Doug Brunk

Brooke Jackson, M.D., describes herself as a "late bloomer" to the notion of exercising on a regular basis.

Her turning point came in 1997, when she moved to Houston for her Mohs fellowship at Baylor College of Medicine. One day she spotted a newspaper ad placed by a group of local runners.

"The ad said, 'We'll train you to run a marathon,'" Dr. Jackson recalled. "I had no intention of ever doing a marathon. I had never run a race in my life. I just figured it would be nice to get out with a group of people and run a little bit. I'd be happy getting up to 5 miles."

Only 6 months later, she found herself at the starting line of her first marathon, "wondering what I had gotten myself into," she said. "I had such a good time doing it that I went back the next year."

After running her second marathon and completing her Mohs fellowship, Dr. Jackson moved to Chicago's South Side in 1999 to set up a dermatology practice. One of her first priorities was finding a group of people to run with. "A couple of nights a week, most running stores will have a group of people that will go out and run 3, 4, or 5 miles," she said. "I joined that group. That's how I met my husband."

She also formed a marathon-training group as a way to meet people and inspire others to exercise. In that first year, 75 people joined the group. By 2003, the number grew to 400.

The way she sees it, running is "something you can do anywhere, at any time, with anybody," said Dr. Jackson. "It's a great way to meet people and take care of yourself, too. I'm a firm believer that until you take good care of yourself, you really aren't in the position to take care of anybody else."

Although the clinical benefits of even moderate exercise—like a brisk walk—are well known, few physicians make concerted efforts to incorporate it into their daily routine, according to Tedd Mitchell, M.D. He described the fitness levels and habits of physicians, priests, preachers, and rabbis as "abysmal" compared with that of the general population because of the service-related nature of their work. In these professions, "it's all about everyone else, not about you," noted Dr. Mitchell, an internist who is vice president of the Cooper Clinic in Dallas.

One reason physicians as a group may not exercise "is because inconsistency is built into your schedule," he said. "You have call; that affects your routine. Your day-to-day schedule is not that of a banker, so it makes it more difficult to follow any type of routine consistently, whether it's exercise or good nutrition."

He shared the following tips that he and his associates share with patients who attend the Cooper Clinic:

▸ Know the "FIT" principle of aerobic training. "F" stands for frequency of exercise sessions; "I" stands for intensity of the exercise, and "T" stands for length of time per session.

Of the three variables, frequency is the most important, said Dr. Mitchell, who is also a member of the President's Council on Physical Fitness and Sports. "Think of exercise as another medication," he said. "If you're not taking your medicine regularly, you don't get the benefit. It's the same thing with exercise. From a frequency standpoint, if your weight is not an issue and all you're after is some health benefits, exercising three times a week is okay. However, if you have any tendency toward high cholesterol, triglycerides, blood pressure, weight, or stress, you need it five times a week."

Once you establish the frequency, the next most important variable is the length of time you exercise. "Thirty minutes is great," he said. "You can walk for 30 minutes or jog for 20."

Intensity is the last variable you tackle. Consistent, moderate exercise is what you're after. "Physicians tend to work out infrequently and hard," Dr. Mitchell noted. "That formula is backward for the benefits, but it's just right for pulling hamstrings."

▸ Exercise in the morning. People who routinely exercise in the morning are more likely to do it long term compared with people who try to exercise at other times of the day, "because you can control the morning schedule better than you can control anything else," Dr. Mitchell said. "Even the surgeons can do this. Rather than always taking the 7 a.m. time slot in the [operating room], give yourself an 8 a.m. time slot and get the activity done."

Nicolette Horbach, M.D., started working out at a local gym with a personal trainer 4 years ago. She meets with the trainer at 7 a.m. on 2 days during the workweek. "I plan to see patients on those days at 8:45 a.m. instead of at 8 a.m." said Dr. Horbach, a urogynecologist in private practice in Annandale, Va. "That extra 45 minutes gives me the time to do what I need to do."

▸ Keep it simple and practical. "You're better off having a treadmill at your house that you can use every morning than you are joining the best club in town if it means you've got to get in a car and drive over there," Dr. Mitchell said.

At his ob.gyn. group practice in Naperville, Ill., Christopher Olson, M.D., converted a procedure room into an exercise room with a step machine, a stationary bike, and some free weights. Intended for use by his entire staff, the exercise room is where Dr. Olson typically works out during the Chicago winter months, although he prefers outdoor activities like jogging and golf during warmer months. "There's a shower in the office, too, so it makes it harder to come up with excuses" for not using the room, said Dr. Olson.

He added that his office, house, and nearest golf club are within 1.5 miles of each other, "so I can play six holes at dusk and be home for dinner, and it's very convenient," he said. "To me, one of the secrets to playing hard and working hard is that I try to keep everything very convenient. If it's not convenient, I'm never going to do it."

If you travel frequently, bring along your running or walking shoes and carve out some time for exercise when you reach your destination. "Running is one of the things that you can do anywhere, so there's no excuse," Dr. Jackson said. "It doesn't take a lot of time. All you need is a pair of shoes."

▸ Keep it short. Physicians tend to embrace the notion of "all or none" or "no pain, no gain," Dr. Mitchell said. "If you could walk 30 minutes in the morning on a treadmill or around the neighborhood at a brisk pace, or if you could jog for 20 minutes, you will get far better benefit doing that than joining a club and going over there once or twice a week and [overdoing] it," he noted.

▸ Keep it consistent. Schedule each session of preferred physical activity just as you schedule patient appointments and everything else. "Keep a workweek mind-set," Dr. Mitchell advised. "For example, I went up to Washington a couple weeks ago and we had meetings all day for the president's council. As we were setting meeting times, I said, 'Don't start them before this time, because I'm going to exercise.'"

Making a Plan for Exercise? No Sweat.

The skinny on exercise boils down to this: If you can find time for three 10-minute walks a day, you'll achieve certain health benefits.

"I don't care how busy you are. You can find a way to do that on most days if you do a little planning and problem-solving," said 65-year-old Steven N. Blair, president and CEO of the Cooper Institute in Dallas and primary author of "Active Living Every Day: 20 Weeks to Lifelong Vitality" (Champaign, Ill.: Human Kinetics Publishers, 2001).

Mr. Blair has been a daily runner for more than 35 years. Although his habit of being physically active is long established, he still asks himself two questions every evening: "What's my schedule tomorrow?" and "When do I have time to fit in my exercise?"

"I always start with my personal assumption that I'm going to get some exercise tomorrow," said Mr. Blair. "Exercise is a high priority. I know it's very important to health, so I'm going to find [a way] to do it tomorrow sometime."

He offered the following hypothetical schedule to illustrate how he would manage to meet his exercise goal despite apparent obstacles.

"Tomorrow I leave the house at 6 a.m. and I'm flying to Seattle to give a presentation," he said. "I arrive in Seattle at 5 p.m. and my talk is at 6 p.m. It doesn't look like I'll be able to run, but I am changing planes in Denver, and I have an hour and a half layover. I can't run in the Denver airport, but I sure can get a 30-minute walk in."

Findings from studies conducted at the Cooper Institute have concluded that patients who use such planning and problem-solving techniques are more likely to establish long-term exercise habits than are those who don't. These same patients will also make commitments like, "I vow to be active nearly every day."

The consensus public health recommendations on physical activity that emerged in the mid-1990s from the Centers for Disease Control and Prevention, the American College of Sports Medicine, and the U.S. Surgeon General's report recommended that people accumulate at least 30 minutes of moderate intensity activity on most days of the week.

"'Most' means 5 days, so 30 minutes of walking 5 days a week," Dr. Blair said. "'Accumulate' means you don't have to go for a 30-minute walk. You can go for two 15-minute walks or three 10-minute walks, or four 8-minute walks."

Brooke Jackson, M.D., describes herself as a "late bloomer" to the notion of exercising on a regular basis.

Her turning point came in 1997, when she moved to Houston for her Mohs fellowship at Baylor College of Medicine. One day she spotted a newspaper ad placed by a group of local runners.

"The ad said, 'We'll train you to run a marathon,'" Dr. Jackson recalled. "I had no intention of ever doing a marathon. I had never run a race in my life. I just figured it would be nice to get out with a group of people and run a little bit. I'd be happy getting up to 5 miles."

Only 6 months later, she found herself at the starting line of her first marathon, "wondering what I had gotten myself into," she said. "I had such a good time doing it that I went back the next year."

After running her second marathon and completing her Mohs fellowship, Dr. Jackson moved to Chicago's South Side in 1999 to set up a dermatology practice. One of her first priorities was finding a group of people to run with. "A couple of nights a week, most running stores will have a group of people that will go out and run 3, 4, or 5 miles," she said. "I joined that group. That's how I met my husband."

She also formed a marathon-training group as a way to meet people and inspire others to exercise. In that first year, 75 people joined the group. By 2003, the number grew to 400.

The way she sees it, running is "something you can do anywhere, at any time, with anybody," said Dr. Jackson. "It's a great way to meet people and take care of yourself, too. I'm a firm believer that until you take good care of yourself, you really aren't in the position to take care of anybody else."

Although the clinical benefits of even moderate exercise—like a brisk walk—are well known, few physicians make concerted efforts to incorporate it into their daily routine, according to Tedd Mitchell, M.D. He described the fitness levels and habits of physicians, priests, preachers, and rabbis as "abysmal" compared with that of the general population because of the service-related nature of their work. In these professions, "it's all about everyone else, not about you," noted Dr. Mitchell, an internist who is vice president of the Cooper Clinic in Dallas.

One reason physicians as a group may not exercise "is because inconsistency is built into your schedule," he said. "You have call; that affects your routine. Your day-to-day schedule is not that of a banker, so it makes it more difficult to follow any type of routine consistently, whether it's exercise or good nutrition."

He shared the following tips that he and his associates share with patients who attend the Cooper Clinic:

▸ Know the "FIT" principle of aerobic training. "F" stands for frequency of exercise sessions; "I" stands for intensity of the exercise, and "T" stands for length of time per session.

Of the three variables, frequency is the most important, said Dr. Mitchell, who is also a member of the President's Council on Physical Fitness and Sports. "Think of exercise as another medication," he said. "If you're not taking your medicine regularly, you don't get the benefit. It's the same thing with exercise. From a frequency standpoint, if your weight is not an issue and all you're after is some health benefits, exercising three times a week is okay. However, if you have any tendency toward high cholesterol, triglycerides, blood pressure, weight, or stress, you need it five times a week."

Once you establish the frequency, the next most important variable is the length of time you exercise. "Thirty minutes is great," he said. "You can walk for 30 minutes or jog for 20."

Intensity is the last variable you tackle. Consistent, moderate exercise is what you're after. "Physicians tend to work out infrequently and hard," Dr. Mitchell noted. "That formula is backward for the benefits, but it's just right for pulling hamstrings."

▸ Exercise in the morning. People who routinely exercise in the morning are more likely to do it long term compared with people who try to exercise at other times of the day, "because you can control the morning schedule better than you can control anything else," Dr. Mitchell said. "Even the surgeons can do this. Rather than always taking the 7 a.m. time slot in the [operating room], give yourself an 8 a.m. time slot and get the activity done."

Nicolette Horbach, M.D., started working out at a local gym with a personal trainer 4 years ago. She meets with the trainer at 7 a.m. on 2 days during the workweek. "I plan to see patients on those days at 8:45 a.m. instead of at 8 a.m." said Dr. Horbach, a urogynecologist in private practice in Annandale, Va. "That extra 45 minutes gives me the time to do what I need to do."

▸ Keep it simple and practical. "You're better off having a treadmill at your house that you can use every morning than you are joining the best club in town if it means you've got to get in a car and drive over there," Dr. Mitchell said.

At his ob.gyn. group practice in Naperville, Ill., Christopher Olson, M.D., converted a procedure room into an exercise room with a step machine, a stationary bike, and some free weights. Intended for use by his entire staff, the exercise room is where Dr. Olson typically works out during the Chicago winter months, although he prefers outdoor activities like jogging and golf during warmer months. "There's a shower in the office, too, so it makes it harder to come up with excuses" for not using the room, said Dr. Olson.

He added that his office, house, and nearest golf club are within 1.5 miles of each other, "so I can play six holes at dusk and be home for dinner, and it's very convenient," he said. "To me, one of the secrets to playing hard and working hard is that I try to keep everything very convenient. If it's not convenient, I'm never going to do it."

If you travel frequently, bring along your running or walking shoes and carve out some time for exercise when you reach your destination. "Running is one of the things that you can do anywhere, so there's no excuse," Dr. Jackson said. "It doesn't take a lot of time. All you need is a pair of shoes."

▸ Keep it short. Physicians tend to embrace the notion of "all or none" or "no pain, no gain," Dr. Mitchell said. "If you could walk 30 minutes in the morning on a treadmill or around the neighborhood at a brisk pace, or if you could jog for 20 minutes, you will get far better benefit doing that than joining a club and going over there once or twice a week and [overdoing] it," he noted.

▸ Keep it consistent. Schedule each session of preferred physical activity just as you schedule patient appointments and everything else. "Keep a workweek mind-set," Dr. Mitchell advised. "For example, I went up to Washington a couple weeks ago and we had meetings all day for the president's council. As we were setting meeting times, I said, 'Don't start them before this time, because I'm going to exercise.'"

Making a Plan for Exercise? No Sweat.

The skinny on exercise boils down to this: If you can find time for three 10-minute walks a day, you'll achieve certain health benefits.

"I don't care how busy you are. You can find a way to do that on most days if you do a little planning and problem-solving," said 65-year-old Steven N. Blair, president and CEO of the Cooper Institute in Dallas and primary author of "Active Living Every Day: 20 Weeks to Lifelong Vitality" (Champaign, Ill.: Human Kinetics Publishers, 2001).

Mr. Blair has been a daily runner for more than 35 years. Although his habit of being physically active is long established, he still asks himself two questions every evening: "What's my schedule tomorrow?" and "When do I have time to fit in my exercise?"

"I always start with my personal assumption that I'm going to get some exercise tomorrow," said Mr. Blair. "Exercise is a high priority. I know it's very important to health, so I'm going to find [a way] to do it tomorrow sometime."

He offered the following hypothetical schedule to illustrate how he would manage to meet his exercise goal despite apparent obstacles.

"Tomorrow I leave the house at 6 a.m. and I'm flying to Seattle to give a presentation," he said. "I arrive in Seattle at 5 p.m. and my talk is at 6 p.m. It doesn't look like I'll be able to run, but I am changing planes in Denver, and I have an hour and a half layover. I can't run in the Denver airport, but I sure can get a 30-minute walk in."

Findings from studies conducted at the Cooper Institute have concluded that patients who use such planning and problem-solving techniques are more likely to establish long-term exercise habits than are those who don't. These same patients will also make commitments like, "I vow to be active nearly every day."

The consensus public health recommendations on physical activity that emerged in the mid-1990s from the Centers for Disease Control and Prevention, the American College of Sports Medicine, and the U.S. Surgeon General's report recommended that people accumulate at least 30 minutes of moderate intensity activity on most days of the week.

"'Most' means 5 days, so 30 minutes of walking 5 days a week," Dr. Blair said. "'Accumulate' means you don't have to go for a 30-minute walk. You can go for two 15-minute walks or three 10-minute walks, or four 8-minute walks."

Brooke Jackson, M.D., describes herself as a "late bloomer" to the notion of exercising on a regular basis.

Her turning point came in 1997, when she moved to Houston for her Mohs fellowship at Baylor College of Medicine. One day she spotted a newspaper ad placed by a group of local runners.

"The ad said, 'We'll train you to run a marathon,'" Dr. Jackson recalled. "I had no intention of ever doing a marathon. I had never run a race in my life. I just figured it would be nice to get out with a group of people and run a little bit. I'd be happy getting up to 5 miles."

Only 6 months later, she found herself at the starting line of her first marathon, "wondering what I had gotten myself into," she said. "I had such a good time doing it that I went back the next year."

After running her second marathon and completing her Mohs fellowship, Dr. Jackson moved to Chicago's South Side in 1999 to set up a dermatology practice. One of her first priorities was finding a group of people to run with. "A couple of nights a week, most running stores will have a group of people that will go out and run 3, 4, or 5 miles," she said. "I joined that group. That's how I met my husband."

She also formed a marathon-training group as a way to meet people and inspire others to exercise. In that first year, 75 people joined the group. By 2003, the number grew to 400.

The way she sees it, running is "something you can do anywhere, at any time, with anybody," said Dr. Jackson. "It's a great way to meet people and take care of yourself, too. I'm a firm believer that until you take good care of yourself, you really aren't in the position to take care of anybody else."

Although the clinical benefits of even moderate exercise—like a brisk walk—are well known, few physicians make concerted efforts to incorporate it into their daily routine, according to Tedd Mitchell, M.D. He described the fitness levels and habits of physicians, priests, preachers, and rabbis as "abysmal" compared with that of the general population because of the service-related nature of their work. In these professions, "it's all about everyone else, not about you," noted Dr. Mitchell, an internist who is vice president of the Cooper Clinic in Dallas.

One reason physicians as a group may not exercise "is because inconsistency is built into your schedule," he said. "You have call; that affects your routine. Your day-to-day schedule is not that of a banker, so it makes it more difficult to follow any type of routine consistently, whether it's exercise or good nutrition."

He shared the following tips that he and his associates share with patients who attend the Cooper Clinic:

▸ Know the "FIT" principle of aerobic training. "F" stands for frequency of exercise sessions; "I" stands for intensity of the exercise, and "T" stands for length of time per session.

Of the three variables, frequency is the most important, said Dr. Mitchell, who is also a member of the President's Council on Physical Fitness and Sports. "Think of exercise as another medication," he said. "If you're not taking your medicine regularly, you don't get the benefit. It's the same thing with exercise. From a frequency standpoint, if your weight is not an issue and all you're after is some health benefits, exercising three times a week is okay. However, if you have any tendency toward high cholesterol, triglycerides, blood pressure, weight, or stress, you need it five times a week."

Once you establish the frequency, the next most important variable is the length of time you exercise. "Thirty minutes is great," he said. "You can walk for 30 minutes or jog for 20."

Intensity is the last variable you tackle. Consistent, moderate exercise is what you're after. "Physicians tend to work out infrequently and hard," Dr. Mitchell noted. "That formula is backward for the benefits, but it's just right for pulling hamstrings."

▸ Exercise in the morning. People who routinely exercise in the morning are more likely to do it long term compared with people who try to exercise at other times of the day, "because you can control the morning schedule better than you can control anything else," Dr. Mitchell said. "Even the surgeons can do this. Rather than always taking the 7 a.m. time slot in the [operating room], give yourself an 8 a.m. time slot and get the activity done."

Nicolette Horbach, M.D., started working out at a local gym with a personal trainer 4 years ago. She meets with the trainer at 7 a.m. on 2 days during the workweek. "I plan to see patients on those days at 8:45 a.m. instead of at 8 a.m." said Dr. Horbach, a urogynecologist in private practice in Annandale, Va. "That extra 45 minutes gives me the time to do what I need to do."

▸ Keep it simple and practical. "You're better off having a treadmill at your house that you can use every morning than you are joining the best club in town if it means you've got to get in a car and drive over there," Dr. Mitchell said.

At his ob.gyn. group practice in Naperville, Ill., Christopher Olson, M.D., converted a procedure room into an exercise room with a step machine, a stationary bike, and some free weights. Intended for use by his entire staff, the exercise room is where Dr. Olson typically works out during the Chicago winter months, although he prefers outdoor activities like jogging and golf during warmer months. "There's a shower in the office, too, so it makes it harder to come up with excuses" for not using the room, said Dr. Olson.

He added that his office, house, and nearest golf club are within 1.5 miles of each other, "so I can play six holes at dusk and be home for dinner, and it's very convenient," he said. "To me, one of the secrets to playing hard and working hard is that I try to keep everything very convenient. If it's not convenient, I'm never going to do it."

If you travel frequently, bring along your running or walking shoes and carve out some time for exercise when you reach your destination. "Running is one of the things that you can do anywhere, so there's no excuse," Dr. Jackson said. "It doesn't take a lot of time. All you need is a pair of shoes."

▸ Keep it short. Physicians tend to embrace the notion of "all or none" or "no pain, no gain," Dr. Mitchell said. "If you could walk 30 minutes in the morning on a treadmill or around the neighborhood at a brisk pace, or if you could jog for 20 minutes, you will get far better benefit doing that than joining a club and going over there once or twice a week and [overdoing] it," he noted.

▸ Keep it consistent. Schedule each session of preferred physical activity just as you schedule patient appointments and everything else. "Keep a workweek mind-set," Dr. Mitchell advised. "For example, I went up to Washington a couple weeks ago and we had meetings all day for the president's council. As we were setting meeting times, I said, 'Don't start them before this time, because I'm going to exercise.'"

Making a Plan for Exercise? No Sweat.

The skinny on exercise boils down to this: If you can find time for three 10-minute walks a day, you'll achieve certain health benefits.

"I don't care how busy you are. You can find a way to do that on most days if you do a little planning and problem-solving," said 65-year-old Steven N. Blair, president and CEO of the Cooper Institute in Dallas and primary author of "Active Living Every Day: 20 Weeks to Lifelong Vitality" (Champaign, Ill.: Human Kinetics Publishers, 2001).

Mr. Blair has been a daily runner for more than 35 years. Although his habit of being physically active is long established, he still asks himself two questions every evening: "What's my schedule tomorrow?" and "When do I have time to fit in my exercise?"

"I always start with my personal assumption that I'm going to get some exercise tomorrow," said Mr. Blair. "Exercise is a high priority. I know it's very important to health, so I'm going to find [a way] to do it tomorrow sometime."

He offered the following hypothetical schedule to illustrate how he would manage to meet his exercise goal despite apparent obstacles.

"Tomorrow I leave the house at 6 a.m. and I'm flying to Seattle to give a presentation," he said. "I arrive in Seattle at 5 p.m. and my talk is at 6 p.m. It doesn't look like I'll be able to run, but I am changing planes in Denver, and I have an hour and a half layover. I can't run in the Denver airport, but I sure can get a 30-minute walk in."

Findings from studies conducted at the Cooper Institute have concluded that patients who use such planning and problem-solving techniques are more likely to establish long-term exercise habits than are those who don't. These same patients will also make commitments like, "I vow to be active nearly every day."

The consensus public health recommendations on physical activity that emerged in the mid-1990s from the Centers for Disease Control and Prevention, the American College of Sports Medicine, and the U.S. Surgeon General's report recommended that people accumulate at least 30 minutes of moderate intensity activity on most days of the week.

"'Most' means 5 days, so 30 minutes of walking 5 days a week," Dr. Blair said. "'Accumulate' means you don't have to go for a 30-minute walk. You can go for two 15-minute walks or three 10-minute walks, or four 8-minute walks."

LAS VEGAS — Combining liposuction with Thermage—a radiofrequency energy system that heats the skin to produce collagen tightening and shortening—led to clinically significant tightening of abdominal skin at 28 weeks, compared with either treatment alone, results from a small study suggest.

Combining the two procedures "can be particularly useful in patients with loose skin or striae prior to liposuction," David Avram, M.D., said at the 13th International Symposium on Cosmetic Laser Surgery. "This can be a way of enhancing our results in those patients. However, this was a small study. We obviously need to perform more studies with more patients."

For the study, Dr. Avram and his associates treated 14 patients with standard tumescent liposuction plus Thermage (group 1), four patients with liposuction only (group 2), and two patients with Thermage only (group 3).

After liposuction, patients in group 1 had four tattoo markers placed in a rectangular pattern in areas of loose abdominal skin. The area was calculated and recorded prior to treatment with Thermage, said Dr. Avram, a cosmetic dermatologist who practices in New York City.

Patients were treated three times with Thermage at 4-week intervals (4, 8, and 12 weeks postoperatively). The treatments were done in a single pass using the ThermaCool TC System. Energy levels ranged from 13.5 J/sec to 15.0 J/sec at each visit. Patients were asked to return for follow-up visits at 1 month and at 4 months after the last Thermage treatment. Two independent observers recorded the size of the treated area at each follow-up visit.

"We've heard a lot of subjective data about Thermage," Dr. Avram commented. "I think what's nice here is that we really went for objective data with tattoo markers to see if there would be any [skin] tightening."

Patients in group 2 had tattoo markers placed in the abdominal area 4 weeks after liposuction. Investigators recorded the area of tattoo markers during postoperative follow-up visits at 8, 12, 16, and 28 weeks.

Patients in group 3 had tattoo markers placed in the abdominal area on the initial visit and then underwent the same Thermage treatment and follow-up regimen as patients in group 1.

At 4 weeks, there were no differences in skin tightening among patients in the three groups. (See box.) However, by 28 weeks, patients in group 1 achieved 18% skin tightening while patients in groups 2 and 3 achieved only 10% skin tightening.

The 10% tightening seen in the group 2 patients "is probably from the trauma that's caused from liposuction," Dr. Avram said. So Thermage is as effective in tightening skin as is liposuction only. "When you combine the treatment modalities, you are able to have skin tightening up to 18%."

Dr. Avram noted that patients treated with Thermage had "moderate discomfort" during treatment, but no long-term adverse events were observed. Lidocaine topical anesthetic cream was applied 1 hour before treatment, and no oral pain medicines were given.

One patient had four superficial blisters after treatment, "but they healed without a scar," he said.

He added that he is using combined liposuction and Thermage to treat fat on the arms and noted that some clinicians are applying it to breast reduction.

The current Food and Drug Administration-approved indications for the ThermaCool TC System are for noninvasive treatment of wrinkles in the periorbital area as well as full-face treatment.

LAS VEGAS — Combining liposuction with Thermage—a radiofrequency energy system that heats the skin to produce collagen tightening and shortening—led to clinically significant tightening of abdominal skin at 28 weeks, compared with either treatment alone, results from a small study suggest.

Combining the two procedures "can be particularly useful in patients with loose skin or striae prior to liposuction," David Avram, M.D., said at the 13th International Symposium on Cosmetic Laser Surgery. "This can be a way of enhancing our results in those patients. However, this was a small study. We obviously need to perform more studies with more patients."

For the study, Dr. Avram and his associates treated 14 patients with standard tumescent liposuction plus Thermage (group 1), four patients with liposuction only (group 2), and two patients with Thermage only (group 3).

After liposuction, patients in group 1 had four tattoo markers placed in a rectangular pattern in areas of loose abdominal skin. The area was calculated and recorded prior to treatment with Thermage, said Dr. Avram, a cosmetic dermatologist who practices in New York City.

Patients were treated three times with Thermage at 4-week intervals (4, 8, and 12 weeks postoperatively). The treatments were done in a single pass using the ThermaCool TC System. Energy levels ranged from 13.5 J/sec to 15.0 J/sec at each visit. Patients were asked to return for follow-up visits at 1 month and at 4 months after the last Thermage treatment. Two independent observers recorded the size of the treated area at each follow-up visit.

"We've heard a lot of subjective data about Thermage," Dr. Avram commented. "I think what's nice here is that we really went for objective data with tattoo markers to see if there would be any [skin] tightening."

Patients in group 2 had tattoo markers placed in the abdominal area 4 weeks after liposuction. Investigators recorded the area of tattoo markers during postoperative follow-up visits at 8, 12, 16, and 28 weeks.

Patients in group 3 had tattoo markers placed in the abdominal area on the initial visit and then underwent the same Thermage treatment and follow-up regimen as patients in group 1.

At 4 weeks, there were no differences in skin tightening among patients in the three groups. (See box.) However, by 28 weeks, patients in group 1 achieved 18% skin tightening while patients in groups 2 and 3 achieved only 10% skin tightening.

The 10% tightening seen in the group 2 patients "is probably from the trauma that's caused from liposuction," Dr. Avram said. So Thermage is as effective in tightening skin as is liposuction only. "When you combine the treatment modalities, you are able to have skin tightening up to 18%."

Dr. Avram noted that patients treated with Thermage had "moderate discomfort" during treatment, but no long-term adverse events were observed. Lidocaine topical anesthetic cream was applied 1 hour before treatment, and no oral pain medicines were given.

One patient had four superficial blisters after treatment, "but they healed without a scar," he said.

He added that he is using combined liposuction and Thermage to treat fat on the arms and noted that some clinicians are applying it to breast reduction.

The current Food and Drug Administration-approved indications for the ThermaCool TC System are for noninvasive treatment of wrinkles in the periorbital area as well as full-face treatment.

LAS VEGAS — Combining liposuction with Thermage—a radiofrequency energy system that heats the skin to produce collagen tightening and shortening—led to clinically significant tightening of abdominal skin at 28 weeks, compared with either treatment alone, results from a small study suggest.

Combining the two procedures "can be particularly useful in patients with loose skin or striae prior to liposuction," David Avram, M.D., said at the 13th International Symposium on Cosmetic Laser Surgery. "This can be a way of enhancing our results in those patients. However, this was a small study. We obviously need to perform more studies with more patients."

For the study, Dr. Avram and his associates treated 14 patients with standard tumescent liposuction plus Thermage (group 1), four patients with liposuction only (group 2), and two patients with Thermage only (group 3).

After liposuction, patients in group 1 had four tattoo markers placed in a rectangular pattern in areas of loose abdominal skin. The area was calculated and recorded prior to treatment with Thermage, said Dr. Avram, a cosmetic dermatologist who practices in New York City.

Patients were treated three times with Thermage at 4-week intervals (4, 8, and 12 weeks postoperatively). The treatments were done in a single pass using the ThermaCool TC System. Energy levels ranged from 13.5 J/sec to 15.0 J/sec at each visit. Patients were asked to return for follow-up visits at 1 month and at 4 months after the last Thermage treatment. Two independent observers recorded the size of the treated area at each follow-up visit.

"We've heard a lot of subjective data about Thermage," Dr. Avram commented. "I think what's nice here is that we really went for objective data with tattoo markers to see if there would be any [skin] tightening."

Patients in group 2 had tattoo markers placed in the abdominal area 4 weeks after liposuction. Investigators recorded the area of tattoo markers during postoperative follow-up visits at 8, 12, 16, and 28 weeks.

Patients in group 3 had tattoo markers placed in the abdominal area on the initial visit and then underwent the same Thermage treatment and follow-up regimen as patients in group 1.

At 4 weeks, there were no differences in skin tightening among patients in the three groups. (See box.) However, by 28 weeks, patients in group 1 achieved 18% skin tightening while patients in groups 2 and 3 achieved only 10% skin tightening.

The 10% tightening seen in the group 2 patients "is probably from the trauma that's caused from liposuction," Dr. Avram said. So Thermage is as effective in tightening skin as is liposuction only. "When you combine the treatment modalities, you are able to have skin tightening up to 18%."

Dr. Avram noted that patients treated with Thermage had "moderate discomfort" during treatment, but no long-term adverse events were observed. Lidocaine topical anesthetic cream was applied 1 hour before treatment, and no oral pain medicines were given.

One patient had four superficial blisters after treatment, "but they healed without a scar," he said.

He added that he is using combined liposuction and Thermage to treat fat on the arms and noted that some clinicians are applying it to breast reduction.

The current Food and Drug Administration-approved indications for the ThermaCool TC System are for noninvasive treatment of wrinkles in the periorbital area as well as full-face treatment.

SAN DIEGO — In recent years, the transconjunctival approach to lower blepharoplasty has become a popular alternative to the traditional transcutaneous approach, but which technique is best?

The answer "is not entirely clear," Hayes B. Gladstone, M.D., said at the joint annual meeting of the American Society for Dermatologic Surgery and the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

"The transconjunctival approach to lower blepharoplasty is safe, but edema and wrinkled skin are the two most common complications," said Dr. Gladstone, director of the division of dermatologic surgery in the department of dermatology at Stanford (Calif.) University.

"It also seems that with the transconjunctival approach, an adjunct procedure such as laser resurfacing or chemical peels is an important consideration," he said.

Reported advantages of the transcutaneous approach are that it provides easy access to the skin, the fat pads are usually well visualized, and it removes excess skin, he said. The reported disadvantages of this approach include risk for eyelid malposition, risk for ectropion, and the fact that it leaves a visible scar.

Reported advantages of the transconjunctival approach are that it leaves no scar and it poses a decreased risk for eyelid malposition as well as ectropion. Reported disadvantages include difficult access to the skin, less visualization of all fat pads, potential for inferior oblique injury, and the fact that "it doesn't address excess infraorbital skin," he said.

Dr. Gladstone conducted a metaanalysis of the transcutaneous and transconjunctival approaches to lower blepharoplasty based on relevant studies published in the medical literature from 1970 to the present. He evaluated components of the studies that concerned complications, patient satisfaction, and physician assessment.

The studies he reviewed included 4,460 patients who underwent transcutaneous lower blepharoplasty and 3,438 patients who underwent transconjunctival lower blepharoplasty.

Edema occurred in 18% of patients who underwent the transconjunctival approach, compared with 0.2% of those who underwent the transcutaneous approach. In addition, 11% of patients in the transconjunctival group experienced wrinkling, compared with 2.4% of patients in the transcutaneous group.

Dr. Gladstone also observed that 32% of patients who underwent the transconjunctival approach required an adjunctive procedure such as laser resurfacing or chemical peels, compared with 1.5% of patients who underwent the transcutaneous approach.

The patient assessment of lower blepharoplasty "was not clear" in studies of the transcutaneous approach, he said.

Among patients who underwent the transconjunctival approach, more than half (52%) described being satisfied by the procedure, while only 29% described their results as excellent. "They wouldn't even consider that they had excellent results, which I think is a problem when you're doing a cosmetic procedure," Dr. Gladstone commented.

He was not able to quantify physician assessment of the two approaches from the studies he reviewed.

SAN DIEGO — In recent years, the transconjunctival approach to lower blepharoplasty has become a popular alternative to the traditional transcutaneous approach, but which technique is best?

The answer "is not entirely clear," Hayes B. Gladstone, M.D., said at the joint annual meeting of the American Society for Dermatologic Surgery and the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

"The transconjunctival approach to lower blepharoplasty is safe, but edema and wrinkled skin are the two most common complications," said Dr. Gladstone, director of the division of dermatologic surgery in the department of dermatology at Stanford (Calif.) University.

"It also seems that with the transconjunctival approach, an adjunct procedure such as laser resurfacing or chemical peels is an important consideration," he said.

Reported advantages of the transcutaneous approach are that it provides easy access to the skin, the fat pads are usually well visualized, and it removes excess skin, he said. The reported disadvantages of this approach include risk for eyelid malposition, risk for ectropion, and the fact that it leaves a visible scar.

Reported advantages of the transconjunctival approach are that it leaves no scar and it poses a decreased risk for eyelid malposition as well as ectropion. Reported disadvantages include difficult access to the skin, less visualization of all fat pads, potential for inferior oblique injury, and the fact that "it doesn't address excess infraorbital skin," he said.

Dr. Gladstone conducted a metaanalysis of the transcutaneous and transconjunctival approaches to lower blepharoplasty based on relevant studies published in the medical literature from 1970 to the present. He evaluated components of the studies that concerned complications, patient satisfaction, and physician assessment.

The studies he reviewed included 4,460 patients who underwent transcutaneous lower blepharoplasty and 3,438 patients who underwent transconjunctival lower blepharoplasty.

Edema occurred in 18% of patients who underwent the transconjunctival approach, compared with 0.2% of those who underwent the transcutaneous approach. In addition, 11% of patients in the transconjunctival group experienced wrinkling, compared with 2.4% of patients in the transcutaneous group.

Dr. Gladstone also observed that 32% of patients who underwent the transconjunctival approach required an adjunctive procedure such as laser resurfacing or chemical peels, compared with 1.5% of patients who underwent the transcutaneous approach.

The patient assessment of lower blepharoplasty "was not clear" in studies of the transcutaneous approach, he said.

Among patients who underwent the transconjunctival approach, more than half (52%) described being satisfied by the procedure, while only 29% described their results as excellent. "They wouldn't even consider that they had excellent results, which I think is a problem when you're doing a cosmetic procedure," Dr. Gladstone commented.

He was not able to quantify physician assessment of the two approaches from the studies he reviewed.

SAN DIEGO — In recent years, the transconjunctival approach to lower blepharoplasty has become a popular alternative to the traditional transcutaneous approach, but which technique is best?

The answer "is not entirely clear," Hayes B. Gladstone, M.D., said at the joint annual meeting of the American Society for Dermatologic Surgery and the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

"The transconjunctival approach to lower blepharoplasty is safe, but edema and wrinkled skin are the two most common complications," said Dr. Gladstone, director of the division of dermatologic surgery in the department of dermatology at Stanford (Calif.) University.

"It also seems that with the transconjunctival approach, an adjunct procedure such as laser resurfacing or chemical peels is an important consideration," he said.

Reported advantages of the transcutaneous approach are that it provides easy access to the skin, the fat pads are usually well visualized, and it removes excess skin, he said. The reported disadvantages of this approach include risk for eyelid malposition, risk for ectropion, and the fact that it leaves a visible scar.

Reported advantages of the transconjunctival approach are that it leaves no scar and it poses a decreased risk for eyelid malposition as well as ectropion. Reported disadvantages include difficult access to the skin, less visualization of all fat pads, potential for inferior oblique injury, and the fact that "it doesn't address excess infraorbital skin," he said.

Dr. Gladstone conducted a metaanalysis of the transcutaneous and transconjunctival approaches to lower blepharoplasty based on relevant studies published in the medical literature from 1970 to the present. He evaluated components of the studies that concerned complications, patient satisfaction, and physician assessment.

The studies he reviewed included 4,460 patients who underwent transcutaneous lower blepharoplasty and 3,438 patients who underwent transconjunctival lower blepharoplasty.

Edema occurred in 18% of patients who underwent the transconjunctival approach, compared with 0.2% of those who underwent the transcutaneous approach. In addition, 11% of patients in the transconjunctival group experienced wrinkling, compared with 2.4% of patients in the transcutaneous group.

Dr. Gladstone also observed that 32% of patients who underwent the transconjunctival approach required an adjunctive procedure such as laser resurfacing or chemical peels, compared with 1.5% of patients who underwent the transcutaneous approach.

The patient assessment of lower blepharoplasty "was not clear" in studies of the transcutaneous approach, he said.

Among patients who underwent the transconjunctival approach, more than half (52%) described being satisfied by the procedure, while only 29% described their results as excellent. "They wouldn't even consider that they had excellent results, which I think is a problem when you're doing a cosmetic procedure," Dr. Gladstone commented.

He was not able to quantify physician assessment of the two approaches from the studies he reviewed.

SAN DIEGO — Pregnant women who present with changing nevi should not be treated differently from other patients of similar age, Dina R. Massry, M.D., said at a melanoma update sponsored by the Scripps Clinic.

“Prompt biopsy is key,” said Dr. Massry, a dermatologist with the division of dermatology and cutaneous surgery at the Scripps Clinic-Torrey Pines, La Jolla, Calif.

While it is commonly accepted that nevi enlarge and change during pregnancy and that new nevi develop, pregnant women “may get a false sense of security and disregard something that may be potentially worrisome and not get evaluated,” she noted. Pregnant women may not be aware that they should be concerned about irregular or changing moles.

Any changing mole—especially one that has become irregular or asymmetric—could be a melanoma. Synchronous and homogeneous darkening of multiple moles “is probably normal but still should be evaluated,” she said. A delayed diagnosis of melanoma in pregnant patients illustrates that physicians should treat changing nevi exactly the same in pregnant and nonpregnant patients, and biopsy the moles promptly.

No study has identified a difference in survival rates between pregnant patients with melanoma and nonpregnant, age-matched controls, but studies consistently show an increase in median thickness among pregnant patients with melanoma, compared with nonpregnant, age-matched controls. While a delay in melanoma diagnosis is the likely cause for this difference, Dr. Massry said that there are no data to confirm or refute the possible role of growth factors that induce thicker and more rapidly growing melanomas.

In her presentation, she also addressed the following questions related to melanoma:

▸ How does one approach recurrent melanoma in pregnant patients with stage II-IV disease? CT and x-ray can be used if the benefits and risks are discussed with the patient. One study supports the use of MRI in the systemic work-up (Semin. Oncol. 2000; 27:623–32).

Another analysis (Curr. Opin. Oncol. 1999;11:129–31) reports that the manufacturers and suppliers of interferon have “sparse data” on pregnant patients that suggest babies delivered to mothers receiving interferon therapy have low birth weights, Dr. Massry said.

She added that dacarbazine is considered the best treatment for pregnant patients with advanced disease.

▸ What is the risk to the fetus in a pregnancy complicated by melanoma? Transplacental metastases occur only in patients with hematogenous dissemination of melanoma. The incidence of maternal malignancy during pregnancy is 1 per 1,000, and melanoma accounts for 8% of all cancers during pregnancy.

“About 25% of the cancer that is metastatic to the parts of conception involve the fetus,” Dr. Massry said. “Of cases with fetal involvement, 58% or so arise via melanoma.”

At birth, she advised, “you want to do a thorough evaluation of the infant, a gross microscopic examination of the placenta, and [an examination of] the cord blood buffy coat for tumor cells.”

▸ When can a woman safely become pregnant after treatment of melanoma? The commonly accepted advice is to avoid conception for 2–3 years if their lesions were 1.5 mm or smaller and 5–8 years if their lesions were greater than 1.5 mm. Part of this recommendation has to do with [when] most recurrences are likely to occur, she said. “If you're talking to a 20-year-old woman versus maybe a 40-year-old woman, the recommendations may change, depending on what their sense of urgency is” regarding childbearing.”

Some investigators support the notion of individualized recommendations depending on tumor thickness, stage of diagnosis, age of the patient, and the desire of the patient to become pregnant (Cancer 2003;9:2130–3).

▸ Is there a link between melanoma and use of oral contraceptives or hormone therapy? Older studies suggest that high-dose oral contraceptives raise the risk of melanoma, but newer studies that include epidemiologic analysis refute the earlier data. For example, a controlled study of more than 2,000 women found no relationship between the incidence of melanoma and oral contraceptive use, age at onset of use, number of years used, or proximal relationship to use (Br. J. Cancer 2002; 86:1085–92).

Dr. Massry noted that there is “a paucity of information” on hormone therapy and melanoma. Some investigators maintain that there is no reason to withhold hormone therapy from a woman if it is otherwise recommended (Climacteric 2002;5:197–200).

SAN DIEGO — Pregnant women who present with changing nevi should not be treated differently from other patients of similar age, Dina R. Massry, M.D., said at a melanoma update sponsored by the Scripps Clinic.

“Prompt biopsy is key,” said Dr. Massry, a dermatologist with the division of dermatology and cutaneous surgery at the Scripps Clinic-Torrey Pines, La Jolla, Calif.

While it is commonly accepted that nevi enlarge and change during pregnancy and that new nevi develop, pregnant women “may get a false sense of security and disregard something that may be potentially worrisome and not get evaluated,” she noted. Pregnant women may not be aware that they should be concerned about irregular or changing moles.

Any changing mole—especially one that has become irregular or asymmetric—could be a melanoma. Synchronous and homogeneous darkening of multiple moles “is probably normal but still should be evaluated,” she said. A delayed diagnosis of melanoma in pregnant patients illustrates that physicians should treat changing nevi exactly the same in pregnant and nonpregnant patients, and biopsy the moles promptly.

No study has identified a difference in survival rates between pregnant patients with melanoma and nonpregnant, age-matched controls, but studies consistently show an increase in median thickness among pregnant patients with melanoma, compared with nonpregnant, age-matched controls. While a delay in melanoma diagnosis is the likely cause for this difference, Dr. Massry said that there are no data to confirm or refute the possible role of growth factors that induce thicker and more rapidly growing melanomas.

In her presentation, she also addressed the following questions related to melanoma:

▸ How does one approach recurrent melanoma in pregnant patients with stage II-IV disease? CT and x-ray can be used if the benefits and risks are discussed with the patient. One study supports the use of MRI in the systemic work-up (Semin. Oncol. 2000; 27:623–32).

Another analysis (Curr. Opin. Oncol. 1999;11:129–31) reports that the manufacturers and suppliers of interferon have “sparse data” on pregnant patients that suggest babies delivered to mothers receiving interferon therapy have low birth weights, Dr. Massry said.

She added that dacarbazine is considered the best treatment for pregnant patients with advanced disease.

▸ What is the risk to the fetus in a pregnancy complicated by melanoma? Transplacental metastases occur only in patients with hematogenous dissemination of melanoma. The incidence of maternal malignancy during pregnancy is 1 per 1,000, and melanoma accounts for 8% of all cancers during pregnancy.

“About 25% of the cancer that is metastatic to the parts of conception involve the fetus,” Dr. Massry said. “Of cases with fetal involvement, 58% or so arise via melanoma.”

At birth, she advised, “you want to do a thorough evaluation of the infant, a gross microscopic examination of the placenta, and [an examination of] the cord blood buffy coat for tumor cells.”

▸ When can a woman safely become pregnant after treatment of melanoma? The commonly accepted advice is to avoid conception for 2–3 years if their lesions were 1.5 mm or smaller and 5–8 years if their lesions were greater than 1.5 mm. Part of this recommendation has to do with [when] most recurrences are likely to occur, she said. “If you're talking to a 20-year-old woman versus maybe a 40-year-old woman, the recommendations may change, depending on what their sense of urgency is” regarding childbearing.”

Some investigators support the notion of individualized recommendations depending on tumor thickness, stage of diagnosis, age of the patient, and the desire of the patient to become pregnant (Cancer 2003;9:2130–3).

▸ Is there a link between melanoma and use of oral contraceptives or hormone therapy? Older studies suggest that high-dose oral contraceptives raise the risk of melanoma, but newer studies that include epidemiologic analysis refute the earlier data. For example, a controlled study of more than 2,000 women found no relationship between the incidence of melanoma and oral contraceptive use, age at onset of use, number of years used, or proximal relationship to use (Br. J. Cancer 2002; 86:1085–92).

Dr. Massry noted that there is “a paucity of information” on hormone therapy and melanoma. Some investigators maintain that there is no reason to withhold hormone therapy from a woman if it is otherwise recommended (Climacteric 2002;5:197–200).

SAN DIEGO — Pregnant women who present with changing nevi should not be treated differently from other patients of similar age, Dina R. Massry, M.D., said at a melanoma update sponsored by the Scripps Clinic.

“Prompt biopsy is key,” said Dr. Massry, a dermatologist with the division of dermatology and cutaneous surgery at the Scripps Clinic-Torrey Pines, La Jolla, Calif.

While it is commonly accepted that nevi enlarge and change during pregnancy and that new nevi develop, pregnant women “may get a false sense of security and disregard something that may be potentially worrisome and not get evaluated,” she noted. Pregnant women may not be aware that they should be concerned about irregular or changing moles.

Any changing mole—especially one that has become irregular or asymmetric—could be a melanoma. Synchronous and homogeneous darkening of multiple moles “is probably normal but still should be evaluated,” she said. A delayed diagnosis of melanoma in pregnant patients illustrates that physicians should treat changing nevi exactly the same in pregnant and nonpregnant patients, and biopsy the moles promptly.

No study has identified a difference in survival rates between pregnant patients with melanoma and nonpregnant, age-matched controls, but studies consistently show an increase in median thickness among pregnant patients with melanoma, compared with nonpregnant, age-matched controls. While a delay in melanoma diagnosis is the likely cause for this difference, Dr. Massry said that there are no data to confirm or refute the possible role of growth factors that induce thicker and more rapidly growing melanomas.

In her presentation, she also addressed the following questions related to melanoma:

▸ How does one approach recurrent melanoma in pregnant patients with stage II-IV disease? CT and x-ray can be used if the benefits and risks are discussed with the patient. One study supports the use of MRI in the systemic work-up (Semin. Oncol. 2000; 27:623–32).

Another analysis (Curr. Opin. Oncol. 1999;11:129–31) reports that the manufacturers and suppliers of interferon have “sparse data” on pregnant patients that suggest babies delivered to mothers receiving interferon therapy have low birth weights, Dr. Massry said.

She added that dacarbazine is considered the best treatment for pregnant patients with advanced disease.

▸ What is the risk to the fetus in a pregnancy complicated by melanoma? Transplacental metastases occur only in patients with hematogenous dissemination of melanoma. The incidence of maternal malignancy during pregnancy is 1 per 1,000, and melanoma accounts for 8% of all cancers during pregnancy.

“About 25% of the cancer that is metastatic to the parts of conception involve the fetus,” Dr. Massry said. “Of cases with fetal involvement, 58% or so arise via melanoma.”

At birth, she advised, “you want to do a thorough evaluation of the infant, a gross microscopic examination of the placenta, and [an examination of] the cord blood buffy coat for tumor cells.”

▸ When can a woman safely become pregnant after treatment of melanoma? The commonly accepted advice is to avoid conception for 2–3 years if their lesions were 1.5 mm or smaller and 5–8 years if their lesions were greater than 1.5 mm. Part of this recommendation has to do with [when] most recurrences are likely to occur, she said. “If you're talking to a 20-year-old woman versus maybe a 40-year-old woman, the recommendations may change, depending on what their sense of urgency is” regarding childbearing.”

Some investigators support the notion of individualized recommendations depending on tumor thickness, stage of diagnosis, age of the patient, and the desire of the patient to become pregnant (Cancer 2003;9:2130–3).

▸ Is there a link between melanoma and use of oral contraceptives or hormone therapy? Older studies suggest that high-dose oral contraceptives raise the risk of melanoma, but newer studies that include epidemiologic analysis refute the earlier data. For example, a controlled study of more than 2,000 women found no relationship between the incidence of melanoma and oral contraceptive use, age at onset of use, number of years used, or proximal relationship to use (Br. J. Cancer 2002; 86:1085–92).

Dr. Massry noted that there is “a paucity of information” on hormone therapy and melanoma. Some investigators maintain that there is no reason to withhold hormone therapy from a woman if it is otherwise recommended (Climacteric 2002;5:197–200).

SEATTLE — Patients diagnosed with chronic obstructive pulmonary disease were less likely to have a confirmatory test than were patients diagnosed with heart failure, according to results from a study conducted at a Boston-based hospital.

The finding highlights a “disconnect” between the role of spirometry for confirming pulmonary diseases and that of 2-D echocardiography in confirming heart failure, Mahendra Damarla, M.D., said at the annual meeting of the American College of Chest Physicians.

“We all know that COPD is an underdiagnosed phenomenon,” said Dr. Damarla of Caritas St. Elizabeth's Medical Center, Boston. “We definitely need to improve the practice of ordering confirmatory tests in patients suspected of having COPD.”

He and his associates conducted a 6-month chart review of patients with a discharge diagnosis of COPD and either primary or secondary heart failure. They searched the hospital's pulmonary function test and echocardiography lab databases to determine if patients had had a spirometry or a 2-D echo performed.

They undertook the analysis because they “started to notice patients in the ICU who were diagnosed with COPD who ended up in respiratory failure on mechanical ventilation,” he explained.

Of the 553 patients diagnosed with COPD, only 169 (30%) had had pulmonary function tests performed within the past 7 years. By contrast, of the 789 patients diagnosed with heart failure, 619 (78%) had had a 2-D echo performed within the past 7 years.

Of the 219 patients with a diagnosis of both COPD and heart failure, 105 (48%) had had a 2-D echo only, 4 (2%) had had spirometry only, 74 (34%) had had both tests performed, and 36 (16%) had had neither test performed.

SEATTLE — Patients diagnosed with chronic obstructive pulmonary disease were less likely to have a confirmatory test than were patients diagnosed with heart failure, according to results from a study conducted at a Boston-based hospital.

The finding highlights a “disconnect” between the role of spirometry for confirming pulmonary diseases and that of 2-D echocardiography in confirming heart failure, Mahendra Damarla, M.D., said at the annual meeting of the American College of Chest Physicians.

“We all know that COPD is an underdiagnosed phenomenon,” said Dr. Damarla of Caritas St. Elizabeth's Medical Center, Boston. “We definitely need to improve the practice of ordering confirmatory tests in patients suspected of having COPD.”

He and his associates conducted a 6-month chart review of patients with a discharge diagnosis of COPD and either primary or secondary heart failure. They searched the hospital's pulmonary function test and echocardiography lab databases to determine if patients had had a spirometry or a 2-D echo performed.

They undertook the analysis because they “started to notice patients in the ICU who were diagnosed with COPD who ended up in respiratory failure on mechanical ventilation,” he explained.

Of the 553 patients diagnosed with COPD, only 169 (30%) had had pulmonary function tests performed within the past 7 years. By contrast, of the 789 patients diagnosed with heart failure, 619 (78%) had had a 2-D echo performed within the past 7 years.

Of the 219 patients with a diagnosis of both COPD and heart failure, 105 (48%) had had a 2-D echo only, 4 (2%) had had spirometry only, 74 (34%) had had both tests performed, and 36 (16%) had had neither test performed.

SEATTLE — Patients diagnosed with chronic obstructive pulmonary disease were less likely to have a confirmatory test than were patients diagnosed with heart failure, according to results from a study conducted at a Boston-based hospital.

The finding highlights a “disconnect” between the role of spirometry for confirming pulmonary diseases and that of 2-D echocardiography in confirming heart failure, Mahendra Damarla, M.D., said at the annual meeting of the American College of Chest Physicians.

“We all know that COPD is an underdiagnosed phenomenon,” said Dr. Damarla of Caritas St. Elizabeth's Medical Center, Boston. “We definitely need to improve the practice of ordering confirmatory tests in patients suspected of having COPD.”

He and his associates conducted a 6-month chart review of patients with a discharge diagnosis of COPD and either primary or secondary heart failure. They searched the hospital's pulmonary function test and echocardiography lab databases to determine if patients had had a spirometry or a 2-D echo performed.

They undertook the analysis because they “started to notice patients in the ICU who were diagnosed with COPD who ended up in respiratory failure on mechanical ventilation,” he explained.

Of the 553 patients diagnosed with COPD, only 169 (30%) had had pulmonary function tests performed within the past 7 years. By contrast, of the 789 patients diagnosed with heart failure, 619 (78%) had had a 2-D echo performed within the past 7 years.

Of the 219 patients with a diagnosis of both COPD and heart failure, 105 (48%) had had a 2-D echo only, 4 (2%) had had spirometry only, 74 (34%) had had both tests performed, and 36 (16%) had had neither test performed.

SEATTLE — The long-term use of b-blockers in heart failure patients with chronic obstructive pulmonary disease and/or asthma did not increase the risk of respiratory complications, results from a large retrospective study have shown.

“Although a history of asthma and/or COPD is still considered a relative contraindication to the use of b-blockers in the management of [heart failure], our study found that long-term use did not increase the risk for respiratory complications,” Jay I. Peters, M.D., said at a press briefing during the annual meeting of the American College of Chest Physicians. “We did not see any differences in outcome with the use of cardioselective vs. noncardioselective b-blockers. The proven mortality benefit of b-blocking medication in [heart failure] mandates their use whenever possible.”

During the 1960s, physicians viewed b-blockers as contraindicated in patients with heart failure. “Subsequent research revealed that the use of cardioselective b-blockers upregulated the b-receptor and was useful” in patients with heart failure, said Dr. Peters of the division of pulmonary diseases and critical care medicine at the University of Texas Health Science Center at San Antonio.

In fact, results of recent studies have shown improved survival among heart failure patients on b-blockers: For every 20 patients treated with these drugs, one life is saved (Ann. Intern. Med. 2001;134:550–60 and N. Engl. J. Med. 2001;344:1711–2).

“Unfortunately, many review articles and guidelines often list asthma and COPD as relative contraindications to using b-blockers. Many physicians in the community are hesitant to use these medications if the patient has any history of obstructive lung disease,” he noted.

A recent metaanalysis of data on 141 patients concluded that cardioselective b-blockers are not associated with increased respiratory symptoms or inhaler use, and that b-blockers may enhance the effect of inhaled b-agonist (Cochrane Database Syst. Rev. 2002;[4]:CD002992). But “the duration of the studies was only 3 days to 4 weeks, and only 46 patients had pulmonary function tests,” Dr. Peters said.

In a study funded by the U.S. Department of Defense, he and his associates evaluated the prevalence of b-blocker use and the prevalence of respiratory events in patients with COPD and/or asthma. Their retrospective analysis of prospectively collected data included 1,067 patients with heart failure who were followed over 18 months. Investigators reviewed every nonroutine office visit, emergency department visit, and hospitalization over the 18-month period to evaluate respiratory symptoms and cardiac symptoms.

The prevalence of asthma was 5.9%, the prevalence of COPD was 11.2%, and 2.5% of patients had both COPD and asthma. “So, overall, 19.6% of patients had obstructive lung disease and could have benefited from b-blockers,” Dr. Peters said.

Only 39% of patients with asthma and obstructive lung disease were on b-blockers. About 45% of asthmatics and 35% of patients with COPD were on b-blockers. In addition, 49% of the patients were prescribed cardioselective b-blockers “that are felt to be safer in patients with obstructive lung disease.”

Patients with heart failure and any respiratory diagnosis had a threefold increase in respiratory encounters, compared with patients who had a diagnosis of heart failure alone.

Overall, the use of b-blockers in patients with asthma and/or COPD did not increase the number of respiratory emergencies, and in patients with asthma and COPD, statistically lowered the rate of respiratory events. However, this group was small, and larger studies are needed to confirm this finding,

SEATTLE — The long-term use of b-blockers in heart failure patients with chronic obstructive pulmonary disease and/or asthma did not increase the risk of respiratory complications, results from a large retrospective study have shown.

“Although a history of asthma and/or COPD is still considered a relative contraindication to the use of b-blockers in the management of [heart failure], our study found that long-term use did not increase the risk for respiratory complications,” Jay I. Peters, M.D., said at a press briefing during the annual meeting of the American College of Chest Physicians. “We did not see any differences in outcome with the use of cardioselective vs. noncardioselective b-blockers. The proven mortality benefit of b-blocking medication in [heart failure] mandates their use whenever possible.”

During the 1960s, physicians viewed b-blockers as contraindicated in patients with heart failure. “Subsequent research revealed that the use of cardioselective b-blockers upregulated the b-receptor and was useful” in patients with heart failure, said Dr. Peters of the division of pulmonary diseases and critical care medicine at the University of Texas Health Science Center at San Antonio.

In fact, results of recent studies have shown improved survival among heart failure patients on b-blockers: For every 20 patients treated with these drugs, one life is saved (Ann. Intern. Med. 2001;134:550–60 and N. Engl. J. Med. 2001;344:1711–2).

“Unfortunately, many review articles and guidelines often list asthma and COPD as relative contraindications to using b-blockers. Many physicians in the community are hesitant to use these medications if the patient has any history of obstructive lung disease,” he noted.

A recent metaanalysis of data on 141 patients concluded that cardioselective b-blockers are not associated with increased respiratory symptoms or inhaler use, and that b-blockers may enhance the effect of inhaled b-agonist (Cochrane Database Syst. Rev. 2002;[4]:CD002992). But “the duration of the studies was only 3 days to 4 weeks, and only 46 patients had pulmonary function tests,” Dr. Peters said.

In a study funded by the U.S. Department of Defense, he and his associates evaluated the prevalence of b-blocker use and the prevalence of respiratory events in patients with COPD and/or asthma. Their retrospective analysis of prospectively collected data included 1,067 patients with heart failure who were followed over 18 months. Investigators reviewed every nonroutine office visit, emergency department visit, and hospitalization over the 18-month period to evaluate respiratory symptoms and cardiac symptoms.

The prevalence of asthma was 5.9%, the prevalence of COPD was 11.2%, and 2.5% of patients had both COPD and asthma. “So, overall, 19.6% of patients had obstructive lung disease and could have benefited from b-blockers,” Dr. Peters said.

Only 39% of patients with asthma and obstructive lung disease were on b-blockers. About 45% of asthmatics and 35% of patients with COPD were on b-blockers. In addition, 49% of the patients were prescribed cardioselective b-blockers “that are felt to be safer in patients with obstructive lung disease.”

Patients with heart failure and any respiratory diagnosis had a threefold increase in respiratory encounters, compared with patients who had a diagnosis of heart failure alone.

Overall, the use of b-blockers in patients with asthma and/or COPD did not increase the number of respiratory emergencies, and in patients with asthma and COPD, statistically lowered the rate of respiratory events. However, this group was small, and larger studies are needed to confirm this finding,

SEATTLE — The long-term use of b-blockers in heart failure patients with chronic obstructive pulmonary disease and/or asthma did not increase the risk of respiratory complications, results from a large retrospective study have shown.

“Although a history of asthma and/or COPD is still considered a relative contraindication to the use of b-blockers in the management of [heart failure], our study found that long-term use did not increase the risk for respiratory complications,” Jay I. Peters, M.D., said at a press briefing during the annual meeting of the American College of Chest Physicians. “We did not see any differences in outcome with the use of cardioselective vs. noncardioselective b-blockers. The proven mortality benefit of b-blocking medication in [heart failure] mandates their use whenever possible.”

During the 1960s, physicians viewed b-blockers as contraindicated in patients with heart failure. “Subsequent research revealed that the use of cardioselective b-blockers upregulated the b-receptor and was useful” in patients with heart failure, said Dr. Peters of the division of pulmonary diseases and critical care medicine at the University of Texas Health Science Center at San Antonio.

In fact, results of recent studies have shown improved survival among heart failure patients on b-blockers: For every 20 patients treated with these drugs, one life is saved (Ann. Intern. Med. 2001;134:550–60 and N. Engl. J. Med. 2001;344:1711–2).

“Unfortunately, many review articles and guidelines often list asthma and COPD as relative contraindications to using b-blockers. Many physicians in the community are hesitant to use these medications if the patient has any history of obstructive lung disease,” he noted.

A recent metaanalysis of data on 141 patients concluded that cardioselective b-blockers are not associated with increased respiratory symptoms or inhaler use, and that b-blockers may enhance the effect of inhaled b-agonist (Cochrane Database Syst. Rev. 2002;[4]:CD002992). But “the duration of the studies was only 3 days to 4 weeks, and only 46 patients had pulmonary function tests,” Dr. Peters said.

In a study funded by the U.S. Department of Defense, he and his associates evaluated the prevalence of b-blocker use and the prevalence of respiratory events in patients with COPD and/or asthma. Their retrospective analysis of prospectively collected data included 1,067 patients with heart failure who were followed over 18 months. Investigators reviewed every nonroutine office visit, emergency department visit, and hospitalization over the 18-month period to evaluate respiratory symptoms and cardiac symptoms.

The prevalence of asthma was 5.9%, the prevalence of COPD was 11.2%, and 2.5% of patients had both COPD and asthma. “So, overall, 19.6% of patients had obstructive lung disease and could have benefited from b-blockers,” Dr. Peters said.

Only 39% of patients with asthma and obstructive lung disease were on b-blockers. About 45% of asthmatics and 35% of patients with COPD were on b-blockers. In addition, 49% of the patients were prescribed cardioselective b-blockers “that are felt to be safer in patients with obstructive lung disease.”

Patients with heart failure and any respiratory diagnosis had a threefold increase in respiratory encounters, compared with patients who had a diagnosis of heart failure alone.

Overall, the use of b-blockers in patients with asthma and/or COPD did not increase the number of respiratory emergencies, and in patients with asthma and COPD, statistically lowered the rate of respiratory events. However, this group was small, and larger studies are needed to confirm this finding,

LAS VEGAS — When patients newly diagnosed with psoriasis ask Elaine C. Siegfried, M.D., what they can expect, she offers up her usual response.

“I say, 'The only thing predictable about psoriasis is that it's unpredictable,'” Dr. Siegfried said at a dermatology conference sponsored by the Skin Disease Education Foundation.

This notion is highly applicable to flare, a term used to indicate worsening of psoriasis during or after treatment. Flare “reflects the unpredictable nature of psoriasis and potential for environmental triggers,” said Dr. Siegfried of St. Louis University.

The biologic agent efalizumab (Raptiva) may increase the risk of flare in a subset of patients, she said. Two types of flare have been described in patients taking the drug: localized flare that occurs during therapy, appears at new sites, and remains localized; and generalized flare, which occurs more often in nonresponders.

Flare may occur with efalizumab “slightly more than other drugs, but it certainly occurs with other [biologics] as well,” Dr. Siegfried emphasized, adding that flaring is not a phenomenon that's unique to efalizumab.

“There are lots of triggers that make psoriasis worse in a subset of patients,” she added. “Strep throat is one.” Other anecdotal triggers that she has observed in her patients include naproxen, hydrochlorothiazide, acute sinusitis, and Eucerin.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

LAS VEGAS — When patients newly diagnosed with psoriasis ask Elaine C. Siegfried, M.D., what they can expect, she offers up her usual response.

“I say, 'The only thing predictable about psoriasis is that it's unpredictable,'” Dr. Siegfried said at a dermatology conference sponsored by the Skin Disease Education Foundation.

This notion is highly applicable to flare, a term used to indicate worsening of psoriasis during or after treatment. Flare “reflects the unpredictable nature of psoriasis and potential for environmental triggers,” said Dr. Siegfried of St. Louis University.

The biologic agent efalizumab (Raptiva) may increase the risk of flare in a subset of patients, she said. Two types of flare have been described in patients taking the drug: localized flare that occurs during therapy, appears at new sites, and remains localized; and generalized flare, which occurs more often in nonresponders.

Flare may occur with efalizumab “slightly more than other drugs, but it certainly occurs with other [biologics] as well,” Dr. Siegfried emphasized, adding that flaring is not a phenomenon that's unique to efalizumab.

“There are lots of triggers that make psoriasis worse in a subset of patients,” she added. “Strep throat is one.” Other anecdotal triggers that she has observed in her patients include naproxen, hydrochlorothiazide, acute sinusitis, and Eucerin.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

LAS VEGAS — When patients newly diagnosed with psoriasis ask Elaine C. Siegfried, M.D., what they can expect, she offers up her usual response.

“I say, 'The only thing predictable about psoriasis is that it's unpredictable,'” Dr. Siegfried said at a dermatology conference sponsored by the Skin Disease Education Foundation.

This notion is highly applicable to flare, a term used to indicate worsening of psoriasis during or after treatment. Flare “reflects the unpredictable nature of psoriasis and potential for environmental triggers,” said Dr. Siegfried of St. Louis University.

The biologic agent efalizumab (Raptiva) may increase the risk of flare in a subset of patients, she said. Two types of flare have been described in patients taking the drug: localized flare that occurs during therapy, appears at new sites, and remains localized; and generalized flare, which occurs more often in nonresponders.

Flare may occur with efalizumab “slightly more than other drugs, but it certainly occurs with other [biologics] as well,” Dr. Siegfried emphasized, adding that flaring is not a phenomenon that's unique to efalizumab.

“There are lots of triggers that make psoriasis worse in a subset of patients,” she added. “Strep throat is one.” Other anecdotal triggers that she has observed in her patients include naproxen, hydrochlorothiazide, acute sinusitis, and Eucerin.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

LAS VEGAS — You may think of perioral dermatitis as an adult-only disease, but it affects children as well, Patricia M. Witman, M.D., said at a dermatology seminar sponsored by the Skin Disease Education Foundation.

The exact incidence of perioral dermatitis in children is unknown, said Dr. Witman of the Mayo Clinic, Rochester, Minn. It tends to occur in prepubertal children but can also affect those as young as 7 months. The adult form of the disease usually favors women, whereas in children, it is seen with equal frequency in boys and girls.

“It can have a perioral distribution, but periocular and perinasal lesions are also common,” Dr. Witman said.

Although the cause is unknown, the disease may manifest from genetic inheritance, corticosteroids, fluoride in toothpaste, cosmetics, and certain ingredients found in chewing gum.

Treatment requires antibiotics “and some patience,” she said. For mild cases, Dr. Witman usually recommends topical metronidazole. “Sometimes I'll use it in a lotion form if I'm starting it on a child with sensitive skin that may be irritated,” she said.

Other topical options include erythromycin and sodium sulfacetamide.

If the disease is more inflammatory or if the lesions are granulomatous, Dr. Witman recommends using systemic antibiotics. Erythromycin and amoxicillin are the typical choices for children 8 years or younger; tetracycline is an option for older children.

In childhood granulomatous periorificial dermatitis, a variant of perioral dermatitis, “inflammation is more intense, and one can almost see granulomatous or infiltrativelike lesions in a similar distribution to that seen in the more common variant,” she said.

This variant tends to affect prepubertal children and can involve nonfacial sites such as the scalp, trunk, extremities, and the genitals.

Histology often reveals more inflammation and actual granuloma formation, compared with that seen in the common form of perioral dermatitis.

Dr. Witman discussed other adult skin diseases that can affect children:

▸ Rosacea. The exact incidence is unknown in children, but it tends to affect those with fair skin. Of these, an estimated 20% will have affected parents, “suggesting a genetic relationship,” she said.

So-called steroid rosacea is the most common type. “These are usually kids who have been treated with topical steroids for another reason and then develop the eruption,” she explained. “They can have the typical things that they expect to see in the adults: flushing, erythema, pustules, telangectasias.”

Rosacea can be treated with the same topical and oral agents used for perioral dermatitis.

“Treatment response is usually excellent, but occasionally you will have patients who have a chronic course,” Dr. Witman said.

Ocular involvement is common, and Dr. Witman advises sending children to an ophthalmologist if the disease persists.

▸ Rosacealike demodicosis. This skin eruption looks like rosacea but is thought to be aggravated by the Demodex mite. “It's quite controversial whether the Demodex mite really causes this disease or not, but there appear to be some situations where Demodex mites may multiply and actually cause a facial eruption that looks very much like rosacea,” she said.

Cases of rosacealike demodicosis have been noted in immunosuppressed children and those on maintenance chemotherapy for acute lymphoblastic leukemia.

Treatment options include permethrin cream, metronidazole gel, or oral erythromycin.

▸ Schamberg's disease. This skin discoloration, also known as progressive pigmentary purpura, “can cause a lot of anxiety for parents,” Dr. Witman said.

Differential diagnoses include drug-induced capillaritis, trauma- or self-induced purpura, leukocytoclastic vasculitis, benign hypergammaglobulinemic purpura of Waldenstrom, and cutaneous T-cell lymphoma.

The incidence of Schamberg's in children is unclear. In a recently published series of 13 cases of the disease in children aged 1–9 years, most were female, and the most common location of disease was the legs, mainly the distal lower extremities (J. Am. Acad. Dermatol. 2003;48:31–3). The disease can also present on the trunk and the arms.

Three of the children had a unilateral distribution, all of them had normal lab studies, and one-third had fading of their lesions in 1–4 years. One patient still had disease after 7 years.

Dr. Witman recommends reassuring patients that their lesions will clear with time. “There are reports of the use of systemic steroids and PUVA therapy that can clear these conditions, but because this is a chronic condition and those therapies carry some risks, I often just reassure patients,” she said.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

Perioral dermatitis (left) is often misdiagnosed in children. When treated with medications like topical steroids, it only worsens. Schamberg's disease, also called progressive pigmentary purpura (right), is a chronic condition. Photos courtesy Dr. Patricia M. Witman

LAS VEGAS — You may think of perioral dermatitis as an adult-only disease, but it affects children as well, Patricia M. Witman, M.D., said at a dermatology seminar sponsored by the Skin Disease Education Foundation.

The exact incidence of perioral dermatitis in children is unknown, said Dr. Witman of the Mayo Clinic, Rochester, Minn. It tends to occur in prepubertal children but can also affect those as young as 7 months. The adult form of the disease usually favors women, whereas in children, it is seen with equal frequency in boys and girls.

“It can have a perioral distribution, but periocular and perinasal lesions are also common,” Dr. Witman said.

Although the cause is unknown, the disease may manifest from genetic inheritance, corticosteroids, fluoride in toothpaste, cosmetics, and certain ingredients found in chewing gum.

Treatment requires antibiotics “and some patience,” she said. For mild cases, Dr. Witman usually recommends topical metronidazole. “Sometimes I'll use it in a lotion form if I'm starting it on a child with sensitive skin that may be irritated,” she said.

Other topical options include erythromycin and sodium sulfacetamide.

If the disease is more inflammatory or if the lesions are granulomatous, Dr. Witman recommends using systemic antibiotics. Erythromycin and amoxicillin are the typical choices for children 8 years or younger; tetracycline is an option for older children.

In childhood granulomatous periorificial dermatitis, a variant of perioral dermatitis, “inflammation is more intense, and one can almost see granulomatous or infiltrativelike lesions in a similar distribution to that seen in the more common variant,” she said.

This variant tends to affect prepubertal children and can involve nonfacial sites such as the scalp, trunk, extremities, and the genitals.

Histology often reveals more inflammation and actual granuloma formation, compared with that seen in the common form of perioral dermatitis.

Dr. Witman discussed other adult skin diseases that can affect children:

▸ Rosacea. The exact incidence is unknown in children, but it tends to affect those with fair skin. Of these, an estimated 20% will have affected parents, “suggesting a genetic relationship,” she said.

So-called steroid rosacea is the most common type. “These are usually kids who have been treated with topical steroids for another reason and then develop the eruption,” she explained. “They can have the typical things that they expect to see in the adults: flushing, erythema, pustules, telangectasias.”

Rosacea can be treated with the same topical and oral agents used for perioral dermatitis.

“Treatment response is usually excellent, but occasionally you will have patients who have a chronic course,” Dr. Witman said.

Ocular involvement is common, and Dr. Witman advises sending children to an ophthalmologist if the disease persists.

▸ Rosacealike demodicosis. This skin eruption looks like rosacea but is thought to be aggravated by the Demodex mite. “It's quite controversial whether the Demodex mite really causes this disease or not, but there appear to be some situations where Demodex mites may multiply and actually cause a facial eruption that looks very much like rosacea,” she said.

Cases of rosacealike demodicosis have been noted in immunosuppressed children and those on maintenance chemotherapy for acute lymphoblastic leukemia.

Treatment options include permethrin cream, metronidazole gel, or oral erythromycin.

▸ Schamberg's disease. This skin discoloration, also known as progressive pigmentary purpura, “can cause a lot of anxiety for parents,” Dr. Witman said.

Differential diagnoses include drug-induced capillaritis, trauma- or self-induced purpura, leukocytoclastic vasculitis, benign hypergammaglobulinemic purpura of Waldenstrom, and cutaneous T-cell lymphoma.

The incidence of Schamberg's in children is unclear. In a recently published series of 13 cases of the disease in children aged 1–9 years, most were female, and the most common location of disease was the legs, mainly the distal lower extremities (J. Am. Acad. Dermatol. 2003;48:31–3). The disease can also present on the trunk and the arms.

Three of the children had a unilateral distribution, all of them had normal lab studies, and one-third had fading of their lesions in 1–4 years. One patient still had disease after 7 years.

Dr. Witman recommends reassuring patients that their lesions will clear with time. “There are reports of the use of systemic steroids and PUVA therapy that can clear these conditions, but because this is a chronic condition and those therapies carry some risks, I often just reassure patients,” she said.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

Perioral dermatitis (left) is often misdiagnosed in children. When treated with medications like topical steroids, it only worsens. Schamberg's disease, also called progressive pigmentary purpura (right), is a chronic condition. Photos courtesy Dr. Patricia M. Witman

LAS VEGAS — You may think of perioral dermatitis as an adult-only disease, but it affects children as well, Patricia M. Witman, M.D., said at a dermatology seminar sponsored by the Skin Disease Education Foundation.

The exact incidence of perioral dermatitis in children is unknown, said Dr. Witman of the Mayo Clinic, Rochester, Minn. It tends to occur in prepubertal children but can also affect those as young as 7 months. The adult form of the disease usually favors women, whereas in children, it is seen with equal frequency in boys and girls.

“It can have a perioral distribution, but periocular and perinasal lesions are also common,” Dr. Witman said.

Although the cause is unknown, the disease may manifest from genetic inheritance, corticosteroids, fluoride in toothpaste, cosmetics, and certain ingredients found in chewing gum.

Treatment requires antibiotics “and some patience,” she said. For mild cases, Dr. Witman usually recommends topical metronidazole. “Sometimes I'll use it in a lotion form if I'm starting it on a child with sensitive skin that may be irritated,” she said.

Other topical options include erythromycin and sodium sulfacetamide.

If the disease is more inflammatory or if the lesions are granulomatous, Dr. Witman recommends using systemic antibiotics. Erythromycin and amoxicillin are the typical choices for children 8 years or younger; tetracycline is an option for older children.

In childhood granulomatous periorificial dermatitis, a variant of perioral dermatitis, “inflammation is more intense, and one can almost see granulomatous or infiltrativelike lesions in a similar distribution to that seen in the more common variant,” she said.

This variant tends to affect prepubertal children and can involve nonfacial sites such as the scalp, trunk, extremities, and the genitals.

Histology often reveals more inflammation and actual granuloma formation, compared with that seen in the common form of perioral dermatitis.

Dr. Witman discussed other adult skin diseases that can affect children:

▸ Rosacea. The exact incidence is unknown in children, but it tends to affect those with fair skin. Of these, an estimated 20% will have affected parents, “suggesting a genetic relationship,” she said.

So-called steroid rosacea is the most common type. “These are usually kids who have been treated with topical steroids for another reason and then develop the eruption,” she explained. “They can have the typical things that they expect to see in the adults: flushing, erythema, pustules, telangectasias.”

Rosacea can be treated with the same topical and oral agents used for perioral dermatitis.

“Treatment response is usually excellent, but occasionally you will have patients who have a chronic course,” Dr. Witman said.

Ocular involvement is common, and Dr. Witman advises sending children to an ophthalmologist if the disease persists.

▸ Rosacealike demodicosis. This skin eruption looks like rosacea but is thought to be aggravated by the Demodex mite. “It's quite controversial whether the Demodex mite really causes this disease or not, but there appear to be some situations where Demodex mites may multiply and actually cause a facial eruption that looks very much like rosacea,” she said.

Cases of rosacealike demodicosis have been noted in immunosuppressed children and those on maintenance chemotherapy for acute lymphoblastic leukemia.

Treatment options include permethrin cream, metronidazole gel, or oral erythromycin.

▸ Schamberg's disease. This skin discoloration, also known as progressive pigmentary purpura, “can cause a lot of anxiety for parents,” Dr. Witman said.

Differential diagnoses include drug-induced capillaritis, trauma- or self-induced purpura, leukocytoclastic vasculitis, benign hypergammaglobulinemic purpura of Waldenstrom, and cutaneous T-cell lymphoma.

The incidence of Schamberg's in children is unclear. In a recently published series of 13 cases of the disease in children aged 1–9 years, most were female, and the most common location of disease was the legs, mainly the distal lower extremities (J. Am. Acad. Dermatol. 2003;48:31–3). The disease can also present on the trunk and the arms.

Three of the children had a unilateral distribution, all of them had normal lab studies, and one-third had fading of their lesions in 1–4 years. One patient still had disease after 7 years.

Dr. Witman recommends reassuring patients that their lesions will clear with time. “There are reports of the use of systemic steroids and PUVA therapy that can clear these conditions, but because this is a chronic condition and those therapies carry some risks, I often just reassure patients,” she said.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

Perioral dermatitis (left) is often misdiagnosed in children. When treated with medications like topical steroids, it only worsens. Schamberg's disease, also called progressive pigmentary purpura (right), is a chronic condition. Photos courtesy Dr. Patricia M. Witman

If you're a sports junkie who longs for a chance to coach youth sports teams at the community level, but you figure you just don't have the time to get involved, Fred Duboe, M.D., has some advice for you.

Just do it.

“When all is said and done, I don't think people are going to count how much salary you took home or how many babies you delivered,” said Dr. Duboe, an ob.gyn. who practices in Hoffman Estates, Ill., northwest of Chicago. “People are going to count what you gave to society and how you helped kids grow up—how you helped people in the community and what difference you made in your community in the long run.”

“Show kids that doctors aren't 24-hours-a-day, 7-days-a-week scientists. Show them that that they are humans, with a real feel for life outside the hospital,” Dr. Duboe suggested.

For the last 11 years, Dr. Duboe has helped coach boys' baseball teams in the Buffalo Grove (Ill.) Recreational Association. He started coaching when his oldest son, Michael, turned 8. He then coached his middle son, Jason. Last year he served as an assistant coach for a traveling team featuring his youngest son, Eric.

Eric is 12, and Michael and Jason have moved on to college and high school, respectively. Dr. Duboe said he has gained personal fulfillment from watching his sons “learn how to play as part of a team and not simply be engulfed in individual accomplishments alone; having them learn the discipline,” he said.

“They have a rigorous school schedule. For them to balance sports with their school schedule also helps them prepare for later years, when life is going to be not just a matter of A vs. B; it's a matter of integrating recreation and athletics, as well as working hard. If they play hard, they work hard. I think they learn to apportion their time more efficiently. They learn to be happy when they're active. Every kid deserves a little bit of time sitting around, but I think [sports] has helped them to gain confidence and interpersonal skills with their friends.”

He added that his role as assistant coach is a “tremendous stress outlet” from the pressures of increasing managed care, declining reimbursement, and increasing malpractice insurance rates that obstetricians and other physicians face from day to day.

“It allows you to go back to work a little bit more refreshed than you would otherwise,” Dr. Duboe said. “I'm very dedicated to my patients and my job, but it's a great source of recreation for me, [and] of health. I hope it will keep my heart a little bit younger as I get into my decades coming up.”

Last winter, Neil Goldberg, M.D., served as head coach for a sixth-grade basketball team that his son Ross played on as part of the Scarsdale (N.Y.) Tri-County Basketball League. “The parents would come to almost every game, so I got to see kids star in front of their parents, brothers, and sisters,” said Dr. Goldberg, a dermatologist in private practice in Bronxville. “I got to see kids star and shine. With basketball, you could make just one good shot, and even if you played poorly for the rest of the game, that's enough to carry you for a whole week. It was just so rewarding to me to be in the middle of it all the time.”

Coaching has also provided opportunities for him to spend time with his son. “Kids quickly get old enough that they don't want to hang out with their parents,” Dr. Goldberg noted. “And they quickly get old enough that they're coached by real coaches in school. There are only so many years that a dad can coach his kids playing sports, and they should just grab every minute.”

You don't have to look far to land a coaching opportunity on a youth sports team. Good places to start include your local YMCA, Boys & Girls Club, community recreation center, Little League, or American Youth Soccer Organization (AYSO), to name a few.

Dr. Goldberg first volunteered to help train and coach basketball skills to youngsters when Ross was in kindergarten. “I started to be one of the people who did the organizing,” he recalled. “I finally got to be one of the people who did the coaching; then I worked my way up to being the head coach. It's a long process, because there are a lot of dads who would like to coach these teams.”

Dr. Goldberg described his team's style of play as vigorous. “We play an in-your-face, up-every-second, high pressure defense with a lot of substitutions,” he explained. “Every kid is tired when they finish playing us and when they play for us.”

Coaching also helps physicians assume a different role in the community, noted Rafael Silva, M.D., a family physician who coaches an AYSO team in Chula Vista, Calif.

“I've made a lot of friends by being involved, and I run into people who know me as the coach for their kid a year ago or 2 years ago,” said Dr. Silva, who practices at the Bonita branch of Kaiser Permanente. “That's been a real plus.”

Moreover, the players you coach sometimes become your patients. “I have a couple of kids who were on the first team I coached who found out I'm a doctor, so they decided to come and see me as a patient,” he said. “That's going to be fun to watch them grow up and know that they were on my first team.”

Another reward for him is watching youngsters improve their skills and learn good sportsmanship. “It's a precious moment when they score their first goal ever,” he added. “Their face lights up.”

Coaching can also bring self-reflection. “My dad was a traveling salesman, and he didn't have a lot of time to devote to sports because he was so busy working his tail off,” Dr. Duboe said.

“Hopefully, coaching will be something my kids will carry on to their kids, as well,” he added.

Coaching isn't just for dads. Melinda Silva, M.D., serves as an assistant coach for her husband's team. The couple got involved with AYSO 5 years ago when their oldest son, Rafael III, turned 6 years old.

“The level of involvement that you have is not really as important as that you are involved somehow, whether that means you help them stretch before the game for 10 or 15 minutes,” said Dr. Silva, a family physician at the Otay Mesa, Calif., branch of Kaiser Permanente.

“It's amazing how much an impression will make on a child for how little involvement you give. People are afraid [to get involved] because they're always afraid of what the time commitment means, but you can have varying levels of involvement. Just try.”

Having young children of your own is not a prerequisite to becoming a coach, noted Dr. Rafael Silva, who played soccer in high school and in adult leagues. He plans to continue coaching in some capacity after his other three children move beyond school age.

“I still love the smell of freshly cut grass and mud on my cleats,” he said. “I still have the love of the sport, and that's what keeps me going back.”

Dr. Neil Goldberg, who served as head coach for his son's sixth-grade basketball team last winter in Scarsdale, N.Y., standing with his son, Ross. Courtesy Dr. Neil Goldberg

How to Make Time for Coaching Sports

So you decide to help out as a coach for a youth sports team, but you wonder: “How am I going to fit this in into my schedule?”

Physician-coaches interviewed for this column offered this advice:

▸ Coordinate with your office staff and practice partners. Set your office hours once the practice times and game times have been finalized. “I make it balance by being efficient with office work and with reviewing charts and trading time between partners, maximizing the time off and vacations as much as possible,” Dr. Duboe said. “The fact that I have four partners and a nurse-midwife makes things manageable, as well.”

Dr. Goldberg noted that it pays to achieve the rank of head coach, because in most cases, that person gets to arrange practice times and sometimes even games around his or her own schedule. “For practice nights, I picked the days I didn't work late,” he said. “I got to schedule the Saturdays. I saw patients on Saturdays where I knew I didn't have early morning games.”

That strategy works for indoor sports, but when Saturday matches of outdoor sports like baseball and soccer are canceled due to inclement weather, “you're home not making any money and not doing anything, and the kids can't play,” Dr. Goldberg said. “That drives me crazy.”

▸ Consider reducing your work hours. Dr. Rafael Silva works a 90% schedule so he can preside over his soccer team's Thursday afternoon practices. “I chose to take a 10% pay cut to have a free afternoon so I can do something else,” he said.

His wife, Dr. Melinda Silva, works an 80% schedule so she can help with team activities, as well as other family activities. “That's a priority we made because it's important for us to have that balance in our lives,” she said.

▸ Start slowly. Dr. Rafael Silva advised starting out as a team parent or an assistant coach to gain some baseline coaching experience. That way you get a realistic idea of the time commitment required. “If they see that they would like to be a head coach the following year, then they can jump right in,” he said. “I think the position to be a team parent or an assistant coach is a good way to learn. That way you don't feel stressed out about starting something totally new.”

If you're a sports junkie who longs for a chance to coach youth sports teams at the community level, but you figure you just don't have the time to get involved, Fred Duboe, M.D., has some advice for you.

Just do it.

“When all is said and done, I don't think people are going to count how much salary you took home or how many babies you delivered,” said Dr. Duboe, an ob.gyn. who practices in Hoffman Estates, Ill., northwest of Chicago. “People are going to count what you gave to society and how you helped kids grow up—how you helped people in the community and what difference you made in your community in the long run.”

“Show kids that doctors aren't 24-hours-a-day, 7-days-a-week scientists. Show them that that they are humans, with a real feel for life outside the hospital,” Dr. Duboe suggested.

For the last 11 years, Dr. Duboe has helped coach boys' baseball teams in the Buffalo Grove (Ill.) Recreational Association. He started coaching when his oldest son, Michael, turned 8. He then coached his middle son, Jason. Last year he served as an assistant coach for a traveling team featuring his youngest son, Eric.

Eric is 12, and Michael and Jason have moved on to college and high school, respectively. Dr. Duboe said he has gained personal fulfillment from watching his sons “learn how to play as part of a team and not simply be engulfed in individual accomplishments alone; having them learn the discipline,” he said.

“They have a rigorous school schedule. For them to balance sports with their school schedule also helps them prepare for later years, when life is going to be not just a matter of A vs. B; it's a matter of integrating recreation and athletics, as well as working hard. If they play hard, they work hard. I think they learn to apportion their time more efficiently. They learn to be happy when they're active. Every kid deserves a little bit of time sitting around, but I think [sports] has helped them to gain confidence and interpersonal skills with their friends.”

He added that his role as assistant coach is a “tremendous stress outlet” from the pressures of increasing managed care, declining reimbursement, and increasing malpractice insurance rates that obstetricians and other physicians face from day to day.

“It allows you to go back to work a little bit more refreshed than you would otherwise,” Dr. Duboe said. “I'm very dedicated to my patients and my job, but it's a great source of recreation for me, [and] of health. I hope it will keep my heart a little bit younger as I get into my decades coming up.”

Last winter, Neil Goldberg, M.D., served as head coach for a sixth-grade basketball team that his son Ross played on as part of the Scarsdale (N.Y.) Tri-County Basketball League. “The parents would come to almost every game, so I got to see kids star in front of their parents, brothers, and sisters,” said Dr. Goldberg, a dermatologist in private practice in Bronxville. “I got to see kids star and shine. With basketball, you could make just one good shot, and even if you played poorly for the rest of the game, that's enough to carry you for a whole week. It was just so rewarding to me to be in the middle of it all the time.”

Coaching has also provided opportunities for him to spend time with his son. “Kids quickly get old enough that they don't want to hang out with their parents,” Dr. Goldberg noted. “And they quickly get old enough that they're coached by real coaches in school. There are only so many years that a dad can coach his kids playing sports, and they should just grab every minute.”

You don't have to look far to land a coaching opportunity on a youth sports team. Good places to start include your local YMCA, Boys & Girls Club, community recreation center, Little League, or American Youth Soccer Organization (AYSO), to name a few.

Dr. Goldberg first volunteered to help train and coach basketball skills to youngsters when Ross was in kindergarten. “I started to be one of the people who did the organizing,” he recalled. “I finally got to be one of the people who did the coaching; then I worked my way up to being the head coach. It's a long process, because there are a lot of dads who would like to coach these teams.”

Dr. Goldberg described his team's style of play as vigorous. “We play an in-your-face, up-every-second, high pressure defense with a lot of substitutions,” he explained. “Every kid is tired when they finish playing us and when they play for us.”

Coaching also helps physicians assume a different role in the community, noted Rafael Silva, M.D., a family physician who coaches an AYSO team in Chula Vista, Calif.

“I've made a lot of friends by being involved, and I run into people who know me as the coach for their kid a year ago or 2 years ago,” said Dr. Silva, who practices at the Bonita branch of Kaiser Permanente. “That's been a real plus.”

Moreover, the players you coach sometimes become your patients. “I have a couple of kids who were on the first team I coached who found out I'm a doctor, so they decided to come and see me as a patient,” he said. “That's going to be fun to watch them grow up and know that they were on my first team.”

Another reward for him is watching youngsters improve their skills and learn good sportsmanship. “It's a precious moment when they score their first goal ever,” he added. “Their face lights up.”

Coaching can also bring self-reflection. “My dad was a traveling salesman, and he didn't have a lot of time to devote to sports because he was so busy working his tail off,” Dr. Duboe said.

“Hopefully, coaching will be something my kids will carry on to their kids, as well,” he added.

Coaching isn't just for dads. Melinda Silva, M.D., serves as an assistant coach for her husband's team. The couple got involved with AYSO 5 years ago when their oldest son, Rafael III, turned 6 years old.

“The level of involvement that you have is not really as important as that you are involved somehow, whether that means you help them stretch before the game for 10 or 15 minutes,” said Dr. Silva, a family physician at the Otay Mesa, Calif., branch of Kaiser Permanente.

“It's amazing how much an impression will make on a child for how little involvement you give. People are afraid [to get involved] because they're always afraid of what the time commitment means, but you can have varying levels of involvement. Just try.”

Having young children of your own is not a prerequisite to becoming a coach, noted Dr. Rafael Silva, who played soccer in high school and in adult leagues. He plans to continue coaching in some capacity after his other three children move beyond school age.

“I still love the smell of freshly cut grass and mud on my cleats,” he said. “I still have the love of the sport, and that's what keeps me going back.”

Dr. Neil Goldberg, who served as head coach for his son's sixth-grade basketball team last winter in Scarsdale, N.Y., standing with his son, Ross. Courtesy Dr. Neil Goldberg

How to Make Time for Coaching Sports

So you decide to help out as a coach for a youth sports team, but you wonder: “How am I going to fit this in into my schedule?”

Physician-coaches interviewed for this column offered this advice:

▸ Coordinate with your office staff and practice partners. Set your office hours once the practice times and game times have been finalized. “I make it balance by being efficient with office work and with reviewing charts and trading time between partners, maximizing the time off and vacations as much as possible,” Dr. Duboe said. “The fact that I have four partners and a nurse-midwife makes things manageable, as well.”

Dr. Goldberg noted that it pays to achieve the rank of head coach, because in most cases, that person gets to arrange practice times and sometimes even games around his or her own schedule. “For practice nights, I picked the days I didn't work late,” he said. “I got to schedule the Saturdays. I saw patients on Saturdays where I knew I didn't have early morning games.”

That strategy works for indoor sports, but when Saturday matches of outdoor sports like baseball and soccer are canceled due to inclement weather, “you're home not making any money and not doing anything, and the kids can't play,” Dr. Goldberg said. “That drives me crazy.”

▸ Consider reducing your work hours. Dr. Rafael Silva works a 90% schedule so he can preside over his soccer team's Thursday afternoon practices. “I chose to take a 10% pay cut to have a free afternoon so I can do something else,” he said.

His wife, Dr. Melinda Silva, works an 80% schedule so she can help with team activities, as well as other family activities. “That's a priority we made because it's important for us to have that balance in our lives,” she said.

▸ Start slowly. Dr. Rafael Silva advised starting out as a team parent or an assistant coach to gain some baseline coaching experience. That way you get a realistic idea of the time commitment required. “If they see that they would like to be a head coach the following year, then they can jump right in,” he said. “I think the position to be a team parent or an assistant coach is a good way to learn. That way you don't feel stressed out about starting something totally new.”

If you're a sports junkie who longs for a chance to coach youth sports teams at the community level, but you figure you just don't have the time to get involved, Fred Duboe, M.D., has some advice for you.

Just do it.

“When all is said and done, I don't think people are going to count how much salary you took home or how many babies you delivered,” said Dr. Duboe, an ob.gyn. who practices in Hoffman Estates, Ill., northwest of Chicago. “People are going to count what you gave to society and how you helped kids grow up—how you helped people in the community and what difference you made in your community in the long run.”

“Show kids that doctors aren't 24-hours-a-day, 7-days-a-week scientists. Show them that that they are humans, with a real feel for life outside the hospital,” Dr. Duboe suggested.

For the last 11 years, Dr. Duboe has helped coach boys' baseball teams in the Buffalo Grove (Ill.) Recreational Association. He started coaching when his oldest son, Michael, turned 8. He then coached his middle son, Jason. Last year he served as an assistant coach for a traveling team featuring his youngest son, Eric.

Eric is 12, and Michael and Jason have moved on to college and high school, respectively. Dr. Duboe said he has gained personal fulfillment from watching his sons “learn how to play as part of a team and not simply be engulfed in individual accomplishments alone; having them learn the discipline,” he said.

“They have a rigorous school schedule. For them to balance sports with their school schedule also helps them prepare for later years, when life is going to be not just a matter of A vs. B; it's a matter of integrating recreation and athletics, as well as working hard. If they play hard, they work hard. I think they learn to apportion their time more efficiently. They learn to be happy when they're active. Every kid deserves a little bit of time sitting around, but I think [sports] has helped them to gain confidence and interpersonal skills with their friends.”

He added that his role as assistant coach is a “tremendous stress outlet” from the pressures of increasing managed care, declining reimbursement, and increasing malpractice insurance rates that obstetricians and other physicians face from day to day.

“It allows you to go back to work a little bit more refreshed than you would otherwise,” Dr. Duboe said. “I'm very dedicated to my patients and my job, but it's a great source of recreation for me, [and] of health. I hope it will keep my heart a little bit younger as I get into my decades coming up.”

Last winter, Neil Goldberg, M.D., served as head coach for a sixth-grade basketball team that his son Ross played on as part of the Scarsdale (N.Y.) Tri-County Basketball League. “The parents would come to almost every game, so I got to see kids star in front of their parents, brothers, and sisters,” said Dr. Goldberg, a dermatologist in private practice in Bronxville. “I got to see kids star and shine. With basketball, you could make just one good shot, and even if you played poorly for the rest of the game, that's enough to carry you for a whole week. It was just so rewarding to me to be in the middle of it all the time.”

Coaching has also provided opportunities for him to spend time with his son. “Kids quickly get old enough that they don't want to hang out with their parents,” Dr. Goldberg noted. “And they quickly get old enough that they're coached by real coaches in school. There are only so many years that a dad can coach his kids playing sports, and they should just grab every minute.”

You don't have to look far to land a coaching opportunity on a youth sports team. Good places to start include your local YMCA, Boys & Girls Club, community recreation center, Little League, or American Youth Soccer Organization (AYSO), to name a few.

Dr. Goldberg first volunteered to help train and coach basketball skills to youngsters when Ross was in kindergarten. “I started to be one of the people who did the organizing,” he recalled. “I finally got to be one of the people who did the coaching; then I worked my way up to being the head coach. It's a long process, because there are a lot of dads who would like to coach these teams.”

Dr. Goldberg described his team's style of play as vigorous. “We play an in-your-face, up-every-second, high pressure defense with a lot of substitutions,” he explained. “Every kid is tired when they finish playing us and when they play for us.”

Coaching also helps physicians assume a different role in the community, noted Rafael Silva, M.D., a family physician who coaches an AYSO team in Chula Vista, Calif.

“I've made a lot of friends by being involved, and I run into people who know me as the coach for their kid a year ago or 2 years ago,” said Dr. Silva, who practices at the Bonita branch of Kaiser Permanente. “That's been a real plus.”

Moreover, the players you coach sometimes become your patients. “I have a couple of kids who were on the first team I coached who found out I'm a doctor, so they decided to come and see me as a patient,” he said. “That's going to be fun to watch them grow up and know that they were on my first team.”

Another reward for him is watching youngsters improve their skills and learn good sportsmanship. “It's a precious moment when they score their first goal ever,” he added. “Their face lights up.”

Coaching can also bring self-reflection. “My dad was a traveling salesman, and he didn't have a lot of time to devote to sports because he was so busy working his tail off,” Dr. Duboe said.

“Hopefully, coaching will be something my kids will carry on to their kids, as well,” he added.

Coaching isn't just for dads. Melinda Silva, M.D., serves as an assistant coach for her husband's team. The couple got involved with AYSO 5 years ago when their oldest son, Rafael III, turned 6 years old.

“The level of involvement that you have is not really as important as that you are involved somehow, whether that means you help them stretch before the game for 10 or 15 minutes,” said Dr. Silva, a family physician at the Otay Mesa, Calif., branch of Kaiser Permanente.

“It's amazing how much an impression will make on a child for how little involvement you give. People are afraid [to get involved] because they're always afraid of what the time commitment means, but you can have varying levels of involvement. Just try.”

Having young children of your own is not a prerequisite to becoming a coach, noted Dr. Rafael Silva, who played soccer in high school and in adult leagues. He plans to continue coaching in some capacity after his other three children move beyond school age.

“I still love the smell of freshly cut grass and mud on my cleats,” he said. “I still have the love of the sport, and that's what keeps me going back.”

Dr. Neil Goldberg, who served as head coach for his son's sixth-grade basketball team last winter in Scarsdale, N.Y., standing with his son, Ross. Courtesy Dr. Neil Goldberg

How to Make Time for Coaching Sports

So you decide to help out as a coach for a youth sports team, but you wonder: “How am I going to fit this in into my schedule?”

Physician-coaches interviewed for this column offered this advice:

▸ Coordinate with your office staff and practice partners. Set your office hours once the practice times and game times have been finalized. “I make it balance by being efficient with office work and with reviewing charts and trading time between partners, maximizing the time off and vacations as much as possible,” Dr. Duboe said. “The fact that I have four partners and a nurse-midwife makes things manageable, as well.”

Dr. Goldberg noted that it pays to achieve the rank of head coach, because in most cases, that person gets to arrange practice times and sometimes even games around his or her own schedule. “For practice nights, I picked the days I didn't work late,” he said. “I got to schedule the Saturdays. I saw patients on Saturdays where I knew I didn't have early morning games.”

That strategy works for indoor sports, but when Saturday matches of outdoor sports like baseball and soccer are canceled due to inclement weather, “you're home not making any money and not doing anything, and the kids can't play,” Dr. Goldberg said. “That drives me crazy.”

▸ Consider reducing your work hours. Dr. Rafael Silva works a 90% schedule so he can preside over his soccer team's Thursday afternoon practices. “I chose to take a 10% pay cut to have a free afternoon so I can do something else,” he said.

His wife, Dr. Melinda Silva, works an 80% schedule so she can help with team activities, as well as other family activities. “That's a priority we made because it's important for us to have that balance in our lives,” she said.

▸ Start slowly. Dr. Rafael Silva advised starting out as a team parent or an assistant coach to gain some baseline coaching experience. That way you get a realistic idea of the time commitment required. “If they see that they would like to be a head coach the following year, then they can jump right in,” he said. “I think the position to be a team parent or an assistant coach is a good way to learn. That way you don't feel stressed out about starting something totally new.”

SEATTLE — Elderly patients with community-acquired pneumonia who took moxifloxacin were more likely to have symptom relief by day 3–5 of therapy than were those who took levofloxacin, results from a prospective trial have found.

Investigators observed trends that favored moxifloxacin (Avelox) over levofloxacin (Levaquin) in severely ill patients and those aged 75 years and older, but all other efficacy and safety comparisons between the two agents were similar, Michael Niederman, M.D., commented at the annual meeting of the American College of Chest Physicians.

“The safety and efficacy of both of these drugs was demonstrated and shown to be equivalent,” he said in a later interview.

Dr. Niederman and his associates studied 281 patients aged 65 years and older who were hospitalized with community-acquired pneumonia and required initial IV therapy.

Most patients had multiple comorbidities, especially cardiac disease (74%), chronic obstructive pulmonary disease (63%), and diabetes (29%). Also, 18% had severe pneumonia as defined by American Thoracic Society criteria. Slightly more than half of the patients (51%) were male, and their mean age was 78 years, said Dr. Niederman of Winthrop University Hospital, Mineola, N.Y.

At baseline, all patients had a 12-lead electrocardiogram and a repeat ECG at 72 hours. In the interim, they had a 72-hour period of Holter monitoring.

Of the total group, 141 patients were randomized to moxifloxacin 400 mg/day, and 140 received levofloxacin 500 mg/day. Nearly all patients (98%) in the moxifloxacin group had symptom relief by day 3–5 of therapy, compared with 90% of patients in the levofloxacin group.

Overall cure rates were similar between the moxifloxacin group and the levofloxacin group (93% vs. 88%). The cure rates among patients with mild to moderate pneumonia at baseline were also similar (93% vs. 89%).

The cure rates among patients with severe pneumonia were 95% in the moxifloxacin group, compared with 85% in the levofloxacin group—a difference that trended toward statistical significance, Dr. Niederman said.

Cure rates among patients aged 75 years and older were higher in the moxifloxacin group, compared with those in the levofloxacin group (95% vs. 90%), but the difference was not statistically significant.

Cardiac events considered by the investigators as potentially drug-related were reported in 1% of patients in the moxifloxacin group, compared with 4% of patients in the levofloxacin group. The differences were not statistically significant.

Dr. Niederman called the study unique “because it deals exclusively with older people with pneumonia, many of whom had heart disease and had very close cardiac monitoring to document the safety of these drugs.”

The study was sponsored by Bayer Pharmaceuticals Corp., which is the manufacturer of moxifloxacin.

SEATTLE — Elderly patients with community-acquired pneumonia who took moxifloxacin were more likely to have symptom relief by day 3–5 of therapy than were those who took levofloxacin, results from a prospective trial have found.

Investigators observed trends that favored moxifloxacin (Avelox) over levofloxacin (Levaquin) in severely ill patients and those aged 75 years and older, but all other efficacy and safety comparisons between the two agents were similar, Michael Niederman, M.D., commented at the annual meeting of the American College of Chest Physicians.

“The safety and efficacy of both of these drugs was demonstrated and shown to be equivalent,” he said in a later interview.

Dr. Niederman and his associates studied 281 patients aged 65 years and older who were hospitalized with community-acquired pneumonia and required initial IV therapy.

Most patients had multiple comorbidities, especially cardiac disease (74%), chronic obstructive pulmonary disease (63%), and diabetes (29%). Also, 18% had severe pneumonia as defined by American Thoracic Society criteria. Slightly more than half of the patients (51%) were male, and their mean age was 78 years, said Dr. Niederman of Winthrop University Hospital, Mineola, N.Y.

At baseline, all patients had a 12-lead electrocardiogram and a repeat ECG at 72 hours. In the interim, they had a 72-hour period of Holter monitoring.

Of the total group, 141 patients were randomized to moxifloxacin 400 mg/day, and 140 received levofloxacin 500 mg/day. Nearly all patients (98%) in the moxifloxacin group had symptom relief by day 3–5 of therapy, compared with 90% of patients in the levofloxacin group.

Overall cure rates were similar between the moxifloxacin group and the levofloxacin group (93% vs. 88%). The cure rates among patients with mild to moderate pneumonia at baseline were also similar (93% vs. 89%).

The cure rates among patients with severe pneumonia were 95% in the moxifloxacin group, compared with 85% in the levofloxacin group—a difference that trended toward statistical significance, Dr. Niederman said.

Cure rates among patients aged 75 years and older were higher in the moxifloxacin group, compared with those in the levofloxacin group (95% vs. 90%), but the difference was not statistically significant.

Cardiac events considered by the investigators as potentially drug-related were reported in 1% of patients in the moxifloxacin group, compared with 4% of patients in the levofloxacin group. The differences were not statistically significant.

Dr. Niederman called the study unique “because it deals exclusively with older people with pneumonia, many of whom had heart disease and had very close cardiac monitoring to document the safety of these drugs.”

The study was sponsored by Bayer Pharmaceuticals Corp., which is the manufacturer of moxifloxacin.

SEATTLE — Elderly patients with community-acquired pneumonia who took moxifloxacin were more likely to have symptom relief by day 3–5 of therapy than were those who took levofloxacin, results from a prospective trial have found.

Investigators observed trends that favored moxifloxacin (Avelox) over levofloxacin (Levaquin) in severely ill patients and those aged 75 years and older, but all other efficacy and safety comparisons between the two agents were similar, Michael Niederman, M.D., commented at the annual meeting of the American College of Chest Physicians.

“The safety and efficacy of both of these drugs was demonstrated and shown to be equivalent,” he said in a later interview.

Dr. Niederman and his associates studied 281 patients aged 65 years and older who were hospitalized with community-acquired pneumonia and required initial IV therapy.

Most patients had multiple comorbidities, especially cardiac disease (74%), chronic obstructive pulmonary disease (63%), and diabetes (29%). Also, 18% had severe pneumonia as defined by American Thoracic Society criteria. Slightly more than half of the patients (51%) were male, and their mean age was 78 years, said Dr. Niederman of Winthrop University Hospital, Mineola, N.Y.

At baseline, all patients had a 12-lead electrocardiogram and a repeat ECG at 72 hours. In the interim, they had a 72-hour period of Holter monitoring.

Of the total group, 141 patients were randomized to moxifloxacin 400 mg/day, and 140 received levofloxacin 500 mg/day. Nearly all patients (98%) in the moxifloxacin group had symptom relief by day 3–5 of therapy, compared with 90% of patients in the levofloxacin group.

Overall cure rates were similar between the moxifloxacin group and the levofloxacin group (93% vs. 88%). The cure rates among patients with mild to moderate pneumonia at baseline were also similar (93% vs. 89%).

The cure rates among patients with severe pneumonia were 95% in the moxifloxacin group, compared with 85% in the levofloxacin group—a difference that trended toward statistical significance, Dr. Niederman said.

Cure rates among patients aged 75 years and older were higher in the moxifloxacin group, compared with those in the levofloxacin group (95% vs. 90%), but the difference was not statistically significant.

Cardiac events considered by the investigators as potentially drug-related were reported in 1% of patients in the moxifloxacin group, compared with 4% of patients in the levofloxacin group. The differences were not statistically significant.

Dr. Niederman called the study unique “because it deals exclusively with older people with pneumonia, many of whom had heart disease and had very close cardiac monitoring to document the safety of these drugs.”

The study was sponsored by Bayer Pharmaceuticals Corp., which is the manufacturer of moxifloxacin.