Sharon Worcester

The finding that relatively young stroke survivors have less access to care and more difficulty affording the medications that they need, compared with their older counterparts, reflects the more widespread problem of lack of medical insurance in the United States—a problem that has “staggering ramifications,” according to Dr. Steven Levine, professor of neurology and director of the cerebrovascular education program at the Mount Sinai Stroke Center and School of Medicine, New York, speaking in an interview.

“We can no longer assume that younger stroke survivors have better access to care than their older counterparts,” he said, commenting on findings from research by Dr. Deborah A. Levine of the University of Alabama, Birmingham, and her colleagues. (The two doctors are not related.)

Dr. Deborah A. Levine reported that between 1997 and 2004, the number of stroke survivors aged 45–64 years in the United States who were unable to afford prescribed medications increased significantly from 8% to 13% (Stroke 2007;38:1557–64).

The findings, based on the responses of 5,840 individuals who participated in the National Health Interview Survey—an in-person household survey conducted annually by the National Center for Health Statistics—suggest that in 2004, about 76,000 stroke survivors in the United States were unable to afford prescribed medications. Those under age 65 years—along with blacks, women, and those with high comorbidity or low health status—had the lowest rates of being able to afford their medications.

A number of barriers to care and medications were identified among those with reduced ability to afford medication, suggesting these are particularly vulnerable populations.

For example, compared with stroke survivors who were able to afford medications, those who could not more often had a lack of transportation (15% vs. 3%), no health insurance (16% vs. 3%), annual income below $20,000 (66% vs. 40%), no usual place of care (6% vs. 2%), and out-of-pocket medical expenses of $2,000 or more.

These barriers to care likely equate to the barriers to secondary stroke prevention—and thus to an increased risk of subsequent cardiovascular event, according to Dr. Deborah A. Levine and her associates, who noted that medication access is an essential component of secondary stroke prevention.

Ischemic stroke survivors have up to a 14% annual risk of recurrent stroke, and also are at risk for other cardiovascular events that can adversely affect health, quality of life, and financial status; younger patients often are in the most productive years of their lives, and thus may be hit the hardest by these effects.

Stroke tops the list of disabling diseases among adults, with only 1 in 5 returning to work, 1 in 11 returning to work full time, and 1 in 30 becoming institutionalized, according to one study that looked at stroke survivors 3 months following the event (Arch. Phys. Med. Rehab. 2000;81:205–9).

Dr. Deborah A. Levine's findings expand on those from an earlier study in which she and her colleagues found that younger age among stroke survivors was associated with no general doctor visit (odds ratio 1.4), no medical specialist visit (odds ratio 1.69), and an inability to afford medications (odds ratio 2.94) in the previous 12 months after adjusting for sex, race, income, neurologic disability, health status, and comorbidity.

Lack of health insurance explained the lack of access to medical care—which is particularly problematic when it comes to primary care visits since the majority of secondary prevention measures are prescribed by primary care physicians—but did not explain the lack of ability to afford medications. After adjustment for health insurance, younger age remained independently associated with reduced medication affordability, perhaps because of competing expenses or lack of prescription drug coverage, Dr. Deborah A. Levine said in an interview.

For the earlier study, Dr. Deborah A. Levine and her colleagues used 1998–2002 data from the National Health Interview Survey, including responses from 3,681 stroke survivors, representing about 4 million U.S. stroke survivors, nearly a third of whom are aged 45–64 years. The implications of the findings of these studies are numerous and alarming, according to the investigators (Arch. Neurol. 2007;64:37–42).

For example, reduced medication access, specifically patient self-reduction in prescription use, has been associated with increased serious adverse event rates and emergency department visits, a number of adverse health conditions and outcomes in diabetics, and high rates of angina and nonfatal stroke or myocardial infarction in those with cardiovascular disease.

And given that stroke survivors are discharged from rehabilitation with an average of 11 medications with a cost totaling about $750 per month (based on 2004 monthly average wholesale price), according to one study, and given that stroke survival is improving while age-specific stroke incidence is remaining constant and the size of the 65 and older population is increasing—as is the number of uninsured nonelderly in the United States—the the long-term care of stroke survivors will prove costly, Dr. Deborah A. Levine said.

ELSEVIER GLOBAL MEDICAL NEWS

Affordability of Medications Differs According to Geographic Region

In addition to identifying stroke survivor populations unable to afford medications, Dr. Deborah A. Levine and her associates also found certain regional differences in barriers to care.

The inability to afford medications was similar in the South (weighted percentage 11%; population estimate 184,173), West (10%; population estimate 67,872), and Midwest (9%; population estimate 88,369), but significantly lower in the Northeast (5%; population estimate 37,361). Furthermore, the ability to afford medications appears, based on the survey data, to have decreased in the South, West, and Midwest across the study period, while remaining stable in the Northwest, Dr. Levine said.

Other barriers to care, including percentage of population with annual household income lower than $20,000 and percentage with out-of-pocket medical expenses of $2,000 or more were also significantly lower in the Northeast (see graphic, p. 41), and although uninsured rates were similar across the regions, survivors in the South and West had lower rates of private insurance with or without Medicare (the insurance type associated with the best medication coverage).

Other possible explanations for these findings include differences in prescription drug coverage rates, public assistance rates, and competing household costs—none of which could be directly assessed in the study, she noted.

The finding that relatively young stroke survivors have less access to care and more difficulty affording the medications that they need, compared with their older counterparts, reflects the more widespread problem of lack of medical insurance in the United States—a problem that has “staggering ramifications,” according to Dr. Steven Levine, professor of neurology and director of the cerebrovascular education program at the Mount Sinai Stroke Center and School of Medicine, New York, speaking in an interview.

“We can no longer assume that younger stroke survivors have better access to care than their older counterparts,” he said, commenting on findings from research by Dr. Deborah A. Levine of the University of Alabama, Birmingham, and her colleagues. (The two doctors are not related.)

Dr. Deborah A. Levine reported that between 1997 and 2004, the number of stroke survivors aged 45–64 years in the United States who were unable to afford prescribed medications increased significantly from 8% to 13% (Stroke 2007;38:1557–64).

The findings, based on the responses of 5,840 individuals who participated in the National Health Interview Survey—an in-person household survey conducted annually by the National Center for Health Statistics—suggest that in 2004, about 76,000 stroke survivors in the United States were unable to afford prescribed medications. Those under age 65 years—along with blacks, women, and those with high comorbidity or low health status—had the lowest rates of being able to afford their medications.

A number of barriers to care and medications were identified among those with reduced ability to afford medication, suggesting these are particularly vulnerable populations.

For example, compared with stroke survivors who were able to afford medications, those who could not more often had a lack of transportation (15% vs. 3%), no health insurance (16% vs. 3%), annual income below $20,000 (66% vs. 40%), no usual place of care (6% vs. 2%), and out-of-pocket medical expenses of $2,000 or more.

These barriers to care likely equate to the barriers to secondary stroke prevention—and thus to an increased risk of subsequent cardiovascular event, according to Dr. Deborah A. Levine and her associates, who noted that medication access is an essential component of secondary stroke prevention.

Ischemic stroke survivors have up to a 14% annual risk of recurrent stroke, and also are at risk for other cardiovascular events that can adversely affect health, quality of life, and financial status; younger patients often are in the most productive years of their lives, and thus may be hit the hardest by these effects.

Stroke tops the list of disabling diseases among adults, with only 1 in 5 returning to work, 1 in 11 returning to work full time, and 1 in 30 becoming institutionalized, according to one study that looked at stroke survivors 3 months following the event (Arch. Phys. Med. Rehab. 2000;81:205–9).

Dr. Deborah A. Levine's findings expand on those from an earlier study in which she and her colleagues found that younger age among stroke survivors was associated with no general doctor visit (odds ratio 1.4), no medical specialist visit (odds ratio 1.69), and an inability to afford medications (odds ratio 2.94) in the previous 12 months after adjusting for sex, race, income, neurologic disability, health status, and comorbidity.

Lack of health insurance explained the lack of access to medical care—which is particularly problematic when it comes to primary care visits since the majority of secondary prevention measures are prescribed by primary care physicians—but did not explain the lack of ability to afford medications. After adjustment for health insurance, younger age remained independently associated with reduced medication affordability, perhaps because of competing expenses or lack of prescription drug coverage, Dr. Deborah A. Levine said in an interview.

For the earlier study, Dr. Deborah A. Levine and her colleagues used 1998–2002 data from the National Health Interview Survey, including responses from 3,681 stroke survivors, representing about 4 million U.S. stroke survivors, nearly a third of whom are aged 45–64 years. The implications of the findings of these studies are numerous and alarming, according to the investigators (Arch. Neurol. 2007;64:37–42).

For example, reduced medication access, specifically patient self-reduction in prescription use, has been associated with increased serious adverse event rates and emergency department visits, a number of adverse health conditions and outcomes in diabetics, and high rates of angina and nonfatal stroke or myocardial infarction in those with cardiovascular disease.

And given that stroke survivors are discharged from rehabilitation with an average of 11 medications with a cost totaling about $750 per month (based on 2004 monthly average wholesale price), according to one study, and given that stroke survival is improving while age-specific stroke incidence is remaining constant and the size of the 65 and older population is increasing—as is the number of uninsured nonelderly in the United States—the the long-term care of stroke survivors will prove costly, Dr. Deborah A. Levine said.

ELSEVIER GLOBAL MEDICAL NEWS

Affordability of Medications Differs According to Geographic Region

In addition to identifying stroke survivor populations unable to afford medications, Dr. Deborah A. Levine and her associates also found certain regional differences in barriers to care.

The inability to afford medications was similar in the South (weighted percentage 11%; population estimate 184,173), West (10%; population estimate 67,872), and Midwest (9%; population estimate 88,369), but significantly lower in the Northeast (5%; population estimate 37,361). Furthermore, the ability to afford medications appears, based on the survey data, to have decreased in the South, West, and Midwest across the study period, while remaining stable in the Northwest, Dr. Levine said.

Other barriers to care, including percentage of population with annual household income lower than $20,000 and percentage with out-of-pocket medical expenses of $2,000 or more were also significantly lower in the Northeast (see graphic, p. 41), and although uninsured rates were similar across the regions, survivors in the South and West had lower rates of private insurance with or without Medicare (the insurance type associated with the best medication coverage).

Other possible explanations for these findings include differences in prescription drug coverage rates, public assistance rates, and competing household costs—none of which could be directly assessed in the study, she noted.

The finding that relatively young stroke survivors have less access to care and more difficulty affording the medications that they need, compared with their older counterparts, reflects the more widespread problem of lack of medical insurance in the United States—a problem that has “staggering ramifications,” according to Dr. Steven Levine, professor of neurology and director of the cerebrovascular education program at the Mount Sinai Stroke Center and School of Medicine, New York, speaking in an interview.

“We can no longer assume that younger stroke survivors have better access to care than their older counterparts,” he said, commenting on findings from research by Dr. Deborah A. Levine of the University of Alabama, Birmingham, and her colleagues. (The two doctors are not related.)

Dr. Deborah A. Levine reported that between 1997 and 2004, the number of stroke survivors aged 45–64 years in the United States who were unable to afford prescribed medications increased significantly from 8% to 13% (Stroke 2007;38:1557–64).

The findings, based on the responses of 5,840 individuals who participated in the National Health Interview Survey—an in-person household survey conducted annually by the National Center for Health Statistics—suggest that in 2004, about 76,000 stroke survivors in the United States were unable to afford prescribed medications. Those under age 65 years—along with blacks, women, and those with high comorbidity or low health status—had the lowest rates of being able to afford their medications.

A number of barriers to care and medications were identified among those with reduced ability to afford medication, suggesting these are particularly vulnerable populations.

For example, compared with stroke survivors who were able to afford medications, those who could not more often had a lack of transportation (15% vs. 3%), no health insurance (16% vs. 3%), annual income below $20,000 (66% vs. 40%), no usual place of care (6% vs. 2%), and out-of-pocket medical expenses of $2,000 or more.

These barriers to care likely equate to the barriers to secondary stroke prevention—and thus to an increased risk of subsequent cardiovascular event, according to Dr. Deborah A. Levine and her associates, who noted that medication access is an essential component of secondary stroke prevention.

Ischemic stroke survivors have up to a 14% annual risk of recurrent stroke, and also are at risk for other cardiovascular events that can adversely affect health, quality of life, and financial status; younger patients often are in the most productive years of their lives, and thus may be hit the hardest by these effects.

Stroke tops the list of disabling diseases among adults, with only 1 in 5 returning to work, 1 in 11 returning to work full time, and 1 in 30 becoming institutionalized, according to one study that looked at stroke survivors 3 months following the event (Arch. Phys. Med. Rehab. 2000;81:205–9).

Dr. Deborah A. Levine's findings expand on those from an earlier study in which she and her colleagues found that younger age among stroke survivors was associated with no general doctor visit (odds ratio 1.4), no medical specialist visit (odds ratio 1.69), and an inability to afford medications (odds ratio 2.94) in the previous 12 months after adjusting for sex, race, income, neurologic disability, health status, and comorbidity.

Lack of health insurance explained the lack of access to medical care—which is particularly problematic when it comes to primary care visits since the majority of secondary prevention measures are prescribed by primary care physicians—but did not explain the lack of ability to afford medications. After adjustment for health insurance, younger age remained independently associated with reduced medication affordability, perhaps because of competing expenses or lack of prescription drug coverage, Dr. Deborah A. Levine said in an interview.

For the earlier study, Dr. Deborah A. Levine and her colleagues used 1998–2002 data from the National Health Interview Survey, including responses from 3,681 stroke survivors, representing about 4 million U.S. stroke survivors, nearly a third of whom are aged 45–64 years. The implications of the findings of these studies are numerous and alarming, according to the investigators (Arch. Neurol. 2007;64:37–42).

For example, reduced medication access, specifically patient self-reduction in prescription use, has been associated with increased serious adverse event rates and emergency department visits, a number of adverse health conditions and outcomes in diabetics, and high rates of angina and nonfatal stroke or myocardial infarction in those with cardiovascular disease.

And given that stroke survivors are discharged from rehabilitation with an average of 11 medications with a cost totaling about $750 per month (based on 2004 monthly average wholesale price), according to one study, and given that stroke survival is improving while age-specific stroke incidence is remaining constant and the size of the 65 and older population is increasing—as is the number of uninsured nonelderly in the United States—the the long-term care of stroke survivors will prove costly, Dr. Deborah A. Levine said.

ELSEVIER GLOBAL MEDICAL NEWS

Affordability of Medications Differs According to Geographic Region

In addition to identifying stroke survivor populations unable to afford medications, Dr. Deborah A. Levine and her associates also found certain regional differences in barriers to care.

The inability to afford medications was similar in the South (weighted percentage 11%; population estimate 184,173), West (10%; population estimate 67,872), and Midwest (9%; population estimate 88,369), but significantly lower in the Northeast (5%; population estimate 37,361). Furthermore, the ability to afford medications appears, based on the survey data, to have decreased in the South, West, and Midwest across the study period, while remaining stable in the Northwest, Dr. Levine said.

Other barriers to care, including percentage of population with annual household income lower than $20,000 and percentage with out-of-pocket medical expenses of $2,000 or more were also significantly lower in the Northeast (see graphic, p. 41), and although uninsured rates were similar across the regions, survivors in the South and West had lower rates of private insurance with or without Medicare (the insurance type associated with the best medication coverage).

Other possible explanations for these findings include differences in prescription drug coverage rates, public assistance rates, and competing household costs—none of which could be directly assessed in the study, she noted.

Use of an alcohol-based hand sanitizer is the preferred method of hand hygiene in most situations in the office, according to a newly updated American Academy of Pediatrics policy statement on infection prevention and control in ambulatory settings.

The updates to the statement, entitled “Infection Prevention and Control in Pediatric Ambulatory Settings,” were prompted by a flurry of new recommendations for preventing the spread of infectious disease, according to Dr. Joseph A. Bocchini Jr., chair of the AAP Committee on Infectious Diseases, which developed the statement (Pediatrics 2007;120:650-65).

Dr. Bocchini, who also is professor and chairman of pediatrics at the Louisiana State University Health Sciences Center, Shreveport, called the statement a must-read for those practicing in pediatric ambulatory care settings. It is “very comprehensive and includes a significant amount of information and guidance on how to reduce infection risk for patients and for personnel.”

Although significant emphasis has been placed on preventing infection in hospitals, most patients are seen in ambulatory settings, so control and prevention of the spread of infection in this setting is very important, he added.

The committee's nod regarding the use of alcohol-based hand sanitizers is one of numerous updates to the statement, which was initially published in Pediatrics in 2000. “This is an important alternative hand hygiene technique that is safe and effective,” Dr. Bocchini said in an interview, noting that the recommendation applies only to alcohol-based sanitizers, and is a category IA guideline, indicating that it is based on a strong recommendation for implementation, strongly supported by well-designed studies.

Such products are more effective than standard handwashing techniques in most cases, and should be the primary mode of hand hygiene before and after each patient contact. Soap and water still are effective—and in fact are preferred when there is a high likelihood of exposure to organisms such as Clostridium difficile, when hands are visibly contaminated with blood or other body fluids from a patient, before eating, and after using the toilet. But, in general, sanitizers are preferred because they are quick and easy to use, so they can improve office flow, he noted.

An emphasis on initiating infection control procedures from the time of a patient's first phone call to the office is another important addition to the statement, Dr. Bocchini noted.

With that first phone call, the likelihood of contagious disease should be assessed, and decisions should be made about how to triage the patient through the office to reduce exposure to other patients, family members, and office staff, he said.

According to the statement, “patients with potentially contagious diseases and immunocompromised children should be promptly triaged. Contact between contagious children and uninfected children should be minimized.” This recommendation is listed as category IB, indicating a strong recommendation for implementation, supported by certain studies and a strong theoretical rationale.

“In addition, there have been considerable updates of recommendations for the prevention of exposure to blood-borne pathogens by needles and other sharps,” Dr. Bocchini said.

Based on new recommendations from the Occupational Safety and Health Administration, the AAP now calls for written policies and specific educational programs to make staff aware of the proper handling of sharps, and for consideration of adopting into practice any new and potentially safer medical devices and systems that become available to reduce the risk of needle-stick injuries. This category IA recommendation also is listed as category IC, indicating that it is required for implementation as mandated by federal or state regulation or standard.

Other important updates to the statement include:

▸ A call for implementation of new Centers for Disease Control and Prevention strategies for respiratory hygiene and cough etiquette for patients with suspected influenza or other respiratory tract pathogens, which were recently added to its list of standard precautions for hospitalized patients. That list was modified by the AAP for children, and includes, among other things, recommendations for providing visual alerts for patients to alert staff of respiratory tract infections and for reminding them of cough etiquette. This is a category II recommendation, indicating it is suggested for implementation based on suggestive studies or theoretical rationale.

▸ More detailed guidelines on infection control and prevention in physician's office waiting rooms. In addition to standard precautions, the statement outlines category IC procedures for sterilization, disinfection, and antisepsis.

▸ Added emphasis on the use of vaccines available for reducing employee's risk of acquisition or transmission of certain infectious diseases, such as influenza, tetanus, pertussis, and hepatitis. This category IB and IC policy states that employees should be vaccinated annually against influenza and should show documentation of immunity to other vaccine-preventable infections.

▸ New emphasis on the importance of developing policies and procedures for communicating with state and local authorities for prompt reporting of communicable disease and suspected outbreaks as required by law (category IC).

Use of an alcohol-based hand sanitizer is the preferred method of hand hygiene in most situations in the office, according to a newly updated American Academy of Pediatrics policy statement on infection prevention and control in ambulatory settings.

The updates to the statement, entitled “Infection Prevention and Control in Pediatric Ambulatory Settings,” were prompted by a flurry of new recommendations for preventing the spread of infectious disease, according to Dr. Joseph A. Bocchini Jr., chair of the AAP Committee on Infectious Diseases, which developed the statement (Pediatrics 2007;120:650-65).

Dr. Bocchini, who also is professor and chairman of pediatrics at the Louisiana State University Health Sciences Center, Shreveport, called the statement a must-read for those practicing in pediatric ambulatory care settings. It is “very comprehensive and includes a significant amount of information and guidance on how to reduce infection risk for patients and for personnel.”

Although significant emphasis has been placed on preventing infection in hospitals, most patients are seen in ambulatory settings, so control and prevention of the spread of infection in this setting is very important, he added.

The committee's nod regarding the use of alcohol-based hand sanitizers is one of numerous updates to the statement, which was initially published in Pediatrics in 2000. “This is an important alternative hand hygiene technique that is safe and effective,” Dr. Bocchini said in an interview, noting that the recommendation applies only to alcohol-based sanitizers, and is a category IA guideline, indicating that it is based on a strong recommendation for implementation, strongly supported by well-designed studies.

Such products are more effective than standard handwashing techniques in most cases, and should be the primary mode of hand hygiene before and after each patient contact. Soap and water still are effective—and in fact are preferred when there is a high likelihood of exposure to organisms such as Clostridium difficile, when hands are visibly contaminated with blood or other body fluids from a patient, before eating, and after using the toilet. But, in general, sanitizers are preferred because they are quick and easy to use, so they can improve office flow, he noted.

An emphasis on initiating infection control procedures from the time of a patient's first phone call to the office is another important addition to the statement, Dr. Bocchini noted.

With that first phone call, the likelihood of contagious disease should be assessed, and decisions should be made about how to triage the patient through the office to reduce exposure to other patients, family members, and office staff, he said.

According to the statement, “patients with potentially contagious diseases and immunocompromised children should be promptly triaged. Contact between contagious children and uninfected children should be minimized.” This recommendation is listed as category IB, indicating a strong recommendation for implementation, supported by certain studies and a strong theoretical rationale.

“In addition, there have been considerable updates of recommendations for the prevention of exposure to blood-borne pathogens by needles and other sharps,” Dr. Bocchini said.

Based on new recommendations from the Occupational Safety and Health Administration, the AAP now calls for written policies and specific educational programs to make staff aware of the proper handling of sharps, and for consideration of adopting into practice any new and potentially safer medical devices and systems that become available to reduce the risk of needle-stick injuries. This category IA recommendation also is listed as category IC, indicating that it is required for implementation as mandated by federal or state regulation or standard.

Other important updates to the statement include:

▸ A call for implementation of new Centers for Disease Control and Prevention strategies for respiratory hygiene and cough etiquette for patients with suspected influenza or other respiratory tract pathogens, which were recently added to its list of standard precautions for hospitalized patients. That list was modified by the AAP for children, and includes, among other things, recommendations for providing visual alerts for patients to alert staff of respiratory tract infections and for reminding them of cough etiquette. This is a category II recommendation, indicating it is suggested for implementation based on suggestive studies or theoretical rationale.

▸ More detailed guidelines on infection control and prevention in physician's office waiting rooms. In addition to standard precautions, the statement outlines category IC procedures for sterilization, disinfection, and antisepsis.

▸ Added emphasis on the use of vaccines available for reducing employee's risk of acquisition or transmission of certain infectious diseases, such as influenza, tetanus, pertussis, and hepatitis. This category IB and IC policy states that employees should be vaccinated annually against influenza and should show documentation of immunity to other vaccine-preventable infections.

▸ New emphasis on the importance of developing policies and procedures for communicating with state and local authorities for prompt reporting of communicable disease and suspected outbreaks as required by law (category IC).

Use of an alcohol-based hand sanitizer is the preferred method of hand hygiene in most situations in the office, according to a newly updated American Academy of Pediatrics policy statement on infection prevention and control in ambulatory settings.

The updates to the statement, entitled “Infection Prevention and Control in Pediatric Ambulatory Settings,” were prompted by a flurry of new recommendations for preventing the spread of infectious disease, according to Dr. Joseph A. Bocchini Jr., chair of the AAP Committee on Infectious Diseases, which developed the statement (Pediatrics 2007;120:650-65).

Dr. Bocchini, who also is professor and chairman of pediatrics at the Louisiana State University Health Sciences Center, Shreveport, called the statement a must-read for those practicing in pediatric ambulatory care settings. It is “very comprehensive and includes a significant amount of information and guidance on how to reduce infection risk for patients and for personnel.”

Although significant emphasis has been placed on preventing infection in hospitals, most patients are seen in ambulatory settings, so control and prevention of the spread of infection in this setting is very important, he added.

The committee's nod regarding the use of alcohol-based hand sanitizers is one of numerous updates to the statement, which was initially published in Pediatrics in 2000. “This is an important alternative hand hygiene technique that is safe and effective,” Dr. Bocchini said in an interview, noting that the recommendation applies only to alcohol-based sanitizers, and is a category IA guideline, indicating that it is based on a strong recommendation for implementation, strongly supported by well-designed studies.

Such products are more effective than standard handwashing techniques in most cases, and should be the primary mode of hand hygiene before and after each patient contact. Soap and water still are effective—and in fact are preferred when there is a high likelihood of exposure to organisms such as Clostridium difficile, when hands are visibly contaminated with blood or other body fluids from a patient, before eating, and after using the toilet. But, in general, sanitizers are preferred because they are quick and easy to use, so they can improve office flow, he noted.

An emphasis on initiating infection control procedures from the time of a patient's first phone call to the office is another important addition to the statement, Dr. Bocchini noted.

With that first phone call, the likelihood of contagious disease should be assessed, and decisions should be made about how to triage the patient through the office to reduce exposure to other patients, family members, and office staff, he said.

According to the statement, “patients with potentially contagious diseases and immunocompromised children should be promptly triaged. Contact between contagious children and uninfected children should be minimized.” This recommendation is listed as category IB, indicating a strong recommendation for implementation, supported by certain studies and a strong theoretical rationale.

“In addition, there have been considerable updates of recommendations for the prevention of exposure to blood-borne pathogens by needles and other sharps,” Dr. Bocchini said.

Based on new recommendations from the Occupational Safety and Health Administration, the AAP now calls for written policies and specific educational programs to make staff aware of the proper handling of sharps, and for consideration of adopting into practice any new and potentially safer medical devices and systems that become available to reduce the risk of needle-stick injuries. This category IA recommendation also is listed as category IC, indicating that it is required for implementation as mandated by federal or state regulation or standard.

Other important updates to the statement include:

▸ A call for implementation of new Centers for Disease Control and Prevention strategies for respiratory hygiene and cough etiquette for patients with suspected influenza or other respiratory tract pathogens, which were recently added to its list of standard precautions for hospitalized patients. That list was modified by the AAP for children, and includes, among other things, recommendations for providing visual alerts for patients to alert staff of respiratory tract infections and for reminding them of cough etiquette. This is a category II recommendation, indicating it is suggested for implementation based on suggestive studies or theoretical rationale.

▸ More detailed guidelines on infection control and prevention in physician's office waiting rooms. In addition to standard precautions, the statement outlines category IC procedures for sterilization, disinfection, and antisepsis.

▸ Added emphasis on the use of vaccines available for reducing employee's risk of acquisition or transmission of certain infectious diseases, such as influenza, tetanus, pertussis, and hepatitis. This category IB and IC policy states that employees should be vaccinated annually against influenza and should show documentation of immunity to other vaccine-preventable infections.

▸ New emphasis on the importance of developing policies and procedures for communicating with state and local authorities for prompt reporting of communicable disease and suspected outbreaks as required by law (category IC).

Recent data linking human papillomavirus with oropharyngeal cancers, which typically occur in men, suggest a need for stepped-up efforts to gain approval for use of the HPV vaccine in young men and adolescent boys, according to Dr. Erich Sturgis and Dr. Paul M. Cinciripini, of the University of Texas M.D. Anderson Cancer Center, Houston.

Although the incidence of most types of squamous cell carcinomas of the head and neck have declined over the past 20 years, in tandem with declines in the prevalence of smoking, the incidence of oropharyngeal cancers has remained stagnant—a trend that may be attributable to the growing incidence of oncogenic HPV-associated cancers, the authors wrote (Cancer 2007 Oct. [doi:10.1002/cncr.22963]).

They praised efforts to promote the recently approved HPV-16/18 vaccination of young women and adolescent girls to reduce the incidence of cervical cancer and dysplasia, but warned that limiting vaccination programs to females would delay potential benefits of preventing the HPV-16/18 oropharyngeal cancers in males.

Dr. Cinciripini has acted as a consultant for GlaxoSmithKline, the manufacturer of Cervarix, a vaccine against HPV 16/18.

Data have shown an increase in the incidence of oral tongue cancer in young adults and of oropharyngeal cancers, particularly tonsil and base of tongue cancer, in those younger than 45 years. In addition, the literature consistently shows a link between oncogenic HPV and oropharyngeal cancers, with HPV DNA being identified in about half of all oropharyngeal cancers and in a particularly high proportion of oropharyngeal cancers in nonsmokers. More than 90% of HPV-positive oropharyngeal cancers are a result of HPV-16.

The similarities between HPV-related oropharyngeal cancer and cervical carcinogenesis, and the “biologic plausibility of the HPV carcinogenesis model all support HPV causality of a proportion of oropharyngeal cancers,” they noted.

The mode of transmission of HPV in patients with HPV-related oropharyngeal cancer is not clear, but some reports suggest the sexual history of oncogenic HPV-positive oropharyngeal cancer patients mirrors that of women with cervical cancer, and it is likely that risk factors such as multiple sexual partners and oral-genital sex play a role, the authors said.

Recent data linking human papillomavirus with oropharyngeal cancers, which typically occur in men, suggest a need for stepped-up efforts to gain approval for use of the HPV vaccine in young men and adolescent boys, according to Dr. Erich Sturgis and Dr. Paul M. Cinciripini, of the University of Texas M.D. Anderson Cancer Center, Houston.

Although the incidence of most types of squamous cell carcinomas of the head and neck have declined over the past 20 years, in tandem with declines in the prevalence of smoking, the incidence of oropharyngeal cancers has remained stagnant—a trend that may be attributable to the growing incidence of oncogenic HPV-associated cancers, the authors wrote (Cancer 2007 Oct. [doi:10.1002/cncr.22963]).

They praised efforts to promote the recently approved HPV-16/18 vaccination of young women and adolescent girls to reduce the incidence of cervical cancer and dysplasia, but warned that limiting vaccination programs to females would delay potential benefits of preventing the HPV-16/18 oropharyngeal cancers in males.

Dr. Cinciripini has acted as a consultant for GlaxoSmithKline, the manufacturer of Cervarix, a vaccine against HPV 16/18.

Data have shown an increase in the incidence of oral tongue cancer in young adults and of oropharyngeal cancers, particularly tonsil and base of tongue cancer, in those younger than 45 years. In addition, the literature consistently shows a link between oncogenic HPV and oropharyngeal cancers, with HPV DNA being identified in about half of all oropharyngeal cancers and in a particularly high proportion of oropharyngeal cancers in nonsmokers. More than 90% of HPV-positive oropharyngeal cancers are a result of HPV-16.

The similarities between HPV-related oropharyngeal cancer and cervical carcinogenesis, and the “biologic plausibility of the HPV carcinogenesis model all support HPV causality of a proportion of oropharyngeal cancers,” they noted.

The mode of transmission of HPV in patients with HPV-related oropharyngeal cancer is not clear, but some reports suggest the sexual history of oncogenic HPV-positive oropharyngeal cancer patients mirrors that of women with cervical cancer, and it is likely that risk factors such as multiple sexual partners and oral-genital sex play a role, the authors said.

Recent data linking human papillomavirus with oropharyngeal cancers, which typically occur in men, suggest a need for stepped-up efforts to gain approval for use of the HPV vaccine in young men and adolescent boys, according to Dr. Erich Sturgis and Dr. Paul M. Cinciripini, of the University of Texas M.D. Anderson Cancer Center, Houston.

Although the incidence of most types of squamous cell carcinomas of the head and neck have declined over the past 20 years, in tandem with declines in the prevalence of smoking, the incidence of oropharyngeal cancers has remained stagnant—a trend that may be attributable to the growing incidence of oncogenic HPV-associated cancers, the authors wrote (Cancer 2007 Oct. [doi:10.1002/cncr.22963]).

They praised efforts to promote the recently approved HPV-16/18 vaccination of young women and adolescent girls to reduce the incidence of cervical cancer and dysplasia, but warned that limiting vaccination programs to females would delay potential benefits of preventing the HPV-16/18 oropharyngeal cancers in males.

Dr. Cinciripini has acted as a consultant for GlaxoSmithKline, the manufacturer of Cervarix, a vaccine against HPV 16/18.

Data have shown an increase in the incidence of oral tongue cancer in young adults and of oropharyngeal cancers, particularly tonsil and base of tongue cancer, in those younger than 45 years. In addition, the literature consistently shows a link between oncogenic HPV and oropharyngeal cancers, with HPV DNA being identified in about half of all oropharyngeal cancers and in a particularly high proportion of oropharyngeal cancers in nonsmokers. More than 90% of HPV-positive oropharyngeal cancers are a result of HPV-16.

The similarities between HPV-related oropharyngeal cancer and cervical carcinogenesis, and the “biologic plausibility of the HPV carcinogenesis model all support HPV causality of a proportion of oropharyngeal cancers,” they noted.

The mode of transmission of HPV in patients with HPV-related oropharyngeal cancer is not clear, but some reports suggest the sexual history of oncogenic HPV-positive oropharyngeal cancer patients mirrors that of women with cervical cancer, and it is likely that risk factors such as multiple sexual partners and oral-genital sex play a role, the authors said.

NEW ORLEANS — Increased physical activity levels were associated with lower intra-abdominal fat levels in 330 middle-aged women participating in the Study of Women's Health Across the Nation (SWAN), Dr. Sheila Ann Dugan reported at the annual meeting of the American College of Sports Medicine.

In the biracial cohort of women who participated in the ancillary SWAN Diabetes Risk study, a highly statistically significant association was seen between self-reported physical activity, including household and exercise activities, and the level of intra-abdominal fat, Dr. Dugan reported in a poster at the meeting.

The association remained highly significant after adjusting for total percent fat mass, age, ethnicity, hormonal status, educational level, depression score, and parity, and the findings were similar in black and white women, explained Dr. Dugan of Rush University Medical Center, Chicago.

Intra-abdominal fat is a risk factor for diabetes, hypertension, and heart disease, and can be present even in women of normal weight. The study's finding is encouraging because it reinforces the fact that intra-abdominal fat is preventable and modifiable, Dr. Dugan noted in a statement.

Exercising and avoiding overeating can help prevent excess intra-abdominal fat; the American College of Sports Medicine recommends 30–60 minutes of moderate-intensity physical activity per day in healthy adults, according to the statement.

Motivating women to increase their physical activity during their middle years, when visceral fat levels tend to increase due to age-related weight gain and menopause, can positively modify age-related increases in women's intra-abdominal fat and may improve their cardiovascular risk profiles, Dr. Dugan concluded.

NEW ORLEANS — Increased physical activity levels were associated with lower intra-abdominal fat levels in 330 middle-aged women participating in the Study of Women's Health Across the Nation (SWAN), Dr. Sheila Ann Dugan reported at the annual meeting of the American College of Sports Medicine.

In the biracial cohort of women who participated in the ancillary SWAN Diabetes Risk study, a highly statistically significant association was seen between self-reported physical activity, including household and exercise activities, and the level of intra-abdominal fat, Dr. Dugan reported in a poster at the meeting.

The association remained highly significant after adjusting for total percent fat mass, age, ethnicity, hormonal status, educational level, depression score, and parity, and the findings were similar in black and white women, explained Dr. Dugan of Rush University Medical Center, Chicago.

Intra-abdominal fat is a risk factor for diabetes, hypertension, and heart disease, and can be present even in women of normal weight. The study's finding is encouraging because it reinforces the fact that intra-abdominal fat is preventable and modifiable, Dr. Dugan noted in a statement.

Exercising and avoiding overeating can help prevent excess intra-abdominal fat; the American College of Sports Medicine recommends 30–60 minutes of moderate-intensity physical activity per day in healthy adults, according to the statement.

Motivating women to increase their physical activity during their middle years, when visceral fat levels tend to increase due to age-related weight gain and menopause, can positively modify age-related increases in women's intra-abdominal fat and may improve their cardiovascular risk profiles, Dr. Dugan concluded.

NEW ORLEANS — Increased physical activity levels were associated with lower intra-abdominal fat levels in 330 middle-aged women participating in the Study of Women's Health Across the Nation (SWAN), Dr. Sheila Ann Dugan reported at the annual meeting of the American College of Sports Medicine.

In the biracial cohort of women who participated in the ancillary SWAN Diabetes Risk study, a highly statistically significant association was seen between self-reported physical activity, including household and exercise activities, and the level of intra-abdominal fat, Dr. Dugan reported in a poster at the meeting.

The association remained highly significant after adjusting for total percent fat mass, age, ethnicity, hormonal status, educational level, depression score, and parity, and the findings were similar in black and white women, explained Dr. Dugan of Rush University Medical Center, Chicago.

Intra-abdominal fat is a risk factor for diabetes, hypertension, and heart disease, and can be present even in women of normal weight. The study's finding is encouraging because it reinforces the fact that intra-abdominal fat is preventable and modifiable, Dr. Dugan noted in a statement.

Exercising and avoiding overeating can help prevent excess intra-abdominal fat; the American College of Sports Medicine recommends 30–60 minutes of moderate-intensity physical activity per day in healthy adults, according to the statement.

Motivating women to increase their physical activity during their middle years, when visceral fat levels tend to increase due to age-related weight gain and menopause, can positively modify age-related increases in women's intra-abdominal fat and may improve their cardiovascular risk profiles, Dr. Dugan concluded.

NEW ORLEANS — Physical activity and fitness levels are low in individuals with newly diagnosed type 2 diabetes, compared with reference populations, Kate. J. Fitzsimons reported in a poster presentation at the annual meeting of the American College of Sports Medicine.

Baseline data from 155 men and 110 women enrolled in the Early Activity in Diabetes (Early ACTID) study—a randomized controlled trial comparing diet plus exercise with diet alone and usual care in adults with type 2 diabetes—were used in the analysis. Participants had a mean age of 58 years (range of 31–79 years) and had been diagnosed with type 2 diabetes in the 5–8 months prior to study entry.

Habitual physical activity levels were measured using an accelerometer, which is a device that uses motion sensors to provide an objective measurement of physical activity. The device was worn by participants during all waking hours for 7 consecutive days.

Average activity volume in the participants, calculated as accelerometer counts per minute (cpm), was 238, and time spent in moderate to vigorous physical activity (based on an established cut point of 2,100 cpm that is equivalent to 2–5 miles per hour) averaged 21 minutes daily for both men and women, reported Ms. Fitzsimons, a doctoral student at the University of Bristol (England), and a member of the Early ACTID study team.

Activity volume in these Early ACTID participants was substantially lower than in overweight and obese nondiabetic participants in a prior University of Bristol study of daily physical activity patterns in 84 adults employed in sedentary occupations. For example, Early ACTID obese individuals (those with a body mass index of 30–39.9 kg/m

Furthermore, cardiorespiratory fitness levels in the Early ACTID participants, which were calculated for 210 participants who were not taking β-blockers, and which were assessed using a submaximal 1-mile track walk test on an indoor, level track, were also low in a majority of participants. Mean predicted maximal oxygen uptake (VO₂ max), which was predicted based on time taken to complete the walk test, heart rate at completion, weight, age, and gender, was 30 mL/kg per min for men and 21 mL/kg per min for women. Based on normative data from healthy populations, 61% of participants had a predicted VO₂ max value considered poor or very poor, Ms. Fitzsimons noted.

When participants' physical activity levels were stratified based on body mass index, no differences were found on weekdays, but during weekends, obese individuals and morbidly obese individuals (BMI of 40 kg/m

Although improvements in physical activity and cardiorespiratory fitness are believed to have importance in the management of type 2 diabetes, objective data regarding the levels of these factors in those with newly diagnosed disease have been lacking, Ms. Fitzsimons said.

“The low levels of physical activity and fitness in people in the early stages of type 2 diabetes support the use of interventions aimed at increasing physical activity and improving fitness,” she wrote.

NEW ORLEANS — Physical activity and fitness levels are low in individuals with newly diagnosed type 2 diabetes, compared with reference populations, Kate. J. Fitzsimons reported in a poster presentation at the annual meeting of the American College of Sports Medicine.

Baseline data from 155 men and 110 women enrolled in the Early Activity in Diabetes (Early ACTID) study—a randomized controlled trial comparing diet plus exercise with diet alone and usual care in adults with type 2 diabetes—were used in the analysis. Participants had a mean age of 58 years (range of 31–79 years) and had been diagnosed with type 2 diabetes in the 5–8 months prior to study entry.

Habitual physical activity levels were measured using an accelerometer, which is a device that uses motion sensors to provide an objective measurement of physical activity. The device was worn by participants during all waking hours for 7 consecutive days.

Average activity volume in the participants, calculated as accelerometer counts per minute (cpm), was 238, and time spent in moderate to vigorous physical activity (based on an established cut point of 2,100 cpm that is equivalent to 2–5 miles per hour) averaged 21 minutes daily for both men and women, reported Ms. Fitzsimons, a doctoral student at the University of Bristol (England), and a member of the Early ACTID study team.

Activity volume in these Early ACTID participants was substantially lower than in overweight and obese nondiabetic participants in a prior University of Bristol study of daily physical activity patterns in 84 adults employed in sedentary occupations. For example, Early ACTID obese individuals (those with a body mass index of 30–39.9 kg/m

Furthermore, cardiorespiratory fitness levels in the Early ACTID participants, which were calculated for 210 participants who were not taking β-blockers, and which were assessed using a submaximal 1-mile track walk test on an indoor, level track, were also low in a majority of participants. Mean predicted maximal oxygen uptake (VO₂ max), which was predicted based on time taken to complete the walk test, heart rate at completion, weight, age, and gender, was 30 mL/kg per min for men and 21 mL/kg per min for women. Based on normative data from healthy populations, 61% of participants had a predicted VO₂ max value considered poor or very poor, Ms. Fitzsimons noted.

When participants' physical activity levels were stratified based on body mass index, no differences were found on weekdays, but during weekends, obese individuals and morbidly obese individuals (BMI of 40 kg/m

Although improvements in physical activity and cardiorespiratory fitness are believed to have importance in the management of type 2 diabetes, objective data regarding the levels of these factors in those with newly diagnosed disease have been lacking, Ms. Fitzsimons said.

“The low levels of physical activity and fitness in people in the early stages of type 2 diabetes support the use of interventions aimed at increasing physical activity and improving fitness,” she wrote.

NEW ORLEANS — Physical activity and fitness levels are low in individuals with newly diagnosed type 2 diabetes, compared with reference populations, Kate. J. Fitzsimons reported in a poster presentation at the annual meeting of the American College of Sports Medicine.

Baseline data from 155 men and 110 women enrolled in the Early Activity in Diabetes (Early ACTID) study—a randomized controlled trial comparing diet plus exercise with diet alone and usual care in adults with type 2 diabetes—were used in the analysis. Participants had a mean age of 58 years (range of 31–79 years) and had been diagnosed with type 2 diabetes in the 5–8 months prior to study entry.

Habitual physical activity levels were measured using an accelerometer, which is a device that uses motion sensors to provide an objective measurement of physical activity. The device was worn by participants during all waking hours for 7 consecutive days.

Average activity volume in the participants, calculated as accelerometer counts per minute (cpm), was 238, and time spent in moderate to vigorous physical activity (based on an established cut point of 2,100 cpm that is equivalent to 2–5 miles per hour) averaged 21 minutes daily for both men and women, reported Ms. Fitzsimons, a doctoral student at the University of Bristol (England), and a member of the Early ACTID study team.

Activity volume in these Early ACTID participants was substantially lower than in overweight and obese nondiabetic participants in a prior University of Bristol study of daily physical activity patterns in 84 adults employed in sedentary occupations. For example, Early ACTID obese individuals (those with a body mass index of 30–39.9 kg/m

Furthermore, cardiorespiratory fitness levels in the Early ACTID participants, which were calculated for 210 participants who were not taking β-blockers, and which were assessed using a submaximal 1-mile track walk test on an indoor, level track, were also low in a majority of participants. Mean predicted maximal oxygen uptake (VO₂ max), which was predicted based on time taken to complete the walk test, heart rate at completion, weight, age, and gender, was 30 mL/kg per min for men and 21 mL/kg per min for women. Based on normative data from healthy populations, 61% of participants had a predicted VO₂ max value considered poor or very poor, Ms. Fitzsimons noted.

When participants' physical activity levels were stratified based on body mass index, no differences were found on weekdays, but during weekends, obese individuals and morbidly obese individuals (BMI of 40 kg/m

Although improvements in physical activity and cardiorespiratory fitness are believed to have importance in the management of type 2 diabetes, objective data regarding the levels of these factors in those with newly diagnosed disease have been lacking, Ms. Fitzsimons said.

“The low levels of physical activity and fitness in people in the early stages of type 2 diabetes support the use of interventions aimed at increasing physical activity and improving fitness,” she wrote.

MIAMI BEACH – The impact of headache disorders extends beyond the patient and can have devastating effects on family life.

Attention to this potential problem can promote improved family functioning, Alvin E. Lake III, Ph.D., said at a symposium sponsored by the American Headache Society.

The problem can be a cyclical one: Family stressors and pressures, and the need to continue functioning in the family setting, can lead to analgesic overuse, which in turn increases the risk of chronic daily headaches; the headache disorder then becomes an issue that adversely affects family life and relationships.

Studies show that migraineurs often miss family social activities, avoid making social plans for fear of canceling, have difficulty accomplishing normal household tasks like housecleaning, and argue more with spouses and children.

In one study of 389 migraineurs who experienced more than five attacks per year, 85% said their migraines caused them to do less housework, 45% said the migraines caused them to miss social activities, and 50% said they were more likely to argue with family members. More than 70% said they also suffered other adverse consequences, said Dr. Lake, director of the psychology division at the Michigan Headache & Neurological Institute, Ann Arbor.

Of 100 spouses who participated in the study, 29% agreed that arguments were more common, and 60% said the migraines had other adverse effects on relationships.

Children are also affected. Another study showed that of 130 children under age 12 with a parent who suffered from migraines, 66% “kept quiet,” 61% experienced canceled plans, 42% received “other child care,” 25% were confused about their situation, and 17% had hostility. Of 88 children over age 12, 87% avoided loud activities, 61% avoided asking for help, 42% had plans canceled, 21% avoided school, and 12% had hostility.

Encourage families to modulate attention to the migraineur's pain. As with patients who have been shown to experience less pain intensity when their attention is diverted from the pain, families will also experience improved functioning if family life doesn't revolve around the pain, Dr. Lake said, and suggested that enabling behaviors should be discouraged.

Families and patients should be advised to set achievable goals for accomplishing tasks or participating in activities, and they should be encouraged to replace all-or-nothing thinking with a mind-set that “some is better than none.” For example, they can agree to attend a social event for an hour rather than avoiding it altogether, he said.

Finally, family members should be encouraged to maintain their own lives. Compromise and balance are key factors in optimizing family functioning, Dr. Lake said.

MIAMI BEACH – The impact of headache disorders extends beyond the patient and can have devastating effects on family life.

Attention to this potential problem can promote improved family functioning, Alvin E. Lake III, Ph.D., said at a symposium sponsored by the American Headache Society.

The problem can be a cyclical one: Family stressors and pressures, and the need to continue functioning in the family setting, can lead to analgesic overuse, which in turn increases the risk of chronic daily headaches; the headache disorder then becomes an issue that adversely affects family life and relationships.

Studies show that migraineurs often miss family social activities, avoid making social plans for fear of canceling, have difficulty accomplishing normal household tasks like housecleaning, and argue more with spouses and children.

In one study of 389 migraineurs who experienced more than five attacks per year, 85% said their migraines caused them to do less housework, 45% said the migraines caused them to miss social activities, and 50% said they were more likely to argue with family members. More than 70% said they also suffered other adverse consequences, said Dr. Lake, director of the psychology division at the Michigan Headache & Neurological Institute, Ann Arbor.

Of 100 spouses who participated in the study, 29% agreed that arguments were more common, and 60% said the migraines had other adverse effects on relationships.

Children are also affected. Another study showed that of 130 children under age 12 with a parent who suffered from migraines, 66% “kept quiet,” 61% experienced canceled plans, 42% received “other child care,” 25% were confused about their situation, and 17% had hostility. Of 88 children over age 12, 87% avoided loud activities, 61% avoided asking for help, 42% had plans canceled, 21% avoided school, and 12% had hostility.

Encourage families to modulate attention to the migraineur's pain. As with patients who have been shown to experience less pain intensity when their attention is diverted from the pain, families will also experience improved functioning if family life doesn't revolve around the pain, Dr. Lake said, and suggested that enabling behaviors should be discouraged.

Families and patients should be advised to set achievable goals for accomplishing tasks or participating in activities, and they should be encouraged to replace all-or-nothing thinking with a mind-set that “some is better than none.” For example, they can agree to attend a social event for an hour rather than avoiding it altogether, he said.

Finally, family members should be encouraged to maintain their own lives. Compromise and balance are key factors in optimizing family functioning, Dr. Lake said.

MIAMI BEACH – The impact of headache disorders extends beyond the patient and can have devastating effects on family life.

Attention to this potential problem can promote improved family functioning, Alvin E. Lake III, Ph.D., said at a symposium sponsored by the American Headache Society.

The problem can be a cyclical one: Family stressors and pressures, and the need to continue functioning in the family setting, can lead to analgesic overuse, which in turn increases the risk of chronic daily headaches; the headache disorder then becomes an issue that adversely affects family life and relationships.

Studies show that migraineurs often miss family social activities, avoid making social plans for fear of canceling, have difficulty accomplishing normal household tasks like housecleaning, and argue more with spouses and children.

In one study of 389 migraineurs who experienced more than five attacks per year, 85% said their migraines caused them to do less housework, 45% said the migraines caused them to miss social activities, and 50% said they were more likely to argue with family members. More than 70% said they also suffered other adverse consequences, said Dr. Lake, director of the psychology division at the Michigan Headache & Neurological Institute, Ann Arbor.

Of 100 spouses who participated in the study, 29% agreed that arguments were more common, and 60% said the migraines had other adverse effects on relationships.

Children are also affected. Another study showed that of 130 children under age 12 with a parent who suffered from migraines, 66% “kept quiet,” 61% experienced canceled plans, 42% received “other child care,” 25% were confused about their situation, and 17% had hostility. Of 88 children over age 12, 87% avoided loud activities, 61% avoided asking for help, 42% had plans canceled, 21% avoided school, and 12% had hostility.

Encourage families to modulate attention to the migraineur's pain. As with patients who have been shown to experience less pain intensity when their attention is diverted from the pain, families will also experience improved functioning if family life doesn't revolve around the pain, Dr. Lake said, and suggested that enabling behaviors should be discouraged.

Families and patients should be advised to set achievable goals for accomplishing tasks or participating in activities, and they should be encouraged to replace all-or-nothing thinking with a mind-set that “some is better than none.” For example, they can agree to attend a social event for an hour rather than avoiding it altogether, he said.

Finally, family members should be encouraged to maintain their own lives. Compromise and balance are key factors in optimizing family functioning, Dr. Lake said.

NEW ORLEANS — Therapeutic lifestyle changes are effective for lowering blood pressure in individuals with prehypertension, but obese individuals may not derive maximum benefit, according to findings from a prospective study of nearly 2,500 patients who had prehypertension at baseline.

Of the 1,113 obese adults (body mass index greater than 30 kg/m

The blood pressure reductions were statistically significant in all groups, but the greatest reductions were seen in the nonoverweight subjects (average reduction of 10/8 mm Hg vs. 7/6 mm Hg for overweight subjects and 6/5 mm Hg for obese subjects), Dr. Barry A. Franklin reported in a poster at the annual meeting of the American College of Sports Medicine.

The greatest changes were seen in the nonoverweight group, despite significantly more weight loss in the obese subjects (6 pounds) and the overweight subjects (3 pounds), compared with the nonoverweight subjects (0 pounds), noted Dr. Franklin of William Beaumont Hospital, Royal Oak, Mich.

Overall, the average resting blood pressure of the study population (125/79 mm Hg) decreased by 6/3 mm Hg. Systolic blood pressure decreased by 7 mm Hg in those with a baseline systolic blood pressure of 120–139 mm Hg, and diastolic blood pressure decreased by 6 mm Hg in those with a baseline diastolic blood pressure of 80–89 mm Hg. All the decreases were statistically significant.

The participants, who were not using any type of drug therapy to control blood pressure, were evaluated at baseline and after an average of 6 months of participation in the program, which involved exercise training, nutrition, weight management, stress management, and smoking cessation interventions.

The findings are important, Dr. Franklin said, because although guidelines promote therapeutic lifestyle changes as a cornerstone in the management of prehypertension, recent research that has focused largely on pharmacotherapy for prehypertension suggests that TLC is ineffective or inadequate.

These data show that TLC can be effective for managing prehypertension, which is a precursor of hypertension and a predictor of excessive cardiovascular risk, but they also suggest that there may be BMI-related differences in the responsiveness of blood pressure to TLC, he concluded.

ELSEVIER GLOBAL MEDICAL NEWS

NEW ORLEANS — Therapeutic lifestyle changes are effective for lowering blood pressure in individuals with prehypertension, but obese individuals may not derive maximum benefit, according to findings from a prospective study of nearly 2,500 patients who had prehypertension at baseline.

Of the 1,113 obese adults (body mass index greater than 30 kg/m

The blood pressure reductions were statistically significant in all groups, but the greatest reductions were seen in the nonoverweight subjects (average reduction of 10/8 mm Hg vs. 7/6 mm Hg for overweight subjects and 6/5 mm Hg for obese subjects), Dr. Barry A. Franklin reported in a poster at the annual meeting of the American College of Sports Medicine.

The greatest changes were seen in the nonoverweight group, despite significantly more weight loss in the obese subjects (6 pounds) and the overweight subjects (3 pounds), compared with the nonoverweight subjects (0 pounds), noted Dr. Franklin of William Beaumont Hospital, Royal Oak, Mich.

Overall, the average resting blood pressure of the study population (125/79 mm Hg) decreased by 6/3 mm Hg. Systolic blood pressure decreased by 7 mm Hg in those with a baseline systolic blood pressure of 120–139 mm Hg, and diastolic blood pressure decreased by 6 mm Hg in those with a baseline diastolic blood pressure of 80–89 mm Hg. All the decreases were statistically significant.

The participants, who were not using any type of drug therapy to control blood pressure, were evaluated at baseline and after an average of 6 months of participation in the program, which involved exercise training, nutrition, weight management, stress management, and smoking cessation interventions.

The findings are important, Dr. Franklin said, because although guidelines promote therapeutic lifestyle changes as a cornerstone in the management of prehypertension, recent research that has focused largely on pharmacotherapy for prehypertension suggests that TLC is ineffective or inadequate.

These data show that TLC can be effective for managing prehypertension, which is a precursor of hypertension and a predictor of excessive cardiovascular risk, but they also suggest that there may be BMI-related differences in the responsiveness of blood pressure to TLC, he concluded.

ELSEVIER GLOBAL MEDICAL NEWS

NEW ORLEANS — Therapeutic lifestyle changes are effective for lowering blood pressure in individuals with prehypertension, but obese individuals may not derive maximum benefit, according to findings from a prospective study of nearly 2,500 patients who had prehypertension at baseline.

Of the 1,113 obese adults (body mass index greater than 30 kg/m

The blood pressure reductions were statistically significant in all groups, but the greatest reductions were seen in the nonoverweight subjects (average reduction of 10/8 mm Hg vs. 7/6 mm Hg for overweight subjects and 6/5 mm Hg for obese subjects), Dr. Barry A. Franklin reported in a poster at the annual meeting of the American College of Sports Medicine.

The greatest changes were seen in the nonoverweight group, despite significantly more weight loss in the obese subjects (6 pounds) and the overweight subjects (3 pounds), compared with the nonoverweight subjects (0 pounds), noted Dr. Franklin of William Beaumont Hospital, Royal Oak, Mich.

Overall, the average resting blood pressure of the study population (125/79 mm Hg) decreased by 6/3 mm Hg. Systolic blood pressure decreased by 7 mm Hg in those with a baseline systolic blood pressure of 120–139 mm Hg, and diastolic blood pressure decreased by 6 mm Hg in those with a baseline diastolic blood pressure of 80–89 mm Hg. All the decreases were statistically significant.

The participants, who were not using any type of drug therapy to control blood pressure, were evaluated at baseline and after an average of 6 months of participation in the program, which involved exercise training, nutrition, weight management, stress management, and smoking cessation interventions.

The findings are important, Dr. Franklin said, because although guidelines promote therapeutic lifestyle changes as a cornerstone in the management of prehypertension, recent research that has focused largely on pharmacotherapy for prehypertension suggests that TLC is ineffective or inadequate.

These data show that TLC can be effective for managing prehypertension, which is a precursor of hypertension and a predictor of excessive cardiovascular risk, but they also suggest that there may be BMI-related differences in the responsiveness of blood pressure to TLC, he concluded.

ELSEVIER GLOBAL MEDICAL NEWS

DESTIN, FLA. — Phaeohyphomycosis usually results from infection by Bipolaris fungi, and it requires wide debridement and immediate treatment with massive doses of itraconazole to reduce the fungal burden, Dr. Dirk Elston said at a meeting sponsored by the Alabama Dermatology Society.

Because the typical empirical treatments for more common fungal infections—such as amphotericin—will not work in this potentially fatal condition, consider this diagnosis, particularly in immunocompromised patients, who tend to develop invasive disease, he advised.

A quick biopsy and a good dermatopathologist are key. "You've got a window of opportunity to treat [these patients]. You have one chance to treat them right, and even with the right treatment they may succumb. But without that, they don't even have a chance," said Dr. Elston, who is director of the department of dermatology at Geisinger Medical Center in Danville, Pa.

Clues to the diagnosis are the presence of a thick refractile wall (as seen with mucormycosis) on histology, and bubbly cytoplasm (as seen with aspergillus or fusarium).

"You've got it nailed based on that [combination]. It's a black mold, a phaeo organism," he said.

He described a case involving a ventilator-dependent infant who developed what appeared to be multiple bedsores. Because of the ventilator, nurses had been unable to rotate the baby, who was born at 22 weeks' gestation in a septic environment following a car accident that resulted in a traumatic placental abruption in the mother.

When the infant was finally able to be rotated, the nurses discovered the lesions. A closer look revealed that the lesions were not bedsores, but fungal sepsis.

The lesions consisted of a black, leathery, depressed central eschar and an "almost bullous edematous scalloped border," Dr. Elston explained, noting that they appeared similar to fungal embolic lesions that occur commonly in leukemia patients.

A biopsy was performed and phaeohyphomycosis was diagnosed, but the infant died despite aggressive therapy. An autopsy revealed that the fungus had invaded every organ in the child's body, he said.

In another case, a diabetic patient with contact dermatitis from his shoes developed invasive phaeohyphomycosis that resulted in bilateral above-the-knee amputations.

"They basically chopped his legs off a bit at a time, starting with forefoot, then hindfoot, then [below-the knee amputation], then above-the-knee, as this plowed through tissue" he said, noting that the patient was never put on itraconazole but was treated with amphotericin.

"The wrong drug [was used] … so nailing the organism is really important for this," he said, reiterating the need for early diagnosis to determine the appropriate course of treatment.

Common manifestations of phaeohyphomycosis include tinea nigra, particularly in hot, humid climates, and phaeohyphomycotic cysts. These tend to develop in immunocompetent patients with these types of infections, whereas invasive disease occurs almost exclusively in immunocompromised patients, Dr. Elston said.

Morphology, rather than a Fontana-Masson stain for the characteristic melanin in the cell wall, should be relied upon for diagnosis in these infections, because Fontana-Masson will stain melanin in a variety of other conditions as well, he noted.

DESTIN, FLA. — Phaeohyphomycosis usually results from infection by Bipolaris fungi, and it requires wide debridement and immediate treatment with massive doses of itraconazole to reduce the fungal burden, Dr. Dirk Elston said at a meeting sponsored by the Alabama Dermatology Society.

Because the typical empirical treatments for more common fungal infections—such as amphotericin—will not work in this potentially fatal condition, consider this diagnosis, particularly in immunocompromised patients, who tend to develop invasive disease, he advised.

A quick biopsy and a good dermatopathologist are key. "You've got a window of opportunity to treat [these patients]. You have one chance to treat them right, and even with the right treatment they may succumb. But without that, they don't even have a chance," said Dr. Elston, who is director of the department of dermatology at Geisinger Medical Center in Danville, Pa.

Clues to the diagnosis are the presence of a thick refractile wall (as seen with mucormycosis) on histology, and bubbly cytoplasm (as seen with aspergillus or fusarium).

"You've got it nailed based on that [combination]. It's a black mold, a phaeo organism," he said.

He described a case involving a ventilator-dependent infant who developed what appeared to be multiple bedsores. Because of the ventilator, nurses had been unable to rotate the baby, who was born at 22 weeks' gestation in a septic environment following a car accident that resulted in a traumatic placental abruption in the mother.

When the infant was finally able to be rotated, the nurses discovered the lesions. A closer look revealed that the lesions were not bedsores, but fungal sepsis.

The lesions consisted of a black, leathery, depressed central eschar and an "almost bullous edematous scalloped border," Dr. Elston explained, noting that they appeared similar to fungal embolic lesions that occur commonly in leukemia patients.

A biopsy was performed and phaeohyphomycosis was diagnosed, but the infant died despite aggressive therapy. An autopsy revealed that the fungus had invaded every organ in the child's body, he said.

In another case, a diabetic patient with contact dermatitis from his shoes developed invasive phaeohyphomycosis that resulted in bilateral above-the-knee amputations.

"They basically chopped his legs off a bit at a time, starting with forefoot, then hindfoot, then [below-the knee amputation], then above-the-knee, as this plowed through tissue" he said, noting that the patient was never put on itraconazole but was treated with amphotericin.

"The wrong drug [was used] … so nailing the organism is really important for this," he said, reiterating the need for early diagnosis to determine the appropriate course of treatment.

Common manifestations of phaeohyphomycosis include tinea nigra, particularly in hot, humid climates, and phaeohyphomycotic cysts. These tend to develop in immunocompetent patients with these types of infections, whereas invasive disease occurs almost exclusively in immunocompromised patients, Dr. Elston said.

Morphology, rather than a Fontana-Masson stain for the characteristic melanin in the cell wall, should be relied upon for diagnosis in these infections, because Fontana-Masson will stain melanin in a variety of other conditions as well, he noted.

DESTIN, FLA. — Phaeohyphomycosis usually results from infection by Bipolaris fungi, and it requires wide debridement and immediate treatment with massive doses of itraconazole to reduce the fungal burden, Dr. Dirk Elston said at a meeting sponsored by the Alabama Dermatology Society.

Because the typical empirical treatments for more common fungal infections—such as amphotericin—will not work in this potentially fatal condition, consider this diagnosis, particularly in immunocompromised patients, who tend to develop invasive disease, he advised.

A quick biopsy and a good dermatopathologist are key. "You've got a window of opportunity to treat [these patients]. You have one chance to treat them right, and even with the right treatment they may succumb. But without that, they don't even have a chance," said Dr. Elston, who is director of the department of dermatology at Geisinger Medical Center in Danville, Pa.

Clues to the diagnosis are the presence of a thick refractile wall (as seen with mucormycosis) on histology, and bubbly cytoplasm (as seen with aspergillus or fusarium).

"You've got it nailed based on that [combination]. It's a black mold, a phaeo organism," he said.

He described a case involving a ventilator-dependent infant who developed what appeared to be multiple bedsores. Because of the ventilator, nurses had been unable to rotate the baby, who was born at 22 weeks' gestation in a septic environment following a car accident that resulted in a traumatic placental abruption in the mother.

When the infant was finally able to be rotated, the nurses discovered the lesions. A closer look revealed that the lesions were not bedsores, but fungal sepsis.

The lesions consisted of a black, leathery, depressed central eschar and an "almost bullous edematous scalloped border," Dr. Elston explained, noting that they appeared similar to fungal embolic lesions that occur commonly in leukemia patients.

A biopsy was performed and phaeohyphomycosis was diagnosed, but the infant died despite aggressive therapy. An autopsy revealed that the fungus had invaded every organ in the child's body, he said.

In another case, a diabetic patient with contact dermatitis from his shoes developed invasive phaeohyphomycosis that resulted in bilateral above-the-knee amputations.

"They basically chopped his legs off a bit at a time, starting with forefoot, then hindfoot, then [below-the knee amputation], then above-the-knee, as this plowed through tissue" he said, noting that the patient was never put on itraconazole but was treated with amphotericin.

"The wrong drug [was used] … so nailing the organism is really important for this," he said, reiterating the need for early diagnosis to determine the appropriate course of treatment.

Common manifestations of phaeohyphomycosis include tinea nigra, particularly in hot, humid climates, and phaeohyphomycotic cysts. These tend to develop in immunocompetent patients with these types of infections, whereas invasive disease occurs almost exclusively in immunocompromised patients, Dr. Elston said.

Morphology, rather than a Fontana-Masson stain for the characteristic melanin in the cell wall, should be relied upon for diagnosis in these infections, because Fontana-Masson will stain melanin in a variety of other conditions as well, he noted.

DESTIN, FLA. — Approval of Reloxin, a botulinum toxin type A product marketed in Europe as Dysport, is expected in the United States within the next 8-12 months, Dr. Patricia Farris said at a meeting sponsored by the Alabama Dermatology Society.

The product, which is similar to Botox, has been proved safe and effective in various trials worldwide, including in recently completed phase III U.S. trials, she said.

"The phase III clinical trial data for Reloxin in this country have not all been collated at this point, but I thank [Medicis Pharmaceutical Corp.] for sharing a little bit of it with me," said Dr. Farris, referring to the company that will develop and market Reloxin in the United States and which sponsored her talk at the meeting.

The 150-day, double-blind, placebo-controlled trial, which was designed to determine the efficacy of a single 50-unit dose for the treatment of glabellar lines, involved 300 patients. Response at 30 days in the 200 patients treated with Reloxin was excellent. "Slightly less than 90% of treated patients, compared with 0% of placebo patients, responded," said Dr. Farris of the department of dermatology at Tulane University, New Orleans.

Patients were considered responders if they improved from a score of 2 or 3 to a score of 0 or 1 on a 4-point scale, with 0 indicating no frown lines, 1 indicating mild frown lines, 2 indicating moderate frown lines, and 3 indicating severe frown lines.

Investigators used a 5-point injection technique, with two 10-unit injections in each of the corrugator muscles, and a single 10-unit injection in the procerus muscle. The 50-unit dose was shown in previous studies to be optimal. Median time to onset was 2 days, and by day 7 about 80% of patients had responded. Median duration was 117 days, Dr. Farris noted.

The product also proved to be safe. The most common adverse event was headache, and there were some ocular events, including two cases of probable Reloxin-related ptosis, she said.

DESTIN, FLA. — Approval of Reloxin, a botulinum toxin type A product marketed in Europe as Dysport, is expected in the United States within the next 8-12 months, Dr. Patricia Farris said at a meeting sponsored by the Alabama Dermatology Society.

The product, which is similar to Botox, has been proved safe and effective in various trials worldwide, including in recently completed phase III U.S. trials, she said.

"The phase III clinical trial data for Reloxin in this country have not all been collated at this point, but I thank [Medicis Pharmaceutical Corp.] for sharing a little bit of it with me," said Dr. Farris, referring to the company that will develop and market Reloxin in the United States and which sponsored her talk at the meeting.

The 150-day, double-blind, placebo-controlled trial, which was designed to determine the efficacy of a single 50-unit dose for the treatment of glabellar lines, involved 300 patients. Response at 30 days in the 200 patients treated with Reloxin was excellent. "Slightly less than 90% of treated patients, compared with 0% of placebo patients, responded," said Dr. Farris of the department of dermatology at Tulane University, New Orleans.

Patients were considered responders if they improved from a score of 2 or 3 to a score of 0 or 1 on a 4-point scale, with 0 indicating no frown lines, 1 indicating mild frown lines, 2 indicating moderate frown lines, and 3 indicating severe frown lines.

Investigators used a 5-point injection technique, with two 10-unit injections in each of the corrugator muscles, and a single 10-unit injection in the procerus muscle. The 50-unit dose was shown in previous studies to be optimal. Median time to onset was 2 days, and by day 7 about 80% of patients had responded. Median duration was 117 days, Dr. Farris noted.

The product also proved to be safe. The most common adverse event was headache, and there were some ocular events, including two cases of probable Reloxin-related ptosis, she said.

DESTIN, FLA. — Approval of Reloxin, a botulinum toxin type A product marketed in Europe as Dysport, is expected in the United States within the next 8-12 months, Dr. Patricia Farris said at a meeting sponsored by the Alabama Dermatology Society.

The product, which is similar to Botox, has been proved safe and effective in various trials worldwide, including in recently completed phase III U.S. trials, she said.

"The phase III clinical trial data for Reloxin in this country have not all been collated at this point, but I thank [Medicis Pharmaceutical Corp.] for sharing a little bit of it with me," said Dr. Farris, referring to the company that will develop and market Reloxin in the United States and which sponsored her talk at the meeting.

The 150-day, double-blind, placebo-controlled trial, which was designed to determine the efficacy of a single 50-unit dose for the treatment of glabellar lines, involved 300 patients. Response at 30 days in the 200 patients treated with Reloxin was excellent. "Slightly less than 90% of treated patients, compared with 0% of placebo patients, responded," said Dr. Farris of the department of dermatology at Tulane University, New Orleans.

Patients were considered responders if they improved from a score of 2 or 3 to a score of 0 or 1 on a 4-point scale, with 0 indicating no frown lines, 1 indicating mild frown lines, 2 indicating moderate frown lines, and 3 indicating severe frown lines.

Investigators used a 5-point injection technique, with two 10-unit injections in each of the corrugator muscles, and a single 10-unit injection in the procerus muscle. The 50-unit dose was shown in previous studies to be optimal. Median time to onset was 2 days, and by day 7 about 80% of patients had responded. Median duration was 117 days, Dr. Farris noted.

The product also proved to be safe. The most common adverse event was headache, and there were some ocular events, including two cases of probable Reloxin-related ptosis, she said.

DESTIN, FLA. — Rosé or cabernet?

Hyaluronic acid cosmetic fillers, it turns out, are a bit like wine: selection depends on whether the occasion calls for something soft and light or something big and bold, Dr. Patricia Farris said at a meeting sponsored by the Alabama Dermatology Society.

"Not all wines are the same, and not all hyaluronic fillers are the same either. … If I'm injecting crow's feet, I'm probably not going to pull for Perlane or Restylane," said Dr. Farris of the department of dermatology at Tulane University, New Orleans.

Those "cabernets" are bolder than necessary for that application. A light "rosé" like Hylaform or a slightly more complex "pinot" like Juvéderm would do the trick, she said.

On the other hand, if a patient comes in asking for a "really, really big Paris lip," her choice is Restylane. If a patient says she wants a fuller lip but doesn't want to look like Angelina Jolie, something like Hylaform or Juvéderm is better, Dr. Farris said.

"These are just softer fillers, and … they are far more forgiving," she said, which is particularly important for novice injectors. Although they can't do what Restylane and Perlane can do, Hylaform and Juvéderm are "easier, smoother, and the flow properties are really good," she noted.

The important thing is to be comfortable with the product. Everyone has their own level of comfort and their own favorites for each application, and it is important to go with what you like and what you know works for that application, and not with what the patient comes in asking for, Dr. Farris stressed.

A patient who wants Restylane for crow's feet doesn't necessarily understand that such a bold filler isn't necessary. The wine analogy is a great way of explaining this to patients.

"I think they get the point," she said.

For deep nasolabial folds, however, go with the cabernet—unless the patient would prefer something lighter, she advised, describing one patient who had a prior bad experience with lumpiness following Restylane injection (probably because of bad injection technique), and wanted to steer clear of that.

"So I got my pinot [Juvéderm] out for her," she said.

Because the various hyaluronic acid fillers are so different, it pays to be experienced with a variety of them.

The hyaluronic acids work well for a number of problem areas, including prejowl grooves, tear troughs, lips, and noses.

The "puffing up" of the prejowl groove area following injection with a hyaluronic acid filler improves contour, and patients tend to be very happy with the "lighter, much nicer look they get with this," Dr. Farris said.

For undereye circles, a filler such as Juvéderm can be injected in the tear trough with a great result.

When it comes to lip enhancement, a number of different fillers will work. Be sure to ask patients what they are looking for. If lipstick line bleeding is the concern, then running the vermilion border with a filler will suffice. In addition to the hyaluronic acids, CosmoPlast also works well for this.

If the patient wants a bigger lip, then both the border and the body of the lip should be injected.

As for noses, the hyaluronic acids can be use to "straighten" a crooked nose, Dr. Faris said. Restylane is great for filling in the area around a bump and thereby deaccentuating it, or for filling in narrow areas.

The hyaluronic acids are easy to use and complications are rare, with the exception of some injection phenomena such as bruising and swelling. Lumpiness and bluish nodules may occur, but these are typically a result of poor injection technique. Sterile abscesses are also common, but they can be effectively treated intralesionally, she said.

A caveat with Perlane is the likelihood of injection phenomena such as bruising and a needle-stick line resulting from the need to use a 27-gauge needle.

"I'll spare you the pain. I tried the 30-gauge needle, but it's almost impossible to get [the product] out because of the 100-micron particle size," Dr. Farris said.

Use the 27-gauge needle but warn the patient of the potential effects, she advised, noting that the product is otherwise great.

Dr. Farris' presentation at the meeting was sponsored by Medicis, manufacturer of Perlane and Restylane.

DESTIN, FLA. — Rosé or cabernet?

Hyaluronic acid cosmetic fillers, it turns out, are a bit like wine: selection depends on whether the occasion calls for something soft and light or something big and bold, Dr. Patricia Farris said at a meeting sponsored by the Alabama Dermatology Society.

"Not all wines are the same, and not all hyaluronic fillers are the same either. … If I'm injecting crow's feet, I'm probably not going to pull for Perlane or Restylane," said Dr. Farris of the department of dermatology at Tulane University, New Orleans.

Those "cabernets" are bolder than necessary for that application. A light "rosé" like Hylaform or a slightly more complex "pinot" like Juvéderm would do the trick, she said.

On the other hand, if a patient comes in asking for a "really, really big Paris lip," her choice is Restylane. If a patient says she wants a fuller lip but doesn't want to look like Angelina Jolie, something like Hylaform or Juvéderm is better, Dr. Farris said.

"These are just softer fillers, and … they are far more forgiving," she said, which is particularly important for novice injectors. Although they can't do what Restylane and Perlane can do, Hylaform and Juvéderm are "easier, smoother, and the flow properties are really good," she noted.

The important thing is to be comfortable with the product. Everyone has their own level of comfort and their own favorites for each application, and it is important to go with what you like and what you know works for that application, and not with what the patient comes in asking for, Dr. Farris stressed.

A patient who wants Restylane for crow's feet doesn't necessarily understand that such a bold filler isn't necessary. The wine analogy is a great way of explaining this to patients.

"I think they get the point," she said.

For deep nasolabial folds, however, go with the cabernet—unless the patient would prefer something lighter, she advised, describing one patient who had a prior bad experience with lumpiness following Restylane injection (probably because of bad injection technique), and wanted to steer clear of that.

"So I got my pinot [Juvéderm] out for her," she said.

Because the various hyaluronic acid fillers are so different, it pays to be experienced with a variety of them.

The hyaluronic acids work well for a number of problem areas, including prejowl grooves, tear troughs, lips, and noses.

The "puffing up" of the prejowl groove area following injection with a hyaluronic acid filler improves contour, and patients tend to be very happy with the "lighter, much nicer look they get with this," Dr. Farris said.

For undereye circles, a filler such as Juvéderm can be injected in the tear trough with a great result.

When it comes to lip enhancement, a number of different fillers will work. Be sure to ask patients what they are looking for. If lipstick line bleeding is the concern, then running the vermilion border with a filler will suffice. In addition to the hyaluronic acids, CosmoPlast also works well for this.

If the patient wants a bigger lip, then both the border and the body of the lip should be injected.

As for noses, the hyaluronic acids can be use to "straighten" a crooked nose, Dr. Faris said. Restylane is great for filling in the area around a bump and thereby deaccentuating it, or for filling in narrow areas.

The hyaluronic acids are easy to use and complications are rare, with the exception of some injection phenomena such as bruising and swelling. Lumpiness and bluish nodules may occur, but these are typically a result of poor injection technique. Sterile abscesses are also common, but they can be effectively treated intralesionally, she said.

A caveat with Perlane is the likelihood of injection phenomena such as bruising and a needle-stick line resulting from the need to use a 27-gauge needle.

"I'll spare you the pain. I tried the 30-gauge needle, but it's almost impossible to get [the product] out because of the 100-micron particle size," Dr. Farris said.

Use the 27-gauge needle but warn the patient of the potential effects, she advised, noting that the product is otherwise great.

Dr. Farris' presentation at the meeting was sponsored by Medicis, manufacturer of Perlane and Restylane.

DESTIN, FLA. — Rosé or cabernet?

Hyaluronic acid cosmetic fillers, it turns out, are a bit like wine: selection depends on whether the occasion calls for something soft and light or something big and bold, Dr. Patricia Farris said at a meeting sponsored by the Alabama Dermatology Society.

"Not all wines are the same, and not all hyaluronic fillers are the same either. … If I'm injecting crow's feet, I'm probably not going to pull for Perlane or Restylane," said Dr. Farris of the department of dermatology at Tulane University, New Orleans.

Those "cabernets" are bolder than necessary for that application. A light "rosé" like Hylaform or a slightly more complex "pinot" like Juvéderm would do the trick, she said.

On the other hand, if a patient comes in asking for a "really, really big Paris lip," her choice is Restylane. If a patient says she wants a fuller lip but doesn't want to look like Angelina Jolie, something like Hylaform or Juvéderm is better, Dr. Farris said.

"These are just softer fillers, and … they are far more forgiving," she said, which is particularly important for novice injectors. Although they can't do what Restylane and Perlane can do, Hylaform and Juvéderm are "easier, smoother, and the flow properties are really good," she noted.

The important thing is to be comfortable with the product. Everyone has their own level of comfort and their own favorites for each application, and it is important to go with what you like and what you know works for that application, and not with what the patient comes in asking for, Dr. Farris stressed.

A patient who wants Restylane for crow's feet doesn't necessarily understand that such a bold filler isn't necessary. The wine analogy is a great way of explaining this to patients.

"I think they get the point," she said.

For deep nasolabial folds, however, go with the cabernet—unless the patient would prefer something lighter, she advised, describing one patient who had a prior bad experience with lumpiness following Restylane injection (probably because of bad injection technique), and wanted to steer clear of that.

"So I got my pinot [Juvéderm] out for her," she said.

Because the various hyaluronic acid fillers are so different, it pays to be experienced with a variety of them.

The hyaluronic acids work well for a number of problem areas, including prejowl grooves, tear troughs, lips, and noses.

The "puffing up" of the prejowl groove area following injection with a hyaluronic acid filler improves contour, and patients tend to be very happy with the "lighter, much nicer look they get with this," Dr. Farris said.

For undereye circles, a filler such as Juvéderm can be injected in the tear trough with a great result.

When it comes to lip enhancement, a number of different fillers will work. Be sure to ask patients what they are looking for. If lipstick line bleeding is the concern, then running the vermilion border with a filler will suffice. In addition to the hyaluronic acids, CosmoPlast also works well for this.

If the patient wants a bigger lip, then both the border and the body of the lip should be injected.

As for noses, the hyaluronic acids can be use to "straighten" a crooked nose, Dr. Faris said. Restylane is great for filling in the area around a bump and thereby deaccentuating it, or for filling in narrow areas.

The hyaluronic acids are easy to use and complications are rare, with the exception of some injection phenomena such as bruising and swelling. Lumpiness and bluish nodules may occur, but these are typically a result of poor injection technique. Sterile abscesses are also common, but they can be effectively treated intralesionally, she said.

A caveat with Perlane is the likelihood of injection phenomena such as bruising and a needle-stick line resulting from the need to use a 27-gauge needle.

"I'll spare you the pain. I tried the 30-gauge needle, but it's almost impossible to get [the product] out because of the 100-micron particle size," Dr. Farris said.

Use the 27-gauge needle but warn the patient of the potential effects, she advised, noting that the product is otherwise great.

Dr. Farris' presentation at the meeting was sponsored by Medicis, manufacturer of Perlane and Restylane.