Doug Brunk

LAS VEGAS — Photodynamic therapy continues to be used for many indications, including actinic keratoses, acne, and photorejuvenation, but other potential uses remain.

Perhaps most promising is the technology's role in chemoprevention, based largely on European studies, Dr. Michael Gold said at the annual meeting of the International Society for Dermatologic Surgery.

"Preliminary data are very promising," said Dr. Gold, a dermatologist who practices in Nashville, Tenn. "Anecdotal data in clinical practice are also encouraging, including longer time to development of new actinic keratoses and nonmelanoma skin cancers after treatment."

The two main photodynamic therapy photosensitizers currently being studied include Levulan (Dusa Pharmaceuticals Inc.) and Metvix (PhotoCure ASA).

Levulan is a 20% 5-aminolevulinic acid (ALA) solution. ALA occurs naturally in cells as an intermediate product formed during the endogenous porphyrin synthesis. It is converted to protoporphyrin IX and is activated by an appropriate light source.

In the United States, Levulan is approved for nonhyperkeratotic actinic keratoses of the face and scalp, with an incubation period of 14–18 hours and a treatment delivery time of 16 minutes and 40 seconds. All other uses are off label.

Metvix is a methyl ester of 20% 5-ALA. In the United States, it is approved for the treatment of actinic keratoses while in Europe and Australia it is widely used for the treatment of skin cancer.

"The FDA did not give this approval," Dr. Gold said. "In addition, there have been three reports in the literature of contact allergy to Metvix, so you have to keep that in mind."

Another photosensitizer available in Europe is PhotoSpray (Danish Dermatologic Development), a product that contains a 0.5% liposome encapsulated 5-ALA. "Patients spray themselves with the product every 5–10 minutes for an hour before undergoing an IPL [intense pulsed light] type of treatment, and they've been getting some very nice results," Dr. Gold said.

In the United States, 5-ALA photosensitizers are being used to treat a variety of dermatologic concerns, including photorejuvenation and associated actinic keratoses, acne vulgaris, sebaceous gland hyperplasia, and hidradenitis suppurativa.

In Europe, the primary niche for their use remains in nonmelanoma skin cancer.

Light sources studied with these agents have included blue light, IPL, and pulsed dye lasers. Five split-face clinical trials published in 2005 and 2006 have confirmed the photorejuvenation results. The studies "showed better results with the IPL or pulsed dye lasers compared with the blue light technology," Dr. Gold said.

In the treatment of acne, studies have demonstrated that 5-ALA gets absorbed into the sebaceous glands, causing a partial destruction of the glands.

Two split-face trials of acne patients showed better results when 5-ALA was combined with IPL compared with IPL alone (Dermatol. Surg. 2005;31:910-5; Dermatol. Surg. 2006;32:991-6).

Dr. Gold disclosed that he is a consultant, performed research, and speaks on behalf of many pharmaceutical and medical device companies, including DUSA Pharmaceuticals Inc. and Lumenis.

A patient with severe acne is shown prior to treatment with a blue-light device.

The patient's acne is much improved after undergoing photodynamic therapy. Photos courtesy Dr. Michael Gold

LAS VEGAS — Photodynamic therapy continues to be used for many indications, including actinic keratoses, acne, and photorejuvenation, but other potential uses remain.

Perhaps most promising is the technology's role in chemoprevention, based largely on European studies, Dr. Michael Gold said at the annual meeting of the International Society for Dermatologic Surgery.

"Preliminary data are very promising," said Dr. Gold, a dermatologist who practices in Nashville, Tenn. "Anecdotal data in clinical practice are also encouraging, including longer time to development of new actinic keratoses and nonmelanoma skin cancers after treatment."

The two main photodynamic therapy photosensitizers currently being studied include Levulan (Dusa Pharmaceuticals Inc.) and Metvix (PhotoCure ASA).

Levulan is a 20% 5-aminolevulinic acid (ALA) solution. ALA occurs naturally in cells as an intermediate product formed during the endogenous porphyrin synthesis. It is converted to protoporphyrin IX and is activated by an appropriate light source.

In the United States, Levulan is approved for nonhyperkeratotic actinic keratoses of the face and scalp, with an incubation period of 14–18 hours and a treatment delivery time of 16 minutes and 40 seconds. All other uses are off label.

Metvix is a methyl ester of 20% 5-ALA. In the United States, it is approved for the treatment of actinic keratoses while in Europe and Australia it is widely used for the treatment of skin cancer.

"The FDA did not give this approval," Dr. Gold said. "In addition, there have been three reports in the literature of contact allergy to Metvix, so you have to keep that in mind."

Another photosensitizer available in Europe is PhotoSpray (Danish Dermatologic Development), a product that contains a 0.5% liposome encapsulated 5-ALA. "Patients spray themselves with the product every 5–10 minutes for an hour before undergoing an IPL [intense pulsed light] type of treatment, and they've been getting some very nice results," Dr. Gold said.

In the United States, 5-ALA photosensitizers are being used to treat a variety of dermatologic concerns, including photorejuvenation and associated actinic keratoses, acne vulgaris, sebaceous gland hyperplasia, and hidradenitis suppurativa.

In Europe, the primary niche for their use remains in nonmelanoma skin cancer.

Light sources studied with these agents have included blue light, IPL, and pulsed dye lasers. Five split-face clinical trials published in 2005 and 2006 have confirmed the photorejuvenation results. The studies "showed better results with the IPL or pulsed dye lasers compared with the blue light technology," Dr. Gold said.

In the treatment of acne, studies have demonstrated that 5-ALA gets absorbed into the sebaceous glands, causing a partial destruction of the glands.

Two split-face trials of acne patients showed better results when 5-ALA was combined with IPL compared with IPL alone (Dermatol. Surg. 2005;31:910-5; Dermatol. Surg. 2006;32:991-6).

Dr. Gold disclosed that he is a consultant, performed research, and speaks on behalf of many pharmaceutical and medical device companies, including DUSA Pharmaceuticals Inc. and Lumenis.

A patient with severe acne is shown prior to treatment with a blue-light device.

The patient's acne is much improved after undergoing photodynamic therapy. Photos courtesy Dr. Michael Gold

LAS VEGAS — Photodynamic therapy continues to be used for many indications, including actinic keratoses, acne, and photorejuvenation, but other potential uses remain.

Perhaps most promising is the technology's role in chemoprevention, based largely on European studies, Dr. Michael Gold said at the annual meeting of the International Society for Dermatologic Surgery.

"Preliminary data are very promising," said Dr. Gold, a dermatologist who practices in Nashville, Tenn. "Anecdotal data in clinical practice are also encouraging, including longer time to development of new actinic keratoses and nonmelanoma skin cancers after treatment."

The two main photodynamic therapy photosensitizers currently being studied include Levulan (Dusa Pharmaceuticals Inc.) and Metvix (PhotoCure ASA).

Levulan is a 20% 5-aminolevulinic acid (ALA) solution. ALA occurs naturally in cells as an intermediate product formed during the endogenous porphyrin synthesis. It is converted to protoporphyrin IX and is activated by an appropriate light source.

In the United States, Levulan is approved for nonhyperkeratotic actinic keratoses of the face and scalp, with an incubation period of 14–18 hours and a treatment delivery time of 16 minutes and 40 seconds. All other uses are off label.

Metvix is a methyl ester of 20% 5-ALA. In the United States, it is approved for the treatment of actinic keratoses while in Europe and Australia it is widely used for the treatment of skin cancer.

"The FDA did not give this approval," Dr. Gold said. "In addition, there have been three reports in the literature of contact allergy to Metvix, so you have to keep that in mind."

Another photosensitizer available in Europe is PhotoSpray (Danish Dermatologic Development), a product that contains a 0.5% liposome encapsulated 5-ALA. "Patients spray themselves with the product every 5–10 minutes for an hour before undergoing an IPL [intense pulsed light] type of treatment, and they've been getting some very nice results," Dr. Gold said.

In the United States, 5-ALA photosensitizers are being used to treat a variety of dermatologic concerns, including photorejuvenation and associated actinic keratoses, acne vulgaris, sebaceous gland hyperplasia, and hidradenitis suppurativa.

In Europe, the primary niche for their use remains in nonmelanoma skin cancer.

Light sources studied with these agents have included blue light, IPL, and pulsed dye lasers. Five split-face clinical trials published in 2005 and 2006 have confirmed the photorejuvenation results. The studies "showed better results with the IPL or pulsed dye lasers compared with the blue light technology," Dr. Gold said.

In the treatment of acne, studies have demonstrated that 5-ALA gets absorbed into the sebaceous glands, causing a partial destruction of the glands.

Two split-face trials of acne patients showed better results when 5-ALA was combined with IPL compared with IPL alone (Dermatol. Surg. 2005;31:910-5; Dermatol. Surg. 2006;32:991-6).

Dr. Gold disclosed that he is a consultant, performed research, and speaks on behalf of many pharmaceutical and medical device companies, including DUSA Pharmaceuticals Inc. and Lumenis.

A patient with severe acne is shown prior to treatment with a blue-light device.

The patient's acne is much improved after undergoing photodynamic therapy. Photos courtesy Dr. Michael Gold

LAS VEGAS — Breast reduction by liposuction using tumescent local anesthesia is a safe and effective procedure, results from a study of 131 patients showed.

The patients ranged in age from 16 to 77 years and their average age was 45 years, Dr. Loek Habbema reported at the annual meeting of the International Society for Dermatologic Surgery.

Breast volume was measured preoperatively and postoperatively in two ways: the amount of fat removed as a percent of breast volume and the percent reduction measured as a difference between breast volumes.

Each patient lost an average of 51% total breast volume, said Dr. Habbema, a dermatologist who practices in Bussum, the Netherlands. The minimum volume lost was 20%, while the maximum volume was 87%. He said that the average loss of fat was 1,040 mL in both breasts combined.

"In women under the age of 30, the percent of breast volume reduction is variable due to the variability of fat content in the breast, but in older women, a reduction of 40% or more is typically reached," Dr. Habbema said.

The average lifting of breast tissue that occurred after the procedure was 2.8 cm. The minimum lift was 0.8 cm and the maximum lift was 7.0 cm, he said.

Complications from the procedure included three cases of erythema, two cases of blistering, two cases of hematoma, one case of contact dermatitis, and one case of retracted nipple.

"This is a great opportunity to help patients, a better way than normally used in breast reduction by excision," Dr. Habbema said of the procedure.

Dr. Habbema had no conflicts to disclose relevant to his presentation.

LAS VEGAS — Breast reduction by liposuction using tumescent local anesthesia is a safe and effective procedure, results from a study of 131 patients showed.

The patients ranged in age from 16 to 77 years and their average age was 45 years, Dr. Loek Habbema reported at the annual meeting of the International Society for Dermatologic Surgery.

Breast volume was measured preoperatively and postoperatively in two ways: the amount of fat removed as a percent of breast volume and the percent reduction measured as a difference between breast volumes.

Each patient lost an average of 51% total breast volume, said Dr. Habbema, a dermatologist who practices in Bussum, the Netherlands. The minimum volume lost was 20%, while the maximum volume was 87%. He said that the average loss of fat was 1,040 mL in both breasts combined.

"In women under the age of 30, the percent of breast volume reduction is variable due to the variability of fat content in the breast, but in older women, a reduction of 40% or more is typically reached," Dr. Habbema said.

The average lifting of breast tissue that occurred after the procedure was 2.8 cm. The minimum lift was 0.8 cm and the maximum lift was 7.0 cm, he said.

Complications from the procedure included three cases of erythema, two cases of blistering, two cases of hematoma, one case of contact dermatitis, and one case of retracted nipple.

"This is a great opportunity to help patients, a better way than normally used in breast reduction by excision," Dr. Habbema said of the procedure.

Dr. Habbema had no conflicts to disclose relevant to his presentation.

LAS VEGAS — Breast reduction by liposuction using tumescent local anesthesia is a safe and effective procedure, results from a study of 131 patients showed.

The patients ranged in age from 16 to 77 years and their average age was 45 years, Dr. Loek Habbema reported at the annual meeting of the International Society for Dermatologic Surgery.

Breast volume was measured preoperatively and postoperatively in two ways: the amount of fat removed as a percent of breast volume and the percent reduction measured as a difference between breast volumes.

Each patient lost an average of 51% total breast volume, said Dr. Habbema, a dermatologist who practices in Bussum, the Netherlands. The minimum volume lost was 20%, while the maximum volume was 87%. He said that the average loss of fat was 1,040 mL in both breasts combined.

"In women under the age of 30, the percent of breast volume reduction is variable due to the variability of fat content in the breast, but in older women, a reduction of 40% or more is typically reached," Dr. Habbema said.

The average lifting of breast tissue that occurred after the procedure was 2.8 cm. The minimum lift was 0.8 cm and the maximum lift was 7.0 cm, he said.

Complications from the procedure included three cases of erythema, two cases of blistering, two cases of hematoma, one case of contact dermatitis, and one case of retracted nipple.

"This is a great opportunity to help patients, a better way than normally used in breast reduction by excision," Dr. Habbema said of the procedure.

Dr. Habbema had no conflicts to disclose relevant to his presentation.

LAS VEGAS — When it comes to lidocaine concentration in tumescent local anesthesia for liposuction, how low can you go?

The recommended dose in the medical literature ranges from 500 to 1,500 mg per 1,000 mL of saline, but in Dr. Loek Habbema's clinical experience in Bussum, the Netherlands, the lower the concentration of lidocaine, the better.

In fact, no more than 500 mg of lidocaine per 1,000 mL of saline is required in patients who undergo liposuction using tumescent local anesthesia, Dr. Habbema said at the annual meeting of the International Society for Dermatologic Surgery.

"A specific complication related to tumescent local anesthesia is lidocaine toxicity," he said. "For this reason, it's important to use a lidocaine concentration as low as possible that still creates adequate anesthesia."

Between 1996 and 2008, Dr. Habbema performed liposuction using tumescent local anesthesia on 3,000 patients. Initially, the concentration of lidocaine was taken from guidelines published in the medical literature, but over time the concentration was reduced to find the minimum concentration required for complete anesthesia.

No intravenous or intramuscular pain management or sedation was used. Lorazepam 1 mg or clonidine 0.05 mg was administered as needed.

In 1996, the majority of his patients received 1,000 mg of lidocaine per 1,000 mL of saline, but by 2008, the majority received 400–500 mg per 1,000 mL of saline. He now uses 400 mg per 1,000 mL of saline for all body areas except the abdomen and breast, which require 500 mg per 1,000 mL of saline, he said.

"No more than 500 mg per 1,000 mL saline is ever necessary," he noted. "That creates adequate anesthesia in all body areas."

In cases where a patient may feel some discomfort during liposuction, "it's no problem to add some tumescent solution during the procedure," Dr. Habbema noted. "Experience has lowered the need for this touch-up during the procedures, thanks to the learning curve for creating optimal tumescence. The more you do it, the less you will need during the procedure."

Dr. Habbema had no conflicts of interest to disclose relevant to his presentation.

LAS VEGAS — When it comes to lidocaine concentration in tumescent local anesthesia for liposuction, how low can you go?

The recommended dose in the medical literature ranges from 500 to 1,500 mg per 1,000 mL of saline, but in Dr. Loek Habbema's clinical experience in Bussum, the Netherlands, the lower the concentration of lidocaine, the better.

In fact, no more than 500 mg of lidocaine per 1,000 mL of saline is required in patients who undergo liposuction using tumescent local anesthesia, Dr. Habbema said at the annual meeting of the International Society for Dermatologic Surgery.

"A specific complication related to tumescent local anesthesia is lidocaine toxicity," he said. "For this reason, it's important to use a lidocaine concentration as low as possible that still creates adequate anesthesia."

Between 1996 and 2008, Dr. Habbema performed liposuction using tumescent local anesthesia on 3,000 patients. Initially, the concentration of lidocaine was taken from guidelines published in the medical literature, but over time the concentration was reduced to find the minimum concentration required for complete anesthesia.

No intravenous or intramuscular pain management or sedation was used. Lorazepam 1 mg or clonidine 0.05 mg was administered as needed.

In 1996, the majority of his patients received 1,000 mg of lidocaine per 1,000 mL of saline, but by 2008, the majority received 400–500 mg per 1,000 mL of saline. He now uses 400 mg per 1,000 mL of saline for all body areas except the abdomen and breast, which require 500 mg per 1,000 mL of saline, he said.

"No more than 500 mg per 1,000 mL saline is ever necessary," he noted. "That creates adequate anesthesia in all body areas."

In cases where a patient may feel some discomfort during liposuction, "it's no problem to add some tumescent solution during the procedure," Dr. Habbema noted. "Experience has lowered the need for this touch-up during the procedures, thanks to the learning curve for creating optimal tumescence. The more you do it, the less you will need during the procedure."

Dr. Habbema had no conflicts of interest to disclose relevant to his presentation.

LAS VEGAS — When it comes to lidocaine concentration in tumescent local anesthesia for liposuction, how low can you go?

The recommended dose in the medical literature ranges from 500 to 1,500 mg per 1,000 mL of saline, but in Dr. Loek Habbema's clinical experience in Bussum, the Netherlands, the lower the concentration of lidocaine, the better.

In fact, no more than 500 mg of lidocaine per 1,000 mL of saline is required in patients who undergo liposuction using tumescent local anesthesia, Dr. Habbema said at the annual meeting of the International Society for Dermatologic Surgery.

"A specific complication related to tumescent local anesthesia is lidocaine toxicity," he said. "For this reason, it's important to use a lidocaine concentration as low as possible that still creates adequate anesthesia."

Between 1996 and 2008, Dr. Habbema performed liposuction using tumescent local anesthesia on 3,000 patients. Initially, the concentration of lidocaine was taken from guidelines published in the medical literature, but over time the concentration was reduced to find the minimum concentration required for complete anesthesia.

No intravenous or intramuscular pain management or sedation was used. Lorazepam 1 mg or clonidine 0.05 mg was administered as needed.

In 1996, the majority of his patients received 1,000 mg of lidocaine per 1,000 mL of saline, but by 2008, the majority received 400–500 mg per 1,000 mL of saline. He now uses 400 mg per 1,000 mL of saline for all body areas except the abdomen and breast, which require 500 mg per 1,000 mL of saline, he said.

"No more than 500 mg per 1,000 mL saline is ever necessary," he noted. "That creates adequate anesthesia in all body areas."

In cases where a patient may feel some discomfort during liposuction, "it's no problem to add some tumescent solution during the procedure," Dr. Habbema noted. "Experience has lowered the need for this touch-up during the procedures, thanks to the learning curve for creating optimal tumescence. The more you do it, the less you will need during the procedure."

Dr. Habbema had no conflicts of interest to disclose relevant to his presentation.

LAS VEGAS — Tumescent liposuction may be the current preferred method for removing unwanted fat, but laser lipolysis and other minimally invasive innovations may be the next frontier in body contouring.

"The toned body look is the new fashion statement and the reflection of youth," said Dr. Mark Nestor at the annual meeting of the International Society for Dermatologic Surgery. "Our patients are scared off by liposuction. They are looking for safe and effective minimally invasive treatments, not only for the face, but for removing unwanted fat."

What's more, he said, tumescent liposuction "is certainly technique dependent. Some people are wonderful at it; others are not as good."

One minimally invasive device for body contouring currently on the market is the Smartlipo (Cynosure Inc.), a 1064-nm and 1320-nm Nd:YAG laser, which requires a small incision to accommodate a 1- to 2-mm cannula and 300- or 600-mcm fiber that will heat and disrupt fat cells.

Cleared by the Food and Drug Administration in November 2006, the device is used in conjunction with tumescent solution and requires local anesthesia. Its photothermal and photomechanical effects cause coagulation of tissue, which results in skin tightening, said Dr. Nestor, a dermatologist who practices in Aventura, Fla. Hemostasis of blood vessels causes less bleeding and bruising, compared with traditional liposuction.

"You're heating the fat, but you're also dragging it behind the dermis," he explained. "Because of that, you're causing collagen remodeling and tightening."

Smartlipo's 1064-nm wavelengths are broadly absorbed by hemoglobin, and the energy delivered is distributed homogeneously into fat, "so it's very good at coagulation," he said. "You get enhanced hemostasis and you get healing."

The 1320-nm wavelengths are absorbed by water and the energy delivered is localized at the tip of the laser, "so you get a lot of fat disruption."

The combination of both wavelengths "tends to work the best," Dr. Nestor said, by allowing for safer, more even and efficient energy delivery. In his clinical experience, patients usually require a single treatment but may require a touch-up for optimal results.

Another system he discussed is the LipoSonix (Medicis Inc.), which has not been cleared by the FDA but is available for use in Europe. This device uses a transducer to focus high-intensity ultrasound within adipose tissue at depths up to 13 mm without harming the skin or underlying tissues and organs.

The transducer is automatically scanned over a relatively large area of skin for ease of use and to ensure uniform energy deposition, "similar to the way a pattern generator works in a cosmetic laser system," Dr. Nestor said.

The transducer scans out a defined volume of tissue, creating what he called "a controlled injury zone." Chemotactic signals "then draw macrophages to the site of the injury, where they engulf lipid and cellular debris and carry it away through the lymphatics," Dr. Nestor said. This results in a reduction of the volume of the treated tissue.

The cellular debris eventually gets absorbed through the liver, and the process does not appear to cause spikes in triglycerides or cholesterol.

LipoSonix "is very precise and sophisticated, and it's easy to use," Dr. Nestor said. "This is a very exciting technology and becoming a prototype for high-energy cellulite removal using ultrasound."

Dr. Nestor disclosed that he has received equipment discounts from Cynosure, and has also received fees for speaking and consulting on behalf of the company. He also disclosed being a member of Medicis's scientific advisory board. He has also received fees for speaking engagements and research conducted on behalf of the company.

'Our patients are scared off by liposuction. They are looking for safe and effective' procedures. DR. NESTOR

LAS VEGAS — Tumescent liposuction may be the current preferred method for removing unwanted fat, but laser lipolysis and other minimally invasive innovations may be the next frontier in body contouring.

"The toned body look is the new fashion statement and the reflection of youth," said Dr. Mark Nestor at the annual meeting of the International Society for Dermatologic Surgery. "Our patients are scared off by liposuction. They are looking for safe and effective minimally invasive treatments, not only for the face, but for removing unwanted fat."

What's more, he said, tumescent liposuction "is certainly technique dependent. Some people are wonderful at it; others are not as good."

One minimally invasive device for body contouring currently on the market is the Smartlipo (Cynosure Inc.), a 1064-nm and 1320-nm Nd:YAG laser, which requires a small incision to accommodate a 1- to 2-mm cannula and 300- or 600-mcm fiber that will heat and disrupt fat cells.

Cleared by the Food and Drug Administration in November 2006, the device is used in conjunction with tumescent solution and requires local anesthesia. Its photothermal and photomechanical effects cause coagulation of tissue, which results in skin tightening, said Dr. Nestor, a dermatologist who practices in Aventura, Fla. Hemostasis of blood vessels causes less bleeding and bruising, compared with traditional liposuction.

"You're heating the fat, but you're also dragging it behind the dermis," he explained. "Because of that, you're causing collagen remodeling and tightening."

Smartlipo's 1064-nm wavelengths are broadly absorbed by hemoglobin, and the energy delivered is distributed homogeneously into fat, "so it's very good at coagulation," he said. "You get enhanced hemostasis and you get healing."

The 1320-nm wavelengths are absorbed by water and the energy delivered is localized at the tip of the laser, "so you get a lot of fat disruption."

The combination of both wavelengths "tends to work the best," Dr. Nestor said, by allowing for safer, more even and efficient energy delivery. In his clinical experience, patients usually require a single treatment but may require a touch-up for optimal results.

Another system he discussed is the LipoSonix (Medicis Inc.), which has not been cleared by the FDA but is available for use in Europe. This device uses a transducer to focus high-intensity ultrasound within adipose tissue at depths up to 13 mm without harming the skin or underlying tissues and organs.

The transducer is automatically scanned over a relatively large area of skin for ease of use and to ensure uniform energy deposition, "similar to the way a pattern generator works in a cosmetic laser system," Dr. Nestor said.

The transducer scans out a defined volume of tissue, creating what he called "a controlled injury zone." Chemotactic signals "then draw macrophages to the site of the injury, where they engulf lipid and cellular debris and carry it away through the lymphatics," Dr. Nestor said. This results in a reduction of the volume of the treated tissue.

The cellular debris eventually gets absorbed through the liver, and the process does not appear to cause spikes in triglycerides or cholesterol.

LipoSonix "is very precise and sophisticated, and it's easy to use," Dr. Nestor said. "This is a very exciting technology and becoming a prototype for high-energy cellulite removal using ultrasound."

Dr. Nestor disclosed that he has received equipment discounts from Cynosure, and has also received fees for speaking and consulting on behalf of the company. He also disclosed being a member of Medicis's scientific advisory board. He has also received fees for speaking engagements and research conducted on behalf of the company.

'Our patients are scared off by liposuction. They are looking for safe and effective' procedures. DR. NESTOR

LAS VEGAS — Tumescent liposuction may be the current preferred method for removing unwanted fat, but laser lipolysis and other minimally invasive innovations may be the next frontier in body contouring.

"The toned body look is the new fashion statement and the reflection of youth," said Dr. Mark Nestor at the annual meeting of the International Society for Dermatologic Surgery. "Our patients are scared off by liposuction. They are looking for safe and effective minimally invasive treatments, not only for the face, but for removing unwanted fat."

What's more, he said, tumescent liposuction "is certainly technique dependent. Some people are wonderful at it; others are not as good."

One minimally invasive device for body contouring currently on the market is the Smartlipo (Cynosure Inc.), a 1064-nm and 1320-nm Nd:YAG laser, which requires a small incision to accommodate a 1- to 2-mm cannula and 300- or 600-mcm fiber that will heat and disrupt fat cells.

Cleared by the Food and Drug Administration in November 2006, the device is used in conjunction with tumescent solution and requires local anesthesia. Its photothermal and photomechanical effects cause coagulation of tissue, which results in skin tightening, said Dr. Nestor, a dermatologist who practices in Aventura, Fla. Hemostasis of blood vessels causes less bleeding and bruising, compared with traditional liposuction.

"You're heating the fat, but you're also dragging it behind the dermis," he explained. "Because of that, you're causing collagen remodeling and tightening."

Smartlipo's 1064-nm wavelengths are broadly absorbed by hemoglobin, and the energy delivered is distributed homogeneously into fat, "so it's very good at coagulation," he said. "You get enhanced hemostasis and you get healing."

The 1320-nm wavelengths are absorbed by water and the energy delivered is localized at the tip of the laser, "so you get a lot of fat disruption."

The combination of both wavelengths "tends to work the best," Dr. Nestor said, by allowing for safer, more even and efficient energy delivery. In his clinical experience, patients usually require a single treatment but may require a touch-up for optimal results.

Another system he discussed is the LipoSonix (Medicis Inc.), which has not been cleared by the FDA but is available for use in Europe. This device uses a transducer to focus high-intensity ultrasound within adipose tissue at depths up to 13 mm without harming the skin or underlying tissues and organs.

The transducer is automatically scanned over a relatively large area of skin for ease of use and to ensure uniform energy deposition, "similar to the way a pattern generator works in a cosmetic laser system," Dr. Nestor said.

The transducer scans out a defined volume of tissue, creating what he called "a controlled injury zone." Chemotactic signals "then draw macrophages to the site of the injury, where they engulf lipid and cellular debris and carry it away through the lymphatics," Dr. Nestor said. This results in a reduction of the volume of the treated tissue.

The cellular debris eventually gets absorbed through the liver, and the process does not appear to cause spikes in triglycerides or cholesterol.

LipoSonix "is very precise and sophisticated, and it's easy to use," Dr. Nestor said. "This is a very exciting technology and becoming a prototype for high-energy cellulite removal using ultrasound."

Dr. Nestor disclosed that he has received equipment discounts from Cynosure, and has also received fees for speaking and consulting on behalf of the company. He also disclosed being a member of Medicis's scientific advisory board. He has also received fees for speaking engagements and research conducted on behalf of the company.

'Our patients are scared off by liposuction. They are looking for safe and effective' procedures. DR. NESTOR

LAS VEGAS — Time after time, Dr. Martin Braun encounters new patients in his Vancouver, B.C.-based practice who have undergone previous cosmetic filler treatments in Europe as well as Asia, but who have no idea what product was used.

Determining product history can be a daunting task because there are more than 100 cosmetic fillers currently being used in the European Union (EU), Dr. Braun said at the annual meeting of the International Society for Dermatologic Surgery.

"Frequently, we have to contact the physician, and I'm introduced to a new filler," he said. "Considering today's sense of a global village, I think it's important for physicians in North America to be familiar with some of these products." Filler products approved for use in the EU are designated with a so-called CE mark, which does not indicate conformity to a standard but rather conformity to the legal requirements of EU directives.

"There may not have been any human trials done on the filler," Dr. Braun said. "It could be something as simple as a certified quality system to ISO 9000 and that's it." (ISO is the International Organization for Standardization.)

He highlighted the following products to keep on the radar:

▸ Evolence (ColBar LifeScience Ltd.). Approved in Canada in 2006 and in the United States in 2008, this product contains 35 mg/mL of porcine collagen (telopeptides removed) cross-linked with D-ribose (nontoxic). No skin testing is required and studies have shown that results last up to 12 months.

However, using it for lip augmentation has resulted in several cases of nodule formation, Dr. Braun said. Of 20 patients he treated in 2006, 16 developed multiple lip nodules that have persisted in one-quarter of the cases for nearly 2 years. "Be very cautious with this product in and around the lips," Dr. Braun said.

He did not evaluate Evolence Breeze, which is said to be less problematic in the lips.

▸ Radiesse (BioForm Medical). Data from clinical studies suggest that this Food and Drug Administration-approved product lasts a few more months than do hyaluronic acid (HA) fillers. "It's the filler of choice for me for very deep nasolabial folds in men, as it appears to lift better than many hyaluronic acid fillers," Dr. Braun commented. "The one disadvantage is that 70% of that Radiesse syringe contains a gel carrier that disappears in 3–4 months. You have to warn the patient[s] of this because they will see a huge decrease in their filling after 3–4 months and have to be injected again." In his experience, Radiesse tends to bruise more than other fillers, feels indurated for the first few weeks, and can't be dissolved with anything.

▸ Juvéderm (Allergan Inc.). Developed from Streptococcus equi fermentation, this FDA-approved product "is very similar to Restylane [Medicis Aesthetics Inc.], but it's not as stiff," Dr. Braun said. "So if you want a skin-stiffening agent to perform the fern injection techniques, Restylane will likely do a better job for you." Juvéderm with lidocaine just became available in Canada but is not yet available in the United States. Dr. Braun predicted that this will become his filler of choice for patients who do not wish to have a proper dental block performed.

▸ Sculptra (Sanofi-Aventis). This product is FDA approved for HIV-associated facial lipoatrophy, but in Canada, it's approved for dermal contouring of the face in all patients. Dr. Braun said he uses Sculptra (poly-L-lactic acid) filler in patients with marked hollowing of the buccal fat pads and temporal fat pads and in those with thin skin, because after it's injected "the skin gets a nice glow, similar to [what] you obtain with IPL [intense pulsed light] photorejuvenation."

▸ Atléan (Stiefel Laboratories Inc.). Purchased by Stiefel in 2008, this product contains hyaluronic acid mixed with tricalcium phosphate. "The idea is that the tricalcium phosphate stimulates new collagen formation which is long lasting, like that associated with calcium hydroxyapatite," Dr. Braun said. In split-face injections, Dr. Braun had to use 5 cc of Atléan for 4 cc of Radiesse to get a similar correction. "So Radiesse will have a competitor here," he said. "And unlike Sculptra (where the water absorbs in 2 days), the immediate volumization achieved with Atléan will endure due to the HA component."

Atléan is not approved for use in the United States.

▸ Laresse (FzioMed Inc.). This polyethylene oxide product is marketed as being nonanimal, nonbacterial, nonpermanent, nontoxic, and nonparticulate—"everything we would want in a filler," Dr. Braun said.

However, when he injected it into the glabellar folds of two patients, induration developed that lasted more than 3 weeks. "I don't think it has a future, because when you inject it, you get an induration."

Laresse is not approved for use in the United States.

▸ ArteFill (Artes Medical Inc.). This FDA-approved product is a successor of Artecoll, a formulation of polymethyl methacrylate (PMMA) spheres suspended in collagen that was found to cause a high incidence of lumps when injected into the lips and delayed granulomatous reactions in the face. "Now the product's PMMA crystals have been polished, and it's being marketed as ArteFill," Dr. Braun said. "Many of the complications I saw came out in year 7, so be very careful injecting this. It remains to be seen if this product is safer than Artecoll."

▸ DermaLive and DermaDeep (DermaTech). This permanent filler, a combination of polyethyl methacrylate and hyaluronic acid, was withdrawn from France in 2003 and later from Canada because nodules and granulomas were reported years after injection.

"I ask patients on my medical history sheet if they've had this filler, because if you inject other things in a DermaLive recipient, you can activate a foreign body reaction," Dr. Braun said.

Dr. Braun disclosed that he has received honoraria from Medicis, which markets Restylane, and Allergan, which markets Juvéderm. He owns no stock in either company.

"Be very cautious,"when using Evolence in the lips, said Dr. Martin Braun. Nodule formation—as shown in the patient above 15 months after injection—can occur. Courtesy Dr. Martin Braun

LAS VEGAS — Time after time, Dr. Martin Braun encounters new patients in his Vancouver, B.C.-based practice who have undergone previous cosmetic filler treatments in Europe as well as Asia, but who have no idea what product was used.

Determining product history can be a daunting task because there are more than 100 cosmetic fillers currently being used in the European Union (EU), Dr. Braun said at the annual meeting of the International Society for Dermatologic Surgery.

"Frequently, we have to contact the physician, and I'm introduced to a new filler," he said. "Considering today's sense of a global village, I think it's important for physicians in North America to be familiar with some of these products." Filler products approved for use in the EU are designated with a so-called CE mark, which does not indicate conformity to a standard but rather conformity to the legal requirements of EU directives.

"There may not have been any human trials done on the filler," Dr. Braun said. "It could be something as simple as a certified quality system to ISO 9000 and that's it." (ISO is the International Organization for Standardization.)

He highlighted the following products to keep on the radar:

▸ Evolence (ColBar LifeScience Ltd.). Approved in Canada in 2006 and in the United States in 2008, this product contains 35 mg/mL of porcine collagen (telopeptides removed) cross-linked with D-ribose (nontoxic). No skin testing is required and studies have shown that results last up to 12 months.

However, using it for lip augmentation has resulted in several cases of nodule formation, Dr. Braun said. Of 20 patients he treated in 2006, 16 developed multiple lip nodules that have persisted in one-quarter of the cases for nearly 2 years. "Be very cautious with this product in and around the lips," Dr. Braun said.

He did not evaluate Evolence Breeze, which is said to be less problematic in the lips.

▸ Radiesse (BioForm Medical). Data from clinical studies suggest that this Food and Drug Administration-approved product lasts a few more months than do hyaluronic acid (HA) fillers. "It's the filler of choice for me for very deep nasolabial folds in men, as it appears to lift better than many hyaluronic acid fillers," Dr. Braun commented. "The one disadvantage is that 70% of that Radiesse syringe contains a gel carrier that disappears in 3–4 months. You have to warn the patient[s] of this because they will see a huge decrease in their filling after 3–4 months and have to be injected again." In his experience, Radiesse tends to bruise more than other fillers, feels indurated for the first few weeks, and can't be dissolved with anything.

▸ Juvéderm (Allergan Inc.). Developed from Streptococcus equi fermentation, this FDA-approved product "is very similar to Restylane [Medicis Aesthetics Inc.], but it's not as stiff," Dr. Braun said. "So if you want a skin-stiffening agent to perform the fern injection techniques, Restylane will likely do a better job for you." Juvéderm with lidocaine just became available in Canada but is not yet available in the United States. Dr. Braun predicted that this will become his filler of choice for patients who do not wish to have a proper dental block performed.

▸ Sculptra (Sanofi-Aventis). This product is FDA approved for HIV-associated facial lipoatrophy, but in Canada, it's approved for dermal contouring of the face in all patients. Dr. Braun said he uses Sculptra (poly-L-lactic acid) filler in patients with marked hollowing of the buccal fat pads and temporal fat pads and in those with thin skin, because after it's injected "the skin gets a nice glow, similar to [what] you obtain with IPL [intense pulsed light] photorejuvenation."

▸ Atléan (Stiefel Laboratories Inc.). Purchased by Stiefel in 2008, this product contains hyaluronic acid mixed with tricalcium phosphate. "The idea is that the tricalcium phosphate stimulates new collagen formation which is long lasting, like that associated with calcium hydroxyapatite," Dr. Braun said. In split-face injections, Dr. Braun had to use 5 cc of Atléan for 4 cc of Radiesse to get a similar correction. "So Radiesse will have a competitor here," he said. "And unlike Sculptra (where the water absorbs in 2 days), the immediate volumization achieved with Atléan will endure due to the HA component."

Atléan is not approved for use in the United States.

▸ Laresse (FzioMed Inc.). This polyethylene oxide product is marketed as being nonanimal, nonbacterial, nonpermanent, nontoxic, and nonparticulate—"everything we would want in a filler," Dr. Braun said.

However, when he injected it into the glabellar folds of two patients, induration developed that lasted more than 3 weeks. "I don't think it has a future, because when you inject it, you get an induration."

Laresse is not approved for use in the United States.

▸ ArteFill (Artes Medical Inc.). This FDA-approved product is a successor of Artecoll, a formulation of polymethyl methacrylate (PMMA) spheres suspended in collagen that was found to cause a high incidence of lumps when injected into the lips and delayed granulomatous reactions in the face. "Now the product's PMMA crystals have been polished, and it's being marketed as ArteFill," Dr. Braun said. "Many of the complications I saw came out in year 7, so be very careful injecting this. It remains to be seen if this product is safer than Artecoll."

▸ DermaLive and DermaDeep (DermaTech). This permanent filler, a combination of polyethyl methacrylate and hyaluronic acid, was withdrawn from France in 2003 and later from Canada because nodules and granulomas were reported years after injection.

"I ask patients on my medical history sheet if they've had this filler, because if you inject other things in a DermaLive recipient, you can activate a foreign body reaction," Dr. Braun said.

Dr. Braun disclosed that he has received honoraria from Medicis, which markets Restylane, and Allergan, which markets Juvéderm. He owns no stock in either company.

"Be very cautious,"when using Evolence in the lips, said Dr. Martin Braun. Nodule formation—as shown in the patient above 15 months after injection—can occur. Courtesy Dr. Martin Braun

LAS VEGAS — Time after time, Dr. Martin Braun encounters new patients in his Vancouver, B.C.-based practice who have undergone previous cosmetic filler treatments in Europe as well as Asia, but who have no idea what product was used.

Determining product history can be a daunting task because there are more than 100 cosmetic fillers currently being used in the European Union (EU), Dr. Braun said at the annual meeting of the International Society for Dermatologic Surgery.

"Frequently, we have to contact the physician, and I'm introduced to a new filler," he said. "Considering today's sense of a global village, I think it's important for physicians in North America to be familiar with some of these products." Filler products approved for use in the EU are designated with a so-called CE mark, which does not indicate conformity to a standard but rather conformity to the legal requirements of EU directives.

"There may not have been any human trials done on the filler," Dr. Braun said. "It could be something as simple as a certified quality system to ISO 9000 and that's it." (ISO is the International Organization for Standardization.)

He highlighted the following products to keep on the radar:

▸ Evolence (ColBar LifeScience Ltd.). Approved in Canada in 2006 and in the United States in 2008, this product contains 35 mg/mL of porcine collagen (telopeptides removed) cross-linked with D-ribose (nontoxic). No skin testing is required and studies have shown that results last up to 12 months.

However, using it for lip augmentation has resulted in several cases of nodule formation, Dr. Braun said. Of 20 patients he treated in 2006, 16 developed multiple lip nodules that have persisted in one-quarter of the cases for nearly 2 years. "Be very cautious with this product in and around the lips," Dr. Braun said.

He did not evaluate Evolence Breeze, which is said to be less problematic in the lips.

▸ Radiesse (BioForm Medical). Data from clinical studies suggest that this Food and Drug Administration-approved product lasts a few more months than do hyaluronic acid (HA) fillers. "It's the filler of choice for me for very deep nasolabial folds in men, as it appears to lift better than many hyaluronic acid fillers," Dr. Braun commented. "The one disadvantage is that 70% of that Radiesse syringe contains a gel carrier that disappears in 3–4 months. You have to warn the patient[s] of this because they will see a huge decrease in their filling after 3–4 months and have to be injected again." In his experience, Radiesse tends to bruise more than other fillers, feels indurated for the first few weeks, and can't be dissolved with anything.

▸ Juvéderm (Allergan Inc.). Developed from Streptococcus equi fermentation, this FDA-approved product "is very similar to Restylane [Medicis Aesthetics Inc.], but it's not as stiff," Dr. Braun said. "So if you want a skin-stiffening agent to perform the fern injection techniques, Restylane will likely do a better job for you." Juvéderm with lidocaine just became available in Canada but is not yet available in the United States. Dr. Braun predicted that this will become his filler of choice for patients who do not wish to have a proper dental block performed.

▸ Sculptra (Sanofi-Aventis). This product is FDA approved for HIV-associated facial lipoatrophy, but in Canada, it's approved for dermal contouring of the face in all patients. Dr. Braun said he uses Sculptra (poly-L-lactic acid) filler in patients with marked hollowing of the buccal fat pads and temporal fat pads and in those with thin skin, because after it's injected "the skin gets a nice glow, similar to [what] you obtain with IPL [intense pulsed light] photorejuvenation."

▸ Atléan (Stiefel Laboratories Inc.). Purchased by Stiefel in 2008, this product contains hyaluronic acid mixed with tricalcium phosphate. "The idea is that the tricalcium phosphate stimulates new collagen formation which is long lasting, like that associated with calcium hydroxyapatite," Dr. Braun said. In split-face injections, Dr. Braun had to use 5 cc of Atléan for 4 cc of Radiesse to get a similar correction. "So Radiesse will have a competitor here," he said. "And unlike Sculptra (where the water absorbs in 2 days), the immediate volumization achieved with Atléan will endure due to the HA component."

Atléan is not approved for use in the United States.

▸ Laresse (FzioMed Inc.). This polyethylene oxide product is marketed as being nonanimal, nonbacterial, nonpermanent, nontoxic, and nonparticulate—"everything we would want in a filler," Dr. Braun said.

However, when he injected it into the glabellar folds of two patients, induration developed that lasted more than 3 weeks. "I don't think it has a future, because when you inject it, you get an induration."

Laresse is not approved for use in the United States.

▸ ArteFill (Artes Medical Inc.). This FDA-approved product is a successor of Artecoll, a formulation of polymethyl methacrylate (PMMA) spheres suspended in collagen that was found to cause a high incidence of lumps when injected into the lips and delayed granulomatous reactions in the face. "Now the product's PMMA crystals have been polished, and it's being marketed as ArteFill," Dr. Braun said. "Many of the complications I saw came out in year 7, so be very careful injecting this. It remains to be seen if this product is safer than Artecoll."

▸ DermaLive and DermaDeep (DermaTech). This permanent filler, a combination of polyethyl methacrylate and hyaluronic acid, was withdrawn from France in 2003 and later from Canada because nodules and granulomas were reported years after injection.

"I ask patients on my medical history sheet if they've had this filler, because if you inject other things in a DermaLive recipient, you can activate a foreign body reaction," Dr. Braun said.

Dr. Braun disclosed that he has received honoraria from Medicis, which markets Restylane, and Allergan, which markets Juvéderm. He owns no stock in either company.

"Be very cautious,"when using Evolence in the lips, said Dr. Martin Braun. Nodule formation—as shown in the patient above 15 months after injection—can occur. Courtesy Dr. Martin Braun

Dr. Bobby Ridgeway's experience as a volunteer firefighter in the early 1970s sparked his interest in medicine. He joined the volunteer firefighter department in his home town of Pinewood, S.C., when he was 14 years old, responding to calls on his bicycle.

“The out-of-town fires required finding someone to take me, or just listening on the scanner,” recalls Dr. Ridgeway, a full-time ob.gyn. in Manning, S.C., and a volunteer firefighter for the Manning City Fire Department and the Clarendon County (S.C.) Fire Department. “By age 16, I had my driver's license and didn't miss many fires. I loved to be the engineer, the guy who runs the pump.”

After completing an EMT (emergency medical technician) course, he attended paramedic school at the urging of local emergency department staff he came to know, as well as his “second family” at the fire department. He completed paramedic school 2 months before his 22nd birthday and got married soon after.

“My encouragers set me straight and told me to continue my education in medical school at the University of South Carolina [Columbia], because I would need to advance my way up the ladder since children usually follow marriage and my EMT salary would probably fall short,” he said. “They were right about the salary but not about the children; my first came between my first and second year of medical school and my second between my first and second year of residency.”

These days, the amount of time he devotes to firefighting varies according to his ob.gyn. call schedule, but he responds to fires, auto wrecks, and other emergencies as time permits. “If I have to go to the hospital, I just leave the fire or accident scene,” said Dr. Ridgeway, who also is medical director for the Clarendon County Fire Department.

He and other volunteers get a stipend of $5 per call to cover the cost of gas, “but that's it.”

He listed several parallels of being an ob.gyn. and a firefighter, including the need for ongoing training and education, critical decision-making skills, a willingness to embrace new technologies, and an approach to work with a certain amount of fearlessness. Firefighters “go places and do things that others wouldn't,” he explained. “In medicine, a lot of physicians shy away from delivering a baby, or from [being an] ob.gyn., in general.”

Perhaps the greatest parallel, he said, is that both professions provide an opportunity to achieve near immediate results.

“When you go to a fire, within several minutes you're usually going to see some results of your activity,” he said, noting that Manning's population is about 6,000 residents. “The same thing applies to being an ob.gyn. If somebody arrives in labor, you're going to see some results of your activity within several hours. Or if you have to do surgery on somebody, you're going to see results of your activities pretty soon. It's not like you have to perform an action and wait several days or months until you figure out if it worked or not.”

Befriended as a Newcomer

When Dr. Tom Simpson arrived in Sterling, Kan., in 1978 to become the town's sole physician at the time, four members of the Sterling Volunteer Fire Department were among the first to befriend him.

“I've always been a guy who enjoyed having male friends to run with, and these were really good guys,” recalled Dr. Simpson, who is trained in family medicine. “They were guys that I came to trust. I enjoyed being with them.”

The men invited Dr. Simpson to join the fire department as a volunteer and he readily accepted. He completed formal firefighter training and worked his way up the ladder (no pun intended) to become chief of the department, a post that he held for 10 years.

“I felt good about the leadership skills I provided to the community during that time,” he said. “A physician can take the role of leader in a small community pretty easily.”

Mindful that he was the only physician in town for more than a decade, “the practice always came first,” Dr. Simpson said. “I didn't leave to fight fires during the daytime.”

However, fire calls don't always come at convenient times in this city with a population of about 2,500 residents. “Sometimes, I've been up all night fighting fires and I've been up all night taking care of sick people in my role as a physician,” he said.

“There is excitement in both jobs. I do obstetrics and I love delivering a babies. It's just about the neatest thing going and, yet, driving a fire truck or fighting a fire is also exciting.”

These days the 61-year-old Dr. Simpson is relegated to truck driver and pumper for the department and spends 2–3 hours per month in meetings and training.

“I don't necessarily put on air packs and run into burning houses with hoses anymore,” he said. “That's okay. But to see the guys that are doing it now and to see how skilled they are and how confident they are … it's neat.”

Dr. Simpson and his wife raised four children in Sterling. They've grown up and left the area, but they “always thought it was neat that their dad was a fireman,” he remarked.

“On the Fourth of July, they'd ride on the fire truck in the community parade because they were fireman's kids. My wife worries about me sometimes, like any fireman's spouse does, because you put yourself in harm's way occasionally.”

The greatest parallel between ob.gyn. and firefighting is that both professions provide an opportunity to achieve near-immediate results, said Dr. Bobby Ridgeway. Courtesy Dr. Bobby Ridgeway

Dr. Bobby Ridgeway's experience as a volunteer firefighter in the early 1970s sparked his interest in medicine. He joined the volunteer firefighter department in his home town of Pinewood, S.C., when he was 14 years old, responding to calls on his bicycle.

“The out-of-town fires required finding someone to take me, or just listening on the scanner,” recalls Dr. Ridgeway, a full-time ob.gyn. in Manning, S.C., and a volunteer firefighter for the Manning City Fire Department and the Clarendon County (S.C.) Fire Department. “By age 16, I had my driver's license and didn't miss many fires. I loved to be the engineer, the guy who runs the pump.”

After completing an EMT (emergency medical technician) course, he attended paramedic school at the urging of local emergency department staff he came to know, as well as his “second family” at the fire department. He completed paramedic school 2 months before his 22nd birthday and got married soon after.

“My encouragers set me straight and told me to continue my education in medical school at the University of South Carolina [Columbia], because I would need to advance my way up the ladder since children usually follow marriage and my EMT salary would probably fall short,” he said. “They were right about the salary but not about the children; my first came between my first and second year of medical school and my second between my first and second year of residency.”

These days, the amount of time he devotes to firefighting varies according to his ob.gyn. call schedule, but he responds to fires, auto wrecks, and other emergencies as time permits. “If I have to go to the hospital, I just leave the fire or accident scene,” said Dr. Ridgeway, who also is medical director for the Clarendon County Fire Department.

He and other volunteers get a stipend of $5 per call to cover the cost of gas, “but that's it.”

He listed several parallels of being an ob.gyn. and a firefighter, including the need for ongoing training and education, critical decision-making skills, a willingness to embrace new technologies, and an approach to work with a certain amount of fearlessness. Firefighters “go places and do things that others wouldn't,” he explained. “In medicine, a lot of physicians shy away from delivering a baby, or from [being an] ob.gyn., in general.”

Perhaps the greatest parallel, he said, is that both professions provide an opportunity to achieve near immediate results.

“When you go to a fire, within several minutes you're usually going to see some results of your activity,” he said, noting that Manning's population is about 6,000 residents. “The same thing applies to being an ob.gyn. If somebody arrives in labor, you're going to see some results of your activity within several hours. Or if you have to do surgery on somebody, you're going to see results of your activities pretty soon. It's not like you have to perform an action and wait several days or months until you figure out if it worked or not.”

Befriended as a Newcomer

When Dr. Tom Simpson arrived in Sterling, Kan., in 1978 to become the town's sole physician at the time, four members of the Sterling Volunteer Fire Department were among the first to befriend him.

“I've always been a guy who enjoyed having male friends to run with, and these were really good guys,” recalled Dr. Simpson, who is trained in family medicine. “They were guys that I came to trust. I enjoyed being with them.”

The men invited Dr. Simpson to join the fire department as a volunteer and he readily accepted. He completed formal firefighter training and worked his way up the ladder (no pun intended) to become chief of the department, a post that he held for 10 years.

“I felt good about the leadership skills I provided to the community during that time,” he said. “A physician can take the role of leader in a small community pretty easily.”

Mindful that he was the only physician in town for more than a decade, “the practice always came first,” Dr. Simpson said. “I didn't leave to fight fires during the daytime.”

However, fire calls don't always come at convenient times in this city with a population of about 2,500 residents. “Sometimes, I've been up all night fighting fires and I've been up all night taking care of sick people in my role as a physician,” he said.

“There is excitement in both jobs. I do obstetrics and I love delivering a babies. It's just about the neatest thing going and, yet, driving a fire truck or fighting a fire is also exciting.”

These days the 61-year-old Dr. Simpson is relegated to truck driver and pumper for the department and spends 2–3 hours per month in meetings and training.

“I don't necessarily put on air packs and run into burning houses with hoses anymore,” he said. “That's okay. But to see the guys that are doing it now and to see how skilled they are and how confident they are … it's neat.”

Dr. Simpson and his wife raised four children in Sterling. They've grown up and left the area, but they “always thought it was neat that their dad was a fireman,” he remarked.

“On the Fourth of July, they'd ride on the fire truck in the community parade because they were fireman's kids. My wife worries about me sometimes, like any fireman's spouse does, because you put yourself in harm's way occasionally.”

The greatest parallel between ob.gyn. and firefighting is that both professions provide an opportunity to achieve near-immediate results, said Dr. Bobby Ridgeway. Courtesy Dr. Bobby Ridgeway

Dr. Bobby Ridgeway's experience as a volunteer firefighter in the early 1970s sparked his interest in medicine. He joined the volunteer firefighter department in his home town of Pinewood, S.C., when he was 14 years old, responding to calls on his bicycle.

“The out-of-town fires required finding someone to take me, or just listening on the scanner,” recalls Dr. Ridgeway, a full-time ob.gyn. in Manning, S.C., and a volunteer firefighter for the Manning City Fire Department and the Clarendon County (S.C.) Fire Department. “By age 16, I had my driver's license and didn't miss many fires. I loved to be the engineer, the guy who runs the pump.”

After completing an EMT (emergency medical technician) course, he attended paramedic school at the urging of local emergency department staff he came to know, as well as his “second family” at the fire department. He completed paramedic school 2 months before his 22nd birthday and got married soon after.

“My encouragers set me straight and told me to continue my education in medical school at the University of South Carolina [Columbia], because I would need to advance my way up the ladder since children usually follow marriage and my EMT salary would probably fall short,” he said. “They were right about the salary but not about the children; my first came between my first and second year of medical school and my second between my first and second year of residency.”

These days, the amount of time he devotes to firefighting varies according to his ob.gyn. call schedule, but he responds to fires, auto wrecks, and other emergencies as time permits. “If I have to go to the hospital, I just leave the fire or accident scene,” said Dr. Ridgeway, who also is medical director for the Clarendon County Fire Department.

He and other volunteers get a stipend of $5 per call to cover the cost of gas, “but that's it.”

He listed several parallels of being an ob.gyn. and a firefighter, including the need for ongoing training and education, critical decision-making skills, a willingness to embrace new technologies, and an approach to work with a certain amount of fearlessness. Firefighters “go places and do things that others wouldn't,” he explained. “In medicine, a lot of physicians shy away from delivering a baby, or from [being an] ob.gyn., in general.”

Perhaps the greatest parallel, he said, is that both professions provide an opportunity to achieve near immediate results.

“When you go to a fire, within several minutes you're usually going to see some results of your activity,” he said, noting that Manning's population is about 6,000 residents. “The same thing applies to being an ob.gyn. If somebody arrives in labor, you're going to see some results of your activity within several hours. Or if you have to do surgery on somebody, you're going to see results of your activities pretty soon. It's not like you have to perform an action and wait several days or months until you figure out if it worked or not.”

Befriended as a Newcomer

When Dr. Tom Simpson arrived in Sterling, Kan., in 1978 to become the town's sole physician at the time, four members of the Sterling Volunteer Fire Department were among the first to befriend him.

“I've always been a guy who enjoyed having male friends to run with, and these were really good guys,” recalled Dr. Simpson, who is trained in family medicine. “They were guys that I came to trust. I enjoyed being with them.”

The men invited Dr. Simpson to join the fire department as a volunteer and he readily accepted. He completed formal firefighter training and worked his way up the ladder (no pun intended) to become chief of the department, a post that he held for 10 years.

“I felt good about the leadership skills I provided to the community during that time,” he said. “A physician can take the role of leader in a small community pretty easily.”

Mindful that he was the only physician in town for more than a decade, “the practice always came first,” Dr. Simpson said. “I didn't leave to fight fires during the daytime.”

However, fire calls don't always come at convenient times in this city with a population of about 2,500 residents. “Sometimes, I've been up all night fighting fires and I've been up all night taking care of sick people in my role as a physician,” he said.

“There is excitement in both jobs. I do obstetrics and I love delivering a babies. It's just about the neatest thing going and, yet, driving a fire truck or fighting a fire is also exciting.”

These days the 61-year-old Dr. Simpson is relegated to truck driver and pumper for the department and spends 2–3 hours per month in meetings and training.

“I don't necessarily put on air packs and run into burning houses with hoses anymore,” he said. “That's okay. But to see the guys that are doing it now and to see how skilled they are and how confident they are … it's neat.”

Dr. Simpson and his wife raised four children in Sterling. They've grown up and left the area, but they “always thought it was neat that their dad was a fireman,” he remarked.

“On the Fourth of July, they'd ride on the fire truck in the community parade because they were fireman's kids. My wife worries about me sometimes, like any fireman's spouse does, because you put yourself in harm's way occasionally.”

The greatest parallel between ob.gyn. and firefighting is that both professions provide an opportunity to achieve near-immediate results, said Dr. Bobby Ridgeway. Courtesy Dr. Bobby Ridgeway

SAN DIEGO — About one-third of medical practices have no emergency medical preparedness plan to deal with disasters such as hurricanes, floods, wildfires, and terrorist attacks, results from a national survey demonstrated.

In fact, more than 60% have not had disaster drills within their practice in the last 12 months and report not knowing how to coordinate actions with federal emergency agencies, researchers led by Christopher D. Stokes reported in a poster session at the annual conference of the Medical Group Management Association.

However, the researchers emphasized that such apparent lack of preparedness is not the sole fault of medical practices. Although the Health and Human Services Department “has made $1.1 billion available to assist public health departments, hospitals, and other health care organizations to strengthen their ability to respond to public health and medical emergencies, very little money is directed toward medical practices. Government agencies do not seek to assist medical practices in their preparation efforts, but expect them to respond and continue operating in the wake of disaster,” they wrote in their poster.

For the study, the researchers electronically surveyed 188 U.S. medical practices to assess their level of emergency preparedness and their attitudes about the government in disaster planning and emergency preparedness. The respondents were invited to participate through MGMA's Legislative and Executive Advocacy Response Network, which conducts research on policy issues that affect medical practices, said Mr. Stokes, program manager at MGMA's center for research.

The majority of respondents (87%) indicated that there was a moderate to high probability of a disaster occurrence in their community within the next 5 years. Respondents from the Western United States listed earthquakes (77%), wildfires (66%), and floods as the top three most likely disasters to affect them, whereas Midwestern respondents cited tornadoes (93%), floods (57%), and avian flu (36%). Southern respondents said they were most likely to face tornadoes (80%), hurricanes (60%), and floods (60%), whereas those from the East listed West Nile virus (52%), avian flu (50%), and tornadoes (47%).

Nearly one-third of respondents (30%) reported having no emergency preparedness plan; 62% have not had drills in their practice in the last 12 months; 68% do not know how to coordinate actions with federal emergency agencies; 71% have not participated in drills with a local hospital in the last 12 months; and 84% have not participated in drills with government agencies in the last 12 months.

More than one-third (36%) said they would participate in an all-day disaster drill without full compensation, whereas 55% said they had not considered the issue.

Respondents listed the following ways they would contact their patients if they had to close their practice because of a disaster: record a message on the voice mail greeting (91%); make telephone calls (91%); tape a message on the door (90%); make announcements on local radio or TV programs (76%); and use computerized outgoing phone calls (42%) and e-mails (24%).

Mr. Stokes and his colleagues concluded that all medical practices “should have an emergency preparedness plan, and the federal government needs to fund medical practice emergency preparation activities.” They went on to note that medical practices “have a mandatory requirement to report communicable diseases, they are often willing to participate in emergencies, and they can quickly disseminate critical health messages to the public. Including [medical] practices in funded preparation activities will strengthen national preparation, improve recovery efforts, and leverage scarce resources.”

The study was funded by the HHS Office of the Assistant Secretary for Preparedness and Response, through the Idaho Bioterrorism Awareness and Preparedness Program.

'The federal government needs to fund medical practice emergency preparation activities.' MR. STOKES

SAN DIEGO — About one-third of medical practices have no emergency medical preparedness plan to deal with disasters such as hurricanes, floods, wildfires, and terrorist attacks, results from a national survey demonstrated.

In fact, more than 60% have not had disaster drills within their practice in the last 12 months and report not knowing how to coordinate actions with federal emergency agencies, researchers led by Christopher D. Stokes reported in a poster session at the annual conference of the Medical Group Management Association.

However, the researchers emphasized that such apparent lack of preparedness is not the sole fault of medical practices. Although the Health and Human Services Department “has made $1.1 billion available to assist public health departments, hospitals, and other health care organizations to strengthen their ability to respond to public health and medical emergencies, very little money is directed toward medical practices. Government agencies do not seek to assist medical practices in their preparation efforts, but expect them to respond and continue operating in the wake of disaster,” they wrote in their poster.

For the study, the researchers electronically surveyed 188 U.S. medical practices to assess their level of emergency preparedness and their attitudes about the government in disaster planning and emergency preparedness. The respondents were invited to participate through MGMA's Legislative and Executive Advocacy Response Network, which conducts research on policy issues that affect medical practices, said Mr. Stokes, program manager at MGMA's center for research.

The majority of respondents (87%) indicated that there was a moderate to high probability of a disaster occurrence in their community within the next 5 years. Respondents from the Western United States listed earthquakes (77%), wildfires (66%), and floods as the top three most likely disasters to affect them, whereas Midwestern respondents cited tornadoes (93%), floods (57%), and avian flu (36%). Southern respondents said they were most likely to face tornadoes (80%), hurricanes (60%), and floods (60%), whereas those from the East listed West Nile virus (52%), avian flu (50%), and tornadoes (47%).

Nearly one-third of respondents (30%) reported having no emergency preparedness plan; 62% have not had drills in their practice in the last 12 months; 68% do not know how to coordinate actions with federal emergency agencies; 71% have not participated in drills with a local hospital in the last 12 months; and 84% have not participated in drills with government agencies in the last 12 months.

More than one-third (36%) said they would participate in an all-day disaster drill without full compensation, whereas 55% said they had not considered the issue.

Respondents listed the following ways they would contact their patients if they had to close their practice because of a disaster: record a message on the voice mail greeting (91%); make telephone calls (91%); tape a message on the door (90%); make announcements on local radio or TV programs (76%); and use computerized outgoing phone calls (42%) and e-mails (24%).

Mr. Stokes and his colleagues concluded that all medical practices “should have an emergency preparedness plan, and the federal government needs to fund medical practice emergency preparation activities.” They went on to note that medical practices “have a mandatory requirement to report communicable diseases, they are often willing to participate in emergencies, and they can quickly disseminate critical health messages to the public. Including [medical] practices in funded preparation activities will strengthen national preparation, improve recovery efforts, and leverage scarce resources.”

The study was funded by the HHS Office of the Assistant Secretary for Preparedness and Response, through the Idaho Bioterrorism Awareness and Preparedness Program.

'The federal government needs to fund medical practice emergency preparation activities.' MR. STOKES

SAN DIEGO — About one-third of medical practices have no emergency medical preparedness plan to deal with disasters such as hurricanes, floods, wildfires, and terrorist attacks, results from a national survey demonstrated.

In fact, more than 60% have not had disaster drills within their practice in the last 12 months and report not knowing how to coordinate actions with federal emergency agencies, researchers led by Christopher D. Stokes reported in a poster session at the annual conference of the Medical Group Management Association.

However, the researchers emphasized that such apparent lack of preparedness is not the sole fault of medical practices. Although the Health and Human Services Department “has made $1.1 billion available to assist public health departments, hospitals, and other health care organizations to strengthen their ability to respond to public health and medical emergencies, very little money is directed toward medical practices. Government agencies do not seek to assist medical practices in their preparation efforts, but expect them to respond and continue operating in the wake of disaster,” they wrote in their poster.

For the study, the researchers electronically surveyed 188 U.S. medical practices to assess their level of emergency preparedness and their attitudes about the government in disaster planning and emergency preparedness. The respondents were invited to participate through MGMA's Legislative and Executive Advocacy Response Network, which conducts research on policy issues that affect medical practices, said Mr. Stokes, program manager at MGMA's center for research.

The majority of respondents (87%) indicated that there was a moderate to high probability of a disaster occurrence in their community within the next 5 years. Respondents from the Western United States listed earthquakes (77%), wildfires (66%), and floods as the top three most likely disasters to affect them, whereas Midwestern respondents cited tornadoes (93%), floods (57%), and avian flu (36%). Southern respondents said they were most likely to face tornadoes (80%), hurricanes (60%), and floods (60%), whereas those from the East listed West Nile virus (52%), avian flu (50%), and tornadoes (47%).

Nearly one-third of respondents (30%) reported having no emergency preparedness plan; 62% have not had drills in their practice in the last 12 months; 68% do not know how to coordinate actions with federal emergency agencies; 71% have not participated in drills with a local hospital in the last 12 months; and 84% have not participated in drills with government agencies in the last 12 months.

More than one-third (36%) said they would participate in an all-day disaster drill without full compensation, whereas 55% said they had not considered the issue.

Respondents listed the following ways they would contact their patients if they had to close their practice because of a disaster: record a message on the voice mail greeting (91%); make telephone calls (91%); tape a message on the door (90%); make announcements on local radio or TV programs (76%); and use computerized outgoing phone calls (42%) and e-mails (24%).

Mr. Stokes and his colleagues concluded that all medical practices “should have an emergency preparedness plan, and the federal government needs to fund medical practice emergency preparation activities.” They went on to note that medical practices “have a mandatory requirement to report communicable diseases, they are often willing to participate in emergencies, and they can quickly disseminate critical health messages to the public. Including [medical] practices in funded preparation activities will strengthen national preparation, improve recovery efforts, and leverage scarce resources.”

The study was funded by the HHS Office of the Assistant Secretary for Preparedness and Response, through the Idaho Bioterrorism Awareness and Preparedness Program.

'The federal government needs to fund medical practice emergency preparation activities.' MR. STOKES

SAN DIEGO — About a third of medical practices have no emergency medical preparedness plan to deal with disasters such as hurricanes and terrorist attacks, results from a national survey showed.

More than 60% have not had disaster drills in their practice in the last 12 months and report not knowing how to coordinate actions with federal emergency agencies, Christopher D. Stokes and his colleagues said in a poster session at the annual conference of the Medical Group Management Association. The Health and Human Services department has made $1.1 billion available for some entities to shore up their emergency plans, but “very little money is directed toward medical practices.”

The researchers surveyed 188 U.S. medical practices to assess their level of emergency preparedness and attitudes about disaster planning and emergency preparedness. The respondents participated through MGMA's Legislative and Executive Advocacy Response Network, which conducts research on medical practice policy issues, said Mr. Stokes, program manager at MGMA's Center for Research.

Most of the respondents (87%) indicated there was a moderate to high probability of disaster occurring in their community within the next 5 years. Nearly a third (30%) reported having no emergency preparedness plan; 68% do not know how to coordinate actions with federal emergency agencies; and in the last 12 months, 71% have not participated in drills with a local hospital, and 84% have not participated in drills with governmental agencies.

“Including [medical] practices in funded preparation activities will strengthen national preparation, improve recovery efforts, and leverage scarce resources,” the researchers said. The study was funded by the HHS Office of the Assistant Secretary for Preparedness and Response through the Idaho State University Institute of Rural Health Idaho Bioterrorism Awareness and Preparedness Program.

SAN DIEGO — About a third of medical practices have no emergency medical preparedness plan to deal with disasters such as hurricanes and terrorist attacks, results from a national survey showed.

More than 60% have not had disaster drills in their practice in the last 12 months and report not knowing how to coordinate actions with federal emergency agencies, Christopher D. Stokes and his colleagues said in a poster session at the annual conference of the Medical Group Management Association. The Health and Human Services department has made $1.1 billion available for some entities to shore up their emergency plans, but “very little money is directed toward medical practices.”

The researchers surveyed 188 U.S. medical practices to assess their level of emergency preparedness and attitudes about disaster planning and emergency preparedness. The respondents participated through MGMA's Legislative and Executive Advocacy Response Network, which conducts research on medical practice policy issues, said Mr. Stokes, program manager at MGMA's Center for Research.

Most of the respondents (87%) indicated there was a moderate to high probability of disaster occurring in their community within the next 5 years. Nearly a third (30%) reported having no emergency preparedness plan; 68% do not know how to coordinate actions with federal emergency agencies; and in the last 12 months, 71% have not participated in drills with a local hospital, and 84% have not participated in drills with governmental agencies.

“Including [medical] practices in funded preparation activities will strengthen national preparation, improve recovery efforts, and leverage scarce resources,” the researchers said. The study was funded by the HHS Office of the Assistant Secretary for Preparedness and Response through the Idaho State University Institute of Rural Health Idaho Bioterrorism Awareness and Preparedness Program.

SAN DIEGO — About a third of medical practices have no emergency medical preparedness plan to deal with disasters such as hurricanes and terrorist attacks, results from a national survey showed.

More than 60% have not had disaster drills in their practice in the last 12 months and report not knowing how to coordinate actions with federal emergency agencies, Christopher D. Stokes and his colleagues said in a poster session at the annual conference of the Medical Group Management Association. The Health and Human Services department has made $1.1 billion available for some entities to shore up their emergency plans, but “very little money is directed toward medical practices.”

The researchers surveyed 188 U.S. medical practices to assess their level of emergency preparedness and attitudes about disaster planning and emergency preparedness. The respondents participated through MGMA's Legislative and Executive Advocacy Response Network, which conducts research on medical practice policy issues, said Mr. Stokes, program manager at MGMA's Center for Research.

Most of the respondents (87%) indicated there was a moderate to high probability of disaster occurring in their community within the next 5 years. Nearly a third (30%) reported having no emergency preparedness plan; 68% do not know how to coordinate actions with federal emergency agencies; and in the last 12 months, 71% have not participated in drills with a local hospital, and 84% have not participated in drills with governmental agencies.

“Including [medical] practices in funded preparation activities will strengthen national preparation, improve recovery efforts, and leverage scarce resources,” the researchers said. The study was funded by the HHS Office of the Assistant Secretary for Preparedness and Response through the Idaho State University Institute of Rural Health Idaho Bioterrorism Awareness and Preparedness Program.

SAN DIEGO — When patients present to primary care clinics complaining of shoulder pain, the injury usually stems from secondary impingement, which results from mechanical dysfunction such as structural glenohumeral laxity or insufficiency of the shoulder's stabilizing muscles.

“It's usually a weak rotator cuff,” Dr. Francis O'Connor said at the annual meeting of the American Academy of Family Physicians. Primary impingement occurs less often and is the result of a structural abnormality that implies bony or ligamentous encroachment on the subacromial space.

About a third of shoulder impingement cases stem from overhead work such as fruit picking, tree pruning, warehouse work, carpentry, and painting. Another third of cases occur in athletes who participate in throwing sports, racquet sports, skiing, or swimming. The remaining cases tend to affect people aged over 60 years.

Clinical workup for suspected shoulder impingement involves a careful examination for deltoid, supraspinatus, infraspinatus, and scapular stabilizer atrophy, which may result from disuse or neuropraxic injury. “Look for asymmetry, atrophy, and deformities,” said Dr. O'Connor, medical director of the Consortium for Health and Military Performance (CHAMP) at the Uniformed Services University of the Health Sciences, Bethesda, Md.

To assess for shoulder impingement, he suggests the Neer impingement test, which is performed by internally rotating the arm with the elbow extended and then passively forward-flexing the arm, attempting to reach 180 degrees. “Positive results of pain are often evident well before 180 degrees of elevation.”

Hawkin's sign or “pour can” test, performed with the shoulder at 90 degrees forward flexion and 45–90 degrees internal rotation, is also effective. The examiner then attempts to further internally rotate the shoulder, driving the greater tuberosity into the coracoacromial arch.

Key tests for anterior shoulder instability include the apprehension (fulcrum) and relocation tests, for which the patient is examined in the supine position, and the shoulder is placed in 90 degrees abduction and external rotation. The examiner's hand then creates an anteriorly directed force across the glenohumeral joint and looks for patient signs of pain or apprehension.

“If there is pain or apprehension with the maneuver, a posteriorly directed force may then be applied to the glenohumeral joint,” Dr. O'Connor said. “If the pain goes away with this maneuver, then it suggests that the patient may have anterior instability as the source of the pain.”

An effective test for inferior or multidirectional shoulder instability is the sulcus sign, which is conducted with the patient seated with the arm to the side. The examiner grabs the elbow and exerts a downward force. The area adjacent to the acromion is observed and dimpling of the skin may indicate inferior instability and/or multidirectional instability.

To test for tears in the labrum, use the crank test, which is performed with the patient in the seated or supine position. The arm is elevated to 160 degrees in the scapular plane and the examiner then applies a load along the axis of the humerus while maximally rotating the humerus internally and externally. A positive test reproduces the patient's symptoms of pain or catching with or without a click.

Most patients don't need x-rays right away. If you do order a shoulder series, ask for a supraspinatus outlet view to rule out primary impingement, as well as internal and external rotation views. He refers to a surgeon if he can't determine the source of the pain or there is no response to therapy in 3 months.

An MRI shows an increased signal in therotator cuff, consistent with tendinopathy. Courtesy Dr. Francis O'Connor

SAN DIEGO — When patients present to primary care clinics complaining of shoulder pain, the injury usually stems from secondary impingement, which results from mechanical dysfunction such as structural glenohumeral laxity or insufficiency of the shoulder's stabilizing muscles.

“It's usually a weak rotator cuff,” Dr. Francis O'Connor said at the annual meeting of the American Academy of Family Physicians. Primary impingement occurs less often and is the result of a structural abnormality that implies bony or ligamentous encroachment on the subacromial space.

About a third of shoulder impingement cases stem from overhead work such as fruit picking, tree pruning, warehouse work, carpentry, and painting. Another third of cases occur in athletes who participate in throwing sports, racquet sports, skiing, or swimming. The remaining cases tend to affect people aged over 60 years.

Clinical workup for suspected shoulder impingement involves a careful examination for deltoid, supraspinatus, infraspinatus, and scapular stabilizer atrophy, which may result from disuse or neuropraxic injury. “Look for asymmetry, atrophy, and deformities,” said Dr. O'Connor, medical director of the Consortium for Health and Military Performance (CHAMP) at the Uniformed Services University of the Health Sciences, Bethesda, Md.

To assess for shoulder impingement, he suggests the Neer impingement test, which is performed by internally rotating the arm with the elbow extended and then passively forward-flexing the arm, attempting to reach 180 degrees. “Positive results of pain are often evident well before 180 degrees of elevation.”

Hawkin's sign or “pour can” test, performed with the shoulder at 90 degrees forward flexion and 45–90 degrees internal rotation, is also effective. The examiner then attempts to further internally rotate the shoulder, driving the greater tuberosity into the coracoacromial arch.

Key tests for anterior shoulder instability include the apprehension (fulcrum) and relocation tests, for which the patient is examined in the supine position, and the shoulder is placed in 90 degrees abduction and external rotation. The examiner's hand then creates an anteriorly directed force across the glenohumeral joint and looks for patient signs of pain or apprehension.

“If there is pain or apprehension with the maneuver, a posteriorly directed force may then be applied to the glenohumeral joint,” Dr. O'Connor said. “If the pain goes away with this maneuver, then it suggests that the patient may have anterior instability as the source of the pain.”

An effective test for inferior or multidirectional shoulder instability is the sulcus sign, which is conducted with the patient seated with the arm to the side. The examiner grabs the elbow and exerts a downward force. The area adjacent to the acromion is observed and dimpling of the skin may indicate inferior instability and/or multidirectional instability.

To test for tears in the labrum, use the crank test, which is performed with the patient in the seated or supine position. The arm is elevated to 160 degrees in the scapular plane and the examiner then applies a load along the axis of the humerus while maximally rotating the humerus internally and externally. A positive test reproduces the patient's symptoms of pain or catching with or without a click.

Most patients don't need x-rays right away. If you do order a shoulder series, ask for a supraspinatus outlet view to rule out primary impingement, as well as internal and external rotation views. He refers to a surgeon if he can't determine the source of the pain or there is no response to therapy in 3 months.

An MRI shows an increased signal in therotator cuff, consistent with tendinopathy. Courtesy Dr. Francis O'Connor

SAN DIEGO — When patients present to primary care clinics complaining of shoulder pain, the injury usually stems from secondary impingement, which results from mechanical dysfunction such as structural glenohumeral laxity or insufficiency of the shoulder's stabilizing muscles.

“It's usually a weak rotator cuff,” Dr. Francis O'Connor said at the annual meeting of the American Academy of Family Physicians. Primary impingement occurs less often and is the result of a structural abnormality that implies bony or ligamentous encroachment on the subacromial space.

About a third of shoulder impingement cases stem from overhead work such as fruit picking, tree pruning, warehouse work, carpentry, and painting. Another third of cases occur in athletes who participate in throwing sports, racquet sports, skiing, or swimming. The remaining cases tend to affect people aged over 60 years.

Clinical workup for suspected shoulder impingement involves a careful examination for deltoid, supraspinatus, infraspinatus, and scapular stabilizer atrophy, which may result from disuse or neuropraxic injury. “Look for asymmetry, atrophy, and deformities,” said Dr. O'Connor, medical director of the Consortium for Health and Military Performance (CHAMP) at the Uniformed Services University of the Health Sciences, Bethesda, Md.

To assess for shoulder impingement, he suggests the Neer impingement test, which is performed by internally rotating the arm with the elbow extended and then passively forward-flexing the arm, attempting to reach 180 degrees. “Positive results of pain are often evident well before 180 degrees of elevation.”

Hawkin's sign or “pour can” test, performed with the shoulder at 90 degrees forward flexion and 45–90 degrees internal rotation, is also effective. The examiner then attempts to further internally rotate the shoulder, driving the greater tuberosity into the coracoacromial arch.

Key tests for anterior shoulder instability include the apprehension (fulcrum) and relocation tests, for which the patient is examined in the supine position, and the shoulder is placed in 90 degrees abduction and external rotation. The examiner's hand then creates an anteriorly directed force across the glenohumeral joint and looks for patient signs of pain or apprehension.

“If there is pain or apprehension with the maneuver, a posteriorly directed force may then be applied to the glenohumeral joint,” Dr. O'Connor said. “If the pain goes away with this maneuver, then it suggests that the patient may have anterior instability as the source of the pain.”

An effective test for inferior or multidirectional shoulder instability is the sulcus sign, which is conducted with the patient seated with the arm to the side. The examiner grabs the elbow and exerts a downward force. The area adjacent to the acromion is observed and dimpling of the skin may indicate inferior instability and/or multidirectional instability.

To test for tears in the labrum, use the crank test, which is performed with the patient in the seated or supine position. The arm is elevated to 160 degrees in the scapular plane and the examiner then applies a load along the axis of the humerus while maximally rotating the humerus internally and externally. A positive test reproduces the patient's symptoms of pain or catching with or without a click.

Most patients don't need x-rays right away. If you do order a shoulder series, ask for a supraspinatus outlet view to rule out primary impingement, as well as internal and external rotation views. He refers to a surgeon if he can't determine the source of the pain or there is no response to therapy in 3 months.

An MRI shows an increased signal in therotator cuff, consistent with tendinopathy. Courtesy Dr. Francis O'Connor

SAN DIEGO — When it comes to helping patients quit smoking, most primary care physicians could stand to improve their communication and persuasion skills.

A 2007 survey of more than 3,000 physicians conducted by the Association of American Medical Colleges found that 84% asked their patients about smoking and 86% advised their patients to quit, but only 31% recommended nicotine replacement therapy, 17% arranged for follow-up, and just 7% referred patients to smoking cessation help lines, also known as quitlines.

“There's a lot of room for making things better,” Dr. Steven A. Schroeder said at the annual meeting of the American Academy of Family Physicians.

Dr. Schroeder, director of the Smoking Cessation Leadership Center at the University of California, San Francisco, maintained that interventions as brief as 30 seconds can have a positive impact on a smoker's decision to quit.

He said he begins his patient encounters by asking if the patient smokes. If the answer is yes, he proceeds with the following script: “Do you know what it does to you? It does a lot of really bad things, including putting you at risk for emphysema, lung cancer, heart disease, and stroke. I'll be glad to talk to you more about that. Would you ever be interested in quitting?”

At that point, he hands the patient a credit card-size American Academy of Family Physicians quitline referral card, which provides the number for the National Network of Tobacco Cessation Quitlines (800–784–8669). The quitlines are staffed by trained smoking cessation experts who tailor a plan and offer advice to each caller. Then he tells the patient to call the number for expert counsel if he or she is ready to quit.

He calls the intervention “take 30 seconds and save a life.”

Physicians can also help smokers quit by becoming experts in smoking cessation counseling and treatment or by setting up cessation systems in the clinical facilities where they work, he said.

Dr. Schroeder noted that a study from Group Health Cooperative in Seattle found that 85% of smokers preferred using a quitline to going to a clinic or a physician's office for help with smoking cessation (Am. J. Prev. Med. 1998;14:46-52).

“It's free, it's convenient, and there's anonymity,” said Dr. Schroeder, the former president and CEO of the Robert Wood Johnson Foundation. “A lot of smokers feel guilty about their smoking. I've had patients who've missed their follow-up visits because they had made a pledge to quit on a certain date but were unable to do so. In the quitline relationship, you don't have that kind of personal issue.”

Another presenter at the meeting, Dr. Carlos Roberto Jaén, a former smoker, discussed specific ways to counsel patients based on the Public Health Service Clinical Practice Guideline, “Treating Tobacco Use and Dependence: 2008 Update” (www.surgeongeneral.gov/tobacco

He noted that patients who express an unwillingness to quit may lack information about the harmful effects of smoking or the benefits of quitting.

“I use humor sometimes,” said Dr. Jaén, who chairs the department of family and community medicine at the University of Texas, San Antonio. “I'll say, 'You're not ready to quit? No problem. I'll wait until you have your heart attack or your stroke, then you'll call me very motivated to quit.'” In that example, a form of motivational interviewing, “you are communicating the sense of harmful effects and benefits of quitting.”

Another principle of motivational interviewing is to express empathy, an approach recommended in the guideline.

“Help the patient understand you know that quitting smoking is a very difficult thing to do,” advised Dr. Jaén, vice chair of the guideline panel. He said he teaches deep-breathing exercises as a way to ward off craving for a cigarette. “I tell them, 'give yourself a minute; the craving goes away.'”

The guideline also recommends pointing out the discrepancy patients may demonstrate between their behavior and their expressed priorities. “If they say they're here to see you about their health, yet they're not ready to quit smoking … say, 'quitting smoking is the one thing you can do that is most effective for your health.'”

If patients resist the notion to quit, “roll with it. It's not for you to try to convince them to change their behavior.” But make sure to bring up smoking in their next office visit. “Sometime I tell my patients, 'every time you see my face I want you to think, quit smoking,'” said Dr. Jaén, who is also a member of AAFP's Tobacco Cessation Advisory Committee.

Physicians can support self-efficacy by helping patients identify and build on past successes. Quitting “doesn't have to happen all at once. It can be changing smoking patterns, asking the patient to share his or her ideas about quitting strategies, or calling the quitline. There are multiple ways to get to the point where they are ready to quit,” he said.

If patients are keen to quit but aren't ready for intensive interventions, then offer practical counseling interventions such as recommending that they throw away all of their ashtrays and cigarette butts on the day they decide to quit, said Dr. Jaén. Other tips include advising patients not to have cigarettes in their car, to walk instead of sitting down after a meal, and to brush their teeth when they crave a cigarette.

He emphasized the importance of social support, saying he urges patients to tell family members, friends, and coworkers about their decision to quit. “Call them up, and ask how they're doing,” he added.

Dr. Jaén said he also warns patients not to consume alcohol when they're in the early stages of quitting, “because alcohol and nicotine are synergistic. Once people start drinking, it's hard for them to stay off cigarettes, especially early on. If people have conflicted relationships, maybe they should avoid that person for a while, too.”

A package of 200 quitline referral cards is available free to AAFP members. The cost for nonmembers is $50 plus shipping. For information, call 800-944-0000 and request item number 966.

Quitlines are free, convenient, and anonymous. A lot of smokers feel guilty about their smoking. DR. SCHROEDER

'Help the patient understand you know that quitting smoking is avery difficult thing to do.' Dr. Jaén

SAN DIEGO — When it comes to helping patients quit smoking, most primary care physicians could stand to improve their communication and persuasion skills.

A 2007 survey of more than 3,000 physicians conducted by the Association of American Medical Colleges found that 84% asked their patients about smoking and 86% advised their patients to quit, but only 31% recommended nicotine replacement therapy, 17% arranged for follow-up, and just 7% referred patients to smoking cessation help lines, also known as quitlines.

“There's a lot of room for making things better,” Dr. Steven A. Schroeder said at the annual meeting of the American Academy of Family Physicians.

Dr. Schroeder, director of the Smoking Cessation Leadership Center at the University of California, San Francisco, maintained that interventions as brief as 30 seconds can have a positive impact on a smoker's decision to quit.

He said he begins his patient encounters by asking if the patient smokes. If the answer is yes, he proceeds with the following script: “Do you know what it does to you? It does a lot of really bad things, including putting you at risk for emphysema, lung cancer, heart disease, and stroke. I'll be glad to talk to you more about that. Would you ever be interested in quitting?”

At that point, he hands the patient a credit card-size American Academy of Family Physicians quitline referral card, which provides the number for the National Network of Tobacco Cessation Quitlines (800–784–8669). The quitlines are staffed by trained smoking cessation experts who tailor a plan and offer advice to each caller. Then he tells the patient to call the number for expert counsel if he or she is ready to quit.

He calls the intervention “take 30 seconds and save a life.”

Physicians can also help smokers quit by becoming experts in smoking cessation counseling and treatment or by setting up cessation systems in the clinical facilities where they work, he said.

Dr. Schroeder noted that a study from Group Health Cooperative in Seattle found that 85% of smokers preferred using a quitline to going to a clinic or a physician's office for help with smoking cessation (Am. J. Prev. Med. 1998;14:46-52).

“It's free, it's convenient, and there's anonymity,” said Dr. Schroeder, the former president and CEO of the Robert Wood Johnson Foundation. “A lot of smokers feel guilty about their smoking. I've had patients who've missed their follow-up visits because they had made a pledge to quit on a certain date but were unable to do so. In the quitline relationship, you don't have that kind of personal issue.”

Another presenter at the meeting, Dr. Carlos Roberto Jaén, a former smoker, discussed specific ways to counsel patients based on the Public Health Service Clinical Practice Guideline, “Treating Tobacco Use and Dependence: 2008 Update” (www.surgeongeneral.gov/tobacco

He noted that patients who express an unwillingness to quit may lack information about the harmful effects of smoking or the benefits of quitting.

“I use humor sometimes,” said Dr. Jaén, who chairs the department of family and community medicine at the University of Texas, San Antonio. “I'll say, 'You're not ready to quit? No problem. I'll wait until you have your heart attack or your stroke, then you'll call me very motivated to quit.'” In that example, a form of motivational interviewing, “you are communicating the sense of harmful effects and benefits of quitting.”

Another principle of motivational interviewing is to express empathy, an approach recommended in the guideline.

“Help the patient understand you know that quitting smoking is a very difficult thing to do,” advised Dr. Jaén, vice chair of the guideline panel. He said he teaches deep-breathing exercises as a way to ward off craving for a cigarette. “I tell them, 'give yourself a minute; the craving goes away.'”

The guideline also recommends pointing out the discrepancy patients may demonstrate between their behavior and their expressed priorities. “If they say they're here to see you about their health, yet they're not ready to quit smoking … say, 'quitting smoking is the one thing you can do that is most effective for your health.'”

If patients resist the notion to quit, “roll with it. It's not for you to try to convince them to change their behavior.” But make sure to bring up smoking in their next office visit. “Sometime I tell my patients, 'every time you see my face I want you to think, quit smoking,'” said Dr. Jaén, who is also a member of AAFP's Tobacco Cessation Advisory Committee.

Physicians can support self-efficacy by helping patients identify and build on past successes. Quitting “doesn't have to happen all at once. It can be changing smoking patterns, asking the patient to share his or her ideas about quitting strategies, or calling the quitline. There are multiple ways to get to the point where they are ready to quit,” he said.

If patients are keen to quit but aren't ready for intensive interventions, then offer practical counseling interventions such as recommending that they throw away all of their ashtrays and cigarette butts on the day they decide to quit, said Dr. Jaén. Other tips include advising patients not to have cigarettes in their car, to walk instead of sitting down after a meal, and to brush their teeth when they crave a cigarette.

He emphasized the importance of social support, saying he urges patients to tell family members, friends, and coworkers about their decision to quit. “Call them up, and ask how they're doing,” he added.

Dr. Jaén said he also warns patients not to consume alcohol when they're in the early stages of quitting, “because alcohol and nicotine are synergistic. Once people start drinking, it's hard for them to stay off cigarettes, especially early on. If people have conflicted relationships, maybe they should avoid that person for a while, too.”

A package of 200 quitline referral cards is available free to AAFP members. The cost for nonmembers is $50 plus shipping. For information, call 800-944-0000 and request item number 966.

Quitlines are free, convenient, and anonymous. A lot of smokers feel guilty about their smoking. DR. SCHROEDER

'Help the patient understand you know that quitting smoking is avery difficult thing to do.' Dr. Jaén

SAN DIEGO — When it comes to helping patients quit smoking, most primary care physicians could stand to improve their communication and persuasion skills.

A 2007 survey of more than 3,000 physicians conducted by the Association of American Medical Colleges found that 84% asked their patients about smoking and 86% advised their patients to quit, but only 31% recommended nicotine replacement therapy, 17% arranged for follow-up, and just 7% referred patients to smoking cessation help lines, also known as quitlines.

“There's a lot of room for making things better,” Dr. Steven A. Schroeder said at the annual meeting of the American Academy of Family Physicians.

Dr. Schroeder, director of the Smoking Cessation Leadership Center at the University of California, San Francisco, maintained that interventions as brief as 30 seconds can have a positive impact on a smoker's decision to quit.

He said he begins his patient encounters by asking if the patient smokes. If the answer is yes, he proceeds with the following script: “Do you know what it does to you? It does a lot of really bad things, including putting you at risk for emphysema, lung cancer, heart disease, and stroke. I'll be glad to talk to you more about that. Would you ever be interested in quitting?”

At that point, he hands the patient a credit card-size American Academy of Family Physicians quitline referral card, which provides the number for the National Network of Tobacco Cessation Quitlines (800–784–8669). The quitlines are staffed by trained smoking cessation experts who tailor a plan and offer advice to each caller. Then he tells the patient to call the number for expert counsel if he or she is ready to quit.

He calls the intervention “take 30 seconds and save a life.”

Physicians can also help smokers quit by becoming experts in smoking cessation counseling and treatment or by setting up cessation systems in the clinical facilities where they work, he said.

Dr. Schroeder noted that a study from Group Health Cooperative in Seattle found that 85% of smokers preferred using a quitline to going to a clinic or a physician's office for help with smoking cessation (Am. J. Prev. Med. 1998;14:46-52).

“It's free, it's convenient, and there's anonymity,” said Dr. Schroeder, the former president and CEO of the Robert Wood Johnson Foundation. “A lot of smokers feel guilty about their smoking. I've had patients who've missed their follow-up visits because they had made a pledge to quit on a certain date but were unable to do so. In the quitline relationship, you don't have that kind of personal issue.”

Another presenter at the meeting, Dr. Carlos Roberto Jaén, a former smoker, discussed specific ways to counsel patients based on the Public Health Service Clinical Practice Guideline, “Treating Tobacco Use and Dependence: 2008 Update” (www.surgeongeneral.gov/tobacco

He noted that patients who express an unwillingness to quit may lack information about the harmful effects of smoking or the benefits of quitting.

“I use humor sometimes,” said Dr. Jaén, who chairs the department of family and community medicine at the University of Texas, San Antonio. “I'll say, 'You're not ready to quit? No problem. I'll wait until you have your heart attack or your stroke, then you'll call me very motivated to quit.'” In that example, a form of motivational interviewing, “you are communicating the sense of harmful effects and benefits of quitting.”

Another principle of motivational interviewing is to express empathy, an approach recommended in the guideline.

“Help the patient understand you know that quitting smoking is a very difficult thing to do,” advised Dr. Jaén, vice chair of the guideline panel. He said he teaches deep-breathing exercises as a way to ward off craving for a cigarette. “I tell them, 'give yourself a minute; the craving goes away.'”

The guideline also recommends pointing out the discrepancy patients may demonstrate between their behavior and their expressed priorities. “If they say they're here to see you about their health, yet they're not ready to quit smoking … say, 'quitting smoking is the one thing you can do that is most effective for your health.'”

If patients resist the notion to quit, “roll with it. It's not for you to try to convince them to change their behavior.” But make sure to bring up smoking in their next office visit. “Sometime I tell my patients, 'every time you see my face I want you to think, quit smoking,'” said Dr. Jaén, who is also a member of AAFP's Tobacco Cessation Advisory Committee.

Physicians can support self-efficacy by helping patients identify and build on past successes. Quitting “doesn't have to happen all at once. It can be changing smoking patterns, asking the patient to share his or her ideas about quitting strategies, or calling the quitline. There are multiple ways to get to the point where they are ready to quit,” he said.

If patients are keen to quit but aren't ready for intensive interventions, then offer practical counseling interventions such as recommending that they throw away all of their ashtrays and cigarette butts on the day they decide to quit, said Dr. Jaén. Other tips include advising patients not to have cigarettes in their car, to walk instead of sitting down after a meal, and to brush their teeth when they crave a cigarette.

He emphasized the importance of social support, saying he urges patients to tell family members, friends, and coworkers about their decision to quit. “Call them up, and ask how they're doing,” he added.

Dr. Jaén said he also warns patients not to consume alcohol when they're in the early stages of quitting, “because alcohol and nicotine are synergistic. Once people start drinking, it's hard for them to stay off cigarettes, especially early on. If people have conflicted relationships, maybe they should avoid that person for a while, too.”

A package of 200 quitline referral cards is available free to AAFP members. The cost for nonmembers is $50 plus shipping. For information, call 800-944-0000 and request item number 966.

Quitlines are free, convenient, and anonymous. A lot of smokers feel guilty about their smoking. DR. SCHROEDER

'Help the patient understand you know that quitting smoking is avery difficult thing to do.' Dr. Jaén