Doug Brunk

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

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

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

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

In addition to being cast in roles, he has served as a theater usher, worked the lighting and other technical jobs, and helped build and disassemble sets. "I also tidied up the theater so much that one of our late community theater actors and volunteer set builders called me the garbage man," Dr. Grossman said. "I did more than empty our garbage. I would sift through it because angle brackets and other things were mistakenly thrown in there that could be reused in future productions. The community theater has a strict budget. None of the theater members are paid. Only guest musicians and guest directors, who may drive long distances, are paid."

Along the way he learned to respect the talents of master playwrights such as Tennessee Williams. He and his fellow cast members held frequent discussions in the green room about what message Williams was trying to convey in his plays. "We could never reach consensus as to what he was trying to get at," he said.

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

Dr. Grossman said that his brush with cancer also motivated him to take up another avocation. Prior to starting his undergraduate studies at Johns Hopkins University, Baltimore, he had appeared as a ballroom dancer for 1 week on "The Buddy Dean Show," a Baltimore-based teen dance television program that featured appearances by the Cordettes, Johnny Mathis, and Frankie Avalon, but Western square dancing had always intrigued him. So he and his wife, Mickey, enrolled in classes at a local university to further develop their ballroom dancing proficiency and to learn Western square dancing. They continue to build on their skills by attending Western square dancing events.

Looking back, Dr. Grossman credits his brush with cancer for motivating him to pursue the avocations he'd long wished to take a crack at. "It's fair to say that my cancer gave me a fairly swift kick in my bottom and got me out into my community," he said.

Dr. Joshua Grossman, with his wife Mickey (far left) and Proud Annie Mystery Theater cast members, began acting after undergoing treatment for papillary carcinoma of the thyroid. Courtesy Dr. Joshua Grossman

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

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

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

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

In addition to being cast in roles, he has served as a theater usher, worked the lighting and other technical jobs, and helped build and disassemble sets. "I also tidied up the theater so much that one of our late community theater actors and volunteer set builders called me the garbage man," Dr. Grossman said. "I did more than empty our garbage. I would sift through it because angle brackets and other things were mistakenly thrown in there that could be reused in future productions. The community theater has a strict budget. None of the theater members are paid. Only guest musicians and guest directors, who may drive long distances, are paid."

Along the way he learned to respect the talents of master playwrights such as Tennessee Williams. He and his fellow cast members held frequent discussions in the green room about what message Williams was trying to convey in his plays. "We could never reach consensus as to what he was trying to get at," he said.

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

Dr. Grossman said that his brush with cancer also motivated him to take up another avocation. Prior to starting his undergraduate studies at Johns Hopkins University, Baltimore, he had appeared as a ballroom dancer for 1 week on "The Buddy Dean Show," a Baltimore-based teen dance television program that featured appearances by the Cordettes, Johnny Mathis, and Frankie Avalon, but Western square dancing had always intrigued him. So he and his wife, Mickey, enrolled in classes at a local university to further develop their ballroom dancing proficiency and to learn Western square dancing. They continue to build on their skills by attending Western square dancing events.

Looking back, Dr. Grossman credits his brush with cancer for motivating him to pursue the avocations he'd long wished to take a crack at. "It's fair to say that my cancer gave me a fairly swift kick in my bottom and got me out into my community," he said.

Dr. Joshua Grossman, with his wife Mickey (far left) and Proud Annie Mystery Theater cast members, began acting after undergoing treatment for papillary carcinoma of the thyroid. Courtesy Dr. Joshua Grossman

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

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

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

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

In addition to being cast in roles, he has served as a theater usher, worked the lighting and other technical jobs, and helped build and disassemble sets. "I also tidied up the theater so much that one of our late community theater actors and volunteer set builders called me the garbage man," Dr. Grossman said. "I did more than empty our garbage. I would sift through it because angle brackets and other things were mistakenly thrown in there that could be reused in future productions. The community theater has a strict budget. None of the theater members are paid. Only guest musicians and guest directors, who may drive long distances, are paid."

Along the way he learned to respect the talents of master playwrights such as Tennessee Williams. He and his fellow cast members held frequent discussions in the green room about what message Williams was trying to convey in his plays. "We could never reach consensus as to what he was trying to get at," he said.

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

Dr. Grossman said that his brush with cancer also motivated him to take up another avocation. Prior to starting his undergraduate studies at Johns Hopkins University, Baltimore, he had appeared as a ballroom dancer for 1 week on "The Buddy Dean Show," a Baltimore-based teen dance television program that featured appearances by the Cordettes, Johnny Mathis, and Frankie Avalon, but Western square dancing had always intrigued him. So he and his wife, Mickey, enrolled in classes at a local university to further develop their ballroom dancing proficiency and to learn Western square dancing. They continue to build on their skills by attending Western square dancing events.

Looking back, Dr. Grossman credits his brush with cancer for motivating him to pursue the avocations he'd long wished to take a crack at. "It's fair to say that my cancer gave me a fairly swift kick in my bottom and got me out into my community," he said.

Dr. Joshua Grossman, with his wife Mickey (far left) and Proud Annie Mystery Theater cast members, began acting after undergoing treatment for papillary carcinoma of the thyroid. Courtesy Dr. Joshua Grossman

LAS VEGAS — The incidence of complications following skin surgery is no different in smokers, compared with nonsmokers, results from a 5-year, single-center study demonstrated.

The finding flies in the face of conventional thinking that smokers "do worse after skin surgery, that they heal slower, and that they get more infections," Dr. Anthony Dixon said at the annual meeting of the International Society for Dermatologic Surgery.

A study from 1992 suggested that smoking compromises wound repair in part because nicotine reduces blood flow to the skin and increases blood platelet aggregation, which raises the risk of microthrombosis (Am. J. Med. 1992;93:22S-4S). The author also said that carbon monoxide decreases oxygen transport and metabolism.

"But unfortunately, until now there hasn't been a long prospective trial to find out whether or not this theory is true," said Dr. Dixon of the dermatology department at Australia's Bond University in Robina, Queensland. "Many dermatologists advise patients to cease smoking for a week prior to having skin surgery. There's no evidence base for that."

He and his associates conducted an observational study of 7,224 lesions excised on 4,197 patients between July 2002 and July 2007. Dr. Dixon performed all procedures; the average patient age was 65 years, and 55% were male.

In all, there were 286 complications (3.96%). The most common complication was infection, followed by bleeding, dehiscence, and skin necrosis.

Dr. Dixon reported that the incidence of total complications was similar between smokers and nonsmokers (3.6% vs. 4.0%, respectively). The incidence of infection was 1.9% in smokers, compared with 2.2% in nonsmokers, a difference that was not statistically significant. Bleeding occurred in 0.2% of smokers and in 0.8% of nonsmokers, a difference that was also not statistically significant.

Logistic regression analysis that adjusted for age, sex, operation type, lesion diagnosis, body site location, and socioeconomic background found that smoking did not predict any complication.

Based on these findings, "we can't justify smoking cessation prior to skin surgery," said Dr. Dixon, who emphasized that he and his fellow researchers "are all nonsmokers and we encourage our patients not to smoke for other health reasons. There are certainly things we try to get our patients to remember prior to surgery, but stopping smoking is not one of them."

In an interview, he acknowledged certain limitations of the study, including the fact that some of the patients may have been smokers but did not declare themselves as such. "Also, Australia has one of the lowest rates of smoking in the Western world and this may not reflect circumstances in countries with much higher smoking rates," he said.

In a separate analysis to be published in Dermatologic Surgery, he and his associates studied the same patient population to investigate the incidence of complications after skin surgery in diabetic and nondiabetic patients. Of the 4,197 patients in the study, 196 had known diabetes and 4,001 did not. The average age of diabetic patients was 72 years.

The incidence of total complications between diabetic and nondiabetic patients was the same, at 1.8%, but the incidence of infection was significantly higher in patients with diabetes (4.2%), compared with those without (2.0%). Bleeding occurred in 0.9% of diabetic patients and 0.7% of nondiabetic patients, a difference that was not statistically significant.

Logistic regression analysis that adjusted for age, sex, operation type, lesion diagnosis, body site location, and socioeconomic background found that a known history of diabetes was predictive of infection.

Dr. Dixon, who is also director of research for a group of skin cancer clinics in Australia, had no disclosures to make.

Patients are advised to cease smoking 1 week before skin surgery. 'There's no evidence base for that.' DR. DIXON

LAS VEGAS — The incidence of complications following skin surgery is no different in smokers, compared with nonsmokers, results from a 5-year, single-center study demonstrated.

The finding flies in the face of conventional thinking that smokers "do worse after skin surgery, that they heal slower, and that they get more infections," Dr. Anthony Dixon said at the annual meeting of the International Society for Dermatologic Surgery.

A study from 1992 suggested that smoking compromises wound repair in part because nicotine reduces blood flow to the skin and increases blood platelet aggregation, which raises the risk of microthrombosis (Am. J. Med. 1992;93:22S-4S). The author also said that carbon monoxide decreases oxygen transport and metabolism.

"But unfortunately, until now there hasn't been a long prospective trial to find out whether or not this theory is true," said Dr. Dixon of the dermatology department at Australia's Bond University in Robina, Queensland. "Many dermatologists advise patients to cease smoking for a week prior to having skin surgery. There's no evidence base for that."

He and his associates conducted an observational study of 7,224 lesions excised on 4,197 patients between July 2002 and July 2007. Dr. Dixon performed all procedures; the average patient age was 65 years, and 55% were male.

In all, there were 286 complications (3.96%). The most common complication was infection, followed by bleeding, dehiscence, and skin necrosis.

Dr. Dixon reported that the incidence of total complications was similar between smokers and nonsmokers (3.6% vs. 4.0%, respectively). The incidence of infection was 1.9% in smokers, compared with 2.2% in nonsmokers, a difference that was not statistically significant. Bleeding occurred in 0.2% of smokers and in 0.8% of nonsmokers, a difference that was also not statistically significant.

Logistic regression analysis that adjusted for age, sex, operation type, lesion diagnosis, body site location, and socioeconomic background found that smoking did not predict any complication.

Based on these findings, "we can't justify smoking cessation prior to skin surgery," said Dr. Dixon, who emphasized that he and his fellow researchers "are all nonsmokers and we encourage our patients not to smoke for other health reasons. There are certainly things we try to get our patients to remember prior to surgery, but stopping smoking is not one of them."

In an interview, he acknowledged certain limitations of the study, including the fact that some of the patients may have been smokers but did not declare themselves as such. "Also, Australia has one of the lowest rates of smoking in the Western world and this may not reflect circumstances in countries with much higher smoking rates," he said.

In a separate analysis to be published in Dermatologic Surgery, he and his associates studied the same patient population to investigate the incidence of complications after skin surgery in diabetic and nondiabetic patients. Of the 4,197 patients in the study, 196 had known diabetes and 4,001 did not. The average age of diabetic patients was 72 years.

The incidence of total complications between diabetic and nondiabetic patients was the same, at 1.8%, but the incidence of infection was significantly higher in patients with diabetes (4.2%), compared with those without (2.0%). Bleeding occurred in 0.9% of diabetic patients and 0.7% of nondiabetic patients, a difference that was not statistically significant.

Logistic regression analysis that adjusted for age, sex, operation type, lesion diagnosis, body site location, and socioeconomic background found that a known history of diabetes was predictive of infection.

Dr. Dixon, who is also director of research for a group of skin cancer clinics in Australia, had no disclosures to make.

Patients are advised to cease smoking 1 week before skin surgery. 'There's no evidence base for that.' DR. DIXON

LAS VEGAS — The incidence of complications following skin surgery is no different in smokers, compared with nonsmokers, results from a 5-year, single-center study demonstrated.

The finding flies in the face of conventional thinking that smokers "do worse after skin surgery, that they heal slower, and that they get more infections," Dr. Anthony Dixon said at the annual meeting of the International Society for Dermatologic Surgery.

A study from 1992 suggested that smoking compromises wound repair in part because nicotine reduces blood flow to the skin and increases blood platelet aggregation, which raises the risk of microthrombosis (Am. J. Med. 1992;93:22S-4S). The author also said that carbon monoxide decreases oxygen transport and metabolism.

"But unfortunately, until now there hasn't been a long prospective trial to find out whether or not this theory is true," said Dr. Dixon of the dermatology department at Australia's Bond University in Robina, Queensland. "Many dermatologists advise patients to cease smoking for a week prior to having skin surgery. There's no evidence base for that."

He and his associates conducted an observational study of 7,224 lesions excised on 4,197 patients between July 2002 and July 2007. Dr. Dixon performed all procedures; the average patient age was 65 years, and 55% were male.

In all, there were 286 complications (3.96%). The most common complication was infection, followed by bleeding, dehiscence, and skin necrosis.

Dr. Dixon reported that the incidence of total complications was similar between smokers and nonsmokers (3.6% vs. 4.0%, respectively). The incidence of infection was 1.9% in smokers, compared with 2.2% in nonsmokers, a difference that was not statistically significant. Bleeding occurred in 0.2% of smokers and in 0.8% of nonsmokers, a difference that was also not statistically significant.

Logistic regression analysis that adjusted for age, sex, operation type, lesion diagnosis, body site location, and socioeconomic background found that smoking did not predict any complication.

Based on these findings, "we can't justify smoking cessation prior to skin surgery," said Dr. Dixon, who emphasized that he and his fellow researchers "are all nonsmokers and we encourage our patients not to smoke for other health reasons. There are certainly things we try to get our patients to remember prior to surgery, but stopping smoking is not one of them."

In an interview, he acknowledged certain limitations of the study, including the fact that some of the patients may have been smokers but did not declare themselves as such. "Also, Australia has one of the lowest rates of smoking in the Western world and this may not reflect circumstances in countries with much higher smoking rates," he said.

In a separate analysis to be published in Dermatologic Surgery, he and his associates studied the same patient population to investigate the incidence of complications after skin surgery in diabetic and nondiabetic patients. Of the 4,197 patients in the study, 196 had known diabetes and 4,001 did not. The average age of diabetic patients was 72 years.

The incidence of total complications between diabetic and nondiabetic patients was the same, at 1.8%, but the incidence of infection was significantly higher in patients with diabetes (4.2%), compared with those without (2.0%). Bleeding occurred in 0.9% of diabetic patients and 0.7% of nondiabetic patients, a difference that was not statistically significant.

Logistic regression analysis that adjusted for age, sex, operation type, lesion diagnosis, body site location, and socioeconomic background found that a known history of diabetes was predictive of infection.

Dr. Dixon, who is also director of research for a group of skin cancer clinics in Australia, had no disclosures to make.

Patients are advised to cease smoking 1 week before skin surgery. 'There's no evidence base for that.' DR. DIXON

LAS VEGAS — The way Dr. Eliot F. Battle Jr. sees it, dermatologists should learn how to treat skin of color with cosmetic laser therapy for two reasons: to increase their revenue base as the world's population of brown-skinned individuals expands, and to improve their proficiency with operating lasers.

"You will never become an expert with lasers if you can't treat brown skin," Dr. Battle said at the annual meeting of the International Society for Dermatologic Surgery. "You have to embrace skin types IV-VI, for through this expertise we improved our ability to treat noninvasively and to treat tanned skin."

His Washington, D.C.-based practice is 37% African American, 27% white, 12% Hispanic, 8% Asian Pacific, 6% Asian, and 10% "other." Three of the top four nonsurgical procedures are laser hair removal, laser complexion blending—which he described as "evening out skin tone"—and laser skin tightening. (Botulinum toxin type A rounds out the top four.)

"We are going through an exciting time to treat skin of color, for we have more ammunition than ever to safely and effectively treat people of color in all areas of skin care, including cosmeceuticals, prescription medicines, aesthetic spa treatments, cosmetic laser treatments, and plastic surgery procedures," said Dr. Battle, a cosmetic dermatologist and laser surgeon.

In light-skinned individuals, melano-somes are small, and are packaged together in membranes. They remain around the basal layer of the epidermis.

In skin of color, melanosomes are more numerous, and are individually dispersed throughout all layers of the epidermis. Skin type VI patients can have melanin even in the stratum corneum. Some dermatologists "don't understand the genetic influence on melanin" Dr. Battle said, and deem darker ethnic skin as more difficult to treat with laser therapy.

Treating skin of color requires mastery of wavelengths, fluence, pulse duration, and cooling, said Dr. Battle, who is also on the faculty of the department of dermatology at Howard University, Washington.

Laser hair removal is especially effective in skin of color because black, coarse hair is an optimal target for the laser beam. "In [whites], hair removal is vanity because conventional methods such as shaving, waxing, and plucking work," Dr. Battle said. "People of color get dark spots from all of those methods."

Thermal side effects after laser therapy occur in skin of color when the skin temperature exceeds 45° C, so Dr. Battle maximizes cooling by using cold gel, slow treatments, ice packs post treatment, and cold air flow. "Be afraid of erythema," he warned. "In [whites] erythema resolves, but people of color get hyperpigmentation and redness. If you are going to do test spots, wait 48 hours for results. You can get blisters up to the second and third day after treatment."

If side effects do occur, be compassionate and empathetic and employ meticulous wound care. "Always be available to the patient," he advised. "Provide them with your cell phone number."

Dr. Battle disclosed having no conflicts of interest relevant to his presentation.

A patient is shown before (above) and 2 years after (below)undergoing nine laser hair removal sessions.

Hair removal is very effective in darker skin because black, coarse hair is an optimal target for the laser beam. Photos courtesy Dr. Eliot F. Battle Jr.

LAS VEGAS — The way Dr. Eliot F. Battle Jr. sees it, dermatologists should learn how to treat skin of color with cosmetic laser therapy for two reasons: to increase their revenue base as the world's population of brown-skinned individuals expands, and to improve their proficiency with operating lasers.

"You will never become an expert with lasers if you can't treat brown skin," Dr. Battle said at the annual meeting of the International Society for Dermatologic Surgery. "You have to embrace skin types IV-VI, for through this expertise we improved our ability to treat noninvasively and to treat tanned skin."

His Washington, D.C.-based practice is 37% African American, 27% white, 12% Hispanic, 8% Asian Pacific, 6% Asian, and 10% "other." Three of the top four nonsurgical procedures are laser hair removal, laser complexion blending—which he described as "evening out skin tone"—and laser skin tightening. (Botulinum toxin type A rounds out the top four.)

"We are going through an exciting time to treat skin of color, for we have more ammunition than ever to safely and effectively treat people of color in all areas of skin care, including cosmeceuticals, prescription medicines, aesthetic spa treatments, cosmetic laser treatments, and plastic surgery procedures," said Dr. Battle, a cosmetic dermatologist and laser surgeon.

In light-skinned individuals, melano-somes are small, and are packaged together in membranes. They remain around the basal layer of the epidermis.

In skin of color, melanosomes are more numerous, and are individually dispersed throughout all layers of the epidermis. Skin type VI patients can have melanin even in the stratum corneum. Some dermatologists "don't understand the genetic influence on melanin" Dr. Battle said, and deem darker ethnic skin as more difficult to treat with laser therapy.

Treating skin of color requires mastery of wavelengths, fluence, pulse duration, and cooling, said Dr. Battle, who is also on the faculty of the department of dermatology at Howard University, Washington.

Laser hair removal is especially effective in skin of color because black, coarse hair is an optimal target for the laser beam. "In [whites], hair removal is vanity because conventional methods such as shaving, waxing, and plucking work," Dr. Battle said. "People of color get dark spots from all of those methods."

Thermal side effects after laser therapy occur in skin of color when the skin temperature exceeds 45° C, so Dr. Battle maximizes cooling by using cold gel, slow treatments, ice packs post treatment, and cold air flow. "Be afraid of erythema," he warned. "In [whites] erythema resolves, but people of color get hyperpigmentation and redness. If you are going to do test spots, wait 48 hours for results. You can get blisters up to the second and third day after treatment."

If side effects do occur, be compassionate and empathetic and employ meticulous wound care. "Always be available to the patient," he advised. "Provide them with your cell phone number."

Dr. Battle disclosed having no conflicts of interest relevant to his presentation.

A patient is shown before (above) and 2 years after (below)undergoing nine laser hair removal sessions.

Hair removal is very effective in darker skin because black, coarse hair is an optimal target for the laser beam. Photos courtesy Dr. Eliot F. Battle Jr.

LAS VEGAS — The way Dr. Eliot F. Battle Jr. sees it, dermatologists should learn how to treat skin of color with cosmetic laser therapy for two reasons: to increase their revenue base as the world's population of brown-skinned individuals expands, and to improve their proficiency with operating lasers.

"You will never become an expert with lasers if you can't treat brown skin," Dr. Battle said at the annual meeting of the International Society for Dermatologic Surgery. "You have to embrace skin types IV-VI, for through this expertise we improved our ability to treat noninvasively and to treat tanned skin."

His Washington, D.C.-based practice is 37% African American, 27% white, 12% Hispanic, 8% Asian Pacific, 6% Asian, and 10% "other." Three of the top four nonsurgical procedures are laser hair removal, laser complexion blending—which he described as "evening out skin tone"—and laser skin tightening. (Botulinum toxin type A rounds out the top four.)

"We are going through an exciting time to treat skin of color, for we have more ammunition than ever to safely and effectively treat people of color in all areas of skin care, including cosmeceuticals, prescription medicines, aesthetic spa treatments, cosmetic laser treatments, and plastic surgery procedures," said Dr. Battle, a cosmetic dermatologist and laser surgeon.

In light-skinned individuals, melano-somes are small, and are packaged together in membranes. They remain around the basal layer of the epidermis.

In skin of color, melanosomes are more numerous, and are individually dispersed throughout all layers of the epidermis. Skin type VI patients can have melanin even in the stratum corneum. Some dermatologists "don't understand the genetic influence on melanin" Dr. Battle said, and deem darker ethnic skin as more difficult to treat with laser therapy.

Treating skin of color requires mastery of wavelengths, fluence, pulse duration, and cooling, said Dr. Battle, who is also on the faculty of the department of dermatology at Howard University, Washington.

Laser hair removal is especially effective in skin of color because black, coarse hair is an optimal target for the laser beam. "In [whites], hair removal is vanity because conventional methods such as shaving, waxing, and plucking work," Dr. Battle said. "People of color get dark spots from all of those methods."

Thermal side effects after laser therapy occur in skin of color when the skin temperature exceeds 45° C, so Dr. Battle maximizes cooling by using cold gel, slow treatments, ice packs post treatment, and cold air flow. "Be afraid of erythema," he warned. "In [whites] erythema resolves, but people of color get hyperpigmentation and redness. If you are going to do test spots, wait 48 hours for results. You can get blisters up to the second and third day after treatment."

If side effects do occur, be compassionate and empathetic and employ meticulous wound care. "Always be available to the patient," he advised. "Provide them with your cell phone number."

Dr. Battle disclosed having no conflicts of interest relevant to his presentation.

A patient is shown before (above) and 2 years after (below)undergoing nine laser hair removal sessions.

Hair removal is very effective in darker skin because black, coarse hair is an optimal target for the laser beam. Photos courtesy Dr. Eliot F. Battle Jr.

LAS VEGAS — A device that delivers supersonic pressure to the skin for rejuvenation is showing efficacy for several conditions, including facial wrinkles, solar keratoses, and acne scars.

The device, which was developed by a Russian rocket scientist, is called the JetPeel-3 and is manufactured by TavTech Ltd. It uses pressurized gas to deliver saline or other liquid nutrients through special handpieces into the superficial layers of the skin at supersonic velocities.

The device was cleared by the Food and Drug Administration in 2006 for delivery of saline into the skin.

"It removes microscopic particles that are usually inaccessible, such as those between cells, in epidermal cracks, in sweat secretions, and in the depression of the hair follicle," Dr. Michael Gold said at the annual meeting of the International Society for Dermatologic Surgery. "Supplements are penetrated through pressurized zones, which stretch skin-widening micro-canals inherent in the skin layers and create new ones. It's a simple, safe, painless, and effective device for skin rejuvenation."

He added that the JetPeel-3 restores a youthful-looking appearance by reducing cellular buildup, strengthening capillary respiration, removing metabolic waste from tissues, hydrating and oxygenating tissues, and energizing cell renewal and the wound-healing process.

The technology "is something I find fascinating," said Dr. Gold, who is a paid consultant of TavTech and uses the JetPeel-3 in his Nashville, Tenn., dermatology practice. At the meeting he showed several before and after pictures of cases that were successfully treated with the device for wrinkles above the lips, crow's feet, solar keratoses, and acne scars.

"Many times you see good results after just one treatment," he said. In his experience, most patients require two to four treatments for optimal correction.

While most studies of the device to date have focused on exfoliation with saline, current research is exploring its role in enhancing laser, intense pulsed light, and other treatments, and in the needleless delivery of mesotherapy products and vitamins. "You can personalize these things," he said.

Nutritional elements currently being used include hyaluronic acid, which enriches the skin's natural connective tissue; vitamin C, which improves the ability of skin cells to even out pigment; and vitamins A, B, and E, "which are important ingredients for the proper functioning of cells," he said.

In an interview at the meeting, Oren Gan, TavTech's vice president of sales and marketing, said that many patients achieve immediate results and their skin typically returns to its natural coloration within 30 minutes after treatment is completed.

"It's a true lunchtime procedure," he said, noting that the price of the JetPeel-3 is $22,900.

Dr. Gold disclosed that he is a consultant to, speaks on behalf of, and has performed research for many pharmaceutical and medical device companies, including TavTech.

'It's a simple, safe, painless, and effective device.' The technology is 'something I find fascinating.' DR. GOLD

LAS VEGAS — A device that delivers supersonic pressure to the skin for rejuvenation is showing efficacy for several conditions, including facial wrinkles, solar keratoses, and acne scars.

The device, which was developed by a Russian rocket scientist, is called the JetPeel-3 and is manufactured by TavTech Ltd. It uses pressurized gas to deliver saline or other liquid nutrients through special handpieces into the superficial layers of the skin at supersonic velocities.

The device was cleared by the Food and Drug Administration in 2006 for delivery of saline into the skin.

"It removes microscopic particles that are usually inaccessible, such as those between cells, in epidermal cracks, in sweat secretions, and in the depression of the hair follicle," Dr. Michael Gold said at the annual meeting of the International Society for Dermatologic Surgery. "Supplements are penetrated through pressurized zones, which stretch skin-widening micro-canals inherent in the skin layers and create new ones. It's a simple, safe, painless, and effective device for skin rejuvenation."

He added that the JetPeel-3 restores a youthful-looking appearance by reducing cellular buildup, strengthening capillary respiration, removing metabolic waste from tissues, hydrating and oxygenating tissues, and energizing cell renewal and the wound-healing process.

The technology "is something I find fascinating," said Dr. Gold, who is a paid consultant of TavTech and uses the JetPeel-3 in his Nashville, Tenn., dermatology practice. At the meeting he showed several before and after pictures of cases that were successfully treated with the device for wrinkles above the lips, crow's feet, solar keratoses, and acne scars.

"Many times you see good results after just one treatment," he said. In his experience, most patients require two to four treatments for optimal correction.

While most studies of the device to date have focused on exfoliation with saline, current research is exploring its role in enhancing laser, intense pulsed light, and other treatments, and in the needleless delivery of mesotherapy products and vitamins. "You can personalize these things," he said.

Nutritional elements currently being used include hyaluronic acid, which enriches the skin's natural connective tissue; vitamin C, which improves the ability of skin cells to even out pigment; and vitamins A, B, and E, "which are important ingredients for the proper functioning of cells," he said.

In an interview at the meeting, Oren Gan, TavTech's vice president of sales and marketing, said that many patients achieve immediate results and their skin typically returns to its natural coloration within 30 minutes after treatment is completed.

"It's a true lunchtime procedure," he said, noting that the price of the JetPeel-3 is $22,900.

Dr. Gold disclosed that he is a consultant to, speaks on behalf of, and has performed research for many pharmaceutical and medical device companies, including TavTech.

'It's a simple, safe, painless, and effective device.' The technology is 'something I find fascinating.' DR. GOLD

LAS VEGAS — A device that delivers supersonic pressure to the skin for rejuvenation is showing efficacy for several conditions, including facial wrinkles, solar keratoses, and acne scars.

The device, which was developed by a Russian rocket scientist, is called the JetPeel-3 and is manufactured by TavTech Ltd. It uses pressurized gas to deliver saline or other liquid nutrients through special handpieces into the superficial layers of the skin at supersonic velocities.

The device was cleared by the Food and Drug Administration in 2006 for delivery of saline into the skin.

"It removes microscopic particles that are usually inaccessible, such as those between cells, in epidermal cracks, in sweat secretions, and in the depression of the hair follicle," Dr. Michael Gold said at the annual meeting of the International Society for Dermatologic Surgery. "Supplements are penetrated through pressurized zones, which stretch skin-widening micro-canals inherent in the skin layers and create new ones. It's a simple, safe, painless, and effective device for skin rejuvenation."

He added that the JetPeel-3 restores a youthful-looking appearance by reducing cellular buildup, strengthening capillary respiration, removing metabolic waste from tissues, hydrating and oxygenating tissues, and energizing cell renewal and the wound-healing process.

The technology "is something I find fascinating," said Dr. Gold, who is a paid consultant of TavTech and uses the JetPeel-3 in his Nashville, Tenn., dermatology practice. At the meeting he showed several before and after pictures of cases that were successfully treated with the device for wrinkles above the lips, crow's feet, solar keratoses, and acne scars.

"Many times you see good results after just one treatment," he said. In his experience, most patients require two to four treatments for optimal correction.

While most studies of the device to date have focused on exfoliation with saline, current research is exploring its role in enhancing laser, intense pulsed light, and other treatments, and in the needleless delivery of mesotherapy products and vitamins. "You can personalize these things," he said.

Nutritional elements currently being used include hyaluronic acid, which enriches the skin's natural connective tissue; vitamin C, which improves the ability of skin cells to even out pigment; and vitamins A, B, and E, "which are important ingredients for the proper functioning of cells," he said.

In an interview at the meeting, Oren Gan, TavTech's vice president of sales and marketing, said that many patients achieve immediate results and their skin typically returns to its natural coloration within 30 minutes after treatment is completed.

"It's a true lunchtime procedure," he said, noting that the price of the JetPeel-3 is $22,900.

Dr. Gold disclosed that he is a consultant to, speaks on behalf of, and has performed research for many pharmaceutical and medical device companies, including TavTech.

'It's a simple, safe, painless, and effective device.' The technology is 'something I find fascinating.' DR. GOLD

LAS VEGAS — While cellulite can be easily identified, the basic science of its makeup remains a mystery.

"We still don't know what the definitive pathologic cause of cellulite is," Dr. Neil Sadick said at the annual meeting of the International Society for Dermatologic Surgery. "There are many aggravating factors such as weight loss that are thought to play a role, but none of them [has] been proven over the past 30 years. We believe that this is a sexual dimorphic secondary trait."

One theory he subscribes to is that cellulite "involves changes in the structure of the adipocyte and the surrounding septa, so that the septa are more vertically oriented, allowing movement of the adipocyte up to the dermis."

Dr. Sadick and his associates in the department of dermatology at Cornell University, New York, plan to launch a series of clinical trials with the New Jersey Medical School, Newark, in an effort to determine the content of fat found in cellulite.

They also plan to study receptors that have been shown to be involved and upregulated in people with cellulite, including peroxisome proliferator-activated receptors, uncoupling protein 1, and androgen receptors α-AR and β-AR. "By understanding more about the basic science of this condition, we hope to be able to introduce better therapies in the future," he said.

The current trend in cellulite therapy is marked by multimodal devices that "attempt to heat adipocytes, remodel adipocytes, and cause dermal remodeling in the septa surrounding the adipocyte cells," Dr. Sadick said. He discussed the following technologies:

▸ VelaShape (Syneron Medical Ltd.). This Food and Drug Administration-approved device combines bipolar radiofrequency power and infrared energy with vacuum and mechanical massage for circumferential reduction.

"There have been a number of publications in the scientific literature showing that there is some degree of efficacy in terms of remodeling the cellulite as well as circumferential fat reduction," he said.

In a study of 40 patients conducted at Dr. Sadick's clinic, 85% had a circumferential reduction of 1 cm or more after 12 treatments and 43% had a circumferential reduction of 2 cm or more.

"Up to 7.2-cm reduction in circumference was achieved" in some cases, he said.

▸ TriActive (Cynosure). This FDA-approved device combines a low-energy diode laser with suction massage that has been shown to achieve a global cellulite improvement in 75% of patients (Am. J. Cosmet. Surg. 2005;224:233–5). "This is a very nice technology that can be used in this setting," Dr. Sadick commented.

▸ Accent (Alma). This FDA-approved device uses dual radiofrequency technology for circumferential reduction.

The unipolar setting targets deep dermal and subdermal layers and is used to treat large volumes of tissue, while the bipolar setting delivers energy superficially and is used to treat areas with a thinner dermis such as the face.

One recent study of 30 patients with cellulite grade III-IV who were treated 6 times over a 2-week period found that 27 achieved clinical improvement with a mean decrease in thigh circumference of 2.45 cm as measured by MRI (Dermatol. Surg. 2008;34:204–9).

▸ SmoothShapes (Elemé Medical). This FDA-approved device combines a laser and an LED light source with mechanical rollers and a vacuum to "mold the adipocytes and to try and improve the metabolic parameters associated with cellulite," Dr. Sadick said.

One randomized trial of 74 patients treated twice a week for 4 weeks found that 81% had a significant volumetric reduction in subcutaneous fat (J. Lasers Surg. Med. 2004; suppl. 16:32). At 13 months post treatment, five patients underwent MRI and four of the five maintained their result.

In the future, he predicted, more "inside-outside" approaches to treating cellulite are likely to evolve, such as combining external technologies with internal laser lipolysis to "heat adipocytes and eat up septa. That probably will give the most effective results."

Dr. Sadick went on to note that while injectable treatment of cellulitis remains popular in the United States, "there is not a lot of good science behind it. We need to distinguish between true mesotherapy and injectable lipolysis. In true mesotherapy, we are attempting to eliminate some fat [and] have an effect on the metabolism of the adipocytes."

Agents being used for treating cellulite in mesotherapy include aminophylline, isoproterenol, ephedrine, calcium pyruvate, carnitine, and ma huang.

Another approach to cellulite treatment is detergent lipolysis, or mesotherapy, in which phosphatidylcholine and deoxycholate act as detergents, causing adipose cell walls to dissolve and break down.

"This is not FDA approved to date but there are FDA studies underway to determine the optimal solution," Dr. Sadick said.

Future treatment approaches may include topical approaches such as Retinol Anti-Cellulite, a cosmeceutical from RoC, as well as electrolipolysis, carboxytherapy, and cryolipolysis.

But for now, "the technology has moved far in advance of what we know about cellulite," he said.

Dr. Sadick disclosed that he has received research funding from Syneron Medical Ltd., DEKA Corp., and Cynosure Inc.

'By understanding more about the basic science of this condition, we hope to be able to introduce better therapies.' DR. SADICK

A patient is shown before (left) and after (right) undergoing four treatments with VelaShape for cellulite reduction. Photos courtesy Dr. Neil Sadick

LAS VEGAS — While cellulite can be easily identified, the basic science of its makeup remains a mystery.

"We still don't know what the definitive pathologic cause of cellulite is," Dr. Neil Sadick said at the annual meeting of the International Society for Dermatologic Surgery. "There are many aggravating factors such as weight loss that are thought to play a role, but none of them [has] been proven over the past 30 years. We believe that this is a sexual dimorphic secondary trait."

One theory he subscribes to is that cellulite "involves changes in the structure of the adipocyte and the surrounding septa, so that the septa are more vertically oriented, allowing movement of the adipocyte up to the dermis."

Dr. Sadick and his associates in the department of dermatology at Cornell University, New York, plan to launch a series of clinical trials with the New Jersey Medical School, Newark, in an effort to determine the content of fat found in cellulite.

They also plan to study receptors that have been shown to be involved and upregulated in people with cellulite, including peroxisome proliferator-activated receptors, uncoupling protein 1, and androgen receptors α-AR and β-AR. "By understanding more about the basic science of this condition, we hope to be able to introduce better therapies in the future," he said.

The current trend in cellulite therapy is marked by multimodal devices that "attempt to heat adipocytes, remodel adipocytes, and cause dermal remodeling in the septa surrounding the adipocyte cells," Dr. Sadick said. He discussed the following technologies:

▸ VelaShape (Syneron Medical Ltd.). This Food and Drug Administration-approved device combines bipolar radiofrequency power and infrared energy with vacuum and mechanical massage for circumferential reduction.

"There have been a number of publications in the scientific literature showing that there is some degree of efficacy in terms of remodeling the cellulite as well as circumferential fat reduction," he said.

In a study of 40 patients conducted at Dr. Sadick's clinic, 85% had a circumferential reduction of 1 cm or more after 12 treatments and 43% had a circumferential reduction of 2 cm or more.

"Up to 7.2-cm reduction in circumference was achieved" in some cases, he said.

▸ TriActive (Cynosure). This FDA-approved device combines a low-energy diode laser with suction massage that has been shown to achieve a global cellulite improvement in 75% of patients (Am. J. Cosmet. Surg. 2005;224:233–5). "This is a very nice technology that can be used in this setting," Dr. Sadick commented.

▸ Accent (Alma). This FDA-approved device uses dual radiofrequency technology for circumferential reduction.

The unipolar setting targets deep dermal and subdermal layers and is used to treat large volumes of tissue, while the bipolar setting delivers energy superficially and is used to treat areas with a thinner dermis such as the face.

One recent study of 30 patients with cellulite grade III-IV who were treated 6 times over a 2-week period found that 27 achieved clinical improvement with a mean decrease in thigh circumference of 2.45 cm as measured by MRI (Dermatol. Surg. 2008;34:204–9).

▸ SmoothShapes (Elemé Medical). This FDA-approved device combines a laser and an LED light source with mechanical rollers and a vacuum to "mold the adipocytes and to try and improve the metabolic parameters associated with cellulite," Dr. Sadick said.

One randomized trial of 74 patients treated twice a week for 4 weeks found that 81% had a significant volumetric reduction in subcutaneous fat (J. Lasers Surg. Med. 2004; suppl. 16:32). At 13 months post treatment, five patients underwent MRI and four of the five maintained their result.

In the future, he predicted, more "inside-outside" approaches to treating cellulite are likely to evolve, such as combining external technologies with internal laser lipolysis to "heat adipocytes and eat up septa. That probably will give the most effective results."

Dr. Sadick went on to note that while injectable treatment of cellulitis remains popular in the United States, "there is not a lot of good science behind it. We need to distinguish between true mesotherapy and injectable lipolysis. In true mesotherapy, we are attempting to eliminate some fat [and] have an effect on the metabolism of the adipocytes."

Agents being used for treating cellulite in mesotherapy include aminophylline, isoproterenol, ephedrine, calcium pyruvate, carnitine, and ma huang.

Another approach to cellulite treatment is detergent lipolysis, or mesotherapy, in which phosphatidylcholine and deoxycholate act as detergents, causing adipose cell walls to dissolve and break down.

"This is not FDA approved to date but there are FDA studies underway to determine the optimal solution," Dr. Sadick said.

Future treatment approaches may include topical approaches such as Retinol Anti-Cellulite, a cosmeceutical from RoC, as well as electrolipolysis, carboxytherapy, and cryolipolysis.

But for now, "the technology has moved far in advance of what we know about cellulite," he said.

Dr. Sadick disclosed that he has received research funding from Syneron Medical Ltd., DEKA Corp., and Cynosure Inc.

'By understanding more about the basic science of this condition, we hope to be able to introduce better therapies.' DR. SADICK

A patient is shown before (left) and after (right) undergoing four treatments with VelaShape for cellulite reduction. Photos courtesy Dr. Neil Sadick

LAS VEGAS — While cellulite can be easily identified, the basic science of its makeup remains a mystery.

"We still don't know what the definitive pathologic cause of cellulite is," Dr. Neil Sadick said at the annual meeting of the International Society for Dermatologic Surgery. "There are many aggravating factors such as weight loss that are thought to play a role, but none of them [has] been proven over the past 30 years. We believe that this is a sexual dimorphic secondary trait."

One theory he subscribes to is that cellulite "involves changes in the structure of the adipocyte and the surrounding septa, so that the septa are more vertically oriented, allowing movement of the adipocyte up to the dermis."

Dr. Sadick and his associates in the department of dermatology at Cornell University, New York, plan to launch a series of clinical trials with the New Jersey Medical School, Newark, in an effort to determine the content of fat found in cellulite.

They also plan to study receptors that have been shown to be involved and upregulated in people with cellulite, including peroxisome proliferator-activated receptors, uncoupling protein 1, and androgen receptors α-AR and β-AR. "By understanding more about the basic science of this condition, we hope to be able to introduce better therapies in the future," he said.

The current trend in cellulite therapy is marked by multimodal devices that "attempt to heat adipocytes, remodel adipocytes, and cause dermal remodeling in the septa surrounding the adipocyte cells," Dr. Sadick said. He discussed the following technologies:

▸ VelaShape (Syneron Medical Ltd.). This Food and Drug Administration-approved device combines bipolar radiofrequency power and infrared energy with vacuum and mechanical massage for circumferential reduction.

"There have been a number of publications in the scientific literature showing that there is some degree of efficacy in terms of remodeling the cellulite as well as circumferential fat reduction," he said.

In a study of 40 patients conducted at Dr. Sadick's clinic, 85% had a circumferential reduction of 1 cm or more after 12 treatments and 43% had a circumferential reduction of 2 cm or more.

"Up to 7.2-cm reduction in circumference was achieved" in some cases, he said.

▸ TriActive (Cynosure). This FDA-approved device combines a low-energy diode laser with suction massage that has been shown to achieve a global cellulite improvement in 75% of patients (Am. J. Cosmet. Surg. 2005;224:233–5). "This is a very nice technology that can be used in this setting," Dr. Sadick commented.

▸ Accent (Alma). This FDA-approved device uses dual radiofrequency technology for circumferential reduction.

The unipolar setting targets deep dermal and subdermal layers and is used to treat large volumes of tissue, while the bipolar setting delivers energy superficially and is used to treat areas with a thinner dermis such as the face.

One recent study of 30 patients with cellulite grade III-IV who were treated 6 times over a 2-week period found that 27 achieved clinical improvement with a mean decrease in thigh circumference of 2.45 cm as measured by MRI (Dermatol. Surg. 2008;34:204–9).

▸ SmoothShapes (Elemé Medical). This FDA-approved device combines a laser and an LED light source with mechanical rollers and a vacuum to "mold the adipocytes and to try and improve the metabolic parameters associated with cellulite," Dr. Sadick said.

One randomized trial of 74 patients treated twice a week for 4 weeks found that 81% had a significant volumetric reduction in subcutaneous fat (J. Lasers Surg. Med. 2004; suppl. 16:32). At 13 months post treatment, five patients underwent MRI and four of the five maintained their result.

In the future, he predicted, more "inside-outside" approaches to treating cellulite are likely to evolve, such as combining external technologies with internal laser lipolysis to "heat adipocytes and eat up septa. That probably will give the most effective results."

Dr. Sadick went on to note that while injectable treatment of cellulitis remains popular in the United States, "there is not a lot of good science behind it. We need to distinguish between true mesotherapy and injectable lipolysis. In true mesotherapy, we are attempting to eliminate some fat [and] have an effect on the metabolism of the adipocytes."

Agents being used for treating cellulite in mesotherapy include aminophylline, isoproterenol, ephedrine, calcium pyruvate, carnitine, and ma huang.

Another approach to cellulite treatment is detergent lipolysis, or mesotherapy, in which phosphatidylcholine and deoxycholate act as detergents, causing adipose cell walls to dissolve and break down.

"This is not FDA approved to date but there are FDA studies underway to determine the optimal solution," Dr. Sadick said.

Future treatment approaches may include topical approaches such as Retinol Anti-Cellulite, a cosmeceutical from RoC, as well as electrolipolysis, carboxytherapy, and cryolipolysis.

But for now, "the technology has moved far in advance of what we know about cellulite," he said.

Dr. Sadick disclosed that he has received research funding from Syneron Medical Ltd., DEKA Corp., and Cynosure Inc.

'By understanding more about the basic science of this condition, we hope to be able to introduce better therapies.' DR. SADICK

A patient is shown before (left) and after (right) undergoing four treatments with VelaShape for cellulite reduction. Photos courtesy Dr. Neil Sadick

LAS VEGAS — About 8 years ago, Dr. Neil Sadick and other dermatologic surgeons nearly gave up on lasers as a treatment option for leg veins because of the high rate of complications that they were seeing.

"We were using shortwave technologies delivered at low energies," Dr. Sadick recalled at the annual meeting of the International Society for Dermatologic Surgery. "We were impeding vessels and using upregulation of inflammatory cytokines, not causing endothelial destruction, so the results were not good. We were seeing lots of side effects, lots of superficial burns."

However, thanks to the advent of lasers with longer wavelengths and multimodal technologies since that time—the Lux1064+ (Palomar Medical Technologies Inc.), the CoolGlide Excel (Cutera Inc.), and the Cynergy III (Cynosure Inc.)—greater clinical efficacy has been achieved. "No laser is a substitute for sclerotherapy," said Dr. Sadick, of the department of dermatology at Cornell University, New York. "That remains the gold standard. But with the use of longer wavelengths we are able to achieve great results in this setting."

Theoretical problems intrinsic to laser therapy in treating leg veins include increased hydrostatic pressure, compared with that required for treating facial telangiectasias. "It is going to be more difficult to eradicate lower extremity vessels even if they're small unless you address the hydrostatic pressure," he said. "We don't have these same concerns in dealing with facial veins."

In addition, compared with facial telangiectasias, lower extremity vessels are located deeper in the dermis, are larger, and have increased basal lamina. "We have also shown that there are altered cytokine patterns when you induce light on the legs, compared with that of the face," Dr. Sadick said. "There is much greater regulation of inflammatory cytokines. That's why we usually don't go back and retreat lower extremity veins for at least 8 weeks."

Dr. Sadick favors a monomodal approach for the laser treatment of leg veins. For vessels smaller than 1 mm his published recommendations include a spot size of 1.5 mm, a fluence of 150–400 J/cm

"A number of studies have shown nice results using 1,064-nm and 1,320-nm technologies, but most people are using 1,064-nm technologies today," he said, noting that most of his patients who present for treatment of leg veins undergo a combination of sclerotherapy and external laser therapy.

In his clinical experience one to three laser treatment sessions are needed for optimal results. "Because you have so much upregulation of cytokines over a long period of time, we wait 8–12 weeks between treatment sessions," Dr. Sadick said. "I've found that if you go back too quickly you get more hypopigmentation, more potential for hypopigmentation, and you're inducing more inflammation which theoretically could induce more neovascularization."

Complications from using 1,064-nm lasers can occur with pulse stacking, especially with longer wavelengths. "The good news about 1,064-nm lasers is that they deliver high energy so you can get efficient eradication of the vessels," Dr. Sadick said. "The bad news is that they are painful. They penetrate deeply so sometimes you need to use analgesia. Also, there is an increased incidence of epidermal necrosis, so you need to be very gentle with these technologies."

Problems can also occur with improper matching of skin type and wavelength. "If someone is tanned or of a darker skinned phenotype, it's important to be conservative or do a spot test first," he advised. "Also, be sure you address hydrostatic pressures. If you use an external laser, a key way to not have successful results is to not treat a small refluxing vein or tiny varicosity before you use a laser to try to eradicate it. That will give you a high complication profile."

Dr. Sadick disclosed that he has received workshop funding and discounted equipment from Syneron Medical Ltd. and Laserscope and workshop funding from Cutera.

LAS VEGAS — About 8 years ago, Dr. Neil Sadick and other dermatologic surgeons nearly gave up on lasers as a treatment option for leg veins because of the high rate of complications that they were seeing.

"We were using shortwave technologies delivered at low energies," Dr. Sadick recalled at the annual meeting of the International Society for Dermatologic Surgery. "We were impeding vessels and using upregulation of inflammatory cytokines, not causing endothelial destruction, so the results were not good. We were seeing lots of side effects, lots of superficial burns."

However, thanks to the advent of lasers with longer wavelengths and multimodal technologies since that time—the Lux1064+ (Palomar Medical Technologies Inc.), the CoolGlide Excel (Cutera Inc.), and the Cynergy III (Cynosure Inc.)—greater clinical efficacy has been achieved. "No laser is a substitute for sclerotherapy," said Dr. Sadick, of the department of dermatology at Cornell University, New York. "That remains the gold standard. But with the use of longer wavelengths we are able to achieve great results in this setting."

Theoretical problems intrinsic to laser therapy in treating leg veins include increased hydrostatic pressure, compared with that required for treating facial telangiectasias. "It is going to be more difficult to eradicate lower extremity vessels even if they're small unless you address the hydrostatic pressure," he said. "We don't have these same concerns in dealing with facial veins."

In addition, compared with facial telangiectasias, lower extremity vessels are located deeper in the dermis, are larger, and have increased basal lamina. "We have also shown that there are altered cytokine patterns when you induce light on the legs, compared with that of the face," Dr. Sadick said. "There is much greater regulation of inflammatory cytokines. That's why we usually don't go back and retreat lower extremity veins for at least 8 weeks."

Dr. Sadick favors a monomodal approach for the laser treatment of leg veins. For vessels smaller than 1 mm his published recommendations include a spot size of 1.5 mm, a fluence of 150–400 J/cm

"A number of studies have shown nice results using 1,064-nm and 1,320-nm technologies, but most people are using 1,064-nm technologies today," he said, noting that most of his patients who present for treatment of leg veins undergo a combination of sclerotherapy and external laser therapy.

In his clinical experience one to three laser treatment sessions are needed for optimal results. "Because you have so much upregulation of cytokines over a long period of time, we wait 8–12 weeks between treatment sessions," Dr. Sadick said. "I've found that if you go back too quickly you get more hypopigmentation, more potential for hypopigmentation, and you're inducing more inflammation which theoretically could induce more neovascularization."

Complications from using 1,064-nm lasers can occur with pulse stacking, especially with longer wavelengths. "The good news about 1,064-nm lasers is that they deliver high energy so you can get efficient eradication of the vessels," Dr. Sadick said. "The bad news is that they are painful. They penetrate deeply so sometimes you need to use analgesia. Also, there is an increased incidence of epidermal necrosis, so you need to be very gentle with these technologies."

Problems can also occur with improper matching of skin type and wavelength. "If someone is tanned or of a darker skinned phenotype, it's important to be conservative or do a spot test first," he advised. "Also, be sure you address hydrostatic pressures. If you use an external laser, a key way to not have successful results is to not treat a small refluxing vein or tiny varicosity before you use a laser to try to eradicate it. That will give you a high complication profile."

Dr. Sadick disclosed that he has received workshop funding and discounted equipment from Syneron Medical Ltd. and Laserscope and workshop funding from Cutera.

LAS VEGAS — About 8 years ago, Dr. Neil Sadick and other dermatologic surgeons nearly gave up on lasers as a treatment option for leg veins because of the high rate of complications that they were seeing.

"We were using shortwave technologies delivered at low energies," Dr. Sadick recalled at the annual meeting of the International Society for Dermatologic Surgery. "We were impeding vessels and using upregulation of inflammatory cytokines, not causing endothelial destruction, so the results were not good. We were seeing lots of side effects, lots of superficial burns."

However, thanks to the advent of lasers with longer wavelengths and multimodal technologies since that time—the Lux1064+ (Palomar Medical Technologies Inc.), the CoolGlide Excel (Cutera Inc.), and the Cynergy III (Cynosure Inc.)—greater clinical efficacy has been achieved. "No laser is a substitute for sclerotherapy," said Dr. Sadick, of the department of dermatology at Cornell University, New York. "That remains the gold standard. But with the use of longer wavelengths we are able to achieve great results in this setting."

Theoretical problems intrinsic to laser therapy in treating leg veins include increased hydrostatic pressure, compared with that required for treating facial telangiectasias. "It is going to be more difficult to eradicate lower extremity vessels even if they're small unless you address the hydrostatic pressure," he said. "We don't have these same concerns in dealing with facial veins."

In addition, compared with facial telangiectasias, lower extremity vessels are located deeper in the dermis, are larger, and have increased basal lamina. "We have also shown that there are altered cytokine patterns when you induce light on the legs, compared with that of the face," Dr. Sadick said. "There is much greater regulation of inflammatory cytokines. That's why we usually don't go back and retreat lower extremity veins for at least 8 weeks."

Dr. Sadick favors a monomodal approach for the laser treatment of leg veins. For vessels smaller than 1 mm his published recommendations include a spot size of 1.5 mm, a fluence of 150–400 J/cm

"A number of studies have shown nice results using 1,064-nm and 1,320-nm technologies, but most people are using 1,064-nm technologies today," he said, noting that most of his patients who present for treatment of leg veins undergo a combination of sclerotherapy and external laser therapy.

In his clinical experience one to three laser treatment sessions are needed for optimal results. "Because you have so much upregulation of cytokines over a long period of time, we wait 8–12 weeks between treatment sessions," Dr. Sadick said. "I've found that if you go back too quickly you get more hypopigmentation, more potential for hypopigmentation, and you're inducing more inflammation which theoretically could induce more neovascularization."

Complications from using 1,064-nm lasers can occur with pulse stacking, especially with longer wavelengths. "The good news about 1,064-nm lasers is that they deliver high energy so you can get efficient eradication of the vessels," Dr. Sadick said. "The bad news is that they are painful. They penetrate deeply so sometimes you need to use analgesia. Also, there is an increased incidence of epidermal necrosis, so you need to be very gentle with these technologies."

Problems can also occur with improper matching of skin type and wavelength. "If someone is tanned or of a darker skinned phenotype, it's important to be conservative or do a spot test first," he advised. "Also, be sure you address hydrostatic pressures. If you use an external laser, a key way to not have successful results is to not treat a small refluxing vein or tiny varicosity before you use a laser to try to eradicate it. That will give you a high complication profile."

Dr. Sadick disclosed that he has received workshop funding and discounted equipment from Syneron Medical Ltd. and Laserscope and workshop funding from Cutera.

Dr. Chris Frost and Dr. Marc Frost acquired their love for off-road motorcycle riding as youngsters growing up in St. Donatus, Iowa, a small town with rolling hills near Dubuque.

Their father was a motor sports enthusiast who thought off-road riding would be a good hobby for his boys, so he bought them motorcycles to tool around with. But he was a stickler for riding safety.

“When we were in grade school our dad told us that if he ever caught us riding a motorcycle either in a crazy way or not wearing a helmet, the motorcycle would be sold and gone,” recalled Chris, a dermatologist who practices in Somerset, Ky. “We believed him, and we never rode without one.”

Chris and Marc put riding on hold during college and medical school but, since 2002, they have been taking occasional weekend outings on off-road designated trails in the 770,000-acre Daniel Boone National Forest in Kentucky, which consists of mostly rugged terrain with steep ridges and sandstone cliffs. They prefer narrow, technically challenging trails littered with water pools, rocks, steep hills, tree roots, and mud holes.

Once every 3 months, Marc and his two teenage children drive 4 hours from their home in Indianapolis to Chris's home in Somerset.

The next day, the crew drives to the forest for a 20- to 30-mile ride on mountainous trails that can last up to 6 hours—but not before a careful inspection of each bike to make sure the bike chain is tight, the fluid levels are capped off, and the tires are properly inflated. “If something goes wrong, you're a long way from being able to easily remedy it,” said Marc, the more mechanically inclined of the two brothers, who has a private dermatology practice in Indianapolis.

“We don't go unless we're sure that the bikes are capable. If a bike's not rideable that day, we stay home,” he said.

The rides “are no piece of cake,” he added, describing each day's ride as the physical equivalent of running a half-marathon. “In fact, I train for our quarterly rides by running in trail marathons and ultra marathons. So 3–4 days of riding leaves us oldsters—I'm 49—a little on the stiff and sore side.”

Riding motorcycles off road “gives me a reason to try and stay in shape,” he said. “For years, I was the sort who was not physically active, and did not really eat well. Now I exercise on a regular basis. I carefully watch what I eat and my weight. My general condition is far better than it was when I was 40.”

There have been mishaps on the trips, like the time a 1996 motorcycle Chris was riding “got away from him” and careened off a cliff. Since he's an experienced rider he knew not to stay on the bike, “but my brother said they watched as the motorcycle went flying off the side of the cliff and I wasn't on it,” Chris said. “They were wondering where I was. When it went off the cliff, it got stuck on a tree and we were able to haul it back.”

Like their dad, the Frost brothers preach safe riding at all times. That means wearing full gear, including a helmet, goggles, gloves, chest protectors, elbow protectors, knee protectors, and good boots. Other essentials they pack include wireless headsets, tools, maps, a compass, water, and snacks.

The Frosts commonly encounter other riders who aren't wearing helmets or who are drinking from open containers of alcohol. “I preach to my kids to ride responsibly; ride within your limits,” Marc said.

They had just finished up a day of riding, before they were interviewed. “Today, there were six of us riding together, but each of us had a partner we'd stick with.” This is important because if something were to happen, you're not out there by yourself. “We never ride alone,” said Marc.

Chris, who is 54 years old, added that he and Marc are smart riders because they are dermatologists who don't like to take chances in their clinical practice. “We're very methodical about what we do in our practice,” he said. “We're also very methodical about riding, and we don't take chances.”

Both brothers remarked about the positive impact of the quarterly motorcycle rides on family life. For Marc, one of the best parts “is getting to spend 4 hours with both of my kids driving down here and 4 hours driving back,” he said, adding, “You'd be amazed at how much family stuff we get to talk about. Anytime teenagers can't wait to do something with their dad or uncle, that's a pretty good gig.”

He also looks forward to talking about dermatology cases with Chris. “As a solo practitioner, I don't normally have that as an outlet,” he said.

Chris described the camaraderie that evolves from the rides as “one of the most valuable things in the world: to get to know your relatives better and to enjoy the limited time you have with them. We're all getting older and need to spend more time with each other.”

Marc, shown on a recent ride, prefers mud-filled, narrow, challenging trails.

Dr. Chris Frost and Dr. Marc Frost always wear full safety gear when riding, noting an occasion when Chris careened off a cliff. Photos courtesy Dr. Andrew Frost

Dr. Chris Frost and Dr. Marc Frost acquired their love for off-road motorcycle riding as youngsters growing up in St. Donatus, Iowa, a small town with rolling hills near Dubuque.

Their father was a motor sports enthusiast who thought off-road riding would be a good hobby for his boys, so he bought them motorcycles to tool around with. But he was a stickler for riding safety.

“When we were in grade school our dad told us that if he ever caught us riding a motorcycle either in a crazy way or not wearing a helmet, the motorcycle would be sold and gone,” recalled Chris, a dermatologist who practices in Somerset, Ky. “We believed him, and we never rode without one.”

Chris and Marc put riding on hold during college and medical school but, since 2002, they have been taking occasional weekend outings on off-road designated trails in the 770,000-acre Daniel Boone National Forest in Kentucky, which consists of mostly rugged terrain with steep ridges and sandstone cliffs. They prefer narrow, technically challenging trails littered with water pools, rocks, steep hills, tree roots, and mud holes.

Once every 3 months, Marc and his two teenage children drive 4 hours from their home in Indianapolis to Chris's home in Somerset.

The next day, the crew drives to the forest for a 20- to 30-mile ride on mountainous trails that can last up to 6 hours—but not before a careful inspection of each bike to make sure the bike chain is tight, the fluid levels are capped off, and the tires are properly inflated. “If something goes wrong, you're a long way from being able to easily remedy it,” said Marc, the more mechanically inclined of the two brothers, who has a private dermatology practice in Indianapolis.

“We don't go unless we're sure that the bikes are capable. If a bike's not rideable that day, we stay home,” he said.

The rides “are no piece of cake,” he added, describing each day's ride as the physical equivalent of running a half-marathon. “In fact, I train for our quarterly rides by running in trail marathons and ultra marathons. So 3–4 days of riding leaves us oldsters—I'm 49—a little on the stiff and sore side.”

Riding motorcycles off road “gives me a reason to try and stay in shape,” he said. “For years, I was the sort who was not physically active, and did not really eat well. Now I exercise on a regular basis. I carefully watch what I eat and my weight. My general condition is far better than it was when I was 40.”

There have been mishaps on the trips, like the time a 1996 motorcycle Chris was riding “got away from him” and careened off a cliff. Since he's an experienced rider he knew not to stay on the bike, “but my brother said they watched as the motorcycle went flying off the side of the cliff and I wasn't on it,” Chris said. “They were wondering where I was. When it went off the cliff, it got stuck on a tree and we were able to haul it back.”

Like their dad, the Frost brothers preach safe riding at all times. That means wearing full gear, including a helmet, goggles, gloves, chest protectors, elbow protectors, knee protectors, and good boots. Other essentials they pack include wireless headsets, tools, maps, a compass, water, and snacks.

The Frosts commonly encounter other riders who aren't wearing helmets or who are drinking from open containers of alcohol. “I preach to my kids to ride responsibly; ride within your limits,” Marc said.

They had just finished up a day of riding, before they were interviewed. “Today, there were six of us riding together, but each of us had a partner we'd stick with.” This is important because if something were to happen, you're not out there by yourself. “We never ride alone,” said Marc.

Chris, who is 54 years old, added that he and Marc are smart riders because they are dermatologists who don't like to take chances in their clinical practice. “We're very methodical about what we do in our practice,” he said. “We're also very methodical about riding, and we don't take chances.”

Both brothers remarked about the positive impact of the quarterly motorcycle rides on family life. For Marc, one of the best parts “is getting to spend 4 hours with both of my kids driving down here and 4 hours driving back,” he said, adding, “You'd be amazed at how much family stuff we get to talk about. Anytime teenagers can't wait to do something with their dad or uncle, that's a pretty good gig.”

He also looks forward to talking about dermatology cases with Chris. “As a solo practitioner, I don't normally have that as an outlet,” he said.

Chris described the camaraderie that evolves from the rides as “one of the most valuable things in the world: to get to know your relatives better and to enjoy the limited time you have with them. We're all getting older and need to spend more time with each other.”

Marc, shown on a recent ride, prefers mud-filled, narrow, challenging trails.

Dr. Chris Frost and Dr. Marc Frost always wear full safety gear when riding, noting an occasion when Chris careened off a cliff. Photos courtesy Dr. Andrew Frost

Dr. Chris Frost and Dr. Marc Frost acquired their love for off-road motorcycle riding as youngsters growing up in St. Donatus, Iowa, a small town with rolling hills near Dubuque.

Their father was a motor sports enthusiast who thought off-road riding would be a good hobby for his boys, so he bought them motorcycles to tool around with. But he was a stickler for riding safety.

“When we were in grade school our dad told us that if he ever caught us riding a motorcycle either in a crazy way or not wearing a helmet, the motorcycle would be sold and gone,” recalled Chris, a dermatologist who practices in Somerset, Ky. “We believed him, and we never rode without one.”

Chris and Marc put riding on hold during college and medical school but, since 2002, they have been taking occasional weekend outings on off-road designated trails in the 770,000-acre Daniel Boone National Forest in Kentucky, which consists of mostly rugged terrain with steep ridges and sandstone cliffs. They prefer narrow, technically challenging trails littered with water pools, rocks, steep hills, tree roots, and mud holes.

Once every 3 months, Marc and his two teenage children drive 4 hours from their home in Indianapolis to Chris's home in Somerset.

The next day, the crew drives to the forest for a 20- to 30-mile ride on mountainous trails that can last up to 6 hours—but not before a careful inspection of each bike to make sure the bike chain is tight, the fluid levels are capped off, and the tires are properly inflated. “If something goes wrong, you're a long way from being able to easily remedy it,” said Marc, the more mechanically inclined of the two brothers, who has a private dermatology practice in Indianapolis.

“We don't go unless we're sure that the bikes are capable. If a bike's not rideable that day, we stay home,” he said.

The rides “are no piece of cake,” he added, describing each day's ride as the physical equivalent of running a half-marathon. “In fact, I train for our quarterly rides by running in trail marathons and ultra marathons. So 3–4 days of riding leaves us oldsters—I'm 49—a little on the stiff and sore side.”

Riding motorcycles off road “gives me a reason to try and stay in shape,” he said. “For years, I was the sort who was not physically active, and did not really eat well. Now I exercise on a regular basis. I carefully watch what I eat and my weight. My general condition is far better than it was when I was 40.”

There have been mishaps on the trips, like the time a 1996 motorcycle Chris was riding “got away from him” and careened off a cliff. Since he's an experienced rider he knew not to stay on the bike, “but my brother said they watched as the motorcycle went flying off the side of the cliff and I wasn't on it,” Chris said. “They were wondering where I was. When it went off the cliff, it got stuck on a tree and we were able to haul it back.”

Like their dad, the Frost brothers preach safe riding at all times. That means wearing full gear, including a helmet, goggles, gloves, chest protectors, elbow protectors, knee protectors, and good boots. Other essentials they pack include wireless headsets, tools, maps, a compass, water, and snacks.

The Frosts commonly encounter other riders who aren't wearing helmets or who are drinking from open containers of alcohol. “I preach to my kids to ride responsibly; ride within your limits,” Marc said.

They had just finished up a day of riding, before they were interviewed. “Today, there were six of us riding together, but each of us had a partner we'd stick with.” This is important because if something were to happen, you're not out there by yourself. “We never ride alone,” said Marc.

Chris, who is 54 years old, added that he and Marc are smart riders because they are dermatologists who don't like to take chances in their clinical practice. “We're very methodical about what we do in our practice,” he said. “We're also very methodical about riding, and we don't take chances.”

Both brothers remarked about the positive impact of the quarterly motorcycle rides on family life. For Marc, one of the best parts “is getting to spend 4 hours with both of my kids driving down here and 4 hours driving back,” he said, adding, “You'd be amazed at how much family stuff we get to talk about. Anytime teenagers can't wait to do something with their dad or uncle, that's a pretty good gig.”

He also looks forward to talking about dermatology cases with Chris. “As a solo practitioner, I don't normally have that as an outlet,” he said.

Chris described the camaraderie that evolves from the rides as “one of the most valuable things in the world: to get to know your relatives better and to enjoy the limited time you have with them. We're all getting older and need to spend more time with each other.”

Marc, shown on a recent ride, prefers mud-filled, narrow, challenging trails.

Dr. Chris Frost and Dr. Marc Frost always wear full safety gear when riding, noting an occasion when Chris careened off a cliff. Photos courtesy Dr. Andrew Frost

SAN DIEGO — As a family physician trained in sports medicine, Dr. Anthony Beutler encounters many primary care providers who struggle with diagnosis and treatment of musculoskeletal conditions.

“Many times we make the right diagnosis but the patient doesn't get better because we're not addressing the underlying problem,” said Dr. Beutler, chief of the Injury Prevention Research Laboratory at the Uniformed Services University of the Health Sciences, Bethesda, Md.

At the annual meeting of the American Academy of Family Physicians, Dr. Beutler discussed how to diagnose and treat four musculoskeletal conditions.

▸ Plantar fasciitis. This condition is the most common cause of heel pain; it affects about 2 million Americans a year, including 10% of all runners. It is marked by microtears of the plantar fascial aponeurosis, which lead to collagen degeneration and pain, said Dr. Beutler, also of family medicine at the university.

A key diagnostic clue is maximal tenderness at the medial tubercle of the calcaneus. Other clues include heel pain that is worst with the first step in the morning or a dull ache in the heel with activity.

Common causes include muscle weakness, training error, overpronation, improper footwear, and tight heel cords. Dr. Beutler noted that 70% of people with plantar fasciitis have gastrocnemius or soleus inflexibility and cannot passively dorsiflex past 0 degrees.

Heel spurs in this patient population may or may not indicate that plantar fasciitis is causing heel pain. The spurs are not the pain source.

First-line treatments include heel cord and plantar fascia stretching; foot strengthening exercises; orthotics for those with pes planus or overpronation; and ice, compression, and elevation for pain relief.

Second-line treatments include steroid injections for short-term pain relief, night splints, and, for pain that lasts more than 6 months, custom orthotics and surgery. Patients should be referred for surgery only after 6–12 months of treatment failure.

Dr. Beutler emphasized that there are no studies to support or refute the benefit of NSAIDs for pain relief. Ultrasound, laser therapy, and magnetic insoles have been found to be of no benefit.

He advised that patients continue activities at 50% of preinjury level and, when pain begins to improve, that they increase activity no more than 10% per week.

▸ Ankle sprain. This ranks as a chief reason for a visit to the emergency room. The lateral ankle is most commonly affected, usually because of injury to the anterior talofibular ligament. The calcaneofibular ligament and posterior talofibular ligament are less commonly injured.

Recommended treatments include rest, ice, compression, elevation, NSAIDs, and a semirigid brace to improve weight-bearing and reduce the risk of reinjury. “Braces are proven. They will decrease your rate of injury for up to 8 months after you injure your ankle.”

Another key component involves rehabilitation exercises, such as sitting in a chair and “writing” each letter of the alphabet with your toes to improve range of motion, or doing the single-leg balance to help the ankle regain its sense of position or proprioception. Do several repetitions on each foot at least twice daily. Patients should return in 4–6 weeks if they are not better.

▸ Patellofemoral pain. This condition is the most common cause of knee pain in patients aged less than 40 years. It is marked by biomechanical imbalance that causes pain in peripatellar structures. Possible pain generators include the anterior synovium, infrapatellar fat pad, subchondral bone, or retinacula.

The pain is often bilateral and is exacerbated by going up and down stairs. Effusion and erythema are rare.

Common culprits include muscle tightness, weakness of quadriceps and gluteus medius, and bony malalignment.

Consider referral to a physical therapist who focuses on stretching or strengthening exercises, such as single-leg squats and single-leg step downs. If the patient comes back to you having been treated “with ice, heat, fancy gels, and no real stretching or strengthening program, don't waste your time on that therapist any more.”

NSAIDs “are not great for femoral pain” but may provide short-term relief, he said. Orthotics or patellar taping and bracing “work very well for a very few patients.”

▸ Trochanteric bursitis. This condition is the second only to osteoarthritis as a chief cause of hip pain. Tightness in the iliotibial band and weakness in the gluteus medius cause compression of the bursa between the tensor fascia latae and the greater trochanter. Patients who present with trochanteric bursitis describe it as lateral hip pain radiating toward the knee and report that it's painful to get up out of a chair. The feeling ranges from nagging pain to pain so severe they're unable to walk. Most evidence supports a steroid and lidocaine injection into the trochanteric bursa as a first-line treatment. No studies to date compare NSAIDs with steroid injection and other forms of treatment. Single-leg step downs, lateral leg lifts, and hula girl exercises improve strength.

Many times the right diagnosis is made, but the patient doesn't get better because of unaddressed underlying issues. DR. BEUTLER

Musculoskeletal Coding Dos and Don'ts

Dr. Beutler shared the following tips for getting paid:

▸ Do capture the time you spend. Brace fitting and care coordination can be included in the patient education or complexity sections of your E&M code. Crutch training can be coded as CPT 97116 or included in your E&M code. Fifteen minutes of exercise teaching can be coded as CPT 97110; smaller amounts of time can be included in your E&M code.

▸ Don't forget to code injections. Use CPT 20610 for most injections. Finger joints are 20600.

▸ Do use a 29 modifier. “If you diagnose subacromial shoulder pain and do a subacromial joint injection at the same visit, use a 29 modifier with your CPT code of 20610,” he said. “This tells the insurance company that you both diagnosed the subacromial pain and did the injection at the same visit.”

▸ Don't forget to bill for durable medical goods. If you provide the braces or the crutches, make sure that shows up on your billing.

▸ Do phone a friend. Phone your orthopedic office or referral center and ask them who does their orthopedic billing and coding. Find that person and take them out to lunch to talk coding, Dr. Beutler advised. “It will be well worth your time.”

SAN DIEGO — As a family physician trained in sports medicine, Dr. Anthony Beutler encounters many primary care providers who struggle with diagnosis and treatment of musculoskeletal conditions.

“Many times we make the right diagnosis but the patient doesn't get better because we're not addressing the underlying problem,” said Dr. Beutler, chief of the Injury Prevention Research Laboratory at the Uniformed Services University of the Health Sciences, Bethesda, Md.

At the annual meeting of the American Academy of Family Physicians, Dr. Beutler discussed how to diagnose and treat four musculoskeletal conditions.

▸ Plantar fasciitis. This condition is the most common cause of heel pain; it affects about 2 million Americans a year, including 10% of all runners. It is marked by microtears of the plantar fascial aponeurosis, which lead to collagen degeneration and pain, said Dr. Beutler, also of family medicine at the university.

A key diagnostic clue is maximal tenderness at the medial tubercle of the calcaneus. Other clues include heel pain that is worst with the first step in the morning or a dull ache in the heel with activity.

Common causes include muscle weakness, training error, overpronation, improper footwear, and tight heel cords. Dr. Beutler noted that 70% of people with plantar fasciitis have gastrocnemius or soleus inflexibility and cannot passively dorsiflex past 0 degrees.

Heel spurs in this patient population may or may not indicate that plantar fasciitis is causing heel pain. The spurs are not the pain source.

First-line treatments include heel cord and plantar fascia stretching; foot strengthening exercises; orthotics for those with pes planus or overpronation; and ice, compression, and elevation for pain relief.

Second-line treatments include steroid injections for short-term pain relief, night splints, and, for pain that lasts more than 6 months, custom orthotics and surgery. Patients should be referred for surgery only after 6–12 months of treatment failure.

Dr. Beutler emphasized that there are no studies to support or refute the benefit of NSAIDs for pain relief. Ultrasound, laser therapy, and magnetic insoles have been found to be of no benefit.

He advised that patients continue activities at 50% of preinjury level and, when pain begins to improve, that they increase activity no more than 10% per week.

▸ Ankle sprain. This ranks as a chief reason for a visit to the emergency room. The lateral ankle is most commonly affected, usually because of injury to the anterior talofibular ligament. The calcaneofibular ligament and posterior talofibular ligament are less commonly injured.

Recommended treatments include rest, ice, compression, elevation, NSAIDs, and a semirigid brace to improve weight-bearing and reduce the risk of reinjury. “Braces are proven. They will decrease your rate of injury for up to 8 months after you injure your ankle.”

Another key component involves rehabilitation exercises, such as sitting in a chair and “writing” each letter of the alphabet with your toes to improve range of motion, or doing the single-leg balance to help the ankle regain its sense of position or proprioception. Do several repetitions on each foot at least twice daily. Patients should return in 4–6 weeks if they are not better.

▸ Patellofemoral pain. This condition is the most common cause of knee pain in patients aged less than 40 years. It is marked by biomechanical imbalance that causes pain in peripatellar structures. Possible pain generators include the anterior synovium, infrapatellar fat pad, subchondral bone, or retinacula.

The pain is often bilateral and is exacerbated by going up and down stairs. Effusion and erythema are rare.

Common culprits include muscle tightness, weakness of quadriceps and gluteus medius, and bony malalignment.

Consider referral to a physical therapist who focuses on stretching or strengthening exercises, such as single-leg squats and single-leg step downs. If the patient comes back to you having been treated “with ice, heat, fancy gels, and no real stretching or strengthening program, don't waste your time on that therapist any more.”

NSAIDs “are not great for femoral pain” but may provide short-term relief, he said. Orthotics or patellar taping and bracing “work very well for a very few patients.”

▸ Trochanteric bursitis. This condition is the second only to osteoarthritis as a chief cause of hip pain. Tightness in the iliotibial band and weakness in the gluteus medius cause compression of the bursa between the tensor fascia latae and the greater trochanter. Patients who present with trochanteric bursitis describe it as lateral hip pain radiating toward the knee and report that it's painful to get up out of a chair. The feeling ranges from nagging pain to pain so severe they're unable to walk. Most evidence supports a steroid and lidocaine injection into the trochanteric bursa as a first-line treatment. No studies to date compare NSAIDs with steroid injection and other forms of treatment. Single-leg step downs, lateral leg lifts, and hula girl exercises improve strength.

Many times the right diagnosis is made, but the patient doesn't get better because of unaddressed underlying issues. DR. BEUTLER

Musculoskeletal Coding Dos and Don'ts

Dr. Beutler shared the following tips for getting paid:

▸ Do capture the time you spend. Brace fitting and care coordination can be included in the patient education or complexity sections of your E&M code. Crutch training can be coded as CPT 97116 or included in your E&M code. Fifteen minutes of exercise teaching can be coded as CPT 97110; smaller amounts of time can be included in your E&M code.

▸ Don't forget to code injections. Use CPT 20610 for most injections. Finger joints are 20600.

▸ Do use a 29 modifier. “If you diagnose subacromial shoulder pain and do a subacromial joint injection at the same visit, use a 29 modifier with your CPT code of 20610,” he said. “This tells the insurance company that you both diagnosed the subacromial pain and did the injection at the same visit.”

▸ Don't forget to bill for durable medical goods. If you provide the braces or the crutches, make sure that shows up on your billing.

▸ Do phone a friend. Phone your orthopedic office or referral center and ask them who does their orthopedic billing and coding. Find that person and take them out to lunch to talk coding, Dr. Beutler advised. “It will be well worth your time.”

SAN DIEGO — As a family physician trained in sports medicine, Dr. Anthony Beutler encounters many primary care providers who struggle with diagnosis and treatment of musculoskeletal conditions.

“Many times we make the right diagnosis but the patient doesn't get better because we're not addressing the underlying problem,” said Dr. Beutler, chief of the Injury Prevention Research Laboratory at the Uniformed Services University of the Health Sciences, Bethesda, Md.

At the annual meeting of the American Academy of Family Physicians, Dr. Beutler discussed how to diagnose and treat four musculoskeletal conditions.

▸ Plantar fasciitis. This condition is the most common cause of heel pain; it affects about 2 million Americans a year, including 10% of all runners. It is marked by microtears of the plantar fascial aponeurosis, which lead to collagen degeneration and pain, said Dr. Beutler, also of family medicine at the university.

A key diagnostic clue is maximal tenderness at the medial tubercle of the calcaneus. Other clues include heel pain that is worst with the first step in the morning or a dull ache in the heel with activity.

Common causes include muscle weakness, training error, overpronation, improper footwear, and tight heel cords. Dr. Beutler noted that 70% of people with plantar fasciitis have gastrocnemius or soleus inflexibility and cannot passively dorsiflex past 0 degrees.

Heel spurs in this patient population may or may not indicate that plantar fasciitis is causing heel pain. The spurs are not the pain source.

First-line treatments include heel cord and plantar fascia stretching; foot strengthening exercises; orthotics for those with pes planus or overpronation; and ice, compression, and elevation for pain relief.

Second-line treatments include steroid injections for short-term pain relief, night splints, and, for pain that lasts more than 6 months, custom orthotics and surgery. Patients should be referred for surgery only after 6–12 months of treatment failure.

Dr. Beutler emphasized that there are no studies to support or refute the benefit of NSAIDs for pain relief. Ultrasound, laser therapy, and magnetic insoles have been found to be of no benefit.

He advised that patients continue activities at 50% of preinjury level and, when pain begins to improve, that they increase activity no more than 10% per week.

▸ Ankle sprain. This ranks as a chief reason for a visit to the emergency room. The lateral ankle is most commonly affected, usually because of injury to the anterior talofibular ligament. The calcaneofibular ligament and posterior talofibular ligament are less commonly injured.

Recommended treatments include rest, ice, compression, elevation, NSAIDs, and a semirigid brace to improve weight-bearing and reduce the risk of reinjury. “Braces are proven. They will decrease your rate of injury for up to 8 months after you injure your ankle.”

Another key component involves rehabilitation exercises, such as sitting in a chair and “writing” each letter of the alphabet with your toes to improve range of motion, or doing the single-leg balance to help the ankle regain its sense of position or proprioception. Do several repetitions on each foot at least twice daily. Patients should return in 4–6 weeks if they are not better.

▸ Patellofemoral pain. This condition is the most common cause of knee pain in patients aged less than 40 years. It is marked by biomechanical imbalance that causes pain in peripatellar structures. Possible pain generators include the anterior synovium, infrapatellar fat pad, subchondral bone, or retinacula.

The pain is often bilateral and is exacerbated by going up and down stairs. Effusion and erythema are rare.

Common culprits include muscle tightness, weakness of quadriceps and gluteus medius, and bony malalignment.

Consider referral to a physical therapist who focuses on stretching or strengthening exercises, such as single-leg squats and single-leg step downs. If the patient comes back to you having been treated “with ice, heat, fancy gels, and no real stretching or strengthening program, don't waste your time on that therapist any more.”

NSAIDs “are not great for femoral pain” but may provide short-term relief, he said. Orthotics or patellar taping and bracing “work very well for a very few patients.”

▸ Trochanteric bursitis. This condition is the second only to osteoarthritis as a chief cause of hip pain. Tightness in the iliotibial band and weakness in the gluteus medius cause compression of the bursa between the tensor fascia latae and the greater trochanter. Patients who present with trochanteric bursitis describe it as lateral hip pain radiating toward the knee and report that it's painful to get up out of a chair. The feeling ranges from nagging pain to pain so severe they're unable to walk. Most evidence supports a steroid and lidocaine injection into the trochanteric bursa as a first-line treatment. No studies to date compare NSAIDs with steroid injection and other forms of treatment. Single-leg step downs, lateral leg lifts, and hula girl exercises improve strength.

Many times the right diagnosis is made, but the patient doesn't get better because of unaddressed underlying issues. DR. BEUTLER

Musculoskeletal Coding Dos and Don'ts

Dr. Beutler shared the following tips for getting paid:

▸ Do capture the time you spend. Brace fitting and care coordination can be included in the patient education or complexity sections of your E&M code. Crutch training can be coded as CPT 97116 or included in your E&M code. Fifteen minutes of exercise teaching can be coded as CPT 97110; smaller amounts of time can be included in your E&M code.

▸ Don't forget to code injections. Use CPT 20610 for most injections. Finger joints are 20600.

▸ Do use a 29 modifier. “If you diagnose subacromial shoulder pain and do a subacromial joint injection at the same visit, use a 29 modifier with your CPT code of 20610,” he said. “This tells the insurance company that you both diagnosed the subacromial pain and did the injection at the same visit.”

▸ Don't forget to bill for durable medical goods. If you provide the braces or the crutches, make sure that shows up on your billing.

▸ Do phone a friend. Phone your orthopedic office or referral center and ask them who does their orthopedic billing and coding. Find that person and take them out to lunch to talk coding, Dr. Beutler advised. “It will be well worth your time.”

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

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

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

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

He has served, too, as a theater usher, worked the lighting and other technical jobs, and helped build and disassemble sets. “I also tidied up the theater so much that one of our late community theater actors and volunteer set builders called me the garbage man,” he said. “I did more than empty our garbage. I would sift through it because angle brackets and other things were mistakenly thrown in there that could be reused in future productions. The community theater has a strict budget. None of the theater members are paid. Only guest musicians and guest directors, who may drive long distances, are paid.”

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

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

Dr. Grossman said his brush with cancer also motivated him to take up another avocation. Prior to starting his undergraduate studies at Johns Hopkins University, Baltimore, he had appeared as a ballroom dancer for 1 week on “The Buddy Dean Show,” a Baltimore-based teen dance television program that featured appearances by the Cordettes, Johnny Mathis, and Frankie Avalon, but Western square dancing had always intrigued him. So he and his wife, Mickey, enrolled in classes at a local university to develop their ballroom dancing and learn Western square dancing. They continue to build on their skills by attending local Western square dancing events.

Looking back, Dr. Grossman credits his brush with cancer for motivating him to pursue the avocations he'd long wished to take a crack at. “It's fair to say that my cancer gave me a fairly swift kick in my bottom and got me out into my community,” he said.

Dr. Joshua Grossman, with his wife Mickey (far left) and Proud Annie Mystery Theater cast members, began acting after undergoing treatment for thyroid cancer. Courtesy Dr. Joshua Grossman

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

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

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

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

He has served, too, as a theater usher, worked the lighting and other technical jobs, and helped build and disassemble sets. “I also tidied up the theater so much that one of our late community theater actors and volunteer set builders called me the garbage man,” he said. “I did more than empty our garbage. I would sift through it because angle brackets and other things were mistakenly thrown in there that could be reused in future productions. The community theater has a strict budget. None of the theater members are paid. Only guest musicians and guest directors, who may drive long distances, are paid.”

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

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

Dr. Grossman said his brush with cancer also motivated him to take up another avocation. Prior to starting his undergraduate studies at Johns Hopkins University, Baltimore, he had appeared as a ballroom dancer for 1 week on “The Buddy Dean Show,” a Baltimore-based teen dance television program that featured appearances by the Cordettes, Johnny Mathis, and Frankie Avalon, but Western square dancing had always intrigued him. So he and his wife, Mickey, enrolled in classes at a local university to develop their ballroom dancing and learn Western square dancing. They continue to build on their skills by attending local Western square dancing events.

Looking back, Dr. Grossman credits his brush with cancer for motivating him to pursue the avocations he'd long wished to take a crack at. “It's fair to say that my cancer gave me a fairly swift kick in my bottom and got me out into my community,” he said.

Dr. Joshua Grossman, with his wife Mickey (far left) and Proud Annie Mystery Theater cast members, began acting after undergoing treatment for thyroid cancer. Courtesy Dr. Joshua Grossman

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

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

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

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

He has served, too, as a theater usher, worked the lighting and other technical jobs, and helped build and disassemble sets. “I also tidied up the theater so much that one of our late community theater actors and volunteer set builders called me the garbage man,” he said. “I did more than empty our garbage. I would sift through it because angle brackets and other things were mistakenly thrown in there that could be reused in future productions. The community theater has a strict budget. None of the theater members are paid. Only guest musicians and guest directors, who may drive long distances, are paid.”

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

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

Dr. Grossman said his brush with cancer also motivated him to take up another avocation. Prior to starting his undergraduate studies at Johns Hopkins University, Baltimore, he had appeared as a ballroom dancer for 1 week on “The Buddy Dean Show,” a Baltimore-based teen dance television program that featured appearances by the Cordettes, Johnny Mathis, and Frankie Avalon, but Western square dancing had always intrigued him. So he and his wife, Mickey, enrolled in classes at a local university to develop their ballroom dancing and learn Western square dancing. They continue to build on their skills by attending local Western square dancing events.

Looking back, Dr. Grossman credits his brush with cancer for motivating him to pursue the avocations he'd long wished to take a crack at. “It's fair to say that my cancer gave me a fairly swift kick in my bottom and got me out into my community,” he said.

Dr. Joshua Grossman, with his wife Mickey (far left) and Proud Annie Mystery Theater cast members, began acting after undergoing treatment for thyroid cancer. Courtesy Dr. Joshua Grossman

CALGARY, ALTA. — The way Dr. Beth L. Abramson sees it, menopause provides the ideal opportunity to review with patients their risk for heart disease and stroke, and to reinforce heart-healthy behaviors.

“Although it's a bit of a paradigm shift, we need to start talking about heart-healthy behavior in gynecologists' offices,” said Dr. Abramson at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada. “There is no doubt that risk of heart disease increases with menopause.”

In Canada, one in three women dies from heart disease and stroke, which makes these two conditions the leading causes of death among women, greater than all forms of cancer combined.

“For the first time in 30 years, women have caught up to men when it comes to the number of deaths from cardiovascular disease,” said Dr. Abramson, a cardiologist who directs the cardiac prevention and rehabilitation center at St. Michael's Hospital and is a spokesperson for the Heart and Stroke Foundation of Ontario, both in Toronto.

Moreover, the risk of dying within the first 30 days of a myocardial infarction is 16% higher for women compared with men. The same goes for stroke, which confers an 11% higher risk of death within 30 days for women compared with men. “Women are less likely to be treated by a specialist, are less likely to be transferred to another facility for treatment, and are less likely to undergo cardiac catheterization or revascularization,” she noted.

Despite the well-known risks, awareness of heart disease risk among women is generally poor. According to Dr. Abramson, only one in eight Canadian women understands that heart disease and stroke are her most serious health concerns, whereas only one woman in three knows that the conditions are the leading causes of death.

In an effort to close the current knowledge gap, Dr. Abramson and her associates at St. Michael's are teaching primary care physicians to administer a Framingham risk calculation as a way to assess a woman's risk of developing coronary artery disease. A software program calculates the woman's 10-year risk of a heart attack based on factors including age, blood pressure, smoking status, lipids, fasting blood glucose, and family history. The score “may underestimate some risk, but it's what we are using,” she said. (The assessment is similar to the National Heart, Lung, and Blood Institute's tool for estimating the 10-year risk of having a heart attack, which can be found at http://hp2010.nhlbihin.net/atpiii/calculator.asp

Dr. Abramson also recommends a discussion of risk reduction strategies—including smoking cessation, healthful eating choices, exercise, and weight-loss tips when needed—during each office visit. “It's very hard to make lifestyle changes,” she acknowledged. “I encourage people to make small changes over time. Most heart attacks aren't sudden; they take many years of preparation.”

Most smokers want to quit, she said, yet only about one-third of smokers report receiving smoking-cessation advice from their physician. She often uses this script, which can be delivered in about 20 seconds: “Do you smoke? I know you understand it's bad for you. It's the worst thing for your health. I can help you quit smoking if you want to.”

Finding a way to personalize the effects of smoking cessation is also key. “Tell the women their skin will look better and younger if they quit,” she said. “That's an important motivator.” So is the phrase, “Your children want you to quit so you can be around for your grandchildren.”

Dr. Abramson pointed out that visceral obesity is associated with conditions that lead to heart disease, including increased LDL cholesterol, decreased HDL cholesterol, high triglycerides, diabetes, insulin resistance, increased insulin levels, abnormal blood clotting, glucose intolerance, and poor blood-vessel function. “In menopause, the fat distribution of women changes,” she said. “They are more likely to take on an apple-shaped figure than a pear-shaped one.”

The Heart and Stroke Foundation of Canada has launched “The Heart Truth” campaign aimed at educating women about their risk for coronary heart disease. The campaign includes a dedicated Web site (www.thehearttruth.ca

The campaign advises women to take action and talk with health care professionals about treatment options for risk factors such as high cholesterol, high blood pressure, and smoking.

“You have a role to play,” Dr. Abramson said. “You have an opportunity to take care of women around the time of menopause and try to reduce their risk factors.”

Dr. Abramson disclosed that she receives ongoing research funds from Astra Zeneca Pharmaceuticals LP, Boehringer-Ingelheim Pharmaceuticals Inc., and Merck & Co., and that she has been a speaker for several other pharmaceutical companies.

The presentation was part of a session sponsored by Bayer Healthcare Pharmaceuticals.

'Women have caught up to men when it comes to … deaths from cardiovascular disease.' DR. ABRAMSON

CALGARY, ALTA. — The way Dr. Beth L. Abramson sees it, menopause provides the ideal opportunity to review with patients their risk for heart disease and stroke, and to reinforce heart-healthy behaviors.

“Although it's a bit of a paradigm shift, we need to start talking about heart-healthy behavior in gynecologists' offices,” said Dr. Abramson at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada. “There is no doubt that risk of heart disease increases with menopause.”

In Canada, one in three women dies from heart disease and stroke, which makes these two conditions the leading causes of death among women, greater than all forms of cancer combined.

“For the first time in 30 years, women have caught up to men when it comes to the number of deaths from cardiovascular disease,” said Dr. Abramson, a cardiologist who directs the cardiac prevention and rehabilitation center at St. Michael's Hospital and is a spokesperson for the Heart and Stroke Foundation of Ontario, both in Toronto.

Moreover, the risk of dying within the first 30 days of a myocardial infarction is 16% higher for women compared with men. The same goes for stroke, which confers an 11% higher risk of death within 30 days for women compared with men. “Women are less likely to be treated by a specialist, are less likely to be transferred to another facility for treatment, and are less likely to undergo cardiac catheterization or revascularization,” she noted.

Despite the well-known risks, awareness of heart disease risk among women is generally poor. According to Dr. Abramson, only one in eight Canadian women understands that heart disease and stroke are her most serious health concerns, whereas only one woman in three knows that the conditions are the leading causes of death.

In an effort to close the current knowledge gap, Dr. Abramson and her associates at St. Michael's are teaching primary care physicians to administer a Framingham risk calculation as a way to assess a woman's risk of developing coronary artery disease. A software program calculates the woman's 10-year risk of a heart attack based on factors including age, blood pressure, smoking status, lipids, fasting blood glucose, and family history. The score “may underestimate some risk, but it's what we are using,” she said. (The assessment is similar to the National Heart, Lung, and Blood Institute's tool for estimating the 10-year risk of having a heart attack, which can be found at http://hp2010.nhlbihin.net/atpiii/calculator.asp

Dr. Abramson also recommends a discussion of risk reduction strategies—including smoking cessation, healthful eating choices, exercise, and weight-loss tips when needed—during each office visit. “It's very hard to make lifestyle changes,” she acknowledged. “I encourage people to make small changes over time. Most heart attacks aren't sudden; they take many years of preparation.”

Most smokers want to quit, she said, yet only about one-third of smokers report receiving smoking-cessation advice from their physician. She often uses this script, which can be delivered in about 20 seconds: “Do you smoke? I know you understand it's bad for you. It's the worst thing for your health. I can help you quit smoking if you want to.”

Finding a way to personalize the effects of smoking cessation is also key. “Tell the women their skin will look better and younger if they quit,” she said. “That's an important motivator.” So is the phrase, “Your children want you to quit so you can be around for your grandchildren.”

Dr. Abramson pointed out that visceral obesity is associated with conditions that lead to heart disease, including increased LDL cholesterol, decreased HDL cholesterol, high triglycerides, diabetes, insulin resistance, increased insulin levels, abnormal blood clotting, glucose intolerance, and poor blood-vessel function. “In menopause, the fat distribution of women changes,” she said. “They are more likely to take on an apple-shaped figure than a pear-shaped one.”

The Heart and Stroke Foundation of Canada has launched “The Heart Truth” campaign aimed at educating women about their risk for coronary heart disease. The campaign includes a dedicated Web site (www.thehearttruth.ca

The campaign advises women to take action and talk with health care professionals about treatment options for risk factors such as high cholesterol, high blood pressure, and smoking.

“You have a role to play,” Dr. Abramson said. “You have an opportunity to take care of women around the time of menopause and try to reduce their risk factors.”

Dr. Abramson disclosed that she receives ongoing research funds from Astra Zeneca Pharmaceuticals LP, Boehringer-Ingelheim Pharmaceuticals Inc., and Merck & Co., and that she has been a speaker for several other pharmaceutical companies.

The presentation was part of a session sponsored by Bayer Healthcare Pharmaceuticals.

'Women have caught up to men when it comes to … deaths from cardiovascular disease.' DR. ABRAMSON

CALGARY, ALTA. — The way Dr. Beth L. Abramson sees it, menopause provides the ideal opportunity to review with patients their risk for heart disease and stroke, and to reinforce heart-healthy behaviors.

“Although it's a bit of a paradigm shift, we need to start talking about heart-healthy behavior in gynecologists' offices,” said Dr. Abramson at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada. “There is no doubt that risk of heart disease increases with menopause.”

In Canada, one in three women dies from heart disease and stroke, which makes these two conditions the leading causes of death among women, greater than all forms of cancer combined.

“For the first time in 30 years, women have caught up to men when it comes to the number of deaths from cardiovascular disease,” said Dr. Abramson, a cardiologist who directs the cardiac prevention and rehabilitation center at St. Michael's Hospital and is a spokesperson for the Heart and Stroke Foundation of Ontario, both in Toronto.

Moreover, the risk of dying within the first 30 days of a myocardial infarction is 16% higher for women compared with men. The same goes for stroke, which confers an 11% higher risk of death within 30 days for women compared with men. “Women are less likely to be treated by a specialist, are less likely to be transferred to another facility for treatment, and are less likely to undergo cardiac catheterization or revascularization,” she noted.

Despite the well-known risks, awareness of heart disease risk among women is generally poor. According to Dr. Abramson, only one in eight Canadian women understands that heart disease and stroke are her most serious health concerns, whereas only one woman in three knows that the conditions are the leading causes of death.

In an effort to close the current knowledge gap, Dr. Abramson and her associates at St. Michael's are teaching primary care physicians to administer a Framingham risk calculation as a way to assess a woman's risk of developing coronary artery disease. A software program calculates the woman's 10-year risk of a heart attack based on factors including age, blood pressure, smoking status, lipids, fasting blood glucose, and family history. The score “may underestimate some risk, but it's what we are using,” she said. (The assessment is similar to the National Heart, Lung, and Blood Institute's tool for estimating the 10-year risk of having a heart attack, which can be found at http://hp2010.nhlbihin.net/atpiii/calculator.asp

Dr. Abramson also recommends a discussion of risk reduction strategies—including smoking cessation, healthful eating choices, exercise, and weight-loss tips when needed—during each office visit. “It's very hard to make lifestyle changes,” she acknowledged. “I encourage people to make small changes over time. Most heart attacks aren't sudden; they take many years of preparation.”

Most smokers want to quit, she said, yet only about one-third of smokers report receiving smoking-cessation advice from their physician. She often uses this script, which can be delivered in about 20 seconds: “Do you smoke? I know you understand it's bad for you. It's the worst thing for your health. I can help you quit smoking if you want to.”

Finding a way to personalize the effects of smoking cessation is also key. “Tell the women their skin will look better and younger if they quit,” she said. “That's an important motivator.” So is the phrase, “Your children want you to quit so you can be around for your grandchildren.”

Dr. Abramson pointed out that visceral obesity is associated with conditions that lead to heart disease, including increased LDL cholesterol, decreased HDL cholesterol, high triglycerides, diabetes, insulin resistance, increased insulin levels, abnormal blood clotting, glucose intolerance, and poor blood-vessel function. “In menopause, the fat distribution of women changes,” she said. “They are more likely to take on an apple-shaped figure than a pear-shaped one.”

The Heart and Stroke Foundation of Canada has launched “The Heart Truth” campaign aimed at educating women about their risk for coronary heart disease. The campaign includes a dedicated Web site (www.thehearttruth.ca

The campaign advises women to take action and talk with health care professionals about treatment options for risk factors such as high cholesterol, high blood pressure, and smoking.

“You have a role to play,” Dr. Abramson said. “You have an opportunity to take care of women around the time of menopause and try to reduce their risk factors.”

Dr. Abramson disclosed that she receives ongoing research funds from Astra Zeneca Pharmaceuticals LP, Boehringer-Ingelheim Pharmaceuticals Inc., and Merck & Co., and that she has been a speaker for several other pharmaceutical companies.

The presentation was part of a session sponsored by Bayer Healthcare Pharmaceuticals.

'Women have caught up to men when it comes to … deaths from cardiovascular disease.' DR. ABRAMSON