Sharon Worcester

DESTIN, FLA. – Myopathy that occurs following initiation of statin therapy certainly may result from the drug, but don’t be too quick to rule out other causes.

In one case described by Dr. Robert Wortmann at the Congress of Clinical Rheumatology, the problem was actually profound hypothyroidism.

The 58-year-old patient, a physician who presented with muscle weakness of 6 months’ duration, had started taking a statin 1 month prior as treatment for hyperlipidemia. The patient’s creatine phosphokinase (CPK) values ranged from 1,100 to 1,500 U/L, and both the muscle weakness and CPK elevations persisted at 3 months after discontinuation of the statin.

Statins, as well as fibric acid derivatives and niacin, are important considerations in patients with myopathic symptoms. They can be associated with asymptomatic "hyper-CPK-emia"; transient myalgia and cramps with increased or normal CPK levels; persistent myalgia and cramps or weakness with increased or normal CPK levels; and rhabdomyolysis with myoglobinuria, renal failure, and, when these are unrecognized and untreated, death, said Dr. Wortmann, professor of medicine at Dartmouth Medical School, Lebanon, N.H.

Statin myopathies can occur due to various triggers.

"We know that when you take a statin and interfere with cholesterol synthesis, you can interfere with membrane formation, and this can lead to specific membrane effects and damage and myopathy," he explained, adding that certain genetic polymorphisms – particularly those associated with statin metabolism – also seem to put some people at greater risk for statin myopathies, as does the unmasking of underlying metabolic disorders by statins in some patients.

A particularly interesting statin myopathy is immune-mediated necrotizing myopathy, Dr. Wortmann said.

This potentially painful and debilitating myopathy appears to be associated with anti-HMG CoA reductase antibodies, and it is believed to be immune mediated because it responds to immunosuppressive therapy, he noted.

Patients with this necrotizing myopathy typically require multiple drugs given simultaneously to control the disease.

In the case presented by Dr. Wortmann, however, the problem was much simpler.

"I share this with you because I walked right by this. This was my mistake," he said, explaining that he had arranged for the physician to undergo an electromyogram and muscle biopsy.

"Fortunately, he went and saw his primary care physician again before we could get those done, [who] checked his [thyroid stimulating hormone] and it was way up there. He treated the hypothyroidism, his CPK went back to normal, his muscle symptoms went away, and he was continued on his statin," Dr. Wortmann said.

The most common musculoskeletal manifestation of hypothyroidism is carpal tunnel syndrome, but it can also be associated with sensory or sensorimotor polyneuropathy, asymptomatic hyper-CPK-emia, and myopathy. Myopathy is usually proximal, and may involve myalgias and cramps, with normal or high CPK levels, he noted, adding that although one older case report involved a patient with levels as high as 21,000 U/L, most are in the 700- to 1,200-U/L range.

"So hypothyroidism is a good thing to screen for if you see someone with muscle weakness, because if you pick it up, it’s easy [to manage]," he said. "The take-home message is that just because you see a patient who’s taking a drug [then] experience a side effect that may be found from that drug, it doesn’t mean that’s where it’s coming from."

Dr. Wortmann reported that he had no financial conflicts of interest that were relevant to his presentation.

DESTIN, FLA. – Myopathy that occurs following initiation of statin therapy certainly may result from the drug, but don’t be too quick to rule out other causes.

In one case described by Dr. Robert Wortmann at the Congress of Clinical Rheumatology, the problem was actually profound hypothyroidism.

The 58-year-old patient, a physician who presented with muscle weakness of 6 months’ duration, had started taking a statin 1 month prior as treatment for hyperlipidemia. The patient’s creatine phosphokinase (CPK) values ranged from 1,100 to 1,500 U/L, and both the muscle weakness and CPK elevations persisted at 3 months after discontinuation of the statin.

Statins, as well as fibric acid derivatives and niacin, are important considerations in patients with myopathic symptoms. They can be associated with asymptomatic "hyper-CPK-emia"; transient myalgia and cramps with increased or normal CPK levels; persistent myalgia and cramps or weakness with increased or normal CPK levels; and rhabdomyolysis with myoglobinuria, renal failure, and, when these are unrecognized and untreated, death, said Dr. Wortmann, professor of medicine at Dartmouth Medical School, Lebanon, N.H.

Statin myopathies can occur due to various triggers.

"We know that when you take a statin and interfere with cholesterol synthesis, you can interfere with membrane formation, and this can lead to specific membrane effects and damage and myopathy," he explained, adding that certain genetic polymorphisms – particularly those associated with statin metabolism – also seem to put some people at greater risk for statin myopathies, as does the unmasking of underlying metabolic disorders by statins in some patients.

A particularly interesting statin myopathy is immune-mediated necrotizing myopathy, Dr. Wortmann said.

This potentially painful and debilitating myopathy appears to be associated with anti-HMG CoA reductase antibodies, and it is believed to be immune mediated because it responds to immunosuppressive therapy, he noted.

Patients with this necrotizing myopathy typically require multiple drugs given simultaneously to control the disease.

In the case presented by Dr. Wortmann, however, the problem was much simpler.

"I share this with you because I walked right by this. This was my mistake," he said, explaining that he had arranged for the physician to undergo an electromyogram and muscle biopsy.

"Fortunately, he went and saw his primary care physician again before we could get those done, [who] checked his [thyroid stimulating hormone] and it was way up there. He treated the hypothyroidism, his CPK went back to normal, his muscle symptoms went away, and he was continued on his statin," Dr. Wortmann said.

The most common musculoskeletal manifestation of hypothyroidism is carpal tunnel syndrome, but it can also be associated with sensory or sensorimotor polyneuropathy, asymptomatic hyper-CPK-emia, and myopathy. Myopathy is usually proximal, and may involve myalgias and cramps, with normal or high CPK levels, he noted, adding that although one older case report involved a patient with levels as high as 21,000 U/L, most are in the 700- to 1,200-U/L range.

"So hypothyroidism is a good thing to screen for if you see someone with muscle weakness, because if you pick it up, it’s easy [to manage]," he said. "The take-home message is that just because you see a patient who’s taking a drug [then] experience a side effect that may be found from that drug, it doesn’t mean that’s where it’s coming from."

Dr. Wortmann reported that he had no financial conflicts of interest that were relevant to his presentation.

DESTIN, FLA. – Myopathy that occurs following initiation of statin therapy certainly may result from the drug, but don’t be too quick to rule out other causes.

In one case described by Dr. Robert Wortmann at the Congress of Clinical Rheumatology, the problem was actually profound hypothyroidism.

The 58-year-old patient, a physician who presented with muscle weakness of 6 months’ duration, had started taking a statin 1 month prior as treatment for hyperlipidemia. The patient’s creatine phosphokinase (CPK) values ranged from 1,100 to 1,500 U/L, and both the muscle weakness and CPK elevations persisted at 3 months after discontinuation of the statin.

Statins, as well as fibric acid derivatives and niacin, are important considerations in patients with myopathic symptoms. They can be associated with asymptomatic "hyper-CPK-emia"; transient myalgia and cramps with increased or normal CPK levels; persistent myalgia and cramps or weakness with increased or normal CPK levels; and rhabdomyolysis with myoglobinuria, renal failure, and, when these are unrecognized and untreated, death, said Dr. Wortmann, professor of medicine at Dartmouth Medical School, Lebanon, N.H.

Statin myopathies can occur due to various triggers.

"We know that when you take a statin and interfere with cholesterol synthesis, you can interfere with membrane formation, and this can lead to specific membrane effects and damage and myopathy," he explained, adding that certain genetic polymorphisms – particularly those associated with statin metabolism – also seem to put some people at greater risk for statin myopathies, as does the unmasking of underlying metabolic disorders by statins in some patients.

A particularly interesting statin myopathy is immune-mediated necrotizing myopathy, Dr. Wortmann said.

This potentially painful and debilitating myopathy appears to be associated with anti-HMG CoA reductase antibodies, and it is believed to be immune mediated because it responds to immunosuppressive therapy, he noted.

Patients with this necrotizing myopathy typically require multiple drugs given simultaneously to control the disease.

In the case presented by Dr. Wortmann, however, the problem was much simpler.

"I share this with you because I walked right by this. This was my mistake," he said, explaining that he had arranged for the physician to undergo an electromyogram and muscle biopsy.

"Fortunately, he went and saw his primary care physician again before we could get those done, [who] checked his [thyroid stimulating hormone] and it was way up there. He treated the hypothyroidism, his CPK went back to normal, his muscle symptoms went away, and he was continued on his statin," Dr. Wortmann said.

The most common musculoskeletal manifestation of hypothyroidism is carpal tunnel syndrome, but it can also be associated with sensory or sensorimotor polyneuropathy, asymptomatic hyper-CPK-emia, and myopathy. Myopathy is usually proximal, and may involve myalgias and cramps, with normal or high CPK levels, he noted, adding that although one older case report involved a patient with levels as high as 21,000 U/L, most are in the 700- to 1,200-U/L range.

"So hypothyroidism is a good thing to screen for if you see someone with muscle weakness, because if you pick it up, it’s easy [to manage]," he said. "The take-home message is that just because you see a patient who’s taking a drug [then] experience a side effect that may be found from that drug, it doesn’t mean that’s where it’s coming from."

Dr. Wortmann reported that he had no financial conflicts of interest that were relevant to his presentation.

Early diagnosis and treatment of infantile spasms, particularly with adrenocorticotropic hormone, may lead to improved long-term developmental outcomes, according to an updated guideline from the American Academy of Neurology and the Child Neurology Society.

The evidence-based guideline update – the first since the guideline was issued in 2004 – focuses on the latest evidence with respect to treatment of the rare disorder and is published in the June 12 issue of Neurology. Members of the Guideline Development Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society undertook the review because of extensive variations in practice patterns with respect to the treatment of infantile spasms.

"Although the underlying etiology of infantile spasms is an important outcome determination (based on the literature review), we highlighted the importance of prompt diagnosis of infantile spasm to shorten the lag time to treatment and improve long-term developmental outcomes," said the lead author, Dr. Cristina Y. Go of the Hospital for Sick Children in Toronto, and her colleagues.

The committee members reviewed more than 1,900 articles from 2002 through 2012, including 68 that were selected for detailed review; 26 were included in the final analysis (Neurology 2012;78:1974-80).

Studies indicate that hormonal therapy using adrenocorticotropic hormone (ACTH) or prednisolone may lead to better neurodevelopmental outcomes in children with cryptogenic spasms, relative to the seizure drug vigabatrin (VGB), and that a shorter lag time to treatment – with either ACTH or VGB – "to possibly improve" long-term developmental outcomes, Dr. Go said in an interview.

This recommendation is based on findings from six studies published since the initial guideline was developed, including one large, randomized, controlled trial that provided class II evidence, and others that provided class II, III, and IV evidence for intermediate- to long-term outcomes.

A previous class III study and a newer class II study also demonstrated that shorter lag time to treatment improves long-term cognitive outcomes, according to the updated guidelines.

Low-dose ACTH should be considered in place of a high-dose because moderate (level B) evidence suggests that it is just as effective but with fewer side effects. However, questions remain regarding the optimal ACTH formulation, dose, and treatment duration.

The available evidence remains insufficient to recommend other therapies, including prednisolone, dexamethasone, and methylprednisolone as being as effective as ACTH for short-term treatment of infantile spasms, the authors said.

The available evidence also remains insufficient for recommending the use of other treatments or approaches, including valproic acid, vitamin B6, nitrazepam, levetiracetam, zonisamide, topiramate, the ketogenic diet, or other novel or combination therapies.

Additional studies with multiple treatment arms are needed to determine the most effective therapy for infantile spasms, the authors concluded, adding that these studies should include electroencephalograms, clinical seizure occurrence, and standardized development outcome measures.

Dr. Go and five of the six other authors reported having no disclosures. One author reported receiving honoraria from UCB Pharma, Jansen Cilag, and Sanofi-Aventis for presentations at industry-sponsored symposia.

Early diagnosis and treatment of infantile spasms, particularly with adrenocorticotropic hormone, may lead to improved long-term developmental outcomes, according to an updated guideline from the American Academy of Neurology and the Child Neurology Society.

The evidence-based guideline update – the first since the guideline was issued in 2004 – focuses on the latest evidence with respect to treatment of the rare disorder and is published in the June 12 issue of Neurology. Members of the Guideline Development Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society undertook the review because of extensive variations in practice patterns with respect to the treatment of infantile spasms.

"Although the underlying etiology of infantile spasms is an important outcome determination (based on the literature review), we highlighted the importance of prompt diagnosis of infantile spasm to shorten the lag time to treatment and improve long-term developmental outcomes," said the lead author, Dr. Cristina Y. Go of the Hospital for Sick Children in Toronto, and her colleagues.

The committee members reviewed more than 1,900 articles from 2002 through 2012, including 68 that were selected for detailed review; 26 were included in the final analysis (Neurology 2012;78:1974-80).

Studies indicate that hormonal therapy using adrenocorticotropic hormone (ACTH) or prednisolone may lead to better neurodevelopmental outcomes in children with cryptogenic spasms, relative to the seizure drug vigabatrin (VGB), and that a shorter lag time to treatment – with either ACTH or VGB – "to possibly improve" long-term developmental outcomes, Dr. Go said in an interview.

This recommendation is based on findings from six studies published since the initial guideline was developed, including one large, randomized, controlled trial that provided class II evidence, and others that provided class II, III, and IV evidence for intermediate- to long-term outcomes.

A previous class III study and a newer class II study also demonstrated that shorter lag time to treatment improves long-term cognitive outcomes, according to the updated guidelines.

Low-dose ACTH should be considered in place of a high-dose because moderate (level B) evidence suggests that it is just as effective but with fewer side effects. However, questions remain regarding the optimal ACTH formulation, dose, and treatment duration.

The available evidence remains insufficient to recommend other therapies, including prednisolone, dexamethasone, and methylprednisolone as being as effective as ACTH for short-term treatment of infantile spasms, the authors said.

The available evidence also remains insufficient for recommending the use of other treatments or approaches, including valproic acid, vitamin B6, nitrazepam, levetiracetam, zonisamide, topiramate, the ketogenic diet, or other novel or combination therapies.

Additional studies with multiple treatment arms are needed to determine the most effective therapy for infantile spasms, the authors concluded, adding that these studies should include electroencephalograms, clinical seizure occurrence, and standardized development outcome measures.

Dr. Go and five of the six other authors reported having no disclosures. One author reported receiving honoraria from UCB Pharma, Jansen Cilag, and Sanofi-Aventis for presentations at industry-sponsored symposia.

Early diagnosis and treatment of infantile spasms, particularly with adrenocorticotropic hormone, may lead to improved long-term developmental outcomes, according to an updated guideline from the American Academy of Neurology and the Child Neurology Society.

The evidence-based guideline update – the first since the guideline was issued in 2004 – focuses on the latest evidence with respect to treatment of the rare disorder and is published in the June 12 issue of Neurology. Members of the Guideline Development Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society undertook the review because of extensive variations in practice patterns with respect to the treatment of infantile spasms.

"Although the underlying etiology of infantile spasms is an important outcome determination (based on the literature review), we highlighted the importance of prompt diagnosis of infantile spasm to shorten the lag time to treatment and improve long-term developmental outcomes," said the lead author, Dr. Cristina Y. Go of the Hospital for Sick Children in Toronto, and her colleagues.

The committee members reviewed more than 1,900 articles from 2002 through 2012, including 68 that were selected for detailed review; 26 were included in the final analysis (Neurology 2012;78:1974-80).

Studies indicate that hormonal therapy using adrenocorticotropic hormone (ACTH) or prednisolone may lead to better neurodevelopmental outcomes in children with cryptogenic spasms, relative to the seizure drug vigabatrin (VGB), and that a shorter lag time to treatment – with either ACTH or VGB – "to possibly improve" long-term developmental outcomes, Dr. Go said in an interview.

This recommendation is based on findings from six studies published since the initial guideline was developed, including one large, randomized, controlled trial that provided class II evidence, and others that provided class II, III, and IV evidence for intermediate- to long-term outcomes.

A previous class III study and a newer class II study also demonstrated that shorter lag time to treatment improves long-term cognitive outcomes, according to the updated guidelines.

Low-dose ACTH should be considered in place of a high-dose because moderate (level B) evidence suggests that it is just as effective but with fewer side effects. However, questions remain regarding the optimal ACTH formulation, dose, and treatment duration.

The available evidence remains insufficient to recommend other therapies, including prednisolone, dexamethasone, and methylprednisolone as being as effective as ACTH for short-term treatment of infantile spasms, the authors said.

The available evidence also remains insufficient for recommending the use of other treatments or approaches, including valproic acid, vitamin B6, nitrazepam, levetiracetam, zonisamide, topiramate, the ketogenic diet, or other novel or combination therapies.

Additional studies with multiple treatment arms are needed to determine the most effective therapy for infantile spasms, the authors concluded, adding that these studies should include electroencephalograms, clinical seizure occurrence, and standardized development outcome measures.

Dr. Go and five of the six other authors reported having no disclosures. One author reported receiving honoraria from UCB Pharma, Jansen Cilag, and Sanofi-Aventis for presentations at industry-sponsored symposia.

Getting prediabetes patients to regain glucose control as early as possible provides the best shot at preventing disease progression, regardless of whether it is achieved through lifestyle interventions or drug therapy, according to the latest analysis from the landmark Diabetes Prevention Program.

In fact, even a transient reversion to normal glucose regulation was associated with a significantly reduced risk of diabetes among participants in the DPP, a major randomized trial comparing weight loss and dietary changes with drug therapy for preventing the onset of type 2 diabetes.

Compared with 1,096 participants in that multicenter trial who consistently had prediabetes, the risk of diabetes was 56% lower (hazard ratio, 0.44) among 894 individuals who had returned to normal glucose regulation during the intervention period, according to findings from the Diabetes Prevention Program Outcomes Study (DPPOS), an ongoing postintervention observational study, Dr. Leigh Perreault of the University of Colorado, Aurora, and her colleagues reported online in the June 9 Lancet.

"Diabetes risk reduction was strongly associated with the number of times normal glucose regulation was achieved. Specifically, diabetes risk was reduced 47% in DPPOS if normal glucose regulation was attained only once (HR, 0.53); 61% if it was reached twice (HR,0.39); and 67% if it was reached three times (HR, 0.33)," the investigators said (Lancet 2012 June 9 [doi:10.106/S0140-6736(12)60525-X]).

At baseline, all 3,234 participants were at risk for developing diabetes. They were randomized to receive lifestyle interventions, metformin treatment, or placebo, and were followed for a median of 3.2 years during the intervention.

The current analysis, at a median follow-up of 5.7 years, shows that the reduced risk for diabetes among those subjects who returned to normal glucose regulation during the intervention was not affected by group assignment, the investigators said.

Factors associated with increased diabetes risk during DPPOS included age younger than 45 years (HR, 1.47), and African American ethnic origin (HR, 1.77).

"Paradoxically, increased weight loss during DPP adversely affected diabetes risk (HR, 1.26) in DPPOS independent of previous treatment," the investigators also noted, adding that this was "probably because of the high rate of weight regain in DPPOS with associated adverse effects on diabetes risk."

High body mass index at the beginning of DPPOS also related to diabetes risk during DPPOS follow-up (HR, 1.14). Higher beta-cell function and insulin sensitivity were protective (HR, 0.80 and 0.83, respectively).

Those who consistently had prediabetes during DPP – despite intensive lifestyle interventions – had an increased risk of developing diabetes during DPPOS, compared with those who didn’t have prediabetes and who were in the placebo group (HR, 1.31).

"Although there is widespread consensus that diabetes prevention is crucially important, there is less agreement with respect to the particular intervention," the investigators noted. "Results from the present analysis would contend that the strategy is unimportant as long as the intervention is early (when someone has prediabetes) and can restore normal glucose regulation, even if transiently."

The findings also suggest that maintenance of prediabetes despite intensive lifestyle modification represents a high-risk state that may warrant additional interventions, she and her colleagues said.

"Together, these data serve as essential clinical information to support early and aggressive measures for long-term prevention of diabetes in people at risk," they concluded.

This study was funded by the National Institutes of Health. The authors reported having no relevant financial conflicts.

Getting prediabetes patients to regain glucose control as early as possible provides the best shot at preventing disease progression, regardless of whether it is achieved through lifestyle interventions or drug therapy, according to the latest analysis from the landmark Diabetes Prevention Program.

In fact, even a transient reversion to normal glucose regulation was associated with a significantly reduced risk of diabetes among participants in the DPP, a major randomized trial comparing weight loss and dietary changes with drug therapy for preventing the onset of type 2 diabetes.

Compared with 1,096 participants in that multicenter trial who consistently had prediabetes, the risk of diabetes was 56% lower (hazard ratio, 0.44) among 894 individuals who had returned to normal glucose regulation during the intervention period, according to findings from the Diabetes Prevention Program Outcomes Study (DPPOS), an ongoing postintervention observational study, Dr. Leigh Perreault of the University of Colorado, Aurora, and her colleagues reported online in the June 9 Lancet.

"Diabetes risk reduction was strongly associated with the number of times normal glucose regulation was achieved. Specifically, diabetes risk was reduced 47% in DPPOS if normal glucose regulation was attained only once (HR, 0.53); 61% if it was reached twice (HR,0.39); and 67% if it was reached three times (HR, 0.33)," the investigators said (Lancet 2012 June 9 [doi:10.106/S0140-6736(12)60525-X]).

At baseline, all 3,234 participants were at risk for developing diabetes. They were randomized to receive lifestyle interventions, metformin treatment, or placebo, and were followed for a median of 3.2 years during the intervention.

The current analysis, at a median follow-up of 5.7 years, shows that the reduced risk for diabetes among those subjects who returned to normal glucose regulation during the intervention was not affected by group assignment, the investigators said.

Factors associated with increased diabetes risk during DPPOS included age younger than 45 years (HR, 1.47), and African American ethnic origin (HR, 1.77).

"Paradoxically, increased weight loss during DPP adversely affected diabetes risk (HR, 1.26) in DPPOS independent of previous treatment," the investigators also noted, adding that this was "probably because of the high rate of weight regain in DPPOS with associated adverse effects on diabetes risk."

High body mass index at the beginning of DPPOS also related to diabetes risk during DPPOS follow-up (HR, 1.14). Higher beta-cell function and insulin sensitivity were protective (HR, 0.80 and 0.83, respectively).

Those who consistently had prediabetes during DPP – despite intensive lifestyle interventions – had an increased risk of developing diabetes during DPPOS, compared with those who didn’t have prediabetes and who were in the placebo group (HR, 1.31).

"Although there is widespread consensus that diabetes prevention is crucially important, there is less agreement with respect to the particular intervention," the investigators noted. "Results from the present analysis would contend that the strategy is unimportant as long as the intervention is early (when someone has prediabetes) and can restore normal glucose regulation, even if transiently."

The findings also suggest that maintenance of prediabetes despite intensive lifestyle modification represents a high-risk state that may warrant additional interventions, she and her colleagues said.

"Together, these data serve as essential clinical information to support early and aggressive measures for long-term prevention of diabetes in people at risk," they concluded.

This study was funded by the National Institutes of Health. The authors reported having no relevant financial conflicts.

Getting prediabetes patients to regain glucose control as early as possible provides the best shot at preventing disease progression, regardless of whether it is achieved through lifestyle interventions or drug therapy, according to the latest analysis from the landmark Diabetes Prevention Program.

In fact, even a transient reversion to normal glucose regulation was associated with a significantly reduced risk of diabetes among participants in the DPP, a major randomized trial comparing weight loss and dietary changes with drug therapy for preventing the onset of type 2 diabetes.

Compared with 1,096 participants in that multicenter trial who consistently had prediabetes, the risk of diabetes was 56% lower (hazard ratio, 0.44) among 894 individuals who had returned to normal glucose regulation during the intervention period, according to findings from the Diabetes Prevention Program Outcomes Study (DPPOS), an ongoing postintervention observational study, Dr. Leigh Perreault of the University of Colorado, Aurora, and her colleagues reported online in the June 9 Lancet.

"Diabetes risk reduction was strongly associated with the number of times normal glucose regulation was achieved. Specifically, diabetes risk was reduced 47% in DPPOS if normal glucose regulation was attained only once (HR, 0.53); 61% if it was reached twice (HR,0.39); and 67% if it was reached three times (HR, 0.33)," the investigators said (Lancet 2012 June 9 [doi:10.106/S0140-6736(12)60525-X]).

At baseline, all 3,234 participants were at risk for developing diabetes. They were randomized to receive lifestyle interventions, metformin treatment, or placebo, and were followed for a median of 3.2 years during the intervention.

The current analysis, at a median follow-up of 5.7 years, shows that the reduced risk for diabetes among those subjects who returned to normal glucose regulation during the intervention was not affected by group assignment, the investigators said.

Factors associated with increased diabetes risk during DPPOS included age younger than 45 years (HR, 1.47), and African American ethnic origin (HR, 1.77).

"Paradoxically, increased weight loss during DPP adversely affected diabetes risk (HR, 1.26) in DPPOS independent of previous treatment," the investigators also noted, adding that this was "probably because of the high rate of weight regain in DPPOS with associated adverse effects on diabetes risk."

High body mass index at the beginning of DPPOS also related to diabetes risk during DPPOS follow-up (HR, 1.14). Higher beta-cell function and insulin sensitivity were protective (HR, 0.80 and 0.83, respectively).

Those who consistently had prediabetes during DPP – despite intensive lifestyle interventions – had an increased risk of developing diabetes during DPPOS, compared with those who didn’t have prediabetes and who were in the placebo group (HR, 1.31).

"Although there is widespread consensus that diabetes prevention is crucially important, there is less agreement with respect to the particular intervention," the investigators noted. "Results from the present analysis would contend that the strategy is unimportant as long as the intervention is early (when someone has prediabetes) and can restore normal glucose regulation, even if transiently."

The findings also suggest that maintenance of prediabetes despite intensive lifestyle modification represents a high-risk state that may warrant additional interventions, she and her colleagues said.

"Together, these data serve as essential clinical information to support early and aggressive measures for long-term prevention of diabetes in people at risk," they concluded.

This study was funded by the National Institutes of Health. The authors reported having no relevant financial conflicts.

Quality improvement strategies that aim to optimize systems of care have significant favorable effects on diabetes care outcomes, Andrea C. Tricco, Ph.D., of Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, and her colleagues reported online June 9 in the Lancet.

While QI interventions targeting patients might be beneficial irrespective of baseline HbA_1c, those interventions targeting providers only seem beneficial when baseline HbA_1c is greater than 8.0%, according to the findings of their systematic review and meta-analysis, which together involved more than 123,000 patients.

The results were reported simultaneously at the annual meeting of the American Diabetes Association in Philadelphia.

Based on data from a total of 120 relevant trials, QI strategies reduced HbA_1c by a mean difference of 0.37%; and reduced LDL cholesterol by 0.10 mmol/L, systolic blood pressure by 3.13 mm Hg, and diastolic blood pressure by 1.55 mm Hg versus usual care over a median 12-month period, the authors found (Lancet 2012 June 9 [doi: 10.1016/S0140-6736(12)60480-2]).

Specifically, strategies targeting clinicians’ education and audit and feedback led to HbA_1c reductions of 0.33% and 0.44%, respectively, when baseline HbA_1c concentrations were greater than 8.0%, compared with no improvement when baseline HbA_1c was less than 8.0%.

Patient education seemed more effective than reminders when baseline HbA_1c was greater than 8.0%, but less effective when it was less than 8.0%.

Furthermore, QI strategies were associated with increases in aspirin use; use of any antihypertensive drugs; and screening for retinopathy, renal involvement, and foot complications over median follow-up periods ranging from 12 to 18 months. The QI strategies did not, however, have a significant effect on statin use, adequate control of hypertension, or smoking cessation rates over median follow-up periods ranging from 12 to 19 months.

In trials that enrolled patients with an HbA_1c of greater than 8.0%, declines of more than 0.5% were seen with certain QI strategies (specifically, those targeting team changes, case management, patient education, and promotion of self-management). In trials enrolling those with an HbA_1c of 8.0% or less, declines of that magnitude were seen for one QI strategy (facilitated relay).

Nonetheless, "after adjustment for median baseline HbA_1c values and effective sample size, the QI strategies were associated with significantly lower HbA_1c than usual care was," they said.

"We noted greater improvements in HbA_1c control for QI strategies targeting health systems and patients. In fact, all QI strategies were associated with significant changes in HbA_1c except for clinician education," they said.

The trials included in this review and meta-analysis were reported between July 2003 and July 2010, and were selected using 11 predefined QI strategies or financial incentives targeting health care professionals for the management of adult outpatients with diabetes.

"The QI strategies targeted health systems (e.g., team changes), professionals (e.g., professional reminders), or patients (e.g., promotion of self-management)," the investigators explained.

The findings, which represent an update of a previous review that assessed the effects of QI strategies on glycemic control, provide an assessment of the effects of QI strategies on a broader range of diabetic care.

The analysis was limited by the complexity of the QI strategies studied, the inability to control for all potential confounding factors, and the short duration of follow-up in many of the trials, the authors wrote.

Despite these limitations, the findings indicate that diabetes outcomes can be improved by QI interventions. Wide implementation of QI strategies could lead to important population benefits, as data have shown that a 1% reduction in mean HbA_1c results in 21% fewer deaths, 14% fewer myocardial infarctions, and a 37% decrease in microvascular complications at the population level, the investigators noted.

"Further research is needed to identify which interventions and combinations of QI strategies will optimally improve important outcomes in patients with diabetes at an acceptable cost to aid health-system planning," they concluded.

This study was funded by the Ontario Ministry of Health and Long-term Care and the Alberta Heritage Foundation for Medical Research Interdisciplinary Team Grants program. The authors reported having no conflicts of interest.

Quality improvement strategies that aim to optimize systems of care have significant favorable effects on diabetes care outcomes, Andrea C. Tricco, Ph.D., of Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, and her colleagues reported online June 9 in the Lancet.

While QI interventions targeting patients might be beneficial irrespective of baseline HbA_1c, those interventions targeting providers only seem beneficial when baseline HbA_1c is greater than 8.0%, according to the findings of their systematic review and meta-analysis, which together involved more than 123,000 patients.

The results were reported simultaneously at the annual meeting of the American Diabetes Association in Philadelphia.

Based on data from a total of 120 relevant trials, QI strategies reduced HbA_1c by a mean difference of 0.37%; and reduced LDL cholesterol by 0.10 mmol/L, systolic blood pressure by 3.13 mm Hg, and diastolic blood pressure by 1.55 mm Hg versus usual care over a median 12-month period, the authors found (Lancet 2012 June 9 [doi: 10.1016/S0140-6736(12)60480-2]).

Specifically, strategies targeting clinicians’ education and audit and feedback led to HbA_1c reductions of 0.33% and 0.44%, respectively, when baseline HbA_1c concentrations were greater than 8.0%, compared with no improvement when baseline HbA_1c was less than 8.0%.

Patient education seemed more effective than reminders when baseline HbA_1c was greater than 8.0%, but less effective when it was less than 8.0%.

Furthermore, QI strategies were associated with increases in aspirin use; use of any antihypertensive drugs; and screening for retinopathy, renal involvement, and foot complications over median follow-up periods ranging from 12 to 18 months. The QI strategies did not, however, have a significant effect on statin use, adequate control of hypertension, or smoking cessation rates over median follow-up periods ranging from 12 to 19 months.

In trials that enrolled patients with an HbA_1c of greater than 8.0%, declines of more than 0.5% were seen with certain QI strategies (specifically, those targeting team changes, case management, patient education, and promotion of self-management). In trials enrolling those with an HbA_1c of 8.0% or less, declines of that magnitude were seen for one QI strategy (facilitated relay).

Nonetheless, "after adjustment for median baseline HbA_1c values and effective sample size, the QI strategies were associated with significantly lower HbA_1c than usual care was," they said.

"We noted greater improvements in HbA_1c control for QI strategies targeting health systems and patients. In fact, all QI strategies were associated with significant changes in HbA_1c except for clinician education," they said.

The trials included in this review and meta-analysis were reported between July 2003 and July 2010, and were selected using 11 predefined QI strategies or financial incentives targeting health care professionals for the management of adult outpatients with diabetes.

"The QI strategies targeted health systems (e.g., team changes), professionals (e.g., professional reminders), or patients (e.g., promotion of self-management)," the investigators explained.

The findings, which represent an update of a previous review that assessed the effects of QI strategies on glycemic control, provide an assessment of the effects of QI strategies on a broader range of diabetic care.

The analysis was limited by the complexity of the QI strategies studied, the inability to control for all potential confounding factors, and the short duration of follow-up in many of the trials, the authors wrote.

Despite these limitations, the findings indicate that diabetes outcomes can be improved by QI interventions. Wide implementation of QI strategies could lead to important population benefits, as data have shown that a 1% reduction in mean HbA_1c results in 21% fewer deaths, 14% fewer myocardial infarctions, and a 37% decrease in microvascular complications at the population level, the investigators noted.

"Further research is needed to identify which interventions and combinations of QI strategies will optimally improve important outcomes in patients with diabetes at an acceptable cost to aid health-system planning," they concluded.

This study was funded by the Ontario Ministry of Health and Long-term Care and the Alberta Heritage Foundation for Medical Research Interdisciplinary Team Grants program. The authors reported having no conflicts of interest.

Quality improvement strategies that aim to optimize systems of care have significant favorable effects on diabetes care outcomes, Andrea C. Tricco, Ph.D., of Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, and her colleagues reported online June 9 in the Lancet.

While QI interventions targeting patients might be beneficial irrespective of baseline HbA_1c, those interventions targeting providers only seem beneficial when baseline HbA_1c is greater than 8.0%, according to the findings of their systematic review and meta-analysis, which together involved more than 123,000 patients.

The results were reported simultaneously at the annual meeting of the American Diabetes Association in Philadelphia.

Based on data from a total of 120 relevant trials, QI strategies reduced HbA_1c by a mean difference of 0.37%; and reduced LDL cholesterol by 0.10 mmol/L, systolic blood pressure by 3.13 mm Hg, and diastolic blood pressure by 1.55 mm Hg versus usual care over a median 12-month period, the authors found (Lancet 2012 June 9 [doi: 10.1016/S0140-6736(12)60480-2]).

Specifically, strategies targeting clinicians’ education and audit and feedback led to HbA_1c reductions of 0.33% and 0.44%, respectively, when baseline HbA_1c concentrations were greater than 8.0%, compared with no improvement when baseline HbA_1c was less than 8.0%.

Patient education seemed more effective than reminders when baseline HbA_1c was greater than 8.0%, but less effective when it was less than 8.0%.

Furthermore, QI strategies were associated with increases in aspirin use; use of any antihypertensive drugs; and screening for retinopathy, renal involvement, and foot complications over median follow-up periods ranging from 12 to 18 months. The QI strategies did not, however, have a significant effect on statin use, adequate control of hypertension, or smoking cessation rates over median follow-up periods ranging from 12 to 19 months.

In trials that enrolled patients with an HbA_1c of greater than 8.0%, declines of more than 0.5% were seen with certain QI strategies (specifically, those targeting team changes, case management, patient education, and promotion of self-management). In trials enrolling those with an HbA_1c of 8.0% or less, declines of that magnitude were seen for one QI strategy (facilitated relay).

Nonetheless, "after adjustment for median baseline HbA_1c values and effective sample size, the QI strategies were associated with significantly lower HbA_1c than usual care was," they said.

"We noted greater improvements in HbA_1c control for QI strategies targeting health systems and patients. In fact, all QI strategies were associated with significant changes in HbA_1c except for clinician education," they said.

The trials included in this review and meta-analysis were reported between July 2003 and July 2010, and were selected using 11 predefined QI strategies or financial incentives targeting health care professionals for the management of adult outpatients with diabetes.

"The QI strategies targeted health systems (e.g., team changes), professionals (e.g., professional reminders), or patients (e.g., promotion of self-management)," the investigators explained.

The findings, which represent an update of a previous review that assessed the effects of QI strategies on glycemic control, provide an assessment of the effects of QI strategies on a broader range of diabetic care.

The analysis was limited by the complexity of the QI strategies studied, the inability to control for all potential confounding factors, and the short duration of follow-up in many of the trials, the authors wrote.

Despite these limitations, the findings indicate that diabetes outcomes can be improved by QI interventions. Wide implementation of QI strategies could lead to important population benefits, as data have shown that a 1% reduction in mean HbA_1c results in 21% fewer deaths, 14% fewer myocardial infarctions, and a 37% decrease in microvascular complications at the population level, the investigators noted.

"Further research is needed to identify which interventions and combinations of QI strategies will optimally improve important outcomes in patients with diabetes at an acceptable cost to aid health-system planning," they concluded.

This study was funded by the Ontario Ministry of Health and Long-term Care and the Alberta Heritage Foundation for Medical Research Interdisciplinary Team Grants program. The authors reported having no conflicts of interest.

A novel risk score for predicting serious infections in individual patients with rheumatoid arthritis who are treated with either tumor necrosis factor–alpha inhibitors or conventional disease-modifying antirheumatic drugs showed high agreement between observed and expected rates of serious infection, said Dr. Angela Zink at the annual European Congress of Rheumatology.

The score, known as the RABBIT risk score, is named for the German biologics register from which patients were enrolled. The risk score was previously evaluated in 5,044 patients enrolled in the RABBIT register between May 2001 and December 2006, and was shown to provide detailed information about the expected absolute risk of serious infection findings (Ann. Rheum. Dis. 2011;70:1914-20).

The new findings demonstrate the value of the score in a new population of patients not included in the previous analysis because they enrolled in the register after January 2009. Taken together, the two sets of data suggest that the score will serve as a useful tool with which rheumatologists can identify patients at increased risk of infection. By knowing the score, rheumatologists can avoid the use of treatment combinations that confer an increased risk for serious infection, said Dr. Zink of the German Rheumatism Research Center, Berlin.

"We showed that the risk of an individual patient at any point in time results from background risks such as age, comorbidity, or treatment history, and from risks that change over time, such as the activity of the disease, functional status, comedication with glucocorticoids, or treatment with TNF inhibitors or conventional DMARDs," Dr. Zink said, noting that multivariate methods were used to calculate the relative contributions of each of these factors. Dr. Zink presented the results for Dr. Anja Strangfeld, a colleague at the German Rheumatism Research Center.

For the analysis the investigators used data from 1,327 RA patients who were treated with TNF-alpha inhibitors and 1,276 RA patients treated with conventional DMARDs. The patients included in this analysis were enrolled in the RABBIT register at the start of their treatment with anti-TNF-alphas or DMARDs. The investigators used the RABBIT score to determine the serious infection risk, and they compared the observed serious infection rate with the expected rate in the total cohort and certain defined subgroups.

Agreement between the observed and expected rates of serious infection was high, as was agreement in subgroups of patients with a higher risk of infections. For example, the observed and expected rates of serious infection in those taking a TNF-alpha inhibitor were 3.2 and 3.0 serious infections per 100 person-years, respectively, and the observed and expected rates of serious infection in those taking a conventional DMARD were 1.3 and 1.5 serious infections per 100 person-years, respectively. Among those at high risk (based on the presence of one or more risk factors) who were taking a TNF-alpha inhibitor, the observed and expected rates were 5.2 and 4.3 serious infections per 100 person-years, respectively, and among those at high risk who were taking a conventional DMARD, the observed and expected rates were 1.7 and 1.9 serious infections per 100 person-years, respectively.

"We think that long-term observational studies of new treatments offer excellent opportunities to understand what happens during the treatment of real-life patients," Dr. Zink said of the value of biologics registers in general.

These data allow us to balance risks against each other, she added.

"For instance, an almost fivefold risk of serious infection was found in patients who had to be treated with dosages of glucocorticoids of 15 mg/day or above, compared to those with less than 7.5mg/day. TNF inhibition, which was associated with a 1.8-fold increased overall risk of infection, can lead to a decrease in risk if the disease activity is successfully suppressed, thereby allowing the glucocorticoid dose to be reduced," she explained.

The researchers did not disclose any conflicts of interest. This research was supported by a joint unconditional grant from Abbott, Amgen/Swedish Orphan Biovitrum, Bristol Myers Squibb, Essex/MSD, Pfizer, Roche, and UCB.

A novel risk score for predicting serious infections in individual patients with rheumatoid arthritis who are treated with either tumor necrosis factor–alpha inhibitors or conventional disease-modifying antirheumatic drugs showed high agreement between observed and expected rates of serious infection, said Dr. Angela Zink at the annual European Congress of Rheumatology.

The score, known as the RABBIT risk score, is named for the German biologics register from which patients were enrolled. The risk score was previously evaluated in 5,044 patients enrolled in the RABBIT register between May 2001 and December 2006, and was shown to provide detailed information about the expected absolute risk of serious infection findings (Ann. Rheum. Dis. 2011;70:1914-20).

The new findings demonstrate the value of the score in a new population of patients not included in the previous analysis because they enrolled in the register after January 2009. Taken together, the two sets of data suggest that the score will serve as a useful tool with which rheumatologists can identify patients at increased risk of infection. By knowing the score, rheumatologists can avoid the use of treatment combinations that confer an increased risk for serious infection, said Dr. Zink of the German Rheumatism Research Center, Berlin.

"We showed that the risk of an individual patient at any point in time results from background risks such as age, comorbidity, or treatment history, and from risks that change over time, such as the activity of the disease, functional status, comedication with glucocorticoids, or treatment with TNF inhibitors or conventional DMARDs," Dr. Zink said, noting that multivariate methods were used to calculate the relative contributions of each of these factors. Dr. Zink presented the results for Dr. Anja Strangfeld, a colleague at the German Rheumatism Research Center.

For the analysis the investigators used data from 1,327 RA patients who were treated with TNF-alpha inhibitors and 1,276 RA patients treated with conventional DMARDs. The patients included in this analysis were enrolled in the RABBIT register at the start of their treatment with anti-TNF-alphas or DMARDs. The investigators used the RABBIT score to determine the serious infection risk, and they compared the observed serious infection rate with the expected rate in the total cohort and certain defined subgroups.

Agreement between the observed and expected rates of serious infection was high, as was agreement in subgroups of patients with a higher risk of infections. For example, the observed and expected rates of serious infection in those taking a TNF-alpha inhibitor were 3.2 and 3.0 serious infections per 100 person-years, respectively, and the observed and expected rates of serious infection in those taking a conventional DMARD were 1.3 and 1.5 serious infections per 100 person-years, respectively. Among those at high risk (based on the presence of one or more risk factors) who were taking a TNF-alpha inhibitor, the observed and expected rates were 5.2 and 4.3 serious infections per 100 person-years, respectively, and among those at high risk who were taking a conventional DMARD, the observed and expected rates were 1.7 and 1.9 serious infections per 100 person-years, respectively.

"We think that long-term observational studies of new treatments offer excellent opportunities to understand what happens during the treatment of real-life patients," Dr. Zink said of the value of biologics registers in general.

These data allow us to balance risks against each other, she added.

"For instance, an almost fivefold risk of serious infection was found in patients who had to be treated with dosages of glucocorticoids of 15 mg/day or above, compared to those with less than 7.5mg/day. TNF inhibition, which was associated with a 1.8-fold increased overall risk of infection, can lead to a decrease in risk if the disease activity is successfully suppressed, thereby allowing the glucocorticoid dose to be reduced," she explained.

The researchers did not disclose any conflicts of interest. This research was supported by a joint unconditional grant from Abbott, Amgen/Swedish Orphan Biovitrum, Bristol Myers Squibb, Essex/MSD, Pfizer, Roche, and UCB.

A novel risk score for predicting serious infections in individual patients with rheumatoid arthritis who are treated with either tumor necrosis factor–alpha inhibitors or conventional disease-modifying antirheumatic drugs showed high agreement between observed and expected rates of serious infection, said Dr. Angela Zink at the annual European Congress of Rheumatology.

The score, known as the RABBIT risk score, is named for the German biologics register from which patients were enrolled. The risk score was previously evaluated in 5,044 patients enrolled in the RABBIT register between May 2001 and December 2006, and was shown to provide detailed information about the expected absolute risk of serious infection findings (Ann. Rheum. Dis. 2011;70:1914-20).

The new findings demonstrate the value of the score in a new population of patients not included in the previous analysis because they enrolled in the register after January 2009. Taken together, the two sets of data suggest that the score will serve as a useful tool with which rheumatologists can identify patients at increased risk of infection. By knowing the score, rheumatologists can avoid the use of treatment combinations that confer an increased risk for serious infection, said Dr. Zink of the German Rheumatism Research Center, Berlin.

"We showed that the risk of an individual patient at any point in time results from background risks such as age, comorbidity, or treatment history, and from risks that change over time, such as the activity of the disease, functional status, comedication with glucocorticoids, or treatment with TNF inhibitors or conventional DMARDs," Dr. Zink said, noting that multivariate methods were used to calculate the relative contributions of each of these factors. Dr. Zink presented the results for Dr. Anja Strangfeld, a colleague at the German Rheumatism Research Center.

For the analysis the investigators used data from 1,327 RA patients who were treated with TNF-alpha inhibitors and 1,276 RA patients treated with conventional DMARDs. The patients included in this analysis were enrolled in the RABBIT register at the start of their treatment with anti-TNF-alphas or DMARDs. The investigators used the RABBIT score to determine the serious infection risk, and they compared the observed serious infection rate with the expected rate in the total cohort and certain defined subgroups.

Agreement between the observed and expected rates of serious infection was high, as was agreement in subgroups of patients with a higher risk of infections. For example, the observed and expected rates of serious infection in those taking a TNF-alpha inhibitor were 3.2 and 3.0 serious infections per 100 person-years, respectively, and the observed and expected rates of serious infection in those taking a conventional DMARD were 1.3 and 1.5 serious infections per 100 person-years, respectively. Among those at high risk (based on the presence of one or more risk factors) who were taking a TNF-alpha inhibitor, the observed and expected rates were 5.2 and 4.3 serious infections per 100 person-years, respectively, and among those at high risk who were taking a conventional DMARD, the observed and expected rates were 1.7 and 1.9 serious infections per 100 person-years, respectively.

"We think that long-term observational studies of new treatments offer excellent opportunities to understand what happens during the treatment of real-life patients," Dr. Zink said of the value of biologics registers in general.

These data allow us to balance risks against each other, she added.

"For instance, an almost fivefold risk of serious infection was found in patients who had to be treated with dosages of glucocorticoids of 15 mg/day or above, compared to those with less than 7.5mg/day. TNF inhibition, which was associated with a 1.8-fold increased overall risk of infection, can lead to a decrease in risk if the disease activity is successfully suppressed, thereby allowing the glucocorticoid dose to be reduced," she explained.

The researchers did not disclose any conflicts of interest. This research was supported by a joint unconditional grant from Abbott, Amgen/Swedish Orphan Biovitrum, Bristol Myers Squibb, Essex/MSD, Pfizer, Roche, and UCB.

Early remission and sustained remission are associated with improved survival in patients with inflammatory polyarthritis, according to findings from the Norfolk Arthritis Register presented by Dr. Carlo Alberto Scirè at the annual European Congress of Rheumatology.

The findings provide further evidence of the importance of targeting remission, Dr. Scirè said in an interview.

"Several previous studies have demonstrated the influence of clinical remission in terms of reduction of joint damage and development of functional disability in patients with inflammatory polyarthritis, including rheumatoid arthritis. Given that rheumatoid arthritis also associates with increased mortality, we aimed to explore the relationship between clinical remission and mortality," said Dr. Scirè of the epidemiology unit of the Italian Society for Rheumatology, Milan, who is also currently a visiting scholar at the arthritis epidemiology unit of Manchester (England) University.

The Norfolk Arthritis Register, a primary care–based inception cohort of patients with inflammatory polyarthritis, provides a unique source of data with which to explore this relationship, he noted.

For the study, Dr. Scirè and his coinvestigators analyzed data from the more than 1,600 patients who were recruited in 1990-1994 and 2000-2004 and were followed for a median of 10 years. The investigators used three definitions of remission that varied in their strictness. More than a third of the patients met at least the most liberal definition of remission criteria at least once within the first 3 years. The strictest definition of remission allowed for the patient to have not a single swollen or tender joint in a 51 joint count exam. The least stringent allowed for a single swollen or tender joint in a 28-joint count exam, Dr. Scirè explained.

After the investigators adjusted for demographics, baseline disease activity, baseline disease severity, and cumulative treatment variables, 20% more of these patients survived compared with those who did not achieve remission within the first 3 years of follow-up.

The number of times patients achieved remission was also associated with a significant decrease in the risk of all-cause mortality, with a 10% decrease in risk per each additional time they achieved remission.

The greatest reduction in mortality risk was seen in those who achieved remission (as defined by the strictest standard) at 1 year after the first assessment, compared with those who did not achieve remission during the first 3 years. No similar association was found for patients who achieved remission after the first year, Dr. Scirè noted.

Registry patients included in the study were consecutive patients with early inflammatory polyarthritis. They were assessed at baseline through the 51 tender and swollen joint count, the Health Assessment Questionnaire, and blood testing. The joint counts were also assessed at the 1-, 2-, and 3-year follow-up.

Remission for this study was defined as the absence of clinically detectable joint inflammation.

"This study provides evidence of an association between the achievement of the absence of clinically detectable joint inflammation [used as an indicator of clinical remission] and decrease [in] mortality, supporting the relevance of targeting remission when treating rheumatoid arthritis in clinical practice," Dr. Scirè said.

Patients who met the strictest definition of remission seem to lengthen their survival by 2-3 years, according to Dr. Scirè. An audience member noted that the diagnosis of rheumatoid arthritis shortens life by about 7 years, so meeting a strict definition of remission within the first year after diagnosis comes close to halving that increased mortality burden.

Early remission and sustained remission are associated with improved survival in patients with inflammatory polyarthritis, according to findings from the Norfolk Arthritis Register presented by Dr. Carlo Alberto Scirè at the annual European Congress of Rheumatology.

The findings provide further evidence of the importance of targeting remission, Dr. Scirè said in an interview.

"Several previous studies have demonstrated the influence of clinical remission in terms of reduction of joint damage and development of functional disability in patients with inflammatory polyarthritis, including rheumatoid arthritis. Given that rheumatoid arthritis also associates with increased mortality, we aimed to explore the relationship between clinical remission and mortality," said Dr. Scirè of the epidemiology unit of the Italian Society for Rheumatology, Milan, who is also currently a visiting scholar at the arthritis epidemiology unit of Manchester (England) University.

The Norfolk Arthritis Register, a primary care–based inception cohort of patients with inflammatory polyarthritis, provides a unique source of data with which to explore this relationship, he noted.

For the study, Dr. Scirè and his coinvestigators analyzed data from the more than 1,600 patients who were recruited in 1990-1994 and 2000-2004 and were followed for a median of 10 years. The investigators used three definitions of remission that varied in their strictness. More than a third of the patients met at least the most liberal definition of remission criteria at least once within the first 3 years. The strictest definition of remission allowed for the patient to have not a single swollen or tender joint in a 51 joint count exam. The least stringent allowed for a single swollen or tender joint in a 28-joint count exam, Dr. Scirè explained.

After the investigators adjusted for demographics, baseline disease activity, baseline disease severity, and cumulative treatment variables, 20% more of these patients survived compared with those who did not achieve remission within the first 3 years of follow-up.

The number of times patients achieved remission was also associated with a significant decrease in the risk of all-cause mortality, with a 10% decrease in risk per each additional time they achieved remission.

The greatest reduction in mortality risk was seen in those who achieved remission (as defined by the strictest standard) at 1 year after the first assessment, compared with those who did not achieve remission during the first 3 years. No similar association was found for patients who achieved remission after the first year, Dr. Scirè noted.

Registry patients included in the study were consecutive patients with early inflammatory polyarthritis. They were assessed at baseline through the 51 tender and swollen joint count, the Health Assessment Questionnaire, and blood testing. The joint counts were also assessed at the 1-, 2-, and 3-year follow-up.

Remission for this study was defined as the absence of clinically detectable joint inflammation.

"This study provides evidence of an association between the achievement of the absence of clinically detectable joint inflammation [used as an indicator of clinical remission] and decrease [in] mortality, supporting the relevance of targeting remission when treating rheumatoid arthritis in clinical practice," Dr. Scirè said.

Patients who met the strictest definition of remission seem to lengthen their survival by 2-3 years, according to Dr. Scirè. An audience member noted that the diagnosis of rheumatoid arthritis shortens life by about 7 years, so meeting a strict definition of remission within the first year after diagnosis comes close to halving that increased mortality burden.

Early remission and sustained remission are associated with improved survival in patients with inflammatory polyarthritis, according to findings from the Norfolk Arthritis Register presented by Dr. Carlo Alberto Scirè at the annual European Congress of Rheumatology.

The findings provide further evidence of the importance of targeting remission, Dr. Scirè said in an interview.

"Several previous studies have demonstrated the influence of clinical remission in terms of reduction of joint damage and development of functional disability in patients with inflammatory polyarthritis, including rheumatoid arthritis. Given that rheumatoid arthritis also associates with increased mortality, we aimed to explore the relationship between clinical remission and mortality," said Dr. Scirè of the epidemiology unit of the Italian Society for Rheumatology, Milan, who is also currently a visiting scholar at the arthritis epidemiology unit of Manchester (England) University.

The Norfolk Arthritis Register, a primary care–based inception cohort of patients with inflammatory polyarthritis, provides a unique source of data with which to explore this relationship, he noted.

For the study, Dr. Scirè and his coinvestigators analyzed data from the more than 1,600 patients who were recruited in 1990-1994 and 2000-2004 and were followed for a median of 10 years. The investigators used three definitions of remission that varied in their strictness. More than a third of the patients met at least the most liberal definition of remission criteria at least once within the first 3 years. The strictest definition of remission allowed for the patient to have not a single swollen or tender joint in a 51 joint count exam. The least stringent allowed for a single swollen or tender joint in a 28-joint count exam, Dr. Scirè explained.

After the investigators adjusted for demographics, baseline disease activity, baseline disease severity, and cumulative treatment variables, 20% more of these patients survived compared with those who did not achieve remission within the first 3 years of follow-up.

The number of times patients achieved remission was also associated with a significant decrease in the risk of all-cause mortality, with a 10% decrease in risk per each additional time they achieved remission.

The greatest reduction in mortality risk was seen in those who achieved remission (as defined by the strictest standard) at 1 year after the first assessment, compared with those who did not achieve remission during the first 3 years. No similar association was found for patients who achieved remission after the first year, Dr. Scirè noted.

Registry patients included in the study were consecutive patients with early inflammatory polyarthritis. They were assessed at baseline through the 51 tender and swollen joint count, the Health Assessment Questionnaire, and blood testing. The joint counts were also assessed at the 1-, 2-, and 3-year follow-up.

Remission for this study was defined as the absence of clinically detectable joint inflammation.

"This study provides evidence of an association between the achievement of the absence of clinically detectable joint inflammation [used as an indicator of clinical remission] and decrease [in] mortality, supporting the relevance of targeting remission when treating rheumatoid arthritis in clinical practice," Dr. Scirè said.

Patients who met the strictest definition of remission seem to lengthen their survival by 2-3 years, according to Dr. Scirè. An audience member noted that the diagnosis of rheumatoid arthritis shortens life by about 7 years, so meeting a strict definition of remission within the first year after diagnosis comes close to halving that increased mortality burden.

The 2010 American College of Rheumatology/European League Against Rheumatism classification criteria for rheumatoid arthritis appear to be more sensitive than the 1987 criteria for the early identification of RA patients, but the two sets of criteria may identify different patient groups, judging from findings presented by Jenny Humphreys, Ph.D.

Looking at 260 patients enrolled in the Norfolk Arthritis Register, a primary care–based inception cohort, who presented between 1990 and 1995 with early inflammatory arthritis symptoms, the investigators found that the 2010 criteria identified as many patients with early RA at baseline as did the 1987 criteria over 5 years, Dr. Humphreys said in an interview at the Annual European Congress of Rheumatology meeting. All subjects were 16 years of age or older at the time they enrolled in the Norfolk Arthritis Register.

Specifically, the incidence rates for RA according to the 2010 criteria were 53.9 cases per 100,000 population for women at baseline and 24.5 cases per 100,000 population for men at baseline, which were similar to the cumulative 5-year incidence rates of 55.7 cases for women and 26.5 cases for men according to the 1987 criteria, said Dr. Humphreys, a clinical research fellow at the Arthritis Research UK Epidemiology Unit, University of Manchester (England).

This suggests that "the 2010 criteria are allowing us to identify these patients earlier on, which is useful," she said, noting that the 1987 criteria identified only 44 cases/100,000 population for women with RA at baseline and only 19 cases/100,000 population for men at baseline.

This is the first study to estimate the incidence of RA using the 2010 ACR/EULAR classification criteria for RA, she noted.

"What we have shown is that the incidence of RA using the 2010 criteria is greater when patients first present to health care services," compared with the previous criteria from 1987, Dr. Humphreys said.

However, although the total numbers of patients identified at baseline by the 2010 criteria, and over 5 years by the 1987 criteria, were similar, those identified "were not exactly the same group of patients," she noted.

For example, 4% of patients who satisfied the 1987 criteria cumulatively over 5 years never satisfied the new criteria, and 14% who satisfied the new criteria never satisfied the 1987 criteria. The patients who satisfied the earlier criteria but not the new criteria had more hand joint involvement, symmetrical arthritis, and morning stiffness than did those who satisfied both sets of criteria or just the 2010 criteria.

"This means we need to explore in detail the long-term outcomes in those patients who only ever meet one criteria set," Dr. Humphreys said.

The incidence of a disease is always important in health economics because it gives an idea of the frequency of its occurrence in the population, and resources may be allocated based on this. In addition, it has been suggested that the 2010 criteria could be used as eligibility criteria for certain interventions in RA patients, although this has not been validated and is not currently recommended. "Our data suggest that if that were the case, similar amounts of resources would be required but they may need to be made available earlier, when patients first present with symptoms," she said.

Dr. Humphreys reported that she had no financial conflicts of interest that were relevant to this research.

The 2010 American College of Rheumatology/European League Against Rheumatism classification criteria for rheumatoid arthritis appear to be more sensitive than the 1987 criteria for the early identification of RA patients, but the two sets of criteria may identify different patient groups, judging from findings presented by Jenny Humphreys, Ph.D.

Looking at 260 patients enrolled in the Norfolk Arthritis Register, a primary care–based inception cohort, who presented between 1990 and 1995 with early inflammatory arthritis symptoms, the investigators found that the 2010 criteria identified as many patients with early RA at baseline as did the 1987 criteria over 5 years, Dr. Humphreys said in an interview at the Annual European Congress of Rheumatology meeting. All subjects were 16 years of age or older at the time they enrolled in the Norfolk Arthritis Register.

Specifically, the incidence rates for RA according to the 2010 criteria were 53.9 cases per 100,000 population for women at baseline and 24.5 cases per 100,000 population for men at baseline, which were similar to the cumulative 5-year incidence rates of 55.7 cases for women and 26.5 cases for men according to the 1987 criteria, said Dr. Humphreys, a clinical research fellow at the Arthritis Research UK Epidemiology Unit, University of Manchester (England).

This suggests that "the 2010 criteria are allowing us to identify these patients earlier on, which is useful," she said, noting that the 1987 criteria identified only 44 cases/100,000 population for women with RA at baseline and only 19 cases/100,000 population for men at baseline.

This is the first study to estimate the incidence of RA using the 2010 ACR/EULAR classification criteria for RA, she noted.

"What we have shown is that the incidence of RA using the 2010 criteria is greater when patients first present to health care services," compared with the previous criteria from 1987, Dr. Humphreys said.

However, although the total numbers of patients identified at baseline by the 2010 criteria, and over 5 years by the 1987 criteria, were similar, those identified "were not exactly the same group of patients," she noted.

For example, 4% of patients who satisfied the 1987 criteria cumulatively over 5 years never satisfied the new criteria, and 14% who satisfied the new criteria never satisfied the 1987 criteria. The patients who satisfied the earlier criteria but not the new criteria had more hand joint involvement, symmetrical arthritis, and morning stiffness than did those who satisfied both sets of criteria or just the 2010 criteria.

"This means we need to explore in detail the long-term outcomes in those patients who only ever meet one criteria set," Dr. Humphreys said.

The incidence of a disease is always important in health economics because it gives an idea of the frequency of its occurrence in the population, and resources may be allocated based on this. In addition, it has been suggested that the 2010 criteria could be used as eligibility criteria for certain interventions in RA patients, although this has not been validated and is not currently recommended. "Our data suggest that if that were the case, similar amounts of resources would be required but they may need to be made available earlier, when patients first present with symptoms," she said.

Dr. Humphreys reported that she had no financial conflicts of interest that were relevant to this research.

The 2010 American College of Rheumatology/European League Against Rheumatism classification criteria for rheumatoid arthritis appear to be more sensitive than the 1987 criteria for the early identification of RA patients, but the two sets of criteria may identify different patient groups, judging from findings presented by Jenny Humphreys, Ph.D.

Looking at 260 patients enrolled in the Norfolk Arthritis Register, a primary care–based inception cohort, who presented between 1990 and 1995 with early inflammatory arthritis symptoms, the investigators found that the 2010 criteria identified as many patients with early RA at baseline as did the 1987 criteria over 5 years, Dr. Humphreys said in an interview at the Annual European Congress of Rheumatology meeting. All subjects were 16 years of age or older at the time they enrolled in the Norfolk Arthritis Register.

Specifically, the incidence rates for RA according to the 2010 criteria were 53.9 cases per 100,000 population for women at baseline and 24.5 cases per 100,000 population for men at baseline, which were similar to the cumulative 5-year incidence rates of 55.7 cases for women and 26.5 cases for men according to the 1987 criteria, said Dr. Humphreys, a clinical research fellow at the Arthritis Research UK Epidemiology Unit, University of Manchester (England).

This suggests that "the 2010 criteria are allowing us to identify these patients earlier on, which is useful," she said, noting that the 1987 criteria identified only 44 cases/100,000 population for women with RA at baseline and only 19 cases/100,000 population for men at baseline.

This is the first study to estimate the incidence of RA using the 2010 ACR/EULAR classification criteria for RA, she noted.

"What we have shown is that the incidence of RA using the 2010 criteria is greater when patients first present to health care services," compared with the previous criteria from 1987, Dr. Humphreys said.

However, although the total numbers of patients identified at baseline by the 2010 criteria, and over 5 years by the 1987 criteria, were similar, those identified "were not exactly the same group of patients," she noted.

For example, 4% of patients who satisfied the 1987 criteria cumulatively over 5 years never satisfied the new criteria, and 14% who satisfied the new criteria never satisfied the 1987 criteria. The patients who satisfied the earlier criteria but not the new criteria had more hand joint involvement, symmetrical arthritis, and morning stiffness than did those who satisfied both sets of criteria or just the 2010 criteria.

"This means we need to explore in detail the long-term outcomes in those patients who only ever meet one criteria set," Dr. Humphreys said.

The incidence of a disease is always important in health economics because it gives an idea of the frequency of its occurrence in the population, and resources may be allocated based on this. In addition, it has been suggested that the 2010 criteria could be used as eligibility criteria for certain interventions in RA patients, although this has not been validated and is not currently recommended. "Our data suggest that if that were the case, similar amounts of resources would be required but they may need to be made available earlier, when patients first present with symptoms," she said.

Dr. Humphreys reported that she had no financial conflicts of interest that were relevant to this research.

About half of the children with juvenile idiopathic arthritis who are treated with etanercept achieve inactive disease status, and those who experience early disease onset and lack of involvement of the wrist joint at baseline are more likely to do so, according to data presented by Dr. Nicoletta Solari during the pediatric rheumatology session of the annual European Congress of Rheumatology.

Dr. Solari presented findings from a chart review of 187 consecutive children with JIA who were treated with etanercept between 2002 and 2011 and then were followed for at least 6 months after treatment initiation.

Based on Wallace criteria for disease inactivity (J. Rheum. 2004;31:2290-4), 50.3% of patients had disease inactivity at their last follow-up, and the time to disease inactivity ranged from 2 months to 6.3 years, with a median of just 0.7 years, according to Dr. Solari of the University of Genoa, Italy.

The chart review showed that the strongest predictors of achieving inactive disease status at the last follow-up were age at onset of less than 3.6 years and lack of wrist joint involvement (adjusted odds ratio, 1.8 and 2.1, respectively).

"The patients included in the study had disease duration ranging from 3 months to 21 years, with a median duration of 5 years. Treatment duration from baseline to follow-up among the 173 patients who were treated for at least 6 months was up to 10.5 years, with a median of 2.4 years," Dr. Solari said in an interview.

All patients were treated with the standard 0.8 mg/kg per week dose of etanercept during the study period.

The increasing use of biologic agents, along with the results that have been seen with these agents, has raised the bar when it comes to expectations for remission in patients with juvenile idiopathic arthritis, but clinical studies of these agents typically fail to include assessment of remission, Dr. Solari said, noting that even less is known about the predictors of achieving remission.

"These findings indicate that about half of the children with JIA who are treated with etanercept in real-life clinical settings are able to attain a state of complete disease quiescence," according to Dr. Solari.

The findings are consistent with those reported from German and Dutch national registries, as well as from two previous studies that also aimed to evaluate the prevalence of inactive disease in patients whose JIA was treated with etanercept.

"Notably, these results refer to all JIA subtypes, including systemic patients," Dr. Solari said, explaining that several prior studies have shown that the systemic subtype of JIA responds less to etanercept than do the other disease categories.

The findings of the current study may have important implications for clinical practice.

"In our study, the lack of involvement of the wrist joint was the strongest predictor of both achievement of inactive disease at last follow-up visit and a shorter time to attainment of inactive disease after etanercept initiation," Dr. Solari said. This observation implies that wrist disease is a marker of poorer therapeutic outcome in children with JIA treated with etanercept, she noted.

"Thus, the presence of arthritis in the wrist joint might identify a subgroup of JIA patients with poorer outcome and who subsequently may have an indication for earlier introduction of etanercept during their disease course or the administration of etanercept in combination with methotrexate. This finding might help to improve the rate of remission," she said.

Session chair Dr. Nico Wulffraat of the University of Utrecht (the Netherlands) commented: "Many of us feel that involvement of the hips and neck are poor prognostic features."

Dr. Solari replied that she and her coinvestigators looked at that specifically, but they did not find a significant difference in response to etanercept with involvement of the joints.

About half of the children with juvenile idiopathic arthritis who are treated with etanercept achieve inactive disease status, and those who experience early disease onset and lack of involvement of the wrist joint at baseline are more likely to do so, according to data presented by Dr. Nicoletta Solari during the pediatric rheumatology session of the annual European Congress of Rheumatology.

Dr. Solari presented findings from a chart review of 187 consecutive children with JIA who were treated with etanercept between 2002 and 2011 and then were followed for at least 6 months after treatment initiation.

Based on Wallace criteria for disease inactivity (J. Rheum. 2004;31:2290-4), 50.3% of patients had disease inactivity at their last follow-up, and the time to disease inactivity ranged from 2 months to 6.3 years, with a median of just 0.7 years, according to Dr. Solari of the University of Genoa, Italy.

The chart review showed that the strongest predictors of achieving inactive disease status at the last follow-up were age at onset of less than 3.6 years and lack of wrist joint involvement (adjusted odds ratio, 1.8 and 2.1, respectively).

"The patients included in the study had disease duration ranging from 3 months to 21 years, with a median duration of 5 years. Treatment duration from baseline to follow-up among the 173 patients who were treated for at least 6 months was up to 10.5 years, with a median of 2.4 years," Dr. Solari said in an interview.

All patients were treated with the standard 0.8 mg/kg per week dose of etanercept during the study period.

The increasing use of biologic agents, along with the results that have been seen with these agents, has raised the bar when it comes to expectations for remission in patients with juvenile idiopathic arthritis, but clinical studies of these agents typically fail to include assessment of remission, Dr. Solari said, noting that even less is known about the predictors of achieving remission.

"These findings indicate that about half of the children with JIA who are treated with etanercept in real-life clinical settings are able to attain a state of complete disease quiescence," according to Dr. Solari.

The findings are consistent with those reported from German and Dutch national registries, as well as from two previous studies that also aimed to evaluate the prevalence of inactive disease in patients whose JIA was treated with etanercept.

"Notably, these results refer to all JIA subtypes, including systemic patients," Dr. Solari said, explaining that several prior studies have shown that the systemic subtype of JIA responds less to etanercept than do the other disease categories.

The findings of the current study may have important implications for clinical practice.

"In our study, the lack of involvement of the wrist joint was the strongest predictor of both achievement of inactive disease at last follow-up visit and a shorter time to attainment of inactive disease after etanercept initiation," Dr. Solari said. This observation implies that wrist disease is a marker of poorer therapeutic outcome in children with JIA treated with etanercept, she noted.

"Thus, the presence of arthritis in the wrist joint might identify a subgroup of JIA patients with poorer outcome and who subsequently may have an indication for earlier introduction of etanercept during their disease course or the administration of etanercept in combination with methotrexate. This finding might help to improve the rate of remission," she said.

Session chair Dr. Nico Wulffraat of the University of Utrecht (the Netherlands) commented: "Many of us feel that involvement of the hips and neck are poor prognostic features."

Dr. Solari replied that she and her coinvestigators looked at that specifically, but they did not find a significant difference in response to etanercept with involvement of the joints.

About half of the children with juvenile idiopathic arthritis who are treated with etanercept achieve inactive disease status, and those who experience early disease onset and lack of involvement of the wrist joint at baseline are more likely to do so, according to data presented by Dr. Nicoletta Solari during the pediatric rheumatology session of the annual European Congress of Rheumatology.

Dr. Solari presented findings from a chart review of 187 consecutive children with JIA who were treated with etanercept between 2002 and 2011 and then were followed for at least 6 months after treatment initiation.

Based on Wallace criteria for disease inactivity (J. Rheum. 2004;31:2290-4), 50.3% of patients had disease inactivity at their last follow-up, and the time to disease inactivity ranged from 2 months to 6.3 years, with a median of just 0.7 years, according to Dr. Solari of the University of Genoa, Italy.

The chart review showed that the strongest predictors of achieving inactive disease status at the last follow-up were age at onset of less than 3.6 years and lack of wrist joint involvement (adjusted odds ratio, 1.8 and 2.1, respectively).

"The patients included in the study had disease duration ranging from 3 months to 21 years, with a median duration of 5 years. Treatment duration from baseline to follow-up among the 173 patients who were treated for at least 6 months was up to 10.5 years, with a median of 2.4 years," Dr. Solari said in an interview.

All patients were treated with the standard 0.8 mg/kg per week dose of etanercept during the study period.

The increasing use of biologic agents, along with the results that have been seen with these agents, has raised the bar when it comes to expectations for remission in patients with juvenile idiopathic arthritis, but clinical studies of these agents typically fail to include assessment of remission, Dr. Solari said, noting that even less is known about the predictors of achieving remission.

"These findings indicate that about half of the children with JIA who are treated with etanercept in real-life clinical settings are able to attain a state of complete disease quiescence," according to Dr. Solari.

The findings are consistent with those reported from German and Dutch national registries, as well as from two previous studies that also aimed to evaluate the prevalence of inactive disease in patients whose JIA was treated with etanercept.

"Notably, these results refer to all JIA subtypes, including systemic patients," Dr. Solari said, explaining that several prior studies have shown that the systemic subtype of JIA responds less to etanercept than do the other disease categories.

The findings of the current study may have important implications for clinical practice.

"In our study, the lack of involvement of the wrist joint was the strongest predictor of both achievement of inactive disease at last follow-up visit and a shorter time to attainment of inactive disease after etanercept initiation," Dr. Solari said. This observation implies that wrist disease is a marker of poorer therapeutic outcome in children with JIA treated with etanercept, she noted.

"Thus, the presence of arthritis in the wrist joint might identify a subgroup of JIA patients with poorer outcome and who subsequently may have an indication for earlier introduction of etanercept during their disease course or the administration of etanercept in combination with methotrexate. This finding might help to improve the rate of remission," she said.

Session chair Dr. Nico Wulffraat of the University of Utrecht (the Netherlands) commented: "Many of us feel that involvement of the hips and neck are poor prognostic features."

Dr. Solari replied that she and her coinvestigators looked at that specifically, but they did not find a significant difference in response to etanercept with involvement of the joints.

It was questionable whether in 1952, when Dr. Norman Orentreich performed the first hair transplant and Dr. George Mackee reported on his 50-year experience with phenol chemical peels, anyone envisioned how far the field of dermatologic surgery would advance, but there’s no question now: The specialty has come a long way.

"Dermatologic surgery has blossomed into a full and diverse specialty with many elements," Dr. C. William Hanke noted in the June issue of Seminars in Cutaneous Medicine and Surgery (2012;31:52-9). He highlighted key events that shaped the burgeoning specialty.

Historical Highlights

From the first report on phenol peels by Dr. Mackee (Br. J. Dermatol. 1952;64:456-9), to the coining of the term "tumescent local anesthesia" by Dr. Hanke and his colleagues in 1998 – and publication of a comprehensive text on the tumescent technique 2 years later by Dr. Jeffery A. Klein ("Tumescent Technique: Tumescent Anesthesia and Microcannular Liposuction," St. Louis, Mosby, 2000) – Dr. Hanke chronicled the specialty’s evolution.

For example, he noted that in 1961, Dr. Leon Goldman became the first physician to treat patients with lasers. "He is acknowledged as the father of lasers in medicine and surgery," Dr. Hanke, a dermatologist in private practice in Carmel, Indiana, wrote. He added that the pioneer's first medicinal use of a laser launched 3 decades of related leadership, practice, and research.

Among other events that stand out in the history of the specialty, according to Dr. Hanke, are the first reports on cryosurgery with liquid nitrogen in 1966 by Dr. Setrag Zacarian ("Cryosurgery of Skin Cancer and Cutaneous Disorders," Mosby, St. Louis, 1985), and on ambulatory phlebectomy by Dr. Robert Muller the same year (Phlebologie 1966;19:227-9).

And, in 1967, Dr. Frederic E. Mohs founded the American College of Chemosurgery, which is today known as the American College of Mohs Surgery. "Mohs surgery continues to be an important part of the dermatologic surgery curriculum," Dr. Hanke said.

Advancements in vein ablation took pace in 1982 when the first report on hypertonic saline injections for treating leg veins, by Bruce Chrisman, was published (Hawaii Med. J. 1982;41:406-8).

In 1986, Dr. Saul Asken published the "Manual of Liposuction Surgery and Autologous Fat Transplantation Under Local Anesthesia" (Terry and Associates, Irvine, Calif.), and the following year, Dr. Jeffery A. Klein published the first report on the tumescent technique for liposuction (Am. J. Cosm. Surg. 1987;4:263-7).

Dr. Alastair Carruthers and Dr. Jean Carruthers revolutionized the field in 1987 when they began using botulinum toxin for cosmetic purposes. "Their joint observation that botulinum toxin can affect the muscles of facial expression began a revolution in cosmetic dermatology," wrote Dr. Hanke.

He also highlighted the launch of numerous societies and publications that helped to advance the specialty, including the founding of the American Society for Dermatologic Surgery in 1970, the launch of the Journal of Dermatologic Surgery in 1975, and the founding of the American Society for Lasers in Medicine and Surgery in 1981. And the specialty has continued to evolve at a rapid pace since that time, he noted.

Work by Dr. R. Rox Anderson and Dr. John A. Parrish on selective photothermolysis, for example, launched research leading to the fractionated laser technology in use today; and ongoing work by the Carruthers on botulinum toxin launched a new era in noninvasive facial rejuvenation, he said.

"Facelift bypass" procedures have satisfied many patients without subjecting them to the expense or morbidity of extensive facial surgery, Dr. Hanke noted, adding that new filler materials can be placed in the subcutaneous or supraperiosteal planes of the face with good results and minimal complications.

"A newly approved hyaluronic acid from Germany will allow treatment of very superficial wrinkles without the risk of the 'Tyndall effect,' " he added.

Also in the last decade, dermatologic surgery-related educational initiatives have been advanced. In 2004, 1-year fellowship training programs were approved by the Accreditation Council for Graduate Medical Education for training in dermatologic surgery; and last year, there were 47 ACGME-accredited procedural dermatology fellowship training programs in place, he said.

"Dermatologic surgery is an important component of nearly all dermatology postgraduate courses," added Dr. Hanke.

The history of fractional laser technology and fillers were addressed in separate articles in the same issue of Seminars in Cutaneous Medicine and Surgery, underscoring the importance of the two recent developments.

Fillers

The next phase of development in injectable fillers has begun, according to Dr. Richard G. Glogau.

"The concept of augmentation has moved from simple lines, scars, and wrinkles to revolumizing the aging face," noted Dr. Glogau, a clinical professor of dermatology at the University of California, San Francisco. "While seeking extended duration of effect balanced against the safety profile of the injectable, our focus is now directed to extending the lifting or volumizing effect that one can achieve with these fillers."

The initial movement into 3-dimensional correction with injectable fillers began with the dramatic improvement seen in lip volume championed in the 1980s, and each of a litany of fillers that followed, including fat, collagen, silicone, hyaluronic acids, poly-l-lactic acids, calcium hydroxylapatite, and polymethylmethacrylate (Sem. Cut. Med. Surg. 2012;31:78-87).

New fillers, some which represent refinements of existing technologies, continue to undergo review. Aquamid a biocompatible, nonabsorbable, permanent injectable hydrogel implant is currently under review by the Food and Drug Administration and is approved for use in Europe.

It is also possible that fillers will move beyond the traditional concept of inert medical devices and into the realm of true biologics – "materials that will improve the texture, elasticity, radiance, and possibly color, of the skin itself," he added.

"Just as the last 40 years has seen the movement from 2 to 3 dimensions, the next 2 decades will see movement form the macro to the micro level, and fillers will become systems for active metabolic manipulation and protection of the aging skin," he concluded.

Fractionation

The development of fractional photothermolysis was "a milestone in the history of laser technology and cutaneous resurfacing," according to Dr. Nazanin Saedi, a dermatologist in private practice in Chestnut Hill, Mass., and her colleagues.

The technology, noted the study authors, builds on the knowledge gained from early CO₂ and Er:YAG laser treatment experiences, achieving greater optimization of parameters to induce the types of benefits seen with CO₂ resurfacing, but without the significant postoperative morbidity, complications, and discomfort associated with the earlier technologies.

Furthermore, the older therapies destroyed the barrier protection, which "significantly increased the risk of infection throughout the recovery period and required extensive home care. The risk of scarring, delayed-onset permanent hypopigmentation, and demarcation lines was significant even in the hands of an experienced operator," they wrote (Sem. Cut. Med. Surg. 2012;31:105-9).

In an en effort to overcome these problems, what followed was nonablative dermal remodeling (with less than impressive results), and ultimately, the "idea of fractionated laser technology," they continued.

First used in hair transplant surgery, the technology led to development of the 1,550-nm nonablative "Fraxel" laser (now called the Fraxel Re:Store by Solta Medical), which debuted in the literature in 2004. This and other fractional laser technologies are now used to treat photoaging, superficial and deep rhytids, scars (including in patients with darker skin types), and pigmentation.

Both nonablative and ablative fractional resurfacing have proved to be safer than have traditional ablative lasers, Dr. Saedi and her colleagues noted. However, complications can still occur, such as infections (with herpes simplex virus being the most common), acneiform eruptions, prolonged erythema, pigmentary alteration, and scarring (rare, but can also result from infection associated with treatment).

"Counterintuitively, nonablative or ablative fractionated devices at low energies and densities can be useful in the treatment of scarring, including hypertrophic scars" as previously mentioned, they noted.

"While [fractional lasers are] inherently safer due to the pixelated manner of the treatment, complications can be further prevented with attentive surgical technique and judicious use of prophylaxis," they wrote.

The future of fractional laser technology promises to hold exciting developments. For example, since ablative fractional resurfacing creates microscopic vertical holes in tissue, the delivery of topical drugs through these holes is possible. In animal models, the photosensitizer methylaminolevulinic acid has been delivered using this approach, and tests suggest that low density treatment would be sufficient for deep dermal drug delivery.

"Treatment of skin in a porcine model showed enhanced depth of photodynamic therapy following porphyrin application after pretreatment with fractional resurfacing. An in vitro study utilizing low fluence fractionated Erbium:YAG demonstrated upwards of a 125-fold increase in imiquimod delivery," they noted.

Trials in humans are underway to assess the feasibility and safety of enhanced drug delivery using this approach, and there is speculation that ultimately, it could be used for delivery of biologic peptides and vaccines.

Tattoo removal is another promising use for fractional lasers, with early studies demonstrating good results, noted Dr. Saedi and her colleagues, explaining that ablative fractional lasers, when used in conjunction with a Q-switched laser, appear to provide enhanced tattoo removal capabilities.

"With new devices and wavelengths, the applications of this technology continue to grow," they wrote, concluding that "the future remains bright for fractionated laser devices."

Likewise, the future of dermatologic surgery in general remains promising, Dr. Hanke said. "Many new procedures and advances lie ahead."

Neither Dr. Hanke nor Dr. Saedi had disclosures to report. Another author on the article by Dr. Saedi (Dr. Christopher Zachary) reported receiving an honorarium from Solta Medical.

It was questionable whether in 1952, when Dr. Norman Orentreich performed the first hair transplant and Dr. George Mackee reported on his 50-year experience with phenol chemical peels, anyone envisioned how far the field of dermatologic surgery would advance, but there’s no question now: The specialty has come a long way.

"Dermatologic surgery has blossomed into a full and diverse specialty with many elements," Dr. C. William Hanke noted in the June issue of Seminars in Cutaneous Medicine and Surgery (2012;31:52-9). He highlighted key events that shaped the burgeoning specialty.

Historical Highlights

From the first report on phenol peels by Dr. Mackee (Br. J. Dermatol. 1952;64:456-9), to the coining of the term "tumescent local anesthesia" by Dr. Hanke and his colleagues in 1998 – and publication of a comprehensive text on the tumescent technique 2 years later by Dr. Jeffery A. Klein ("Tumescent Technique: Tumescent Anesthesia and Microcannular Liposuction," St. Louis, Mosby, 2000) – Dr. Hanke chronicled the specialty’s evolution.

For example, he noted that in 1961, Dr. Leon Goldman became the first physician to treat patients with lasers. "He is acknowledged as the father of lasers in medicine and surgery," Dr. Hanke, a dermatologist in private practice in Carmel, Indiana, wrote. He added that the pioneer's first medicinal use of a laser launched 3 decades of related leadership, practice, and research.

Among other events that stand out in the history of the specialty, according to Dr. Hanke, are the first reports on cryosurgery with liquid nitrogen in 1966 by Dr. Setrag Zacarian ("Cryosurgery of Skin Cancer and Cutaneous Disorders," Mosby, St. Louis, 1985), and on ambulatory phlebectomy by Dr. Robert Muller the same year (Phlebologie 1966;19:227-9).

And, in 1967, Dr. Frederic E. Mohs founded the American College of Chemosurgery, which is today known as the American College of Mohs Surgery. "Mohs surgery continues to be an important part of the dermatologic surgery curriculum," Dr. Hanke said.

Advancements in vein ablation took pace in 1982 when the first report on hypertonic saline injections for treating leg veins, by Bruce Chrisman, was published (Hawaii Med. J. 1982;41:406-8).

In 1986, Dr. Saul Asken published the "Manual of Liposuction Surgery and Autologous Fat Transplantation Under Local Anesthesia" (Terry and Associates, Irvine, Calif.), and the following year, Dr. Jeffery A. Klein published the first report on the tumescent technique for liposuction (Am. J. Cosm. Surg. 1987;4:263-7).

Dr. Alastair Carruthers and Dr. Jean Carruthers revolutionized the field in 1987 when they began using botulinum toxin for cosmetic purposes. "Their joint observation that botulinum toxin can affect the muscles of facial expression began a revolution in cosmetic dermatology," wrote Dr. Hanke.

He also highlighted the launch of numerous societies and publications that helped to advance the specialty, including the founding of the American Society for Dermatologic Surgery in 1970, the launch of the Journal of Dermatologic Surgery in 1975, and the founding of the American Society for Lasers in Medicine and Surgery in 1981. And the specialty has continued to evolve at a rapid pace since that time, he noted.

Work by Dr. R. Rox Anderson and Dr. John A. Parrish on selective photothermolysis, for example, launched research leading to the fractionated laser technology in use today; and ongoing work by the Carruthers on botulinum toxin launched a new era in noninvasive facial rejuvenation, he said.

"Facelift bypass" procedures have satisfied many patients without subjecting them to the expense or morbidity of extensive facial surgery, Dr. Hanke noted, adding that new filler materials can be placed in the subcutaneous or supraperiosteal planes of the face with good results and minimal complications.

"A newly approved hyaluronic acid from Germany will allow treatment of very superficial wrinkles without the risk of the 'Tyndall effect,' " he added.

Also in the last decade, dermatologic surgery-related educational initiatives have been advanced. In 2004, 1-year fellowship training programs were approved by the Accreditation Council for Graduate Medical Education for training in dermatologic surgery; and last year, there were 47 ACGME-accredited procedural dermatology fellowship training programs in place, he said.

"Dermatologic surgery is an important component of nearly all dermatology postgraduate courses," added Dr. Hanke.

The history of fractional laser technology and fillers were addressed in separate articles in the same issue of Seminars in Cutaneous Medicine and Surgery, underscoring the importance of the two recent developments.

Fillers

The next phase of development in injectable fillers has begun, according to Dr. Richard G. Glogau.

"The concept of augmentation has moved from simple lines, scars, and wrinkles to revolumizing the aging face," noted Dr. Glogau, a clinical professor of dermatology at the University of California, San Francisco. "While seeking extended duration of effect balanced against the safety profile of the injectable, our focus is now directed to extending the lifting or volumizing effect that one can achieve with these fillers."

The initial movement into 3-dimensional correction with injectable fillers began with the dramatic improvement seen in lip volume championed in the 1980s, and each of a litany of fillers that followed, including fat, collagen, silicone, hyaluronic acids, poly-l-lactic acids, calcium hydroxylapatite, and polymethylmethacrylate (Sem. Cut. Med. Surg. 2012;31:78-87).

New fillers, some which represent refinements of existing technologies, continue to undergo review. Aquamid a biocompatible, nonabsorbable, permanent injectable hydrogel implant is currently under review by the Food and Drug Administration and is approved for use in Europe.

It is also possible that fillers will move beyond the traditional concept of inert medical devices and into the realm of true biologics – "materials that will improve the texture, elasticity, radiance, and possibly color, of the skin itself," he added.

"Just as the last 40 years has seen the movement from 2 to 3 dimensions, the next 2 decades will see movement form the macro to the micro level, and fillers will become systems for active metabolic manipulation and protection of the aging skin," he concluded.

Fractionation

The development of fractional photothermolysis was "a milestone in the history of laser technology and cutaneous resurfacing," according to Dr. Nazanin Saedi, a dermatologist in private practice in Chestnut Hill, Mass., and her colleagues.

The technology, noted the study authors, builds on the knowledge gained from early CO₂ and Er:YAG laser treatment experiences, achieving greater optimization of parameters to induce the types of benefits seen with CO₂ resurfacing, but without the significant postoperative morbidity, complications, and discomfort associated with the earlier technologies.

Furthermore, the older therapies destroyed the barrier protection, which "significantly increased the risk of infection throughout the recovery period and required extensive home care. The risk of scarring, delayed-onset permanent hypopigmentation, and demarcation lines was significant even in the hands of an experienced operator," they wrote (Sem. Cut. Med. Surg. 2012;31:105-9).

In an en effort to overcome these problems, what followed was nonablative dermal remodeling (with less than impressive results), and ultimately, the "idea of fractionated laser technology," they continued.

First used in hair transplant surgery, the technology led to development of the 1,550-nm nonablative "Fraxel" laser (now called the Fraxel Re:Store by Solta Medical), which debuted in the literature in 2004. This and other fractional laser technologies are now used to treat photoaging, superficial and deep rhytids, scars (including in patients with darker skin types), and pigmentation.

Both nonablative and ablative fractional resurfacing have proved to be safer than have traditional ablative lasers, Dr. Saedi and her colleagues noted. However, complications can still occur, such as infections (with herpes simplex virus being the most common), acneiform eruptions, prolonged erythema, pigmentary alteration, and scarring (rare, but can also result from infection associated with treatment).

"Counterintuitively, nonablative or ablative fractionated devices at low energies and densities can be useful in the treatment of scarring, including hypertrophic scars" as previously mentioned, they noted.

"While [fractional lasers are] inherently safer due to the pixelated manner of the treatment, complications can be further prevented with attentive surgical technique and judicious use of prophylaxis," they wrote.

The future of fractional laser technology promises to hold exciting developments. For example, since ablative fractional resurfacing creates microscopic vertical holes in tissue, the delivery of topical drugs through these holes is possible. In animal models, the photosensitizer methylaminolevulinic acid has been delivered using this approach, and tests suggest that low density treatment would be sufficient for deep dermal drug delivery.

"Treatment of skin in a porcine model showed enhanced depth of photodynamic therapy following porphyrin application after pretreatment with fractional resurfacing. An in vitro study utilizing low fluence fractionated Erbium:YAG demonstrated upwards of a 125-fold increase in imiquimod delivery," they noted.

Trials in humans are underway to assess the feasibility and safety of enhanced drug delivery using this approach, and there is speculation that ultimately, it could be used for delivery of biologic peptides and vaccines.

Tattoo removal is another promising use for fractional lasers, with early studies demonstrating good results, noted Dr. Saedi and her colleagues, explaining that ablative fractional lasers, when used in conjunction with a Q-switched laser, appear to provide enhanced tattoo removal capabilities.

"With new devices and wavelengths, the applications of this technology continue to grow," they wrote, concluding that "the future remains bright for fractionated laser devices."

Likewise, the future of dermatologic surgery in general remains promising, Dr. Hanke said. "Many new procedures and advances lie ahead."

Neither Dr. Hanke nor Dr. Saedi had disclosures to report. Another author on the article by Dr. Saedi (Dr. Christopher Zachary) reported receiving an honorarium from Solta Medical.

It was questionable whether in 1952, when Dr. Norman Orentreich performed the first hair transplant and Dr. George Mackee reported on his 50-year experience with phenol chemical peels, anyone envisioned how far the field of dermatologic surgery would advance, but there’s no question now: The specialty has come a long way.

"Dermatologic surgery has blossomed into a full and diverse specialty with many elements," Dr. C. William Hanke noted in the June issue of Seminars in Cutaneous Medicine and Surgery (2012;31:52-9). He highlighted key events that shaped the burgeoning specialty.

Historical Highlights

From the first report on phenol peels by Dr. Mackee (Br. J. Dermatol. 1952;64:456-9), to the coining of the term "tumescent local anesthesia" by Dr. Hanke and his colleagues in 1998 – and publication of a comprehensive text on the tumescent technique 2 years later by Dr. Jeffery A. Klein ("Tumescent Technique: Tumescent Anesthesia and Microcannular Liposuction," St. Louis, Mosby, 2000) – Dr. Hanke chronicled the specialty’s evolution.

For example, he noted that in 1961, Dr. Leon Goldman became the first physician to treat patients with lasers. "He is acknowledged as the father of lasers in medicine and surgery," Dr. Hanke, a dermatologist in private practice in Carmel, Indiana, wrote. He added that the pioneer's first medicinal use of a laser launched 3 decades of related leadership, practice, and research.

Among other events that stand out in the history of the specialty, according to Dr. Hanke, are the first reports on cryosurgery with liquid nitrogen in 1966 by Dr. Setrag Zacarian ("Cryosurgery of Skin Cancer and Cutaneous Disorders," Mosby, St. Louis, 1985), and on ambulatory phlebectomy by Dr. Robert Muller the same year (Phlebologie 1966;19:227-9).

And, in 1967, Dr. Frederic E. Mohs founded the American College of Chemosurgery, which is today known as the American College of Mohs Surgery. "Mohs surgery continues to be an important part of the dermatologic surgery curriculum," Dr. Hanke said.

Advancements in vein ablation took pace in 1982 when the first report on hypertonic saline injections for treating leg veins, by Bruce Chrisman, was published (Hawaii Med. J. 1982;41:406-8).

In 1986, Dr. Saul Asken published the "Manual of Liposuction Surgery and Autologous Fat Transplantation Under Local Anesthesia" (Terry and Associates, Irvine, Calif.), and the following year, Dr. Jeffery A. Klein published the first report on the tumescent technique for liposuction (Am. J. Cosm. Surg. 1987;4:263-7).

Dr. Alastair Carruthers and Dr. Jean Carruthers revolutionized the field in 1987 when they began using botulinum toxin for cosmetic purposes. "Their joint observation that botulinum toxin can affect the muscles of facial expression began a revolution in cosmetic dermatology," wrote Dr. Hanke.

He also highlighted the launch of numerous societies and publications that helped to advance the specialty, including the founding of the American Society for Dermatologic Surgery in 1970, the launch of the Journal of Dermatologic Surgery in 1975, and the founding of the American Society for Lasers in Medicine and Surgery in 1981. And the specialty has continued to evolve at a rapid pace since that time, he noted.

Work by Dr. R. Rox Anderson and Dr. John A. Parrish on selective photothermolysis, for example, launched research leading to the fractionated laser technology in use today; and ongoing work by the Carruthers on botulinum toxin launched a new era in noninvasive facial rejuvenation, he said.

"Facelift bypass" procedures have satisfied many patients without subjecting them to the expense or morbidity of extensive facial surgery, Dr. Hanke noted, adding that new filler materials can be placed in the subcutaneous or supraperiosteal planes of the face with good results and minimal complications.

"A newly approved hyaluronic acid from Germany will allow treatment of very superficial wrinkles without the risk of the 'Tyndall effect,' " he added.

Also in the last decade, dermatologic surgery-related educational initiatives have been advanced. In 2004, 1-year fellowship training programs were approved by the Accreditation Council for Graduate Medical Education for training in dermatologic surgery; and last year, there were 47 ACGME-accredited procedural dermatology fellowship training programs in place, he said.

"Dermatologic surgery is an important component of nearly all dermatology postgraduate courses," added Dr. Hanke.

The history of fractional laser technology and fillers were addressed in separate articles in the same issue of Seminars in Cutaneous Medicine and Surgery, underscoring the importance of the two recent developments.

Fillers

The next phase of development in injectable fillers has begun, according to Dr. Richard G. Glogau.

"The concept of augmentation has moved from simple lines, scars, and wrinkles to revolumizing the aging face," noted Dr. Glogau, a clinical professor of dermatology at the University of California, San Francisco. "While seeking extended duration of effect balanced against the safety profile of the injectable, our focus is now directed to extending the lifting or volumizing effect that one can achieve with these fillers."

The initial movement into 3-dimensional correction with injectable fillers began with the dramatic improvement seen in lip volume championed in the 1980s, and each of a litany of fillers that followed, including fat, collagen, silicone, hyaluronic acids, poly-l-lactic acids, calcium hydroxylapatite, and polymethylmethacrylate (Sem. Cut. Med. Surg. 2012;31:78-87).

New fillers, some which represent refinements of existing technologies, continue to undergo review. Aquamid a biocompatible, nonabsorbable, permanent injectable hydrogel implant is currently under review by the Food and Drug Administration and is approved for use in Europe.

It is also possible that fillers will move beyond the traditional concept of inert medical devices and into the realm of true biologics – "materials that will improve the texture, elasticity, radiance, and possibly color, of the skin itself," he added.

"Just as the last 40 years has seen the movement from 2 to 3 dimensions, the next 2 decades will see movement form the macro to the micro level, and fillers will become systems for active metabolic manipulation and protection of the aging skin," he concluded.

Fractionation

The development of fractional photothermolysis was "a milestone in the history of laser technology and cutaneous resurfacing," according to Dr. Nazanin Saedi, a dermatologist in private practice in Chestnut Hill, Mass., and her colleagues.

The technology, noted the study authors, builds on the knowledge gained from early CO₂ and Er:YAG laser treatment experiences, achieving greater optimization of parameters to induce the types of benefits seen with CO₂ resurfacing, but without the significant postoperative morbidity, complications, and discomfort associated with the earlier technologies.

Furthermore, the older therapies destroyed the barrier protection, which "significantly increased the risk of infection throughout the recovery period and required extensive home care. The risk of scarring, delayed-onset permanent hypopigmentation, and demarcation lines was significant even in the hands of an experienced operator," they wrote (Sem. Cut. Med. Surg. 2012;31:105-9).

In an en effort to overcome these problems, what followed was nonablative dermal remodeling (with less than impressive results), and ultimately, the "idea of fractionated laser technology," they continued.

First used in hair transplant surgery, the technology led to development of the 1,550-nm nonablative "Fraxel" laser (now called the Fraxel Re:Store by Solta Medical), which debuted in the literature in 2004. This and other fractional laser technologies are now used to treat photoaging, superficial and deep rhytids, scars (including in patients with darker skin types), and pigmentation.

Both nonablative and ablative fractional resurfacing have proved to be safer than have traditional ablative lasers, Dr. Saedi and her colleagues noted. However, complications can still occur, such as infections (with herpes simplex virus being the most common), acneiform eruptions, prolonged erythema, pigmentary alteration, and scarring (rare, but can also result from infection associated with treatment).

"Counterintuitively, nonablative or ablative fractionated devices at low energies and densities can be useful in the treatment of scarring, including hypertrophic scars" as previously mentioned, they noted.

"While [fractional lasers are] inherently safer due to the pixelated manner of the treatment, complications can be further prevented with attentive surgical technique and judicious use of prophylaxis," they wrote.

The future of fractional laser technology promises to hold exciting developments. For example, since ablative fractional resurfacing creates microscopic vertical holes in tissue, the delivery of topical drugs through these holes is possible. In animal models, the photosensitizer methylaminolevulinic acid has been delivered using this approach, and tests suggest that low density treatment would be sufficient for deep dermal drug delivery.

"Treatment of skin in a porcine model showed enhanced depth of photodynamic therapy following porphyrin application after pretreatment with fractional resurfacing. An in vitro study utilizing low fluence fractionated Erbium:YAG demonstrated upwards of a 125-fold increase in imiquimod delivery," they noted.

Trials in humans are underway to assess the feasibility and safety of enhanced drug delivery using this approach, and there is speculation that ultimately, it could be used for delivery of biologic peptides and vaccines.

Tattoo removal is another promising use for fractional lasers, with early studies demonstrating good results, noted Dr. Saedi and her colleagues, explaining that ablative fractional lasers, when used in conjunction with a Q-switched laser, appear to provide enhanced tattoo removal capabilities.

"With new devices and wavelengths, the applications of this technology continue to grow," they wrote, concluding that "the future remains bright for fractionated laser devices."

Likewise, the future of dermatologic surgery in general remains promising, Dr. Hanke said. "Many new procedures and advances lie ahead."

Neither Dr. Hanke nor Dr. Saedi had disclosures to report. Another author on the article by Dr. Saedi (Dr. Christopher Zachary) reported receiving an honorarium from Solta Medical.

DESTIN, FLA. – An increasing number of patients are presenting with muscular dystrophy in adulthood.

"We’re now finding more and more patients who are presenting with muscular dystrophy [and] becoming symptomatic in adulthood, not just at age 20, but even at age 30, 40, or 50 years old," Dr. Robert Wortmann said at the Congress of Clinical Rheumatology.

In one case, a patient was diagnosed with a limb-girdle muscular dystrophy at 82 years of age, said Dr. Wortmann, professor of medicine at Dartmouth Medical School, Lebanon, N.H.

"So these are more common, more prevalent, and we’re learning a lot more about this disease," he added.

As an example, Dr. Wortmann presented one case involving a 20-year-old Brazilian exchange student with a 6-month history of progressive proximal muscle weakness. She had creatine phosphokinase (CPK) values that ranged between 20 and 60 times the upper limit of normal; a muscle biopsy showed lymphocytic inflammation. Corticosteroid and methotrexate treatment did not improve her condition.

She was found to have an autosomal recessive limb-girdle muscular dystrophy associated with dysferlin deficiency (limb-girdle muscular dystrophy type 2B, or LGMD2B). Dysferlin is one of the most common proteins to be deficient in this type of muscular dystrophy, Dr. Wortmann said.

Characteristics of LGMD2B include symmetric proximal myopathy, onset at 11-48 years of age (which has been expanded from an earlier identified range of late teens to early 20s), and very high CPK levels.

Caused by genetic defects in muscle cell proteins, muscular dystrophies are typically characterized by proximal muscle weakness, and later by muscle wasting. Early on in dystrophy, histology will look very similar to that of polymyositis.

"It may not be as profound a lymphocytic infiltrate, but it’s the same cells and the same distribution within the tissue," he said.

In fact, about 30% of cases in one series were first diagnosed with polymyositis, he said, noting that patients may even have some response to steroids.

Over time, however, this inflammation tends to decrease, and the muscle wastes and is replaced by fibrous tissue and fat," he said.

The muscle wasting represents an important distinction between polymyositis and muscular dystrophies, noted Dr. Wortmann.

The roles of various proteins in the associated genetic abnormalities continue to be defined, and limb-girdle muscular dystrophy is now considered to have 7 different autosomal dominant forms with different gene mutations, and 11 autosomal recessive forms that affect different structured proteins in the muscle and result in the identical presentation to polymyositis – including the LGMD2B disease identified in the case patient.

Not all patients with limb-girdle muscular dystrophy present with proximal myopathy, however.

In some cases, Miyoshi myopathy occurs, which is distal, late-onset myopathy. In other cases, there is mixed proximal and distal myopathy, he said.

"One thing I don’t understand – and I hope we learn some day why – is that some genetic disease that affects muscle will cause one phenotypic expression in one patient, and the same genetic defect in another patient will cause a different presentation," Dr. Wortmann said, adding that those that first appear to be polymyositis are generally the cases referred to rheumatologists and those with distal myopathy are generally those referred to neurologists.

Dr. Wortmann disclosed a financial relationship with Questcor.

DESTIN, FLA. – An increasing number of patients are presenting with muscular dystrophy in adulthood.

"We’re now finding more and more patients who are presenting with muscular dystrophy [and] becoming symptomatic in adulthood, not just at age 20, but even at age 30, 40, or 50 years old," Dr. Robert Wortmann said at the Congress of Clinical Rheumatology.

In one case, a patient was diagnosed with a limb-girdle muscular dystrophy at 82 years of age, said Dr. Wortmann, professor of medicine at Dartmouth Medical School, Lebanon, N.H.

"So these are more common, more prevalent, and we’re learning a lot more about this disease," he added.

As an example, Dr. Wortmann presented one case involving a 20-year-old Brazilian exchange student with a 6-month history of progressive proximal muscle weakness. She had creatine phosphokinase (CPK) values that ranged between 20 and 60 times the upper limit of normal; a muscle biopsy showed lymphocytic inflammation. Corticosteroid and methotrexate treatment did not improve her condition.

She was found to have an autosomal recessive limb-girdle muscular dystrophy associated with dysferlin deficiency (limb-girdle muscular dystrophy type 2B, or LGMD2B). Dysferlin is one of the most common proteins to be deficient in this type of muscular dystrophy, Dr. Wortmann said.

Characteristics of LGMD2B include symmetric proximal myopathy, onset at 11-48 years of age (which has been expanded from an earlier identified range of late teens to early 20s), and very high CPK levels.

Caused by genetic defects in muscle cell proteins, muscular dystrophies are typically characterized by proximal muscle weakness, and later by muscle wasting. Early on in dystrophy, histology will look very similar to that of polymyositis.

"It may not be as profound a lymphocytic infiltrate, but it’s the same cells and the same distribution within the tissue," he said.

In fact, about 30% of cases in one series were first diagnosed with polymyositis, he said, noting that patients may even have some response to steroids.

Over time, however, this inflammation tends to decrease, and the muscle wastes and is replaced by fibrous tissue and fat," he said.

The muscle wasting represents an important distinction between polymyositis and muscular dystrophies, noted Dr. Wortmann.

The roles of various proteins in the associated genetic abnormalities continue to be defined, and limb-girdle muscular dystrophy is now considered to have 7 different autosomal dominant forms with different gene mutations, and 11 autosomal recessive forms that affect different structured proteins in the muscle and result in the identical presentation to polymyositis – including the LGMD2B disease identified in the case patient.

Not all patients with limb-girdle muscular dystrophy present with proximal myopathy, however.

In some cases, Miyoshi myopathy occurs, which is distal, late-onset myopathy. In other cases, there is mixed proximal and distal myopathy, he said.

"One thing I don’t understand – and I hope we learn some day why – is that some genetic disease that affects muscle will cause one phenotypic expression in one patient, and the same genetic defect in another patient will cause a different presentation," Dr. Wortmann said, adding that those that first appear to be polymyositis are generally the cases referred to rheumatologists and those with distal myopathy are generally those referred to neurologists.

Dr. Wortmann disclosed a financial relationship with Questcor.

DESTIN, FLA. – An increasing number of patients are presenting with muscular dystrophy in adulthood.

"We’re now finding more and more patients who are presenting with muscular dystrophy [and] becoming symptomatic in adulthood, not just at age 20, but even at age 30, 40, or 50 years old," Dr. Robert Wortmann said at the Congress of Clinical Rheumatology.

In one case, a patient was diagnosed with a limb-girdle muscular dystrophy at 82 years of age, said Dr. Wortmann, professor of medicine at Dartmouth Medical School, Lebanon, N.H.

"So these are more common, more prevalent, and we’re learning a lot more about this disease," he added.

As an example, Dr. Wortmann presented one case involving a 20-year-old Brazilian exchange student with a 6-month history of progressive proximal muscle weakness. She had creatine phosphokinase (CPK) values that ranged between 20 and 60 times the upper limit of normal; a muscle biopsy showed lymphocytic inflammation. Corticosteroid and methotrexate treatment did not improve her condition.

She was found to have an autosomal recessive limb-girdle muscular dystrophy associated with dysferlin deficiency (limb-girdle muscular dystrophy type 2B, or LGMD2B). Dysferlin is one of the most common proteins to be deficient in this type of muscular dystrophy, Dr. Wortmann said.

Characteristics of LGMD2B include symmetric proximal myopathy, onset at 11-48 years of age (which has been expanded from an earlier identified range of late teens to early 20s), and very high CPK levels.

Caused by genetic defects in muscle cell proteins, muscular dystrophies are typically characterized by proximal muscle weakness, and later by muscle wasting. Early on in dystrophy, histology will look very similar to that of polymyositis.

"It may not be as profound a lymphocytic infiltrate, but it’s the same cells and the same distribution within the tissue," he said.

In fact, about 30% of cases in one series were first diagnosed with polymyositis, he said, noting that patients may even have some response to steroids.

Over time, however, this inflammation tends to decrease, and the muscle wastes and is replaced by fibrous tissue and fat," he said.

The muscle wasting represents an important distinction between polymyositis and muscular dystrophies, noted Dr. Wortmann.

The roles of various proteins in the associated genetic abnormalities continue to be defined, and limb-girdle muscular dystrophy is now considered to have 7 different autosomal dominant forms with different gene mutations, and 11 autosomal recessive forms that affect different structured proteins in the muscle and result in the identical presentation to polymyositis – including the LGMD2B disease identified in the case patient.

Not all patients with limb-girdle muscular dystrophy present with proximal myopathy, however.

In some cases, Miyoshi myopathy occurs, which is distal, late-onset myopathy. In other cases, there is mixed proximal and distal myopathy, he said.

"One thing I don’t understand – and I hope we learn some day why – is that some genetic disease that affects muscle will cause one phenotypic expression in one patient, and the same genetic defect in another patient will cause a different presentation," Dr. Wortmann said, adding that those that first appear to be polymyositis are generally the cases referred to rheumatologists and those with distal myopathy are generally those referred to neurologists.

Dr. Wortmann disclosed a financial relationship with Questcor.