Sharon Worcester

PARIS – Traumatic brain injury may double the risk of developing dementia, according to findings from a study of more than 280,000 U.S. veterans.

The risk of dementia over 7 years was 15.3% in 4,902 veterans who had a traumatic brain injury (TBI) diagnosis in 1997-2000, compared with 6.8% in those without a TBI diagnosis. The comparison yielded a hazard ratio of 2.3 for those with any TBI diagnosis after adjustment for age, sex, race, and multiple medical and psychiatric conditions.

The difference was statistically significant for all TBI types, including intracranial injury (the most common form, which accounted for 40% of the injuries among the veterans) as well as for concussion, postconcussion syndrome, head fracture, and unspecified head injury, Dr. Kristine Yaffe and her colleagues reported in a poster on July 18 at the International Conference on Alzheimer’s Disease.

The findings also offer some hope that early treatment and rehabilitation after TBI could help ward off dementia, and they underscore the need for monitoring affected older adults for signs of cognitive impairment following a TBI, Dr. Yaffe said at the conference.

"The issue is important because TBI is very common," according to Dr. Yaffe, professor of psychiatry, neurology, and epidemiology at the University of California, San Francisco, who noted that the condition is common in the general population as well as among veterans.

About 1.7 million people experience a TBI each year in the United States, most often as a result of falls and car crashes, according to data from the U.S. Centers for Disease Control and Prevention. About 2% of the veterans included in this study had a TBI diagnosis during the study period.

In fact, TBI is known as the "signature wound" incurred by soldiers involved in conflicts in Iraq and Afghanistan, because it accounts for 22% of casualties and 59% of blast-related injuries. Findings from this and prior studies that suggest an association between such injuries and the development of symptomatic dementia raise concern about potential long-term consequences for affected veterans, as well as for older adults in the general population who experience a TBI, said Dr. Yaffe, who is also director of the memory disorders clinic at the San Francisco VA Medical Center.

That is particularly true because amyloid plaques similar to those seen in the brains of Alzheimer’s patients are also present in nearly a third of TBI patients who don’t survive their injuries.

"It is possible that these injuries result in the death of axons and neurons, even after a single TBI. Loss of axons and neurons could result in earlier manifestation of Alzheimer’s symptoms," the researchers said in a statement regarding the findings.

Veterans included in the study were aged 55 years or older with no dementia diagnosis at baseline. Each veteran had received care through the Veterans Health Administration, had at least one visit during 1997-2000, and had a follow-up visit from 2001-2007.

Dr. Yaffe’s research was funded by the U.S. Department of Defense. She had no other relevant disclosures.

PARIS – Traumatic brain injury may double the risk of developing dementia, according to findings from a study of more than 280,000 U.S. veterans.

The risk of dementia over 7 years was 15.3% in 4,902 veterans who had a traumatic brain injury (TBI) diagnosis in 1997-2000, compared with 6.8% in those without a TBI diagnosis. The comparison yielded a hazard ratio of 2.3 for those with any TBI diagnosis after adjustment for age, sex, race, and multiple medical and psychiatric conditions.

The difference was statistically significant for all TBI types, including intracranial injury (the most common form, which accounted for 40% of the injuries among the veterans) as well as for concussion, postconcussion syndrome, head fracture, and unspecified head injury, Dr. Kristine Yaffe and her colleagues reported in a poster on July 18 at the International Conference on Alzheimer’s Disease.

The findings also offer some hope that early treatment and rehabilitation after TBI could help ward off dementia, and they underscore the need for monitoring affected older adults for signs of cognitive impairment following a TBI, Dr. Yaffe said at the conference.

"The issue is important because TBI is very common," according to Dr. Yaffe, professor of psychiatry, neurology, and epidemiology at the University of California, San Francisco, who noted that the condition is common in the general population as well as among veterans.

About 1.7 million people experience a TBI each year in the United States, most often as a result of falls and car crashes, according to data from the U.S. Centers for Disease Control and Prevention. About 2% of the veterans included in this study had a TBI diagnosis during the study period.

In fact, TBI is known as the "signature wound" incurred by soldiers involved in conflicts in Iraq and Afghanistan, because it accounts for 22% of casualties and 59% of blast-related injuries. Findings from this and prior studies that suggest an association between such injuries and the development of symptomatic dementia raise concern about potential long-term consequences for affected veterans, as well as for older adults in the general population who experience a TBI, said Dr. Yaffe, who is also director of the memory disorders clinic at the San Francisco VA Medical Center.

That is particularly true because amyloid plaques similar to those seen in the brains of Alzheimer’s patients are also present in nearly a third of TBI patients who don’t survive their injuries.

"It is possible that these injuries result in the death of axons and neurons, even after a single TBI. Loss of axons and neurons could result in earlier manifestation of Alzheimer’s symptoms," the researchers said in a statement regarding the findings.

Veterans included in the study were aged 55 years or older with no dementia diagnosis at baseline. Each veteran had received care through the Veterans Health Administration, had at least one visit during 1997-2000, and had a follow-up visit from 2001-2007.

Dr. Yaffe’s research was funded by the U.S. Department of Defense. She had no other relevant disclosures.

PARIS – Traumatic brain injury may double the risk of developing dementia, according to findings from a study of more than 280,000 U.S. veterans.

The risk of dementia over 7 years was 15.3% in 4,902 veterans who had a traumatic brain injury (TBI) diagnosis in 1997-2000, compared with 6.8% in those without a TBI diagnosis. The comparison yielded a hazard ratio of 2.3 for those with any TBI diagnosis after adjustment for age, sex, race, and multiple medical and psychiatric conditions.

The difference was statistically significant for all TBI types, including intracranial injury (the most common form, which accounted for 40% of the injuries among the veterans) as well as for concussion, postconcussion syndrome, head fracture, and unspecified head injury, Dr. Kristine Yaffe and her colleagues reported in a poster on July 18 at the International Conference on Alzheimer’s Disease.

The findings also offer some hope that early treatment and rehabilitation after TBI could help ward off dementia, and they underscore the need for monitoring affected older adults for signs of cognitive impairment following a TBI, Dr. Yaffe said at the conference.

"The issue is important because TBI is very common," according to Dr. Yaffe, professor of psychiatry, neurology, and epidemiology at the University of California, San Francisco, who noted that the condition is common in the general population as well as among veterans.

About 1.7 million people experience a TBI each year in the United States, most often as a result of falls and car crashes, according to data from the U.S. Centers for Disease Control and Prevention. About 2% of the veterans included in this study had a TBI diagnosis during the study period.

In fact, TBI is known as the "signature wound" incurred by soldiers involved in conflicts in Iraq and Afghanistan, because it accounts for 22% of casualties and 59% of blast-related injuries. Findings from this and prior studies that suggest an association between such injuries and the development of symptomatic dementia raise concern about potential long-term consequences for affected veterans, as well as for older adults in the general population who experience a TBI, said Dr. Yaffe, who is also director of the memory disorders clinic at the San Francisco VA Medical Center.

That is particularly true because amyloid plaques similar to those seen in the brains of Alzheimer’s patients are also present in nearly a third of TBI patients who don’t survive their injuries.

"It is possible that these injuries result in the death of axons and neurons, even after a single TBI. Loss of axons and neurons could result in earlier manifestation of Alzheimer’s symptoms," the researchers said in a statement regarding the findings.

Veterans included in the study were aged 55 years or older with no dementia diagnosis at baseline. Each veteran had received care through the Veterans Health Administration, had at least one visit during 1997-2000, and had a follow-up visit from 2001-2007.

Dr. Yaffe’s research was funded by the U.S. Department of Defense. She had no other relevant disclosures.

Cardiac dysfunction remains the most common cause of death in patients with Friedreich’s ataxia, according to the findings of a retrospective study.

The majority (59%) of 61 deceased patients studied died as a result of cardiac dysfunction, most often congestive heart failure or arrhythmia; another 3% died of probable cardiac dysfunction, Dr. Amy Y. Tsou of the University of Pennsylvania, Philadelphia, and her colleagues found (J. Neurol. Sci. 2011;307:46-9).

Cardiac dysfunction is widely accepted as the leading cause of death in patients with Friedreich’s ataxia (FRDA), but this has not been well studied in the years since clinical and genetic diagnostic criteria were developed and led to improved diagnostic accuracy for this inherited ataxia, Dr. Tsou and her associates said.

FRDA is characterized by dysarthria, areflexia, and loss of vibratory and proprioceptive sensation. Systemic manifestations of the disease can include cardiomyopathy, diabetes, and scoliosis.

Noncardiac deaths accounted for 28% of the 61 deaths, and unknown causes accounted for the remaining 10%, the investigators reported.

In a comparison with patients who suffered noncardiac deaths, patients who died from cardiac causes died at younger ages (median of 26 years vs. 41 years) and with shorter disease duration (mean of 19.6 years vs. 30.1 years). Those with a disease duration of 20 years or more had significantly lower odds of death from cardiac dysfunction, compared with a disease duration of less than 20 years (odds ratio 0.19). Patients who died from cardiac dysfunction also had a significantly longer mean GAA triplet repeat length than did patients who died from a noncardiac cause (687 vs. 508).

In a case-control analysis of 20 of the deceased patients whose records were particularly detailed and 40 living age- and sex-matched control patients with FRDA, deceased patients were significantly more likely to have arrhythmia (75% vs. 15%), dilated cardiomyopathy (65% vs. 5%), congestive heart failure (65% vs. 5%), stroke (20% vs. 0%), or be wheelchair bound (75% vs. 48%). However, the presence of hypertrophic cardiomyopathy did not differ significantly between the groups.

"As cardiac hypertrophy in FRDA is common but not associated with mortality in our study, further investigation to identify factors that predict development of dilatation may allow improved prognostication and targeting of future research. In addition, while hypertrophy has been used as a primary endpoint in several clinical trials, our results suggest that other manifestations of cardiac dysfunction such as a dilated cardiomyopathy or arrhythmia are more relevant indicators of clinical significance," the investigators wrote.

They noted that because their cohort had a young mean age of onset (12 years) and mean age of death (37 years) in comparison with large living cohorts, the study may not be "entirely representative of the general FRDA population," despite the fact that they drew patients from a wide geographical area that included patients from a community group as well as multiple academic medical centers. "The difficulties with selection in our study highlight how relevant the problem of selection bias in FRDA studies continues to be, particularly when working with smaller numbers of patients."

This study was supported by a grant to coauthor David R. Lynch from the Friedreich’s Ataxia Research Alliance.

Cardiac dysfunction remains the most common cause of death in patients with Friedreich’s ataxia, according to the findings of a retrospective study.

The majority (59%) of 61 deceased patients studied died as a result of cardiac dysfunction, most often congestive heart failure or arrhythmia; another 3% died of probable cardiac dysfunction, Dr. Amy Y. Tsou of the University of Pennsylvania, Philadelphia, and her colleagues found (J. Neurol. Sci. 2011;307:46-9).

Cardiac dysfunction is widely accepted as the leading cause of death in patients with Friedreich’s ataxia (FRDA), but this has not been well studied in the years since clinical and genetic diagnostic criteria were developed and led to improved diagnostic accuracy for this inherited ataxia, Dr. Tsou and her associates said.

FRDA is characterized by dysarthria, areflexia, and loss of vibratory and proprioceptive sensation. Systemic manifestations of the disease can include cardiomyopathy, diabetes, and scoliosis.

Noncardiac deaths accounted for 28% of the 61 deaths, and unknown causes accounted for the remaining 10%, the investigators reported.

In a comparison with patients who suffered noncardiac deaths, patients who died from cardiac causes died at younger ages (median of 26 years vs. 41 years) and with shorter disease duration (mean of 19.6 years vs. 30.1 years). Those with a disease duration of 20 years or more had significantly lower odds of death from cardiac dysfunction, compared with a disease duration of less than 20 years (odds ratio 0.19). Patients who died from cardiac dysfunction also had a significantly longer mean GAA triplet repeat length than did patients who died from a noncardiac cause (687 vs. 508).

In a case-control analysis of 20 of the deceased patients whose records were particularly detailed and 40 living age- and sex-matched control patients with FRDA, deceased patients were significantly more likely to have arrhythmia (75% vs. 15%), dilated cardiomyopathy (65% vs. 5%), congestive heart failure (65% vs. 5%), stroke (20% vs. 0%), or be wheelchair bound (75% vs. 48%). However, the presence of hypertrophic cardiomyopathy did not differ significantly between the groups.

"As cardiac hypertrophy in FRDA is common but not associated with mortality in our study, further investigation to identify factors that predict development of dilatation may allow improved prognostication and targeting of future research. In addition, while hypertrophy has been used as a primary endpoint in several clinical trials, our results suggest that other manifestations of cardiac dysfunction such as a dilated cardiomyopathy or arrhythmia are more relevant indicators of clinical significance," the investigators wrote.

They noted that because their cohort had a young mean age of onset (12 years) and mean age of death (37 years) in comparison with large living cohorts, the study may not be "entirely representative of the general FRDA population," despite the fact that they drew patients from a wide geographical area that included patients from a community group as well as multiple academic medical centers. "The difficulties with selection in our study highlight how relevant the problem of selection bias in FRDA studies continues to be, particularly when working with smaller numbers of patients."

This study was supported by a grant to coauthor David R. Lynch from the Friedreich’s Ataxia Research Alliance.

Cardiac dysfunction remains the most common cause of death in patients with Friedreich’s ataxia, according to the findings of a retrospective study.

The majority (59%) of 61 deceased patients studied died as a result of cardiac dysfunction, most often congestive heart failure or arrhythmia; another 3% died of probable cardiac dysfunction, Dr. Amy Y. Tsou of the University of Pennsylvania, Philadelphia, and her colleagues found (J. Neurol. Sci. 2011;307:46-9).

Cardiac dysfunction is widely accepted as the leading cause of death in patients with Friedreich’s ataxia (FRDA), but this has not been well studied in the years since clinical and genetic diagnostic criteria were developed and led to improved diagnostic accuracy for this inherited ataxia, Dr. Tsou and her associates said.

FRDA is characterized by dysarthria, areflexia, and loss of vibratory and proprioceptive sensation. Systemic manifestations of the disease can include cardiomyopathy, diabetes, and scoliosis.

Noncardiac deaths accounted for 28% of the 61 deaths, and unknown causes accounted for the remaining 10%, the investigators reported.

In a comparison with patients who suffered noncardiac deaths, patients who died from cardiac causes died at younger ages (median of 26 years vs. 41 years) and with shorter disease duration (mean of 19.6 years vs. 30.1 years). Those with a disease duration of 20 years or more had significantly lower odds of death from cardiac dysfunction, compared with a disease duration of less than 20 years (odds ratio 0.19). Patients who died from cardiac dysfunction also had a significantly longer mean GAA triplet repeat length than did patients who died from a noncardiac cause (687 vs. 508).

In a case-control analysis of 20 of the deceased patients whose records were particularly detailed and 40 living age- and sex-matched control patients with FRDA, deceased patients were significantly more likely to have arrhythmia (75% vs. 15%), dilated cardiomyopathy (65% vs. 5%), congestive heart failure (65% vs. 5%), stroke (20% vs. 0%), or be wheelchair bound (75% vs. 48%). However, the presence of hypertrophic cardiomyopathy did not differ significantly between the groups.

"As cardiac hypertrophy in FRDA is common but not associated with mortality in our study, further investigation to identify factors that predict development of dilatation may allow improved prognostication and targeting of future research. In addition, while hypertrophy has been used as a primary endpoint in several clinical trials, our results suggest that other manifestations of cardiac dysfunction such as a dilated cardiomyopathy or arrhythmia are more relevant indicators of clinical significance," the investigators wrote.

They noted that because their cohort had a young mean age of onset (12 years) and mean age of death (37 years) in comparison with large living cohorts, the study may not be "entirely representative of the general FRDA population," despite the fact that they drew patients from a wide geographical area that included patients from a community group as well as multiple academic medical centers. "The difficulties with selection in our study highlight how relevant the problem of selection bias in FRDA studies continues to be, particularly when working with smaller numbers of patients."

This study was supported by a grant to coauthor David R. Lynch from the Friedreich’s Ataxia Research Alliance.

BOCA RATON, FLA. – There’s good news and bad news when it comes to doctor-bashing websites that can destroy a reputation that has taken years to build, according to Dr. Kevin C. Smith.

The bad news is that the sites aren’t going away. The good news is that they don’t appear to be lucrative. Site views are declining, "rate the rating sites" are emerging, and laws that may help protect victims of anonymous doctor-bashing posts are evolving, Dr. Smith, a dermatologist in private practice in Niagara Falls, Ontario, said at the Annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

One site, www.ratemds.com, had a value estimation of nearly $75,000 in February 2010 but was valued at under $65,500 in February 2011 by an online resource, which showed that page views over that time period declined from about 150,000 page views/month to about 90,000/month. Three other well-known sites have current estimated values of only $10,820 (www.doctorscorecard.com), $8,447 (www.healthcarereviews.com), and $2,992 (www.mydochub.com), based on their number of page views, he said.

"These things have very little value," he said, noting that the decline in page views is likely a result of consumers becoming more savvy and knowing that in many cases "something just isn’t right" about a lot of the sites.

Sites that rate rating sites could also be useful for patients. One such website, Informed Patient Institute (www.informedpatientinstitute.org), grades sites and provides a "What we like" and "What we don’t like" section that spells out the pros and cons of a given site.

Current Law

Under current U.S. law, website owners cannot be held liable for comments posted on their sites; the right to speak anonymously both in print and online is constitutionally protected free speech, Dr. Smith said.

Courtesy of www.mydochub.com

In Canada, the rules governing online defamation differ from U.S. laws because they make no distinction between libel published in a newspaper or online. Canadian laws hold both the individual who authors the statements and the individual who arranged for its publication or republication responsible. Doctors in Canada have "unmasked people making false statements ... and caused them enormous amounts of trouble," he noted.

Furthermore, according to at least one Canadian legal expert, courts there would have jurisdiction in cases in which a libelous statement about a Canadian citizen was made on a U.S. website, he said.

He predicted that U.S. and Canadian laws will "eventually converge."

"Patients and others who post ill-considered or defamatory comments about physicians on the Internet may feel like they are ‘getting away with it’ ... but they might feel differently and use better judgment if they were aware that the laws regarding anonymous online defamation are evolving; and they may, in the not-too-distant future, be stripped of their anonymity and dragged into court to defend themselves and their online statements," he said.

Protecting Your Online Reputation

In the meantime, there are steps that can be taken to protect one’s reputation and perform some damage control in the face of damaging statements made online.

In some cases, a site will remove a post upon request, particularly if there is no evidence the person who posted the comment is a patient. Dr. Smith gave an example of someone who did not like his billboard advertisement and posted a negative comment.

Dr. Clifford W. Lober of the dermatology and cutaneous surgery department at the University of South Florida, Tampa, added that in almost a third of cases, a site will agree to remove posts upon request, particularly if the person who posts a comment violates a site rule (such as using obscenities).

Using a notification system, such as Google Alerts, can also help physicians stay abreast of negative information. Steps can be taken – by using search engine optimization techniques, for example – to suppress such negative information by "burying" it under positive posts, Dr. Smith said.

By developing a deep social network, issuing press releases, and asking satisfied patients to post their own reviews, negative information can be buried; studies show that most Web users don’t look past the first few pages of an Internet search, according to Dr. Lober, who is also an attorney.

Using services such as www.drscore.com can also help. DrScore.com, a service run by a North Carolina dermatologist, does not allow anonymous posting. Instead, patients are invited to offer comments, which are sent only to the doctor, not posted online. Unhappy patients may provide useful feedback, and since they are given the opportunity to do so, they may be less likely to go to the trouble of posting comments or ratings elsewhere online, Dr. Smith said.

Seeking help through one of the emerging reputation-management sites or seeking legal remedies are also options, as is posting responses on the offending sites – some of which allow doctors to create a free account to reply or request that a post be removed. However, it is important to consider the additional attention that can be brought to negative reviews by taking such actions, he said.

Dr. Lober had no disclosures. Dr. Smith disclosed having no relevant disclosures.

BOCA RATON, FLA. – There’s good news and bad news when it comes to doctor-bashing websites that can destroy a reputation that has taken years to build, according to Dr. Kevin C. Smith.

The bad news is that the sites aren’t going away. The good news is that they don’t appear to be lucrative. Site views are declining, "rate the rating sites" are emerging, and laws that may help protect victims of anonymous doctor-bashing posts are evolving, Dr. Smith, a dermatologist in private practice in Niagara Falls, Ontario, said at the Annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

One site, www.ratemds.com, had a value estimation of nearly $75,000 in February 2010 but was valued at under $65,500 in February 2011 by an online resource, which showed that page views over that time period declined from about 150,000 page views/month to about 90,000/month. Three other well-known sites have current estimated values of only $10,820 (www.doctorscorecard.com), $8,447 (www.healthcarereviews.com), and $2,992 (www.mydochub.com), based on their number of page views, he said.

"These things have very little value," he said, noting that the decline in page views is likely a result of consumers becoming more savvy and knowing that in many cases "something just isn’t right" about a lot of the sites.

Sites that rate rating sites could also be useful for patients. One such website, Informed Patient Institute (www.informedpatientinstitute.org), grades sites and provides a "What we like" and "What we don’t like" section that spells out the pros and cons of a given site.

Current Law

Under current U.S. law, website owners cannot be held liable for comments posted on their sites; the right to speak anonymously both in print and online is constitutionally protected free speech, Dr. Smith said.

Courtesy of www.mydochub.com

In Canada, the rules governing online defamation differ from U.S. laws because they make no distinction between libel published in a newspaper or online. Canadian laws hold both the individual who authors the statements and the individual who arranged for its publication or republication responsible. Doctors in Canada have "unmasked people making false statements ... and caused them enormous amounts of trouble," he noted.

Furthermore, according to at least one Canadian legal expert, courts there would have jurisdiction in cases in which a libelous statement about a Canadian citizen was made on a U.S. website, he said.

He predicted that U.S. and Canadian laws will "eventually converge."

"Patients and others who post ill-considered or defamatory comments about physicians on the Internet may feel like they are ‘getting away with it’ ... but they might feel differently and use better judgment if they were aware that the laws regarding anonymous online defamation are evolving; and they may, in the not-too-distant future, be stripped of their anonymity and dragged into court to defend themselves and their online statements," he said.

Protecting Your Online Reputation

In the meantime, there are steps that can be taken to protect one’s reputation and perform some damage control in the face of damaging statements made online.

In some cases, a site will remove a post upon request, particularly if there is no evidence the person who posted the comment is a patient. Dr. Smith gave an example of someone who did not like his billboard advertisement and posted a negative comment.

Dr. Clifford W. Lober of the dermatology and cutaneous surgery department at the University of South Florida, Tampa, added that in almost a third of cases, a site will agree to remove posts upon request, particularly if the person who posts a comment violates a site rule (such as using obscenities).

Using a notification system, such as Google Alerts, can also help physicians stay abreast of negative information. Steps can be taken – by using search engine optimization techniques, for example – to suppress such negative information by "burying" it under positive posts, Dr. Smith said.

By developing a deep social network, issuing press releases, and asking satisfied patients to post their own reviews, negative information can be buried; studies show that most Web users don’t look past the first few pages of an Internet search, according to Dr. Lober, who is also an attorney.

Using services such as www.drscore.com can also help. DrScore.com, a service run by a North Carolina dermatologist, does not allow anonymous posting. Instead, patients are invited to offer comments, which are sent only to the doctor, not posted online. Unhappy patients may provide useful feedback, and since they are given the opportunity to do so, they may be less likely to go to the trouble of posting comments or ratings elsewhere online, Dr. Smith said.

Seeking help through one of the emerging reputation-management sites or seeking legal remedies are also options, as is posting responses on the offending sites – some of which allow doctors to create a free account to reply or request that a post be removed. However, it is important to consider the additional attention that can be brought to negative reviews by taking such actions, he said.

Dr. Lober had no disclosures. Dr. Smith disclosed having no relevant disclosures.

BOCA RATON, FLA. – There’s good news and bad news when it comes to doctor-bashing websites that can destroy a reputation that has taken years to build, according to Dr. Kevin C. Smith.

The bad news is that the sites aren’t going away. The good news is that they don’t appear to be lucrative. Site views are declining, "rate the rating sites" are emerging, and laws that may help protect victims of anonymous doctor-bashing posts are evolving, Dr. Smith, a dermatologist in private practice in Niagara Falls, Ontario, said at the Annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

One site, www.ratemds.com, had a value estimation of nearly $75,000 in February 2010 but was valued at under $65,500 in February 2011 by an online resource, which showed that page views over that time period declined from about 150,000 page views/month to about 90,000/month. Three other well-known sites have current estimated values of only $10,820 (www.doctorscorecard.com), $8,447 (www.healthcarereviews.com), and $2,992 (www.mydochub.com), based on their number of page views, he said.

"These things have very little value," he said, noting that the decline in page views is likely a result of consumers becoming more savvy and knowing that in many cases "something just isn’t right" about a lot of the sites.

Sites that rate rating sites could also be useful for patients. One such website, Informed Patient Institute (www.informedpatientinstitute.org), grades sites and provides a "What we like" and "What we don’t like" section that spells out the pros and cons of a given site.

Current Law

Under current U.S. law, website owners cannot be held liable for comments posted on their sites; the right to speak anonymously both in print and online is constitutionally protected free speech, Dr. Smith said.

Courtesy of www.mydochub.com

In Canada, the rules governing online defamation differ from U.S. laws because they make no distinction between libel published in a newspaper or online. Canadian laws hold both the individual who authors the statements and the individual who arranged for its publication or republication responsible. Doctors in Canada have "unmasked people making false statements ... and caused them enormous amounts of trouble," he noted.

Furthermore, according to at least one Canadian legal expert, courts there would have jurisdiction in cases in which a libelous statement about a Canadian citizen was made on a U.S. website, he said.

He predicted that U.S. and Canadian laws will "eventually converge."

"Patients and others who post ill-considered or defamatory comments about physicians on the Internet may feel like they are ‘getting away with it’ ... but they might feel differently and use better judgment if they were aware that the laws regarding anonymous online defamation are evolving; and they may, in the not-too-distant future, be stripped of their anonymity and dragged into court to defend themselves and their online statements," he said.

Protecting Your Online Reputation

In the meantime, there are steps that can be taken to protect one’s reputation and perform some damage control in the face of damaging statements made online.

In some cases, a site will remove a post upon request, particularly if there is no evidence the person who posted the comment is a patient. Dr. Smith gave an example of someone who did not like his billboard advertisement and posted a negative comment.

Dr. Clifford W. Lober of the dermatology and cutaneous surgery department at the University of South Florida, Tampa, added that in almost a third of cases, a site will agree to remove posts upon request, particularly if the person who posts a comment violates a site rule (such as using obscenities).

Using a notification system, such as Google Alerts, can also help physicians stay abreast of negative information. Steps can be taken – by using search engine optimization techniques, for example – to suppress such negative information by "burying" it under positive posts, Dr. Smith said.

By developing a deep social network, issuing press releases, and asking satisfied patients to post their own reviews, negative information can be buried; studies show that most Web users don’t look past the first few pages of an Internet search, according to Dr. Lober, who is also an attorney.

Using services such as www.drscore.com can also help. DrScore.com, a service run by a North Carolina dermatologist, does not allow anonymous posting. Instead, patients are invited to offer comments, which are sent only to the doctor, not posted online. Unhappy patients may provide useful feedback, and since they are given the opportunity to do so, they may be less likely to go to the trouble of posting comments or ratings elsewhere online, Dr. Smith said.

Seeking help through one of the emerging reputation-management sites or seeking legal remedies are also options, as is posting responses on the offending sites – some of which allow doctors to create a free account to reply or request that a post be removed. However, it is important to consider the additional attention that can be brought to negative reviews by taking such actions, he said.

Dr. Lober had no disclosures. Dr. Smith disclosed having no relevant disclosures.

BOCA RATON, FLA. – There’s good news and bad news when it comes to doctor-bashing websites that can destroy a reputation that has taken years to build, according to Dr. Kevin C. Smith.

The bad news is that the sites aren’t going away. The good news is that they don’t appear to be lucrative. Site views are declining, "rate the rating sites" are emerging, and laws that may help protect victims of anonymous doctor-bashing posts are evolving, Dr. Smith, a dermatologist in private practice in Niagara Falls, Ontario, said at the Annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

One site, www.ratemds.com, had a value estimation of nearly $75,000 in February 2010 but was valued at under $65,500 in February 2011 by an online resource, which showed that page views over that time period declined from about 150,000 page views/month to about 90,000/month. Three other well-known sites have current estimated values of only $10,820 (www.doctorscorecard.com), $8,447 (www.healthcarereviews.com), and $2,992 (www.mydochub.com), based on their number of page views, he said.

"These things have very little value," he said, noting that the decline in page views is likely a result of consumers becoming more savvy and knowing that in many cases "something just isn’t right" about a lot of the sites.

Sites that rate rating sites could also be useful for patients. One such website, Informed Patient Institute (www.informedpatientinstitute.org), grades sites and provides a "What we like" and "What we don’t like" section that spells out the pros and cons of a given site.

Current Law

Under current U.S. law, website owners cannot be held liable for comments posted on their sites; the right to speak anonymously both in print and online is constitutionally protected free speech, Dr. Smith said.

Courtesy of www.mydochub.com

In Canada, the rules governing online defamation differ from U.S. laws because they make no distinction between libel published in a newspaper or online. Canadian laws hold both the individual who authors the statements and the individual who arranged for its publication or republication responsible. Doctors in Canada have "unmasked people making false statements ... and caused them enormous amounts of trouble," he noted.

Furthermore, according to at least one Canadian legal expert, courts there would have jurisdiction in cases in which a libelous statement about a Canadian citizen was made on a U.S. website, he said.

He predicted that U.S. and Canadian laws will "eventually converge."

"Patients and others who post ill-considered or defamatory comments about physicians on the Internet may feel like they are ‘getting away with it’ ... but they might feel differently and use better judgment if they were aware that the laws regarding anonymous online defamation are evolving; and they may, in the not-too-distant future, be stripped of their anonymity and dragged into court to defend themselves and their online statements," he said.

Protecting Your Online Reputation

In the meantime, there are steps that can be taken to protect one’s reputation and perform some damage control in the face of damaging statements made online.

In some cases, a site will remove a post upon request, particularly if there is no evidence the person who posted the comment is a patient. Dr. Smith gave an example of someone who did not like his billboard advertisement and posted a negative comment.

Dr. Clifford W. Lober of the dermatology and cutaneous surgery department at the University of South Florida, Tampa, added that in almost a third of cases, a site will agree to remove posts upon request, particularly if the person who posts a comment violates a site rule (such as using obscenities).

Using a notification system, such as Google Alerts, can also help physicians stay abreast of negative information. Steps can be taken – by using search engine optimization techniques, for example – to suppress such negative information by "burying" it under positive posts, Dr. Smith said.

By developing a deep social network, issuing press releases, and asking satisfied patients to post their own reviews, negative information can be buried; studies show that most Web users don’t look past the first few pages of an Internet search, according to Dr. Lober, who is also an attorney.

Using services such as www.drscore.com can also help. DrScore.com, a service run by a North Carolina dermatologist, does not allow anonymous posting. Instead, patients are invited to offer comments, which are sent only to the doctor, not posted online. Unhappy patients may provide useful feedback, and since they are given the opportunity to do so, they may be less likely to go to the trouble of posting comments or ratings elsewhere online, Dr. Smith said.

Seeking help through one of the emerging reputation-management sites or seeking legal remedies are also options, as is posting responses on the offending sites – some of which allow doctors to create a free account to reply or request that a post be removed. However, it is important to consider the additional attention that can be brought to negative reviews by taking such actions, he said.

Dr. Lober had no disclosures. Dr. Smith disclosed having no relevant disclosures.

BOCA RATON, FLA. – There’s good news and bad news when it comes to doctor-bashing websites that can destroy a reputation that has taken years to build, according to Dr. Kevin C. Smith.

The bad news is that the sites aren’t going away. The good news is that they don’t appear to be lucrative. Site views are declining, "rate the rating sites" are emerging, and laws that may help protect victims of anonymous doctor-bashing posts are evolving, Dr. Smith, a dermatologist in private practice in Niagara Falls, Ontario, said at the Annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

One site, www.ratemds.com, had a value estimation of nearly $75,000 in February 2010 but was valued at under $65,500 in February 2011 by an online resource, which showed that page views over that time period declined from about 150,000 page views/month to about 90,000/month. Three other well-known sites have current estimated values of only $10,820 (www.doctorscorecard.com), $8,447 (www.healthcarereviews.com), and $2,992 (www.mydochub.com), based on their number of page views, he said.

"These things have very little value," he said, noting that the decline in page views is likely a result of consumers becoming more savvy and knowing that in many cases "something just isn’t right" about a lot of the sites.

Sites that rate rating sites could also be useful for patients. One such website, Informed Patient Institute (www.informedpatientinstitute.org), grades sites and provides a "What we like" and "What we don’t like" section that spells out the pros and cons of a given site.

Current Law

Under current U.S. law, website owners cannot be held liable for comments posted on their sites; the right to speak anonymously both in print and online is constitutionally protected free speech, Dr. Smith said.

Courtesy of www.mydochub.com

In Canada, the rules governing online defamation differ from U.S. laws because they make no distinction between libel published in a newspaper or online. Canadian laws hold both the individual who authors the statements and the individual who arranged for its publication or republication responsible. Doctors in Canada have "unmasked people making false statements ... and caused them enormous amounts of trouble," he noted.

Furthermore, according to at least one Canadian legal expert, courts there would have jurisdiction in cases in which a libelous statement about a Canadian citizen was made on a U.S. website, he said.

He predicted that U.S. and Canadian laws will "eventually converge."

"Patients and others who post ill-considered or defamatory comments about physicians on the Internet may feel like they are ‘getting away with it’ ... but they might feel differently and use better judgment if they were aware that the laws regarding anonymous online defamation are evolving; and they may, in the not-too-distant future, be stripped of their anonymity and dragged into court to defend themselves and their online statements," he said.

Protecting Your Online Reputation

In the meantime, there are steps that can be taken to protect one’s reputation and perform some damage control in the face of damaging statements made online.

In some cases, a site will remove a post upon request, particularly if there is no evidence the person who posted the comment is a patient. Dr. Smith gave an example of someone who did not like his billboard advertisement and posted a negative comment.

Dr. Clifford W. Lober of the dermatology and cutaneous surgery department at the University of South Florida, Tampa, added that in almost a third of cases, a site will agree to remove posts upon request, particularly if the person who posts a comment violates a site rule (such as using obscenities).

Using a notification system, such as Google Alerts, can also help physicians stay abreast of negative information. Steps can be taken – by using search engine optimization techniques, for example – to suppress such negative information by "burying" it under positive posts, Dr. Smith said.

By developing a deep social network, issuing press releases, and asking satisfied patients to post their own reviews, negative information can be buried; studies show that most Web users don’t look past the first few pages of an Internet search, according to Dr. Lober, who is also an attorney.

Using services such as www.drscore.com can also help. DrScore.com, a service run by a North Carolina dermatologist, does not allow anonymous posting. Instead, patients are invited to offer comments, which are sent only to the doctor, not posted online. Unhappy patients may provide useful feedback, and since they are given the opportunity to do so, they may be less likely to go to the trouble of posting comments or ratings elsewhere online, Dr. Smith said.

Seeking help through one of the emerging reputation-management sites or seeking legal remedies are also options, as is posting responses on the offending sites – some of which allow doctors to create a free account to reply or request that a post be removed. However, it is important to consider the additional attention that can be brought to negative reviews by taking such actions, he said.

Dr. Lober had no disclosures. Dr. Smith disclosed having no relevant disclosures.

BOCA RATON, FLA. – There’s good news and bad news when it comes to doctor-bashing websites that can destroy a reputation that has taken years to build, according to Dr. Kevin C. Smith.

The bad news is that the sites aren’t going away. The good news is that they don’t appear to be lucrative. Site views are declining, "rate the rating sites" are emerging, and laws that may help protect victims of anonymous doctor-bashing posts are evolving, Dr. Smith, a dermatologist in private practice in Niagara Falls, Ontario, said at the Annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

One site, www.ratemds.com, had a value estimation of nearly $75,000 in February 2010 but was valued at under $65,500 in February 2011 by an online resource, which showed that page views over that time period declined from about 150,000 page views/month to about 90,000/month. Three other well-known sites have current estimated values of only $10,820 (www.doctorscorecard.com), $8,447 (www.healthcarereviews.com), and $2,992 (www.mydochub.com), based on their number of page views, he said.

"These things have very little value," he said, noting that the decline in page views is likely a result of consumers becoming more savvy and knowing that in many cases "something just isn’t right" about a lot of the sites.

Sites that rate rating sites could also be useful for patients. One such website, Informed Patient Institute (www.informedpatientinstitute.org), grades sites and provides a "What we like" and "What we don’t like" section that spells out the pros and cons of a given site.

Current Law

Under current U.S. law, website owners cannot be held liable for comments posted on their sites; the right to speak anonymously both in print and online is constitutionally protected free speech, Dr. Smith said.

Courtesy of www.mydochub.com

In Canada, the rules governing online defamation differ from U.S. laws because they make no distinction between libel published in a newspaper or online. Canadian laws hold both the individual who authors the statements and the individual who arranged for its publication or republication responsible. Doctors in Canada have "unmasked people making false statements ... and caused them enormous amounts of trouble," he noted.

Furthermore, according to at least one Canadian legal expert, courts there would have jurisdiction in cases in which a libelous statement about a Canadian citizen was made on a U.S. website, he said.

He predicted that U.S. and Canadian laws will "eventually converge."

"Patients and others who post ill-considered or defamatory comments about physicians on the Internet may feel like they are ‘getting away with it’ ... but they might feel differently and use better judgment if they were aware that the laws regarding anonymous online defamation are evolving; and they may, in the not-too-distant future, be stripped of their anonymity and dragged into court to defend themselves and their online statements," he said.

Protecting Your Online Reputation

In the meantime, there are steps that can be taken to protect one’s reputation and perform some damage control in the face of damaging statements made online.

In some cases, a site will remove a post upon request, particularly if there is no evidence the person who posted the comment is a patient. Dr. Smith gave an example of someone who did not like his billboard advertisement and posted a negative comment.

Dr. Clifford W. Lober of the dermatology and cutaneous surgery department at the University of South Florida, Tampa, added that in almost a third of cases, a site will agree to remove posts upon request, particularly if the person who posts a comment violates a site rule (such as using obscenities).

Using a notification system, such as Google Alerts, can also help physicians stay abreast of negative information. Steps can be taken – by using search engine optimization techniques, for example – to suppress such negative information by "burying" it under positive posts, Dr. Smith said.

By developing a deep social network, issuing press releases, and asking satisfied patients to post their own reviews, negative information can be buried; studies show that most Web users don’t look past the first few pages of an Internet search, according to Dr. Lober, who is also an attorney.

Using services such as www.drscore.com can also help. DrScore.com, a service run by a North Carolina dermatologist, does not allow anonymous posting. Instead, patients are invited to offer comments, which are sent only to the doctor, not posted online. Unhappy patients may provide useful feedback, and since they are given the opportunity to do so, they may be less likely to go to the trouble of posting comments or ratings elsewhere online, Dr. Smith said.

Seeking help through one of the emerging reputation-management sites or seeking legal remedies are also options, as is posting responses on the offending sites – some of which allow doctors to create a free account to reply or request that a post be removed. However, it is important to consider the additional attention that can be brought to negative reviews by taking such actions, he said.

Dr. Lober had no disclosures. Dr. Smith disclosed having no relevant disclosures.

BOCA RATON, FLA. – There’s good news and bad news when it comes to doctor-bashing websites that can destroy a reputation that has taken years to build, according to Dr. Kevin C. Smith.

The bad news is that the sites aren’t going away. The good news is that they don’t appear to be lucrative. Site views are declining, "rate the rating sites" are emerging, and laws that may help protect victims of anonymous doctor-bashing posts are evolving, Dr. Smith, a dermatologist in private practice in Niagara Falls, Ontario, said at the Annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

One site, www.ratemds.com, had a value estimation of nearly $75,000 in February 2010 but was valued at under $65,500 in February 2011 by an online resource, which showed that page views over that time period declined from about 150,000 page views/month to about 90,000/month. Three other well-known sites have current estimated values of only $10,820 (www.doctorscorecard.com), $8,447 (www.healthcarereviews.com), and $2,992 (www.mydochub.com), based on their number of page views, he said.

"These things have very little value," he said, noting that the decline in page views is likely a result of consumers becoming more savvy and knowing that in many cases "something just isn’t right" about a lot of the sites.

Sites that rate rating sites could also be useful for patients. One such website, Informed Patient Institute (www.informedpatientinstitute.org), grades sites and provides a "What we like" and "What we don’t like" section that spells out the pros and cons of a given site.

Current Law

Under current U.S. law, website owners cannot be held liable for comments posted on their sites; the right to speak anonymously both in print and online is constitutionally protected free speech, Dr. Smith said.

Courtesy of www.mydochub.com

In Canada, the rules governing online defamation differ from U.S. laws because they make no distinction between libel published in a newspaper or online. Canadian laws hold both the individual who authors the statements and the individual who arranged for its publication or republication responsible. Doctors in Canada have "unmasked people making false statements ... and caused them enormous amounts of trouble," he noted.

Furthermore, according to at least one Canadian legal expert, courts there would have jurisdiction in cases in which a libelous statement about a Canadian citizen was made on a U.S. website, he said.

He predicted that U.S. and Canadian laws will "eventually converge."

"Patients and others who post ill-considered or defamatory comments about physicians on the Internet may feel like they are ‘getting away with it’ ... but they might feel differently and use better judgment if they were aware that the laws regarding anonymous online defamation are evolving; and they may, in the not-too-distant future, be stripped of their anonymity and dragged into court to defend themselves and their online statements," he said.

Protecting Your Online Reputation

In the meantime, there are steps that can be taken to protect one’s reputation and perform some damage control in the face of damaging statements made online.

In some cases, a site will remove a post upon request, particularly if there is no evidence the person who posted the comment is a patient. Dr. Smith gave an example of someone who did not like his billboard advertisement and posted a negative comment.

Dr. Clifford W. Lober of the dermatology and cutaneous surgery department at the University of South Florida, Tampa, added that in almost a third of cases, a site will agree to remove posts upon request, particularly if the person who posts a comment violates a site rule (such as using obscenities).

Using a notification system, such as Google Alerts, can also help physicians stay abreast of negative information. Steps can be taken – by using search engine optimization techniques, for example – to suppress such negative information by "burying" it under positive posts, Dr. Smith said.

By developing a deep social network, issuing press releases, and asking satisfied patients to post their own reviews, negative information can be buried; studies show that most Web users don’t look past the first few pages of an Internet search, according to Dr. Lober, who is also an attorney.

Using services such as www.drscore.com can also help. DrScore.com, a service run by a North Carolina dermatologist, does not allow anonymous posting. Instead, patients are invited to offer comments, which are sent only to the doctor, not posted online. Unhappy patients may provide useful feedback, and since they are given the opportunity to do so, they may be less likely to go to the trouble of posting comments or ratings elsewhere online, Dr. Smith said.

Seeking help through one of the emerging reputation-management sites or seeking legal remedies are also options, as is posting responses on the offending sites – some of which allow doctors to create a free account to reply or request that a post be removed. However, it is important to consider the additional attention that can be brought to negative reviews by taking such actions, he said.

Dr. Lober had no disclosures. Dr. Smith disclosed having no relevant disclosures.

BOCA RATON, FLA. – There’s good news and bad news when it comes to doctor-bashing websites that can destroy a reputation that has taken years to build, according to Dr. Kevin C. Smith.

The bad news is that the sites aren’t going away. The good news is that they don’t appear to be lucrative. Site views are declining, "rate the rating sites" are emerging, and laws that may help protect victims of anonymous doctor-bashing posts are evolving, Dr. Smith, a dermatologist in private practice in Niagara Falls, Ontario, said at the Annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

One site, www.ratemds.com, had a value estimation of nearly $75,000 in February 2010 but was valued at under $65,500 in February 2011 by an online resource, which showed that page views over that time period declined from about 150,000 page views/month to about 90,000/month. Three other well-known sites have current estimated values of only $10,820 (www.doctorscorecard.com), $8,447 (www.healthcarereviews.com), and $2,992 (www.mydochub.com), based on their number of page views, he said.

"These things have very little value," he said, noting that the decline in page views is likely a result of consumers becoming more savvy and knowing that in many cases "something just isn’t right" about a lot of the sites.

Sites that rate rating sites could also be useful for patients. One such website, Informed Patient Institute (www.informedpatientinstitute.org), grades sites and provides a "What we like" and "What we don’t like" section that spells out the pros and cons of a given site.

Current Law

Under current U.S. law, website owners cannot be held liable for comments posted on their sites; the right to speak anonymously both in print and online is constitutionally protected free speech, Dr. Smith said.

Courtesy of www.mydochub.com

In Canada, the rules governing online defamation differ from U.S. laws because they make no distinction between libel published in a newspaper or online. Canadian laws hold both the individual who authors the statements and the individual who arranged for its publication or republication responsible. Doctors in Canada have "unmasked people making false statements ... and caused them enormous amounts of trouble," he noted.

Furthermore, according to at least one Canadian legal expert, courts there would have jurisdiction in cases in which a libelous statement about a Canadian citizen was made on a U.S. website, he said.

He predicted that U.S. and Canadian laws will "eventually converge."

"Patients and others who post ill-considered or defamatory comments about physicians on the Internet may feel like they are ‘getting away with it’ ... but they might feel differently and use better judgment if they were aware that the laws regarding anonymous online defamation are evolving; and they may, in the not-too-distant future, be stripped of their anonymity and dragged into court to defend themselves and their online statements," he said.

Protecting Your Online Reputation

In the meantime, there are steps that can be taken to protect one’s reputation and perform some damage control in the face of damaging statements made online.

In some cases, a site will remove a post upon request, particularly if there is no evidence the person who posted the comment is a patient. Dr. Smith gave an example of someone who did not like his billboard advertisement and posted a negative comment.

Dr. Clifford W. Lober of the dermatology and cutaneous surgery department at the University of South Florida, Tampa, added that in almost a third of cases, a site will agree to remove posts upon request, particularly if the person who posts a comment violates a site rule (such as using obscenities).

Using a notification system, such as Google Alerts, can also help physicians stay abreast of negative information. Steps can be taken – by using search engine optimization techniques, for example – to suppress such negative information by "burying" it under positive posts, Dr. Smith said.

By developing a deep social network, issuing press releases, and asking satisfied patients to post their own reviews, negative information can be buried; studies show that most Web users don’t look past the first few pages of an Internet search, according to Dr. Lober, who is also an attorney.

Using services such as www.drscore.com can also help. DrScore.com, a service run by a North Carolina dermatologist, does not allow anonymous posting. Instead, patients are invited to offer comments, which are sent only to the doctor, not posted online. Unhappy patients may provide useful feedback, and since they are given the opportunity to do so, they may be less likely to go to the trouble of posting comments or ratings elsewhere online, Dr. Smith said.

Seeking help through one of the emerging reputation-management sites or seeking legal remedies are also options, as is posting responses on the offending sites – some of which allow doctors to create a free account to reply or request that a post be removed. However, it is important to consider the additional attention that can be brought to negative reviews by taking such actions, he said.

Dr. Lober had no disclosures. Dr. Smith disclosed having no relevant disclosures.

BOCA RATON, FLA. – There’s good news and bad news when it comes to doctor-bashing websites that can destroy a reputation that has taken years to build, according to Dr. Kevin C. Smith.

The bad news is that the sites aren’t going away. The good news is that they don’t appear to be lucrative. Site views are declining, "rate the rating sites" are emerging, and laws that may help protect victims of anonymous doctor-bashing posts are evolving, Dr. Smith, a dermatologist in private practice in Niagara Falls, Ontario, said at the Annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

One site, www.ratemds.com, had a value estimation of nearly $75,000 in February 2010 but was valued at under $65,500 in February 2011 by an online resource, which showed that page views over that time period declined from about 150,000 page views/month to about 90,000/month. Three other well-known sites have current estimated values of only $10,820 (www.doctorscorecard.com), $8,447 (www.healthcarereviews.com), and $2,992 (www.mydochub.com), based on their number of page views, he said.

"These things have very little value," he said, noting that the decline in page views is likely a result of consumers becoming more savvy and knowing that in many cases "something just isn’t right" about a lot of the sites.

Sites that rate rating sites could also be useful for patients. One such website, Informed Patient Institute (www.informedpatientinstitute.org), grades sites and provides a "What we like" and "What we don’t like" section that spells out the pros and cons of a given site.

Current Law

Under current U.S. law, website owners cannot be held liable for comments posted on their sites; the right to speak anonymously both in print and online is constitutionally protected free speech, Dr. Smith said.

Courtesy of www.mydochub.com

In Canada, the rules governing online defamation differ from U.S. laws because they make no distinction between libel published in a newspaper or online. Canadian laws hold both the individual who authors the statements and the individual who arranged for its publication or republication responsible. Doctors in Canada have "unmasked people making false statements ... and caused them enormous amounts of trouble," he noted.

Furthermore, according to at least one Canadian legal expert, courts there would have jurisdiction in cases in which a libelous statement about a Canadian citizen was made on a U.S. website, he said.

He predicted that U.S. and Canadian laws will "eventually converge."

"Patients and others who post ill-considered or defamatory comments about physicians on the Internet may feel like they are ‘getting away with it’ ... but they might feel differently and use better judgment if they were aware that the laws regarding anonymous online defamation are evolving; and they may, in the not-too-distant future, be stripped of their anonymity and dragged into court to defend themselves and their online statements," he said.

Protecting Your Online Reputation

In the meantime, there are steps that can be taken to protect one’s reputation and perform some damage control in the face of damaging statements made online.

In some cases, a site will remove a post upon request, particularly if there is no evidence the person who posted the comment is a patient. Dr. Smith gave an example of someone who did not like his billboard advertisement and posted a negative comment.

Dr. Clifford W. Lober of the dermatology and cutaneous surgery department at the University of South Florida, Tampa, added that in almost a third of cases, a site will agree to remove posts upon request, particularly if the person who posts a comment violates a site rule (such as using obscenities).

Using a notification system, such as Google Alerts, can also help physicians stay abreast of negative information. Steps can be taken – by using search engine optimization techniques, for example – to suppress such negative information by "burying" it under positive posts, Dr. Smith said.

By developing a deep social network, issuing press releases, and asking satisfied patients to post their own reviews, negative information can be buried; studies show that most Web users don’t look past the first few pages of an Internet search, according to Dr. Lober, who is also an attorney.

Using services such as www.drscore.com can also help. DrScore.com, a service run by a North Carolina dermatologist, does not allow anonymous posting. Instead, patients are invited to offer comments, which are sent only to the doctor, not posted online. Unhappy patients may provide useful feedback, and since they are given the opportunity to do so, they may be less likely to go to the trouble of posting comments or ratings elsewhere online, Dr. Smith said.

Seeking help through one of the emerging reputation-management sites or seeking legal remedies are also options, as is posting responses on the offending sites – some of which allow doctors to create a free account to reply or request that a post be removed. However, it is important to consider the additional attention that can be brought to negative reviews by taking such actions, he said.

Dr. Lober had no disclosures. Dr. Smith disclosed having no relevant disclosures.

BOCA RATON, FLA. – There’s good news and bad news when it comes to doctor-bashing websites that can destroy a reputation that has taken years to build, according to Dr. Kevin C. Smith.

The bad news is that the sites aren’t going away. The good news is that they don’t appear to be lucrative. Site views are declining, "rate the rating sites" are emerging, and laws that may help protect victims of anonymous doctor-bashing posts are evolving, Dr. Smith, a dermatologist in private practice in Niagara Falls, Ontario, said at the Annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

One site, www.ratemds.com, had a value estimation of nearly $75,000 in February 2010 but was valued at under $65,500 in February 2011 by an online resource, which showed that page views over that time period declined from about 150,000 page views/month to about 90,000/month. Three other well-known sites have current estimated values of only $10,820 (www.doctorscorecard.com), $8,447 (www.healthcarereviews.com), and $2,992 (www.mydochub.com), based on their number of page views, he said.

"These things have very little value," he said, noting that the decline in page views is likely a result of consumers becoming more savvy and knowing that in many cases "something just isn’t right" about a lot of the sites.

Sites that rate rating sites could also be useful for patients. One such website, Informed Patient Institute (www.informedpatientinstitute.org), grades sites and provides a "What we like" and "What we don’t like" section that spells out the pros and cons of a given site.

Current Law

Under current U.S. law, website owners cannot be held liable for comments posted on their sites; the right to speak anonymously both in print and online is constitutionally protected free speech, Dr. Smith said.

Courtesy of www.mydochub.com

In Canada, the rules governing online defamation differ from U.S. laws because they make no distinction between libel published in a newspaper or online. Canadian laws hold both the individual who authors the statements and the individual who arranged for its publication or republication responsible. Doctors in Canada have "unmasked people making false statements ... and caused them enormous amounts of trouble," he noted.

Furthermore, according to at least one Canadian legal expert, courts there would have jurisdiction in cases in which a libelous statement about a Canadian citizen was made on a U.S. website, he said.

He predicted that U.S. and Canadian laws will "eventually converge."

"Patients and others who post ill-considered or defamatory comments about physicians on the Internet may feel like they are ‘getting away with it’ ... but they might feel differently and use better judgment if they were aware that the laws regarding anonymous online defamation are evolving; and they may, in the not-too-distant future, be stripped of their anonymity and dragged into court to defend themselves and their online statements," he said.

Protecting Your Online Reputation

In the meantime, there are steps that can be taken to protect one’s reputation and perform some damage control in the face of damaging statements made online.

In some cases, a site will remove a post upon request, particularly if there is no evidence the person who posted the comment is a patient. Dr. Smith gave an example of someone who did not like his billboard advertisement and posted a negative comment.

Dr. Clifford W. Lober of the dermatology and cutaneous surgery department at the University of South Florida, Tampa, added that in almost a third of cases, a site will agree to remove posts upon request, particularly if the person who posts a comment violates a site rule (such as using obscenities).

Using a notification system, such as Google Alerts, can also help physicians stay abreast of negative information. Steps can be taken – by using search engine optimization techniques, for example – to suppress such negative information by "burying" it under positive posts, Dr. Smith said.

By developing a deep social network, issuing press releases, and asking satisfied patients to post their own reviews, negative information can be buried; studies show that most Web users don’t look past the first few pages of an Internet search, according to Dr. Lober, who is also an attorney.

Using services such as www.drscore.com can also help. DrScore.com, a service run by a North Carolina dermatologist, does not allow anonymous posting. Instead, patients are invited to offer comments, which are sent only to the doctor, not posted online. Unhappy patients may provide useful feedback, and since they are given the opportunity to do so, they may be less likely to go to the trouble of posting comments or ratings elsewhere online, Dr. Smith said.

Seeking help through one of the emerging reputation-management sites or seeking legal remedies are also options, as is posting responses on the offending sites – some of which allow doctors to create a free account to reply or request that a post be removed. However, it is important to consider the additional attention that can be brought to negative reviews by taking such actions, he said.

Dr. Lober had no disclosures. Dr. Smith disclosed having no relevant disclosures.

BOCA RATON, FLA. – There’s good news and bad news when it comes to doctor-bashing websites that can destroy a reputation that has taken years to build, according to Dr. Kevin C. Smith.

The bad news is that the sites aren’t going away. The good news is that they don’t appear to be lucrative. Site views are declining, "rate the rating sites" are emerging, and laws that may help protect victims of anonymous doctor-bashing posts are evolving, Dr. Smith, a dermatologist in private practice in Niagara Falls, Ontario, said at the Annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

One site, www.ratemds.com, had a value estimation of nearly $75,000 in February 2010 but was valued at under $65,500 in February 2011 by an online resource, which showed that page views over that time period declined from about 150,000 page views/month to about 90,000/month. Three other well-known sites have current estimated values of only $10,820 (www.doctorscorecard.com), $8,447 (www.healthcarereviews.com), and $2,992 (www.mydochub.com), based on their number of page views, he said.

"These things have very little value," he said, noting that the decline in page views is likely a result of consumers becoming more savvy and knowing that in many cases "something just isn’t right" about a lot of the sites.

Sites that rate rating sites could also be useful for patients. One such website, Informed Patient Institute (www.informedpatientinstitute.org), grades sites and provides a "What we like" and "What we don’t like" section that spells out the pros and cons of a given site.

Current Law

Under current U.S. law, website owners cannot be held liable for comments posted on their sites; the right to speak anonymously both in print and online is constitutionally protected free speech, Dr. Smith said.

Courtesy of www.mydochub.com

In Canada, the rules governing online defamation differ from U.S. laws because they make no distinction between libel published in a newspaper or online. Canadian laws hold both the individual who authors the statements and the individual who arranged for its publication or republication responsible. Doctors in Canada have "unmasked people making false statements ... and caused them enormous amounts of trouble," he noted.

Furthermore, according to at least one Canadian legal expert, courts there would have jurisdiction in cases in which a libelous statement about a Canadian citizen was made on a U.S. website, he said.

He predicted that U.S. and Canadian laws will "eventually converge."

"Patients and others who post ill-considered or defamatory comments about physicians on the Internet may feel like they are ‘getting away with it’ ... but they might feel differently and use better judgment if they were aware that the laws regarding anonymous online defamation are evolving; and they may, in the not-too-distant future, be stripped of their anonymity and dragged into court to defend themselves and their online statements," he said.

Protecting Your Online Reputation

In the meantime, there are steps that can be taken to protect one’s reputation and perform some damage control in the face of damaging statements made online.

In some cases, a site will remove a post upon request, particularly if there is no evidence the person who posted the comment is a patient. Dr. Smith gave an example of someone who did not like his billboard advertisement and posted a negative comment.

Dr. Clifford W. Lober of the dermatology and cutaneous surgery department at the University of South Florida, Tampa, added that in almost a third of cases, a site will agree to remove posts upon request, particularly if the person who posts a comment violates a site rule (such as using obscenities).

Using a notification system, such as Google Alerts, can also help physicians stay abreast of negative information. Steps can be taken – by using search engine optimization techniques, for example – to suppress such negative information by "burying" it under positive posts, Dr. Smith said.

By developing a deep social network, issuing press releases, and asking satisfied patients to post their own reviews, negative information can be buried; studies show that most Web users don’t look past the first few pages of an Internet search, according to Dr. Lober, who is also an attorney.

Using services such as www.drscore.com can also help. DrScore.com, a service run by a North Carolina dermatologist, does not allow anonymous posting. Instead, patients are invited to offer comments, which are sent only to the doctor, not posted online. Unhappy patients may provide useful feedback, and since they are given the opportunity to do so, they may be less likely to go to the trouble of posting comments or ratings elsewhere online, Dr. Smith said.

Seeking help through one of the emerging reputation-management sites or seeking legal remedies are also options, as is posting responses on the offending sites – some of which allow doctors to create a free account to reply or request that a post be removed. However, it is important to consider the additional attention that can be brought to negative reviews by taking such actions, he said.

Dr. Lober had no disclosures. Dr. Smith disclosed having no relevant disclosures.

BOCA RATON, FLA. – There’s good news and bad news when it comes to doctor-bashing websites that can destroy a reputation that has taken years to build, according to Dr. Kevin C. Smith.

The bad news is that the sites aren’t going away. The good news is that they don’t appear to be lucrative. Site views are declining, "rate the rating sites" are emerging, and laws that may help protect victims of anonymous doctor-bashing posts are evolving, Dr. Smith, a dermatologist in private practice in Niagara Falls, Ontario, said at the Annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

One site, www.ratemds.com, had a value estimation of nearly $75,000 in February 2010 but was valued at under $65,500 in February 2011 by an online resource, which showed that page views over that time period declined from about 150,000 page views/month to about 90,000/month. Three other well-known sites have current estimated values of only $10,820 (www.doctorscorecard.com), $8,447 (www.healthcarereviews.com), and $2,992 (www.mydochub.com), based on their number of page views, he said.

"These things have very little value," he said, noting that the decline in page views is likely a result of consumers becoming more savvy and knowing that in many cases "something just isn’t right" about a lot of the sites.

Sites that rate rating sites could also be useful for patients. One such website, Informed Patient Institute (www.informedpatientinstitute.org), grades sites and provides a "What we like" and "What we don’t like" section that spells out the pros and cons of a given site.

Current Law

Under current U.S. law, website owners cannot be held liable for comments posted on their sites; the right to speak anonymously both in print and online is constitutionally protected free speech, Dr. Smith said.

Courtesy of www.mydochub.com

In Canada, the rules governing online defamation differ from U.S. laws because they make no distinction between libel published in a newspaper or online. Canadian laws hold both the individual who authors the statements and the individual who arranged for its publication or republication responsible. Doctors in Canada have "unmasked people making false statements ... and caused them enormous amounts of trouble," he noted.

Furthermore, according to at least one Canadian legal expert, courts there would have jurisdiction in cases in which a libelous statement about a Canadian citizen was made on a U.S. website, he said.

He predicted that U.S. and Canadian laws will "eventually converge."

"Patients and others who post ill-considered or defamatory comments about physicians on the Internet may feel like they are ‘getting away with it’ ... but they might feel differently and use better judgment if they were aware that the laws regarding anonymous online defamation are evolving; and they may, in the not-too-distant future, be stripped of their anonymity and dragged into court to defend themselves and their online statements," he said.

Protecting Your Online Reputation

In the meantime, there are steps that can be taken to protect one’s reputation and perform some damage control in the face of damaging statements made online.

In some cases, a site will remove a post upon request, particularly if there is no evidence the person who posted the comment is a patient. Dr. Smith gave an example of someone who did not like his billboard advertisement and posted a negative comment.

Dr. Clifford W. Lober of the dermatology and cutaneous surgery department at the University of South Florida, Tampa, added that in almost a third of cases, a site will agree to remove posts upon request, particularly if the person who posts a comment violates a site rule (such as using obscenities).

Using a notification system, such as Google Alerts, can also help physicians stay abreast of negative information. Steps can be taken – by using search engine optimization techniques, for example – to suppress such negative information by "burying" it under positive posts, Dr. Smith said.

By developing a deep social network, issuing press releases, and asking satisfied patients to post their own reviews, negative information can be buried; studies show that most Web users don’t look past the first few pages of an Internet search, according to Dr. Lober, who is also an attorney.

Using services such as www.drscore.com can also help. DrScore.com, a service run by a North Carolina dermatologist, does not allow anonymous posting. Instead, patients are invited to offer comments, which are sent only to the doctor, not posted online. Unhappy patients may provide useful feedback, and since they are given the opportunity to do so, they may be less likely to go to the trouble of posting comments or ratings elsewhere online, Dr. Smith said.

Seeking help through one of the emerging reputation-management sites or seeking legal remedies are also options, as is posting responses on the offending sites – some of which allow doctors to create a free account to reply or request that a post be removed. However, it is important to consider the additional attention that can be brought to negative reviews by taking such actions, he said.

Dr. Lober had no disclosures. Dr. Smith disclosed having no relevant disclosures.

BOCA RATON, FLA. – Androgenetic alopecia is fairly common in the pediatric population, and in adolescent girls it should prompt an evaluation for hyperandrogenism, according to Dr. Seth J. Orlow.

Androgenetic alopecia is a presenting symptom of polycystic ovary syndrome (PCOS) in a considerable number of cases, he said at the meeting. “I think this is a place where we can really make a difference,” said Dr. Orlow, chair of dermatology and professor of pediatric dermatology, cell biology, and pediatrics at New York University.

One of the most useful lab tests in adolescent girls presenting with early androgenetic alopecia is free and total testosterone, which at elevated levels can serve as a marker for PCOS.

“In a girl who presents with early-onset androgenetic alopecia, think about early presentation of PCOS. It's definitely worth it to test them,” he said.

A chart review of 438 consecutive pediatric patients with alopecia seen by Dr. Orlow and his colleagues over a 12-year period underscored the importance of looking for this diagnosis, and illustrated other characteristics of androgenetic alopecia in both girls and boys. The study showed that androgenetic alopecia was the second most common type of alopecia (after alopecia areata, which accounted for 55% of cases), involving 13% of the cases overall.

Among the 123 adolescent patients, however, 42% (52 patients: 36 boys and 16 girls) had androgenetic alopecia, for a total of 38 boys and 19 girls with androgenetic alopecia among the 438 studied.

Female Findings

Of the 19 girls, 9 had hyperandrogenism. Three had clinical signs and six had biochemical signs of hyperandrogenism. Of the six with biochemical signs, three had elevated free and total testosterone levels, one had elevated free and total testosterone and elevated dihydroepiandrosterone sulfate, one had an elevated free testosterone level only, and one had an elevated total testosterone level only. Seven of the girls were oligomenorrheic, and two were premenarchal. Clinical signs other than the androgenetic alopecia included hirsutism in four girls, acne in six, and seborrheic dermatitis in two.

Other laboratory findings in the 19 girls with androgenetic alopecia included antithyroid antibodies in 1of 5 tested and low serum iron in 3 of 14 tested. None of the girls tested had abnormal thyroid function, iron deficiency anemia, or low testosterone levels, Dr. Orlow said.

The most common presentations in girls were diffuse scalp thinning and thinning at the crown, each occurring in 8 of the 19 patients. The remaining three girls presented with frontal thinning only.

Male Findings

Findings in the boys presenting with androgenetic alopecia included antithyroid antibodies in 1 of 7 tested, hyperandrogenemia in 2 of 14 tested, and low testosterone levels in 3 of 14 tested. None of the boys had abnormal thyroid function, low serum iron, or iron deficiency anemia.

A disproportionate number of boys (13 of the 38) presented with classic female pattern androgenetic alopecia with diffuse thinning of the crown. The remaining boys presented with bitemporal vertex thinning (18 boys), vertex only thinning (4 boys), or frontal and vertex thinning (3 boys), Dr. Orlow said.

Concomitant findings included acne in 32% of the girls and 50% of the boys, and seborrheic dermatitis in 37% of the girls and 16% of the boys. A family history of androgenetic alopecia was present in both, with 82% of the boys and 87% of the girls having an affected first- or second-degree relative.

Differential Diagnoses

It is important to consider possible differential diagnoses in patients presenting with what appears to be androgenetic alopecia. These include acute telogen effluvium, chronic telogen effluvium (particularly in girls), and diffuse alopecia areata, he said.

If the clinical diagnosis is unclear – in boys with female pattern hair loss, in girls with very young onset, or if the patient or parents have a great deal of anxiety about the diagnosis – a biopsy may be helpful, he said.

Of the 57 patients with androgenetic alopecia included in his chart review, 14 (5 girls and 9 boys) underwent biopsy; all of the biopsies showed typical features of androgenetic alopecia, including increased vellus/telogen hairs and connective tissue streamers/follicular stelae below small vellus follicles.

Eight of the 14 also had varying degrees of peri-infundibular lymphocytic inflammatory infiltrate and fibrosis.

Treatment

Treatment options for patients with androgenetic alopecia include minoxidil, finasteride (in boys), and spironolactone.

Minoxidil was used in 16 of the 19 girls; 4 of 6 with greater than 6 months of follow-up had stabilized at 1 year. One developed increased facial hair on treatment, which resolved with a switch from a 5% to a 2% formulation, Dr. Orlow said. Two patients discontinued treatment because of a lack of efficacy and/or headache and nausea.

In the boys, 36 of the 38 were treated with minoxidil, and 18 of 23 with at least 6 months of follow-up were stabilized. Two never started treatment and two discontinued for lack of efficacy and acne.

Finasteride was used in nine boys, including seven who also received minoxidil. In six boys, with at least 6 months of follow-up, all had better hair density (including four on concomitant minoxidil). One experienced sexual dysfunction, which resolved spontaneously, Dr. Orlow said.

“I did not treat – and would not treat girls [with finasteride], nor did I find any case reports of finasteride use in girls,” he said. There are a few case reports, however, of spironolactone being used in girls with some success.

The findings of the chart review (Br. J. Dermatol. 2010; 163:378-85) underscore the importance of understanding that alopecia is a common complaint in the pediatric population, that androgenetic alopecia is the most common form of hair loss in adolescents, and that it can be a presenting sign of an underlying endocrine disorder, said Dr. Orlow, who reported having no relevant financial disclosures.

Androgenetic alopecia is a presenting symptom of PCOS in a considerable number of cases.

Source DR. ORLOW

BOCA RATON, FLA. – Androgenetic alopecia is fairly common in the pediatric population, and in adolescent girls it should prompt an evaluation for hyperandrogenism, according to Dr. Seth J. Orlow.

Androgenetic alopecia is a presenting symptom of polycystic ovary syndrome (PCOS) in a considerable number of cases, he said at the meeting. “I think this is a place where we can really make a difference,” said Dr. Orlow, chair of dermatology and professor of pediatric dermatology, cell biology, and pediatrics at New York University.

One of the most useful lab tests in adolescent girls presenting with early androgenetic alopecia is free and total testosterone, which at elevated levels can serve as a marker for PCOS.

“In a girl who presents with early-onset androgenetic alopecia, think about early presentation of PCOS. It's definitely worth it to test them,” he said.

A chart review of 438 consecutive pediatric patients with alopecia seen by Dr. Orlow and his colleagues over a 12-year period underscored the importance of looking for this diagnosis, and illustrated other characteristics of androgenetic alopecia in both girls and boys. The study showed that androgenetic alopecia was the second most common type of alopecia (after alopecia areata, which accounted for 55% of cases), involving 13% of the cases overall.

Among the 123 adolescent patients, however, 42% (52 patients: 36 boys and 16 girls) had androgenetic alopecia, for a total of 38 boys and 19 girls with androgenetic alopecia among the 438 studied.

Female Findings

Of the 19 girls, 9 had hyperandrogenism. Three had clinical signs and six had biochemical signs of hyperandrogenism. Of the six with biochemical signs, three had elevated free and total testosterone levels, one had elevated free and total testosterone and elevated dihydroepiandrosterone sulfate, one had an elevated free testosterone level only, and one had an elevated total testosterone level only. Seven of the girls were oligomenorrheic, and two were premenarchal. Clinical signs other than the androgenetic alopecia included hirsutism in four girls, acne in six, and seborrheic dermatitis in two.

Other laboratory findings in the 19 girls with androgenetic alopecia included antithyroid antibodies in 1of 5 tested and low serum iron in 3 of 14 tested. None of the girls tested had abnormal thyroid function, iron deficiency anemia, or low testosterone levels, Dr. Orlow said.

The most common presentations in girls were diffuse scalp thinning and thinning at the crown, each occurring in 8 of the 19 patients. The remaining three girls presented with frontal thinning only.

Male Findings

Findings in the boys presenting with androgenetic alopecia included antithyroid antibodies in 1 of 7 tested, hyperandrogenemia in 2 of 14 tested, and low testosterone levels in 3 of 14 tested. None of the boys had abnormal thyroid function, low serum iron, or iron deficiency anemia.

A disproportionate number of boys (13 of the 38) presented with classic female pattern androgenetic alopecia with diffuse thinning of the crown. The remaining boys presented with bitemporal vertex thinning (18 boys), vertex only thinning (4 boys), or frontal and vertex thinning (3 boys), Dr. Orlow said.

Concomitant findings included acne in 32% of the girls and 50% of the boys, and seborrheic dermatitis in 37% of the girls and 16% of the boys. A family history of androgenetic alopecia was present in both, with 82% of the boys and 87% of the girls having an affected first- or second-degree relative.

Differential Diagnoses

It is important to consider possible differential diagnoses in patients presenting with what appears to be androgenetic alopecia. These include acute telogen effluvium, chronic telogen effluvium (particularly in girls), and diffuse alopecia areata, he said.

If the clinical diagnosis is unclear – in boys with female pattern hair loss, in girls with very young onset, or if the patient or parents have a great deal of anxiety about the diagnosis – a biopsy may be helpful, he said.

Of the 57 patients with androgenetic alopecia included in his chart review, 14 (5 girls and 9 boys) underwent biopsy; all of the biopsies showed typical features of androgenetic alopecia, including increased vellus/telogen hairs and connective tissue streamers/follicular stelae below small vellus follicles.

Eight of the 14 also had varying degrees of peri-infundibular lymphocytic inflammatory infiltrate and fibrosis.

Treatment

Treatment options for patients with androgenetic alopecia include minoxidil, finasteride (in boys), and spironolactone.

Minoxidil was used in 16 of the 19 girls; 4 of 6 with greater than 6 months of follow-up had stabilized at 1 year. One developed increased facial hair on treatment, which resolved with a switch from a 5% to a 2% formulation, Dr. Orlow said. Two patients discontinued treatment because of a lack of efficacy and/or headache and nausea.

In the boys, 36 of the 38 were treated with minoxidil, and 18 of 23 with at least 6 months of follow-up were stabilized. Two never started treatment and two discontinued for lack of efficacy and acne.

Finasteride was used in nine boys, including seven who also received minoxidil. In six boys, with at least 6 months of follow-up, all had better hair density (including four on concomitant minoxidil). One experienced sexual dysfunction, which resolved spontaneously, Dr. Orlow said.

“I did not treat – and would not treat girls [with finasteride], nor did I find any case reports of finasteride use in girls,” he said. There are a few case reports, however, of spironolactone being used in girls with some success.

The findings of the chart review (Br. J. Dermatol. 2010; 163:378-85) underscore the importance of understanding that alopecia is a common complaint in the pediatric population, that androgenetic alopecia is the most common form of hair loss in adolescents, and that it can be a presenting sign of an underlying endocrine disorder, said Dr. Orlow, who reported having no relevant financial disclosures.

Androgenetic alopecia is a presenting symptom of PCOS in a considerable number of cases.

Source DR. ORLOW

BOCA RATON, FLA. – Androgenetic alopecia is fairly common in the pediatric population, and in adolescent girls it should prompt an evaluation for hyperandrogenism, according to Dr. Seth J. Orlow.

Androgenetic alopecia is a presenting symptom of polycystic ovary syndrome (PCOS) in a considerable number of cases, he said at the meeting. “I think this is a place where we can really make a difference,” said Dr. Orlow, chair of dermatology and professor of pediatric dermatology, cell biology, and pediatrics at New York University.

One of the most useful lab tests in adolescent girls presenting with early androgenetic alopecia is free and total testosterone, which at elevated levels can serve as a marker for PCOS.

“In a girl who presents with early-onset androgenetic alopecia, think about early presentation of PCOS. It's definitely worth it to test them,” he said.

A chart review of 438 consecutive pediatric patients with alopecia seen by Dr. Orlow and his colleagues over a 12-year period underscored the importance of looking for this diagnosis, and illustrated other characteristics of androgenetic alopecia in both girls and boys. The study showed that androgenetic alopecia was the second most common type of alopecia (after alopecia areata, which accounted for 55% of cases), involving 13% of the cases overall.

Among the 123 adolescent patients, however, 42% (52 patients: 36 boys and 16 girls) had androgenetic alopecia, for a total of 38 boys and 19 girls with androgenetic alopecia among the 438 studied.

Female Findings

Of the 19 girls, 9 had hyperandrogenism. Three had clinical signs and six had biochemical signs of hyperandrogenism. Of the six with biochemical signs, three had elevated free and total testosterone levels, one had elevated free and total testosterone and elevated dihydroepiandrosterone sulfate, one had an elevated free testosterone level only, and one had an elevated total testosterone level only. Seven of the girls were oligomenorrheic, and two were premenarchal. Clinical signs other than the androgenetic alopecia included hirsutism in four girls, acne in six, and seborrheic dermatitis in two.

Other laboratory findings in the 19 girls with androgenetic alopecia included antithyroid antibodies in 1of 5 tested and low serum iron in 3 of 14 tested. None of the girls tested had abnormal thyroid function, iron deficiency anemia, or low testosterone levels, Dr. Orlow said.

The most common presentations in girls were diffuse scalp thinning and thinning at the crown, each occurring in 8 of the 19 patients. The remaining three girls presented with frontal thinning only.

Male Findings

Findings in the boys presenting with androgenetic alopecia included antithyroid antibodies in 1 of 7 tested, hyperandrogenemia in 2 of 14 tested, and low testosterone levels in 3 of 14 tested. None of the boys had abnormal thyroid function, low serum iron, or iron deficiency anemia.

A disproportionate number of boys (13 of the 38) presented with classic female pattern androgenetic alopecia with diffuse thinning of the crown. The remaining boys presented with bitemporal vertex thinning (18 boys), vertex only thinning (4 boys), or frontal and vertex thinning (3 boys), Dr. Orlow said.

Concomitant findings included acne in 32% of the girls and 50% of the boys, and seborrheic dermatitis in 37% of the girls and 16% of the boys. A family history of androgenetic alopecia was present in both, with 82% of the boys and 87% of the girls having an affected first- or second-degree relative.

Differential Diagnoses

It is important to consider possible differential diagnoses in patients presenting with what appears to be androgenetic alopecia. These include acute telogen effluvium, chronic telogen effluvium (particularly in girls), and diffuse alopecia areata, he said.

If the clinical diagnosis is unclear – in boys with female pattern hair loss, in girls with very young onset, or if the patient or parents have a great deal of anxiety about the diagnosis – a biopsy may be helpful, he said.

Of the 57 patients with androgenetic alopecia included in his chart review, 14 (5 girls and 9 boys) underwent biopsy; all of the biopsies showed typical features of androgenetic alopecia, including increased vellus/telogen hairs and connective tissue streamers/follicular stelae below small vellus follicles.

Eight of the 14 also had varying degrees of peri-infundibular lymphocytic inflammatory infiltrate and fibrosis.

Treatment

Treatment options for patients with androgenetic alopecia include minoxidil, finasteride (in boys), and spironolactone.

Minoxidil was used in 16 of the 19 girls; 4 of 6 with greater than 6 months of follow-up had stabilized at 1 year. One developed increased facial hair on treatment, which resolved with a switch from a 5% to a 2% formulation, Dr. Orlow said. Two patients discontinued treatment because of a lack of efficacy and/or headache and nausea.

In the boys, 36 of the 38 were treated with minoxidil, and 18 of 23 with at least 6 months of follow-up were stabilized. Two never started treatment and two discontinued for lack of efficacy and acne.

Finasteride was used in nine boys, including seven who also received minoxidil. In six boys, with at least 6 months of follow-up, all had better hair density (including four on concomitant minoxidil). One experienced sexual dysfunction, which resolved spontaneously, Dr. Orlow said.

“I did not treat – and would not treat girls [with finasteride], nor did I find any case reports of finasteride use in girls,” he said. There are a few case reports, however, of spironolactone being used in girls with some success.

The findings of the chart review (Br. J. Dermatol. 2010; 163:378-85) underscore the importance of understanding that alopecia is a common complaint in the pediatric population, that androgenetic alopecia is the most common form of hair loss in adolescents, and that it can be a presenting sign of an underlying endocrine disorder, said Dr. Orlow, who reported having no relevant financial disclosures.

Androgenetic alopecia is a presenting symptom of PCOS in a considerable number of cases.

Source DR. ORLOW

CHICAGO – A diagnosis of autoimmune hepatitis does not necessarily mandate therapy.

Rather, a decision about therapy should be based on the natural history of the disease, according to Dr. Bruce Luxon.

Patients for whom treatment is mandatory are those with aspartate aminotransferase (AST) levels greater than 10 times the upper limit of normal, or 5 times the upper limit of normal plus gamma globulin levels greater than twice the upper limit of normal. Data from the 1970s showed that patients with these disease characteristics had a 6-month mortality of 60%, said Dr. Luxon, professor and chair of the department of internal medicine at Georgetown University, Washington.

Similarly, treatment is needed when a biopsy shows “bridging” – or multilobular – necrosis, as studies have shown that progression to cirrhosis occurs in more than 80% of such patients, and 5-year mortality is about 45%.

“In contrast, there is a group of patients whose AST and [alanine transaminase (ALT)] were quite normal or very close to normal [less than twice the normal value]. Those people had a 10-year life expectancy greater than 80%,” he said, noting that these patients generally don't require treatment.

Cirrhotic patients with significant inflammation, on the other hand, might benefit from a 3 to 6-month trial of therapy to slow down progression, he said adding: “That's really a decision for a hepatologist to make.”

In those who will be treated, prednisone remains the mainstay of therapy, as it has for 50 years, he noted.

It is given initially at a high dose of 60 mg for the first week (or 30 mg plus 50 mg of azathioprine, which is usually given to allow lowering of the prednisone dose). Prednisone is lowered to 40 mg for week 2 (or 20 mg and 50 mg of prednisone and azathioprine, respectively), and to 30 mg for weeks 3 and 4 (or 15 mg and 50 mg of prednisone and azathioprine, respectively).

After week 4, the dose remains 20 mg (or 10 mg and 50 mg of prednisone and azathioprine, respectively) until the clinical end point is reached.

Use of the combination therapy is associated with a much lower occurrence of corticosteroid-related side effects (10% vs. 44%), but not all patients can tolerate the azathioprine. It is fine to give prednisone monotherapy in such patients, he said.

The typical side effects of steroid therapy can occur, including weight gain, unwanted hair growth, acne, and – importantly – bone disease.

“You really want to make sure they are on calcium and vitamin D,” he said, noting bisphosphonates, rather than controversial estrogen replacement, are usually prescribed as well.

Azathioprine side effects can include gastrointestinal upset, drug-induced hepatitis in rare cases, and cancer in very rare cases.

The efficacy of treatment should be evaluated on a biochemical or histological basis. But keep in mind that while a failure to normalize liver enzymes suggests residual disease, about half of those who do have normalization will still go on to have significant liver fibrosis and inflammation on biopsy. “So it's not sufficient to just normalize transaminases,” he said.

Since biopsy improvement lags behind biochemical improvement by about 6 months, a repeat biopsy at that time is warranted. These serial biopsies, which are important in this disease, can also predict whether a patient can be taken off therapy, he said.

Patients with a normal liver biopsy at follow-up will have only about a 15%–20% risk of relapse, so it is reasonable to take them off treatment, he noted.

Conversely, those with interface hepatitis and inflammation on follow-up biopsy will relapse about 90% of the time and require ongoing treatment.

In most cases, autoimmune hepatitis can be controlled, although ongoing treatment might be required. About 65% of patients will remit within 18 months, while only about 10% of patients will fail treatment altogether – and those patients typically have other contributing factors, such as excessive alcohol use, concurrent viral infection such as hepatitis B or C, or an overlap syndrome.

Another 10% of patients won't tolerate treatment.

Among those who require treatment indefinitely due to relapse, maintenance therapy with 7.5 mg/day of prednisone and 2 mg per kg/day of azathioprine can be effective for maintaining control. In one study, 85% of patients who relapsed were managed effectively with this strategy at a mean follow-up of 149 months, Dr. Luxon noted.

These patients generally have survival similar to age- and gender-matched controls, so although they have to stay on these low doses of treatment for life, the treatment is quite effective.

In those who fail therapy, it might be useful to increase prednisone to 60 mg/day and azathioprine to 150 mg/day. If there is still no response, it is worth trying mycophenolate mofetil or a calcineurin inhibitor such as tacrolimus, although these have only been assessed in small pilot studies and haven't proved very successful, he said.

Dr. Luxon had no relevant disclosures to report.

CHICAGO – A diagnosis of autoimmune hepatitis does not necessarily mandate therapy.

Rather, a decision about therapy should be based on the natural history of the disease, according to Dr. Bruce Luxon.

Patients for whom treatment is mandatory are those with aspartate aminotransferase (AST) levels greater than 10 times the upper limit of normal, or 5 times the upper limit of normal plus gamma globulin levels greater than twice the upper limit of normal. Data from the 1970s showed that patients with these disease characteristics had a 6-month mortality of 60%, said Dr. Luxon, professor and chair of the department of internal medicine at Georgetown University, Washington.

Similarly, treatment is needed when a biopsy shows “bridging” – or multilobular – necrosis, as studies have shown that progression to cirrhosis occurs in more than 80% of such patients, and 5-year mortality is about 45%.

“In contrast, there is a group of patients whose AST and [alanine transaminase (ALT)] were quite normal or very close to normal [less than twice the normal value]. Those people had a 10-year life expectancy greater than 80%,” he said, noting that these patients generally don't require treatment.

Cirrhotic patients with significant inflammation, on the other hand, might benefit from a 3 to 6-month trial of therapy to slow down progression, he said adding: “That's really a decision for a hepatologist to make.”

In those who will be treated, prednisone remains the mainstay of therapy, as it has for 50 years, he noted.

It is given initially at a high dose of 60 mg for the first week (or 30 mg plus 50 mg of azathioprine, which is usually given to allow lowering of the prednisone dose). Prednisone is lowered to 40 mg for week 2 (or 20 mg and 50 mg of prednisone and azathioprine, respectively), and to 30 mg for weeks 3 and 4 (or 15 mg and 50 mg of prednisone and azathioprine, respectively).

After week 4, the dose remains 20 mg (or 10 mg and 50 mg of prednisone and azathioprine, respectively) until the clinical end point is reached.

Use of the combination therapy is associated with a much lower occurrence of corticosteroid-related side effects (10% vs. 44%), but not all patients can tolerate the azathioprine. It is fine to give prednisone monotherapy in such patients, he said.

The typical side effects of steroid therapy can occur, including weight gain, unwanted hair growth, acne, and – importantly – bone disease.

“You really want to make sure they are on calcium and vitamin D,” he said, noting bisphosphonates, rather than controversial estrogen replacement, are usually prescribed as well.

Azathioprine side effects can include gastrointestinal upset, drug-induced hepatitis in rare cases, and cancer in very rare cases.

The efficacy of treatment should be evaluated on a biochemical or histological basis. But keep in mind that while a failure to normalize liver enzymes suggests residual disease, about half of those who do have normalization will still go on to have significant liver fibrosis and inflammation on biopsy. “So it's not sufficient to just normalize transaminases,” he said.

Since biopsy improvement lags behind biochemical improvement by about 6 months, a repeat biopsy at that time is warranted. These serial biopsies, which are important in this disease, can also predict whether a patient can be taken off therapy, he said.

Patients with a normal liver biopsy at follow-up will have only about a 15%–20% risk of relapse, so it is reasonable to take them off treatment, he noted.

Conversely, those with interface hepatitis and inflammation on follow-up biopsy will relapse about 90% of the time and require ongoing treatment.

In most cases, autoimmune hepatitis can be controlled, although ongoing treatment might be required. About 65% of patients will remit within 18 months, while only about 10% of patients will fail treatment altogether – and those patients typically have other contributing factors, such as excessive alcohol use, concurrent viral infection such as hepatitis B or C, or an overlap syndrome.

Another 10% of patients won't tolerate treatment.

Among those who require treatment indefinitely due to relapse, maintenance therapy with 7.5 mg/day of prednisone and 2 mg per kg/day of azathioprine can be effective for maintaining control. In one study, 85% of patients who relapsed were managed effectively with this strategy at a mean follow-up of 149 months, Dr. Luxon noted.

These patients generally have survival similar to age- and gender-matched controls, so although they have to stay on these low doses of treatment for life, the treatment is quite effective.

In those who fail therapy, it might be useful to increase prednisone to 60 mg/day and azathioprine to 150 mg/day. If there is still no response, it is worth trying mycophenolate mofetil or a calcineurin inhibitor such as tacrolimus, although these have only been assessed in small pilot studies and haven't proved very successful, he said.

Dr. Luxon had no relevant disclosures to report.

CHICAGO – A diagnosis of autoimmune hepatitis does not necessarily mandate therapy.

Rather, a decision about therapy should be based on the natural history of the disease, according to Dr. Bruce Luxon.

Patients for whom treatment is mandatory are those with aspartate aminotransferase (AST) levels greater than 10 times the upper limit of normal, or 5 times the upper limit of normal plus gamma globulin levels greater than twice the upper limit of normal. Data from the 1970s showed that patients with these disease characteristics had a 6-month mortality of 60%, said Dr. Luxon, professor and chair of the department of internal medicine at Georgetown University, Washington.

Similarly, treatment is needed when a biopsy shows “bridging” – or multilobular – necrosis, as studies have shown that progression to cirrhosis occurs in more than 80% of such patients, and 5-year mortality is about 45%.

“In contrast, there is a group of patients whose AST and [alanine transaminase (ALT)] were quite normal or very close to normal [less than twice the normal value]. Those people had a 10-year life expectancy greater than 80%,” he said, noting that these patients generally don't require treatment.

Cirrhotic patients with significant inflammation, on the other hand, might benefit from a 3 to 6-month trial of therapy to slow down progression, he said adding: “That's really a decision for a hepatologist to make.”

In those who will be treated, prednisone remains the mainstay of therapy, as it has for 50 years, he noted.

It is given initially at a high dose of 60 mg for the first week (or 30 mg plus 50 mg of azathioprine, which is usually given to allow lowering of the prednisone dose). Prednisone is lowered to 40 mg for week 2 (or 20 mg and 50 mg of prednisone and azathioprine, respectively), and to 30 mg for weeks 3 and 4 (or 15 mg and 50 mg of prednisone and azathioprine, respectively).

After week 4, the dose remains 20 mg (or 10 mg and 50 mg of prednisone and azathioprine, respectively) until the clinical end point is reached.

Use of the combination therapy is associated with a much lower occurrence of corticosteroid-related side effects (10% vs. 44%), but not all patients can tolerate the azathioprine. It is fine to give prednisone monotherapy in such patients, he said.

The typical side effects of steroid therapy can occur, including weight gain, unwanted hair growth, acne, and – importantly – bone disease.

“You really want to make sure they are on calcium and vitamin D,” he said, noting bisphosphonates, rather than controversial estrogen replacement, are usually prescribed as well.

Azathioprine side effects can include gastrointestinal upset, drug-induced hepatitis in rare cases, and cancer in very rare cases.

The efficacy of treatment should be evaluated on a biochemical or histological basis. But keep in mind that while a failure to normalize liver enzymes suggests residual disease, about half of those who do have normalization will still go on to have significant liver fibrosis and inflammation on biopsy. “So it's not sufficient to just normalize transaminases,” he said.

Since biopsy improvement lags behind biochemical improvement by about 6 months, a repeat biopsy at that time is warranted. These serial biopsies, which are important in this disease, can also predict whether a patient can be taken off therapy, he said.

Patients with a normal liver biopsy at follow-up will have only about a 15%–20% risk of relapse, so it is reasonable to take them off treatment, he noted.

Conversely, those with interface hepatitis and inflammation on follow-up biopsy will relapse about 90% of the time and require ongoing treatment.

In most cases, autoimmune hepatitis can be controlled, although ongoing treatment might be required. About 65% of patients will remit within 18 months, while only about 10% of patients will fail treatment altogether – and those patients typically have other contributing factors, such as excessive alcohol use, concurrent viral infection such as hepatitis B or C, or an overlap syndrome.

Another 10% of patients won't tolerate treatment.

Among those who require treatment indefinitely due to relapse, maintenance therapy with 7.5 mg/day of prednisone and 2 mg per kg/day of azathioprine can be effective for maintaining control. In one study, 85% of patients who relapsed were managed effectively with this strategy at a mean follow-up of 149 months, Dr. Luxon noted.

These patients generally have survival similar to age- and gender-matched controls, so although they have to stay on these low doses of treatment for life, the treatment is quite effective.

In those who fail therapy, it might be useful to increase prednisone to 60 mg/day and azathioprine to 150 mg/day. If there is still no response, it is worth trying mycophenolate mofetil or a calcineurin inhibitor such as tacrolimus, although these have only been assessed in small pilot studies and haven't proved very successful, he said.

Dr. Luxon had no relevant disclosures to report.

CHICAGO – Plasma exchange remains a reasonable treatment option for certain patients with refractory antineutrophil cytoplasmic antibody–associated vasculitis, according to Dr. Phillip Seo.

For example, in patients with antineutrophil cytoplasmic antibody (ANCA)–associated glomerulonephritis who present with renal failure, this “more traditional therapy that we don't think about much anymore” can delay progression to dialysis and can buy time for patients awaiting renal transplant, Dr. Seo said at the symposium.

Dr. Seo, codirector of the vasculitis center at Johns Hopkins University, Baltimore, presented a case involving a 64-year-old woman diagnosed with pauci-immune glomerulonephritis consistent with ANCA-associated vasculitis (AAV). She was treated with standard high-dose prednisone and cyclophosphamide, but she returned to the emergency department 2 weeks later with dyspnea and was found to have pulmonary hemorrhage.

In patients like this, it is reasonable to consider plasma exchange, he said.

In a randomized trial comparing plasma exchange and methylprednisolone as additional therapy for ANCA-associated glomerulonephritis (the Randomized Trial of Plasma Exchange Versus Methylprednisolone as Additional Therapy for ANCA-Associated Glomerulonephritis or MEPEX), patients randomized to receive seven courses of plasma exchange had significantly better renal survival at 3 months than did those who received methylprednisolone (81% vs. 61% of surviving patients in the groups, respectively, were dialysis independent at 3 months), Dr. Seo said, noting that this effect persisted for the duration of the 12-month observation period.

The problem – and the main reason that plasma exchange has fallen by the wayside as a treatment option for these patients – is that long-term survival did not differ between the groups, he said.

While it is “very reasonable to consider plasma exchange as a standard treatment regimen” because it can potentially allow for a year off hemodialysis, or a year during which a patient can be prepared for renal transplant, patients don't survive any longer, thus it is also reasonable to not offer plasma exchange, he said. “For those of you who don't have access to plasma exchange on a routine basis at your hospital, I think you should still sleep well at night.”

That's not to say the treatment won't regain favor for broader use, he added.

A study now underway – the Plasma Exchange and Glucocorticoids for Treatment of ANCA-Associated Vasculitis (PEXIVAS) trial – is evaluating whether plasma exchange is beneficial in patients with AAV with milder forms of glomerulonephritis, as well as in those with pulmonary capillaritis and hemorrhage.

Dr. Seo disclosed that he is a consultant for Genentech.

CHICAGO – Plasma exchange remains a reasonable treatment option for certain patients with refractory antineutrophil cytoplasmic antibody–associated vasculitis, according to Dr. Phillip Seo.

For example, in patients with antineutrophil cytoplasmic antibody (ANCA)–associated glomerulonephritis who present with renal failure, this “more traditional therapy that we don't think about much anymore” can delay progression to dialysis and can buy time for patients awaiting renal transplant, Dr. Seo said at the symposium.

Dr. Seo, codirector of the vasculitis center at Johns Hopkins University, Baltimore, presented a case involving a 64-year-old woman diagnosed with pauci-immune glomerulonephritis consistent with ANCA-associated vasculitis (AAV). She was treated with standard high-dose prednisone and cyclophosphamide, but she returned to the emergency department 2 weeks later with dyspnea and was found to have pulmonary hemorrhage.

In patients like this, it is reasonable to consider plasma exchange, he said.

In a randomized trial comparing plasma exchange and methylprednisolone as additional therapy for ANCA-associated glomerulonephritis (the Randomized Trial of Plasma Exchange Versus Methylprednisolone as Additional Therapy for ANCA-Associated Glomerulonephritis or MEPEX), patients randomized to receive seven courses of plasma exchange had significantly better renal survival at 3 months than did those who received methylprednisolone (81% vs. 61% of surviving patients in the groups, respectively, were dialysis independent at 3 months), Dr. Seo said, noting that this effect persisted for the duration of the 12-month observation period.

The problem – and the main reason that plasma exchange has fallen by the wayside as a treatment option for these patients – is that long-term survival did not differ between the groups, he said.

While it is “very reasonable to consider plasma exchange as a standard treatment regimen” because it can potentially allow for a year off hemodialysis, or a year during which a patient can be prepared for renal transplant, patients don't survive any longer, thus it is also reasonable to not offer plasma exchange, he said. “For those of you who don't have access to plasma exchange on a routine basis at your hospital, I think you should still sleep well at night.”

That's not to say the treatment won't regain favor for broader use, he added.

A study now underway – the Plasma Exchange and Glucocorticoids for Treatment of ANCA-Associated Vasculitis (PEXIVAS) trial – is evaluating whether plasma exchange is beneficial in patients with AAV with milder forms of glomerulonephritis, as well as in those with pulmonary capillaritis and hemorrhage.

Dr. Seo disclosed that he is a consultant for Genentech.

CHICAGO – Plasma exchange remains a reasonable treatment option for certain patients with refractory antineutrophil cytoplasmic antibody–associated vasculitis, according to Dr. Phillip Seo.

For example, in patients with antineutrophil cytoplasmic antibody (ANCA)–associated glomerulonephritis who present with renal failure, this “more traditional therapy that we don't think about much anymore” can delay progression to dialysis and can buy time for patients awaiting renal transplant, Dr. Seo said at the symposium.

Dr. Seo, codirector of the vasculitis center at Johns Hopkins University, Baltimore, presented a case involving a 64-year-old woman diagnosed with pauci-immune glomerulonephritis consistent with ANCA-associated vasculitis (AAV). She was treated with standard high-dose prednisone and cyclophosphamide, but she returned to the emergency department 2 weeks later with dyspnea and was found to have pulmonary hemorrhage.

In patients like this, it is reasonable to consider plasma exchange, he said.

In a randomized trial comparing plasma exchange and methylprednisolone as additional therapy for ANCA-associated glomerulonephritis (the Randomized Trial of Plasma Exchange Versus Methylprednisolone as Additional Therapy for ANCA-Associated Glomerulonephritis or MEPEX), patients randomized to receive seven courses of plasma exchange had significantly better renal survival at 3 months than did those who received methylprednisolone (81% vs. 61% of surviving patients in the groups, respectively, were dialysis independent at 3 months), Dr. Seo said, noting that this effect persisted for the duration of the 12-month observation period.

The problem – and the main reason that plasma exchange has fallen by the wayside as a treatment option for these patients – is that long-term survival did not differ between the groups, he said.

While it is “very reasonable to consider plasma exchange as a standard treatment regimen” because it can potentially allow for a year off hemodialysis, or a year during which a patient can be prepared for renal transplant, patients don't survive any longer, thus it is also reasonable to not offer plasma exchange, he said. “For those of you who don't have access to plasma exchange on a routine basis at your hospital, I think you should still sleep well at night.”

That's not to say the treatment won't regain favor for broader use, he added.

A study now underway – the Plasma Exchange and Glucocorticoids for Treatment of ANCA-Associated Vasculitis (PEXIVAS) trial – is evaluating whether plasma exchange is beneficial in patients with AAV with milder forms of glomerulonephritis, as well as in those with pulmonary capillaritis and hemorrhage.

Dr. Seo disclosed that he is a consultant for Genentech.

DESTIN, FLA. – The proteasome inhibitor bortezomib depletes long-lived plasma cells and thus appears to have great potential as an effective treatment for lupus, according to Dr. R. John Looney.

Bortezomib (Velcade) is approved for the treatment of multiple myeloma and mantle cell lymphoma, and in fact has become a very important drug for these conditions. This “real breakthrough drug” has extensive activity against long-lived plasma cells, which in systemic lupus erythematosus – as in myelomas – are believed to produce harmful antibodies, are extremely resistant to existing therapies, and are associated with refractory disease.

The drug has been shown in some “very, very positive” mouse models to protect against nephritis in lupus-like disease, and recent case reports suggest it might do the same in humans, said Dr. Looney, professor of medicine at the University of Rochester, New York.

The cases, which were presented at the 2010 annual European Congress of Rheumatology, demonstrated that intravenous treatment with bortezomib at 1.3 mg/m

Urine sediments in both patients were inactive at 6 weeks and proteinuria had markedly decreased, reaching normal in one of the patients after 4 months. Furthermore, anti-dsDNA antibodies had markedly decreased within 4 weeks, Dr. Looney said.

The treatment was associated with some minor toxicities. One patient had myalgias, fever, and headache. Also, antibodies to hepatitis B surface antigen and tetanus toxoid decreased, but protective levels were maintained nonetheless.

Providing additional evidence of a potential role for this drug for protecting against renal damage in lupus, studies suggest it is also useful as an antirejection drug in the setting of renal transplant, Dr. Looney said.

Bortezomib has been shown to directly target long-lived plasma cells producing antihuman leukocyte antigen antibodies. Treatment depletes the plasma cells and achieves dramatic reductions in the anti-HLA antibody levels, thereby improving allograft function.

In addition to the interest in the transplant field for using bortezomib as an antirejection drug, it is also likely that this type of drug – a proteasome inhibitor that targets plasma cells – will be among the new agents available for lupus in the coming years, he said.

Dr. Looney disclosed that he has been an adviser for Genentech.

DESTIN, FLA. – The proteasome inhibitor bortezomib depletes long-lived plasma cells and thus appears to have great potential as an effective treatment for lupus, according to Dr. R. John Looney.

Bortezomib (Velcade) is approved for the treatment of multiple myeloma and mantle cell lymphoma, and in fact has become a very important drug for these conditions. This “real breakthrough drug” has extensive activity against long-lived plasma cells, which in systemic lupus erythematosus – as in myelomas – are believed to produce harmful antibodies, are extremely resistant to existing therapies, and are associated with refractory disease.

The drug has been shown in some “very, very positive” mouse models to protect against nephritis in lupus-like disease, and recent case reports suggest it might do the same in humans, said Dr. Looney, professor of medicine at the University of Rochester, New York.

The cases, which were presented at the 2010 annual European Congress of Rheumatology, demonstrated that intravenous treatment with bortezomib at 1.3 mg/m

Urine sediments in both patients were inactive at 6 weeks and proteinuria had markedly decreased, reaching normal in one of the patients after 4 months. Furthermore, anti-dsDNA antibodies had markedly decreased within 4 weeks, Dr. Looney said.

The treatment was associated with some minor toxicities. One patient had myalgias, fever, and headache. Also, antibodies to hepatitis B surface antigen and tetanus toxoid decreased, but protective levels were maintained nonetheless.

Providing additional evidence of a potential role for this drug for protecting against renal damage in lupus, studies suggest it is also useful as an antirejection drug in the setting of renal transplant, Dr. Looney said.

Bortezomib has been shown to directly target long-lived plasma cells producing antihuman leukocyte antigen antibodies. Treatment depletes the plasma cells and achieves dramatic reductions in the anti-HLA antibody levels, thereby improving allograft function.

In addition to the interest in the transplant field for using bortezomib as an antirejection drug, it is also likely that this type of drug – a proteasome inhibitor that targets plasma cells – will be among the new agents available for lupus in the coming years, he said.

Dr. Looney disclosed that he has been an adviser for Genentech.

DESTIN, FLA. – The proteasome inhibitor bortezomib depletes long-lived plasma cells and thus appears to have great potential as an effective treatment for lupus, according to Dr. R. John Looney.

Bortezomib (Velcade) is approved for the treatment of multiple myeloma and mantle cell lymphoma, and in fact has become a very important drug for these conditions. This “real breakthrough drug” has extensive activity against long-lived plasma cells, which in systemic lupus erythematosus – as in myelomas – are believed to produce harmful antibodies, are extremely resistant to existing therapies, and are associated with refractory disease.

The drug has been shown in some “very, very positive” mouse models to protect against nephritis in lupus-like disease, and recent case reports suggest it might do the same in humans, said Dr. Looney, professor of medicine at the University of Rochester, New York.

The cases, which were presented at the 2010 annual European Congress of Rheumatology, demonstrated that intravenous treatment with bortezomib at 1.3 mg/m

Urine sediments in both patients were inactive at 6 weeks and proteinuria had markedly decreased, reaching normal in one of the patients after 4 months. Furthermore, anti-dsDNA antibodies had markedly decreased within 4 weeks, Dr. Looney said.

The treatment was associated with some minor toxicities. One patient had myalgias, fever, and headache. Also, antibodies to hepatitis B surface antigen and tetanus toxoid decreased, but protective levels were maintained nonetheless.

Providing additional evidence of a potential role for this drug for protecting against renal damage in lupus, studies suggest it is also useful as an antirejection drug in the setting of renal transplant, Dr. Looney said.

Bortezomib has been shown to directly target long-lived plasma cells producing antihuman leukocyte antigen antibodies. Treatment depletes the plasma cells and achieves dramatic reductions in the anti-HLA antibody levels, thereby improving allograft function.

In addition to the interest in the transplant field for using bortezomib as an antirejection drug, it is also likely that this type of drug – a proteasome inhibitor that targets plasma cells – will be among the new agents available for lupus in the coming years, he said.

Dr. Looney disclosed that he has been an adviser for Genentech.