Doug Brunk

SAN DIEGO — The prevalence of dyspareunia in menopausal women ranges from 11% to 45%, according to the best estimates in the medical literature.

However, “the literature [on this topic] is terribly flawed,” Dr. Andrew T. Goldstein said at the annual meeting of the North American Menopause Society.

“Age alone is often used instead of menstrual status, there's a failure to indicate surgical versus natural menopause, and there's a failure to indicate if women are on hormone replacement therapy, and if so, what types. Also, the use of validated questionnaires is sorely lacking,” said Dr. Goldstein, an ob.gyn. practicing in Annapolis, Md., who specializes in the treatment of vulvovaginal disorders.

If anything, he continued, the prevalence of dyspareunia in menopausal women seems to be increasing because of a variety of factors, including the fact that fewer women are taking hormone therapy; overall, 22%–45% of women not on hormone therapy have dyspareunia. In addition, “changing attitudes of postmenopausal women and their sexuality [are factors]. They expect to have sex later in life.”

Another contributing factor is the proliferation of phosphodiesterase type 5 inhibitors in recent years, which allow the partners of these women to resume or increase sexual activity.

“Changes in the types of [hormone therapy] are also contributing, going from systemic [HT] to such things as vaginal estradiol tablets or rings which do not treat the vulva,” he said.

Dr. Goldstein cautioned clinicians not to assume that the cause of dyspareunia in menopausal women is always atrophic vaginitis. “There are many different causes of postmenopausal dyspareunia,” he said.

Many premenopausal women have dyspareunia that is never adequately treated, Dr. Goldstein added. A study by other researchers showed that 40% of women with vulvar pain never sought primary treatment (J. Am. Med. Womens Assoc. 2003;58:82–8). “In addition, at best, only 75% of women given adequate estradiol treatment are cured of their pain,” Dr. Goldstein said.

However, with a thorough history, physical, and differential diagnosis, “the specific disease process can be determined, and this will determine the correct diagnosis and treatment,” he noted.

Evaluations should include an assessment of when the dyspareunia started, the location of the pain, and the nature of the symptoms. “Different symptoms point us in different directions,” Dr. Goldstein said. “A throbbing, dull, or stabbing pain can often suggest a pelvic floor dysfunction, whereas dryness or tearing can suggest an estrogen deficiency or vulvar dermatoses. Symptoms such as hesitancy, urgency, frequency, or incomplete emptying, constipation, and rectal fissures can also suggest hypertonus pelvic floor muscles.”

He recommended that the physical exam include a careful inspection of the vulva, as at least 75% of dyspareunia cases are vulvar in origin. Special attention should be paid to the vulvar vestibule, “but we have to look at all of the structures,” he said.

The exam also should include vulvoscopy to look for areas of erythema, lichenification, fissures, erosions, ulcerations, scarring and architectural changes, evidence of atrophy, hypopigmentation and hyperpigmentation, and evidence of vulvar intraepithelial neoplasm, he said.

Another component of his exam is the “Q-tip test.” Begin by touching a moistened Q-tips swab lateral to and then just medial to Hart's line. Touch the vestibule at 1 o'clock and 11 o'clock adjacent to the urethra at the ostia of the Skene's glands. Then touch the vestibule at 4 o'clock and 8 o'clock at the ostia of the Bartholin's gland.

“Frequently there will just be pain posteriorly and not anteriorly,” Dr. Goldstein said. “I believe that if you just have posterior pain and not anterior pain, that's almost always a sign of hypertonus of the pelvic floor musculature, and that's often the cause of the dyspareunia. If you have diffuse pain at the entire vestibule, that [points to] an intrinsic problem within the vestibular tissue.”

Evaluation of the pelvic floor muscles is also warranted for all women who present with dyspareunia. For this, he said, insert one finger through the hymenal ring. Press posteriorly toward the rectum, and tell the patient “this is pressure.” Then palpate the pubococcygeal, transverse perineal, and internal obturator muscles. “For each muscle,” he said, “ask, 'Is this pressure or pain?' Are there trigger points? Is there hypertonicity? Can she relax the muscles?”

Next, palpate the urethra and bladder. This “should cause urgency but not burning or pain,” Dr. Goldstein said. “If there is intrinsic pain of the bladder, this may suggest interstitial cystitis/painful bladder syndrome.”

Last, palpate the pudendal nerves at the ischial spines. Are the nerves more painful than the muscles, or is one side more tender? Tender nerves can indicate pudendal neuralgia or entrapment.

Lab tests should include a wet mount, “which is absolutely essential”; cultures for speciation and sensitivity; tests for gonorrhea, chlamydia, and herpes simplex virus types 1 and 2; and serum tests of estradiol, total and free testosterone, and sex hormone–binding globulin.

“I'm a big proponent of vulvar punch biopsies,” Dr. Goldstein added. “I always send my punch biopsies with a differential diagnosis to a dermatopathologist, and I always close the biopsy with one or two interrupted Vicryl sutures.”

Atrophic vulvovaginitis is the most common cause of dyspareunia in menopausal women, he said, followed by pelvic floor dysfunction and vulvar dermatoses. Less common causes include vulvar granuloma fissuratum, desquamative inflammatory vaginitis, and interstitial cystitis.

He said he believes the addition of low-dose testosterone to estradiol helps to treat atrophy at the vulvar vestibule, but he acknowledged that this belief is based on his clinical experience and lacks evidence-based studies.

Dr. Goldstein disclosed that he serves on the advisory boards of Boehringer Ingelheim Pharmaceuticals Inc. and Wyeth. He has also received research funding from Novartis.

Postmenopausal women 'expect to have sex later in life.'

Source Dr. Goldstein

SAN DIEGO — The prevalence of dyspareunia in menopausal women ranges from 11% to 45%, according to the best estimates in the medical literature.

However, “the literature [on this topic] is terribly flawed,” Dr. Andrew T. Goldstein said at the annual meeting of the North American Menopause Society.

“Age alone is often used instead of menstrual status, there's a failure to indicate surgical versus natural menopause, and there's a failure to indicate if women are on hormone replacement therapy, and if so, what types. Also, the use of validated questionnaires is sorely lacking,” said Dr. Goldstein, an ob.gyn. practicing in Annapolis, Md., who specializes in the treatment of vulvovaginal disorders.

If anything, he continued, the prevalence of dyspareunia in menopausal women seems to be increasing because of a variety of factors, including the fact that fewer women are taking hormone therapy; overall, 22%–45% of women not on hormone therapy have dyspareunia. In addition, “changing attitudes of postmenopausal women and their sexuality [are factors]. They expect to have sex later in life.”

Another contributing factor is the proliferation of phosphodiesterase type 5 inhibitors in recent years, which allow the partners of these women to resume or increase sexual activity.

“Changes in the types of [hormone therapy] are also contributing, going from systemic [HT] to such things as vaginal estradiol tablets or rings which do not treat the vulva,” he said.

Dr. Goldstein cautioned clinicians not to assume that the cause of dyspareunia in menopausal women is always atrophic vaginitis. “There are many different causes of postmenopausal dyspareunia,” he said.

Many premenopausal women have dyspareunia that is never adequately treated, Dr. Goldstein added. A study by other researchers showed that 40% of women with vulvar pain never sought primary treatment (J. Am. Med. Womens Assoc. 2003;58:82–8). “In addition, at best, only 75% of women given adequate estradiol treatment are cured of their pain,” Dr. Goldstein said.

However, with a thorough history, physical, and differential diagnosis, “the specific disease process can be determined, and this will determine the correct diagnosis and treatment,” he noted.

Evaluations should include an assessment of when the dyspareunia started, the location of the pain, and the nature of the symptoms. “Different symptoms point us in different directions,” Dr. Goldstein said. “A throbbing, dull, or stabbing pain can often suggest a pelvic floor dysfunction, whereas dryness or tearing can suggest an estrogen deficiency or vulvar dermatoses. Symptoms such as hesitancy, urgency, frequency, or incomplete emptying, constipation, and rectal fissures can also suggest hypertonus pelvic floor muscles.”

He recommended that the physical exam include a careful inspection of the vulva, as at least 75% of dyspareunia cases are vulvar in origin. Special attention should be paid to the vulvar vestibule, “but we have to look at all of the structures,” he said.

The exam also should include vulvoscopy to look for areas of erythema, lichenification, fissures, erosions, ulcerations, scarring and architectural changes, evidence of atrophy, hypopigmentation and hyperpigmentation, and evidence of vulvar intraepithelial neoplasm, he said.

Another component of his exam is the “Q-tip test.” Begin by touching a moistened Q-tips swab lateral to and then just medial to Hart's line. Touch the vestibule at 1 o'clock and 11 o'clock adjacent to the urethra at the ostia of the Skene's glands. Then touch the vestibule at 4 o'clock and 8 o'clock at the ostia of the Bartholin's gland.

“Frequently there will just be pain posteriorly and not anteriorly,” Dr. Goldstein said. “I believe that if you just have posterior pain and not anterior pain, that's almost always a sign of hypertonus of the pelvic floor musculature, and that's often the cause of the dyspareunia. If you have diffuse pain at the entire vestibule, that [points to] an intrinsic problem within the vestibular tissue.”

Evaluation of the pelvic floor muscles is also warranted for all women who present with dyspareunia. For this, he said, insert one finger through the hymenal ring. Press posteriorly toward the rectum, and tell the patient “this is pressure.” Then palpate the pubococcygeal, transverse perineal, and internal obturator muscles. “For each muscle,” he said, “ask, 'Is this pressure or pain?' Are there trigger points? Is there hypertonicity? Can she relax the muscles?”

Next, palpate the urethra and bladder. This “should cause urgency but not burning or pain,” Dr. Goldstein said. “If there is intrinsic pain of the bladder, this may suggest interstitial cystitis/painful bladder syndrome.”

Last, palpate the pudendal nerves at the ischial spines. Are the nerves more painful than the muscles, or is one side more tender? Tender nerves can indicate pudendal neuralgia or entrapment.

Lab tests should include a wet mount, “which is absolutely essential”; cultures for speciation and sensitivity; tests for gonorrhea, chlamydia, and herpes simplex virus types 1 and 2; and serum tests of estradiol, total and free testosterone, and sex hormone–binding globulin.

“I'm a big proponent of vulvar punch biopsies,” Dr. Goldstein added. “I always send my punch biopsies with a differential diagnosis to a dermatopathologist, and I always close the biopsy with one or two interrupted Vicryl sutures.”

Atrophic vulvovaginitis is the most common cause of dyspareunia in menopausal women, he said, followed by pelvic floor dysfunction and vulvar dermatoses. Less common causes include vulvar granuloma fissuratum, desquamative inflammatory vaginitis, and interstitial cystitis.

He said he believes the addition of low-dose testosterone to estradiol helps to treat atrophy at the vulvar vestibule, but he acknowledged that this belief is based on his clinical experience and lacks evidence-based studies.

Dr. Goldstein disclosed that he serves on the advisory boards of Boehringer Ingelheim Pharmaceuticals Inc. and Wyeth. He has also received research funding from Novartis.

Postmenopausal women 'expect to have sex later in life.'

Source Dr. Goldstein

SAN DIEGO — The prevalence of dyspareunia in menopausal women ranges from 11% to 45%, according to the best estimates in the medical literature.

However, “the literature [on this topic] is terribly flawed,” Dr. Andrew T. Goldstein said at the annual meeting of the North American Menopause Society.

“Age alone is often used instead of menstrual status, there's a failure to indicate surgical versus natural menopause, and there's a failure to indicate if women are on hormone replacement therapy, and if so, what types. Also, the use of validated questionnaires is sorely lacking,” said Dr. Goldstein, an ob.gyn. practicing in Annapolis, Md., who specializes in the treatment of vulvovaginal disorders.

If anything, he continued, the prevalence of dyspareunia in menopausal women seems to be increasing because of a variety of factors, including the fact that fewer women are taking hormone therapy; overall, 22%–45% of women not on hormone therapy have dyspareunia. In addition, “changing attitudes of postmenopausal women and their sexuality [are factors]. They expect to have sex later in life.”

Another contributing factor is the proliferation of phosphodiesterase type 5 inhibitors in recent years, which allow the partners of these women to resume or increase sexual activity.

“Changes in the types of [hormone therapy] are also contributing, going from systemic [HT] to such things as vaginal estradiol tablets or rings which do not treat the vulva,” he said.

Dr. Goldstein cautioned clinicians not to assume that the cause of dyspareunia in menopausal women is always atrophic vaginitis. “There are many different causes of postmenopausal dyspareunia,” he said.

Many premenopausal women have dyspareunia that is never adequately treated, Dr. Goldstein added. A study by other researchers showed that 40% of women with vulvar pain never sought primary treatment (J. Am. Med. Womens Assoc. 2003;58:82–8). “In addition, at best, only 75% of women given adequate estradiol treatment are cured of their pain,” Dr. Goldstein said.

However, with a thorough history, physical, and differential diagnosis, “the specific disease process can be determined, and this will determine the correct diagnosis and treatment,” he noted.

Evaluations should include an assessment of when the dyspareunia started, the location of the pain, and the nature of the symptoms. “Different symptoms point us in different directions,” Dr. Goldstein said. “A throbbing, dull, or stabbing pain can often suggest a pelvic floor dysfunction, whereas dryness or tearing can suggest an estrogen deficiency or vulvar dermatoses. Symptoms such as hesitancy, urgency, frequency, or incomplete emptying, constipation, and rectal fissures can also suggest hypertonus pelvic floor muscles.”

He recommended that the physical exam include a careful inspection of the vulva, as at least 75% of dyspareunia cases are vulvar in origin. Special attention should be paid to the vulvar vestibule, “but we have to look at all of the structures,” he said.

The exam also should include vulvoscopy to look for areas of erythema, lichenification, fissures, erosions, ulcerations, scarring and architectural changes, evidence of atrophy, hypopigmentation and hyperpigmentation, and evidence of vulvar intraepithelial neoplasm, he said.

Another component of his exam is the “Q-tip test.” Begin by touching a moistened Q-tips swab lateral to and then just medial to Hart's line. Touch the vestibule at 1 o'clock and 11 o'clock adjacent to the urethra at the ostia of the Skene's glands. Then touch the vestibule at 4 o'clock and 8 o'clock at the ostia of the Bartholin's gland.

“Frequently there will just be pain posteriorly and not anteriorly,” Dr. Goldstein said. “I believe that if you just have posterior pain and not anterior pain, that's almost always a sign of hypertonus of the pelvic floor musculature, and that's often the cause of the dyspareunia. If you have diffuse pain at the entire vestibule, that [points to] an intrinsic problem within the vestibular tissue.”

Evaluation of the pelvic floor muscles is also warranted for all women who present with dyspareunia. For this, he said, insert one finger through the hymenal ring. Press posteriorly toward the rectum, and tell the patient “this is pressure.” Then palpate the pubococcygeal, transverse perineal, and internal obturator muscles. “For each muscle,” he said, “ask, 'Is this pressure or pain?' Are there trigger points? Is there hypertonicity? Can she relax the muscles?”

Next, palpate the urethra and bladder. This “should cause urgency but not burning or pain,” Dr. Goldstein said. “If there is intrinsic pain of the bladder, this may suggest interstitial cystitis/painful bladder syndrome.”

Last, palpate the pudendal nerves at the ischial spines. Are the nerves more painful than the muscles, or is one side more tender? Tender nerves can indicate pudendal neuralgia or entrapment.

Lab tests should include a wet mount, “which is absolutely essential”; cultures for speciation and sensitivity; tests for gonorrhea, chlamydia, and herpes simplex virus types 1 and 2; and serum tests of estradiol, total and free testosterone, and sex hormone–binding globulin.

“I'm a big proponent of vulvar punch biopsies,” Dr. Goldstein added. “I always send my punch biopsies with a differential diagnosis to a dermatopathologist, and I always close the biopsy with one or two interrupted Vicryl sutures.”

Atrophic vulvovaginitis is the most common cause of dyspareunia in menopausal women, he said, followed by pelvic floor dysfunction and vulvar dermatoses. Less common causes include vulvar granuloma fissuratum, desquamative inflammatory vaginitis, and interstitial cystitis.

He said he believes the addition of low-dose testosterone to estradiol helps to treat atrophy at the vulvar vestibule, but he acknowledged that this belief is based on his clinical experience and lacks evidence-based studies.

Dr. Goldstein disclosed that he serves on the advisory boards of Boehringer Ingelheim Pharmaceuticals Inc. and Wyeth. He has also received research funding from Novartis.

Postmenopausal women 'expect to have sex later in life.'

Source Dr. Goldstein

According to Dr. Joel Ang, his vocation as a full-time family physician and his avocation as a violinist are irrevocably intertwined.

In family medicine, he explained, “you have to think of a patient as someone who is multidimensional. In music, you do the same thing. You're trying to put things together, trying to work on very specific details of that piece.”

Born in the Philippines, Dr. Ang was raised in Raleigh, N.C., where he started playing violin at the age of 12 years in an orchestra at the public school he attended and went on to excel with the instrument. He enrolled in music camps each summer, played in state orchestras in high school, and earned a spot in the Duke University Symphony in Durham, N.C., as a college undergraduate.

He kept playing during medical school—though not as much as he would have liked—and viewed his avocation as “a way to keep stress from building up.”

As he improved, he became intrigued by the technical demands of the violin, noting that “a lot of brain power and technical work is required before you achieve proficiency with the instrument,” said Dr. Ang, who practices family medicine in Washington.

These days, Dr. Ang is a violinist with the Washington Metropolitan Philharmonic Association orchestra and serves as its associate concertmaster. He is also a member of the World Doctors Orchestra, which convenes twice a year for concerts in different cities around the globe and donates concert proceeds to charity (www.world-doctors-orchestra.org). The group's most recent performance was in Berlin on July 4, 2009, an experience that was unforgettable for Dr. Ang.

“Berlin was a standout because the music our conductor chose was pretty difficult, a piece by [the late composer] Gustav Mahler,” he said. “The symphony was about 75 minutes long, and we only had 4 days to rehearse before the performance. We played from 9 a.m. until about 6 p.m. each day. It was a pretty intense time, but it was good because I shared it with close to 100 other physicians. It was inspirational to me.”

Dr. Ang practices on a daily basis and is currently taking private lessons from a violinist with the National Symphony Orchestra. “I keep myself pretty full with the music,” he said.

Steered Clear of Burnout

When Dr. Marilyn Kellam started practicing internal medicine in 1985, she quickly realized that she could easily become a “serious workaholic” if she didn't find an outlet for creativity.

“I could see it coming that I could spend all of my time in the hospital taking care of patients,” said Dr. Kellam, who currently practices at Shore Memorial Hospital in Nassawadox, Va. “This drove me to make sure that I had a healthy mix of work and avocation and to make sure that I was more well rounded.”

That outlet became singing, an avocation she pursued after attending a production of “The Fantasticks” at the local Trawler Dinner Theater. The cast members “looked like they were having so much fun,” recalled Dr. Kellam, who took piano lessons as a youngster but no formal voice lessons. After the show, attendees were informed that the theatre's next production would be Camelot. Dr. Kellam decided that she “would like to get involved with that show in some way,” so she auditioned and earned a role as a tree.

“It also turned out to be a part as one of the ladies of the roundtable,” she said. “I also got a part as a singer and dancer as part of the chorus. At the first rehearsal, I was totally hooked; I was sucked in.”

Mindful that she would benefit from professional voice training she enrolled at the University of Maryland Eastern Shore in Princess Anne and took personal lessons from voice teacher Dr. Gerald W. Johnson for several years, developing a proficiency in classical music style. She performed in about 35 productions at the Trawler Dinner Theater under the direction of Judi Beck before it closed in 2000.

Determined to pursue singing as a creative outlet, she auditioned for a role in a production of Turandot staged by the Norfolk-based Virginia Opera. She earned a role in the chorus, and since then has performed in about two Virginia Opera productions each year and has understudied for some principal roles as well.

“When I'm involved with an opera it only involves 2 months of my time,” she said. “But it's an intense amount of time. It involves rehearsals Monday, Tuesday, and Saturday, and commuting 60 miles each way.”

Dr. Kellam, who considers current voice teacher, Sondra Gelb, a key influence, described her involvement in the opera production as “pure joy; no strings attached. It's something I do for me, and there's camaraderie, a team spirit. There's a creative spirit and, of course, the magic of music, and I don't have to worry about hurting anybody.”

Roles have varied over the years and have included Carrie Pipperidge in “Carousel,” Snoopy in “You're a Good Man, Charlie Brown,” and the Wicked Witch of the West in “The Wizard of Oz.”

Dr. Joel Ang is a member of the World Doctors Orchestra, which convenes twice a year to perform concerts for charity.

Photo Courtesy World Doctors Orchestra

Email us your stories! The purpose of "The Rest of Your Life" is to celebrate the interests and passions of physicians outside of medicine. If you have an idea or this column or would like to tell your story, send an email to d.brunk@elsevier.com.

According to Dr. Joel Ang, his vocation as a full-time family physician and his avocation as a violinist are irrevocably intertwined.

In family medicine, he explained, “you have to think of a patient as someone who is multidimensional. In music, you do the same thing. You're trying to put things together, trying to work on very specific details of that piece.”

Born in the Philippines, Dr. Ang was raised in Raleigh, N.C., where he started playing violin at the age of 12 years in an orchestra at the public school he attended and went on to excel with the instrument. He enrolled in music camps each summer, played in state orchestras in high school, and earned a spot in the Duke University Symphony in Durham, N.C., as a college undergraduate.

He kept playing during medical school—though not as much as he would have liked—and viewed his avocation as “a way to keep stress from building up.”

As he improved, he became intrigued by the technical demands of the violin, noting that “a lot of brain power and technical work is required before you achieve proficiency with the instrument,” said Dr. Ang, who practices family medicine in Washington.

These days, Dr. Ang is a violinist with the Washington Metropolitan Philharmonic Association orchestra and serves as its associate concertmaster. He is also a member of the World Doctors Orchestra, which convenes twice a year for concerts in different cities around the globe and donates concert proceeds to charity (www.world-doctors-orchestra.org). The group's most recent performance was in Berlin on July 4, 2009, an experience that was unforgettable for Dr. Ang.

“Berlin was a standout because the music our conductor chose was pretty difficult, a piece by [the late composer] Gustav Mahler,” he said. “The symphony was about 75 minutes long, and we only had 4 days to rehearse before the performance. We played from 9 a.m. until about 6 p.m. each day. It was a pretty intense time, but it was good because I shared it with close to 100 other physicians. It was inspirational to me.”

Dr. Ang practices on a daily basis and is currently taking private lessons from a violinist with the National Symphony Orchestra. “I keep myself pretty full with the music,” he said.

Steered Clear of Burnout

When Dr. Marilyn Kellam started practicing internal medicine in 1985, she quickly realized that she could easily become a “serious workaholic” if she didn't find an outlet for creativity.

“I could see it coming that I could spend all of my time in the hospital taking care of patients,” said Dr. Kellam, who currently practices at Shore Memorial Hospital in Nassawadox, Va. “This drove me to make sure that I had a healthy mix of work and avocation and to make sure that I was more well rounded.”

That outlet became singing, an avocation she pursued after attending a production of “The Fantasticks” at the local Trawler Dinner Theater. The cast members “looked like they were having so much fun,” recalled Dr. Kellam, who took piano lessons as a youngster but no formal voice lessons. After the show, attendees were informed that the theatre's next production would be Camelot. Dr. Kellam decided that she “would like to get involved with that show in some way,” so she auditioned and earned a role as a tree.

“It also turned out to be a part as one of the ladies of the roundtable,” she said. “I also got a part as a singer and dancer as part of the chorus. At the first rehearsal, I was totally hooked; I was sucked in.”

Mindful that she would benefit from professional voice training she enrolled at the University of Maryland Eastern Shore in Princess Anne and took personal lessons from voice teacher Dr. Gerald W. Johnson for several years, developing a proficiency in classical music style. She performed in about 35 productions at the Trawler Dinner Theater under the direction of Judi Beck before it closed in 2000.

Determined to pursue singing as a creative outlet, she auditioned for a role in a production of Turandot staged by the Norfolk-based Virginia Opera. She earned a role in the chorus, and since then has performed in about two Virginia Opera productions each year and has understudied for some principal roles as well.

“When I'm involved with an opera it only involves 2 months of my time,” she said. “But it's an intense amount of time. It involves rehearsals Monday, Tuesday, and Saturday, and commuting 60 miles each way.”

Dr. Kellam, who considers current voice teacher, Sondra Gelb, a key influence, described her involvement in the opera production as “pure joy; no strings attached. It's something I do for me, and there's camaraderie, a team spirit. There's a creative spirit and, of course, the magic of music, and I don't have to worry about hurting anybody.”

Roles have varied over the years and have included Carrie Pipperidge in “Carousel,” Snoopy in “You're a Good Man, Charlie Brown,” and the Wicked Witch of the West in “The Wizard of Oz.”

Dr. Joel Ang is a member of the World Doctors Orchestra, which convenes twice a year to perform concerts for charity.

Photo Courtesy World Doctors Orchestra

Email us your stories! The purpose of "The Rest of Your Life" is to celebrate the interests and passions of physicians outside of medicine. If you have an idea or this column or would like to tell your story, send an email to d.brunk@elsevier.com.

According to Dr. Joel Ang, his vocation as a full-time family physician and his avocation as a violinist are irrevocably intertwined.

In family medicine, he explained, “you have to think of a patient as someone who is multidimensional. In music, you do the same thing. You're trying to put things together, trying to work on very specific details of that piece.”

Born in the Philippines, Dr. Ang was raised in Raleigh, N.C., where he started playing violin at the age of 12 years in an orchestra at the public school he attended and went on to excel with the instrument. He enrolled in music camps each summer, played in state orchestras in high school, and earned a spot in the Duke University Symphony in Durham, N.C., as a college undergraduate.

He kept playing during medical school—though not as much as he would have liked—and viewed his avocation as “a way to keep stress from building up.”

As he improved, he became intrigued by the technical demands of the violin, noting that “a lot of brain power and technical work is required before you achieve proficiency with the instrument,” said Dr. Ang, who practices family medicine in Washington.

These days, Dr. Ang is a violinist with the Washington Metropolitan Philharmonic Association orchestra and serves as its associate concertmaster. He is also a member of the World Doctors Orchestra, which convenes twice a year for concerts in different cities around the globe and donates concert proceeds to charity (www.world-doctors-orchestra.org). The group's most recent performance was in Berlin on July 4, 2009, an experience that was unforgettable for Dr. Ang.

“Berlin was a standout because the music our conductor chose was pretty difficult, a piece by [the late composer] Gustav Mahler,” he said. “The symphony was about 75 minutes long, and we only had 4 days to rehearse before the performance. We played from 9 a.m. until about 6 p.m. each day. It was a pretty intense time, but it was good because I shared it with close to 100 other physicians. It was inspirational to me.”

Dr. Ang practices on a daily basis and is currently taking private lessons from a violinist with the National Symphony Orchestra. “I keep myself pretty full with the music,” he said.

Steered Clear of Burnout

When Dr. Marilyn Kellam started practicing internal medicine in 1985, she quickly realized that she could easily become a “serious workaholic” if she didn't find an outlet for creativity.

“I could see it coming that I could spend all of my time in the hospital taking care of patients,” said Dr. Kellam, who currently practices at Shore Memorial Hospital in Nassawadox, Va. “This drove me to make sure that I had a healthy mix of work and avocation and to make sure that I was more well rounded.”

That outlet became singing, an avocation she pursued after attending a production of “The Fantasticks” at the local Trawler Dinner Theater. The cast members “looked like they were having so much fun,” recalled Dr. Kellam, who took piano lessons as a youngster but no formal voice lessons. After the show, attendees were informed that the theatre's next production would be Camelot. Dr. Kellam decided that she “would like to get involved with that show in some way,” so she auditioned and earned a role as a tree.

“It also turned out to be a part as one of the ladies of the roundtable,” she said. “I also got a part as a singer and dancer as part of the chorus. At the first rehearsal, I was totally hooked; I was sucked in.”

Mindful that she would benefit from professional voice training she enrolled at the University of Maryland Eastern Shore in Princess Anne and took personal lessons from voice teacher Dr. Gerald W. Johnson for several years, developing a proficiency in classical music style. She performed in about 35 productions at the Trawler Dinner Theater under the direction of Judi Beck before it closed in 2000.

Determined to pursue singing as a creative outlet, she auditioned for a role in a production of Turandot staged by the Norfolk-based Virginia Opera. She earned a role in the chorus, and since then has performed in about two Virginia Opera productions each year and has understudied for some principal roles as well.

“When I'm involved with an opera it only involves 2 months of my time,” she said. “But it's an intense amount of time. It involves rehearsals Monday, Tuesday, and Saturday, and commuting 60 miles each way.”

Dr. Kellam, who considers current voice teacher, Sondra Gelb, a key influence, described her involvement in the opera production as “pure joy; no strings attached. It's something I do for me, and there's camaraderie, a team spirit. There's a creative spirit and, of course, the magic of music, and I don't have to worry about hurting anybody.”

Roles have varied over the years and have included Carrie Pipperidge in “Carousel,” Snoopy in “You're a Good Man, Charlie Brown,” and the Wicked Witch of the West in “The Wizard of Oz.”

Dr. Joel Ang is a member of the World Doctors Orchestra, which convenes twice a year to perform concerts for charity.

Photo Courtesy World Doctors Orchestra

Email us your stories! The purpose of "The Rest of Your Life" is to celebrate the interests and passions of physicians outside of medicine. If you have an idea or this column or would like to tell your story, send an email to d.brunk@elsevier.com.

PORTLAND, ORE. — If an infant presents with at least three hypopigmented macules, think tuberous sclerosis.

Tuberous sclerosis is described as a triad of neurologic impairment, multisystem hamartomas, and skin findings (such as ash leaf macules and facial angiofibromas). The disease is of autosomal dominant inheritance, with an incidence of 1:6,000 to 1:10,000. Spontaneous mutation occurs in 50%-75% of cases.

Ash leaf spots or hypopigmented macules occur in 90% of patients with the disease, Dr. Dawn Siegel said at the annual meeting of the Pacific Dermatologic Association. They can range in size from 1 to 12 cm in diameter and “are rounded at one end and tapered at the other, resembling the leaf of an ash tree. They can vary quite a bit in their presentation. In some cases, they present as confetti macules, which are only 1–2 mm in diameter,” she said.

If an infant presents with more than three hypopigmented macules, she recommends screening evaluations, which could include a renal ultrasound, an eye exam, and a cardiac echocardiogram. “I usually reserve head MRI or CT for babies who are developing seizures, or who have a positive finding on one of the other screening tests, or if I have a high clinical suspicion,” said Dr. Siegel, assistant professor of dermatology and pediatrics at Oregon Health and Science University, Portland.

Infantile spasms, the most common presenting neurologic sign, tend to develop by 4–5 months of age in about 70% of patients.

Establishing a definitive diagnosis of tuberous sclerosis requires the presence of two major clinical diagnostic criteria or one major and two minor criteria.

Major criteria include facial angiofibromas or forehead plaque, nontraumatic ungual fibroma, three or more hypomelanotic macules, shagreen patch (most commonly on the torso and chest), multiple retinal nodular hamartomas, cortical tuber, subependymal nodule, subependymal giant cell astrocytoma, single or multiple cardiac rhabdomyoma, renal angiomyolipoma, and pulmonary lymphangiomyomatosis, said Dr. Siegel.

Minor clinical criteria include multiple randomly distributed pits in dental enamel, hamartomatous rectal polyps, bone cysts, cerebral white matter radial migration lines, gingival fibromas, nonrenal hamartoma, retinal achromic patch, “confetti” skin lesions, and multiple renal cysts.

Current treatments for the facial angiofibromas include pulsed dye laser and pulsed KTP (532 nm) laser. “Some people use a CO₂ laser or the erbium: YAG laser to try and flatten down the lesions,” Dr. Siegel said.

Studies of oral and topical rapamycin are underway after a published case report demonstrated that the agent significantly improved angiofibroma lesions in a patient with tuberous sclerosis complex who took rapamycin after undergoing renal transplantation (Br. J. Dermatol. 2008;159:473–5).

“This would be exciting, because angiofibromas are so disfiguring and treatment has been frustrating,” she said.

Incontinentia Pigmenti

Dr. Siegel went on to discuss incontinentia pigmenti, which is caused by a genomic rearrangement of the gene for nuclear factor kappa B essential modulator and has an incidence of 1:40,000. The skin disorder is marked by four stages that occur in most patients.

In stage I, vesicles in linear streaks follow the lines of Blaschko. These lesions are present at birth in 50% of cases and wax and wane for up to 1 year. In stage II, verrucous-hyperkeratotic streaks usually appear at 2–6 months of age. Stage III is marked by hyperpigmentation in streaks along the lines of Blaschko in a so-called “marble-cake pattern,” she said.

Cutaneous findings in stage IV typically involve atrophy and hypopigmentation that may be subtle. Affected infants may have a lack of hair along the lines of Blaschko.

Recurrence of the vesicular phase may occur, but this typically lasts only 1–2 weeks and is often preceded by a viral illness. “Sometimes these lesions are mistaken for herpes zoster,” Dr. Siegel noted.

Additional findings of incontinentia pigmenti may include scarring alopecia, most commonly on the vertex; conical or peg-shaped teeth; absence of teeth; nail dystrophy; and abnormal sweating.

“The management of incontinentia pigmenti in the newborn period should focus on skin care with emollients and monitoring for skin infection,” she said.

“Topical steroids can sometimes be beneficial for symptomatic relief in the verrucous phase. Referral to an ophthalmologist for a retinal exam is important. If neurologic symptoms are present, then evaluation includes an EEG and an MRI,” she added.

Neurofibromatosis Type 1

Dr. Siegel concluded her presentation by discussing neurofibromatosis type 1 (NF1), a multisystem disorder caused by a mutation of a gene on the long arm of chromosome 17 that occurs in about 1 in 4,000 births.

According to the 1988 National Institutes of Health Consensus Development Conference, a diagnosis of NF1 requires two or more of the following clinical features: six or more café-au-lait macules, two or more neurofibromas or one or more plexiform neurofibromas, freckling in the axilla and inguinal region (Crowe's sign), tumor of the optic nerve pathway, two or more Lisch nodules (iris hamartomas), and distinctive osseous lesions.

Café-au-lait macules, the hallmark clinical feature, are present in nearly all cases. The size is age dependent, with macules typically exceeding 5 mm in prepubertal children and 15 mm in postpubertal children.

“They often appear in the first few months of life and increase in number over the first couple of years of life,” Dr. Siegel said.

Axillary or inguinal freckling tends to present later in childhood, while neurofibromas begin to appear in childhood or later. “They are not usually present in infancy,” she said. “They increase in number in puberty and during pregnancy.”

Plexiform neurofibromas present in about 25% of cases in infancy. They can have associated hypertrichosis and hyperpigmentation, and can run along the lines of nerves. “It's difficult to excise them for that reason,” she said.

Plexiform neurofibromas also can be painful and, although rare, there is a risk that they will develop a malignant peripheral nerve sheath tumor.

“Because they're difficult to completely excise, it's always hard to know when they develop to cancer in the plexiform neurofibroma, or if the lesion is just growing,” she noted.

“There are a lot of clinical trials going on right now looking at various medical, nonsurgical treatments for plexiform neurofibromas,” Dr. Siegel added.

Dermatologic exams for children with NF1 should include evaluation for the presence of café-au-lait spots, neurofibromas, plexiform neurofibromas, and skinfold freckling. “Enlarging or disfiguring plexiform neurofibromas may require referral to a surgical specialist to discuss debulking or to a specialty center for enrollment in a clinical trial,” she said.

Dr. Siegel disclosed having no relevant conflicts of interest.

Viral illness can precede recurrence of the vesicular phase of incontinentia pigmenti (shown on an infant's arm).

Source Photo courtesy Dr. Dawn Siegel

Recurrence of the vesicular phase of incontinentia pigmenti (shown on an infant's leg) typically lasts 1–2 weeks.

Source Photo courtesy Dr. Dawn Siegel

PORTLAND, ORE. — If an infant presents with at least three hypopigmented macules, think tuberous sclerosis.

Tuberous sclerosis is described as a triad of neurologic impairment, multisystem hamartomas, and skin findings (such as ash leaf macules and facial angiofibromas). The disease is of autosomal dominant inheritance, with an incidence of 1:6,000 to 1:10,000. Spontaneous mutation occurs in 50%-75% of cases.

Ash leaf spots or hypopigmented macules occur in 90% of patients with the disease, Dr. Dawn Siegel said at the annual meeting of the Pacific Dermatologic Association. They can range in size from 1 to 12 cm in diameter and “are rounded at one end and tapered at the other, resembling the leaf of an ash tree. They can vary quite a bit in their presentation. In some cases, they present as confetti macules, which are only 1–2 mm in diameter,” she said.

If an infant presents with more than three hypopigmented macules, she recommends screening evaluations, which could include a renal ultrasound, an eye exam, and a cardiac echocardiogram. “I usually reserve head MRI or CT for babies who are developing seizures, or who have a positive finding on one of the other screening tests, or if I have a high clinical suspicion,” said Dr. Siegel, assistant professor of dermatology and pediatrics at Oregon Health and Science University, Portland.

Infantile spasms, the most common presenting neurologic sign, tend to develop by 4–5 months of age in about 70% of patients.

Establishing a definitive diagnosis of tuberous sclerosis requires the presence of two major clinical diagnostic criteria or one major and two minor criteria.

Major criteria include facial angiofibromas or forehead plaque, nontraumatic ungual fibroma, three or more hypomelanotic macules, shagreen patch (most commonly on the torso and chest), multiple retinal nodular hamartomas, cortical tuber, subependymal nodule, subependymal giant cell astrocytoma, single or multiple cardiac rhabdomyoma, renal angiomyolipoma, and pulmonary lymphangiomyomatosis, said Dr. Siegel.

Minor clinical criteria include multiple randomly distributed pits in dental enamel, hamartomatous rectal polyps, bone cysts, cerebral white matter radial migration lines, gingival fibromas, nonrenal hamartoma, retinal achromic patch, “confetti” skin lesions, and multiple renal cysts.

Current treatments for the facial angiofibromas include pulsed dye laser and pulsed KTP (532 nm) laser. “Some people use a CO₂ laser or the erbium: YAG laser to try and flatten down the lesions,” Dr. Siegel said.

Studies of oral and topical rapamycin are underway after a published case report demonstrated that the agent significantly improved angiofibroma lesions in a patient with tuberous sclerosis complex who took rapamycin after undergoing renal transplantation (Br. J. Dermatol. 2008;159:473–5).

“This would be exciting, because angiofibromas are so disfiguring and treatment has been frustrating,” she said.

Incontinentia Pigmenti

Dr. Siegel went on to discuss incontinentia pigmenti, which is caused by a genomic rearrangement of the gene for nuclear factor kappa B essential modulator and has an incidence of 1:40,000. The skin disorder is marked by four stages that occur in most patients.

In stage I, vesicles in linear streaks follow the lines of Blaschko. These lesions are present at birth in 50% of cases and wax and wane for up to 1 year. In stage II, verrucous-hyperkeratotic streaks usually appear at 2–6 months of age. Stage III is marked by hyperpigmentation in streaks along the lines of Blaschko in a so-called “marble-cake pattern,” she said.

Cutaneous findings in stage IV typically involve atrophy and hypopigmentation that may be subtle. Affected infants may have a lack of hair along the lines of Blaschko.

Recurrence of the vesicular phase may occur, but this typically lasts only 1–2 weeks and is often preceded by a viral illness. “Sometimes these lesions are mistaken for herpes zoster,” Dr. Siegel noted.

Additional findings of incontinentia pigmenti may include scarring alopecia, most commonly on the vertex; conical or peg-shaped teeth; absence of teeth; nail dystrophy; and abnormal sweating.

“The management of incontinentia pigmenti in the newborn period should focus on skin care with emollients and monitoring for skin infection,” she said.

“Topical steroids can sometimes be beneficial for symptomatic relief in the verrucous phase. Referral to an ophthalmologist for a retinal exam is important. If neurologic symptoms are present, then evaluation includes an EEG and an MRI,” she added.

Neurofibromatosis Type 1

Dr. Siegel concluded her presentation by discussing neurofibromatosis type 1 (NF1), a multisystem disorder caused by a mutation of a gene on the long arm of chromosome 17 that occurs in about 1 in 4,000 births.

According to the 1988 National Institutes of Health Consensus Development Conference, a diagnosis of NF1 requires two or more of the following clinical features: six or more café-au-lait macules, two or more neurofibromas or one or more plexiform neurofibromas, freckling in the axilla and inguinal region (Crowe's sign), tumor of the optic nerve pathway, two or more Lisch nodules (iris hamartomas), and distinctive osseous lesions.

Café-au-lait macules, the hallmark clinical feature, are present in nearly all cases. The size is age dependent, with macules typically exceeding 5 mm in prepubertal children and 15 mm in postpubertal children.

“They often appear in the first few months of life and increase in number over the first couple of years of life,” Dr. Siegel said.

Axillary or inguinal freckling tends to present later in childhood, while neurofibromas begin to appear in childhood or later. “They are not usually present in infancy,” she said. “They increase in number in puberty and during pregnancy.”

Plexiform neurofibromas present in about 25% of cases in infancy. They can have associated hypertrichosis and hyperpigmentation, and can run along the lines of nerves. “It's difficult to excise them for that reason,” she said.

Plexiform neurofibromas also can be painful and, although rare, there is a risk that they will develop a malignant peripheral nerve sheath tumor.

“Because they're difficult to completely excise, it's always hard to know when they develop to cancer in the plexiform neurofibroma, or if the lesion is just growing,” she noted.

“There are a lot of clinical trials going on right now looking at various medical, nonsurgical treatments for plexiform neurofibromas,” Dr. Siegel added.

Dermatologic exams for children with NF1 should include evaluation for the presence of café-au-lait spots, neurofibromas, plexiform neurofibromas, and skinfold freckling. “Enlarging or disfiguring plexiform neurofibromas may require referral to a surgical specialist to discuss debulking or to a specialty center for enrollment in a clinical trial,” she said.

Dr. Siegel disclosed having no relevant conflicts of interest.

Viral illness can precede recurrence of the vesicular phase of incontinentia pigmenti (shown on an infant's arm).

Source Photo courtesy Dr. Dawn Siegel

Recurrence of the vesicular phase of incontinentia pigmenti (shown on an infant's leg) typically lasts 1–2 weeks.

Source Photo courtesy Dr. Dawn Siegel

PORTLAND, ORE. — If an infant presents with at least three hypopigmented macules, think tuberous sclerosis.

Tuberous sclerosis is described as a triad of neurologic impairment, multisystem hamartomas, and skin findings (such as ash leaf macules and facial angiofibromas). The disease is of autosomal dominant inheritance, with an incidence of 1:6,000 to 1:10,000. Spontaneous mutation occurs in 50%-75% of cases.

Ash leaf spots or hypopigmented macules occur in 90% of patients with the disease, Dr. Dawn Siegel said at the annual meeting of the Pacific Dermatologic Association. They can range in size from 1 to 12 cm in diameter and “are rounded at one end and tapered at the other, resembling the leaf of an ash tree. They can vary quite a bit in their presentation. In some cases, they present as confetti macules, which are only 1–2 mm in diameter,” she said.

If an infant presents with more than three hypopigmented macules, she recommends screening evaluations, which could include a renal ultrasound, an eye exam, and a cardiac echocardiogram. “I usually reserve head MRI or CT for babies who are developing seizures, or who have a positive finding on one of the other screening tests, or if I have a high clinical suspicion,” said Dr. Siegel, assistant professor of dermatology and pediatrics at Oregon Health and Science University, Portland.

Infantile spasms, the most common presenting neurologic sign, tend to develop by 4–5 months of age in about 70% of patients.

Establishing a definitive diagnosis of tuberous sclerosis requires the presence of two major clinical diagnostic criteria or one major and two minor criteria.

Major criteria include facial angiofibromas or forehead plaque, nontraumatic ungual fibroma, three or more hypomelanotic macules, shagreen patch (most commonly on the torso and chest), multiple retinal nodular hamartomas, cortical tuber, subependymal nodule, subependymal giant cell astrocytoma, single or multiple cardiac rhabdomyoma, renal angiomyolipoma, and pulmonary lymphangiomyomatosis, said Dr. Siegel.

Minor clinical criteria include multiple randomly distributed pits in dental enamel, hamartomatous rectal polyps, bone cysts, cerebral white matter radial migration lines, gingival fibromas, nonrenal hamartoma, retinal achromic patch, “confetti” skin lesions, and multiple renal cysts.

Current treatments for the facial angiofibromas include pulsed dye laser and pulsed KTP (532 nm) laser. “Some people use a CO₂ laser or the erbium: YAG laser to try and flatten down the lesions,” Dr. Siegel said.

Studies of oral and topical rapamycin are underway after a published case report demonstrated that the agent significantly improved angiofibroma lesions in a patient with tuberous sclerosis complex who took rapamycin after undergoing renal transplantation (Br. J. Dermatol. 2008;159:473–5).

“This would be exciting, because angiofibromas are so disfiguring and treatment has been frustrating,” she said.

Incontinentia Pigmenti

Dr. Siegel went on to discuss incontinentia pigmenti, which is caused by a genomic rearrangement of the gene for nuclear factor kappa B essential modulator and has an incidence of 1:40,000. The skin disorder is marked by four stages that occur in most patients.

In stage I, vesicles in linear streaks follow the lines of Blaschko. These lesions are present at birth in 50% of cases and wax and wane for up to 1 year. In stage II, verrucous-hyperkeratotic streaks usually appear at 2–6 months of age. Stage III is marked by hyperpigmentation in streaks along the lines of Blaschko in a so-called “marble-cake pattern,” she said.

Cutaneous findings in stage IV typically involve atrophy and hypopigmentation that may be subtle. Affected infants may have a lack of hair along the lines of Blaschko.

Recurrence of the vesicular phase may occur, but this typically lasts only 1–2 weeks and is often preceded by a viral illness. “Sometimes these lesions are mistaken for herpes zoster,” Dr. Siegel noted.

Additional findings of incontinentia pigmenti may include scarring alopecia, most commonly on the vertex; conical or peg-shaped teeth; absence of teeth; nail dystrophy; and abnormal sweating.

“The management of incontinentia pigmenti in the newborn period should focus on skin care with emollients and monitoring for skin infection,” she said.

“Topical steroids can sometimes be beneficial for symptomatic relief in the verrucous phase. Referral to an ophthalmologist for a retinal exam is important. If neurologic symptoms are present, then evaluation includes an EEG and an MRI,” she added.

Neurofibromatosis Type 1

Dr. Siegel concluded her presentation by discussing neurofibromatosis type 1 (NF1), a multisystem disorder caused by a mutation of a gene on the long arm of chromosome 17 that occurs in about 1 in 4,000 births.

According to the 1988 National Institutes of Health Consensus Development Conference, a diagnosis of NF1 requires two or more of the following clinical features: six or more café-au-lait macules, two or more neurofibromas or one or more plexiform neurofibromas, freckling in the axilla and inguinal region (Crowe's sign), tumor of the optic nerve pathway, two or more Lisch nodules (iris hamartomas), and distinctive osseous lesions.

Café-au-lait macules, the hallmark clinical feature, are present in nearly all cases. The size is age dependent, with macules typically exceeding 5 mm in prepubertal children and 15 mm in postpubertal children.

“They often appear in the first few months of life and increase in number over the first couple of years of life,” Dr. Siegel said.

Axillary or inguinal freckling tends to present later in childhood, while neurofibromas begin to appear in childhood or later. “They are not usually present in infancy,” she said. “They increase in number in puberty and during pregnancy.”

Plexiform neurofibromas present in about 25% of cases in infancy. They can have associated hypertrichosis and hyperpigmentation, and can run along the lines of nerves. “It's difficult to excise them for that reason,” she said.

Plexiform neurofibromas also can be painful and, although rare, there is a risk that they will develop a malignant peripheral nerve sheath tumor.

“Because they're difficult to completely excise, it's always hard to know when they develop to cancer in the plexiform neurofibroma, or if the lesion is just growing,” she noted.

“There are a lot of clinical trials going on right now looking at various medical, nonsurgical treatments for plexiform neurofibromas,” Dr. Siegel added.

Dermatologic exams for children with NF1 should include evaluation for the presence of café-au-lait spots, neurofibromas, plexiform neurofibromas, and skinfold freckling. “Enlarging or disfiguring plexiform neurofibromas may require referral to a surgical specialist to discuss debulking or to a specialty center for enrollment in a clinical trial,” she said.

Dr. Siegel disclosed having no relevant conflicts of interest.

Viral illness can precede recurrence of the vesicular phase of incontinentia pigmenti (shown on an infant's arm).

Source Photo courtesy Dr. Dawn Siegel

Recurrence of the vesicular phase of incontinentia pigmenti (shown on an infant's leg) typically lasts 1–2 weeks.

Source Photo courtesy Dr. Dawn Siegel

The way Dr. Joseph Kim sees it, influenza vaccine development needs an extreme makeover.

"Every year, three flu strains are selected by the flu experts around the world, which determines which strains the vaccine makers should make," Dr. Kim, president and CEO of San Diego–based Inovio Biomedical Corp., said in an interview. "They can guess right, or they can guess wrong, but every year, you have to change the vaccine." He wants to change that paradigm.

Since 2005, he and his associates at Inovio have been developing DNA-based influenza vaccines capable of providing broad protection against existing as well as newly emerging, unknown seasonal and pandemic influenza strains. To design vaccines, the company developed a process known as SynCon, a way of targeting consensus proteins from multiple strains of H1N1, H2N2, H3N2, and H5N1, "which have collectively caused greater than 90% of all seasonal and pandemic flu events in people in the last 100-plus years," Dr. Kim said.

What separates Inovio's SynCon approach from that of other DNA vaccine manufacturers is that the SynCon vaccines demonstrate potential to protect against new strains that do not specifically match the vaccine. "So, if the 2009 H1N1 virus mutates, there is no plan B," Dr. Kim said. "There is no backup option; 2009 swine flu could be a big problem or not."

Origins of an Alternative

DNA-based influenza vaccines began to draw serious attention about 6 years ago, when infectious diseases experts around the globe expressed concern about a pandemic of H5N1 influenza virus, noted Dr. William Schaffner, chair of the department of preventive medicine at Vanderbilt University, Nashville, Tenn.

"Since that time, the United States government and private capital have gone into research to develop more improved influenza vaccines and to improve the vaccine technology. There has been more research into those areas in the past 5 or 6 years than there has been in the previous 50 years," said Dr. Schaffner.

The concept of DNA vaccines first emerged in the early 1990s, when academic scientists discovered that immunizing animals with plasmids—a circular string of DNA that encodes for a specific antigen or vaccine target—generates vaccine responses.

"The beauty of this technology is speed," said Vijay B. Samant, president and CEO of San Diego–based Vical, which develops DNA vaccines. "It's not cell culture. It's not egg-based. It's simple fermentation and two purification steps. It does not require the manufacturer to handle the pathogen. All it needs is a gene sequence; that's good enough for us to make the vaccine."

Instead of viruses, "you're taking a very simple plasmid … and you're putting in a genetic blueprint designed for a specific target, in this case hemagglutinin," Dr. Kim explained. Once injected, "it uses our own cellular machinery to manufacture those proteins as antigens, and presents them in a customized way. It's like mimicking viral infection without the side effects and replication. DNA vaccines can never replicate. They do not infect; they do not cause disease, ever."

Delivery Poses Challenges

Until recently, Dr. Kim and other researchers in the field faced a barrier to the advancement of DNA vaccines: inefficient delivery. However, a technology developed in the 1990s known as in vivo electroporation is proving to be an effective way to deliver DNA vaccines.

Electroporation works like this: After a DNA vaccine is injected via syringe into the upper arm or into skin, a short, controlled electrical pulse is delivered directly into that tissue. This "coaxes the cell membranes to open up their pores," Dr. Kim said. "That brings in the DNA. We remove the electric field and the pores close up. This has been shown in animal species to be effective in up to a 1,000-fold increase in DNA vaccine uptake."

Not all DNA vaccine manufacturers are using electroporation.

Vical, the first company to produce a vaccine against the pandemic influenza A(H1N1) virus after initial reports of outbreaks in Mexico, uses a patented adjuvant known as Vaxfectin, "which does an amazing job of protecting the DNA before it enters the skeletal muscle cells," Mr. Samant said. "Being a proinflammatory, it attracts the immune system toward the site of the injection to facilitate creation of the right immune response and immune memory."

Phase I Trials Begin

In October, the U.S. Navy awarded Vical a contract to support a phase I clinical trial of its vaccine against H1N1 influenza. "Our goal is to get that trial done by later this year," Mr. Samant said.

In a virus challenge and protection study of Inovio's SynCon H1N1 vaccine, mice were injected with the H1N1 virus that caused the 1918 Spanish flu. Mice that received the H1N1 vaccine were completely protected from the virus, whereas all of the unvaccinated animals died within 1 week.

In 2010, the SynCon H5N1 vaccine will undergo human testing in healthy volunteers, followed by tests in combination with the SynCon H1N1 vaccine.

Potential Pitfall

"If we are correct, we can revolutionize how flu vaccines are made and delivered," Dr. Kim said. One potential pitfall of the DNA vaccine technology is the impending backlash from vaccine naysayers, cautioned Dr. Schaffner. "We have a hardcore group of vaccine skeptics," he said. "Any innovation, whether it is the addition of an adjuvant, or a new technology such as this, will come to their attention and draw some of their skepticism and opposition. We have to brace for this."

Dr. Schaffner has been a consultant for various vaccine manufacturers. He also is a member of a data safety committee for Merck for experimental vaccines.

'DNA vaccines can never replicate. They do not infect; they do not cause disease, ever.'

Source DR. KIM

The way Dr. Joseph Kim sees it, influenza vaccine development needs an extreme makeover.

"Every year, three flu strains are selected by the flu experts around the world, which determines which strains the vaccine makers should make," Dr. Kim, president and CEO of San Diego–based Inovio Biomedical Corp., said in an interview. "They can guess right, or they can guess wrong, but every year, you have to change the vaccine." He wants to change that paradigm.

Since 2005, he and his associates at Inovio have been developing DNA-based influenza vaccines capable of providing broad protection against existing as well as newly emerging, unknown seasonal and pandemic influenza strains. To design vaccines, the company developed a process known as SynCon, a way of targeting consensus proteins from multiple strains of H1N1, H2N2, H3N2, and H5N1, "which have collectively caused greater than 90% of all seasonal and pandemic flu events in people in the last 100-plus years," Dr. Kim said.

What separates Inovio's SynCon approach from that of other DNA vaccine manufacturers is that the SynCon vaccines demonstrate potential to protect against new strains that do not specifically match the vaccine. "So, if the 2009 H1N1 virus mutates, there is no plan B," Dr. Kim said. "There is no backup option; 2009 swine flu could be a big problem or not."

Origins of an Alternative

DNA-based influenza vaccines began to draw serious attention about 6 years ago, when infectious diseases experts around the globe expressed concern about a pandemic of H5N1 influenza virus, noted Dr. William Schaffner, chair of the department of preventive medicine at Vanderbilt University, Nashville, Tenn.

"Since that time, the United States government and private capital have gone into research to develop more improved influenza vaccines and to improve the vaccine technology. There has been more research into those areas in the past 5 or 6 years than there has been in the previous 50 years," said Dr. Schaffner.

The concept of DNA vaccines first emerged in the early 1990s, when academic scientists discovered that immunizing animals with plasmids—a circular string of DNA that encodes for a specific antigen or vaccine target—generates vaccine responses.

"The beauty of this technology is speed," said Vijay B. Samant, president and CEO of San Diego–based Vical, which develops DNA vaccines. "It's not cell culture. It's not egg-based. It's simple fermentation and two purification steps. It does not require the manufacturer to handle the pathogen. All it needs is a gene sequence; that's good enough for us to make the vaccine."

Instead of viruses, "you're taking a very simple plasmid … and you're putting in a genetic blueprint designed for a specific target, in this case hemagglutinin," Dr. Kim explained. Once injected, "it uses our own cellular machinery to manufacture those proteins as antigens, and presents them in a customized way. It's like mimicking viral infection without the side effects and replication. DNA vaccines can never replicate. They do not infect; they do not cause disease, ever."

Delivery Poses Challenges

Until recently, Dr. Kim and other researchers in the field faced a barrier to the advancement of DNA vaccines: inefficient delivery. However, a technology developed in the 1990s known as in vivo electroporation is proving to be an effective way to deliver DNA vaccines.

Electroporation works like this: After a DNA vaccine is injected via syringe into the upper arm or into skin, a short, controlled electrical pulse is delivered directly into that tissue. This "coaxes the cell membranes to open up their pores," Dr. Kim said. "That brings in the DNA. We remove the electric field and the pores close up. This has been shown in animal species to be effective in up to a 1,000-fold increase in DNA vaccine uptake."

Not all DNA vaccine manufacturers are using electroporation.

Vical, the first company to produce a vaccine against the pandemic influenza A(H1N1) virus after initial reports of outbreaks in Mexico, uses a patented adjuvant known as Vaxfectin, "which does an amazing job of protecting the DNA before it enters the skeletal muscle cells," Mr. Samant said. "Being a proinflammatory, it attracts the immune system toward the site of the injection to facilitate creation of the right immune response and immune memory."

Phase I Trials Begin

In October, the U.S. Navy awarded Vical a contract to support a phase I clinical trial of its vaccine against H1N1 influenza. "Our goal is to get that trial done by later this year," Mr. Samant said.

In a virus challenge and protection study of Inovio's SynCon H1N1 vaccine, mice were injected with the H1N1 virus that caused the 1918 Spanish flu. Mice that received the H1N1 vaccine were completely protected from the virus, whereas all of the unvaccinated animals died within 1 week.

In 2010, the SynCon H5N1 vaccine will undergo human testing in healthy volunteers, followed by tests in combination with the SynCon H1N1 vaccine.

Potential Pitfall

"If we are correct, we can revolutionize how flu vaccines are made and delivered," Dr. Kim said. One potential pitfall of the DNA vaccine technology is the impending backlash from vaccine naysayers, cautioned Dr. Schaffner. "We have a hardcore group of vaccine skeptics," he said. "Any innovation, whether it is the addition of an adjuvant, or a new technology such as this, will come to their attention and draw some of their skepticism and opposition. We have to brace for this."

Dr. Schaffner has been a consultant for various vaccine manufacturers. He also is a member of a data safety committee for Merck for experimental vaccines.

'DNA vaccines can never replicate. They do not infect; they do not cause disease, ever.'

Source DR. KIM

The way Dr. Joseph Kim sees it, influenza vaccine development needs an extreme makeover.

"Every year, three flu strains are selected by the flu experts around the world, which determines which strains the vaccine makers should make," Dr. Kim, president and CEO of San Diego–based Inovio Biomedical Corp., said in an interview. "They can guess right, or they can guess wrong, but every year, you have to change the vaccine." He wants to change that paradigm.

Since 2005, he and his associates at Inovio have been developing DNA-based influenza vaccines capable of providing broad protection against existing as well as newly emerging, unknown seasonal and pandemic influenza strains. To design vaccines, the company developed a process known as SynCon, a way of targeting consensus proteins from multiple strains of H1N1, H2N2, H3N2, and H5N1, "which have collectively caused greater than 90% of all seasonal and pandemic flu events in people in the last 100-plus years," Dr. Kim said.

What separates Inovio's SynCon approach from that of other DNA vaccine manufacturers is that the SynCon vaccines demonstrate potential to protect against new strains that do not specifically match the vaccine. "So, if the 2009 H1N1 virus mutates, there is no plan B," Dr. Kim said. "There is no backup option; 2009 swine flu could be a big problem or not."

Origins of an Alternative

DNA-based influenza vaccines began to draw serious attention about 6 years ago, when infectious diseases experts around the globe expressed concern about a pandemic of H5N1 influenza virus, noted Dr. William Schaffner, chair of the department of preventive medicine at Vanderbilt University, Nashville, Tenn.

"Since that time, the United States government and private capital have gone into research to develop more improved influenza vaccines and to improve the vaccine technology. There has been more research into those areas in the past 5 or 6 years than there has been in the previous 50 years," said Dr. Schaffner.

The concept of DNA vaccines first emerged in the early 1990s, when academic scientists discovered that immunizing animals with plasmids—a circular string of DNA that encodes for a specific antigen or vaccine target—generates vaccine responses.

"The beauty of this technology is speed," said Vijay B. Samant, president and CEO of San Diego–based Vical, which develops DNA vaccines. "It's not cell culture. It's not egg-based. It's simple fermentation and two purification steps. It does not require the manufacturer to handle the pathogen. All it needs is a gene sequence; that's good enough for us to make the vaccine."

Instead of viruses, "you're taking a very simple plasmid … and you're putting in a genetic blueprint designed for a specific target, in this case hemagglutinin," Dr. Kim explained. Once injected, "it uses our own cellular machinery to manufacture those proteins as antigens, and presents them in a customized way. It's like mimicking viral infection without the side effects and replication. DNA vaccines can never replicate. They do not infect; they do not cause disease, ever."

Delivery Poses Challenges

Until recently, Dr. Kim and other researchers in the field faced a barrier to the advancement of DNA vaccines: inefficient delivery. However, a technology developed in the 1990s known as in vivo electroporation is proving to be an effective way to deliver DNA vaccines.

Electroporation works like this: After a DNA vaccine is injected via syringe into the upper arm or into skin, a short, controlled electrical pulse is delivered directly into that tissue. This "coaxes the cell membranes to open up their pores," Dr. Kim said. "That brings in the DNA. We remove the electric field and the pores close up. This has been shown in animal species to be effective in up to a 1,000-fold increase in DNA vaccine uptake."

Not all DNA vaccine manufacturers are using electroporation.

Vical, the first company to produce a vaccine against the pandemic influenza A(H1N1) virus after initial reports of outbreaks in Mexico, uses a patented adjuvant known as Vaxfectin, "which does an amazing job of protecting the DNA before it enters the skeletal muscle cells," Mr. Samant said. "Being a proinflammatory, it attracts the immune system toward the site of the injection to facilitate creation of the right immune response and immune memory."

Phase I Trials Begin

In October, the U.S. Navy awarded Vical a contract to support a phase I clinical trial of its vaccine against H1N1 influenza. "Our goal is to get that trial done by later this year," Mr. Samant said.

In a virus challenge and protection study of Inovio's SynCon H1N1 vaccine, mice were injected with the H1N1 virus that caused the 1918 Spanish flu. Mice that received the H1N1 vaccine were completely protected from the virus, whereas all of the unvaccinated animals died within 1 week.

In 2010, the SynCon H5N1 vaccine will undergo human testing in healthy volunteers, followed by tests in combination with the SynCon H1N1 vaccine.

Potential Pitfall

"If we are correct, we can revolutionize how flu vaccines are made and delivered," Dr. Kim said. One potential pitfall of the DNA vaccine technology is the impending backlash from vaccine naysayers, cautioned Dr. Schaffner. "We have a hardcore group of vaccine skeptics," he said. "Any innovation, whether it is the addition of an adjuvant, or a new technology such as this, will come to their attention and draw some of their skepticism and opposition. We have to brace for this."

Dr. Schaffner has been a consultant for various vaccine manufacturers. He also is a member of a data safety committee for Merck for experimental vaccines.

'DNA vaccines can never replicate. They do not infect; they do not cause disease, ever.'

Source DR. KIM

San Francisco — A newly approved cream containing 5% acyclovir and 1% hydrocortisone prevented ulcerated lesions in patients with recurrent herpes simplex labialis, compared with both topical acyclovir and placebo, a large multicenter study showed.

The product, ME-609 (Lipsovir), was approved for marketing in the United States in late July and is indicated for the early treatment of recurrent herpes labialis (cold sores) to reduce the likelihood of ulcerative cold sores and to shorten lesion healing time.

"This is the first product to prevent the development of cold sores," Dr. Spotswood L. Spruance said in an interview during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. "Other products have been shown to reduce the duration of the disease, but this has been shown to block the development of ulcers and blisters."

Developed by Medivir of Huddinge, Sweden, ME-609 is not yet available in the United States because Medivir has not yet partnered with a company to distribute and market the product. A company spokeswoman estimated that ME-609 would be available in the United States some time in 2010.

For the study, researchers led by Dr. Christopher M. Hull of the department of dermatology at the University of Utah, Salt Lake City, randomized 1,443 patients aged 18 years and older with at least three episodes of herpes simplex labialis to one of three treatment groups: ME-609 vehicle containing 5% acyclovir and 1% hydrocortisone (n=601), acyclovir alone in ME-609 vehicle (n=610), or placebo (n=232).

The patients were instructed to start treatment at home five times daily for 5 days at the earliest sign or symptom of their next recurrence of herpes simplex labialis, and to keep a diary of symptoms.

The mean age of patients was 44 years, and 28% were male.

Dr. Spruance of the division of infectious diseases at the University of Utah reported that, at the end of treatment, the proportion of patients with nonulcerative recurrences was 42% in the ME-609 group, compared with 35% for acyclovir and 26% for placebo.

Among patients who developed an ulcerative lesion despite treatment, the duration of lesions was reduced by ME-609 to a similar extent as acyclovir alone (a mean of 5.7 days vs. a mean of 5.9 days, respectively); both were significantly shorter than placebo (a mean of 6.5 days), he said at the meeting, which was sponsored by the American Society for Microbiology.

Lesion healing time was reduced by ME-609 to a similar extent as acyclovir alone (a mean of 9.6 days vs. 9.9 days, respectively), with both significantly shorter than placebo (11 days).

The cumulative lesion area was reduced by one-half in the ME-609 group, compared with the placebo group, and the differences in cumulative lesion area between ME-609 and the other two groups were statistically significant.

Frequency of secondary herpes recurrences was 5% in the ME-609 group, 7% in the acyclovir group, and 7% in the placebo group, while the proportion of patients with positive viral cultures was 22%, 24%, and 40%, respectively.

The frequency and nature of adverse events was similar between the groups.

Medivir funded the study. Dr. Spruance disclosed that he is a paid consultant for the company.

This product 'has been shown to block the development of ulcers and blisters.'

Source DR. SPRUANCE

San Francisco — A newly approved cream containing 5% acyclovir and 1% hydrocortisone prevented ulcerated lesions in patients with recurrent herpes simplex labialis, compared with both topical acyclovir and placebo, a large multicenter study showed.

The product, ME-609 (Lipsovir), was approved for marketing in the United States in late July and is indicated for the early treatment of recurrent herpes labialis (cold sores) to reduce the likelihood of ulcerative cold sores and to shorten lesion healing time.

"This is the first product to prevent the development of cold sores," Dr. Spotswood L. Spruance said in an interview during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. "Other products have been shown to reduce the duration of the disease, but this has been shown to block the development of ulcers and blisters."

Developed by Medivir of Huddinge, Sweden, ME-609 is not yet available in the United States because Medivir has not yet partnered with a company to distribute and market the product. A company spokeswoman estimated that ME-609 would be available in the United States some time in 2010.

For the study, researchers led by Dr. Christopher M. Hull of the department of dermatology at the University of Utah, Salt Lake City, randomized 1,443 patients aged 18 years and older with at least three episodes of herpes simplex labialis to one of three treatment groups: ME-609 vehicle containing 5% acyclovir and 1% hydrocortisone (n=601), acyclovir alone in ME-609 vehicle (n=610), or placebo (n=232).

The patients were instructed to start treatment at home five times daily for 5 days at the earliest sign or symptom of their next recurrence of herpes simplex labialis, and to keep a diary of symptoms.

The mean age of patients was 44 years, and 28% were male.

Dr. Spruance of the division of infectious diseases at the University of Utah reported that, at the end of treatment, the proportion of patients with nonulcerative recurrences was 42% in the ME-609 group, compared with 35% for acyclovir and 26% for placebo.

Among patients who developed an ulcerative lesion despite treatment, the duration of lesions was reduced by ME-609 to a similar extent as acyclovir alone (a mean of 5.7 days vs. a mean of 5.9 days, respectively); both were significantly shorter than placebo (a mean of 6.5 days), he said at the meeting, which was sponsored by the American Society for Microbiology.

Lesion healing time was reduced by ME-609 to a similar extent as acyclovir alone (a mean of 9.6 days vs. 9.9 days, respectively), with both significantly shorter than placebo (11 days).

The cumulative lesion area was reduced by one-half in the ME-609 group, compared with the placebo group, and the differences in cumulative lesion area between ME-609 and the other two groups were statistically significant.

Frequency of secondary herpes recurrences was 5% in the ME-609 group, 7% in the acyclovir group, and 7% in the placebo group, while the proportion of patients with positive viral cultures was 22%, 24%, and 40%, respectively.

The frequency and nature of adverse events was similar between the groups.

Medivir funded the study. Dr. Spruance disclosed that he is a paid consultant for the company.

This product 'has been shown to block the development of ulcers and blisters.'

Source DR. SPRUANCE

San Francisco — A newly approved cream containing 5% acyclovir and 1% hydrocortisone prevented ulcerated lesions in patients with recurrent herpes simplex labialis, compared with both topical acyclovir and placebo, a large multicenter study showed.

The product, ME-609 (Lipsovir), was approved for marketing in the United States in late July and is indicated for the early treatment of recurrent herpes labialis (cold sores) to reduce the likelihood of ulcerative cold sores and to shorten lesion healing time.

"This is the first product to prevent the development of cold sores," Dr. Spotswood L. Spruance said in an interview during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. "Other products have been shown to reduce the duration of the disease, but this has been shown to block the development of ulcers and blisters."

Developed by Medivir of Huddinge, Sweden, ME-609 is not yet available in the United States because Medivir has not yet partnered with a company to distribute and market the product. A company spokeswoman estimated that ME-609 would be available in the United States some time in 2010.

For the study, researchers led by Dr. Christopher M. Hull of the department of dermatology at the University of Utah, Salt Lake City, randomized 1,443 patients aged 18 years and older with at least three episodes of herpes simplex labialis to one of three treatment groups: ME-609 vehicle containing 5% acyclovir and 1% hydrocortisone (n=601), acyclovir alone in ME-609 vehicle (n=610), or placebo (n=232).

The patients were instructed to start treatment at home five times daily for 5 days at the earliest sign or symptom of their next recurrence of herpes simplex labialis, and to keep a diary of symptoms.

The mean age of patients was 44 years, and 28% were male.

Dr. Spruance of the division of infectious diseases at the University of Utah reported that, at the end of treatment, the proportion of patients with nonulcerative recurrences was 42% in the ME-609 group, compared with 35% for acyclovir and 26% for placebo.

Among patients who developed an ulcerative lesion despite treatment, the duration of lesions was reduced by ME-609 to a similar extent as acyclovir alone (a mean of 5.7 days vs. a mean of 5.9 days, respectively); both were significantly shorter than placebo (a mean of 6.5 days), he said at the meeting, which was sponsored by the American Society for Microbiology.

Lesion healing time was reduced by ME-609 to a similar extent as acyclovir alone (a mean of 9.6 days vs. 9.9 days, respectively), with both significantly shorter than placebo (11 days).

The cumulative lesion area was reduced by one-half in the ME-609 group, compared with the placebo group, and the differences in cumulative lesion area between ME-609 and the other two groups were statistically significant.

Frequency of secondary herpes recurrences was 5% in the ME-609 group, 7% in the acyclovir group, and 7% in the placebo group, while the proportion of patients with positive viral cultures was 22%, 24%, and 40%, respectively.

The frequency and nature of adverse events was similar between the groups.

Medivir funded the study. Dr. Spruance disclosed that he is a paid consultant for the company.

This product 'has been shown to block the development of ulcers and blisters.'

Source DR. SPRUANCE

According to Dr. Joel Ang, his vocation as a full-time family physician and his avocation as a violinist are irrevocably intertwined.

In family medicine, he explained, “you have to think of a patient as someone who is multidimensional. In music, you do the same thing. You're trying to put things together, trying to work on very specific details of that piece. I learn a lot of medicine through the music and playing the violin because you have to think that way. The thought process is the same.”

Born in the Philippines, Dr. Ang was raised in Raleigh, N.C., where he started playing violin at the age of 12 years in an orchestra at the public school he attended and went on to excel with the instrument. He enrolled in music camps each summer, played in state orchestras in high school, and earned a spot in the Duke University Symphony in Durham, N.C., as a college undergraduate.

He kept playing during medical school—though not as much as he would have liked—and viewed his avocation as “a way to keep stress from building up.”

As he improved, he became intrigued by the technical demands of the violin, noting that “a lot of brain power and technical work is required before you achieve proficiency with the instrument,” said Dr. Ang, who practices family medicine in Washington. “You're using a lot more of your right brain in actually producing that, letting that happen. Allowing emotion to come out of the instrument is an incredible experience.”

These days, Dr. Ang is a violinist with the Washington Metropolitan Philharmonic Association orchestra and serves as its associate concertmaster (www.wmpamusic.orgwww.world-doctors-orchestra.org

“The music our conductor chose was pretty difficult, a piece by [the late composer] Gustav Mahler,” he said. “The symphony was about 75 minutes long, and we only had 4 days to rehearse before the performance. We played from 9 a.m. until about 6 p.m. each day. It was a pretty intense time, but it was good because I shared it with close to 100 other physicians. It was inspirational to me.”

Dr. Ang practices on a daily basis and is currently taking private lessons from a violinist with the National Symphony Orchestra. “I keep myself pretty full with the music,” he said. “The good thing is that I think it really balances out my life, and I meet incredible people. I feel extremely fortunate.”

Steered Clear of Burnout

When Dr. Marilyn Kellam started practicing internal medicine in 1985, she quickly realized that she could easily become a “serious workaholic” if she didn't find an outlet for creativity.

“I could see it coming that I could spend all of my time in the hospital taking care of patients,” said Dr. Kellam, who currently practices at Shore Memorial Hospital in Nassawadox, Va.

Her outlet became singing, an avocation she pursued after attending a production of “The Fantasticks” at the local Trawler Dinner Theater. The cast members “looked like they were having so much fun,” recalled Dr. Kellam. After the show, attendees were informed that the theatre's next production would be Camelot. Dr. Kellam decided that she “would like to get involved with that show in some way,” so she auditioned and earned a role as a tree.

“I also got a part as a singer and dancer as part of the chorus,” she said. “At the first rehearsal, I was totally hooked.”

Mindful that she would benefit from professional voice training she enrolled at the University of Maryland Eastern Shore in Princess Anne and took personal lessons from voice teacher Dr. Gerald W. Johnson for several years, developing a proficiency in classical music style. She performed in about 35 productions at the Trawler Dinner Theater before it closed in 2000.

Determined to pursue singing as a creative outlet, she auditioned for a role in a production of Turandot staged by the Norfolk-based Virginia Opera (

www.vaopera.org

“When I'm involved with an opera it only involves 2 months of my time,” she said. “But it's an intense amount of time. It involves rehearsals Monday, Tuesday, and Saturday, and commuting 60 miles each way.”

Some patients who are aware of her avocation worry about losing their physician to a career in music, but Dr. Kellam assures them she's not about to leave medicine. “If I had to make my living as a musician, it would lose the joy, because now it's just that: sheer joy,” she said. “I don't have to worry about the business of music.

Dr. Marilyn Kellam played Carrie Pipperidge in “Carousel.”

Source Courtesy Virginia Opera

Dr. Joel Ang is a member of the World Doctors Orchestra, which convenes twice a year to perform concerts for charity.

Source Courtesy World Doctors Orchestra

According to Dr. Joel Ang, his vocation as a full-time family physician and his avocation as a violinist are irrevocably intertwined.

In family medicine, he explained, “you have to think of a patient as someone who is multidimensional. In music, you do the same thing. You're trying to put things together, trying to work on very specific details of that piece. I learn a lot of medicine through the music and playing the violin because you have to think that way. The thought process is the same.”

Born in the Philippines, Dr. Ang was raised in Raleigh, N.C., where he started playing violin at the age of 12 years in an orchestra at the public school he attended and went on to excel with the instrument. He enrolled in music camps each summer, played in state orchestras in high school, and earned a spot in the Duke University Symphony in Durham, N.C., as a college undergraduate.

He kept playing during medical school—though not as much as he would have liked—and viewed his avocation as “a way to keep stress from building up.”

As he improved, he became intrigued by the technical demands of the violin, noting that “a lot of brain power and technical work is required before you achieve proficiency with the instrument,” said Dr. Ang, who practices family medicine in Washington. “You're using a lot more of your right brain in actually producing that, letting that happen. Allowing emotion to come out of the instrument is an incredible experience.”

These days, Dr. Ang is a violinist with the Washington Metropolitan Philharmonic Association orchestra and serves as its associate concertmaster (www.wmpamusic.orgwww.world-doctors-orchestra.org

“The music our conductor chose was pretty difficult, a piece by [the late composer] Gustav Mahler,” he said. “The symphony was about 75 minutes long, and we only had 4 days to rehearse before the performance. We played from 9 a.m. until about 6 p.m. each day. It was a pretty intense time, but it was good because I shared it with close to 100 other physicians. It was inspirational to me.”

Dr. Ang practices on a daily basis and is currently taking private lessons from a violinist with the National Symphony Orchestra. “I keep myself pretty full with the music,” he said. “The good thing is that I think it really balances out my life, and I meet incredible people. I feel extremely fortunate.”

Steered Clear of Burnout

When Dr. Marilyn Kellam started practicing internal medicine in 1985, she quickly realized that she could easily become a “serious workaholic” if she didn't find an outlet for creativity.

“I could see it coming that I could spend all of my time in the hospital taking care of patients,” said Dr. Kellam, who currently practices at Shore Memorial Hospital in Nassawadox, Va.

Her outlet became singing, an avocation she pursued after attending a production of “The Fantasticks” at the local Trawler Dinner Theater. The cast members “looked like they were having so much fun,” recalled Dr. Kellam. After the show, attendees were informed that the theatre's next production would be Camelot. Dr. Kellam decided that she “would like to get involved with that show in some way,” so she auditioned and earned a role as a tree.

“I also got a part as a singer and dancer as part of the chorus,” she said. “At the first rehearsal, I was totally hooked.”

Mindful that she would benefit from professional voice training she enrolled at the University of Maryland Eastern Shore in Princess Anne and took personal lessons from voice teacher Dr. Gerald W. Johnson for several years, developing a proficiency in classical music style. She performed in about 35 productions at the Trawler Dinner Theater before it closed in 2000.

Determined to pursue singing as a creative outlet, she auditioned for a role in a production of Turandot staged by the Norfolk-based Virginia Opera (

www.vaopera.org

“When I'm involved with an opera it only involves 2 months of my time,” she said. “But it's an intense amount of time. It involves rehearsals Monday, Tuesday, and Saturday, and commuting 60 miles each way.”

Some patients who are aware of her avocation worry about losing their physician to a career in music, but Dr. Kellam assures them she's not about to leave medicine. “If I had to make my living as a musician, it would lose the joy, because now it's just that: sheer joy,” she said. “I don't have to worry about the business of music.

Dr. Marilyn Kellam played Carrie Pipperidge in “Carousel.”

Source Courtesy Virginia Opera

Dr. Joel Ang is a member of the World Doctors Orchestra, which convenes twice a year to perform concerts for charity.

Source Courtesy World Doctors Orchestra

According to Dr. Joel Ang, his vocation as a full-time family physician and his avocation as a violinist are irrevocably intertwined.

In family medicine, he explained, “you have to think of a patient as someone who is multidimensional. In music, you do the same thing. You're trying to put things together, trying to work on very specific details of that piece. I learn a lot of medicine through the music and playing the violin because you have to think that way. The thought process is the same.”

Born in the Philippines, Dr. Ang was raised in Raleigh, N.C., where he started playing violin at the age of 12 years in an orchestra at the public school he attended and went on to excel with the instrument. He enrolled in music camps each summer, played in state orchestras in high school, and earned a spot in the Duke University Symphony in Durham, N.C., as a college undergraduate.

He kept playing during medical school—though not as much as he would have liked—and viewed his avocation as “a way to keep stress from building up.”

As he improved, he became intrigued by the technical demands of the violin, noting that “a lot of brain power and technical work is required before you achieve proficiency with the instrument,” said Dr. Ang, who practices family medicine in Washington. “You're using a lot more of your right brain in actually producing that, letting that happen. Allowing emotion to come out of the instrument is an incredible experience.”

These days, Dr. Ang is a violinist with the Washington Metropolitan Philharmonic Association orchestra and serves as its associate concertmaster (www.wmpamusic.orgwww.world-doctors-orchestra.org

“The music our conductor chose was pretty difficult, a piece by [the late composer] Gustav Mahler,” he said. “The symphony was about 75 minutes long, and we only had 4 days to rehearse before the performance. We played from 9 a.m. until about 6 p.m. each day. It was a pretty intense time, but it was good because I shared it with close to 100 other physicians. It was inspirational to me.”

Dr. Ang practices on a daily basis and is currently taking private lessons from a violinist with the National Symphony Orchestra. “I keep myself pretty full with the music,” he said. “The good thing is that I think it really balances out my life, and I meet incredible people. I feel extremely fortunate.”

Steered Clear of Burnout

When Dr. Marilyn Kellam started practicing internal medicine in 1985, she quickly realized that she could easily become a “serious workaholic” if she didn't find an outlet for creativity.

“I could see it coming that I could spend all of my time in the hospital taking care of patients,” said Dr. Kellam, who currently practices at Shore Memorial Hospital in Nassawadox, Va.

Her outlet became singing, an avocation she pursued after attending a production of “The Fantasticks” at the local Trawler Dinner Theater. The cast members “looked like they were having so much fun,” recalled Dr. Kellam. After the show, attendees were informed that the theatre's next production would be Camelot. Dr. Kellam decided that she “would like to get involved with that show in some way,” so she auditioned and earned a role as a tree.

“I also got a part as a singer and dancer as part of the chorus,” she said. “At the first rehearsal, I was totally hooked.”

Mindful that she would benefit from professional voice training she enrolled at the University of Maryland Eastern Shore in Princess Anne and took personal lessons from voice teacher Dr. Gerald W. Johnson for several years, developing a proficiency in classical music style. She performed in about 35 productions at the Trawler Dinner Theater before it closed in 2000.

Determined to pursue singing as a creative outlet, she auditioned for a role in a production of Turandot staged by the Norfolk-based Virginia Opera (

www.vaopera.org

“When I'm involved with an opera it only involves 2 months of my time,” she said. “But it's an intense amount of time. It involves rehearsals Monday, Tuesday, and Saturday, and commuting 60 miles each way.”

Some patients who are aware of her avocation worry about losing their physician to a career in music, but Dr. Kellam assures them she's not about to leave medicine. “If I had to make my living as a musician, it would lose the joy, because now it's just that: sheer joy,” she said. “I don't have to worry about the business of music.

Dr. Marilyn Kellam played Carrie Pipperidge in “Carousel.”

Source Courtesy Virginia Opera

Dr. Joel Ang is a member of the World Doctors Orchestra, which convenes twice a year to perform concerts for charity.

Source Courtesy World Doctors Orchestra

SAN FRANCISCO — Patients with Clostridium difficile infection who were treated with the novel macrocylic antibiotic fidaxomicin had a 45% lower rate of recurrence compared with those who were treated with vancomycin.

“It's encouraging because fidaxomicin is an easier drug to take compared with the current therapies,” Dr. Yoav Golan said in an interview during a poster session at the annual meeting of the Interscience Conference on Antimicrobial Agents and Chemotherapy. “It's only twice a day dosing versus 3 and 4 times a day for metronidazole and vancomycin. Also, it seems to have a much smaller impact on emergence of resistance among gut pathogens. This was shown previously.”

The analysis involved 432 patients enrolled in a multicenter, randomized trial to compare the safety and efficacy of fidaxomicin, 200 mg every 12 hours, with vancomycin, 125 mg every 6 hours for 10 days, in patients with C. difficile infection.

Fidaxomicin (Dificid) is a minimally absorbed, narrow spectrum antibiotic with limited impact on gut flora. It has been developed by Optimer Pharmaceuticals Inc., San Diego, Calif., which sponsored the trial. Dr. Golan disclosed that his relationship with Optimer Pharmaceuticals is limited to functioning as an investigator in the fidaxomicin clinical trials.

The drug has not been approved for use in the United States. Dr. Pamela Sears, executive director of biology and preclinical trials at Optimer Pharmaceuticals, anticipates that company will file for new drug approval with the FDA by early 2011.

For the study, Dr. Golan and his associates analyzed the rate of recurrent C. difficile infection among 221 patients in the vancomycin group and 211 patients in the fidaxomicin group. This was defined as recurrence of diarrhea and positive toxin within 4 weeks after the end of therapy. The mean age of patients was 62 years.

The researchers reported that of the 432 patients, 81 (19%) had a recurrence of C. difficile infection. The overall recurrence rate was significantly lower among patients in the fidaxomicin group compared with those in the vancomycin group (13% vs. 24%, respectively). This translated into a relative reduction of 45% in the fidaxomicin group compared with the vancomycin group.

Rates of recurrence were highest in patients aged 75 years and older (31%) and in those aged 65-74 years of age (18%), and in those who were hospitalized (22% vs. 15% in outpatients).

Of the 81 patients with recurrent C. difficile infection, recurrence developed later among patients who took fidaxomicin. For example, 25% of patients in the fidaxomicin group developed recurrence within 10 days after initial treatment completion compared with 57% of patients in the vancomycin group, while 36% of patients in the fidaxomicin group developed recurrence within 21-30 days after initial treatment completion compared with 15% of patients in the vancomycin group.

The researchers also reported that the recurrence rate was significantly lower for patients in the fidaxomicin group who had not received any C. difficile infection–active antibiotics 24 hours prior to study enrollment (11%, compared with a rate of 24% for their counterparts in the vancomycin group). This finding suggests the potential for a high clinical benefit for fidaxomicin when being used as a first-line therapy, said Dr. Golan, assistant professor of medicine at Tufts Medical Center, Boston.

“The future for treating C. diff. is [to use] very narrow spectrum antibiotics compared to the very broad spectrum antibiotics we've been using,” he concluded.

The recurrence rate was 13% in the fidaxomicin group, compared with 24% in the vancomycin group.

Source DR. GOLAN

SAN FRANCISCO — Patients with Clostridium difficile infection who were treated with the novel macrocylic antibiotic fidaxomicin had a 45% lower rate of recurrence compared with those who were treated with vancomycin.

“It's encouraging because fidaxomicin is an easier drug to take compared with the current therapies,” Dr. Yoav Golan said in an interview during a poster session at the annual meeting of the Interscience Conference on Antimicrobial Agents and Chemotherapy. “It's only twice a day dosing versus 3 and 4 times a day for metronidazole and vancomycin. Also, it seems to have a much smaller impact on emergence of resistance among gut pathogens. This was shown previously.”

The analysis involved 432 patients enrolled in a multicenter, randomized trial to compare the safety and efficacy of fidaxomicin, 200 mg every 12 hours, with vancomycin, 125 mg every 6 hours for 10 days, in patients with C. difficile infection.

Fidaxomicin (Dificid) is a minimally absorbed, narrow spectrum antibiotic with limited impact on gut flora. It has been developed by Optimer Pharmaceuticals Inc., San Diego, Calif., which sponsored the trial. Dr. Golan disclosed that his relationship with Optimer Pharmaceuticals is limited to functioning as an investigator in the fidaxomicin clinical trials.

The drug has not been approved for use in the United States. Dr. Pamela Sears, executive director of biology and preclinical trials at Optimer Pharmaceuticals, anticipates that company will file for new drug approval with the FDA by early 2011.

For the study, Dr. Golan and his associates analyzed the rate of recurrent C. difficile infection among 221 patients in the vancomycin group and 211 patients in the fidaxomicin group. This was defined as recurrence of diarrhea and positive toxin within 4 weeks after the end of therapy. The mean age of patients was 62 years.

The researchers reported that of the 432 patients, 81 (19%) had a recurrence of C. difficile infection. The overall recurrence rate was significantly lower among patients in the fidaxomicin group compared with those in the vancomycin group (13% vs. 24%, respectively). This translated into a relative reduction of 45% in the fidaxomicin group compared with the vancomycin group.

Rates of recurrence were highest in patients aged 75 years and older (31%) and in those aged 65-74 years of age (18%), and in those who were hospitalized (22% vs. 15% in outpatients).

Of the 81 patients with recurrent C. difficile infection, recurrence developed later among patients who took fidaxomicin. For example, 25% of patients in the fidaxomicin group developed recurrence within 10 days after initial treatment completion compared with 57% of patients in the vancomycin group, while 36% of patients in the fidaxomicin group developed recurrence within 21-30 days after initial treatment completion compared with 15% of patients in the vancomycin group.

The researchers also reported that the recurrence rate was significantly lower for patients in the fidaxomicin group who had not received any C. difficile infection–active antibiotics 24 hours prior to study enrollment (11%, compared with a rate of 24% for their counterparts in the vancomycin group). This finding suggests the potential for a high clinical benefit for fidaxomicin when being used as a first-line therapy, said Dr. Golan, assistant professor of medicine at Tufts Medical Center, Boston.

“The future for treating C. diff. is [to use] very narrow spectrum antibiotics compared to the very broad spectrum antibiotics we've been using,” he concluded.

The recurrence rate was 13% in the fidaxomicin group, compared with 24% in the vancomycin group.

Source DR. GOLAN

SAN FRANCISCO — Patients with Clostridium difficile infection who were treated with the novel macrocylic antibiotic fidaxomicin had a 45% lower rate of recurrence compared with those who were treated with vancomycin.

“It's encouraging because fidaxomicin is an easier drug to take compared with the current therapies,” Dr. Yoav Golan said in an interview during a poster session at the annual meeting of the Interscience Conference on Antimicrobial Agents and Chemotherapy. “It's only twice a day dosing versus 3 and 4 times a day for metronidazole and vancomycin. Also, it seems to have a much smaller impact on emergence of resistance among gut pathogens. This was shown previously.”

The analysis involved 432 patients enrolled in a multicenter, randomized trial to compare the safety and efficacy of fidaxomicin, 200 mg every 12 hours, with vancomycin, 125 mg every 6 hours for 10 days, in patients with C. difficile infection.

Fidaxomicin (Dificid) is a minimally absorbed, narrow spectrum antibiotic with limited impact on gut flora. It has been developed by Optimer Pharmaceuticals Inc., San Diego, Calif., which sponsored the trial. Dr. Golan disclosed that his relationship with Optimer Pharmaceuticals is limited to functioning as an investigator in the fidaxomicin clinical trials.

The drug has not been approved for use in the United States. Dr. Pamela Sears, executive director of biology and preclinical trials at Optimer Pharmaceuticals, anticipates that company will file for new drug approval with the FDA by early 2011.

For the study, Dr. Golan and his associates analyzed the rate of recurrent C. difficile infection among 221 patients in the vancomycin group and 211 patients in the fidaxomicin group. This was defined as recurrence of diarrhea and positive toxin within 4 weeks after the end of therapy. The mean age of patients was 62 years.

The researchers reported that of the 432 patients, 81 (19%) had a recurrence of C. difficile infection. The overall recurrence rate was significantly lower among patients in the fidaxomicin group compared with those in the vancomycin group (13% vs. 24%, respectively). This translated into a relative reduction of 45% in the fidaxomicin group compared with the vancomycin group.

Rates of recurrence were highest in patients aged 75 years and older (31%) and in those aged 65-74 years of age (18%), and in those who were hospitalized (22% vs. 15% in outpatients).

Of the 81 patients with recurrent C. difficile infection, recurrence developed later among patients who took fidaxomicin. For example, 25% of patients in the fidaxomicin group developed recurrence within 10 days after initial treatment completion compared with 57% of patients in the vancomycin group, while 36% of patients in the fidaxomicin group developed recurrence within 21-30 days after initial treatment completion compared with 15% of patients in the vancomycin group.

The researchers also reported that the recurrence rate was significantly lower for patients in the fidaxomicin group who had not received any C. difficile infection–active antibiotics 24 hours prior to study enrollment (11%, compared with a rate of 24% for their counterparts in the vancomycin group). This finding suggests the potential for a high clinical benefit for fidaxomicin when being used as a first-line therapy, said Dr. Golan, assistant professor of medicine at Tufts Medical Center, Boston.

“The future for treating C. diff. is [to use] very narrow spectrum antibiotics compared to the very broad spectrum antibiotics we've been using,” he concluded.

The recurrence rate was 13% in the fidaxomicin group, compared with 24% in the vancomycin group.

Source DR. GOLAN

When Dr. Marilyn Kellam started practicing internal medicine in 1985, she quickly realized that she could easily become a “serious workaholic” if she did not find an outlet for creativity.

“I could see it coming that I could spend all of my time in the hospital taking care of patients,” said Dr. Kellam, who practices at Shore Memorial Hospital in Nassawadox, Va. “This drove me to make sure that I had a healthy mix of work and avocation and to make sure that I was more well rounded.”

That outlet became singing, an avocation she pursued after attending a production of “The Fantasticks” at the local Trawler Dinner Theater. The cast members “looked like they were having so much fun,” recalled Dr. Kellam, who took piano lessons as a youngster but no formal voice lessons. After the show, attendees were told that the theatre's next production would be “Camelot.” Dr. Kellam decided that she “would like to get involved with that show in some way,” so she auditioned and earned a role as a tree.

“It also turned out to be a part as one of the ladies of the roundtable,” she said. “I also got a part as a singer and dancer as part of the chorus. At the first rehearsal, I was totally hooked. I was sucked in.”

Mindful that she would benefit from professional voice training, she enrolled at the University of Maryland Eastern Shore in Princess Anne and took personal lessons from voice teacher Dr. Gerald W. Johnson for several years, developing a proficiency in classical music style. She performed in about 35 productions at the Trawler Dinner Theater under the direction of Judi Beck before it closed in 2000.

Determined to pursue singing as a creative outlet, she auditioned for a role in a production of “Turandot” staged by the Norfolk-based Virginia Opera (www.vaopera.org

“When I'm involved with an opera it only involves 2 months of my time,” she said. “But it's an intense amount of time. It involves rehearsals Monday, Tuesday, and Saturday, and commuting 60 miles each way.”

Dr. Kellam, who considers current voice teacher, Sondra Gelb, a key influence, described her involvement in the opera production as “pure joy, no strings attached. It's something I do for me, and there's camaraderie, a team spirit. There's a creative spirit and, of course, the magic of music, and I don't have to worry about hurting anybody.”

Her roles have varied over the years and have included Carrie Pipperidge in “Carousel,” Snoopy in “You're a Good Man, Charlie Brown,” and the Wicked Witch of the West in “The Wizard of Oz.”

Some patients who are aware of her avocation worry about losing their physician to a career in music, but Dr. Kellam assures them she's not about to leave her career in medicine. “If I had to make my living as a musician, it would lose the joy, because now it's just that: sheer joy,” she said. “I don't have to worry about the business of music. This got me involved with people who are completely uninvolved in medicine, a completely different bunch of people. I get tired of talking about medicine. Not that I don't love it and don't love my patients, but I like the nonmedical world, too.”

Finding Inspiration in Music

According to Dr. Joel Ang, his vocation as a full-time family physician and his avocation as a violinist are irrevocably intertwined.

In family medicine, he explained, “you have to think of a patient as someone who is multidimensional. In music, you do the same thing. You're trying to put things together, trying to work on very specific details of that piece. I learn a lot of medicine through the music and playing the violin because you have to think that way. The thought process is the same.”

Born in the Philippines, Dr. Ang was raised in Raleigh, N.C., where he started playing violin at the age of 12 years in an orchestra at the public school he attended and went on to excel with the instrument. He enrolled in music camps each summer, played in state orchestras in high school, and earned a spot in the Duke University Symphony in Durham, N.C., as a college undergraduate.

He kept playing during medical school—though not as much as he would have liked—and viewed his avocation as “a way to keep stress from building up.”

As he improved, he became intrigued by the technical demands of the violin, noting that “a lot of brain power and technical work is required before you achieve proficiency with the instrument,” said Dr. Ang, who practices in Washington. “You're using a lot more of your right brain in actually producing that, letting that happen. Allowing emotion to come out of the instrument is an incredible experience.”

These days, Dr. Ang is a violinist with the Washington Metropolitan Philharmonic Association orchestra and serves as its associate concertmaster (

www.wmpamusic.org

www.world-doctors-orchestra.org

“Berlin was a standout because the music our conductor chose was pretty difficult, a piece by [the late composer] Gustav Mahler,” he said. “The symphony was about 75 minutes long, and we only had 4 days to rehearse before the performance. We played from 9 a.m. until about 6 p.m. each day. It was a pretty intense time, but it was good because I shared it with close to 100 other physicians. It was inspirational to me.”

The skill set of many World Doctors Orchestra members “has been amazing,” he added. “There are people who I think probably would have been musicians but chose to practice medicine instead.”

Dr. Ang practices on a daily basis and is currently taking private lessons from a violinist with the National Symphony Orchestra. “I keep myself pretty full with the music,” he said. “The good thing is that I think it really balances out my life, and I meet incredible people. I feel extremely fortunate.”

Dr. Marilyn Kellam's theatrical roles have included Carrie in “Carousel.”

Source Courtesy Virginia Opera

When Dr. Marilyn Kellam started practicing internal medicine in 1985, she quickly realized that she could easily become a “serious workaholic” if she did not find an outlet for creativity.

“I could see it coming that I could spend all of my time in the hospital taking care of patients,” said Dr. Kellam, who practices at Shore Memorial Hospital in Nassawadox, Va. “This drove me to make sure that I had a healthy mix of work and avocation and to make sure that I was more well rounded.”

That outlet became singing, an avocation she pursued after attending a production of “The Fantasticks” at the local Trawler Dinner Theater. The cast members “looked like they were having so much fun,” recalled Dr. Kellam, who took piano lessons as a youngster but no formal voice lessons. After the show, attendees were told that the theatre's next production would be “Camelot.” Dr. Kellam decided that she “would like to get involved with that show in some way,” so she auditioned and earned a role as a tree.

“It also turned out to be a part as one of the ladies of the roundtable,” she said. “I also got a part as a singer and dancer as part of the chorus. At the first rehearsal, I was totally hooked. I was sucked in.”

Mindful that she would benefit from professional voice training, she enrolled at the University of Maryland Eastern Shore in Princess Anne and took personal lessons from voice teacher Dr. Gerald W. Johnson for several years, developing a proficiency in classical music style. She performed in about 35 productions at the Trawler Dinner Theater under the direction of Judi Beck before it closed in 2000.

Determined to pursue singing as a creative outlet, she auditioned for a role in a production of “Turandot” staged by the Norfolk-based Virginia Opera (www.vaopera.org

“When I'm involved with an opera it only involves 2 months of my time,” she said. “But it's an intense amount of time. It involves rehearsals Monday, Tuesday, and Saturday, and commuting 60 miles each way.”

Dr. Kellam, who considers current voice teacher, Sondra Gelb, a key influence, described her involvement in the opera production as “pure joy, no strings attached. It's something I do for me, and there's camaraderie, a team spirit. There's a creative spirit and, of course, the magic of music, and I don't have to worry about hurting anybody.”

Her roles have varied over the years and have included Carrie Pipperidge in “Carousel,” Snoopy in “You're a Good Man, Charlie Brown,” and the Wicked Witch of the West in “The Wizard of Oz.”

Some patients who are aware of her avocation worry about losing their physician to a career in music, but Dr. Kellam assures them she's not about to leave her career in medicine. “If I had to make my living as a musician, it would lose the joy, because now it's just that: sheer joy,” she said. “I don't have to worry about the business of music. This got me involved with people who are completely uninvolved in medicine, a completely different bunch of people. I get tired of talking about medicine. Not that I don't love it and don't love my patients, but I like the nonmedical world, too.”

Finding Inspiration in Music

According to Dr. Joel Ang, his vocation as a full-time family physician and his avocation as a violinist are irrevocably intertwined.

In family medicine, he explained, “you have to think of a patient as someone who is multidimensional. In music, you do the same thing. You're trying to put things together, trying to work on very specific details of that piece. I learn a lot of medicine through the music and playing the violin because you have to think that way. The thought process is the same.”

Born in the Philippines, Dr. Ang was raised in Raleigh, N.C., where he started playing violin at the age of 12 years in an orchestra at the public school he attended and went on to excel with the instrument. He enrolled in music camps each summer, played in state orchestras in high school, and earned a spot in the Duke University Symphony in Durham, N.C., as a college undergraduate.

He kept playing during medical school—though not as much as he would have liked—and viewed his avocation as “a way to keep stress from building up.”

As he improved, he became intrigued by the technical demands of the violin, noting that “a lot of brain power and technical work is required before you achieve proficiency with the instrument,” said Dr. Ang, who practices in Washington. “You're using a lot more of your right brain in actually producing that, letting that happen. Allowing emotion to come out of the instrument is an incredible experience.”

These days, Dr. Ang is a violinist with the Washington Metropolitan Philharmonic Association orchestra and serves as its associate concertmaster (

www.wmpamusic.org

www.world-doctors-orchestra.org

“Berlin was a standout because the music our conductor chose was pretty difficult, a piece by [the late composer] Gustav Mahler,” he said. “The symphony was about 75 minutes long, and we only had 4 days to rehearse before the performance. We played from 9 a.m. until about 6 p.m. each day. It was a pretty intense time, but it was good because I shared it with close to 100 other physicians. It was inspirational to me.”

The skill set of many World Doctors Orchestra members “has been amazing,” he added. “There are people who I think probably would have been musicians but chose to practice medicine instead.”

Dr. Ang practices on a daily basis and is currently taking private lessons from a violinist with the National Symphony Orchestra. “I keep myself pretty full with the music,” he said. “The good thing is that I think it really balances out my life, and I meet incredible people. I feel extremely fortunate.”

Dr. Marilyn Kellam's theatrical roles have included Carrie in “Carousel.”

Source Courtesy Virginia Opera

When Dr. Marilyn Kellam started practicing internal medicine in 1985, she quickly realized that she could easily become a “serious workaholic” if she did not find an outlet for creativity.

“I could see it coming that I could spend all of my time in the hospital taking care of patients,” said Dr. Kellam, who practices at Shore Memorial Hospital in Nassawadox, Va. “This drove me to make sure that I had a healthy mix of work and avocation and to make sure that I was more well rounded.”

That outlet became singing, an avocation she pursued after attending a production of “The Fantasticks” at the local Trawler Dinner Theater. The cast members “looked like they were having so much fun,” recalled Dr. Kellam, who took piano lessons as a youngster but no formal voice lessons. After the show, attendees were told that the theatre's next production would be “Camelot.” Dr. Kellam decided that she “would like to get involved with that show in some way,” so she auditioned and earned a role as a tree.

“It also turned out to be a part as one of the ladies of the roundtable,” she said. “I also got a part as a singer and dancer as part of the chorus. At the first rehearsal, I was totally hooked. I was sucked in.”

Mindful that she would benefit from professional voice training, she enrolled at the University of Maryland Eastern Shore in Princess Anne and took personal lessons from voice teacher Dr. Gerald W. Johnson for several years, developing a proficiency in classical music style. She performed in about 35 productions at the Trawler Dinner Theater under the direction of Judi Beck before it closed in 2000.

Determined to pursue singing as a creative outlet, she auditioned for a role in a production of “Turandot” staged by the Norfolk-based Virginia Opera (www.vaopera.org

“When I'm involved with an opera it only involves 2 months of my time,” she said. “But it's an intense amount of time. It involves rehearsals Monday, Tuesday, and Saturday, and commuting 60 miles each way.”

Dr. Kellam, who considers current voice teacher, Sondra Gelb, a key influence, described her involvement in the opera production as “pure joy, no strings attached. It's something I do for me, and there's camaraderie, a team spirit. There's a creative spirit and, of course, the magic of music, and I don't have to worry about hurting anybody.”

Her roles have varied over the years and have included Carrie Pipperidge in “Carousel,” Snoopy in “You're a Good Man, Charlie Brown,” and the Wicked Witch of the West in “The Wizard of Oz.”

Some patients who are aware of her avocation worry about losing their physician to a career in music, but Dr. Kellam assures them she's not about to leave her career in medicine. “If I had to make my living as a musician, it would lose the joy, because now it's just that: sheer joy,” she said. “I don't have to worry about the business of music. This got me involved with people who are completely uninvolved in medicine, a completely different bunch of people. I get tired of talking about medicine. Not that I don't love it and don't love my patients, but I like the nonmedical world, too.”

Finding Inspiration in Music

According to Dr. Joel Ang, his vocation as a full-time family physician and his avocation as a violinist are irrevocably intertwined.

In family medicine, he explained, “you have to think of a patient as someone who is multidimensional. In music, you do the same thing. You're trying to put things together, trying to work on very specific details of that piece. I learn a lot of medicine through the music and playing the violin because you have to think that way. The thought process is the same.”

Born in the Philippines, Dr. Ang was raised in Raleigh, N.C., where he started playing violin at the age of 12 years in an orchestra at the public school he attended and went on to excel with the instrument. He enrolled in music camps each summer, played in state orchestras in high school, and earned a spot in the Duke University Symphony in Durham, N.C., as a college undergraduate.

He kept playing during medical school—though not as much as he would have liked—and viewed his avocation as “a way to keep stress from building up.”

As he improved, he became intrigued by the technical demands of the violin, noting that “a lot of brain power and technical work is required before you achieve proficiency with the instrument,” said Dr. Ang, who practices in Washington. “You're using a lot more of your right brain in actually producing that, letting that happen. Allowing emotion to come out of the instrument is an incredible experience.”

These days, Dr. Ang is a violinist with the Washington Metropolitan Philharmonic Association orchestra and serves as its associate concertmaster (

www.wmpamusic.org

www.world-doctors-orchestra.org

“Berlin was a standout because the music our conductor chose was pretty difficult, a piece by [the late composer] Gustav Mahler,” he said. “The symphony was about 75 minutes long, and we only had 4 days to rehearse before the performance. We played from 9 a.m. until about 6 p.m. each day. It was a pretty intense time, but it was good because I shared it with close to 100 other physicians. It was inspirational to me.”

The skill set of many World Doctors Orchestra members “has been amazing,” he added. “There are people who I think probably would have been musicians but chose to practice medicine instead.”

Dr. Ang practices on a daily basis and is currently taking private lessons from a violinist with the National Symphony Orchestra. “I keep myself pretty full with the music,” he said. “The good thing is that I think it really balances out my life, and I meet incredible people. I feel extremely fortunate.”

Dr. Marilyn Kellam's theatrical roles have included Carrie in “Carousel.”

Source Courtesy Virginia Opera

SAN DIEGO — A population-based monitoring program is underway in four states to develop clinical data on metabolic conditions screened at birth using tandem mass spectrometry.

The goal is to develop sustainable, population-based longitudinal monitoring that includes measures of clinical and public health impact, researchers led by Dr. Lorenzo D. Botto reported during a poster session at the annual meeting of the Society for Inherited Metabolic Disorders.

“There are major data gaps on metabolic conditions diagnosed by newborn screenings, [including] few data on clinical and public health impact and long term outcomes,” the researchers stated. “To better prevent disease and improve health it is crucial to have a strong evidence base to know what to test, what we find, what to treat, [and] what benefits to expect.”

Funded through September 2011 by the Centers for Disease Control and Prevention, the pilot study is assessing how existing birth defect surveillance programs in California, Iowa, New York, and Utah can expand to monitor 19 metabolic disorders identified by the American College of Medical Genetics.

At the meeting, Dr. Botto of the division of medical genetics at the University of Utah, and his associates presented preliminary data from 461,226 babies born in the four states in 2006 on the prevalence of four common conditions: glutaric aciduria type 1 (GA-1), 3-methylcrotonyl-CoA carboxylase deficiency (3-MCC), medium chain acyl-CoA dehydrogenase deficiency (MCAD), and phenylketonuria (PKU).

In 2006, there were 33 cases of 3-MCC (a rate of 7.2 per 100,000 births); 27 cases of PKU (5.9 per 100,000 births); 17 cases of MCAD (3.7 per 100,000 births), and 3 cases of GA-1 (0.7 per 100,000 births). The cases occurred in predominantly non-Hispanic white infants.

The next steps are to collect health, outcomes, and use of medical services data on the 2006 cohort; add the 2007 birth cohort; and, for the combined 2006–2007 cohort, evaluate morbidity, mortality, disability, and health service use through the second year of life.

“Funding challenges persist, even for pilot studies,” the researchers noted. “Integrating funding and activities between different public agencies and professional organizations would be very beneficial.”

The work is funded by a grant from the CDC's National Center on Birth Defects and Developmental Disabilities.

SAN DIEGO — A population-based monitoring program is underway in four states to develop clinical data on metabolic conditions screened at birth using tandem mass spectrometry.

The goal is to develop sustainable, population-based longitudinal monitoring that includes measures of clinical and public health impact, researchers led by Dr. Lorenzo D. Botto reported during a poster session at the annual meeting of the Society for Inherited Metabolic Disorders.

“There are major data gaps on metabolic conditions diagnosed by newborn screenings, [including] few data on clinical and public health impact and long term outcomes,” the researchers stated. “To better prevent disease and improve health it is crucial to have a strong evidence base to know what to test, what we find, what to treat, [and] what benefits to expect.”

Funded through September 2011 by the Centers for Disease Control and Prevention, the pilot study is assessing how existing birth defect surveillance programs in California, Iowa, New York, and Utah can expand to monitor 19 metabolic disorders identified by the American College of Medical Genetics.

At the meeting, Dr. Botto of the division of medical genetics at the University of Utah, and his associates presented preliminary data from 461,226 babies born in the four states in 2006 on the prevalence of four common conditions: glutaric aciduria type 1 (GA-1), 3-methylcrotonyl-CoA carboxylase deficiency (3-MCC), medium chain acyl-CoA dehydrogenase deficiency (MCAD), and phenylketonuria (PKU).

In 2006, there were 33 cases of 3-MCC (a rate of 7.2 per 100,000 births); 27 cases of PKU (5.9 per 100,000 births); 17 cases of MCAD (3.7 per 100,000 births), and 3 cases of GA-1 (0.7 per 100,000 births). The cases occurred in predominantly non-Hispanic white infants.

The next steps are to collect health, outcomes, and use of medical services data on the 2006 cohort; add the 2007 birth cohort; and, for the combined 2006–2007 cohort, evaluate morbidity, mortality, disability, and health service use through the second year of life.

“Funding challenges persist, even for pilot studies,” the researchers noted. “Integrating funding and activities between different public agencies and professional organizations would be very beneficial.”

The work is funded by a grant from the CDC's National Center on Birth Defects and Developmental Disabilities.

SAN DIEGO — A population-based monitoring program is underway in four states to develop clinical data on metabolic conditions screened at birth using tandem mass spectrometry.

The goal is to develop sustainable, population-based longitudinal monitoring that includes measures of clinical and public health impact, researchers led by Dr. Lorenzo D. Botto reported during a poster session at the annual meeting of the Society for Inherited Metabolic Disorders.

“There are major data gaps on metabolic conditions diagnosed by newborn screenings, [including] few data on clinical and public health impact and long term outcomes,” the researchers stated. “To better prevent disease and improve health it is crucial to have a strong evidence base to know what to test, what we find, what to treat, [and] what benefits to expect.”

Funded through September 2011 by the Centers for Disease Control and Prevention, the pilot study is assessing how existing birth defect surveillance programs in California, Iowa, New York, and Utah can expand to monitor 19 metabolic disorders identified by the American College of Medical Genetics.

At the meeting, Dr. Botto of the division of medical genetics at the University of Utah, and his associates presented preliminary data from 461,226 babies born in the four states in 2006 on the prevalence of four common conditions: glutaric aciduria type 1 (GA-1), 3-methylcrotonyl-CoA carboxylase deficiency (3-MCC), medium chain acyl-CoA dehydrogenase deficiency (MCAD), and phenylketonuria (PKU).

In 2006, there were 33 cases of 3-MCC (a rate of 7.2 per 100,000 births); 27 cases of PKU (5.9 per 100,000 births); 17 cases of MCAD (3.7 per 100,000 births), and 3 cases of GA-1 (0.7 per 100,000 births). The cases occurred in predominantly non-Hispanic white infants.

The next steps are to collect health, outcomes, and use of medical services data on the 2006 cohort; add the 2007 birth cohort; and, for the combined 2006–2007 cohort, evaluate morbidity, mortality, disability, and health service use through the second year of life.

“Funding challenges persist, even for pilot studies,” the researchers noted. “Integrating funding and activities between different public agencies and professional organizations would be very beneficial.”

The work is funded by a grant from the CDC's National Center on Birth Defects and Developmental Disabilities.

SAN DIEGO — Reduced bone mineral density is common in children with cystic fibrosis, and few have normal serum concentrations of vitamin D, based on the results of a multicenter, cross-sectional study of 100 children with cystic fibrosis.

“The most important factors influencing bone mineral density are glucocorticoid use, poor nutrition, hypogonadism, physical inactivity, and malabsorption of vitamin D, [but] the exact pathogenesis of low bone mineral density in patients with cystic fibrosis is still unclear,” said lead investigator Dr. Dorota Sands of the department of pediatrics at the Institute of Mother and Child, Warsaw, Poland.

The average age of the patients (51 boys and 49 girls) was 13 years, and all had severe pancreatic insufficiency and were compliant with vitamin supplementation. All patients completed a 3-day dietary questionnaire and underwent standard biochemical blood tests and bone mineral density (BMD) testing with dual-energy x-ray absorptiometry, Dr. Sands reported in a poster session at the annual meeting of the Society for Inherited Metabolic Disorders.

Results of the cross-sectional component of the study revealed that 55 patients had a BMD within the normal range and 45 had a z score of −1 or below. The mean body mass index (BMI) for the group was 17.5 kg/m

“Only 12% had a sufficient dietetic supply of vitamin D,” Dr. Sands added. “Dietetic supply of vitamin D was on a low level, providing on average only 37% of [the] Recommended Daily Allowance [RDA]; 55% of patients did not achieve [the] RDA for calcium intake.”

A longitudinal analysis was performed in the 45 study participants who had a z score of −1 or below. These patients received an intervention consisting of 0.25 mcg of vitamin D₃ for 1 year. The mean age of this subgroup of patients was 15 years, their mean BMI was 17 kg/m

SAN DIEGO — Reduced bone mineral density is common in children with cystic fibrosis, and few have normal serum concentrations of vitamin D, based on the results of a multicenter, cross-sectional study of 100 children with cystic fibrosis.

“The most important factors influencing bone mineral density are glucocorticoid use, poor nutrition, hypogonadism, physical inactivity, and malabsorption of vitamin D, [but] the exact pathogenesis of low bone mineral density in patients with cystic fibrosis is still unclear,” said lead investigator Dr. Dorota Sands of the department of pediatrics at the Institute of Mother and Child, Warsaw, Poland.

The average age of the patients (51 boys and 49 girls) was 13 years, and all had severe pancreatic insufficiency and were compliant with vitamin supplementation. All patients completed a 3-day dietary questionnaire and underwent standard biochemical blood tests and bone mineral density (BMD) testing with dual-energy x-ray absorptiometry, Dr. Sands reported in a poster session at the annual meeting of the Society for Inherited Metabolic Disorders.

Results of the cross-sectional component of the study revealed that 55 patients had a BMD within the normal range and 45 had a z score of −1 or below. The mean body mass index (BMI) for the group was 17.5 kg/m

“Only 12% had a sufficient dietetic supply of vitamin D,” Dr. Sands added. “Dietetic supply of vitamin D was on a low level, providing on average only 37% of [the] Recommended Daily Allowance [RDA]; 55% of patients did not achieve [the] RDA for calcium intake.”

A longitudinal analysis was performed in the 45 study participants who had a z score of −1 or below. These patients received an intervention consisting of 0.25 mcg of vitamin D₃ for 1 year. The mean age of this subgroup of patients was 15 years, their mean BMI was 17 kg/m

SAN DIEGO — Reduced bone mineral density is common in children with cystic fibrosis, and few have normal serum concentrations of vitamin D, based on the results of a multicenter, cross-sectional study of 100 children with cystic fibrosis.

“The most important factors influencing bone mineral density are glucocorticoid use, poor nutrition, hypogonadism, physical inactivity, and malabsorption of vitamin D, [but] the exact pathogenesis of low bone mineral density in patients with cystic fibrosis is still unclear,” said lead investigator Dr. Dorota Sands of the department of pediatrics at the Institute of Mother and Child, Warsaw, Poland.

The average age of the patients (51 boys and 49 girls) was 13 years, and all had severe pancreatic insufficiency and were compliant with vitamin supplementation. All patients completed a 3-day dietary questionnaire and underwent standard biochemical blood tests and bone mineral density (BMD) testing with dual-energy x-ray absorptiometry, Dr. Sands reported in a poster session at the annual meeting of the Society for Inherited Metabolic Disorders.

Results of the cross-sectional component of the study revealed that 55 patients had a BMD within the normal range and 45 had a z score of −1 or below. The mean body mass index (BMI) for the group was 17.5 kg/m

“Only 12% had a sufficient dietetic supply of vitamin D,” Dr. Sands added. “Dietetic supply of vitamin D was on a low level, providing on average only 37% of [the] Recommended Daily Allowance [RDA]; 55% of patients did not achieve [the] RDA for calcium intake.”

A longitudinal analysis was performed in the 45 study participants who had a z score of −1 or below. These patients received an intervention consisting of 0.25 mcg of vitamin D₃ for 1 year. The mean age of this subgroup of patients was 15 years, their mean BMI was 17 kg/m