Doug Brunk

LAS VEGAS — In Dr. David M. Duffy's opinion, the perfect cosmetic filler doesn't exist and probably never will.

Current fillers on the market "are really a trade-off between results that don't last long enough and complications that last forever," he said. "In my view, the ideal filler would last 2-3 years, enough to give patients their money's worth, but not long enough to give them the problems that may occur."

Dr. Duffy, who practices dermatology in Torrance, Calif., discussed the contraindications and benefits of permanent fillers at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Patients demand permanent fillers for superficial defects from time to time without understanding that "there may be lots of serious, unreported complications with permanent fillers, particularly silicone, which has been used (pure or adulterated) in over 1 million patients," he said. "In fact, for every complication we see published, there are probably 10 that we've never heard about."

Key reasons to avoid permanent fillers in most patients, he said, are that temporary and semipermanent fillers are more profitable and less demanding to use, and more forgiving. "If you make mistakes with permanent fillers, they're for good; there's no margin for error," he noted.

Permanent fillers also require more time to inject, which makes them an unattractive option for hurried patients who want a true "lunchtime" procedure.

"You shouldn't use permanent filler before you get to know your patient," Dr. Duffy advised. "Temporary fillers give you an idea of how they're going to comply and respond."

Then there's the need for thorough training to properly place the filler. "Patient selection is quite demanding and there is a narrower range of appropriate defects than you have for the temporary fillers," he said.

"Be careful of the psychologically unstable patient who's had permanent filler placed by another practitioner and wants more," Dr. Duffy warned. "I won't treat patients who have had silicone placed previously. Problems can be delayed for 20 years, and you'll be blamed if they occur. I won't use permanent filler in polyallergic patients, and I won't make lips the size of Cleveland, no matter what they ask for."

Permanent fillers can be used appropriately in defects that are pliable enough so that when elevated the surrounding tissue is unaffected. They should not be used in areas where the skin is thin and hyperdistensible. Superficial defects "are very easy to overcorrect with permanent fillers, and if you do, it's there for good," Dr. Duffy said. "You can have delayed excessive fibrosis, particularly in high motion areas like the lips. And the implant may become visible as patients age."

Despite his misgivings about permanent fillers, Dr. Duffy currently uses liquid silicone in some cases. The product he uses most often is 1000 centistoke liquid silicone (Silikon 1000), which has 10 times the viscosity of water. "It's appealing because it's permanent, inexpensive, and wonderful to use," Dr. Duffy said.

For patients with atrophy related to HIV, he prefers 5000 centistoke liquid silicone (AdatoSil 5000), which has 50 times the viscosity of water.

The liquid silicone fillers don't have to be refrigerated, they will not support bacterial growth, and patients don't require allergy testing prior to use, said Dr. Duffy. "Most of the problems that I've see with silicone have occurred with infectious processes, particularly in patients with dental problems or sinus problems."

The most serious problems occur following misuse of silicone in "back room" operations. These include ulceration, cellulitis, granulomas, fistulation, blindness, and death.

"There are people who have made a lifestyle of criticizing silicone, because they see nothing but complications" and would never use them, he said. "Meanwhile, I've received some wonderful letters from patients who've received liquid silicone. I think there is a place for these products."

The conundrum about liquid silicone is the lack of objective data supporting its use and the lack of standardized product in years past, Dr. Duffy said. "Everything's anecdotal, with the exception of one unpublished study. This makes it difficult. Can you use these safely? Yes, you can. But you have to pick your patients well and know what you're doing. In the proper patient, silicone has no equal; good results are the norm and patients are enormously satisfied. Conversely, silicone's reputation makes it risky to use and the risk is particularly prominent for the physician, not the patient."

Dr. Duffy had no relevant conflicts of interest to disclose.

Despite Dr. David M. Duffy's misgivings about permanent fillers, he uses liquid silicone in some cases, such as in the patient above (shown before and after). PHOTOS COURTESY DR. DAVID M. DUFFY

LAS VEGAS — In Dr. David M. Duffy's opinion, the perfect cosmetic filler doesn't exist and probably never will.

Current fillers on the market "are really a trade-off between results that don't last long enough and complications that last forever," he said. "In my view, the ideal filler would last 2-3 years, enough to give patients their money's worth, but not long enough to give them the problems that may occur."

Dr. Duffy, who practices dermatology in Torrance, Calif., discussed the contraindications and benefits of permanent fillers at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Patients demand permanent fillers for superficial defects from time to time without understanding that "there may be lots of serious, unreported complications with permanent fillers, particularly silicone, which has been used (pure or adulterated) in over 1 million patients," he said. "In fact, for every complication we see published, there are probably 10 that we've never heard about."

Key reasons to avoid permanent fillers in most patients, he said, are that temporary and semipermanent fillers are more profitable and less demanding to use, and more forgiving. "If you make mistakes with permanent fillers, they're for good; there's no margin for error," he noted.

Permanent fillers also require more time to inject, which makes them an unattractive option for hurried patients who want a true "lunchtime" procedure.

"You shouldn't use permanent filler before you get to know your patient," Dr. Duffy advised. "Temporary fillers give you an idea of how they're going to comply and respond."

Then there's the need for thorough training to properly place the filler. "Patient selection is quite demanding and there is a narrower range of appropriate defects than you have for the temporary fillers," he said.

"Be careful of the psychologically unstable patient who's had permanent filler placed by another practitioner and wants more," Dr. Duffy warned. "I won't treat patients who have had silicone placed previously. Problems can be delayed for 20 years, and you'll be blamed if they occur. I won't use permanent filler in polyallergic patients, and I won't make lips the size of Cleveland, no matter what they ask for."

Permanent fillers can be used appropriately in defects that are pliable enough so that when elevated the surrounding tissue is unaffected. They should not be used in areas where the skin is thin and hyperdistensible. Superficial defects "are very easy to overcorrect with permanent fillers, and if you do, it's there for good," Dr. Duffy said. "You can have delayed excessive fibrosis, particularly in high motion areas like the lips. And the implant may become visible as patients age."

Despite his misgivings about permanent fillers, Dr. Duffy currently uses liquid silicone in some cases. The product he uses most often is 1000 centistoke liquid silicone (Silikon 1000), which has 10 times the viscosity of water. "It's appealing because it's permanent, inexpensive, and wonderful to use," Dr. Duffy said.

For patients with atrophy related to HIV, he prefers 5000 centistoke liquid silicone (AdatoSil 5000), which has 50 times the viscosity of water.

The liquid silicone fillers don't have to be refrigerated, they will not support bacterial growth, and patients don't require allergy testing prior to use, said Dr. Duffy. "Most of the problems that I've see with silicone have occurred with infectious processes, particularly in patients with dental problems or sinus problems."

The most serious problems occur following misuse of silicone in "back room" operations. These include ulceration, cellulitis, granulomas, fistulation, blindness, and death.

"There are people who have made a lifestyle of criticizing silicone, because they see nothing but complications" and would never use them, he said. "Meanwhile, I've received some wonderful letters from patients who've received liquid silicone. I think there is a place for these products."

The conundrum about liquid silicone is the lack of objective data supporting its use and the lack of standardized product in years past, Dr. Duffy said. "Everything's anecdotal, with the exception of one unpublished study. This makes it difficult. Can you use these safely? Yes, you can. But you have to pick your patients well and know what you're doing. In the proper patient, silicone has no equal; good results are the norm and patients are enormously satisfied. Conversely, silicone's reputation makes it risky to use and the risk is particularly prominent for the physician, not the patient."

Dr. Duffy had no relevant conflicts of interest to disclose.

Despite Dr. David M. Duffy's misgivings about permanent fillers, he uses liquid silicone in some cases, such as in the patient above (shown before and after). PHOTOS COURTESY DR. DAVID M. DUFFY

LAS VEGAS — In Dr. David M. Duffy's opinion, the perfect cosmetic filler doesn't exist and probably never will.

Current fillers on the market "are really a trade-off between results that don't last long enough and complications that last forever," he said. "In my view, the ideal filler would last 2-3 years, enough to give patients their money's worth, but not long enough to give them the problems that may occur."

Dr. Duffy, who practices dermatology in Torrance, Calif., discussed the contraindications and benefits of permanent fillers at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Patients demand permanent fillers for superficial defects from time to time without understanding that "there may be lots of serious, unreported complications with permanent fillers, particularly silicone, which has been used (pure or adulterated) in over 1 million patients," he said. "In fact, for every complication we see published, there are probably 10 that we've never heard about."

Key reasons to avoid permanent fillers in most patients, he said, are that temporary and semipermanent fillers are more profitable and less demanding to use, and more forgiving. "If you make mistakes with permanent fillers, they're for good; there's no margin for error," he noted.

Permanent fillers also require more time to inject, which makes them an unattractive option for hurried patients who want a true "lunchtime" procedure.

"You shouldn't use permanent filler before you get to know your patient," Dr. Duffy advised. "Temporary fillers give you an idea of how they're going to comply and respond."

Then there's the need for thorough training to properly place the filler. "Patient selection is quite demanding and there is a narrower range of appropriate defects than you have for the temporary fillers," he said.

"Be careful of the psychologically unstable patient who's had permanent filler placed by another practitioner and wants more," Dr. Duffy warned. "I won't treat patients who have had silicone placed previously. Problems can be delayed for 20 years, and you'll be blamed if they occur. I won't use permanent filler in polyallergic patients, and I won't make lips the size of Cleveland, no matter what they ask for."

Permanent fillers can be used appropriately in defects that are pliable enough so that when elevated the surrounding tissue is unaffected. They should not be used in areas where the skin is thin and hyperdistensible. Superficial defects "are very easy to overcorrect with permanent fillers, and if you do, it's there for good," Dr. Duffy said. "You can have delayed excessive fibrosis, particularly in high motion areas like the lips. And the implant may become visible as patients age."

Despite his misgivings about permanent fillers, Dr. Duffy currently uses liquid silicone in some cases. The product he uses most often is 1000 centistoke liquid silicone (Silikon 1000), which has 10 times the viscosity of water. "It's appealing because it's permanent, inexpensive, and wonderful to use," Dr. Duffy said.

For patients with atrophy related to HIV, he prefers 5000 centistoke liquid silicone (AdatoSil 5000), which has 50 times the viscosity of water.

The liquid silicone fillers don't have to be refrigerated, they will not support bacterial growth, and patients don't require allergy testing prior to use, said Dr. Duffy. "Most of the problems that I've see with silicone have occurred with infectious processes, particularly in patients with dental problems or sinus problems."

The most serious problems occur following misuse of silicone in "back room" operations. These include ulceration, cellulitis, granulomas, fistulation, blindness, and death.

"There are people who have made a lifestyle of criticizing silicone, because they see nothing but complications" and would never use them, he said. "Meanwhile, I've received some wonderful letters from patients who've received liquid silicone. I think there is a place for these products."

The conundrum about liquid silicone is the lack of objective data supporting its use and the lack of standardized product in years past, Dr. Duffy said. "Everything's anecdotal, with the exception of one unpublished study. This makes it difficult. Can you use these safely? Yes, you can. But you have to pick your patients well and know what you're doing. In the proper patient, silicone has no equal; good results are the norm and patients are enormously satisfied. Conversely, silicone's reputation makes it risky to use and the risk is particularly prominent for the physician, not the patient."

Dr. Duffy had no relevant conflicts of interest to disclose.

Despite Dr. David M. Duffy's misgivings about permanent fillers, he uses liquid silicone in some cases, such as in the patient above (shown before and after). PHOTOS COURTESY DR. DAVID M. DUFFY

LAS VEGAS — After laparoscopic cystectomy, the long-term use of oral contraceptives can effectively prevent recurrence of ovarian endometrioma, based on results from a single-center study.

In the 2-year study of 217 patients, two groups got either cyclic or continuous oral contraceptives after laparoscopic cystectomy, and one group went untreated.

The recurrence rate for endometriomas was 29% in the untreated group, a rate that was significantly higher than the recurrence rates in the groups who took OCs.

“Oral contraceptive pills can provide a better option in terms of safety, tolerability, and cost” than do other hormones for adjuvant therapy following laparoscopic surgery, Dr. Mohamed Mabrouk said at the annual meeting of the AAGL. “However, data from clinical trials on this topic are few and controversial.”

In one cohort study, long-term exposure to oral contraceptives after conservative surgery for ovarian endometriosis was associated with a major reduction in the risk of endometrioma recurrence, with a gradient effect observed with regard to duration of treatment (Am. J. Obstet. Gynecol. 2008;198:504.e1–5).

Although researchers in an earlier retrospective study found that treatment with oral contraceptives for a mean of 9.5 months after laparoscopic excision did not significantly influence endometrioma recurrence, they did suggest that a longer period of treatment might prevent recurrence (Hum. Reprod. 2006;21:2171–4).

The only published, randomized, controlled trial on the topic dem-onstrated that the postoperative cyclic use of OCs does not significantly influence long-term endometrioma recurrence rates (Am. J. Obstet. Gynecol. 2000;183:588–92).

However, in this trial, OCs were administered for only 6 months after the operation, said Dr. Mabrouk of the minimally invasive gynecologic surgery unit at the University of Bologna (Italy).

“Based on our observational process, we noticed that patients who used oral contraceptives for a longer period of time had lower recurrence rates,” he explained. “So we hypothesized that the length of treatment seems to be an important factor in the long-term efficacy of therapy.”

To test this hypothesis, he and his associates conducted a randomized trial to evaluate the efficacy of long-term cyclic and continuous administration of monophasic, combined low-dose oral contraceptives in preventing endometrioma recurrence in 217 patients (mean age, 29 years) who underwent laparoscopic cystectomy at the university.

Every 6 months for 24 months, the researchers conducted clinical and ultrasonographic studies of all patients, noting the presence of recurrence (defined as the presence of an ovarian endometrioma measuring more than 1.5 cm in diameter), time of recurrence, size of recurrent endometrioma, and increase in mean diameter.

Of the 217 patients, 69 received no therapy, 75 got cyclic oral contraceptives, and 73 received continuous oral contraceptives. The contraceptives contained 0.020 mg ethinylestradiol and 0.075 mg gestodene.

At 2 years' follow-up, 37 endometrioma recurrences were detected in the three groups. Nearly two-thirds of the recurrences (65%) took place between 12 and 18 months after surgery.

The recurrence rate was 29% in the untreated group, a rate that was significantly higher than the recurrence rates in the groups who took OCs (15% for the cyclic therapy group, and 8% for the continuous therapy group).

The mean diameter of recurrent endometrioma in the untreated patients at 2 years' follow-up was 2.73 cm, which was significantly larger than the mean diameter in the treated groups (2.17 cm in the cyclic therapy group and 1.71 cm in the continuous therapy group).

“Our study showed that the mean diameter of recurrent cysts at first observation was significantly smaller in cyclic and continuous users, proving that oral contraceptives can even influence disease expression and reduce its severity,” Dr. Mabrouk said.

He also reported that the mean increase in diameter in the untreated group at every 6 months of follow-up was 0.48 cm, which was significantly larger than that for the treated patients (0.31 cm for the cyclic group vs. 0.25 cm for the continuous group).

No statistically significant differences were observed between the treated groups in terms of the number, size, and growth of recurrent endometriomas.

“However, there was a positive trend in patients receiving continuous therapy regarding size and growth of recurrent endometriomas,” he reported.

Dr. Mabrouk stated that he had no relevant financial disclosures to report.

Oral contraceptive pills 'can provide a better option in terms of safety, tolerability, and cost.' DR. MABROUK

LAS VEGAS — After laparoscopic cystectomy, the long-term use of oral contraceptives can effectively prevent recurrence of ovarian endometrioma, based on results from a single-center study.

In the 2-year study of 217 patients, two groups got either cyclic or continuous oral contraceptives after laparoscopic cystectomy, and one group went untreated.

The recurrence rate for endometriomas was 29% in the untreated group, a rate that was significantly higher than the recurrence rates in the groups who took OCs.

“Oral contraceptive pills can provide a better option in terms of safety, tolerability, and cost” than do other hormones for adjuvant therapy following laparoscopic surgery, Dr. Mohamed Mabrouk said at the annual meeting of the AAGL. “However, data from clinical trials on this topic are few and controversial.”

In one cohort study, long-term exposure to oral contraceptives after conservative surgery for ovarian endometriosis was associated with a major reduction in the risk of endometrioma recurrence, with a gradient effect observed with regard to duration of treatment (Am. J. Obstet. Gynecol. 2008;198:504.e1–5).

Although researchers in an earlier retrospective study found that treatment with oral contraceptives for a mean of 9.5 months after laparoscopic excision did not significantly influence endometrioma recurrence, they did suggest that a longer period of treatment might prevent recurrence (Hum. Reprod. 2006;21:2171–4).

The only published, randomized, controlled trial on the topic dem-onstrated that the postoperative cyclic use of OCs does not significantly influence long-term endometrioma recurrence rates (Am. J. Obstet. Gynecol. 2000;183:588–92).

However, in this trial, OCs were administered for only 6 months after the operation, said Dr. Mabrouk of the minimally invasive gynecologic surgery unit at the University of Bologna (Italy).

“Based on our observational process, we noticed that patients who used oral contraceptives for a longer period of time had lower recurrence rates,” he explained. “So we hypothesized that the length of treatment seems to be an important factor in the long-term efficacy of therapy.”

To test this hypothesis, he and his associates conducted a randomized trial to evaluate the efficacy of long-term cyclic and continuous administration of monophasic, combined low-dose oral contraceptives in preventing endometrioma recurrence in 217 patients (mean age, 29 years) who underwent laparoscopic cystectomy at the university.

Every 6 months for 24 months, the researchers conducted clinical and ultrasonographic studies of all patients, noting the presence of recurrence (defined as the presence of an ovarian endometrioma measuring more than 1.5 cm in diameter), time of recurrence, size of recurrent endometrioma, and increase in mean diameter.

Of the 217 patients, 69 received no therapy, 75 got cyclic oral contraceptives, and 73 received continuous oral contraceptives. The contraceptives contained 0.020 mg ethinylestradiol and 0.075 mg gestodene.

At 2 years' follow-up, 37 endometrioma recurrences were detected in the three groups. Nearly two-thirds of the recurrences (65%) took place between 12 and 18 months after surgery.

The recurrence rate was 29% in the untreated group, a rate that was significantly higher than the recurrence rates in the groups who took OCs (15% for the cyclic therapy group, and 8% for the continuous therapy group).

The mean diameter of recurrent endometrioma in the untreated patients at 2 years' follow-up was 2.73 cm, which was significantly larger than the mean diameter in the treated groups (2.17 cm in the cyclic therapy group and 1.71 cm in the continuous therapy group).

“Our study showed that the mean diameter of recurrent cysts at first observation was significantly smaller in cyclic and continuous users, proving that oral contraceptives can even influence disease expression and reduce its severity,” Dr. Mabrouk said.

He also reported that the mean increase in diameter in the untreated group at every 6 months of follow-up was 0.48 cm, which was significantly larger than that for the treated patients (0.31 cm for the cyclic group vs. 0.25 cm for the continuous group).

No statistically significant differences were observed between the treated groups in terms of the number, size, and growth of recurrent endometriomas.

“However, there was a positive trend in patients receiving continuous therapy regarding size and growth of recurrent endometriomas,” he reported.

Dr. Mabrouk stated that he had no relevant financial disclosures to report.

Oral contraceptive pills 'can provide a better option in terms of safety, tolerability, and cost.' DR. MABROUK

LAS VEGAS — After laparoscopic cystectomy, the long-term use of oral contraceptives can effectively prevent recurrence of ovarian endometrioma, based on results from a single-center study.

In the 2-year study of 217 patients, two groups got either cyclic or continuous oral contraceptives after laparoscopic cystectomy, and one group went untreated.

The recurrence rate for endometriomas was 29% in the untreated group, a rate that was significantly higher than the recurrence rates in the groups who took OCs.

“Oral contraceptive pills can provide a better option in terms of safety, tolerability, and cost” than do other hormones for adjuvant therapy following laparoscopic surgery, Dr. Mohamed Mabrouk said at the annual meeting of the AAGL. “However, data from clinical trials on this topic are few and controversial.”

In one cohort study, long-term exposure to oral contraceptives after conservative surgery for ovarian endometriosis was associated with a major reduction in the risk of endometrioma recurrence, with a gradient effect observed with regard to duration of treatment (Am. J. Obstet. Gynecol. 2008;198:504.e1–5).

Although researchers in an earlier retrospective study found that treatment with oral contraceptives for a mean of 9.5 months after laparoscopic excision did not significantly influence endometrioma recurrence, they did suggest that a longer period of treatment might prevent recurrence (Hum. Reprod. 2006;21:2171–4).

The only published, randomized, controlled trial on the topic dem-onstrated that the postoperative cyclic use of OCs does not significantly influence long-term endometrioma recurrence rates (Am. J. Obstet. Gynecol. 2000;183:588–92).

However, in this trial, OCs were administered for only 6 months after the operation, said Dr. Mabrouk of the minimally invasive gynecologic surgery unit at the University of Bologna (Italy).

“Based on our observational process, we noticed that patients who used oral contraceptives for a longer period of time had lower recurrence rates,” he explained. “So we hypothesized that the length of treatment seems to be an important factor in the long-term efficacy of therapy.”

To test this hypothesis, he and his associates conducted a randomized trial to evaluate the efficacy of long-term cyclic and continuous administration of monophasic, combined low-dose oral contraceptives in preventing endometrioma recurrence in 217 patients (mean age, 29 years) who underwent laparoscopic cystectomy at the university.

Every 6 months for 24 months, the researchers conducted clinical and ultrasonographic studies of all patients, noting the presence of recurrence (defined as the presence of an ovarian endometrioma measuring more than 1.5 cm in diameter), time of recurrence, size of recurrent endometrioma, and increase in mean diameter.

Of the 217 patients, 69 received no therapy, 75 got cyclic oral contraceptives, and 73 received continuous oral contraceptives. The contraceptives contained 0.020 mg ethinylestradiol and 0.075 mg gestodene.

At 2 years' follow-up, 37 endometrioma recurrences were detected in the three groups. Nearly two-thirds of the recurrences (65%) took place between 12 and 18 months after surgery.

The recurrence rate was 29% in the untreated group, a rate that was significantly higher than the recurrence rates in the groups who took OCs (15% for the cyclic therapy group, and 8% for the continuous therapy group).

The mean diameter of recurrent endometrioma in the untreated patients at 2 years' follow-up was 2.73 cm, which was significantly larger than the mean diameter in the treated groups (2.17 cm in the cyclic therapy group and 1.71 cm in the continuous therapy group).

“Our study showed that the mean diameter of recurrent cysts at first observation was significantly smaller in cyclic and continuous users, proving that oral contraceptives can even influence disease expression and reduce its severity,” Dr. Mabrouk said.

He also reported that the mean increase in diameter in the untreated group at every 6 months of follow-up was 0.48 cm, which was significantly larger than that for the treated patients (0.31 cm for the cyclic group vs. 0.25 cm for the continuous group).

No statistically significant differences were observed between the treated groups in terms of the number, size, and growth of recurrent endometriomas.

“However, there was a positive trend in patients receiving continuous therapy regarding size and growth of recurrent endometriomas,” he reported.

Dr. Mabrouk stated that he had no relevant financial disclosures to report.

Oral contraceptive pills 'can provide a better option in terms of safety, tolerability, and cost.' DR. MABROUK

LAS VEGAS — A nonsurgical approach to treating stress urinary incontinence that strengthens transurethral collagen by denaturing it with heat provided measurable durable improvement at 12 months, according to preliminary results from a multicenter clinical trial.

The study involved the use of the Renessa System, which was approved by the Food and Drug Administration in 2005 for the treatment of stress urinary incontinence (SUI) caused by hypermobility in women who have failed conservative care and are not candidates for surgical therapy.

“We have limited treatment options to offer women with stress urinary incontinence,” lead investigator Dr. Denise M. Elser said in an interview after the study was presented during a poster session at a congress sponsored by the AAGL.

“Pelvic muscle exercises are safe but don't work for everyone, and in practical terms, our patients are rarely compliant in the long run. Not all patients want surgery, whether it's due to cost, time off work, or fear of anesthesia and a procedure. There are no FDA-approved medications available to us to use for treating SUI. Renessa offers a safe option that will allow more than half of patients improvement or cure of their incontinence,” said Dr. Elser, who disclosed that she has been a paid consultant to Novasys Medical Inc., the manufacturer of the Rensessa System.

The system includes a small probe that the physician passes through the natural opening of the urethra. The probe heats multiple small treatment sites in the submucosa of the bladder neck and upper urethra, denaturing collagen in the tissue. Previous studies of the system have assessed its safety and initial success rates, but the current study is designed to evaluate patients at baseline and at 3, 6, 12, 18, 24, and 36 months following treatment.

Study participants included 136 women with stress urinary incontinence at 13 physician offices or ambulatory surgery centers in the United States who had failed prior conservative treatment. Their average age was 47 years and they received pretreatment oral antibiotic and local periurethral lidocaine injection.

The Renessa device was placed in the bladder and radiofrequency energy “was delivered in nine 1-minute increments, resulting in collagen denaturation of 36 circumferential sites from the bladder neck to the proximal urethral submucosa,” according to the poster.

At each time point, patients answered questions on the Incontinence Quality of Life (I-QOL), the Urogenital Distress Inventory (UDI-6), the Patient Global Impression of Improvement (PGI-I) surveys, and underwent a 1-hour in-office stress pad weight test.

At baseline the mean number of leaks per day was 2.9; the mean I-QOL score was 51.3 and the mean UDI-6 score was 52.7.

The researchers reported their 12-month results as intention to treat analysis because 63 of the 136 patients did not report for the 12-month follow-up visit. This was done “in an attempt to present the final analysis as comprehensively as possible and to account for those lost to follow-up,” said Dr. Elser, a gynecologist who practices in Oak Lawn, Ill.

At 12 months, the mean number of leaks had dropped to 1.9 per day and 69% of patients reported a greater than 50% reduction in leaked volume on the stress pad weight test (a median reduction of 15.2 g from a baseline of 39.34 g).

The stress pad test also indicated that 45% of women were dry. Of these, 29% had no leaks and 16% had less than one gram of leakage.

The mean I-QOL and UDI-6 scores improved from baseline by 11.8 and 14.1 points, respectively. Results from the PGI-I indicated that 50% of patients deemed their incontinence to be “little,” “much,” or “very much” improved from baseline. No serious adverse events were reported at any time point.

Dr. Elser acknowledged that the number of patients completing the 12-month evaluation was a limitation of the study but the intent to treat analysis attempted to compensate for this.

The study was funded by Novasys Medical.

LAS VEGAS — A nonsurgical approach to treating stress urinary incontinence that strengthens transurethral collagen by denaturing it with heat provided measurable durable improvement at 12 months, according to preliminary results from a multicenter clinical trial.

The study involved the use of the Renessa System, which was approved by the Food and Drug Administration in 2005 for the treatment of stress urinary incontinence (SUI) caused by hypermobility in women who have failed conservative care and are not candidates for surgical therapy.

“We have limited treatment options to offer women with stress urinary incontinence,” lead investigator Dr. Denise M. Elser said in an interview after the study was presented during a poster session at a congress sponsored by the AAGL.

“Pelvic muscle exercises are safe but don't work for everyone, and in practical terms, our patients are rarely compliant in the long run. Not all patients want surgery, whether it's due to cost, time off work, or fear of anesthesia and a procedure. There are no FDA-approved medications available to us to use for treating SUI. Renessa offers a safe option that will allow more than half of patients improvement or cure of their incontinence,” said Dr. Elser, who disclosed that she has been a paid consultant to Novasys Medical Inc., the manufacturer of the Rensessa System.

The system includes a small probe that the physician passes through the natural opening of the urethra. The probe heats multiple small treatment sites in the submucosa of the bladder neck and upper urethra, denaturing collagen in the tissue. Previous studies of the system have assessed its safety and initial success rates, but the current study is designed to evaluate patients at baseline and at 3, 6, 12, 18, 24, and 36 months following treatment.

Study participants included 136 women with stress urinary incontinence at 13 physician offices or ambulatory surgery centers in the United States who had failed prior conservative treatment. Their average age was 47 years and they received pretreatment oral antibiotic and local periurethral lidocaine injection.

The Renessa device was placed in the bladder and radiofrequency energy “was delivered in nine 1-minute increments, resulting in collagen denaturation of 36 circumferential sites from the bladder neck to the proximal urethral submucosa,” according to the poster.

At each time point, patients answered questions on the Incontinence Quality of Life (I-QOL), the Urogenital Distress Inventory (UDI-6), the Patient Global Impression of Improvement (PGI-I) surveys, and underwent a 1-hour in-office stress pad weight test.

At baseline the mean number of leaks per day was 2.9; the mean I-QOL score was 51.3 and the mean UDI-6 score was 52.7.

The researchers reported their 12-month results as intention to treat analysis because 63 of the 136 patients did not report for the 12-month follow-up visit. This was done “in an attempt to present the final analysis as comprehensively as possible and to account for those lost to follow-up,” said Dr. Elser, a gynecologist who practices in Oak Lawn, Ill.

At 12 months, the mean number of leaks had dropped to 1.9 per day and 69% of patients reported a greater than 50% reduction in leaked volume on the stress pad weight test (a median reduction of 15.2 g from a baseline of 39.34 g).

The stress pad test also indicated that 45% of women were dry. Of these, 29% had no leaks and 16% had less than one gram of leakage.

The mean I-QOL and UDI-6 scores improved from baseline by 11.8 and 14.1 points, respectively. Results from the PGI-I indicated that 50% of patients deemed their incontinence to be “little,” “much,” or “very much” improved from baseline. No serious adverse events were reported at any time point.

Dr. Elser acknowledged that the number of patients completing the 12-month evaluation was a limitation of the study but the intent to treat analysis attempted to compensate for this.

The study was funded by Novasys Medical.

LAS VEGAS — A nonsurgical approach to treating stress urinary incontinence that strengthens transurethral collagen by denaturing it with heat provided measurable durable improvement at 12 months, according to preliminary results from a multicenter clinical trial.

The study involved the use of the Renessa System, which was approved by the Food and Drug Administration in 2005 for the treatment of stress urinary incontinence (SUI) caused by hypermobility in women who have failed conservative care and are not candidates for surgical therapy.

“We have limited treatment options to offer women with stress urinary incontinence,” lead investigator Dr. Denise M. Elser said in an interview after the study was presented during a poster session at a congress sponsored by the AAGL.

“Pelvic muscle exercises are safe but don't work for everyone, and in practical terms, our patients are rarely compliant in the long run. Not all patients want surgery, whether it's due to cost, time off work, or fear of anesthesia and a procedure. There are no FDA-approved medications available to us to use for treating SUI. Renessa offers a safe option that will allow more than half of patients improvement or cure of their incontinence,” said Dr. Elser, who disclosed that she has been a paid consultant to Novasys Medical Inc., the manufacturer of the Rensessa System.

The system includes a small probe that the physician passes through the natural opening of the urethra. The probe heats multiple small treatment sites in the submucosa of the bladder neck and upper urethra, denaturing collagen in the tissue. Previous studies of the system have assessed its safety and initial success rates, but the current study is designed to evaluate patients at baseline and at 3, 6, 12, 18, 24, and 36 months following treatment.

Study participants included 136 women with stress urinary incontinence at 13 physician offices or ambulatory surgery centers in the United States who had failed prior conservative treatment. Their average age was 47 years and they received pretreatment oral antibiotic and local periurethral lidocaine injection.

The Renessa device was placed in the bladder and radiofrequency energy “was delivered in nine 1-minute increments, resulting in collagen denaturation of 36 circumferential sites from the bladder neck to the proximal urethral submucosa,” according to the poster.

At each time point, patients answered questions on the Incontinence Quality of Life (I-QOL), the Urogenital Distress Inventory (UDI-6), the Patient Global Impression of Improvement (PGI-I) surveys, and underwent a 1-hour in-office stress pad weight test.

At baseline the mean number of leaks per day was 2.9; the mean I-QOL score was 51.3 and the mean UDI-6 score was 52.7.

The researchers reported their 12-month results as intention to treat analysis because 63 of the 136 patients did not report for the 12-month follow-up visit. This was done “in an attempt to present the final analysis as comprehensively as possible and to account for those lost to follow-up,” said Dr. Elser, a gynecologist who practices in Oak Lawn, Ill.

At 12 months, the mean number of leaks had dropped to 1.9 per day and 69% of patients reported a greater than 50% reduction in leaked volume on the stress pad weight test (a median reduction of 15.2 g from a baseline of 39.34 g).

The stress pad test also indicated that 45% of women were dry. Of these, 29% had no leaks and 16% had less than one gram of leakage.

The mean I-QOL and UDI-6 scores improved from baseline by 11.8 and 14.1 points, respectively. Results from the PGI-I indicated that 50% of patients deemed their incontinence to be “little,” “much,” or “very much” improved from baseline. No serious adverse events were reported at any time point.

Dr. Elser acknowledged that the number of patients completing the 12-month evaluation was a limitation of the study but the intent to treat analysis attempted to compensate for this.

The study was funded by Novasys Medical.

LAS VEGAS — Cutting and coagulation waveforms are equally effective for hysteroscopic endometrial ablation using the rollerball, results from the first clinical study of its kind demonstrated.

An in vitro study from the early 1990s showed that the depth of thermal injury to 3 mm of myometrium (the depth of destruction believed to completely destroy the basal layer) was found to be more consistent with use of the low-voltage cut waveform compared with the high-voltage modulated coag waveform (Obstet. Gynecol. 1993;82:912–8). However, no published clinical trial has compared the two radiofrequency waveforms after rollerball endometrial ablation, Dr. Paul T. Chang said at the annual meeting of the AAGL.

The low-voltage cut waveform, which heats the tissue more slowly, “is more likely to result in deep and homogenous tissue penetration, while the high-voltage modulated coag waveform is more likely to result in superficial tissue desiccation and subsequent increase in tissue impedance,” said Dr. Chang, a specialist in minimally invasive gynecology and infertility at the Toronto Centre for Advanced Reproductive Technology.

In a trial intended to serve as a pilot study for a larger randomized trial, Dr. Chang and his mentor, Dr. George A. Vilos of the University of Western Ontario, London, allocated 47 premenopausal women to hysteroscopic electrocoagulation of the endometrium using a 5-mm diameter rollerball with cut or coag waveforms at 100 watts of power. Eligibility criteria included symptomatic menorrhagia, no desire for future pregnancy, no intramural or submucosal myomas 3 cm or larger, no active pelvic inflammatory disease, and no atypical endometrial hyperplasia or cancer. The average age of the patients was 41 years and the average body mass index was 28 kg/m

Of the 55 women 22 were in the cut waveform group and 23 were in the coag waveform group. One physician experienced in hysteroscopic surgery and two surgical fellows performed all procedures at St. Joseph's Health Care in London, Ont., between November 2004 and March 2005.

Primary outcomes included rates of menstrual reduction, need for reintervention, patient satisfaction as measured by questionnaires, and complications. Two-year follow-up was completed by either questionnaires or telephone contact.

Dr. Chang and his associates hypothesized that patients in the cut waveform would have superior clinical outcomes compared with those in the coag waveform group. However, at 2 years of follow-up, the rate of hypomenorrhea was 52% in the coag group and 32% in the cut group, a difference that was not statistically significant.

There were no statistically significant differences between the coag and cut waveform groups in terms of amenorrhea rates (28% vs. 36%, respectively); reintervention rates (32% vs. 36%), and the percentage of women who reported being either satisfied or very satisfied with the results (68% vs. 64%). No complications occurred in either group.

Dr. Chang pointed out that the trend toward higher amenorrhea rates in the cut waveform group “supports in vitro findings. One significant observation was that the rollerball electrode was rapidly covered with coagulated tissue when using the cut waveform,” he added. “This required the scope to be withdrawn and the rollerball to be cleaned several times during the procedure.” Based on this analysis, he and his associates concluded that both waveform types are safe and equally effective for hysteroscopic endometrial ablation using the rollerball.

Dr. Chang stated that he had no conflicts of interest to disclose.

The low-voltage cut waveform is more likely to result in deep and homogenous tissue penetration. DR. CHANG

Hysteroscopic view of uterine cavity: Rollerball electrode is at upper left.

Brown tissue is area of thermal damage from ablation with a coag waveform. Photos courtesy Dr. Paul T. Chang

LAS VEGAS — Cutting and coagulation waveforms are equally effective for hysteroscopic endometrial ablation using the rollerball, results from the first clinical study of its kind demonstrated.

An in vitro study from the early 1990s showed that the depth of thermal injury to 3 mm of myometrium (the depth of destruction believed to completely destroy the basal layer) was found to be more consistent with use of the low-voltage cut waveform compared with the high-voltage modulated coag waveform (Obstet. Gynecol. 1993;82:912–8). However, no published clinical trial has compared the two radiofrequency waveforms after rollerball endometrial ablation, Dr. Paul T. Chang said at the annual meeting of the AAGL.

The low-voltage cut waveform, which heats the tissue more slowly, “is more likely to result in deep and homogenous tissue penetration, while the high-voltage modulated coag waveform is more likely to result in superficial tissue desiccation and subsequent increase in tissue impedance,” said Dr. Chang, a specialist in minimally invasive gynecology and infertility at the Toronto Centre for Advanced Reproductive Technology.

In a trial intended to serve as a pilot study for a larger randomized trial, Dr. Chang and his mentor, Dr. George A. Vilos of the University of Western Ontario, London, allocated 47 premenopausal women to hysteroscopic electrocoagulation of the endometrium using a 5-mm diameter rollerball with cut or coag waveforms at 100 watts of power. Eligibility criteria included symptomatic menorrhagia, no desire for future pregnancy, no intramural or submucosal myomas 3 cm or larger, no active pelvic inflammatory disease, and no atypical endometrial hyperplasia or cancer. The average age of the patients was 41 years and the average body mass index was 28 kg/m

Of the 55 women 22 were in the cut waveform group and 23 were in the coag waveform group. One physician experienced in hysteroscopic surgery and two surgical fellows performed all procedures at St. Joseph's Health Care in London, Ont., between November 2004 and March 2005.

Primary outcomes included rates of menstrual reduction, need for reintervention, patient satisfaction as measured by questionnaires, and complications. Two-year follow-up was completed by either questionnaires or telephone contact.

Dr. Chang and his associates hypothesized that patients in the cut waveform would have superior clinical outcomes compared with those in the coag waveform group. However, at 2 years of follow-up, the rate of hypomenorrhea was 52% in the coag group and 32% in the cut group, a difference that was not statistically significant.

There were no statistically significant differences between the coag and cut waveform groups in terms of amenorrhea rates (28% vs. 36%, respectively); reintervention rates (32% vs. 36%), and the percentage of women who reported being either satisfied or very satisfied with the results (68% vs. 64%). No complications occurred in either group.

Dr. Chang pointed out that the trend toward higher amenorrhea rates in the cut waveform group “supports in vitro findings. One significant observation was that the rollerball electrode was rapidly covered with coagulated tissue when using the cut waveform,” he added. “This required the scope to be withdrawn and the rollerball to be cleaned several times during the procedure.” Based on this analysis, he and his associates concluded that both waveform types are safe and equally effective for hysteroscopic endometrial ablation using the rollerball.

Dr. Chang stated that he had no conflicts of interest to disclose.

The low-voltage cut waveform is more likely to result in deep and homogenous tissue penetration. DR. CHANG

Hysteroscopic view of uterine cavity: Rollerball electrode is at upper left.

Brown tissue is area of thermal damage from ablation with a coag waveform. Photos courtesy Dr. Paul T. Chang

LAS VEGAS — Cutting and coagulation waveforms are equally effective for hysteroscopic endometrial ablation using the rollerball, results from the first clinical study of its kind demonstrated.

An in vitro study from the early 1990s showed that the depth of thermal injury to 3 mm of myometrium (the depth of destruction believed to completely destroy the basal layer) was found to be more consistent with use of the low-voltage cut waveform compared with the high-voltage modulated coag waveform (Obstet. Gynecol. 1993;82:912–8). However, no published clinical trial has compared the two radiofrequency waveforms after rollerball endometrial ablation, Dr. Paul T. Chang said at the annual meeting of the AAGL.

The low-voltage cut waveform, which heats the tissue more slowly, “is more likely to result in deep and homogenous tissue penetration, while the high-voltage modulated coag waveform is more likely to result in superficial tissue desiccation and subsequent increase in tissue impedance,” said Dr. Chang, a specialist in minimally invasive gynecology and infertility at the Toronto Centre for Advanced Reproductive Technology.

In a trial intended to serve as a pilot study for a larger randomized trial, Dr. Chang and his mentor, Dr. George A. Vilos of the University of Western Ontario, London, allocated 47 premenopausal women to hysteroscopic electrocoagulation of the endometrium using a 5-mm diameter rollerball with cut or coag waveforms at 100 watts of power. Eligibility criteria included symptomatic menorrhagia, no desire for future pregnancy, no intramural or submucosal myomas 3 cm or larger, no active pelvic inflammatory disease, and no atypical endometrial hyperplasia or cancer. The average age of the patients was 41 years and the average body mass index was 28 kg/m

Of the 55 women 22 were in the cut waveform group and 23 were in the coag waveform group. One physician experienced in hysteroscopic surgery and two surgical fellows performed all procedures at St. Joseph's Health Care in London, Ont., between November 2004 and March 2005.

Primary outcomes included rates of menstrual reduction, need for reintervention, patient satisfaction as measured by questionnaires, and complications. Two-year follow-up was completed by either questionnaires or telephone contact.

Dr. Chang and his associates hypothesized that patients in the cut waveform would have superior clinical outcomes compared with those in the coag waveform group. However, at 2 years of follow-up, the rate of hypomenorrhea was 52% in the coag group and 32% in the cut group, a difference that was not statistically significant.

There were no statistically significant differences between the coag and cut waveform groups in terms of amenorrhea rates (28% vs. 36%, respectively); reintervention rates (32% vs. 36%), and the percentage of women who reported being either satisfied or very satisfied with the results (68% vs. 64%). No complications occurred in either group.

Dr. Chang pointed out that the trend toward higher amenorrhea rates in the cut waveform group “supports in vitro findings. One significant observation was that the rollerball electrode was rapidly covered with coagulated tissue when using the cut waveform,” he added. “This required the scope to be withdrawn and the rollerball to be cleaned several times during the procedure.” Based on this analysis, he and his associates concluded that both waveform types are safe and equally effective for hysteroscopic endometrial ablation using the rollerball.

Dr. Chang stated that he had no conflicts of interest to disclose.

The low-voltage cut waveform is more likely to result in deep and homogenous tissue penetration. DR. CHANG

Hysteroscopic view of uterine cavity: Rollerball electrode is at upper left.

Brown tissue is area of thermal damage from ablation with a coag waveform. Photos courtesy Dr. Paul T. Chang

Febrile infants with bronchiolitis treated in primary care settings received a full sepsis evaluation one-half as often as other febrile infants and seemed to have even lower rates of serious bacterial illness, compared with infants treated in emergency departments and hospitals, results from a study of more than 3,000 cases show.

Those are key findings from the first large-scale study to examine primary care treatment and associated bacterial infections among febrile infants with clinically diagnosed bronchiolitis.

Although most existing studies in the medical literature have shown that the rates of serious bacterial illness in children evaluated in emergency departments or hospitalized with fever and bronchiolitis or respiratory syncytial virus (RSV) range from 0% to 10%, “No studies of the office-based care of febrile infants with clinically diagnosed bronchiolitis have been published, leaving primary care practitioners without generalizable guidelines for management,” researchers led by Dr. Lynn M. Luginbuhl of the department of pediatrics at Harvard Medical School, Boston, reported.

In a report from the Pediatric Research in Office Settings (PROS) network, a research program of the American Academy of Pediatrics, Dr. Luginbuhl and her associates prospectively studied 3,066 febrile infants in 219 practices in 44 states who were evaluated between Feb. 28, 1995, and April 25, 1998 (Pediatrics 2008;122:947-54).

Infants were eligible for the trial if they had had a temperature of 38° C or higher in the office or in the preceding 24 hours at home and were previously healthy, without major comorbidity.

They compared the frequency of sepsis evaluation, parenteral antibiotic treatment, and serious bacterial illness in infants with and without clinically diagnosed bronchiolitis, which was defined in the study manual as “an infection of the bronchioles characterized by wheezing, tachypnea, fever, and cough, and is usually associated with respiratory viruses, in particular RSV. Conclusive diagnosis includes isolation of RSV from nasopharyngeal washings or positive RSV antigen. Parainfluenza A and B are also common causes.”

The researchers then used logistic regression to identify predictors of sepsis evaluation and parenteral antibiotic treatment.

Clinicians made a clinical diagnosis of bronchiolitis in 218 of the 3,066 (7%) infants.

Compared with infants without a diagnosis of bronchiolitis, those with the diagnosis were significantly older (a mean of 8 weeks vs. 7 weeks, respectively) and were significantly less likely to undergo a complete sepsis evaluation (14% vs. 28%, respectively); urine testing (33% vs. 54%); cerebrospinal culture (16% vs. 32%); and to receive parenteral antibiotic treatment (33% vs. 45%).

There were no serious bacterial illnesses (SBIs) among infants with a diagnosis of bronchiolitis. SBIs among the infants without a diagnosis of the condition included 167 (5%) cases of urinary tract infection, 49 (2%) cases of bacteremia, and 14 (less than 1%) cases of meningitis.

Dr. Luginbuhl and her associates had no relevant conflicts to disclose.

Febrile infants with bronchiolitis treated in primary care settings received a full sepsis evaluation one-half as often as other febrile infants and seemed to have even lower rates of serious bacterial illness, compared with infants treated in emergency departments and hospitals, results from a study of more than 3,000 cases show.

Those are key findings from the first large-scale study to examine primary care treatment and associated bacterial infections among febrile infants with clinically diagnosed bronchiolitis.

Although most existing studies in the medical literature have shown that the rates of serious bacterial illness in children evaluated in emergency departments or hospitalized with fever and bronchiolitis or respiratory syncytial virus (RSV) range from 0% to 10%, “No studies of the office-based care of febrile infants with clinically diagnosed bronchiolitis have been published, leaving primary care practitioners without generalizable guidelines for management,” researchers led by Dr. Lynn M. Luginbuhl of the department of pediatrics at Harvard Medical School, Boston, reported.

In a report from the Pediatric Research in Office Settings (PROS) network, a research program of the American Academy of Pediatrics, Dr. Luginbuhl and her associates prospectively studied 3,066 febrile infants in 219 practices in 44 states who were evaluated between Feb. 28, 1995, and April 25, 1998 (Pediatrics 2008;122:947-54).

Infants were eligible for the trial if they had had a temperature of 38° C or higher in the office or in the preceding 24 hours at home and were previously healthy, without major comorbidity.

They compared the frequency of sepsis evaluation, parenteral antibiotic treatment, and serious bacterial illness in infants with and without clinically diagnosed bronchiolitis, which was defined in the study manual as “an infection of the bronchioles characterized by wheezing, tachypnea, fever, and cough, and is usually associated with respiratory viruses, in particular RSV. Conclusive diagnosis includes isolation of RSV from nasopharyngeal washings or positive RSV antigen. Parainfluenza A and B are also common causes.”

The researchers then used logistic regression to identify predictors of sepsis evaluation and parenteral antibiotic treatment.

Clinicians made a clinical diagnosis of bronchiolitis in 218 of the 3,066 (7%) infants.

Compared with infants without a diagnosis of bronchiolitis, those with the diagnosis were significantly older (a mean of 8 weeks vs. 7 weeks, respectively) and were significantly less likely to undergo a complete sepsis evaluation (14% vs. 28%, respectively); urine testing (33% vs. 54%); cerebrospinal culture (16% vs. 32%); and to receive parenteral antibiotic treatment (33% vs. 45%).

There were no serious bacterial illnesses (SBIs) among infants with a diagnosis of bronchiolitis. SBIs among the infants without a diagnosis of the condition included 167 (5%) cases of urinary tract infection, 49 (2%) cases of bacteremia, and 14 (less than 1%) cases of meningitis.

Dr. Luginbuhl and her associates had no relevant conflicts to disclose.

Febrile infants with bronchiolitis treated in primary care settings received a full sepsis evaluation one-half as often as other febrile infants and seemed to have even lower rates of serious bacterial illness, compared with infants treated in emergency departments and hospitals, results from a study of more than 3,000 cases show.

Those are key findings from the first large-scale study to examine primary care treatment and associated bacterial infections among febrile infants with clinically diagnosed bronchiolitis.

Although most existing studies in the medical literature have shown that the rates of serious bacterial illness in children evaluated in emergency departments or hospitalized with fever and bronchiolitis or respiratory syncytial virus (RSV) range from 0% to 10%, “No studies of the office-based care of febrile infants with clinically diagnosed bronchiolitis have been published, leaving primary care practitioners without generalizable guidelines for management,” researchers led by Dr. Lynn M. Luginbuhl of the department of pediatrics at Harvard Medical School, Boston, reported.

In a report from the Pediatric Research in Office Settings (PROS) network, a research program of the American Academy of Pediatrics, Dr. Luginbuhl and her associates prospectively studied 3,066 febrile infants in 219 practices in 44 states who were evaluated between Feb. 28, 1995, and April 25, 1998 (Pediatrics 2008;122:947-54).

Infants were eligible for the trial if they had had a temperature of 38° C or higher in the office or in the preceding 24 hours at home and were previously healthy, without major comorbidity.

They compared the frequency of sepsis evaluation, parenteral antibiotic treatment, and serious bacterial illness in infants with and without clinically diagnosed bronchiolitis, which was defined in the study manual as “an infection of the bronchioles characterized by wheezing, tachypnea, fever, and cough, and is usually associated with respiratory viruses, in particular RSV. Conclusive diagnosis includes isolation of RSV from nasopharyngeal washings or positive RSV antigen. Parainfluenza A and B are also common causes.”

The researchers then used logistic regression to identify predictors of sepsis evaluation and parenteral antibiotic treatment.

Clinicians made a clinical diagnosis of bronchiolitis in 218 of the 3,066 (7%) infants.

Compared with infants without a diagnosis of bronchiolitis, those with the diagnosis were significantly older (a mean of 8 weeks vs. 7 weeks, respectively) and were significantly less likely to undergo a complete sepsis evaluation (14% vs. 28%, respectively); urine testing (33% vs. 54%); cerebrospinal culture (16% vs. 32%); and to receive parenteral antibiotic treatment (33% vs. 45%).

There were no serious bacterial illnesses (SBIs) among infants with a diagnosis of bronchiolitis. SBIs among the infants without a diagnosis of the condition included 167 (5%) cases of urinary tract infection, 49 (2%) cases of bacteremia, and 14 (less than 1%) cases of meningitis.

Dr. Luginbuhl and her associates had no relevant conflicts to disclose.

SAN DIEGO — Think your medical practice is immune from employees who commit occupational fraud? Think again.

Of 450 medium- and large-size organizations that participated in KPMG LLP's 2003 United States Fraud Survey, 75% had experienced an incidence of occupational fraud, which the Association of Certified Fraud Examiners (ACFE) defines as “the use of one's occupation for personal enrichment through the deliberate misuse or misapplication of the employing orgajnization's resources or assets.”

What's more, the ACFE's 2008 “Report to the Nation on Occupational Fraud and Abuse” estimated that organizations lost 7% of revenues to fraud and abuse, up from 5% in 2006.

The ACFE report also found that the health care industry had the third highest number of frauds reported, at 8%, and businesses with fewer than 100 employees were more susceptible to occupational fraud, compared with larger businesses.

Motivations behind occupational fraud vary widely and include financial pressures, perceived opportunity, and rationalization. Financial pressures include “things like gambling, lack of money to repay debts, drugs, and seeking status beyond your financial means,” Frederic R. Simmons Jr., certified public accountant, said at the annual conference of the Medical Group Management Association.

Perceived opportunity for fraud can occur when employees “have access to company information and systems and procedures, and knowledge about what the company does,” he added. “Many have heard stories about others who have gotten away with fraud, and they think they can, too.”

Employees may rationalize the fraud, intending to pay back what they steal, but if they aren't caught, the incentive to keep true to that intent fades away. “They get away with it, and the next time they have a need, they try it again and turn into a real dishonest employee,” said Mr. Simmons, CEO of Clearwater (Fla.) Cardiovascular and Interventional Consultants.

In their book “Theft by Employees” (Lexington Books, 1983), sociologists Richard D. Hollinger, Ph.D., and John P. Clark, Ph.D., found that low job satisfaction was a primary cause of employee theft and concluded that the true cost of employee misconduct is grossly underestimated. The authors, who surveyed 10,000 employees, defined misconduct in two ways: property deviance, such as stealing money and office supplies, and production deviance, such as consistently leaving work early or conducting personal business on company time.

In a subset analysis of 4,111 employees who worked in the hospital sector, 27% reported taking hospital supplies, 8% took or used patient medication, and 6% were paid for more hours than they actually worked. In addition, 57% reported taking a long lunch or break without approval, 33% used sick time when they weren't actually sick, and 29% frequently arrived to work late or left early.

According to the ACFE report, more than half of all fraud is committed by employees in the accounting and finance departments or by upper executives. The amount of loss varies by age group, from a median of $25,000 for employees under the age of 26 to a median of $500,000 for those aged 51-60. The frequency of fraud is higher among men, compared with women (59% vs. 41%, respectively).

“People who have been with you a short period of time generally are not the ones who are going to commit the biggest fraud,” Mr. Simmons noted. “It takes a while to understand how businesses' systems and procedures work. It's really the people who have over 5 years experience with you that usually commit the biggest fraud.”

Leading behavioral “red flags” correlated with occupational fraud in the ACFE report include living beyond one's financial means; having financial difficulties; having a “wheeler-dealer” attitude; displaying control issues and an unwillingness to share duties; having divorce or family problems; maintaining an unusually close association with a vendor or customer; displaying irritability, suspiciousness, or defensiveness; dealing with an addiction or with legal problems; having had past employment-related problems; complaining about inadequate pay; and refusing to take vacations.

Lee Ann H. Webster, certified public accountant and administrator of Pathology Associates of Alabama PC, noted that the revenue cycle is a popular target for fraud because “this is generally the largest item on a medical practice financial statement.” The three main types of revenue cycle fraud include skimming unrecorded revenues, such as pocketing the payment from a self-pay patient and not recording the charge; skimming receivables, such as pocketing the payment for a previously recorded charge and covering it up with bogus adjustments or other methods; and lapping, or “robbing Peter to pay Paul.”

Lapping occurs, she said, when patient A pays on account and the perpetrator pockets the payment. Patient B pays on account and the perpetrator records the payment by patient B on patient A's account. This goes on until the perpetrator is caught or covers up the fraud.

Practical ways to detect and prevent revenue cycle fraud, Ms. Webster said, include segregation of duties in the accounting department; using lock box; controlled access to billing system functions; review of accounts receivable aging and past due balances; review of patient accounts with a “hold” code; review of work areas and trash for evidence of secondary record keeping; mandatory vacations (with a substitute performing functions); rotation of duties (preferably without notice); follow-up on old deposits in transit or late deposits; electronic receipt of payments; and follow-up on patient complaints about billing.

Ms. Webster also warned about using facsimile signature stamps. “The person who has access to this has check-signing authority, even if they are not an official check signer,” she said. “If you have one of these, seriously consider getting rid of it. If you have to keep it, make sure that the accounts payable clerks do not have access to it.”

Other ways to prevent and detect occupational fraud include establishing a hotline for tips, conducting criminal background checks before hiring new employees, and providing some ethics training.

SAN DIEGO — Think your medical practice is immune from employees who commit occupational fraud? Think again.

Of 450 medium- and large-size organizations that participated in KPMG LLP's 2003 United States Fraud Survey, 75% had experienced an incidence of occupational fraud, which the Association of Certified Fraud Examiners (ACFE) defines as “the use of one's occupation for personal enrichment through the deliberate misuse or misapplication of the employing orgajnization's resources or assets.”

What's more, the ACFE's 2008 “Report to the Nation on Occupational Fraud and Abuse” estimated that organizations lost 7% of revenues to fraud and abuse, up from 5% in 2006.

The ACFE report also found that the health care industry had the third highest number of frauds reported, at 8%, and businesses with fewer than 100 employees were more susceptible to occupational fraud, compared with larger businesses.

Motivations behind occupational fraud vary widely and include financial pressures, perceived opportunity, and rationalization. Financial pressures include “things like gambling, lack of money to repay debts, drugs, and seeking status beyond your financial means,” Frederic R. Simmons Jr., certified public accountant, said at the annual conference of the Medical Group Management Association.

Perceived opportunity for fraud can occur when employees “have access to company information and systems and procedures, and knowledge about what the company does,” he added. “Many have heard stories about others who have gotten away with fraud, and they think they can, too.”

Employees may rationalize the fraud, intending to pay back what they steal, but if they aren't caught, the incentive to keep true to that intent fades away. “They get away with it, and the next time they have a need, they try it again and turn into a real dishonest employee,” said Mr. Simmons, CEO of Clearwater (Fla.) Cardiovascular and Interventional Consultants.

In their book “Theft by Employees” (Lexington Books, 1983), sociologists Richard D. Hollinger, Ph.D., and John P. Clark, Ph.D., found that low job satisfaction was a primary cause of employee theft and concluded that the true cost of employee misconduct is grossly underestimated. The authors, who surveyed 10,000 employees, defined misconduct in two ways: property deviance, such as stealing money and office supplies, and production deviance, such as consistently leaving work early or conducting personal business on company time.

In a subset analysis of 4,111 employees who worked in the hospital sector, 27% reported taking hospital supplies, 8% took or used patient medication, and 6% were paid for more hours than they actually worked. In addition, 57% reported taking a long lunch or break without approval, 33% used sick time when they weren't actually sick, and 29% frequently arrived to work late or left early.

According to the ACFE report, more than half of all fraud is committed by employees in the accounting and finance departments or by upper executives. The amount of loss varies by age group, from a median of $25,000 for employees under the age of 26 to a median of $500,000 for those aged 51-60. The frequency of fraud is higher among men, compared with women (59% vs. 41%, respectively).

“People who have been with you a short period of time generally are not the ones who are going to commit the biggest fraud,” Mr. Simmons noted. “It takes a while to understand how businesses' systems and procedures work. It's really the people who have over 5 years experience with you that usually commit the biggest fraud.”

Leading behavioral “red flags” correlated with occupational fraud in the ACFE report include living beyond one's financial means; having financial difficulties; having a “wheeler-dealer” attitude; displaying control issues and an unwillingness to share duties; having divorce or family problems; maintaining an unusually close association with a vendor or customer; displaying irritability, suspiciousness, or defensiveness; dealing with an addiction or with legal problems; having had past employment-related problems; complaining about inadequate pay; and refusing to take vacations.

Lee Ann H. Webster, certified public accountant and administrator of Pathology Associates of Alabama PC, noted that the revenue cycle is a popular target for fraud because “this is generally the largest item on a medical practice financial statement.” The three main types of revenue cycle fraud include skimming unrecorded revenues, such as pocketing the payment from a self-pay patient and not recording the charge; skimming receivables, such as pocketing the payment for a previously recorded charge and covering it up with bogus adjustments or other methods; and lapping, or “robbing Peter to pay Paul.”

Lapping occurs, she said, when patient A pays on account and the perpetrator pockets the payment. Patient B pays on account and the perpetrator records the payment by patient B on patient A's account. This goes on until the perpetrator is caught or covers up the fraud.

Practical ways to detect and prevent revenue cycle fraud, Ms. Webster said, include segregation of duties in the accounting department; using lock box; controlled access to billing system functions; review of accounts receivable aging and past due balances; review of patient accounts with a “hold” code; review of work areas and trash for evidence of secondary record keeping; mandatory vacations (with a substitute performing functions); rotation of duties (preferably without notice); follow-up on old deposits in transit or late deposits; electronic receipt of payments; and follow-up on patient complaints about billing.

Ms. Webster also warned about using facsimile signature stamps. “The person who has access to this has check-signing authority, even if they are not an official check signer,” she said. “If you have one of these, seriously consider getting rid of it. If you have to keep it, make sure that the accounts payable clerks do not have access to it.”

Other ways to prevent and detect occupational fraud include establishing a hotline for tips, conducting criminal background checks before hiring new employees, and providing some ethics training.

SAN DIEGO — Think your medical practice is immune from employees who commit occupational fraud? Think again.

Of 450 medium- and large-size organizations that participated in KPMG LLP's 2003 United States Fraud Survey, 75% had experienced an incidence of occupational fraud, which the Association of Certified Fraud Examiners (ACFE) defines as “the use of one's occupation for personal enrichment through the deliberate misuse or misapplication of the employing orgajnization's resources or assets.”

What's more, the ACFE's 2008 “Report to the Nation on Occupational Fraud and Abuse” estimated that organizations lost 7% of revenues to fraud and abuse, up from 5% in 2006.

The ACFE report also found that the health care industry had the third highest number of frauds reported, at 8%, and businesses with fewer than 100 employees were more susceptible to occupational fraud, compared with larger businesses.

Motivations behind occupational fraud vary widely and include financial pressures, perceived opportunity, and rationalization. Financial pressures include “things like gambling, lack of money to repay debts, drugs, and seeking status beyond your financial means,” Frederic R. Simmons Jr., certified public accountant, said at the annual conference of the Medical Group Management Association.

Perceived opportunity for fraud can occur when employees “have access to company information and systems and procedures, and knowledge about what the company does,” he added. “Many have heard stories about others who have gotten away with fraud, and they think they can, too.”

Employees may rationalize the fraud, intending to pay back what they steal, but if they aren't caught, the incentive to keep true to that intent fades away. “They get away with it, and the next time they have a need, they try it again and turn into a real dishonest employee,” said Mr. Simmons, CEO of Clearwater (Fla.) Cardiovascular and Interventional Consultants.

In their book “Theft by Employees” (Lexington Books, 1983), sociologists Richard D. Hollinger, Ph.D., and John P. Clark, Ph.D., found that low job satisfaction was a primary cause of employee theft and concluded that the true cost of employee misconduct is grossly underestimated. The authors, who surveyed 10,000 employees, defined misconduct in two ways: property deviance, such as stealing money and office supplies, and production deviance, such as consistently leaving work early or conducting personal business on company time.

In a subset analysis of 4,111 employees who worked in the hospital sector, 27% reported taking hospital supplies, 8% took or used patient medication, and 6% were paid for more hours than they actually worked. In addition, 57% reported taking a long lunch or break without approval, 33% used sick time when they weren't actually sick, and 29% frequently arrived to work late or left early.

According to the ACFE report, more than half of all fraud is committed by employees in the accounting and finance departments or by upper executives. The amount of loss varies by age group, from a median of $25,000 for employees under the age of 26 to a median of $500,000 for those aged 51-60. The frequency of fraud is higher among men, compared with women (59% vs. 41%, respectively).

“People who have been with you a short period of time generally are not the ones who are going to commit the biggest fraud,” Mr. Simmons noted. “It takes a while to understand how businesses' systems and procedures work. It's really the people who have over 5 years experience with you that usually commit the biggest fraud.”

Leading behavioral “red flags” correlated with occupational fraud in the ACFE report include living beyond one's financial means; having financial difficulties; having a “wheeler-dealer” attitude; displaying control issues and an unwillingness to share duties; having divorce or family problems; maintaining an unusually close association with a vendor or customer; displaying irritability, suspiciousness, or defensiveness; dealing with an addiction or with legal problems; having had past employment-related problems; complaining about inadequate pay; and refusing to take vacations.

Lee Ann H. Webster, certified public accountant and administrator of Pathology Associates of Alabama PC, noted that the revenue cycle is a popular target for fraud because “this is generally the largest item on a medical practice financial statement.” The three main types of revenue cycle fraud include skimming unrecorded revenues, such as pocketing the payment from a self-pay patient and not recording the charge; skimming receivables, such as pocketing the payment for a previously recorded charge and covering it up with bogus adjustments or other methods; and lapping, or “robbing Peter to pay Paul.”

Lapping occurs, she said, when patient A pays on account and the perpetrator pockets the payment. Patient B pays on account and the perpetrator records the payment by patient B on patient A's account. This goes on until the perpetrator is caught or covers up the fraud.

Practical ways to detect and prevent revenue cycle fraud, Ms. Webster said, include segregation of duties in the accounting department; using lock box; controlled access to billing system functions; review of accounts receivable aging and past due balances; review of patient accounts with a “hold” code; review of work areas and trash for evidence of secondary record keeping; mandatory vacations (with a substitute performing functions); rotation of duties (preferably without notice); follow-up on old deposits in transit or late deposits; electronic receipt of payments; and follow-up on patient complaints about billing.

Ms. Webster also warned about using facsimile signature stamps. “The person who has access to this has check-signing authority, even if they are not an official check signer,” she said. “If you have one of these, seriously consider getting rid of it. If you have to keep it, make sure that the accounts payable clerks do not have access to it.”

Other ways to prevent and detect occupational fraud include establishing a hotline for tips, conducting criminal background checks before hiring new employees, and providing some ethics training.

LAS VEGAS — It goes without saying that protection from excessive ultraviolet light throughout life is advocated by dermatologists to prevent skin cancer and photoaging, noted Dr. James M. Spencer.

“We dermatologists basically tell Americans, 'Use sunscreen or sunblock all the time.' That's our public health message, and it's been a consistent message for 20 years,” Dr. Spencer said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. “In animal and human studies, sunscreens have clearly proved to help prevent photoaging, lower the incidence of actinic keratoses, and lower the incidence of squamous cell carcinoma. That's beyond dispute.”

The American Academy of Dermatology recently issued a position statement recommending that “an adequate amount of vitamin D should be obtained from a healthy diet that includes food rich in vitamin D, foods/beverages fortified with vitamin D, and/or vitamin D supplements; it should not be obtained from unprotected ultraviolet (UV) radiation.”

The statement also pointed out that the current intake levels recommended by the Institute of Medicine, the health policy research arm of the National Academy of Sciences, “may be revised upward due to evolving research on the increasing clinical benefit of vitamin D.”

The wisdom of avoiding sun and using sunscreen has been questioned over the last few years, initially by epidemiologists who were looking to correlate human behavior with the development of melanoma, Dr. Spencer said. Then came a review article in 2007 by Dr. Michael F. Holick, an endocrinologist at Boston University, which estimated that 40%–60% of the adult population in the United States is vitamin D deficient (N. Engl. J. Med. 2007;357:266–81). The article calls for “sensible sun exposure” to ensure that adequate amounts of vitamin D are made in the skin, noting that exposure of the arms and legs for 5–30 minutes between 10 a.m. and 3 p.m. twice a week is “adequate” for most people.

“Some moderate sun exposure for both children and adults is appropriate,” Dr. Holick said in an interview. “Yes, you can always wear a broad-rimmed hat or some kind of sun protection for your face. It's the most sun damaged area; it's only about 9% of your body surface, and it doesn't provide you with that much of your vitamin D.”

According to the article, which was supported in part by grants from the National Institutes of Health and the UV Foundation, a key cause of vitamin D deficiency is sunscreen use, which “reduces vitamin D₃ synthesis.” It also states that the ultraviolet B radiation emitted from tanning beds is a good source of vitamin D₃ “when used in moderation.”

The importance of obtaining adequate levels of vitamin D is not in dispute, said Dr. Spencer of Mount Sinai School of Medicine, New York. Vitamin D has emerged as a candidate for the chemoprevention of a variety of malignancies and systemic diseases, including melanoma; breast, colon, and prostate cancer; multiple sclerosis; hypertension; cardiovascular disease; type 1 diabetes; Crohn's disease; schizophrenia; and depression.

However, there is no reason to believe that sun protection dangerously lowers vitamin D levels, said Dr. Spencer, who has a private dermatology practice in St. Petersburg, Fla. “Even if it did, the public has largely ignored our sun protection message, based on results of recent surveys of sun protection habits. It is a mistake to encourage the public to get intentional sun exposure for their health.”

He went on to note that vitamin D production in the skin “is highly variable by such factors as skin pigmentation and time of year, and therefore is not a reliable way to elevate vitamin D. It is unlikely that anyone goes to the beach or the tanning parlor to make more vitamin D, but this issue lets them rationalize that doing something they know is bad for them is actually okay. The people most at risk for vitamin D deficiency—dark-skinned nursing home residents—do not go to tanning salons.”

According to the Institute of Medicine guidelines, the recommended minimal daily intake of vitamin D is 200 IU for children and adults to age 50 years, 400 IU for adults aged 50–70 years, and 600 IU for adults older than 70 years.

The American Academy of Pediatrics Committee on Nutrition recently recommended increasing oral intake in children to 400 IU per day but does not recommend increased sun exposure because of skin cancer risk (Pediatrics 2008;122:1142–52).

In a pharmacokinetic study, a team of researchers that included Dr. Holick demonstrated that healthy men use up to 5,000 IU of vitamin D per day (Am. J. Clin. Nutr. 2003;77:204–10). This is “an order of magnitude higher than we thought we needed,” said Dr. Holick, professor of medicine, physiology, and biophysics at the university, and coauthor of the book, “The UV Advantage” (New York: Ibooks Inc., 2004). “We probably need to increase by 10-fold our vitamin intake to satisfy our body's requirement.”

Good dietary sources of vitamin D include salmon and other oily fish, eggs, fortified milk and cereals, orange juice, and vitamin supplements. “Many multivitamins contain D₂, which is poorly absorbed,” said Dr. Spencer, past cochairman of the National Council on Skin Cancer Prevention. “Look for those that contain vitamin D₃.”

Dr. Holick maintains that it is “next to impossible” to get enough vitamin D from diet alone; some exposure to sunlight must play into the mix. “If you were to go outside in a bathing suit on the beach in the summertime and get a light pinkness to your skin, a minimal erythemal dose—which is 15–20 minutes for a white person—that's equivalent to ingesting 10,000–20,000 IU of vitamin D.”

While it's known how much vitamin D is needed to prevent deficiency and bone disease, Dr. Spencer said, “We do not know what level of vitamin D may be optimal for health maintenance. Therefore, we keep an open mind to future research.”

As for Dr. Holick, he points to a position statement on sun exposure issued in 2006 by groups that included the Australian College of Dermatologists and Cancer Council Australia, which support his view (www.cancer.org.au

The importance of obtaining vitamin D is not in dispute; it is how it is obtained that is, according to Dr. James M. Spencer. Courtesy Dr. James M. Spencer

LAS VEGAS — It goes without saying that protection from excessive ultraviolet light throughout life is advocated by dermatologists to prevent skin cancer and photoaging, noted Dr. James M. Spencer.

“We dermatologists basically tell Americans, 'Use sunscreen or sunblock all the time.' That's our public health message, and it's been a consistent message for 20 years,” Dr. Spencer said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. “In animal and human studies, sunscreens have clearly proved to help prevent photoaging, lower the incidence of actinic keratoses, and lower the incidence of squamous cell carcinoma. That's beyond dispute.”

The American Academy of Dermatology recently issued a position statement recommending that “an adequate amount of vitamin D should be obtained from a healthy diet that includes food rich in vitamin D, foods/beverages fortified with vitamin D, and/or vitamin D supplements; it should not be obtained from unprotected ultraviolet (UV) radiation.”

The statement also pointed out that the current intake levels recommended by the Institute of Medicine, the health policy research arm of the National Academy of Sciences, “may be revised upward due to evolving research on the increasing clinical benefit of vitamin D.”

The wisdom of avoiding sun and using sunscreen has been questioned over the last few years, initially by epidemiologists who were looking to correlate human behavior with the development of melanoma, Dr. Spencer said. Then came a review article in 2007 by Dr. Michael F. Holick, an endocrinologist at Boston University, which estimated that 40%–60% of the adult population in the United States is vitamin D deficient (N. Engl. J. Med. 2007;357:266–81). The article calls for “sensible sun exposure” to ensure that adequate amounts of vitamin D are made in the skin, noting that exposure of the arms and legs for 5–30 minutes between 10 a.m. and 3 p.m. twice a week is “adequate” for most people.

“Some moderate sun exposure for both children and adults is appropriate,” Dr. Holick said in an interview. “Yes, you can always wear a broad-rimmed hat or some kind of sun protection for your face. It's the most sun damaged area; it's only about 9% of your body surface, and it doesn't provide you with that much of your vitamin D.”

According to the article, which was supported in part by grants from the National Institutes of Health and the UV Foundation, a key cause of vitamin D deficiency is sunscreen use, which “reduces vitamin D₃ synthesis.” It also states that the ultraviolet B radiation emitted from tanning beds is a good source of vitamin D₃ “when used in moderation.”

The importance of obtaining adequate levels of vitamin D is not in dispute, said Dr. Spencer of Mount Sinai School of Medicine, New York. Vitamin D has emerged as a candidate for the chemoprevention of a variety of malignancies and systemic diseases, including melanoma; breast, colon, and prostate cancer; multiple sclerosis; hypertension; cardiovascular disease; type 1 diabetes; Crohn's disease; schizophrenia; and depression.

However, there is no reason to believe that sun protection dangerously lowers vitamin D levels, said Dr. Spencer, who has a private dermatology practice in St. Petersburg, Fla. “Even if it did, the public has largely ignored our sun protection message, based on results of recent surveys of sun protection habits. It is a mistake to encourage the public to get intentional sun exposure for their health.”

He went on to note that vitamin D production in the skin “is highly variable by such factors as skin pigmentation and time of year, and therefore is not a reliable way to elevate vitamin D. It is unlikely that anyone goes to the beach or the tanning parlor to make more vitamin D, but this issue lets them rationalize that doing something they know is bad for them is actually okay. The people most at risk for vitamin D deficiency—dark-skinned nursing home residents—do not go to tanning salons.”

According to the Institute of Medicine guidelines, the recommended minimal daily intake of vitamin D is 200 IU for children and adults to age 50 years, 400 IU for adults aged 50–70 years, and 600 IU for adults older than 70 years.

The American Academy of Pediatrics Committee on Nutrition recently recommended increasing oral intake in children to 400 IU per day but does not recommend increased sun exposure because of skin cancer risk (Pediatrics 2008;122:1142–52).

In a pharmacokinetic study, a team of researchers that included Dr. Holick demonstrated that healthy men use up to 5,000 IU of vitamin D per day (Am. J. Clin. Nutr. 2003;77:204–10). This is “an order of magnitude higher than we thought we needed,” said Dr. Holick, professor of medicine, physiology, and biophysics at the university, and coauthor of the book, “The UV Advantage” (New York: Ibooks Inc., 2004). “We probably need to increase by 10-fold our vitamin intake to satisfy our body's requirement.”

Good dietary sources of vitamin D include salmon and other oily fish, eggs, fortified milk and cereals, orange juice, and vitamin supplements. “Many multivitamins contain D₂, which is poorly absorbed,” said Dr. Spencer, past cochairman of the National Council on Skin Cancer Prevention. “Look for those that contain vitamin D₃.”

Dr. Holick maintains that it is “next to impossible” to get enough vitamin D from diet alone; some exposure to sunlight must play into the mix. “If you were to go outside in a bathing suit on the beach in the summertime and get a light pinkness to your skin, a minimal erythemal dose—which is 15–20 minutes for a white person—that's equivalent to ingesting 10,000–20,000 IU of vitamin D.”

While it's known how much vitamin D is needed to prevent deficiency and bone disease, Dr. Spencer said, “We do not know what level of vitamin D may be optimal for health maintenance. Therefore, we keep an open mind to future research.”

As for Dr. Holick, he points to a position statement on sun exposure issued in 2006 by groups that included the Australian College of Dermatologists and Cancer Council Australia, which support his view (www.cancer.org.au

The importance of obtaining vitamin D is not in dispute; it is how it is obtained that is, according to Dr. James M. Spencer. Courtesy Dr. James M. Spencer

LAS VEGAS — It goes without saying that protection from excessive ultraviolet light throughout life is advocated by dermatologists to prevent skin cancer and photoaging, noted Dr. James M. Spencer.

“We dermatologists basically tell Americans, 'Use sunscreen or sunblock all the time.' That's our public health message, and it's been a consistent message for 20 years,” Dr. Spencer said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. “In animal and human studies, sunscreens have clearly proved to help prevent photoaging, lower the incidence of actinic keratoses, and lower the incidence of squamous cell carcinoma. That's beyond dispute.”

The American Academy of Dermatology recently issued a position statement recommending that “an adequate amount of vitamin D should be obtained from a healthy diet that includes food rich in vitamin D, foods/beverages fortified with vitamin D, and/or vitamin D supplements; it should not be obtained from unprotected ultraviolet (UV) radiation.”

The statement also pointed out that the current intake levels recommended by the Institute of Medicine, the health policy research arm of the National Academy of Sciences, “may be revised upward due to evolving research on the increasing clinical benefit of vitamin D.”

The wisdom of avoiding sun and using sunscreen has been questioned over the last few years, initially by epidemiologists who were looking to correlate human behavior with the development of melanoma, Dr. Spencer said. Then came a review article in 2007 by Dr. Michael F. Holick, an endocrinologist at Boston University, which estimated that 40%–60% of the adult population in the United States is vitamin D deficient (N. Engl. J. Med. 2007;357:266–81). The article calls for “sensible sun exposure” to ensure that adequate amounts of vitamin D are made in the skin, noting that exposure of the arms and legs for 5–30 minutes between 10 a.m. and 3 p.m. twice a week is “adequate” for most people.

“Some moderate sun exposure for both children and adults is appropriate,” Dr. Holick said in an interview. “Yes, you can always wear a broad-rimmed hat or some kind of sun protection for your face. It's the most sun damaged area; it's only about 9% of your body surface, and it doesn't provide you with that much of your vitamin D.”

According to the article, which was supported in part by grants from the National Institutes of Health and the UV Foundation, a key cause of vitamin D deficiency is sunscreen use, which “reduces vitamin D₃ synthesis.” It also states that the ultraviolet B radiation emitted from tanning beds is a good source of vitamin D₃ “when used in moderation.”

The importance of obtaining adequate levels of vitamin D is not in dispute, said Dr. Spencer of Mount Sinai School of Medicine, New York. Vitamin D has emerged as a candidate for the chemoprevention of a variety of malignancies and systemic diseases, including melanoma; breast, colon, and prostate cancer; multiple sclerosis; hypertension; cardiovascular disease; type 1 diabetes; Crohn's disease; schizophrenia; and depression.

However, there is no reason to believe that sun protection dangerously lowers vitamin D levels, said Dr. Spencer, who has a private dermatology practice in St. Petersburg, Fla. “Even if it did, the public has largely ignored our sun protection message, based on results of recent surveys of sun protection habits. It is a mistake to encourage the public to get intentional sun exposure for their health.”

He went on to note that vitamin D production in the skin “is highly variable by such factors as skin pigmentation and time of year, and therefore is not a reliable way to elevate vitamin D. It is unlikely that anyone goes to the beach or the tanning parlor to make more vitamin D, but this issue lets them rationalize that doing something they know is bad for them is actually okay. The people most at risk for vitamin D deficiency—dark-skinned nursing home residents—do not go to tanning salons.”

According to the Institute of Medicine guidelines, the recommended minimal daily intake of vitamin D is 200 IU for children and adults to age 50 years, 400 IU for adults aged 50–70 years, and 600 IU for adults older than 70 years.

The American Academy of Pediatrics Committee on Nutrition recently recommended increasing oral intake in children to 400 IU per day but does not recommend increased sun exposure because of skin cancer risk (Pediatrics 2008;122:1142–52).

In a pharmacokinetic study, a team of researchers that included Dr. Holick demonstrated that healthy men use up to 5,000 IU of vitamin D per day (Am. J. Clin. Nutr. 2003;77:204–10). This is “an order of magnitude higher than we thought we needed,” said Dr. Holick, professor of medicine, physiology, and biophysics at the university, and coauthor of the book, “The UV Advantage” (New York: Ibooks Inc., 2004). “We probably need to increase by 10-fold our vitamin intake to satisfy our body's requirement.”

Good dietary sources of vitamin D include salmon and other oily fish, eggs, fortified milk and cereals, orange juice, and vitamin supplements. “Many multivitamins contain D₂, which is poorly absorbed,” said Dr. Spencer, past cochairman of the National Council on Skin Cancer Prevention. “Look for those that contain vitamin D₃.”

Dr. Holick maintains that it is “next to impossible” to get enough vitamin D from diet alone; some exposure to sunlight must play into the mix. “If you were to go outside in a bathing suit on the beach in the summertime and get a light pinkness to your skin, a minimal erythemal dose—which is 15–20 minutes for a white person—that's equivalent to ingesting 10,000–20,000 IU of vitamin D.”

While it's known how much vitamin D is needed to prevent deficiency and bone disease, Dr. Spencer said, “We do not know what level of vitamin D may be optimal for health maintenance. Therefore, we keep an open mind to future research.”

As for Dr. Holick, he points to a position statement on sun exposure issued in 2006 by groups that included the Australian College of Dermatologists and Cancer Council Australia, which support his view (www.cancer.org.au

The importance of obtaining vitamin D is not in dispute; it is how it is obtained that is, according to Dr. James M. Spencer. Courtesy Dr. James M. Spencer

LAS VEGAS — Bipolar radiofrequency ablation and thermal balloon ablation are equally effective for the treatment of menorrhagia, a population-based cohort study showed.

However, women who underwent radiofrequency ablation (RFA, or NovaSure), a technology that was introduced in 2001, were nearly three times more likely to develop postprocedural amenorrhea than were women who underwent thermal balloon ablation (TBA, or ThermaChoice), a technology that was introduced in 1997, Dr. Sherif El-Nashar said at the annual meeting of the AAGL.

“In several randomized clinical trials, the newer global endometrial ablation technologies had comparable efficacy to hysteroscopic endometrial ablation, along with [an] improved safety profile,” said Dr. El-Nashar of the department of obstetrics and gynecology at the Mayo Clinic, Rochester, Minn.

“Despite the wide use of global endometrial ablation technologies in clinical practice, to date, only two randomized controlled trials have directly compared RFA and TBA technologies. Despite their excellent design, they had relatively small sample sizes, were all from single centers, and had a relatively short follow-up,” he added.

In a study led by Dr. El-Nashar's mentor, Dr. Abimbola O. Famuyide, the researchers used the Rochester Epidemiology Project to identify 455 women who resided in Olmsted County, Minn., and underwent global endometrial ablation for menorrhagia between January 1998 and December 2005. The project includes information about patients receiving care at Olmsted Medical Center and the Mayo Clinic.

The researchers then compared the efficacy of RFA to TBA using treatment failure and postprocedure amenorrhea as outcome measures. Treatment failure was defined as reablation or hysterectomy for persistent bleeding or pain; amenorrhea was defined as the complete cessation of menstruation starting immediately post ablation for 12 months or more.

Of the 455 patients, 255 underwent RFA and 200 underwent TBA; both groups were followed for a median of 2.2 years. The patients' average age was 43, and their mean body mass index was 29 kg/m

Dr. El-Nashar reported that there were no significant differences in the time to treatment failure between the two groups, with a 3-year cumulative failure rate of 9% in the RFA group, compared with 12% in the TBA group. This difference remained nonsignificant after adjustment for known predictors of treatment failure including age, parity, pretreatment dysmenorrhea, and tubal ligation.

However, women in the RFA group had significantly higher amenorrhea rates, compared with their counterparts in the TBA group (32% vs. 14%). This difference remained significant after adjustment for known predictors of amenorrhea including age, uterine length, and endometrial thickness (adjusted odds ratio, 2.9).

Complications were infrequent and comparable in the two groups.

Dr. El-Nashar said he had no conflicts of interest to disclose.

The RFA and TBA groups displayed no significant differences in the time to treatment failure. DR. EL-NASHAR

LAS VEGAS — Bipolar radiofrequency ablation and thermal balloon ablation are equally effective for the treatment of menorrhagia, a population-based cohort study showed.

However, women who underwent radiofrequency ablation (RFA, or NovaSure), a technology that was introduced in 2001, were nearly three times more likely to develop postprocedural amenorrhea than were women who underwent thermal balloon ablation (TBA, or ThermaChoice), a technology that was introduced in 1997, Dr. Sherif El-Nashar said at the annual meeting of the AAGL.

“In several randomized clinical trials, the newer global endometrial ablation technologies had comparable efficacy to hysteroscopic endometrial ablation, along with [an] improved safety profile,” said Dr. El-Nashar of the department of obstetrics and gynecology at the Mayo Clinic, Rochester, Minn.

“Despite the wide use of global endometrial ablation technologies in clinical practice, to date, only two randomized controlled trials have directly compared RFA and TBA technologies. Despite their excellent design, they had relatively small sample sizes, were all from single centers, and had a relatively short follow-up,” he added.

In a study led by Dr. El-Nashar's mentor, Dr. Abimbola O. Famuyide, the researchers used the Rochester Epidemiology Project to identify 455 women who resided in Olmsted County, Minn., and underwent global endometrial ablation for menorrhagia between January 1998 and December 2005. The project includes information about patients receiving care at Olmsted Medical Center and the Mayo Clinic.

The researchers then compared the efficacy of RFA to TBA using treatment failure and postprocedure amenorrhea as outcome measures. Treatment failure was defined as reablation or hysterectomy for persistent bleeding or pain; amenorrhea was defined as the complete cessation of menstruation starting immediately post ablation for 12 months or more.

Of the 455 patients, 255 underwent RFA and 200 underwent TBA; both groups were followed for a median of 2.2 years. The patients' average age was 43, and their mean body mass index was 29 kg/m

Dr. El-Nashar reported that there were no significant differences in the time to treatment failure between the two groups, with a 3-year cumulative failure rate of 9% in the RFA group, compared with 12% in the TBA group. This difference remained nonsignificant after adjustment for known predictors of treatment failure including age, parity, pretreatment dysmenorrhea, and tubal ligation.

However, women in the RFA group had significantly higher amenorrhea rates, compared with their counterparts in the TBA group (32% vs. 14%). This difference remained significant after adjustment for known predictors of amenorrhea including age, uterine length, and endometrial thickness (adjusted odds ratio, 2.9).

Complications were infrequent and comparable in the two groups.

Dr. El-Nashar said he had no conflicts of interest to disclose.

The RFA and TBA groups displayed no significant differences in the time to treatment failure. DR. EL-NASHAR

LAS VEGAS — Bipolar radiofrequency ablation and thermal balloon ablation are equally effective for the treatment of menorrhagia, a population-based cohort study showed.

However, women who underwent radiofrequency ablation (RFA, or NovaSure), a technology that was introduced in 2001, were nearly three times more likely to develop postprocedural amenorrhea than were women who underwent thermal balloon ablation (TBA, or ThermaChoice), a technology that was introduced in 1997, Dr. Sherif El-Nashar said at the annual meeting of the AAGL.

“In several randomized clinical trials, the newer global endometrial ablation technologies had comparable efficacy to hysteroscopic endometrial ablation, along with [an] improved safety profile,” said Dr. El-Nashar of the department of obstetrics and gynecology at the Mayo Clinic, Rochester, Minn.

“Despite the wide use of global endometrial ablation technologies in clinical practice, to date, only two randomized controlled trials have directly compared RFA and TBA technologies. Despite their excellent design, they had relatively small sample sizes, were all from single centers, and had a relatively short follow-up,” he added.

In a study led by Dr. El-Nashar's mentor, Dr. Abimbola O. Famuyide, the researchers used the Rochester Epidemiology Project to identify 455 women who resided in Olmsted County, Minn., and underwent global endometrial ablation for menorrhagia between January 1998 and December 2005. The project includes information about patients receiving care at Olmsted Medical Center and the Mayo Clinic.

The researchers then compared the efficacy of RFA to TBA using treatment failure and postprocedure amenorrhea as outcome measures. Treatment failure was defined as reablation or hysterectomy for persistent bleeding or pain; amenorrhea was defined as the complete cessation of menstruation starting immediately post ablation for 12 months or more.

Of the 455 patients, 255 underwent RFA and 200 underwent TBA; both groups were followed for a median of 2.2 years. The patients' average age was 43, and their mean body mass index was 29 kg/m

Dr. El-Nashar reported that there were no significant differences in the time to treatment failure between the two groups, with a 3-year cumulative failure rate of 9% in the RFA group, compared with 12% in the TBA group. This difference remained nonsignificant after adjustment for known predictors of treatment failure including age, parity, pretreatment dysmenorrhea, and tubal ligation.

However, women in the RFA group had significantly higher amenorrhea rates, compared with their counterparts in the TBA group (32% vs. 14%). This difference remained significant after adjustment for known predictors of amenorrhea including age, uterine length, and endometrial thickness (adjusted odds ratio, 2.9).

Complications were infrequent and comparable in the two groups.

Dr. El-Nashar said he had no conflicts of interest to disclose.

The RFA and TBA groups displayed no significant differences in the time to treatment failure. DR. EL-NASHAR

After Dr. Joshua Grossman underwent his second neck dissection for papillary carcinoma of the thyroid gland in 1986, he believed he might not have much time to live. So, at age 45, he decided to audition for a role in a Johnson City (Tenn.) Community Theater production of Irving Berlin's “Annie Get Your Gun.”

“I'd always wanted to do community theater,” said Dr. Grossman, a Johnson City-based internist. “I got a kick in my fanny from my cancer, and I figured, well, I'll get in a couple of shows, and then I'll croak. I actually thought I was dying.”

He was cast as Chief Sitting Bull and went on not only to beat his cancer, but also to earn roles in several subsequent productions staged by area theaters, including Gonzales in Tennessee Williams's “Summer and Smoke,” Padre Perez in “Man of La Mancha,” and Mario in “Ballroom.” All the while serving as a full Colonel in the U. S. Army Medical Corps, from which he retired in 2000.

“When I did 'Annie Get Your Gun,' the night work was being taken over by the interns and residents,” recalled Dr. Grossman, who spent most of his career working at a local Veterans Affairs Medical Center. “The workload was more than 40 hours a week, but it wasn't quite as heavy as a practicing physician's, which is one of the reasons why I was in the VA: so I could spend a little more time with my wife and kids.”

In addition, he has served as a theater usher, worked the lighting and other technical jobs, and helped build and disassemble sets. “I also tidied up the theater so much that one of our late community theater actors and volunteer set builders called me the garbage man. I would sift through it because angle brackets and other things were mistakenly thrown in there that could be reused in future productions,” he said.

Along the way he learned to respect the talents of master playwrights such as Tennessee Williams. He and his fellow cast members held frequent discussions in the green room about what message Williams was trying to convey in his plays. “We could never reach consensus as to what he was trying to get at,” he said. “There's a feeling in general that the I.Q. of poets and playwrights is off the scale.”

Dr. Grossman learned the challenges of sticking to a character. His role as Gonzalez in “Summer and Smoke” called for his character to forcefully grab the shirt of a young doctor, who was being played by a man who had been one of Dr. Grossman's former Cub Scouts when he was a scout leader. “It took many hours of blocking rehearsal before I could do that,” said Dr. Grossman, whose most recent role was that of Joey “the Lump” Marzetti in a fall 2007 dinner theater production of “Funeral for a Gangster,” penned by Eileen Moushey.

Dr. Grossman said that his brush with cancer motivated him to take up another avocation. Prior to starting his undergraduate studies at Johns Hopkins University, Baltimore, he had appeared as a ballroom dancer for 1 week on “The Buddy Dean Show,” a Baltimore-based teen dance television program that featured appearances by the Cordettes, Johnny Mathis, and Frankie Avalon, but Western square dancing had always intrigued him. So he and his wife, Mickey, enrolled in classes at a local university to further develop their ballroom dancing proficiency and to learn Western square dancing. Looking back, Dr. Grossman credits his brush with cancer for motivating him to pursue the avocations he'd long wished to take a crack at. “It's fair to say that my cancer gave me a fairly swift kick in my bottom and got me out into my community,” he said.

Dr. Joshua Grossman is shown with his wife Mickey (far left) and Proud Annie Mystery Theater cast members. Courtesy Dr. Joshua Grossman

After Dr. Joshua Grossman underwent his second neck dissection for papillary carcinoma of the thyroid gland in 1986, he believed he might not have much time to live. So, at age 45, he decided to audition for a role in a Johnson City (Tenn.) Community Theater production of Irving Berlin's “Annie Get Your Gun.”

“I'd always wanted to do community theater,” said Dr. Grossman, a Johnson City-based internist. “I got a kick in my fanny from my cancer, and I figured, well, I'll get in a couple of shows, and then I'll croak. I actually thought I was dying.”

He was cast as Chief Sitting Bull and went on not only to beat his cancer, but also to earn roles in several subsequent productions staged by area theaters, including Gonzales in Tennessee Williams's “Summer and Smoke,” Padre Perez in “Man of La Mancha,” and Mario in “Ballroom.” All the while serving as a full Colonel in the U. S. Army Medical Corps, from which he retired in 2000.

“When I did 'Annie Get Your Gun,' the night work was being taken over by the interns and residents,” recalled Dr. Grossman, who spent most of his career working at a local Veterans Affairs Medical Center. “The workload was more than 40 hours a week, but it wasn't quite as heavy as a practicing physician's, which is one of the reasons why I was in the VA: so I could spend a little more time with my wife and kids.”

In addition, he has served as a theater usher, worked the lighting and other technical jobs, and helped build and disassemble sets. “I also tidied up the theater so much that one of our late community theater actors and volunteer set builders called me the garbage man. I would sift through it because angle brackets and other things were mistakenly thrown in there that could be reused in future productions,” he said.

Along the way he learned to respect the talents of master playwrights such as Tennessee Williams. He and his fellow cast members held frequent discussions in the green room about what message Williams was trying to convey in his plays. “We could never reach consensus as to what he was trying to get at,” he said. “There's a feeling in general that the I.Q. of poets and playwrights is off the scale.”

Dr. Grossman learned the challenges of sticking to a character. His role as Gonzalez in “Summer and Smoke” called for his character to forcefully grab the shirt of a young doctor, who was being played by a man who had been one of Dr. Grossman's former Cub Scouts when he was a scout leader. “It took many hours of blocking rehearsal before I could do that,” said Dr. Grossman, whose most recent role was that of Joey “the Lump” Marzetti in a fall 2007 dinner theater production of “Funeral for a Gangster,” penned by Eileen Moushey.

Dr. Grossman said that his brush with cancer motivated him to take up another avocation. Prior to starting his undergraduate studies at Johns Hopkins University, Baltimore, he had appeared as a ballroom dancer for 1 week on “The Buddy Dean Show,” a Baltimore-based teen dance television program that featured appearances by the Cordettes, Johnny Mathis, and Frankie Avalon, but Western square dancing had always intrigued him. So he and his wife, Mickey, enrolled in classes at a local university to further develop their ballroom dancing proficiency and to learn Western square dancing. Looking back, Dr. Grossman credits his brush with cancer for motivating him to pursue the avocations he'd long wished to take a crack at. “It's fair to say that my cancer gave me a fairly swift kick in my bottom and got me out into my community,” he said.

Dr. Joshua Grossman is shown with his wife Mickey (far left) and Proud Annie Mystery Theater cast members. Courtesy Dr. Joshua Grossman

After Dr. Joshua Grossman underwent his second neck dissection for papillary carcinoma of the thyroid gland in 1986, he believed he might not have much time to live. So, at age 45, he decided to audition for a role in a Johnson City (Tenn.) Community Theater production of Irving Berlin's “Annie Get Your Gun.”

“I'd always wanted to do community theater,” said Dr. Grossman, a Johnson City-based internist. “I got a kick in my fanny from my cancer, and I figured, well, I'll get in a couple of shows, and then I'll croak. I actually thought I was dying.”

He was cast as Chief Sitting Bull and went on not only to beat his cancer, but also to earn roles in several subsequent productions staged by area theaters, including Gonzales in Tennessee Williams's “Summer and Smoke,” Padre Perez in “Man of La Mancha,” and Mario in “Ballroom.” All the while serving as a full Colonel in the U. S. Army Medical Corps, from which he retired in 2000.

“When I did 'Annie Get Your Gun,' the night work was being taken over by the interns and residents,” recalled Dr. Grossman, who spent most of his career working at a local Veterans Affairs Medical Center. “The workload was more than 40 hours a week, but it wasn't quite as heavy as a practicing physician's, which is one of the reasons why I was in the VA: so I could spend a little more time with my wife and kids.”

In addition, he has served as a theater usher, worked the lighting and other technical jobs, and helped build and disassemble sets. “I also tidied up the theater so much that one of our late community theater actors and volunteer set builders called me the garbage man. I would sift through it because angle brackets and other things were mistakenly thrown in there that could be reused in future productions,” he said.

Along the way he learned to respect the talents of master playwrights such as Tennessee Williams. He and his fellow cast members held frequent discussions in the green room about what message Williams was trying to convey in his plays. “We could never reach consensus as to what he was trying to get at,” he said. “There's a feeling in general that the I.Q. of poets and playwrights is off the scale.”

Dr. Grossman learned the challenges of sticking to a character. His role as Gonzalez in “Summer and Smoke” called for his character to forcefully grab the shirt of a young doctor, who was being played by a man who had been one of Dr. Grossman's former Cub Scouts when he was a scout leader. “It took many hours of blocking rehearsal before I could do that,” said Dr. Grossman, whose most recent role was that of Joey “the Lump” Marzetti in a fall 2007 dinner theater production of “Funeral for a Gangster,” penned by Eileen Moushey.

Dr. Grossman said that his brush with cancer motivated him to take up another avocation. Prior to starting his undergraduate studies at Johns Hopkins University, Baltimore, he had appeared as a ballroom dancer for 1 week on “The Buddy Dean Show,” a Baltimore-based teen dance television program that featured appearances by the Cordettes, Johnny Mathis, and Frankie Avalon, but Western square dancing had always intrigued him. So he and his wife, Mickey, enrolled in classes at a local university to further develop their ballroom dancing proficiency and to learn Western square dancing. Looking back, Dr. Grossman credits his brush with cancer for motivating him to pursue the avocations he'd long wished to take a crack at. “It's fair to say that my cancer gave me a fairly swift kick in my bottom and got me out into my community,” he said.

Dr. Joshua Grossman is shown with his wife Mickey (far left) and Proud Annie Mystery Theater cast members. Courtesy Dr. Joshua Grossman

SAN DIEGO — Symptoms of hypothyroidism such as fatigue, depression, myalgias, cold intolerance, and menstrual abnormalities can be so common that they often blur the distinction between screening and case finding.

“Such symptoms are commonly seen in primary care, so you have to have a low threshold to find hypothyroidism,” Dr. William A. Norcross said at the annual meeting of the American Academy of Family Physicians. He discussed other symptoms of hypothyroidism that can be easily overlooked:

▸ Hyperlipidemia. Lipid abnormalities are dependent on the degree of thyroid failure and are more pronounced in patients with thyroid-stimulating hormone levels above 10 mU/L. “So if you're screening a patient for hypercholesterolemia and you detect it, you should give some consideration to checking a TSH because replacement therapy not only will help the patient feel better, but will help the elevated LDL situation,” said Dr. Norcross of the department of family medicine at the University of California, San Diego.

▸ Hyponatremia. “There is a relationship between hypothyroidism and hyponatremia, especially in elderly patients,” he said. “It's important to detect because the hyponatremia can be difficult to treat if you're missing the underlying cause.”

▸ Myalgias/myositis. One of Dr. Norcross's patients, a healthy-looking middle-aged man, presented with severe myalgias and a TSH level of 150 mU/L. “Every muscle in his body ached,” he recalled. “You couldn't duplicate it with palpation. It was very vexing. Hypothyroidism turned out to be the cause of this muscle pain, and his symptoms went away with levothyroxine replacement.”

Such a case “is not an everyday occurrence, but it happens and is important to keep in mind,” said Dr. Norcross, who also directs the physician assessment and clinical education program at the university.

He also noted that certain drugs may affect thyroid function and thyroid test results. These include lithium, drugs that decrease TSH secretion (such as dopa-mine, glucocorticoids, and phenytoin), and drugs that increase TSH secretion (such as metoclopramide, domperidone, and amiodarone).

According to the United States National Health and Nutrition Examination Survey III, the overall incidence of hypothyroidism in the United States is 4.6%. It's eight times more common in women, compared with men.

Dr. Norcross said that he had no conflicts to disclose.

SAN DIEGO — Symptoms of hypothyroidism such as fatigue, depression, myalgias, cold intolerance, and menstrual abnormalities can be so common that they often blur the distinction between screening and case finding.

“Such symptoms are commonly seen in primary care, so you have to have a low threshold to find hypothyroidism,” Dr. William A. Norcross said at the annual meeting of the American Academy of Family Physicians. He discussed other symptoms of hypothyroidism that can be easily overlooked:

▸ Hyperlipidemia. Lipid abnormalities are dependent on the degree of thyroid failure and are more pronounced in patients with thyroid-stimulating hormone levels above 10 mU/L. “So if you're screening a patient for hypercholesterolemia and you detect it, you should give some consideration to checking a TSH because replacement therapy not only will help the patient feel better, but will help the elevated LDL situation,” said Dr. Norcross of the department of family medicine at the University of California, San Diego.

▸ Hyponatremia. “There is a relationship between hypothyroidism and hyponatremia, especially in elderly patients,” he said. “It's important to detect because the hyponatremia can be difficult to treat if you're missing the underlying cause.”

▸ Myalgias/myositis. One of Dr. Norcross's patients, a healthy-looking middle-aged man, presented with severe myalgias and a TSH level of 150 mU/L. “Every muscle in his body ached,” he recalled. “You couldn't duplicate it with palpation. It was very vexing. Hypothyroidism turned out to be the cause of this muscle pain, and his symptoms went away with levothyroxine replacement.”

Such a case “is not an everyday occurrence, but it happens and is important to keep in mind,” said Dr. Norcross, who also directs the physician assessment and clinical education program at the university.

He also noted that certain drugs may affect thyroid function and thyroid test results. These include lithium, drugs that decrease TSH secretion (such as dopa-mine, glucocorticoids, and phenytoin), and drugs that increase TSH secretion (such as metoclopramide, domperidone, and amiodarone).

According to the United States National Health and Nutrition Examination Survey III, the overall incidence of hypothyroidism in the United States is 4.6%. It's eight times more common in women, compared with men.

Dr. Norcross said that he had no conflicts to disclose.

SAN DIEGO — Symptoms of hypothyroidism such as fatigue, depression, myalgias, cold intolerance, and menstrual abnormalities can be so common that they often blur the distinction between screening and case finding.

“Such symptoms are commonly seen in primary care, so you have to have a low threshold to find hypothyroidism,” Dr. William A. Norcross said at the annual meeting of the American Academy of Family Physicians. He discussed other symptoms of hypothyroidism that can be easily overlooked:

▸ Hyperlipidemia. Lipid abnormalities are dependent on the degree of thyroid failure and are more pronounced in patients with thyroid-stimulating hormone levels above 10 mU/L. “So if you're screening a patient for hypercholesterolemia and you detect it, you should give some consideration to checking a TSH because replacement therapy not only will help the patient feel better, but will help the elevated LDL situation,” said Dr. Norcross of the department of family medicine at the University of California, San Diego.

▸ Hyponatremia. “There is a relationship between hypothyroidism and hyponatremia, especially in elderly patients,” he said. “It's important to detect because the hyponatremia can be difficult to treat if you're missing the underlying cause.”

▸ Myalgias/myositis. One of Dr. Norcross's patients, a healthy-looking middle-aged man, presented with severe myalgias and a TSH level of 150 mU/L. “Every muscle in his body ached,” he recalled. “You couldn't duplicate it with palpation. It was very vexing. Hypothyroidism turned out to be the cause of this muscle pain, and his symptoms went away with levothyroxine replacement.”

Such a case “is not an everyday occurrence, but it happens and is important to keep in mind,” said Dr. Norcross, who also directs the physician assessment and clinical education program at the university.

He also noted that certain drugs may affect thyroid function and thyroid test results. These include lithium, drugs that decrease TSH secretion (such as dopa-mine, glucocorticoids, and phenytoin), and drugs that increase TSH secretion (such as metoclopramide, domperidone, and amiodarone).

According to the United States National Health and Nutrition Examination Survey III, the overall incidence of hypothyroidism in the United States is 4.6%. It's eight times more common in women, compared with men.

Dr. Norcross said that he had no conflicts to disclose.