and rushes the woman to a C-section,” Dr. Sibai said. “Assess neurologic status. This is extremely important—do not take her for a C-section if unconscious.” Ask the patient to state her name, where she is, and the time of year.

Taking care of the mother first is important because “the baby will not do well if the mother is not doing well,” Dr. Sibai concluded.

MIAMI BEACH — Eclamptic seizures are a rare but serious complication best treated according to a preestablished protocol, Dr. Baha Sibai said at an ob.gyn. conference sponsored by the University of Miami.

“Don't look for fetal heart rate first or think of the seizure. Don't stop to give meds to stop the seizure, and cover the fetal heart rate monitor,” he said. Instead, take care of the mother first, and “treat the patient according to her vital signs,” said Dr. Sibai, professor of obstetrics and gynecology at the University of Cincinnati.

He suggested the following seven steps for managing eclamptic seizure:

1. Prevent hypoxia by supporting maternal respiratory and cardiovascular functions.

2. Prevent maternal injury and aspiration.

3. Avoid the temptation to try to arrest the first seizure.

4. Prevent convulsions from recurring. This is accomplished chiefly with intravenous magnesium sulfate, administered slowly and never as an intravenous push, Dr. Sibai said. He suggested 6 g administered IV over 20 minutes, with 2 g IV per hour for maintenance. “When you give the loading dose, they feel terrible,” Dr. Sibai said. “I know this feels bad. I gave it to myself when I developed these protocols.” Talk to the patient to prevent magnesium toxicity. “If they are disoriented, they are approaching toxic levels,” Dr. Sibai said. “If a patient on magnesium shows abnormal behavior for any reason, for heaven's sake, stop it. No one has ever died from a lack of magnesium.”

5. Control severe hypertension to prevent cerebrovascular injury. “Most people don't know how to give antihypertension meds,” he said. “Call someone if you don't know, but not someone more ignorant than you. An IV bolus of 5 mg hydralazine, with another 10 mg IV bolus given 20-30 minutes later, can help control severe hypertension, he added. “Notice I haven't mentioned the fetal heart rate or baby yet,” Dr. Sibai said.

6. Manage complications such as disseminated intravascular coagulation and pulmonary edema.

7. Begin induction/delivery within 24 hours. “The worst thing you can do is everyone panics and rushes the woman to a C-section,” Dr. Sibai said. “Assess neurologic status. This is extremely important—do not take her for a C-section if unconscious.” Ask the patient to state her name, where she is, and the time of year.

Taking care of the mother first is important because “the baby will not do well if the mother is not doing well,” Dr. Sibai concluded.

DENVER — Lessons learned by clinicians at a multidisciplinary program regarding the transition of pediatric patients with spina bifida to an adult medical home can help others meeting the same challenges, according to a presentation at a meeting on pediatric neurologic surgery.

“As patients with spina bifida reach adulthood, there is an ongoing challenge,” Dr. Hector E. James said. “Most of us know the difficulty of finding an adult medical home for patients we've seen for years in a multidisciplinary setting. There is a lack of knowledge amongst adult heath care providers as to the needs of the young adult with spina bifida.”

Some answers may come from the Jacksonville Health and Adult Transitional Services (JaxHATS) program. Dr. James reported that JaxHATS has successfully transitioned patients from the spinal defects clinic at Wolfson Children's Hospital in Jacksonville, Fla., to an adult medical home. The program, launched in 2005, includes a pediatrician, internist, nurse-coordinator, unit manager, and medical social worker.

It can be a challenge to find neurosurgeons who are willing to become primary care providers for young adults with spina bifida. “I am obviously generalizing, but it's not an uncommon problem,” he added at the meeting, which was jointly sponsored by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons.

A meeting attendee asked how the JaxHATS clinicians get “buy-in” from adult providers. “We were fortunate in finding a pediatrician and internist who were willing to do this,” Dr. James replied.

These doctors assess the teenager and then educate the adult subspecialist about their special needs.

Also, “incorporating an educational component for residents at our academic institution helped gain acceptance from administrators,” said Dr. James, a pediatric neurosurgeon at the Lucy Gooding Pediatric Neurosurgery Center at Wolfson Children's Hospital.

The adolescent and family are prepared for the transition process into adulthood during visits to the spinal defects clinic. Then intake information is taken by the JaxHATS staff. The clinic coordinator and nurse-coordinator prepare a “transition medical summary” for the pediatrician and internist. Insurance reimbursement must be established in advance, Dr. James said. “It is extremely important to have insurance paperwork done correctly for the first appointment. The social worker and manager assist families with this and follow-up appointments.”

An initial 16 patients have successfully completed the transition. Although the JaxHATS program “is still a work in progress,” Dr. James said, “it is a very rewarding experience. It may not be a model for everyone, but it worked for us.”

DENVER — Lessons learned by clinicians at a multidisciplinary program regarding the transition of pediatric patients with spina bifida to an adult medical home can help others meeting the same challenges, according to a presentation at a meeting on pediatric neurologic surgery.

“As patients with spina bifida reach adulthood, there is an ongoing challenge,” Dr. Hector E. James said. “Most of us know the difficulty of finding an adult medical home for patients we've seen for years in a multidisciplinary setting. There is a lack of knowledge amongst adult heath care providers as to the needs of the young adult with spina bifida.”

Some answers may come from the Jacksonville Health and Adult Transitional Services (JaxHATS) program. Dr. James reported that JaxHATS has successfully transitioned patients from the spinal defects clinic at Wolfson Children's Hospital in Jacksonville, Fla., to an adult medical home. The program, launched in 2005, includes a pediatrician, internist, nurse-coordinator, unit manager, and medical social worker.

It can be a challenge to find neurosurgeons who are willing to become primary care providers for young adults with spina bifida. “I am obviously generalizing, but it's not an uncommon problem,” he added at the meeting, which was jointly sponsored by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons.

A meeting attendee asked how the JaxHATS clinicians get “buy-in” from adult providers. “We were fortunate in finding a pediatrician and internist who were willing to do this,” Dr. James replied.

These doctors assess the teenager and then educate the adult subspecialist about their special needs.

Also, “incorporating an educational component for residents at our academic institution helped gain acceptance from administrators,” said Dr. James, a pediatric neurosurgeon at the Lucy Gooding Pediatric Neurosurgery Center at Wolfson Children's Hospital.

The adolescent and family are prepared for the transition process into adulthood during visits to the spinal defects clinic. Then intake information is taken by the JaxHATS staff. The clinic coordinator and nurse-coordinator prepare a “transition medical summary” for the pediatrician and internist. Insurance reimbursement must be established in advance, Dr. James said. “It is extremely important to have insurance paperwork done correctly for the first appointment. The social worker and manager assist families with this and follow-up appointments.”

An initial 16 patients have successfully completed the transition. Although the JaxHATS program “is still a work in progress,” Dr. James said, “it is a very rewarding experience. It may not be a model for everyone, but it worked for us.”

DENVER — Lessons learned by clinicians at a multidisciplinary program regarding the transition of pediatric patients with spina bifida to an adult medical home can help others meeting the same challenges, according to a presentation at a meeting on pediatric neurologic surgery.

“As patients with spina bifida reach adulthood, there is an ongoing challenge,” Dr. Hector E. James said. “Most of us know the difficulty of finding an adult medical home for patients we've seen for years in a multidisciplinary setting. There is a lack of knowledge amongst adult heath care providers as to the needs of the young adult with spina bifida.”

Some answers may come from the Jacksonville Health and Adult Transitional Services (JaxHATS) program. Dr. James reported that JaxHATS has successfully transitioned patients from the spinal defects clinic at Wolfson Children's Hospital in Jacksonville, Fla., to an adult medical home. The program, launched in 2005, includes a pediatrician, internist, nurse-coordinator, unit manager, and medical social worker.

It can be a challenge to find neurosurgeons who are willing to become primary care providers for young adults with spina bifida. “I am obviously generalizing, but it's not an uncommon problem,” he added at the meeting, which was jointly sponsored by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons.

A meeting attendee asked how the JaxHATS clinicians get “buy-in” from adult providers. “We were fortunate in finding a pediatrician and internist who were willing to do this,” Dr. James replied.

These doctors assess the teenager and then educate the adult subspecialist about their special needs.

Also, “incorporating an educational component for residents at our academic institution helped gain acceptance from administrators,” said Dr. James, a pediatric neurosurgeon at the Lucy Gooding Pediatric Neurosurgery Center at Wolfson Children's Hospital.

The adolescent and family are prepared for the transition process into adulthood during visits to the spinal defects clinic. Then intake information is taken by the JaxHATS staff. The clinic coordinator and nurse-coordinator prepare a “transition medical summary” for the pediatrician and internist. Insurance reimbursement must be established in advance, Dr. James said. “It is extremely important to have insurance paperwork done correctly for the first appointment. The social worker and manager assist families with this and follow-up appointments.”

An initial 16 patients have successfully completed the transition. Although the JaxHATS program “is still a work in progress,” Dr. James said, “it is a very rewarding experience. It may not be a model for everyone, but it worked for us.”

People with low normal thyroid function are at elevated risk for components of the metabolic syndrome, according to the first large, community-based study of this population.

Previous research showed an association between overt hypothyroidism and atherosclerotic cardiovascular disease (J. Clin. Endocrinol. Metab. 2003;88:2438–44; N. Engl. J. Med. 2001;344:501–9). However, the current study indicates that thyroid function can influence lipid metabolism even in the euthyroid range, said Dr. Annemieke Roos, of the department of endocrinology at the University Medical Center Groningen (the Netherlands), and her associates.

They assessed 1,581 euthyroid participants from the Prevention of Renal and Vascular End Stage Disease (PREVEND) study (J. Am. Soc. Nephrol. 2000;11:1882–8). People were considered euthyroid if they were within the reference range for thyroid-stimulating hormone (0.35–4.94 mIU/L) and free T₄ (9.14–23.81 pmol/L) without taking thyroid medication.

A total of 19% of men and 15% of women met the National Cholesterol Education Program's Adult Treatment Panel (ATP) III criteria for metabolic syndrome. After adjustment for age and gender, free T₄ (FT₄) was significantly related to four out of five ATP III criteria: abdominal obesity; glucose intolerance/insulin resistance; atherogenic dyslipidemia; and a proinflammatory/prothrombic state. Association with hypertension, was not significant (J. Clin. Endocrinol. Metab. 2007;92:491–6).

After adjustment for insulin resistance, FT₄ associations with waist circumference, triglycerides, and HDL cholesterol became weaker but remained significant. The finding suggests “mechanisms other than those associated with insulin resistance underlie the relation of FT₄ with these components of the metabolic syndrome.”

People with low normal thyroid function are at elevated risk for components of the metabolic syndrome, according to the first large, community-based study of this population.

Previous research showed an association between overt hypothyroidism and atherosclerotic cardiovascular disease (J. Clin. Endocrinol. Metab. 2003;88:2438–44; N. Engl. J. Med. 2001;344:501–9). However, the current study indicates that thyroid function can influence lipid metabolism even in the euthyroid range, said Dr. Annemieke Roos, of the department of endocrinology at the University Medical Center Groningen (the Netherlands), and her associates.

They assessed 1,581 euthyroid participants from the Prevention of Renal and Vascular End Stage Disease (PREVEND) study (J. Am. Soc. Nephrol. 2000;11:1882–8). People were considered euthyroid if they were within the reference range for thyroid-stimulating hormone (0.35–4.94 mIU/L) and free T₄ (9.14–23.81 pmol/L) without taking thyroid medication.

A total of 19% of men and 15% of women met the National Cholesterol Education Program's Adult Treatment Panel (ATP) III criteria for metabolic syndrome. After adjustment for age and gender, free T₄ (FT₄) was significantly related to four out of five ATP III criteria: abdominal obesity; glucose intolerance/insulin resistance; atherogenic dyslipidemia; and a proinflammatory/prothrombic state. Association with hypertension, was not significant (J. Clin. Endocrinol. Metab. 2007;92:491–6).

After adjustment for insulin resistance, FT₄ associations with waist circumference, triglycerides, and HDL cholesterol became weaker but remained significant. The finding suggests “mechanisms other than those associated with insulin resistance underlie the relation of FT₄ with these components of the metabolic syndrome.”

People with low normal thyroid function are at elevated risk for components of the metabolic syndrome, according to the first large, community-based study of this population.

Previous research showed an association between overt hypothyroidism and atherosclerotic cardiovascular disease (J. Clin. Endocrinol. Metab. 2003;88:2438–44; N. Engl. J. Med. 2001;344:501–9). However, the current study indicates that thyroid function can influence lipid metabolism even in the euthyroid range, said Dr. Annemieke Roos, of the department of endocrinology at the University Medical Center Groningen (the Netherlands), and her associates.

They assessed 1,581 euthyroid participants from the Prevention of Renal and Vascular End Stage Disease (PREVEND) study (J. Am. Soc. Nephrol. 2000;11:1882–8). People were considered euthyroid if they were within the reference range for thyroid-stimulating hormone (0.35–4.94 mIU/L) and free T₄ (9.14–23.81 pmol/L) without taking thyroid medication.

A total of 19% of men and 15% of women met the National Cholesterol Education Program's Adult Treatment Panel (ATP) III criteria for metabolic syndrome. After adjustment for age and gender, free T₄ (FT₄) was significantly related to four out of five ATP III criteria: abdominal obesity; glucose intolerance/insulin resistance; atherogenic dyslipidemia; and a proinflammatory/prothrombic state. Association with hypertension, was not significant (J. Clin. Endocrinol. Metab. 2007;92:491–6).

After adjustment for insulin resistance, FT₄ associations with waist circumference, triglycerides, and HDL cholesterol became weaker but remained significant. The finding suggests “mechanisms other than those associated with insulin resistance underlie the relation of FT₄ with these components of the metabolic syndrome.”

FORT MYERS, FLA. – Increasing methamphetamine use not only boosts violent injuries and law enforcement altercations among trauma patients, but it can create a significant financial burden for a level I trauma center, according to a study.

Methamphetamine-positive trauma patients were more likely to have a violent cause of injury such as assault, gunshot wound, or stabbing, compared with non-meth users, Dr. Sophia M. Swanson said during poster walk rounds at the annual meeting of the Eastern Association for the Surgery of Trauma.

“Methamphetamine is really increasing nationally,” Dr. Swanson said. “An estimated 10 million people have used methamphetamine at least once in their lifetime.”

During the 3 years of the study (2003–2005), there was a steady increase in methamphetamine use, from 9% to 15% of patients. Methamphetamine replaced marijuana as the most common drug of abuse in 2005 among patients at the University of California, San Diego, where Dr. Swanson was a medical student at the time of the study.

To gauge methamphetamine's impact, Dr. Swanson and her associates reviewed a registry of 4,648 consecutive trauma patients who had both a blood and toxicology screen at admission. This patient population is the 71% of all trauma patients who had toxicology screens.

“We found meth users were more likely to be young, male, more severely injured, and more likely to be Hispanic,” Dr. Swanson said at the meeting, which was jointly sponsored by Wake Forest University.

Methamphetamine users had a higher mean injury severity score (10.9) versus nonusers (9.9); were 56% more likely to require mechanical ventilation; and were 53% more likely to undergo an operation.

The users also were more likely than nonusers to leave the emergency department against the recommendations of physicians (5% versus 2%), and were more likely to die from their injuries (6% versus 3%).

Methamphetamine-positive patients had a fivefold increased likelihood of an altercation with law enforcement. “That is really striking,” Dr. Swanson said.

Methamphetamine-positive patients were twice as likely to have violence as the mechanism of injury (47%, versus 26% of nonusers). This finding included 36% more assaults, 85% more gunshot wounds, and 146% more stab wounds than for nonusers.

Adverse effects are not limited to patients. There is an increasingly significant financial burden to trauma centers, Dr. Swanson said. Despite similar length of stays, costs averaged 7% higher for methamphetamine-positive patients. Methamphetamine users were about twice as likely to be uninsured (54% versus 28%). There was an average of $10,000 of uncompensated care per methamphetamine-positive patient, Dr. Swanson said.

Emergency physicians and trauma physicians can make a difference, Dr. Swanson said. One tactic is screening for amphetamine use and a brief intervention. “It's easy, it's quick, and it can be done in the ED. Lack of reimbursement, however, is a concern.” She also recommended that doctors “get involved in community-based methamphetamine prevention programs.”

FORT MYERS, FLA. – Increasing methamphetamine use not only boosts violent injuries and law enforcement altercations among trauma patients, but it can create a significant financial burden for a level I trauma center, according to a study.

Methamphetamine-positive trauma patients were more likely to have a violent cause of injury such as assault, gunshot wound, or stabbing, compared with non-meth users, Dr. Sophia M. Swanson said during poster walk rounds at the annual meeting of the Eastern Association for the Surgery of Trauma.

“Methamphetamine is really increasing nationally,” Dr. Swanson said. “An estimated 10 million people have used methamphetamine at least once in their lifetime.”

During the 3 years of the study (2003–2005), there was a steady increase in methamphetamine use, from 9% to 15% of patients. Methamphetamine replaced marijuana as the most common drug of abuse in 2005 among patients at the University of California, San Diego, where Dr. Swanson was a medical student at the time of the study.

To gauge methamphetamine's impact, Dr. Swanson and her associates reviewed a registry of 4,648 consecutive trauma patients who had both a blood and toxicology screen at admission. This patient population is the 71% of all trauma patients who had toxicology screens.

“We found meth users were more likely to be young, male, more severely injured, and more likely to be Hispanic,” Dr. Swanson said at the meeting, which was jointly sponsored by Wake Forest University.

Methamphetamine users had a higher mean injury severity score (10.9) versus nonusers (9.9); were 56% more likely to require mechanical ventilation; and were 53% more likely to undergo an operation.

The users also were more likely than nonusers to leave the emergency department against the recommendations of physicians (5% versus 2%), and were more likely to die from their injuries (6% versus 3%).

Methamphetamine-positive patients had a fivefold increased likelihood of an altercation with law enforcement. “That is really striking,” Dr. Swanson said.

Methamphetamine-positive patients were twice as likely to have violence as the mechanism of injury (47%, versus 26% of nonusers). This finding included 36% more assaults, 85% more gunshot wounds, and 146% more stab wounds than for nonusers.

Adverse effects are not limited to patients. There is an increasingly significant financial burden to trauma centers, Dr. Swanson said. Despite similar length of stays, costs averaged 7% higher for methamphetamine-positive patients. Methamphetamine users were about twice as likely to be uninsured (54% versus 28%). There was an average of $10,000 of uncompensated care per methamphetamine-positive patient, Dr. Swanson said.

Emergency physicians and trauma physicians can make a difference, Dr. Swanson said. One tactic is screening for amphetamine use and a brief intervention. “It's easy, it's quick, and it can be done in the ED. Lack of reimbursement, however, is a concern.” She also recommended that doctors “get involved in community-based methamphetamine prevention programs.”

FORT MYERS, FLA. – Increasing methamphetamine use not only boosts violent injuries and law enforcement altercations among trauma patients, but it can create a significant financial burden for a level I trauma center, according to a study.

Methamphetamine-positive trauma patients were more likely to have a violent cause of injury such as assault, gunshot wound, or stabbing, compared with non-meth users, Dr. Sophia M. Swanson said during poster walk rounds at the annual meeting of the Eastern Association for the Surgery of Trauma.

“Methamphetamine is really increasing nationally,” Dr. Swanson said. “An estimated 10 million people have used methamphetamine at least once in their lifetime.”

During the 3 years of the study (2003–2005), there was a steady increase in methamphetamine use, from 9% to 15% of patients. Methamphetamine replaced marijuana as the most common drug of abuse in 2005 among patients at the University of California, San Diego, where Dr. Swanson was a medical student at the time of the study.

To gauge methamphetamine's impact, Dr. Swanson and her associates reviewed a registry of 4,648 consecutive trauma patients who had both a blood and toxicology screen at admission. This patient population is the 71% of all trauma patients who had toxicology screens.

“We found meth users were more likely to be young, male, more severely injured, and more likely to be Hispanic,” Dr. Swanson said at the meeting, which was jointly sponsored by Wake Forest University.

Methamphetamine users had a higher mean injury severity score (10.9) versus nonusers (9.9); were 56% more likely to require mechanical ventilation; and were 53% more likely to undergo an operation.

The users also were more likely than nonusers to leave the emergency department against the recommendations of physicians (5% versus 2%), and were more likely to die from their injuries (6% versus 3%).

Methamphetamine-positive patients had a fivefold increased likelihood of an altercation with law enforcement. “That is really striking,” Dr. Swanson said.

Methamphetamine-positive patients were twice as likely to have violence as the mechanism of injury (47%, versus 26% of nonusers). This finding included 36% more assaults, 85% more gunshot wounds, and 146% more stab wounds than for nonusers.

Adverse effects are not limited to patients. There is an increasingly significant financial burden to trauma centers, Dr. Swanson said. Despite similar length of stays, costs averaged 7% higher for methamphetamine-positive patients. Methamphetamine users were about twice as likely to be uninsured (54% versus 28%). There was an average of $10,000 of uncompensated care per methamphetamine-positive patient, Dr. Swanson said.

Emergency physicians and trauma physicians can make a difference, Dr. Swanson said. One tactic is screening for amphetamine use and a brief intervention. “It's easy, it's quick, and it can be done in the ED. Lack of reimbursement, however, is a concern.” She also recommended that doctors “get involved in community-based methamphetamine prevention programs.”

FORT MYERS, FLA. — American surgeons who were stationed in Afghanistan during the early phase of the U.S. military operation in 2002 quickly learned to expect the unexpected, according to a presentation at the annual meeting of the Eastern Association for the Surgery of Trauma.

For example, a U.S. Air Force field transfer hospital that was established solely for stabilizing U.S. military personnel had to accommodate local Afghans needing surgical care, which forced surgeons like Dr. Henry J. Schiller to quickly do more with less.

"We were a reserve combat support hospital. We were not outfitted to take care of indigenous personnel," said Dr. Schiller, who is now on the surgery faculty at the Mayo Clinic in Rochester, Minn. Because of the minimal health care structure in that country, however, "we ended up taking care of everyone," he said.

Surgical management of injuries from land mine explosions was not what surgeons initially expected, either. "We dealt with a lot of kids who stepped on a land mine. The foot that steps on the land mine often gets blown off," Dr. Schiller said at the meeting, which was jointly sponsored by Wake Forest University.

Surgeons soon learned that although most entry point wounds were small and rather innocent looking, they often masked a great deal of debris. X-rays were of limited value because most debris was not metallic.

"The force of the explosion blows grass, dirt, and other debris up into the leg, so there is a large level of contamination. The contralateral limb would be affected as well," Dr. Schiller explained.

"Battlefields are very contaminated places," said Dr. Donald Jenkins, a U.S. Air Force colonel and trauma medical director at Lackland Air Force Base, Texas, in a separate presentation at the meeting.

In some cases, infection already is disseminated when a patient arrives. "In Afghanistan, there can be hours or days before they present, versus the typical 30 minutes in Iraq."

Initial surgical management consisted of limited debridement and wound closure, but many patients developed infections from the extensive contamination. Experience taught the surgeons to make linear extensions to expand the wounds for debridement, to debride frequently, and to leave wounds open whenever possible.

For example, one Afghani man presented as acidotic with a gunshot wound to his groin. His wound was then closed two or three times, Dr. Schiller said. "Finally, we left the wound open and it healed with secondary intention."

"Open wounds are safe—it was a difficult question when to close, if to close," Dr. Schiller said. Open wound management was adopted for most land mine injuries. "Circular amputation is pretty common with land mine injuries," he said. "We leave skin and muscle flaps and let it heal by secondary intention." However, it is not foolproof; another land mine patient who seemed to be doing well developed necrotizing fasciitis and ultimately was lost to multiorgan failure.

"We did sharp debridement," Dr. Schiller said. "Even saline was in short supply." Surgeons debrided wounds each day in the operating room, the most sterile area of the hospital, and used analgesia liberally.

In response to a question about antibiotic therapy for these patients, Dr. Schiller said, "We used Bactrim; we had a fairly good supply."

Dr. Jenkins agreed with Dr. Schiller that the reality was different from what he expected. "Our phrase was, 'We knew what it was supposed to be like with blast injuries, but we didn't know what it was like,' "he said. "It would be akin to [people] without kids reading a Dr. Spock book and watching a nephew for a weekend, and saying they know what it's like to be a parent."

FORT MYERS, FLA. — American surgeons who were stationed in Afghanistan during the early phase of the U.S. military operation in 2002 quickly learned to expect the unexpected, according to a presentation at the annual meeting of the Eastern Association for the Surgery of Trauma.

For example, a U.S. Air Force field transfer hospital that was established solely for stabilizing U.S. military personnel had to accommodate local Afghans needing surgical care, which forced surgeons like Dr. Henry J. Schiller to quickly do more with less.

"We were a reserve combat support hospital. We were not outfitted to take care of indigenous personnel," said Dr. Schiller, who is now on the surgery faculty at the Mayo Clinic in Rochester, Minn. Because of the minimal health care structure in that country, however, "we ended up taking care of everyone," he said.

Surgical management of injuries from land mine explosions was not what surgeons initially expected, either. "We dealt with a lot of kids who stepped on a land mine. The foot that steps on the land mine often gets blown off," Dr. Schiller said at the meeting, which was jointly sponsored by Wake Forest University.

Surgeons soon learned that although most entry point wounds were small and rather innocent looking, they often masked a great deal of debris. X-rays were of limited value because most debris was not metallic.

"The force of the explosion blows grass, dirt, and other debris up into the leg, so there is a large level of contamination. The contralateral limb would be affected as well," Dr. Schiller explained.

"Battlefields are very contaminated places," said Dr. Donald Jenkins, a U.S. Air Force colonel and trauma medical director at Lackland Air Force Base, Texas, in a separate presentation at the meeting.

In some cases, infection already is disseminated when a patient arrives. "In Afghanistan, there can be hours or days before they present, versus the typical 30 minutes in Iraq."

Initial surgical management consisted of limited debridement and wound closure, but many patients developed infections from the extensive contamination. Experience taught the surgeons to make linear extensions to expand the wounds for debridement, to debride frequently, and to leave wounds open whenever possible.

For example, one Afghani man presented as acidotic with a gunshot wound to his groin. His wound was then closed two or three times, Dr. Schiller said. "Finally, we left the wound open and it healed with secondary intention."

"Open wounds are safe—it was a difficult question when to close, if to close," Dr. Schiller said. Open wound management was adopted for most land mine injuries. "Circular amputation is pretty common with land mine injuries," he said. "We leave skin and muscle flaps and let it heal by secondary intention." However, it is not foolproof; another land mine patient who seemed to be doing well developed necrotizing fasciitis and ultimately was lost to multiorgan failure.

"We did sharp debridement," Dr. Schiller said. "Even saline was in short supply." Surgeons debrided wounds each day in the operating room, the most sterile area of the hospital, and used analgesia liberally.

In response to a question about antibiotic therapy for these patients, Dr. Schiller said, "We used Bactrim; we had a fairly good supply."

Dr. Jenkins agreed with Dr. Schiller that the reality was different from what he expected. "Our phrase was, 'We knew what it was supposed to be like with blast injuries, but we didn't know what it was like,' "he said. "It would be akin to [people] without kids reading a Dr. Spock book and watching a nephew for a weekend, and saying they know what it's like to be a parent."

FORT MYERS, FLA. — American surgeons who were stationed in Afghanistan during the early phase of the U.S. military operation in 2002 quickly learned to expect the unexpected, according to a presentation at the annual meeting of the Eastern Association for the Surgery of Trauma.

For example, a U.S. Air Force field transfer hospital that was established solely for stabilizing U.S. military personnel had to accommodate local Afghans needing surgical care, which forced surgeons like Dr. Henry J. Schiller to quickly do more with less.

"We were a reserve combat support hospital. We were not outfitted to take care of indigenous personnel," said Dr. Schiller, who is now on the surgery faculty at the Mayo Clinic in Rochester, Minn. Because of the minimal health care structure in that country, however, "we ended up taking care of everyone," he said.

Surgical management of injuries from land mine explosions was not what surgeons initially expected, either. "We dealt with a lot of kids who stepped on a land mine. The foot that steps on the land mine often gets blown off," Dr. Schiller said at the meeting, which was jointly sponsored by Wake Forest University.

Surgeons soon learned that although most entry point wounds were small and rather innocent looking, they often masked a great deal of debris. X-rays were of limited value because most debris was not metallic.

"The force of the explosion blows grass, dirt, and other debris up into the leg, so there is a large level of contamination. The contralateral limb would be affected as well," Dr. Schiller explained.

"Battlefields are very contaminated places," said Dr. Donald Jenkins, a U.S. Air Force colonel and trauma medical director at Lackland Air Force Base, Texas, in a separate presentation at the meeting.

In some cases, infection already is disseminated when a patient arrives. "In Afghanistan, there can be hours or days before they present, versus the typical 30 minutes in Iraq."

Initial surgical management consisted of limited debridement and wound closure, but many patients developed infections from the extensive contamination. Experience taught the surgeons to make linear extensions to expand the wounds for debridement, to debride frequently, and to leave wounds open whenever possible.

For example, one Afghani man presented as acidotic with a gunshot wound to his groin. His wound was then closed two or three times, Dr. Schiller said. "Finally, we left the wound open and it healed with secondary intention."

"Open wounds are safe—it was a difficult question when to close, if to close," Dr. Schiller said. Open wound management was adopted for most land mine injuries. "Circular amputation is pretty common with land mine injuries," he said. "We leave skin and muscle flaps and let it heal by secondary intention." However, it is not foolproof; another land mine patient who seemed to be doing well developed necrotizing fasciitis and ultimately was lost to multiorgan failure.

"We did sharp debridement," Dr. Schiller said. "Even saline was in short supply." Surgeons debrided wounds each day in the operating room, the most sterile area of the hospital, and used analgesia liberally.

In response to a question about antibiotic therapy for these patients, Dr. Schiller said, "We used Bactrim; we had a fairly good supply."

Dr. Jenkins agreed with Dr. Schiller that the reality was different from what he expected. "Our phrase was, 'We knew what it was supposed to be like with blast injuries, but we didn't know what it was like,' "he said. "It would be akin to [people] without kids reading a Dr. Spock book and watching a nephew for a weekend, and saying they know what it's like to be a parent."

MIAMI BEACH — Cosmetic enhancement with Radiesse is technique dependent, and three experts shared their clinical tips to optimize success with this filler at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

Radiesse (calcium hydroxylapatite, BioForm Medical) is manufactured as synthetic microspheres that are suspended in a resorbable aqueous gel.

Calcium hydroxylapatite provides immediate results and is versatile, moldable, and longer lasting than some other filler products, said Dr. Susan H. Weinkle, who is with the University of South Florida in Tampa.

The product's gel carrier degrades in 3–6 months for 70% of patients, she said.

During this time, new collagen formation is ongoing. "If you avoid the temptation to retreat patients at 6 months when the gel drops, you will see continued improvement," said Dr. David J. Goldberg of the department of dermatology at Mount Sinai School of Medicine in New York.

A meeting attendee wanted to know how to choose between Radiesse, Restylane (Q-Med), and Sculptra (Sanofi-Aventis).

"A lot has to do with what you think will benefit the patient more. If they need a lot of volume, I would go with Sculptra," Dr. Weinkle said. "If they have deep nasolabial folds and [deep wrinkles in] the chin area, I would use Radiesse. There are a lot of considerations, including longevity and cost. With Radiesse, you can have immediate correction, but with Sculptra you cannot promise that."

Radiesse can fill nasolabial folds and marionette lines, but the product is generally not recommended for the glabellar area or lips. Any long-acting filler can cause nodules in the lips, Dr. Goldberg said.

"Success is very technique dependent. This is not a filler to start with," Dr. Weinkle added.

"I get a lot of questions about what needle to use with which filler. Start with what the company recommends," said Dr. Marta Rendon of the University of Miami.

"For smaller areas, use a shorter needle and 27-G—the product will flow nicely," Dr. Goldberg said. "I use mostly the longer needles for nasolabial folds. This stuff is thicker, so you need to push harder. If you do that with Juvederm [Allergan], all the material will be gone right away."

Anesthesia is recommended before the procedure. "Let's be honest, it hurts. It is thicker [than some other fillers]. It's a 25-G needle," Dr. Weinkle said. "Use anesthesia and keep the patient as comfortable as possible."

Dr. Goldberg does a block with 1% lidocaine without epinephrine, and Dr. Rendon blocks with 2% lidocaine without epinephrine.

Inject a small amount of Radiesse on the way in and lay it down retrograde as you pull the needle out, Dr. Weinkle suggested.

Remember to stop injecting as you pull the needle out, Dr. Rendon said. "You don't want to bring out the product. My tip here is to use the blunt end of a Q-tip to push it back in."

"Here is another little pearl," Dr. Rendon said, "The hardest corner to correct is the nasolabial fold just above and lateral to the corner of the mouth. Tent the skin to lift the corner when you inject, and be careful not to inject too superficially."

Place your finger inside the mouth when you first start injecting, Dr. Goldberg said, to feel the material going in. "Early on I injected it right through into the mouth," he said. "Patients will tell you they can taste a granular substance. It doesn't harm them, but you have to start over."

It is important to fill just below the corner of each side of the mouth, Dr. Weinkle said. "I put my finger inside the mouth and mold it right away."

Be careful not to overcorrect the patient's face, she pointed out. "I tell patients there is more where this came from."

A meeting attendee asked about the cost to physicians. "It's actually cost effective. Originally, it was $500 for 1.3 cc, and about a year ago, the company reduced the price to $298 per 1.3-cc syringe. Now that the price has come down, it's much more affordable," Dr. Weinkle said.

The range of what dermatologists charge patients ranges from $500 to $3,000 across the country. Dr. Goldberg said, "It's longer acting, so I think it's fair to charge more for this, compared to what you are charging for hyaluronic acid."

Patient follow-up is essential. "I stress the importance of seeing the patient back at 2 weeks. If they are unhappy with results, you want to be the one to know," Dr. Weinkle said. "I've learned that the 0.3 cc [syringe] is nice for topping off someone who comes back for a touch-up."

Dr. Goldberg and Dr. Weinkle are consultants for BioForm Medical and Dr. Rendon is on the company's advisory board.

MIAMI BEACH — Cosmetic enhancement with Radiesse is technique dependent, and three experts shared their clinical tips to optimize success with this filler at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

Radiesse (calcium hydroxylapatite, BioForm Medical) is manufactured as synthetic microspheres that are suspended in a resorbable aqueous gel.

Calcium hydroxylapatite provides immediate results and is versatile, moldable, and longer lasting than some other filler products, said Dr. Susan H. Weinkle, who is with the University of South Florida in Tampa.

The product's gel carrier degrades in 3–6 months for 70% of patients, she said.

During this time, new collagen formation is ongoing. "If you avoid the temptation to retreat patients at 6 months when the gel drops, you will see continued improvement," said Dr. David J. Goldberg of the department of dermatology at Mount Sinai School of Medicine in New York.

A meeting attendee wanted to know how to choose between Radiesse, Restylane (Q-Med), and Sculptra (Sanofi-Aventis).

"A lot has to do with what you think will benefit the patient more. If they need a lot of volume, I would go with Sculptra," Dr. Weinkle said. "If they have deep nasolabial folds and [deep wrinkles in] the chin area, I would use Radiesse. There are a lot of considerations, including longevity and cost. With Radiesse, you can have immediate correction, but with Sculptra you cannot promise that."

Radiesse can fill nasolabial folds and marionette lines, but the product is generally not recommended for the glabellar area or lips. Any long-acting filler can cause nodules in the lips, Dr. Goldberg said.

"Success is very technique dependent. This is not a filler to start with," Dr. Weinkle added.

"I get a lot of questions about what needle to use with which filler. Start with what the company recommends," said Dr. Marta Rendon of the University of Miami.

"For smaller areas, use a shorter needle and 27-G—the product will flow nicely," Dr. Goldberg said. "I use mostly the longer needles for nasolabial folds. This stuff is thicker, so you need to push harder. If you do that with Juvederm [Allergan], all the material will be gone right away."

Anesthesia is recommended before the procedure. "Let's be honest, it hurts. It is thicker [than some other fillers]. It's a 25-G needle," Dr. Weinkle said. "Use anesthesia and keep the patient as comfortable as possible."

Dr. Goldberg does a block with 1% lidocaine without epinephrine, and Dr. Rendon blocks with 2% lidocaine without epinephrine.

Inject a small amount of Radiesse on the way in and lay it down retrograde as you pull the needle out, Dr. Weinkle suggested.

Remember to stop injecting as you pull the needle out, Dr. Rendon said. "You don't want to bring out the product. My tip here is to use the blunt end of a Q-tip to push it back in."

"Here is another little pearl," Dr. Rendon said, "The hardest corner to correct is the nasolabial fold just above and lateral to the corner of the mouth. Tent the skin to lift the corner when you inject, and be careful not to inject too superficially."

Place your finger inside the mouth when you first start injecting, Dr. Goldberg said, to feel the material going in. "Early on I injected it right through into the mouth," he said. "Patients will tell you they can taste a granular substance. It doesn't harm them, but you have to start over."

It is important to fill just below the corner of each side of the mouth, Dr. Weinkle said. "I put my finger inside the mouth and mold it right away."

Be careful not to overcorrect the patient's face, she pointed out. "I tell patients there is more where this came from."

A meeting attendee asked about the cost to physicians. "It's actually cost effective. Originally, it was $500 for 1.3 cc, and about a year ago, the company reduced the price to $298 per 1.3-cc syringe. Now that the price has come down, it's much more affordable," Dr. Weinkle said.

The range of what dermatologists charge patients ranges from $500 to $3,000 across the country. Dr. Goldberg said, "It's longer acting, so I think it's fair to charge more for this, compared to what you are charging for hyaluronic acid."

Patient follow-up is essential. "I stress the importance of seeing the patient back at 2 weeks. If they are unhappy with results, you want to be the one to know," Dr. Weinkle said. "I've learned that the 0.3 cc [syringe] is nice for topping off someone who comes back for a touch-up."

Dr. Goldberg and Dr. Weinkle are consultants for BioForm Medical and Dr. Rendon is on the company's advisory board.

MIAMI BEACH — Cosmetic enhancement with Radiesse is technique dependent, and three experts shared their clinical tips to optimize success with this filler at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

Radiesse (calcium hydroxylapatite, BioForm Medical) is manufactured as synthetic microspheres that are suspended in a resorbable aqueous gel.

Calcium hydroxylapatite provides immediate results and is versatile, moldable, and longer lasting than some other filler products, said Dr. Susan H. Weinkle, who is with the University of South Florida in Tampa.

The product's gel carrier degrades in 3–6 months for 70% of patients, she said.

During this time, new collagen formation is ongoing. "If you avoid the temptation to retreat patients at 6 months when the gel drops, you will see continued improvement," said Dr. David J. Goldberg of the department of dermatology at Mount Sinai School of Medicine in New York.

A meeting attendee wanted to know how to choose between Radiesse, Restylane (Q-Med), and Sculptra (Sanofi-Aventis).

"A lot has to do with what you think will benefit the patient more. If they need a lot of volume, I would go with Sculptra," Dr. Weinkle said. "If they have deep nasolabial folds and [deep wrinkles in] the chin area, I would use Radiesse. There are a lot of considerations, including longevity and cost. With Radiesse, you can have immediate correction, but with Sculptra you cannot promise that."

Radiesse can fill nasolabial folds and marionette lines, but the product is generally not recommended for the glabellar area or lips. Any long-acting filler can cause nodules in the lips, Dr. Goldberg said.

"Success is very technique dependent. This is not a filler to start with," Dr. Weinkle added.

"I get a lot of questions about what needle to use with which filler. Start with what the company recommends," said Dr. Marta Rendon of the University of Miami.

"For smaller areas, use a shorter needle and 27-G—the product will flow nicely," Dr. Goldberg said. "I use mostly the longer needles for nasolabial folds. This stuff is thicker, so you need to push harder. If you do that with Juvederm [Allergan], all the material will be gone right away."

Anesthesia is recommended before the procedure. "Let's be honest, it hurts. It is thicker [than some other fillers]. It's a 25-G needle," Dr. Weinkle said. "Use anesthesia and keep the patient as comfortable as possible."

Dr. Goldberg does a block with 1% lidocaine without epinephrine, and Dr. Rendon blocks with 2% lidocaine without epinephrine.

Inject a small amount of Radiesse on the way in and lay it down retrograde as you pull the needle out, Dr. Weinkle suggested.

Remember to stop injecting as you pull the needle out, Dr. Rendon said. "You don't want to bring out the product. My tip here is to use the blunt end of a Q-tip to push it back in."

"Here is another little pearl," Dr. Rendon said, "The hardest corner to correct is the nasolabial fold just above and lateral to the corner of the mouth. Tent the skin to lift the corner when you inject, and be careful not to inject too superficially."

Place your finger inside the mouth when you first start injecting, Dr. Goldberg said, to feel the material going in. "Early on I injected it right through into the mouth," he said. "Patients will tell you they can taste a granular substance. It doesn't harm them, but you have to start over."

It is important to fill just below the corner of each side of the mouth, Dr. Weinkle said. "I put my finger inside the mouth and mold it right away."

Be careful not to overcorrect the patient's face, she pointed out. "I tell patients there is more where this came from."

A meeting attendee asked about the cost to physicians. "It's actually cost effective. Originally, it was $500 for 1.3 cc, and about a year ago, the company reduced the price to $298 per 1.3-cc syringe. Now that the price has come down, it's much more affordable," Dr. Weinkle said.

The range of what dermatologists charge patients ranges from $500 to $3,000 across the country. Dr. Goldberg said, "It's longer acting, so I think it's fair to charge more for this, compared to what you are charging for hyaluronic acid."

Patient follow-up is essential. "I stress the importance of seeing the patient back at 2 weeks. If they are unhappy with results, you want to be the one to know," Dr. Weinkle said. "I've learned that the 0.3 cc [syringe] is nice for topping off someone who comes back for a touch-up."

Dr. Goldberg and Dr. Weinkle are consultants for BioForm Medical and Dr. Rendon is on the company's advisory board.

MIAMI BEACH — Inappropriate placement and potential sensitivity reactions are possible complications of fillers, and asymmetry, swelling, and bruising can occur after injections with botulinum toxin, Dr. Joel L. Cohen said at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

"Most people have moved away from injecting Radiesse in lips—it can migrate superficially and give a 'popcorn' appearance," he said. "Most of our patients are of the age that they think back to Goldie Hawn in the 'The First Wives Club.'"

Permanent fillers can be less forgiving and require more expertise to inject. ArteFill became the first nonresorbable, injectable filler implant approved for aesthetic use in the United States in October 2006. Complications reported with an earlier formulation approved outside the United States, ArteColl, might apply to ArteFill as well. "If placed too superficially, like any filler, it can cause nodules, but these are long-term nodules," said Dr. Cohen, a dermatologist in Englewood, Colo.

Adverse events associated with poly-L-lactic acid (Sculptra) include granulomas reported in several studies, especially from the European experience (Dermatol. Surg. 2005;31:772–6), and infections. "Infraorbital skin can be thinner, so infraorbital area injections with Sculptra can be problematic," Dr. Cohen said. To avoid pitfalls, "inject deeper and use higher volume reconstitutions."

When hyaluronic acid fillers are not injected deeply enough, especially in the tear-trough area, there can be a Tyndall effect, he said. Treatment of this adverse event is to nick the skin and try to express the product, or treat with a laser, or try to dissolve the product with hyaluronidase.

Dr. Cohen treated a woman who had previously been injected with a hyaluronic acid product and then developed delayed erythematous nodules (Dermatol. Surg. 2006;32:426–34). It is hard to know if this was an infection or a type of sensitivity. Three negative cultures were performed, and her indurated nodules finally cleared after a few courses of antibiotics over several months, he added.

Other adverse scenarios with fillers include the potential of inducing a herpes simplex virus (HSV) sore. "Think about prophylaxis [for HSV] when doing lip augmentation or injecting etched-in lip lines, especially in patients with a significant history of cold sores. Though, fortunately, I have not yet seen a postprocedure HSV flare with an aesthetic patient, I did see this in one of my Mohs surgery patients a few days after a lip repair," he said.

Necrosis is really the complication of most concern. This process can occur from excessive product placement compressing arterioles or from frank intravascular placement of product, Dr. Cohen said.

To avoid this complication, know the facial vasculature of the areas being injected, he advised. "I have participated in treatment of three patients that received hyaluronic acid fillers who were diagnosed by their injecting physicians with 'impending necrosis' a few hours later. The skin was developing localized areas of patchy, purple reticulated discoloration [visible] on photos sent to me. I recommended hyaluronidase injections in and around the area to try to decompress the vessels and to facilitate flow, and fortunately this was successful." (Case report in press.)

There are fewer adverse events reported with use of botulinum toxin, compared with fillers, but asymmetry, unwanted migration, swelling, and bruising have all been seen and have been reported to the FDA after botulinum toxin injections (J. Am. Acad. Dermatol. 2005;53:407–15).

"Complications from fillers, botulinum toxins, and lasers are very often related to inexperienced injectors/providers or … unsupervised and inadequately trained nonphysician providers," he said.

The physicians who are supposed to be supervising these procedures are rarely present and "have no training or experience themselves in the procedures in which they are supervising and just want to make a buck," said Dr. Cohen, chair of the American Society for Dermatologic Surgery's patient education committee.

He applauded the Florida legislature for passing "very appropriate" supervision guidelines in 2006 and said that these kinds of guidelines are needed on a national basis.

For any procedure, appropriate patient selection is important to minimize complications. For example, "some patients with a significant redundancy in their brow and lid skin should not be treated with botulinum toxin in their lower forehead, as this will only accentuate the problem and exacerbate the brow ptosis and redundant eyelid skin," Dr. Cohen said.

Dr. Cohen evaluates patients while they are animated to help determine botulinum toxin dosing and placement, but he recommends injecting while the patient's face is relaxed. A zygomaticus muscle pulled up at the cheekbone when the lower crow's-feet are being injected, for example, might have a higher risk of inadvertent spread to the muscle that would cause an asymmetric smile for 3–4 months, he said.

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); and a consultant and clinical trial investigator for BioForm, manufacturer of Radiesse.

Many poorly trained physicians are inadequately supervisingpoorly trained nonphysician providers. DR. COHEN

When fillers are not injected deeply enough, lumps under the eye can result. Courtesy Dr. Joel L. Cohen

MIAMI BEACH — Inappropriate placement and potential sensitivity reactions are possible complications of fillers, and asymmetry, swelling, and bruising can occur after injections with botulinum toxin, Dr. Joel L. Cohen said at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

"Most people have moved away from injecting Radiesse in lips—it can migrate superficially and give a 'popcorn' appearance," he said. "Most of our patients are of the age that they think back to Goldie Hawn in the 'The First Wives Club.'"

Permanent fillers can be less forgiving and require more expertise to inject. ArteFill became the first nonresorbable, injectable filler implant approved for aesthetic use in the United States in October 2006. Complications reported with an earlier formulation approved outside the United States, ArteColl, might apply to ArteFill as well. "If placed too superficially, like any filler, it can cause nodules, but these are long-term nodules," said Dr. Cohen, a dermatologist in Englewood, Colo.

Adverse events associated with poly-L-lactic acid (Sculptra) include granulomas reported in several studies, especially from the European experience (Dermatol. Surg. 2005;31:772–6), and infections. "Infraorbital skin can be thinner, so infraorbital area injections with Sculptra can be problematic," Dr. Cohen said. To avoid pitfalls, "inject deeper and use higher volume reconstitutions."

When hyaluronic acid fillers are not injected deeply enough, especially in the tear-trough area, there can be a Tyndall effect, he said. Treatment of this adverse event is to nick the skin and try to express the product, or treat with a laser, or try to dissolve the product with hyaluronidase.

Dr. Cohen treated a woman who had previously been injected with a hyaluronic acid product and then developed delayed erythematous nodules (Dermatol. Surg. 2006;32:426–34). It is hard to know if this was an infection or a type of sensitivity. Three negative cultures were performed, and her indurated nodules finally cleared after a few courses of antibiotics over several months, he added.

Other adverse scenarios with fillers include the potential of inducing a herpes simplex virus (HSV) sore. "Think about prophylaxis [for HSV] when doing lip augmentation or injecting etched-in lip lines, especially in patients with a significant history of cold sores. Though, fortunately, I have not yet seen a postprocedure HSV flare with an aesthetic patient, I did see this in one of my Mohs surgery patients a few days after a lip repair," he said.

Necrosis is really the complication of most concern. This process can occur from excessive product placement compressing arterioles or from frank intravascular placement of product, Dr. Cohen said.

To avoid this complication, know the facial vasculature of the areas being injected, he advised. "I have participated in treatment of three patients that received hyaluronic acid fillers who were diagnosed by their injecting physicians with 'impending necrosis' a few hours later. The skin was developing localized areas of patchy, purple reticulated discoloration [visible] on photos sent to me. I recommended hyaluronidase injections in and around the area to try to decompress the vessels and to facilitate flow, and fortunately this was successful." (Case report in press.)

There are fewer adverse events reported with use of botulinum toxin, compared with fillers, but asymmetry, unwanted migration, swelling, and bruising have all been seen and have been reported to the FDA after botulinum toxin injections (J. Am. Acad. Dermatol. 2005;53:407–15).

"Complications from fillers, botulinum toxins, and lasers are very often related to inexperienced injectors/providers or … unsupervised and inadequately trained nonphysician providers," he said.

The physicians who are supposed to be supervising these procedures are rarely present and "have no training or experience themselves in the procedures in which they are supervising and just want to make a buck," said Dr. Cohen, chair of the American Society for Dermatologic Surgery's patient education committee.

He applauded the Florida legislature for passing "very appropriate" supervision guidelines in 2006 and said that these kinds of guidelines are needed on a national basis.

For any procedure, appropriate patient selection is important to minimize complications. For example, "some patients with a significant redundancy in their brow and lid skin should not be treated with botulinum toxin in their lower forehead, as this will only accentuate the problem and exacerbate the brow ptosis and redundant eyelid skin," Dr. Cohen said.

Dr. Cohen evaluates patients while they are animated to help determine botulinum toxin dosing and placement, but he recommends injecting while the patient's face is relaxed. A zygomaticus muscle pulled up at the cheekbone when the lower crow's-feet are being injected, for example, might have a higher risk of inadvertent spread to the muscle that would cause an asymmetric smile for 3–4 months, he said.

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); and a consultant and clinical trial investigator for BioForm, manufacturer of Radiesse.

Many poorly trained physicians are inadequately supervisingpoorly trained nonphysician providers. DR. COHEN

When fillers are not injected deeply enough, lumps under the eye can result. Courtesy Dr. Joel L. Cohen

MIAMI BEACH — Inappropriate placement and potential sensitivity reactions are possible complications of fillers, and asymmetry, swelling, and bruising can occur after injections with botulinum toxin, Dr. Joel L. Cohen said at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

"Most people have moved away from injecting Radiesse in lips—it can migrate superficially and give a 'popcorn' appearance," he said. "Most of our patients are of the age that they think back to Goldie Hawn in the 'The First Wives Club.'"

Permanent fillers can be less forgiving and require more expertise to inject. ArteFill became the first nonresorbable, injectable filler implant approved for aesthetic use in the United States in October 2006. Complications reported with an earlier formulation approved outside the United States, ArteColl, might apply to ArteFill as well. "If placed too superficially, like any filler, it can cause nodules, but these are long-term nodules," said Dr. Cohen, a dermatologist in Englewood, Colo.

Adverse events associated with poly-L-lactic acid (Sculptra) include granulomas reported in several studies, especially from the European experience (Dermatol. Surg. 2005;31:772–6), and infections. "Infraorbital skin can be thinner, so infraorbital area injections with Sculptra can be problematic," Dr. Cohen said. To avoid pitfalls, "inject deeper and use higher volume reconstitutions."

When hyaluronic acid fillers are not injected deeply enough, especially in the tear-trough area, there can be a Tyndall effect, he said. Treatment of this adverse event is to nick the skin and try to express the product, or treat with a laser, or try to dissolve the product with hyaluronidase.

Dr. Cohen treated a woman who had previously been injected with a hyaluronic acid product and then developed delayed erythematous nodules (Dermatol. Surg. 2006;32:426–34). It is hard to know if this was an infection or a type of sensitivity. Three negative cultures were performed, and her indurated nodules finally cleared after a few courses of antibiotics over several months, he added.

Other adverse scenarios with fillers include the potential of inducing a herpes simplex virus (HSV) sore. "Think about prophylaxis [for HSV] when doing lip augmentation or injecting etched-in lip lines, especially in patients with a significant history of cold sores. Though, fortunately, I have not yet seen a postprocedure HSV flare with an aesthetic patient, I did see this in one of my Mohs surgery patients a few days after a lip repair," he said.

Necrosis is really the complication of most concern. This process can occur from excessive product placement compressing arterioles or from frank intravascular placement of product, Dr. Cohen said.

To avoid this complication, know the facial vasculature of the areas being injected, he advised. "I have participated in treatment of three patients that received hyaluronic acid fillers who were diagnosed by their injecting physicians with 'impending necrosis' a few hours later. The skin was developing localized areas of patchy, purple reticulated discoloration [visible] on photos sent to me. I recommended hyaluronidase injections in and around the area to try to decompress the vessels and to facilitate flow, and fortunately this was successful." (Case report in press.)

There are fewer adverse events reported with use of botulinum toxin, compared with fillers, but asymmetry, unwanted migration, swelling, and bruising have all been seen and have been reported to the FDA after botulinum toxin injections (J. Am. Acad. Dermatol. 2005;53:407–15).

"Complications from fillers, botulinum toxins, and lasers are very often related to inexperienced injectors/providers or … unsupervised and inadequately trained nonphysician providers," he said.

The physicians who are supposed to be supervising these procedures are rarely present and "have no training or experience themselves in the procedures in which they are supervising and just want to make a buck," said Dr. Cohen, chair of the American Society for Dermatologic Surgery's patient education committee.

He applauded the Florida legislature for passing "very appropriate" supervision guidelines in 2006 and said that these kinds of guidelines are needed on a national basis.

For any procedure, appropriate patient selection is important to minimize complications. For example, "some patients with a significant redundancy in their brow and lid skin should not be treated with botulinum toxin in their lower forehead, as this will only accentuate the problem and exacerbate the brow ptosis and redundant eyelid skin," Dr. Cohen said.

Dr. Cohen evaluates patients while they are animated to help determine botulinum toxin dosing and placement, but he recommends injecting while the patient's face is relaxed. A zygomaticus muscle pulled up at the cheekbone when the lower crow's-feet are being injected, for example, might have a higher risk of inadvertent spread to the muscle that would cause an asymmetric smile for 3–4 months, he said.

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); and a consultant and clinical trial investigator for BioForm, manufacturer of Radiesse.

Many poorly trained physicians are inadequately supervisingpoorly trained nonphysician providers. DR. COHEN

When fillers are not injected deeply enough, lumps under the eye can result. Courtesy Dr. Joel L. Cohen

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 noted, “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,” Dr. Pearson said.

“Which one of my patients will really benefit from vaccine prophylaxis?” Dr. Pearson asked. “That is really 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 noted, “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,” Dr. Pearson said.

“Which one of my patients will really benefit from vaccine prophylaxis?” Dr. Pearson asked. “That is really 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 noted, “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,” Dr. Pearson said.

“Which one of my patients will really benefit from vaccine prophylaxis?” Dr. Pearson asked. “That is really a study we want to get started on here at the University of Miami.”

MIAMI BEACH — The latest trend in acne treatment is not new medications but innovative reformulations of existing agents, Dr. Dirk M. Elston said at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

Subantimicrobial-dose doxycycline (Oracea, CollaGenex Pharmaceuticals Inc.) and extended-release minocycline (Solodyn, Medicis Pharmaceutical Corp.) are good examples, he said.

The use of 40 mg of doxycycline for acne would be off label. The Food and Drug Administration approved the agent in May 2006 for the treatment of inflammatory rosacea lesions in adults. The efficacy studies that led to the rosacea indication, however, are a “proof of concept that you can separate its anti-inflammatory effect from its antimicrobial effect,” said Dr. Elston, director of the department of dermatology at Geisinger Health System, Danville, Pa.

Oral antibiotics used to treat acne vulgaris feature both antimicrobial and anti-inflammatory properties (JAMA 2004;292:726–35). A reduction in the emergence of doxycycline resistance is a potential benefit of staying below an effective antimicrobial dose, said Dr. Elston, who is on the advisory boards for both Medicis and CollaGenex.

Clinical concerns with doxycycline include esophageal injury and patient compliance. When physicians at Geisinger prescribe the drug, the electronic record system automatically prints out patient instructions to take the antibiotic with ample water or a meal. There is also a reminder never to take doxycycline at bedtime.

The FDA approved minocycline extended-release tablets, also in May 2006, for the treatment of inflammatory lesions of nonnodular moderate to severe acne vulgaris in patients aged 12 years and older. Extended-release minocycline features a reduced total dosage (1 mg/kg per day) with efficacy equal to higher doses, Dr. Elston said. It is available as a 45-mg, 90-mg, or 135-mg tablet. The once-a-day formulation increases compliance.

Minocycline is much less resistant to isolates of Propionibacterium acnes than is tetracycline or erythromycin, Dr. Elston said.

Adverse events in a phase III trial were similar between 674 patients taking extended-release minocycline and 364 taking a placebo. Headache, nausea, and fatigue were the leading events reported.

Interim results for 345 participants in an ongoing, open-label, long-term safety study show no increase in the number of antinuclear antibody-positive patients, a concern related to lupus. In addition, “there is no evidence of any interaction with birth control drugs,” Dr. Elston said.

In an open-label study with 30 patients, extended-release minocycline did not alter plasma estradiol, FSH, LH, or progestinic hormone levels.

MIAMI BEACH — The latest trend in acne treatment is not new medications but innovative reformulations of existing agents, Dr. Dirk M. Elston said at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

Subantimicrobial-dose doxycycline (Oracea, CollaGenex Pharmaceuticals Inc.) and extended-release minocycline (Solodyn, Medicis Pharmaceutical Corp.) are good examples, he said.

The use of 40 mg of doxycycline for acne would be off label. The Food and Drug Administration approved the agent in May 2006 for the treatment of inflammatory rosacea lesions in adults. The efficacy studies that led to the rosacea indication, however, are a “proof of concept that you can separate its anti-inflammatory effect from its antimicrobial effect,” said Dr. Elston, director of the department of dermatology at Geisinger Health System, Danville, Pa.

Oral antibiotics used to treat acne vulgaris feature both antimicrobial and anti-inflammatory properties (JAMA 2004;292:726–35). A reduction in the emergence of doxycycline resistance is a potential benefit of staying below an effective antimicrobial dose, said Dr. Elston, who is on the advisory boards for both Medicis and CollaGenex.

Clinical concerns with doxycycline include esophageal injury and patient compliance. When physicians at Geisinger prescribe the drug, the electronic record system automatically prints out patient instructions to take the antibiotic with ample water or a meal. There is also a reminder never to take doxycycline at bedtime.

The FDA approved minocycline extended-release tablets, also in May 2006, for the treatment of inflammatory lesions of nonnodular moderate to severe acne vulgaris in patients aged 12 years and older. Extended-release minocycline features a reduced total dosage (1 mg/kg per day) with efficacy equal to higher doses, Dr. Elston said. It is available as a 45-mg, 90-mg, or 135-mg tablet. The once-a-day formulation increases compliance.

Minocycline is much less resistant to isolates of Propionibacterium acnes than is tetracycline or erythromycin, Dr. Elston said.

Adverse events in a phase III trial were similar between 674 patients taking extended-release minocycline and 364 taking a placebo. Headache, nausea, and fatigue were the leading events reported.

Interim results for 345 participants in an ongoing, open-label, long-term safety study show no increase in the number of antinuclear antibody-positive patients, a concern related to lupus. In addition, “there is no evidence of any interaction with birth control drugs,” Dr. Elston said.

In an open-label study with 30 patients, extended-release minocycline did not alter plasma estradiol, FSH, LH, or progestinic hormone levels.

MIAMI BEACH — The latest trend in acne treatment is not new medications but innovative reformulations of existing agents, Dr. Dirk M. Elston said at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

Subantimicrobial-dose doxycycline (Oracea, CollaGenex Pharmaceuticals Inc.) and extended-release minocycline (Solodyn, Medicis Pharmaceutical Corp.) are good examples, he said.

The use of 40 mg of doxycycline for acne would be off label. The Food and Drug Administration approved the agent in May 2006 for the treatment of inflammatory rosacea lesions in adults. The efficacy studies that led to the rosacea indication, however, are a “proof of concept that you can separate its anti-inflammatory effect from its antimicrobial effect,” said Dr. Elston, director of the department of dermatology at Geisinger Health System, Danville, Pa.

Oral antibiotics used to treat acne vulgaris feature both antimicrobial and anti-inflammatory properties (JAMA 2004;292:726–35). A reduction in the emergence of doxycycline resistance is a potential benefit of staying below an effective antimicrobial dose, said Dr. Elston, who is on the advisory boards for both Medicis and CollaGenex.

Clinical concerns with doxycycline include esophageal injury and patient compliance. When physicians at Geisinger prescribe the drug, the electronic record system automatically prints out patient instructions to take the antibiotic with ample water or a meal. There is also a reminder never to take doxycycline at bedtime.

The FDA approved minocycline extended-release tablets, also in May 2006, for the treatment of inflammatory lesions of nonnodular moderate to severe acne vulgaris in patients aged 12 years and older. Extended-release minocycline features a reduced total dosage (1 mg/kg per day) with efficacy equal to higher doses, Dr. Elston said. It is available as a 45-mg, 90-mg, or 135-mg tablet. The once-a-day formulation increases compliance.

Minocycline is much less resistant to isolates of Propionibacterium acnes than is tetracycline or erythromycin, Dr. Elston said.

Adverse events in a phase III trial were similar between 674 patients taking extended-release minocycline and 364 taking a placebo. Headache, nausea, and fatigue were the leading events reported.

Interim results for 345 participants in an ongoing, open-label, long-term safety study show no increase in the number of antinuclear antibody-positive patients, a concern related to lupus. In addition, “there is no evidence of any interaction with birth control drugs,” Dr. Elston said.

In an open-label study with 30 patients, extended-release minocycline did not alter plasma estradiol, FSH, LH, or progestinic hormone levels.

MIAMI BEACH — Intravenous combined with intraperitoneal chemotherapy provides a significant survival benefit to women with advanced epithelial ovarian cancer, compared with intravenous delivery alone, according to three published studies discussed at an ob.gyn. conference sponsored by the University of Miami.

These trials further support a clinical announcement from the National Cancer Institute in January 2006 that recognized a “significant survival benefit” with the combination administration. This protocol is one of the new approaches researchers are assessing to improve overall survival. Currently, 5-year survival is about 44% for women of all races. There are nearly 26,000 new cases of ovarian cancer and approximately 16,000 deaths each year in the United States.

“More and more we are making them live longer and improving their quality of life,” said Dr. Nicholas C. Lambrou who is on the gynecologic oncology faculty at the University of Miami. “The real new chemotherapy is this new mode of delivery.”

The intraperitoneal cavity is a major route of metastatic spread for ovarian cancer. Intraperitoneal chemotherapy provides an increased concentration of drug for a prolonged period of time to target any residual peritoneal tumor. Dual delivery also may decrease bone marrow toxicity, compared with IV-only chemotherapy, Dr. Lambrou said.

Poor tumor penetration of bulk disease and less exposure of any extraperitoneal cancer to chemotherapy are potential limitations of intraperitoneal delivery. Therefore, the combination approach may work best in women with minimal residual disease following surgery.

Three large studies—two published in 2007 and one in 2006—support use of intraperitoneal chemotherapy for women with advanced epithelial ovarian cancer, Dr. Lambrou said. In one, researchers performed a meta-analysis to assess first-line intraperitoneal versus IV chemotherapy for these patients (Cancer 2007;109:692–702).

There were statistically significant overall survival benefits with intraperitoneal cisplatin-containing chemotherapy, compared with IV chemotherapy alone, according to the meta-analysis. In the three largest trials, all phase III studies, overall survival increased by between 8 and 16 months. The survival improvements suggest patients should be offered cisplatin-containing intraperitoneal chemotherapy, despite more common severe adverse events and catheter-related complications, Dr. L. Elit and associates at the Hamilton Regional Cancer Centre in Hamilton, Ont., wrote.

In another study conducted for the Gynecologic Oncology Group (GOG), Dr. L.B. Wenzel and associates at the University of California, Irvine, demonstrated that patients receiving intraperitoneal chemotherapy experienced more disruption of their health-related quality of life, greater abdominal discomfort, and more neurotoxicity during treatment than did patients who received IV therapy (J. Clin. Oncol. 2007;25:437–43). However, they added, only a higher incidence of neurotoxicity remained 1 year after treatment, a finding that should be weighed against improved survival in these patients.

The study is a follow-up to another GOG assessment of the same 415 women with optimally debulked, stage III ovarian cancer (N. Engl. J. Med. 2006;354:34–43). Dr. D. Armstrong and associates at the Johns Hopkins University Kimmel Cancer Center in Baltimore demonstrated improved survival among those treated with IV paclitaxel plus intraperitoneal cisplatin and paclitaxel, compared with conventional IV paclitaxel plus cisplatin. For example, progression-free survival was 24 months in the 205 patients treated with the combination versus 18 months in the 210 patients treated with IV chemotherapy only. In addition, overall survival with combination chemotherapy was 66 months versus 50 months survival in the IV-only group.

Hematologic toxicity was the primary adverse event associated with intraperitoneal chemotherapy in this study, Dr. Lambrou said. Some adverse events related to the abdominal catheter were also reported. “We may see fewer in the future as people get comfortable placing these,” he said. He recommended a Bard-type venous access port placed on a woman's rib to minimize this complication.

MIAMI BEACH — Intravenous combined with intraperitoneal chemotherapy provides a significant survival benefit to women with advanced epithelial ovarian cancer, compared with intravenous delivery alone, according to three published studies discussed at an ob.gyn. conference sponsored by the University of Miami.

These trials further support a clinical announcement from the National Cancer Institute in January 2006 that recognized a “significant survival benefit” with the combination administration. This protocol is one of the new approaches researchers are assessing to improve overall survival. Currently, 5-year survival is about 44% for women of all races. There are nearly 26,000 new cases of ovarian cancer and approximately 16,000 deaths each year in the United States.

“More and more we are making them live longer and improving their quality of life,” said Dr. Nicholas C. Lambrou who is on the gynecologic oncology faculty at the University of Miami. “The real new chemotherapy is this new mode of delivery.”

The intraperitoneal cavity is a major route of metastatic spread for ovarian cancer. Intraperitoneal chemotherapy provides an increased concentration of drug for a prolonged period of time to target any residual peritoneal tumor. Dual delivery also may decrease bone marrow toxicity, compared with IV-only chemotherapy, Dr. Lambrou said.

Poor tumor penetration of bulk disease and less exposure of any extraperitoneal cancer to chemotherapy are potential limitations of intraperitoneal delivery. Therefore, the combination approach may work best in women with minimal residual disease following surgery.

Three large studies—two published in 2007 and one in 2006—support use of intraperitoneal chemotherapy for women with advanced epithelial ovarian cancer, Dr. Lambrou said. In one, researchers performed a meta-analysis to assess first-line intraperitoneal versus IV chemotherapy for these patients (Cancer 2007;109:692–702).

There were statistically significant overall survival benefits with intraperitoneal cisplatin-containing chemotherapy, compared with IV chemotherapy alone, according to the meta-analysis. In the three largest trials, all phase III studies, overall survival increased by between 8 and 16 months. The survival improvements suggest patients should be offered cisplatin-containing intraperitoneal chemotherapy, despite more common severe adverse events and catheter-related complications, Dr. L. Elit and associates at the Hamilton Regional Cancer Centre in Hamilton, Ont., wrote.

In another study conducted for the Gynecologic Oncology Group (GOG), Dr. L.B. Wenzel and associates at the University of California, Irvine, demonstrated that patients receiving intraperitoneal chemotherapy experienced more disruption of their health-related quality of life, greater abdominal discomfort, and more neurotoxicity during treatment than did patients who received IV therapy (J. Clin. Oncol. 2007;25:437–43). However, they added, only a higher incidence of neurotoxicity remained 1 year after treatment, a finding that should be weighed against improved survival in these patients.

The study is a follow-up to another GOG assessment of the same 415 women with optimally debulked, stage III ovarian cancer (N. Engl. J. Med. 2006;354:34–43). Dr. D. Armstrong and associates at the Johns Hopkins University Kimmel Cancer Center in Baltimore demonstrated improved survival among those treated with IV paclitaxel plus intraperitoneal cisplatin and paclitaxel, compared with conventional IV paclitaxel plus cisplatin. For example, progression-free survival was 24 months in the 205 patients treated with the combination versus 18 months in the 210 patients treated with IV chemotherapy only. In addition, overall survival with combination chemotherapy was 66 months versus 50 months survival in the IV-only group.

Hematologic toxicity was the primary adverse event associated with intraperitoneal chemotherapy in this study, Dr. Lambrou said. Some adverse events related to the abdominal catheter were also reported. “We may see fewer in the future as people get comfortable placing these,” he said. He recommended a Bard-type venous access port placed on a woman's rib to minimize this complication.

MIAMI BEACH — Intravenous combined with intraperitoneal chemotherapy provides a significant survival benefit to women with advanced epithelial ovarian cancer, compared with intravenous delivery alone, according to three published studies discussed at an ob.gyn. conference sponsored by the University of Miami.

These trials further support a clinical announcement from the National Cancer Institute in January 2006 that recognized a “significant survival benefit” with the combination administration. This protocol is one of the new approaches researchers are assessing to improve overall survival. Currently, 5-year survival is about 44% for women of all races. There are nearly 26,000 new cases of ovarian cancer and approximately 16,000 deaths each year in the United States.

“More and more we are making them live longer and improving their quality of life,” said Dr. Nicholas C. Lambrou who is on the gynecologic oncology faculty at the University of Miami. “The real new chemotherapy is this new mode of delivery.”

The intraperitoneal cavity is a major route of metastatic spread for ovarian cancer. Intraperitoneal chemotherapy provides an increased concentration of drug for a prolonged period of time to target any residual peritoneal tumor. Dual delivery also may decrease bone marrow toxicity, compared with IV-only chemotherapy, Dr. Lambrou said.

Poor tumor penetration of bulk disease and less exposure of any extraperitoneal cancer to chemotherapy are potential limitations of intraperitoneal delivery. Therefore, the combination approach may work best in women with minimal residual disease following surgery.

Three large studies—two published in 2007 and one in 2006—support use of intraperitoneal chemotherapy for women with advanced epithelial ovarian cancer, Dr. Lambrou said. In one, researchers performed a meta-analysis to assess first-line intraperitoneal versus IV chemotherapy for these patients (Cancer 2007;109:692–702).

There were statistically significant overall survival benefits with intraperitoneal cisplatin-containing chemotherapy, compared with IV chemotherapy alone, according to the meta-analysis. In the three largest trials, all phase III studies, overall survival increased by between 8 and 16 months. The survival improvements suggest patients should be offered cisplatin-containing intraperitoneal chemotherapy, despite more common severe adverse events and catheter-related complications, Dr. L. Elit and associates at the Hamilton Regional Cancer Centre in Hamilton, Ont., wrote.

In another study conducted for the Gynecologic Oncology Group (GOG), Dr. L.B. Wenzel and associates at the University of California, Irvine, demonstrated that patients receiving intraperitoneal chemotherapy experienced more disruption of their health-related quality of life, greater abdominal discomfort, and more neurotoxicity during treatment than did patients who received IV therapy (J. Clin. Oncol. 2007;25:437–43). However, they added, only a higher incidence of neurotoxicity remained 1 year after treatment, a finding that should be weighed against improved survival in these patients.

The study is a follow-up to another GOG assessment of the same 415 women with optimally debulked, stage III ovarian cancer (N. Engl. J. Med. 2006;354:34–43). Dr. D. Armstrong and associates at the Johns Hopkins University Kimmel Cancer Center in Baltimore demonstrated improved survival among those treated with IV paclitaxel plus intraperitoneal cisplatin and paclitaxel, compared with conventional IV paclitaxel plus cisplatin. For example, progression-free survival was 24 months in the 205 patients treated with the combination versus 18 months in the 210 patients treated with IV chemotherapy only. In addition, overall survival with combination chemotherapy was 66 months versus 50 months survival in the IV-only group.

Hematologic toxicity was the primary adverse event associated with intraperitoneal chemotherapy in this study, Dr. Lambrou said. Some adverse events related to the abdominal catheter were also reported. “We may see fewer in the future as people get comfortable placing these,” he said. He recommended a Bard-type venous access port placed on a woman's rib to minimize this complication.