Jeff Evans

NEW YORK — Early use of analgesia in patients with abdominal pain is not associated with a delay in the diagnosis of acute appendicitis, according to findings from a case-control study.

“In the past surgical literature, there have been statements that we should not give early analgesia to patients with undifferentiated abdominal pain until we have a surgical consultation or a final disposition is determined,” said Steven P. Frei, M.D., an emergency physician at Lehigh Valley Hospital and Health Network, Allentown, Pa.

Previous studies that have questioned this reasoning have primarily used surrogate markers such as examination findings before and after analgesia rather than actual outcomes such as true delayed diagnosis of acute appendicitis, Dr. Frei said at the annual meeting of the Society for Academic Emergency Medicine.

In a study of 961 adults with acute appendicitis who were treated by emergency physicians in a three-hospital health network during 1998–2002, 132 patients who had a delayed diagnosis were no more likely to have taken either a nonsteroidal anti-inflammatory drug (NSAID) or opiate within 2 hours of their initial exam than were 132 control patients who did not have a delayed diagnosis of acute appendicitis, Dr. Frei reported.

Similar percentages of patients with a delayed diagnosis and patients without a delayed diagnosis had early use of the NSAID ketorolac (20% vs. 17%, respectively), an opiate (26% vs. 21%), or any of those two types of drugs (41% vs. 35%); some patients received both kinds of medication.

The investigators matched the control patients with cases on age, gender, Alvarado score (a numeric value based on eight signs and symptoms of acute appendicitis), and year of diagnosis. They defined patients with a delayed diagnosis as those who were discharged after their first emergency department visit or had longer than a 20-hour delay from the initial examination to surgery.

The findings did not change when patients with a delayed diagnosis were compared with all patients in the database who had a nondelayed diagnosis, not just nondelayed patients who were matched with delayed-diagnosis patients.

Most patients receiving analgesic medication early had 30 mg of ketorolac intravenously and/or parenteral dosing of 4–6 mg of morphine, 50–75 mg of meperidine, or 50–100 mcg of fentanyl.

NEW YORK — Early use of analgesia in patients with abdominal pain is not associated with a delay in the diagnosis of acute appendicitis, according to findings from a case-control study.

“In the past surgical literature, there have been statements that we should not give early analgesia to patients with undifferentiated abdominal pain until we have a surgical consultation or a final disposition is determined,” said Steven P. Frei, M.D., an emergency physician at Lehigh Valley Hospital and Health Network, Allentown, Pa.

Previous studies that have questioned this reasoning have primarily used surrogate markers such as examination findings before and after analgesia rather than actual outcomes such as true delayed diagnosis of acute appendicitis, Dr. Frei said at the annual meeting of the Society for Academic Emergency Medicine.

In a study of 961 adults with acute appendicitis who were treated by emergency physicians in a three-hospital health network during 1998–2002, 132 patients who had a delayed diagnosis were no more likely to have taken either a nonsteroidal anti-inflammatory drug (NSAID) or opiate within 2 hours of their initial exam than were 132 control patients who did not have a delayed diagnosis of acute appendicitis, Dr. Frei reported.

Similar percentages of patients with a delayed diagnosis and patients without a delayed diagnosis had early use of the NSAID ketorolac (20% vs. 17%, respectively), an opiate (26% vs. 21%), or any of those two types of drugs (41% vs. 35%); some patients received both kinds of medication.

The investigators matched the control patients with cases on age, gender, Alvarado score (a numeric value based on eight signs and symptoms of acute appendicitis), and year of diagnosis. They defined patients with a delayed diagnosis as those who were discharged after their first emergency department visit or had longer than a 20-hour delay from the initial examination to surgery.

The findings did not change when patients with a delayed diagnosis were compared with all patients in the database who had a nondelayed diagnosis, not just nondelayed patients who were matched with delayed-diagnosis patients.

Most patients receiving analgesic medication early had 30 mg of ketorolac intravenously and/or parenteral dosing of 4–6 mg of morphine, 50–75 mg of meperidine, or 50–100 mcg of fentanyl.

NEW YORK — Early use of analgesia in patients with abdominal pain is not associated with a delay in the diagnosis of acute appendicitis, according to findings from a case-control study.

“In the past surgical literature, there have been statements that we should not give early analgesia to patients with undifferentiated abdominal pain until we have a surgical consultation or a final disposition is determined,” said Steven P. Frei, M.D., an emergency physician at Lehigh Valley Hospital and Health Network, Allentown, Pa.

Previous studies that have questioned this reasoning have primarily used surrogate markers such as examination findings before and after analgesia rather than actual outcomes such as true delayed diagnosis of acute appendicitis, Dr. Frei said at the annual meeting of the Society for Academic Emergency Medicine.

In a study of 961 adults with acute appendicitis who were treated by emergency physicians in a three-hospital health network during 1998–2002, 132 patients who had a delayed diagnosis were no more likely to have taken either a nonsteroidal anti-inflammatory drug (NSAID) or opiate within 2 hours of their initial exam than were 132 control patients who did not have a delayed diagnosis of acute appendicitis, Dr. Frei reported.

Similar percentages of patients with a delayed diagnosis and patients without a delayed diagnosis had early use of the NSAID ketorolac (20% vs. 17%, respectively), an opiate (26% vs. 21%), or any of those two types of drugs (41% vs. 35%); some patients received both kinds of medication.

The investigators matched the control patients with cases on age, gender, Alvarado score (a numeric value based on eight signs and symptoms of acute appendicitis), and year of diagnosis. They defined patients with a delayed diagnosis as those who were discharged after their first emergency department visit or had longer than a 20-hour delay from the initial examination to surgery.

The findings did not change when patients with a delayed diagnosis were compared with all patients in the database who had a nondelayed diagnosis, not just nondelayed patients who were matched with delayed-diagnosis patients.

Most patients receiving analgesic medication early had 30 mg of ketorolac intravenously and/or parenteral dosing of 4–6 mg of morphine, 50–75 mg of meperidine, or 50–100 mcg of fentanyl.

AUSTIN, TEX. — Subtle clues in test results will help to differentiate athlete's heart from hypertrophic or dilated cardiomyopathy, Christine E. Lawless, M.D., said at the annual meeting of the American Medical Society for Sports Medicine.

It's tough to distinguish athlete's heart from hypertrophic cardiomyopathy (HCM) when an athlete's left ventricular wall is thickened in a nondilated, normally contractile left ventricle with no systolic anterior motion of the mitral valve, said Dr. Lawless, a cardiologist in group practice in Winfield, Ill.

About 20% of highly trained athletes have what looks like left ventricular hypertrophy, with a left ventricular wall thickness between 1.3 cm and 1.5 cm; normal thickness is 1 cm.

Physicians should suspect HCM rather than athlete's heart if the patient has an unusual pattern of left ventricular hypertrophy, a small left ventricular cavity, left atrial enlargement, an unusual ECG pattern, or abnormal left ventricular filling. Other risk factors for HCM include female gender and a family history of hypertrophy (Circulation 1995;91:1596–601).

“If the thickness decreases with deconditioning, then you know that would be athletic adaptation to exercise,” Dr. Lawless advised.

In one case, a 48-year-old man who had run 18 marathons over a period of 25 years was referred to Dr. Lawless after an irregular heartbeat was found during a physical for a new job.

The patient had a normal cardiovascular examination but showed atrial fibrillation on an ECG, which can be seen both in athletes as they age and in patients with a cardiomyopathy, she said. An echocardiogram showed asymmetric septal hypertrophy, systolic anterior motion of the mitral valve, and moderate mitral valve regurgitation.

At that point, Dr. Lawless was going to err on the side of diagnosing the runner with HCM, but a later echocardiogram showed that his abnormalities had normalized after deconditioning.

“He was one of these folks who fell in the gray zone,” she said.

Genetic testing for 11 mutant genes in HCM will help to detect about 65% of HCMs, Dr. Lawless added, but insurance may not cover testing, which can cost up to $4,500.

A slightly dilated left ventricle may also be the result of athletic conditioning, and not an early manifestation of dilated cardiomyopathy, if the left ventricular ejection fraction (LVEF) is normal. Close to 15% of highly trained athletes appear to have a dilated ventricle with an end-diastolic dimension of about 6.0 cm, compared with a normal value of 5.6 cm, Dr. Lawless said.

Several years ago, Dr. Lawless saw a 39-year-old male cyclist whose father had had a cardiac arrest as a result of dilated cardiomyopathy. The cyclist had a normal cardiac exam besides premature ventricular contractions. Although his left ventricular septal thickness was within the normal range, he had a lower than normal LVEF and larger than normal left ventricular end-systolic and end-diastolic dimensions. Cyclists are known to have a smaller left ventricular end-systolic dimension than patients who have dilated cardiomyopathy.

After deconditioning did not improve the cyclist's LVEF or end-diastolic dimension, she placed him on an ACE inhibitor and a β-blocker. After a course of these medications, he underwent “reverse remodeling” and showed an increase in LVEF and no change in end-diastolic dimension.

Dr. Lawless allowed the man to return to cycling following the reverse remodeling, but cardiologists vary in their opinion on whether patients who normalize their left ventricular ejection fraction can return to sports participation.

“I think a lot of us look at the intensity of the sport, the triggers for sudden death in that particular sport, and we use our best judgment,” she said.

AUSTIN, TEX. — Subtle clues in test results will help to differentiate athlete's heart from hypertrophic or dilated cardiomyopathy, Christine E. Lawless, M.D., said at the annual meeting of the American Medical Society for Sports Medicine.

It's tough to distinguish athlete's heart from hypertrophic cardiomyopathy (HCM) when an athlete's left ventricular wall is thickened in a nondilated, normally contractile left ventricle with no systolic anterior motion of the mitral valve, said Dr. Lawless, a cardiologist in group practice in Winfield, Ill.

About 20% of highly trained athletes have what looks like left ventricular hypertrophy, with a left ventricular wall thickness between 1.3 cm and 1.5 cm; normal thickness is 1 cm.

Physicians should suspect HCM rather than athlete's heart if the patient has an unusual pattern of left ventricular hypertrophy, a small left ventricular cavity, left atrial enlargement, an unusual ECG pattern, or abnormal left ventricular filling. Other risk factors for HCM include female gender and a family history of hypertrophy (Circulation 1995;91:1596–601).

“If the thickness decreases with deconditioning, then you know that would be athletic adaptation to exercise,” Dr. Lawless advised.

In one case, a 48-year-old man who had run 18 marathons over a period of 25 years was referred to Dr. Lawless after an irregular heartbeat was found during a physical for a new job.

The patient had a normal cardiovascular examination but showed atrial fibrillation on an ECG, which can be seen both in athletes as they age and in patients with a cardiomyopathy, she said. An echocardiogram showed asymmetric septal hypertrophy, systolic anterior motion of the mitral valve, and moderate mitral valve regurgitation.

At that point, Dr. Lawless was going to err on the side of diagnosing the runner with HCM, but a later echocardiogram showed that his abnormalities had normalized after deconditioning.

“He was one of these folks who fell in the gray zone,” she said.

Genetic testing for 11 mutant genes in HCM will help to detect about 65% of HCMs, Dr. Lawless added, but insurance may not cover testing, which can cost up to $4,500.

A slightly dilated left ventricle may also be the result of athletic conditioning, and not an early manifestation of dilated cardiomyopathy, if the left ventricular ejection fraction (LVEF) is normal. Close to 15% of highly trained athletes appear to have a dilated ventricle with an end-diastolic dimension of about 6.0 cm, compared with a normal value of 5.6 cm, Dr. Lawless said.

Several years ago, Dr. Lawless saw a 39-year-old male cyclist whose father had had a cardiac arrest as a result of dilated cardiomyopathy. The cyclist had a normal cardiac exam besides premature ventricular contractions. Although his left ventricular septal thickness was within the normal range, he had a lower than normal LVEF and larger than normal left ventricular end-systolic and end-diastolic dimensions. Cyclists are known to have a smaller left ventricular end-systolic dimension than patients who have dilated cardiomyopathy.

After deconditioning did not improve the cyclist's LVEF or end-diastolic dimension, she placed him on an ACE inhibitor and a β-blocker. After a course of these medications, he underwent “reverse remodeling” and showed an increase in LVEF and no change in end-diastolic dimension.

Dr. Lawless allowed the man to return to cycling following the reverse remodeling, but cardiologists vary in their opinion on whether patients who normalize their left ventricular ejection fraction can return to sports participation.

“I think a lot of us look at the intensity of the sport, the triggers for sudden death in that particular sport, and we use our best judgment,” she said.

AUSTIN, TEX. — Subtle clues in test results will help to differentiate athlete's heart from hypertrophic or dilated cardiomyopathy, Christine E. Lawless, M.D., said at the annual meeting of the American Medical Society for Sports Medicine.

It's tough to distinguish athlete's heart from hypertrophic cardiomyopathy (HCM) when an athlete's left ventricular wall is thickened in a nondilated, normally contractile left ventricle with no systolic anterior motion of the mitral valve, said Dr. Lawless, a cardiologist in group practice in Winfield, Ill.

About 20% of highly trained athletes have what looks like left ventricular hypertrophy, with a left ventricular wall thickness between 1.3 cm and 1.5 cm; normal thickness is 1 cm.

Physicians should suspect HCM rather than athlete's heart if the patient has an unusual pattern of left ventricular hypertrophy, a small left ventricular cavity, left atrial enlargement, an unusual ECG pattern, or abnormal left ventricular filling. Other risk factors for HCM include female gender and a family history of hypertrophy (Circulation 1995;91:1596–601).

“If the thickness decreases with deconditioning, then you know that would be athletic adaptation to exercise,” Dr. Lawless advised.

In one case, a 48-year-old man who had run 18 marathons over a period of 25 years was referred to Dr. Lawless after an irregular heartbeat was found during a physical for a new job.

The patient had a normal cardiovascular examination but showed atrial fibrillation on an ECG, which can be seen both in athletes as they age and in patients with a cardiomyopathy, she said. An echocardiogram showed asymmetric septal hypertrophy, systolic anterior motion of the mitral valve, and moderate mitral valve regurgitation.

At that point, Dr. Lawless was going to err on the side of diagnosing the runner with HCM, but a later echocardiogram showed that his abnormalities had normalized after deconditioning.

“He was one of these folks who fell in the gray zone,” she said.

Genetic testing for 11 mutant genes in HCM will help to detect about 65% of HCMs, Dr. Lawless added, but insurance may not cover testing, which can cost up to $4,500.

A slightly dilated left ventricle may also be the result of athletic conditioning, and not an early manifestation of dilated cardiomyopathy, if the left ventricular ejection fraction (LVEF) is normal. Close to 15% of highly trained athletes appear to have a dilated ventricle with an end-diastolic dimension of about 6.0 cm, compared with a normal value of 5.6 cm, Dr. Lawless said.

Several years ago, Dr. Lawless saw a 39-year-old male cyclist whose father had had a cardiac arrest as a result of dilated cardiomyopathy. The cyclist had a normal cardiac exam besides premature ventricular contractions. Although his left ventricular septal thickness was within the normal range, he had a lower than normal LVEF and larger than normal left ventricular end-systolic and end-diastolic dimensions. Cyclists are known to have a smaller left ventricular end-systolic dimension than patients who have dilated cardiomyopathy.

After deconditioning did not improve the cyclist's LVEF or end-diastolic dimension, she placed him on an ACE inhibitor and a β-blocker. After a course of these medications, he underwent “reverse remodeling” and showed an increase in LVEF and no change in end-diastolic dimension.

Dr. Lawless allowed the man to return to cycling following the reverse remodeling, but cardiologists vary in their opinion on whether patients who normalize their left ventricular ejection fraction can return to sports participation.

“I think a lot of us look at the intensity of the sport, the triggers for sudden death in that particular sport, and we use our best judgment,” she said.

WASHINGTON — Cannula obstruction and inflow valve regurgitation of left ventricular assist devices may contribute to recurrent heart failure in long-term users of the devices, according to findings from a small review study.

Among 61 patients who have been implanted with a left ventricular assist device (LVAD) at Sharp Memorial Hospital, San Diego, since 1995, 6 have developed recurrent heart failure. On catheterization of the heart, LVAD, and cannulae, 3 of the 6 patients had inflow cannula valve regurgitation seen on LVAD angiography.

Those 3 patients had received their LVADs between 309 and 696 days prior to the diagnosis of regurgitation.

All 3 of the patients recovered following replacement of the LVAD cannula, David A. Miller reported during a moderated poster session at the annual conference of the American Society for Artificial Internal Organs.

In three other patients, a two-catheter approach helped to identify obstruction of the inflow cannula as a result of a pressure gradient between the LVAD and the left ventricle that was identified during the filling phase. Their duration of LVAD use ranged from 40 to 81 days before they were diagnosed with obstruction of the inflow cannula.

Although the three patients underwent surgical repositioning of the cannula, only one recovered from the surgery, said Mr. Miller, who was a research associate at Sharp Memorial. He is now at the University of California at Irvine.

A control group of four LVAD patients without symptoms of heart failure who were undergoing catheterization for other reasons did not show any dysfunction of the inflow cannula.

WASHINGTON — Cannula obstruction and inflow valve regurgitation of left ventricular assist devices may contribute to recurrent heart failure in long-term users of the devices, according to findings from a small review study.

Among 61 patients who have been implanted with a left ventricular assist device (LVAD) at Sharp Memorial Hospital, San Diego, since 1995, 6 have developed recurrent heart failure. On catheterization of the heart, LVAD, and cannulae, 3 of the 6 patients had inflow cannula valve regurgitation seen on LVAD angiography.

Those 3 patients had received their LVADs between 309 and 696 days prior to the diagnosis of regurgitation.

All 3 of the patients recovered following replacement of the LVAD cannula, David A. Miller reported during a moderated poster session at the annual conference of the American Society for Artificial Internal Organs.

In three other patients, a two-catheter approach helped to identify obstruction of the inflow cannula as a result of a pressure gradient between the LVAD and the left ventricle that was identified during the filling phase. Their duration of LVAD use ranged from 40 to 81 days before they were diagnosed with obstruction of the inflow cannula.

Although the three patients underwent surgical repositioning of the cannula, only one recovered from the surgery, said Mr. Miller, who was a research associate at Sharp Memorial. He is now at the University of California at Irvine.

A control group of four LVAD patients without symptoms of heart failure who were undergoing catheterization for other reasons did not show any dysfunction of the inflow cannula.

WASHINGTON — Cannula obstruction and inflow valve regurgitation of left ventricular assist devices may contribute to recurrent heart failure in long-term users of the devices, according to findings from a small review study.

Among 61 patients who have been implanted with a left ventricular assist device (LVAD) at Sharp Memorial Hospital, San Diego, since 1995, 6 have developed recurrent heart failure. On catheterization of the heart, LVAD, and cannulae, 3 of the 6 patients had inflow cannula valve regurgitation seen on LVAD angiography.

Those 3 patients had received their LVADs between 309 and 696 days prior to the diagnosis of regurgitation.

All 3 of the patients recovered following replacement of the LVAD cannula, David A. Miller reported during a moderated poster session at the annual conference of the American Society for Artificial Internal Organs.

In three other patients, a two-catheter approach helped to identify obstruction of the inflow cannula as a result of a pressure gradient between the LVAD and the left ventricle that was identified during the filling phase. Their duration of LVAD use ranged from 40 to 81 days before they were diagnosed with obstruction of the inflow cannula.

Although the three patients underwent surgical repositioning of the cannula, only one recovered from the surgery, said Mr. Miller, who was a research associate at Sharp Memorial. He is now at the University of California at Irvine.

A control group of four LVAD patients without symptoms of heart failure who were undergoing catheterization for other reasons did not show any dysfunction of the inflow cannula.

QUEBEC CITY — A series of deep injections with hyaluronic acid fillers to lift the cheek and lower eyelid regions appears to provide long-term cosmetic results, Wayne Carey, M.D., said at the annual conference of the Canadian Dermatology Association.

Deep injections of hyaluronic acids have been thought conventionally to be quickly absorbed if injected below the dermis, but deeper bolus injections appear to have long-lasting effects, said Dr. Carey, director of dermatologic surgery at McGill University, Montreal.

Dr. Carey's "tri-site bolus technique" delivers a bolus of hyaluronic acid to tissue about 3–15 mm deep into subcutaneous, supraperiosteal areas, unlike other procedures that employ a threading or microdroplet technique to inject filler to a depth of only 1–2 mm.

"This is a treatment that addresses the midface aging that is not corrected by facelifts or blepharoplasty," he said.

The technique increases the cheek volume, allows sculpting of the cheek in the zygomatic region, lifts or ablates the palpebral sulcus, and may increase the nasolabial fold indirectly by volumetric expansion of the cheek, he explained. It often makes a lower eyelid blepharoplasty or standard facelift unnecessary.

During the procedure, Dr. Carey asks his patients to sit erect while he delivers a continuous deep injection without anesthesia, without moving the needle, and without massaging the injection area; this forms a nonvisible, subcutaneous nodule. Right-handers inject with the right hand and control the migration of the material with the left hand.

He typically injects 1–5 syringes (each is 0.8 mL) into the upper cheek area on each side, although on average he injects 2.5–3 syringes per side. The first site of injection is usually around the location of the infraorbital nerve, followed by the zygomatic and nasal-jugal sulcus areas.

The effects of the technique have lasted over 18–24 months of follow-up and even up to 4 years in one woman, said Dr. Carey, who said he has no conflicts of interest regarding any hyaluronic acid products.

Although Dr. Carey has used only Perlane and Juvederm 30 in more than 75 patients he has treated with his technique, he suggested that deep, bolus injections with Restylane or Hylaform would theoretically give the same longevity seen in his patients, he said in an interview. Perlane and Restylane produce a more swollen appearance in the first few days after injection than other hyaluronic acid products, such as Juvederm, because they draw in more water from their surroundings.

The bolus technique may last longer than other procedures that inject hyaluronic acid products into the dermis because the nodule that is formed with the technique has a lower surface-area-to-volume ratio, making less hyaluronic acid available for hyaluronidase to break down. The body also might wall off the nodule, which would also make it less susceptible to hyaluronidase, Dr. Carey suggested. In a report, a biopsy of an injection site where Restylane persisted for 5 years showed a fibrotic reaction (Ophthal. Plast. Reconstr. Surg. 2004;20:317–8).

Heavy bruising lasting up to 1 week has been a significant problem in most patients who received the injections. One patient had prolonged pigmentation, which might be deposits of hemosiderin or postinflammatory hyperpigmentation, he said. Another patient has had persistent, unilateral lymphedema for about 2 months, but has improved during the last few weeks, Dr. Carey said. He is considering injecting hyaluronidase into the treatment site to relieve the complication.

Before treatment, this patient had malar bags and considerable loss of subcutaneous tissue of the cheeks.

Final results were achieved after injection of 13 syringes of hyaluronic acid. Photos courtesy Dr. Wayne Carey

QUEBEC CITY — A series of deep injections with hyaluronic acid fillers to lift the cheek and lower eyelid regions appears to provide long-term cosmetic results, Wayne Carey, M.D., said at the annual conference of the Canadian Dermatology Association.

Deep injections of hyaluronic acids have been thought conventionally to be quickly absorbed if injected below the dermis, but deeper bolus injections appear to have long-lasting effects, said Dr. Carey, director of dermatologic surgery at McGill University, Montreal.

Dr. Carey's "tri-site bolus technique" delivers a bolus of hyaluronic acid to tissue about 3–15 mm deep into subcutaneous, supraperiosteal areas, unlike other procedures that employ a threading or microdroplet technique to inject filler to a depth of only 1–2 mm.

"This is a treatment that addresses the midface aging that is not corrected by facelifts or blepharoplasty," he said.

The technique increases the cheek volume, allows sculpting of the cheek in the zygomatic region, lifts or ablates the palpebral sulcus, and may increase the nasolabial fold indirectly by volumetric expansion of the cheek, he explained. It often makes a lower eyelid blepharoplasty or standard facelift unnecessary.

During the procedure, Dr. Carey asks his patients to sit erect while he delivers a continuous deep injection without anesthesia, without moving the needle, and without massaging the injection area; this forms a nonvisible, subcutaneous nodule. Right-handers inject with the right hand and control the migration of the material with the left hand.

He typically injects 1–5 syringes (each is 0.8 mL) into the upper cheek area on each side, although on average he injects 2.5–3 syringes per side. The first site of injection is usually around the location of the infraorbital nerve, followed by the zygomatic and nasal-jugal sulcus areas.

The effects of the technique have lasted over 18–24 months of follow-up and even up to 4 years in one woman, said Dr. Carey, who said he has no conflicts of interest regarding any hyaluronic acid products.

Although Dr. Carey has used only Perlane and Juvederm 30 in more than 75 patients he has treated with his technique, he suggested that deep, bolus injections with Restylane or Hylaform would theoretically give the same longevity seen in his patients, he said in an interview. Perlane and Restylane produce a more swollen appearance in the first few days after injection than other hyaluronic acid products, such as Juvederm, because they draw in more water from their surroundings.

The bolus technique may last longer than other procedures that inject hyaluronic acid products into the dermis because the nodule that is formed with the technique has a lower surface-area-to-volume ratio, making less hyaluronic acid available for hyaluronidase to break down. The body also might wall off the nodule, which would also make it less susceptible to hyaluronidase, Dr. Carey suggested. In a report, a biopsy of an injection site where Restylane persisted for 5 years showed a fibrotic reaction (Ophthal. Plast. Reconstr. Surg. 2004;20:317–8).

Heavy bruising lasting up to 1 week has been a significant problem in most patients who received the injections. One patient had prolonged pigmentation, which might be deposits of hemosiderin or postinflammatory hyperpigmentation, he said. Another patient has had persistent, unilateral lymphedema for about 2 months, but has improved during the last few weeks, Dr. Carey said. He is considering injecting hyaluronidase into the treatment site to relieve the complication.

Before treatment, this patient had malar bags and considerable loss of subcutaneous tissue of the cheeks.

Final results were achieved after injection of 13 syringes of hyaluronic acid. Photos courtesy Dr. Wayne Carey

QUEBEC CITY — A series of deep injections with hyaluronic acid fillers to lift the cheek and lower eyelid regions appears to provide long-term cosmetic results, Wayne Carey, M.D., said at the annual conference of the Canadian Dermatology Association.

Deep injections of hyaluronic acids have been thought conventionally to be quickly absorbed if injected below the dermis, but deeper bolus injections appear to have long-lasting effects, said Dr. Carey, director of dermatologic surgery at McGill University, Montreal.

Dr. Carey's "tri-site bolus technique" delivers a bolus of hyaluronic acid to tissue about 3–15 mm deep into subcutaneous, supraperiosteal areas, unlike other procedures that employ a threading or microdroplet technique to inject filler to a depth of only 1–2 mm.

"This is a treatment that addresses the midface aging that is not corrected by facelifts or blepharoplasty," he said.

The technique increases the cheek volume, allows sculpting of the cheek in the zygomatic region, lifts or ablates the palpebral sulcus, and may increase the nasolabial fold indirectly by volumetric expansion of the cheek, he explained. It often makes a lower eyelid blepharoplasty or standard facelift unnecessary.

During the procedure, Dr. Carey asks his patients to sit erect while he delivers a continuous deep injection without anesthesia, without moving the needle, and without massaging the injection area; this forms a nonvisible, subcutaneous nodule. Right-handers inject with the right hand and control the migration of the material with the left hand.

He typically injects 1–5 syringes (each is 0.8 mL) into the upper cheek area on each side, although on average he injects 2.5–3 syringes per side. The first site of injection is usually around the location of the infraorbital nerve, followed by the zygomatic and nasal-jugal sulcus areas.

The effects of the technique have lasted over 18–24 months of follow-up and even up to 4 years in one woman, said Dr. Carey, who said he has no conflicts of interest regarding any hyaluronic acid products.

Although Dr. Carey has used only Perlane and Juvederm 30 in more than 75 patients he has treated with his technique, he suggested that deep, bolus injections with Restylane or Hylaform would theoretically give the same longevity seen in his patients, he said in an interview. Perlane and Restylane produce a more swollen appearance in the first few days after injection than other hyaluronic acid products, such as Juvederm, because they draw in more water from their surroundings.

The bolus technique may last longer than other procedures that inject hyaluronic acid products into the dermis because the nodule that is formed with the technique has a lower surface-area-to-volume ratio, making less hyaluronic acid available for hyaluronidase to break down. The body also might wall off the nodule, which would also make it less susceptible to hyaluronidase, Dr. Carey suggested. In a report, a biopsy of an injection site where Restylane persisted for 5 years showed a fibrotic reaction (Ophthal. Plast. Reconstr. Surg. 2004;20:317–8).

Heavy bruising lasting up to 1 week has been a significant problem in most patients who received the injections. One patient had prolonged pigmentation, which might be deposits of hemosiderin or postinflammatory hyperpigmentation, he said. Another patient has had persistent, unilateral lymphedema for about 2 months, but has improved during the last few weeks, Dr. Carey said. He is considering injecting hyaluronidase into the treatment site to relieve the complication.

Before treatment, this patient had malar bags and considerable loss of subcutaneous tissue of the cheeks.

Final results were achieved after injection of 13 syringes of hyaluronic acid. Photos courtesy Dr. Wayne Carey

ORLANDO — Looking at prognostic features of prostate cancer may help chart the course of primary or secondary treatments, investigators reported at a symposium sponsored by the American Society of Clinical Oncology.

Three studies showed the importance of p53 gene expression, history of prostate-specific antigen (PSA) levels, and Gleason score in predicting the natural history of prostate cancer and its treatment response.

Abnormal p53 Expression

A mutation of the p53 tumor suppressor gene is an independent prognostic factor in predicting death from prostate cancer, according to results from the largest study of p53 ever performed in men.

The p53 gene is mutated in about half of all types of cancer, and cancers with the p53 mutation tend to be clinically aggressive and difficult to cure, said Mingxie Che, M.D., of the department of pathology at Wayne State University, Detroit.

Tissue was available from 777 men with locally advanced prostate cancer who had participated in a clinical trial comparing short-term and long-term androgen deprivation in combination with radiation therapy (J. Clin. Oncol. 2003;21:3972–8).

The investigators detected abnormal p53 in 168 patients (22%). Abnormalities in p53 were detected more often at higher tumor grades: in 14% of cases with Gleason score 2–6, in 21% of those with Gleason score 7, and in 31% of those with Gleason score 8–10. Overall, 74 patients (10%) died from prostate cancer.

In multivariate analyses, patients who had abnormal p53 were 77% more likely to die from prostate cancer and 60% more likely to develop distant metastases at 5 years, compared with men without abnormal p53.

High Annual Preoperative PSA Velocity

A high annual preoperative PSA velocity and a high Gleason score in a biopsy specimen are independent prognostic factors for relapse after radical prostatectomy, Deep A. Patel, M.D., reported in a poster session.

In a review of 202 men who underwent radical retropubic prostatectomy, 31 had biochemical recurrence, defined as a PSA level of 0.2 ng/mL or higher. None of the patients had nodal disease or received neoadjuvant androgen deprivation, which had a median follow-up of 48 months.

Estimated relapse-free survival at 5 years fell with increasingly higher PSA velocity, wrote Dr. Patel, a third-year resident in the department of radiation oncology at Stanford (Calif.) University. Estimated relapse-free survival at 5 years was lower in patients with a preoperative PSA velocity greater than 1 ng/mL per year than in patients with a preoperative PSA velocity of 1 ng/mL per year or less (76% vs. 97%).

Preoperative PSA velocity of more than 1 ng/mL per year was independently associated with a significant, nearly fivefold higher risk of biochemical relapse, compared with a PSA velocity of 1 ng/mL per year or less. Gleason scores of 7 or greater also were independently associated with an approximately fivefold higher risk of biochemical relapse, compared with patients who had Gleason scores of 6 or less.

Cumulative PSA Exposure and Gleason Score

Prostate cancer patients with a high cumulative exposure to PSA and a high Gleason score are at risk for low survival, said Eugeniu Banu, M.D., of the Georges Pompidou European Hospital, Paris.

In a review of 481 patients seen from 1983 to 2004 at a single center, risk groups defined by low or high cumulative exposure to PSA (lower or higher than 60 ng/mL) and low or high Gleason score (5–7 or 8–10) were significantly associated with the duration between prostate cancer diagnosis and death or loss of follow-up.

Only 30% of 76 patients in the highest-risk group (high cumulative exposure to PSA and high Gleason score) were alive at 5 years; patients in this group died or were lost to follow-up a median of 3.3 years after diagnosis, Dr. Banu reported during a poster session at the symposium, which was cosponsored by the Society of Urologic Oncology and the American Society for Therapeutic Radiology and Oncology.

In contrast, 86% of 206 patients in the lowest-risk group (low cumulative exposure to PSA and low Gleason score) were alive at 5 years; 42% were alive at 15 years. A median of 10.5 years passed before these patients died or were lost to follow-up.

ORLANDO — Looking at prognostic features of prostate cancer may help chart the course of primary or secondary treatments, investigators reported at a symposium sponsored by the American Society of Clinical Oncology.

Three studies showed the importance of p53 gene expression, history of prostate-specific antigen (PSA) levels, and Gleason score in predicting the natural history of prostate cancer and its treatment response.

Abnormal p53 Expression

A mutation of the p53 tumor suppressor gene is an independent prognostic factor in predicting death from prostate cancer, according to results from the largest study of p53 ever performed in men.

The p53 gene is mutated in about half of all types of cancer, and cancers with the p53 mutation tend to be clinically aggressive and difficult to cure, said Mingxie Che, M.D., of the department of pathology at Wayne State University, Detroit.

Tissue was available from 777 men with locally advanced prostate cancer who had participated in a clinical trial comparing short-term and long-term androgen deprivation in combination with radiation therapy (J. Clin. Oncol. 2003;21:3972–8).

The investigators detected abnormal p53 in 168 patients (22%). Abnormalities in p53 were detected more often at higher tumor grades: in 14% of cases with Gleason score 2–6, in 21% of those with Gleason score 7, and in 31% of those with Gleason score 8–10. Overall, 74 patients (10%) died from prostate cancer.

In multivariate analyses, patients who had abnormal p53 were 77% more likely to die from prostate cancer and 60% more likely to develop distant metastases at 5 years, compared with men without abnormal p53.

High Annual Preoperative PSA Velocity

A high annual preoperative PSA velocity and a high Gleason score in a biopsy specimen are independent prognostic factors for relapse after radical prostatectomy, Deep A. Patel, M.D., reported in a poster session.

In a review of 202 men who underwent radical retropubic prostatectomy, 31 had biochemical recurrence, defined as a PSA level of 0.2 ng/mL or higher. None of the patients had nodal disease or received neoadjuvant androgen deprivation, which had a median follow-up of 48 months.

Estimated relapse-free survival at 5 years fell with increasingly higher PSA velocity, wrote Dr. Patel, a third-year resident in the department of radiation oncology at Stanford (Calif.) University. Estimated relapse-free survival at 5 years was lower in patients with a preoperative PSA velocity greater than 1 ng/mL per year than in patients with a preoperative PSA velocity of 1 ng/mL per year or less (76% vs. 97%).

Preoperative PSA velocity of more than 1 ng/mL per year was independently associated with a significant, nearly fivefold higher risk of biochemical relapse, compared with a PSA velocity of 1 ng/mL per year or less. Gleason scores of 7 or greater also were independently associated with an approximately fivefold higher risk of biochemical relapse, compared with patients who had Gleason scores of 6 or less.

Cumulative PSA Exposure and Gleason Score

Prostate cancer patients with a high cumulative exposure to PSA and a high Gleason score are at risk for low survival, said Eugeniu Banu, M.D., of the Georges Pompidou European Hospital, Paris.

In a review of 481 patients seen from 1983 to 2004 at a single center, risk groups defined by low or high cumulative exposure to PSA (lower or higher than 60 ng/mL) and low or high Gleason score (5–7 or 8–10) were significantly associated with the duration between prostate cancer diagnosis and death or loss of follow-up.

Only 30% of 76 patients in the highest-risk group (high cumulative exposure to PSA and high Gleason score) were alive at 5 years; patients in this group died or were lost to follow-up a median of 3.3 years after diagnosis, Dr. Banu reported during a poster session at the symposium, which was cosponsored by the Society of Urologic Oncology and the American Society for Therapeutic Radiology and Oncology.

In contrast, 86% of 206 patients in the lowest-risk group (low cumulative exposure to PSA and low Gleason score) were alive at 5 years; 42% were alive at 15 years. A median of 10.5 years passed before these patients died or were lost to follow-up.

ORLANDO — Looking at prognostic features of prostate cancer may help chart the course of primary or secondary treatments, investigators reported at a symposium sponsored by the American Society of Clinical Oncology.

Three studies showed the importance of p53 gene expression, history of prostate-specific antigen (PSA) levels, and Gleason score in predicting the natural history of prostate cancer and its treatment response.

Abnormal p53 Expression

A mutation of the p53 tumor suppressor gene is an independent prognostic factor in predicting death from prostate cancer, according to results from the largest study of p53 ever performed in men.

The p53 gene is mutated in about half of all types of cancer, and cancers with the p53 mutation tend to be clinically aggressive and difficult to cure, said Mingxie Che, M.D., of the department of pathology at Wayne State University, Detroit.

Tissue was available from 777 men with locally advanced prostate cancer who had participated in a clinical trial comparing short-term and long-term androgen deprivation in combination with radiation therapy (J. Clin. Oncol. 2003;21:3972–8).

The investigators detected abnormal p53 in 168 patients (22%). Abnormalities in p53 were detected more often at higher tumor grades: in 14% of cases with Gleason score 2–6, in 21% of those with Gleason score 7, and in 31% of those with Gleason score 8–10. Overall, 74 patients (10%) died from prostate cancer.

In multivariate analyses, patients who had abnormal p53 were 77% more likely to die from prostate cancer and 60% more likely to develop distant metastases at 5 years, compared with men without abnormal p53.

High Annual Preoperative PSA Velocity

A high annual preoperative PSA velocity and a high Gleason score in a biopsy specimen are independent prognostic factors for relapse after radical prostatectomy, Deep A. Patel, M.D., reported in a poster session.

In a review of 202 men who underwent radical retropubic prostatectomy, 31 had biochemical recurrence, defined as a PSA level of 0.2 ng/mL or higher. None of the patients had nodal disease or received neoadjuvant androgen deprivation, which had a median follow-up of 48 months.

Estimated relapse-free survival at 5 years fell with increasingly higher PSA velocity, wrote Dr. Patel, a third-year resident in the department of radiation oncology at Stanford (Calif.) University. Estimated relapse-free survival at 5 years was lower in patients with a preoperative PSA velocity greater than 1 ng/mL per year than in patients with a preoperative PSA velocity of 1 ng/mL per year or less (76% vs. 97%).

Preoperative PSA velocity of more than 1 ng/mL per year was independently associated with a significant, nearly fivefold higher risk of biochemical relapse, compared with a PSA velocity of 1 ng/mL per year or less. Gleason scores of 7 or greater also were independently associated with an approximately fivefold higher risk of biochemical relapse, compared with patients who had Gleason scores of 6 or less.

Cumulative PSA Exposure and Gleason Score

Prostate cancer patients with a high cumulative exposure to PSA and a high Gleason score are at risk for low survival, said Eugeniu Banu, M.D., of the Georges Pompidou European Hospital, Paris.

In a review of 481 patients seen from 1983 to 2004 at a single center, risk groups defined by low or high cumulative exposure to PSA (lower or higher than 60 ng/mL) and low or high Gleason score (5–7 or 8–10) were significantly associated with the duration between prostate cancer diagnosis and death or loss of follow-up.

Only 30% of 76 patients in the highest-risk group (high cumulative exposure to PSA and high Gleason score) were alive at 5 years; patients in this group died or were lost to follow-up a median of 3.3 years after diagnosis, Dr. Banu reported during a poster session at the symposium, which was cosponsored by the Society of Urologic Oncology and the American Society for Therapeutic Radiology and Oncology.

In contrast, 86% of 206 patients in the lowest-risk group (low cumulative exposure to PSA and low Gleason score) were alive at 5 years; 42% were alive at 15 years. A median of 10.5 years passed before these patients died or were lost to follow-up.

ORLANDO — New modalities for detecting prostate cancer metastases may help physicians target treatment more effectively to diseased tissues, speakers said at a symposium on prostate cancer sponsored by the American Society of Clinical Oncology.

Current staging of the lymph nodes of patients with intermediate- or high-risk prostate cancer involves noninvasive tests such as CT and MRI, or the gold standard procedure of pelvic lymphadenectomy, noted Mukesh Harisinghani, M.D., of Massachusetts General Hospital, Boston.

Noninvasive tests rely on the diameter of the short axis of the lymph nodes to determine their status. On MRI, oval nodes less than 10 mm in diameter or round nodes less than 8 mm in size are labeled benign, whereas larger nodes of similar shape are considered malignant. However, Dr. Harisinghani said, “Size criterion is very inaccurate in staging lymph nodes.”

During pelvic lymphadenectomy, surgeons generally sample the lower external iliac and obturator lymph nodes.

A study showed that when the dissection was extended to the higher external, internal, and common iliac lymph nodes as well as the presacral lymph nodes, the metastasis rate increased from 10% to 26% (J. Urol. 2002;167:1681–6).

But even an extended pelvic lymphadenectomy does not allow sampling of all nodes at the time of surgery, Dr. Harisinghani said at the symposium, cosponsored by the Society of Urologic Oncology and the American Society for Therapeutic Radiology and Oncology. Frozen section analysis of lymph node specimens also carries a false-negative rate of up to 30%, he added.

A new MRI technique involves the infusion of tiny, 20-nm-diameter, dextran-coated iron oxide spheres into the bloodstream. The spheres bind to macrophages in the lymph nodes. After 24 hours, nodal areas that did not take in the nanospheres indicate metastatic regions.

In 80 patients with advanced prostate cancer, the nanosphere imaging technique yielded significantly higher sensitivity (91% vs. 35%) and specificity (98% vs. 90%) as well as greater accuracy (97% vs. 76%) than conventional MRI alone in detecting metastases on a node-by-node basis (N. Engl. J. Med. 2003;348:2491–9). About 71% of the malignant nodes were below the size criterion, Dr. Harisinghani noted.

The imaging procedure allows surgeons to pinpoint positive nodes that they normally would not have dissected and to see exactly where they lie in relation to vessels, obturator nerves, and ureters. And by combining MRI data with data from CT scans, cancerous nodes can be targeted, thereby avoiding unnecessary radiation.

Clinicians also desire a test that complements anatomic imaging with CT and MRI or metabolic imaging with PET to determine if prostate cancer has spread to bone or soft tissue, Neil H. Bander, M.D, said in a separate presentation. Bone is the earliest and most common site of metastatic prostate cancer.

Second-generation monoclonal antibodies may offer the best hope for staging metastasizing or recurrent disease in prostate cancer patients, said Dr. Bander, professor of urologic oncology at Weill Medical College of Cornell University, New York.

Antibodies such as

In vivo imaging with J591 shows soft tissue and bone metastases of prostate cancer patients equally well. J591 imaging can detect bone metastases that go unseen in a standard bone scan, Dr. Bander noted.

Few clinicians still use imaging with the first-generation

Findings from clinical studies on Prostascint have shown that the antibody scan detects soft tissue metastases with greater accuracy than MRI or CT, but it does not detect bone metastases very well.

ORLANDO — New modalities for detecting prostate cancer metastases may help physicians target treatment more effectively to diseased tissues, speakers said at a symposium on prostate cancer sponsored by the American Society of Clinical Oncology.

Current staging of the lymph nodes of patients with intermediate- or high-risk prostate cancer involves noninvasive tests such as CT and MRI, or the gold standard procedure of pelvic lymphadenectomy, noted Mukesh Harisinghani, M.D., of Massachusetts General Hospital, Boston.

Noninvasive tests rely on the diameter of the short axis of the lymph nodes to determine their status. On MRI, oval nodes less than 10 mm in diameter or round nodes less than 8 mm in size are labeled benign, whereas larger nodes of similar shape are considered malignant. However, Dr. Harisinghani said, “Size criterion is very inaccurate in staging lymph nodes.”

During pelvic lymphadenectomy, surgeons generally sample the lower external iliac and obturator lymph nodes.

A study showed that when the dissection was extended to the higher external, internal, and common iliac lymph nodes as well as the presacral lymph nodes, the metastasis rate increased from 10% to 26% (J. Urol. 2002;167:1681–6).

But even an extended pelvic lymphadenectomy does not allow sampling of all nodes at the time of surgery, Dr. Harisinghani said at the symposium, cosponsored by the Society of Urologic Oncology and the American Society for Therapeutic Radiology and Oncology. Frozen section analysis of lymph node specimens also carries a false-negative rate of up to 30%, he added.

A new MRI technique involves the infusion of tiny, 20-nm-diameter, dextran-coated iron oxide spheres into the bloodstream. The spheres bind to macrophages in the lymph nodes. After 24 hours, nodal areas that did not take in the nanospheres indicate metastatic regions.

In 80 patients with advanced prostate cancer, the nanosphere imaging technique yielded significantly higher sensitivity (91% vs. 35%) and specificity (98% vs. 90%) as well as greater accuracy (97% vs. 76%) than conventional MRI alone in detecting metastases on a node-by-node basis (N. Engl. J. Med. 2003;348:2491–9). About 71% of the malignant nodes were below the size criterion, Dr. Harisinghani noted.

The imaging procedure allows surgeons to pinpoint positive nodes that they normally would not have dissected and to see exactly where they lie in relation to vessels, obturator nerves, and ureters. And by combining MRI data with data from CT scans, cancerous nodes can be targeted, thereby avoiding unnecessary radiation.

Clinicians also desire a test that complements anatomic imaging with CT and MRI or metabolic imaging with PET to determine if prostate cancer has spread to bone or soft tissue, Neil H. Bander, M.D, said in a separate presentation. Bone is the earliest and most common site of metastatic prostate cancer.

Second-generation monoclonal antibodies may offer the best hope for staging metastasizing or recurrent disease in prostate cancer patients, said Dr. Bander, professor of urologic oncology at Weill Medical College of Cornell University, New York.

Antibodies such as

In vivo imaging with J591 shows soft tissue and bone metastases of prostate cancer patients equally well. J591 imaging can detect bone metastases that go unseen in a standard bone scan, Dr. Bander noted.

Few clinicians still use imaging with the first-generation

Findings from clinical studies on Prostascint have shown that the antibody scan detects soft tissue metastases with greater accuracy than MRI or CT, but it does not detect bone metastases very well.

ORLANDO — New modalities for detecting prostate cancer metastases may help physicians target treatment more effectively to diseased tissues, speakers said at a symposium on prostate cancer sponsored by the American Society of Clinical Oncology.

Current staging of the lymph nodes of patients with intermediate- or high-risk prostate cancer involves noninvasive tests such as CT and MRI, or the gold standard procedure of pelvic lymphadenectomy, noted Mukesh Harisinghani, M.D., of Massachusetts General Hospital, Boston.

Noninvasive tests rely on the diameter of the short axis of the lymph nodes to determine their status. On MRI, oval nodes less than 10 mm in diameter or round nodes less than 8 mm in size are labeled benign, whereas larger nodes of similar shape are considered malignant. However, Dr. Harisinghani said, “Size criterion is very inaccurate in staging lymph nodes.”

During pelvic lymphadenectomy, surgeons generally sample the lower external iliac and obturator lymph nodes.

A study showed that when the dissection was extended to the higher external, internal, and common iliac lymph nodes as well as the presacral lymph nodes, the metastasis rate increased from 10% to 26% (J. Urol. 2002;167:1681–6).

But even an extended pelvic lymphadenectomy does not allow sampling of all nodes at the time of surgery, Dr. Harisinghani said at the symposium, cosponsored by the Society of Urologic Oncology and the American Society for Therapeutic Radiology and Oncology. Frozen section analysis of lymph node specimens also carries a false-negative rate of up to 30%, he added.

A new MRI technique involves the infusion of tiny, 20-nm-diameter, dextran-coated iron oxide spheres into the bloodstream. The spheres bind to macrophages in the lymph nodes. After 24 hours, nodal areas that did not take in the nanospheres indicate metastatic regions.

In 80 patients with advanced prostate cancer, the nanosphere imaging technique yielded significantly higher sensitivity (91% vs. 35%) and specificity (98% vs. 90%) as well as greater accuracy (97% vs. 76%) than conventional MRI alone in detecting metastases on a node-by-node basis (N. Engl. J. Med. 2003;348:2491–9). About 71% of the malignant nodes were below the size criterion, Dr. Harisinghani noted.

The imaging procedure allows surgeons to pinpoint positive nodes that they normally would not have dissected and to see exactly where they lie in relation to vessels, obturator nerves, and ureters. And by combining MRI data with data from CT scans, cancerous nodes can be targeted, thereby avoiding unnecessary radiation.

Clinicians also desire a test that complements anatomic imaging with CT and MRI or metabolic imaging with PET to determine if prostate cancer has spread to bone or soft tissue, Neil H. Bander, M.D, said in a separate presentation. Bone is the earliest and most common site of metastatic prostate cancer.

Second-generation monoclonal antibodies may offer the best hope for staging metastasizing or recurrent disease in prostate cancer patients, said Dr. Bander, professor of urologic oncology at Weill Medical College of Cornell University, New York.

Antibodies such as

In vivo imaging with J591 shows soft tissue and bone metastases of prostate cancer patients equally well. J591 imaging can detect bone metastases that go unseen in a standard bone scan, Dr. Bander noted.

Few clinicians still use imaging with the first-generation

Findings from clinical studies on Prostascint have shown that the antibody scan detects soft tissue metastases with greater accuracy than MRI or CT, but it does not detect bone metastases very well.

NEW YORK — Premenopausal women who undergo cardiac catheterization for classic symptoms of coronary heart disease may be less likely to have findings of the disease than women without those symptoms, according to a small retrospective study.

Andra L. Blomkalns, M.D., of the University of Cincinnati and her colleagues identified 169 premenopausal women (younger than 50 years) who underwent cardiac catheterization (defined as having a stent or angioplasty), from a multicenter registry of 17,713 patients who had a complaint of chest pain and received electrocardiography. Of the 169 patients, 53 (31%) had significant coronary artery disease or stenosis greater than 70%.

A set of factors that put premenopausal women at a significantly increased risk for coronary heart disease (CHD) included increasing age, a moderate- or high-risk initial impression, a history of CHD, and positive cardiac markers. In a multivariate model, this set of risk factors predicted CHD with an accuracy of about 80%, Dr. Blomkalns reported in a poster session at the annual meeting of the Society for Academic Emergency Medicine.

The classic symptoms of CHD such as shortness of breath and pain radiating to the chest or left arm were not significantly associated with an increased risk for CHD in the premenopausal women.

NEW YORK — Premenopausal women who undergo cardiac catheterization for classic symptoms of coronary heart disease may be less likely to have findings of the disease than women without those symptoms, according to a small retrospective study.

Andra L. Blomkalns, M.D., of the University of Cincinnati and her colleagues identified 169 premenopausal women (younger than 50 years) who underwent cardiac catheterization (defined as having a stent or angioplasty), from a multicenter registry of 17,713 patients who had a complaint of chest pain and received electrocardiography. Of the 169 patients, 53 (31%) had significant coronary artery disease or stenosis greater than 70%.

A set of factors that put premenopausal women at a significantly increased risk for coronary heart disease (CHD) included increasing age, a moderate- or high-risk initial impression, a history of CHD, and positive cardiac markers. In a multivariate model, this set of risk factors predicted CHD with an accuracy of about 80%, Dr. Blomkalns reported in a poster session at the annual meeting of the Society for Academic Emergency Medicine.

The classic symptoms of CHD such as shortness of breath and pain radiating to the chest or left arm were not significantly associated with an increased risk for CHD in the premenopausal women.

NEW YORK — Premenopausal women who undergo cardiac catheterization for classic symptoms of coronary heart disease may be less likely to have findings of the disease than women without those symptoms, according to a small retrospective study.

Andra L. Blomkalns, M.D., of the University of Cincinnati and her colleagues identified 169 premenopausal women (younger than 50 years) who underwent cardiac catheterization (defined as having a stent or angioplasty), from a multicenter registry of 17,713 patients who had a complaint of chest pain and received electrocardiography. Of the 169 patients, 53 (31%) had significant coronary artery disease or stenosis greater than 70%.

A set of factors that put premenopausal women at a significantly increased risk for coronary heart disease (CHD) included increasing age, a moderate- or high-risk initial impression, a history of CHD, and positive cardiac markers. In a multivariate model, this set of risk factors predicted CHD with an accuracy of about 80%, Dr. Blomkalns reported in a poster session at the annual meeting of the Society for Academic Emergency Medicine.

The classic symptoms of CHD such as shortness of breath and pain radiating to the chest or left arm were not significantly associated with an increased risk for CHD in the premenopausal women.

WASHINGTON — Patients with left ventricular assist devices who undergo surgery that is unrelated to their device can safely manage the operation without device complications, according to results achieved at a single center.

The likelihood that a patient with a left ventricular assist device (LVAD) will require surgery unrelated to the LVAD is increasing as a result of growing clinical experience with such devices, the development of longer-lasting LVADs, and growth in indications for permanent devices, Devin M. Nelson said during a moderated poster session at the annual conference of the American Society for Artificial Internal Organs.

A total of 16 patients underwent 24 surgical procedures during 1998–2005 at LDS Hospital, Salt Lake City, without any deaths or complications related to the LVAD. Five patients underwent more than one surgery on separate occasions, and two of the patients had two procedures performed during the same surgical session, Mr. Nelson reported.

Most (86%) of the surgical sessions occurred after the patient's hospital discharge for LVAD implantation. LVADs supported the patients for a range of 9–1,511 days before surgery and continued to do so for range of 21–991 days after surgery, said Mr. Nelson, a bioengineering research assistant with the Utah Artificial Heart Program at the hospital.

The most common surgical procedures included hernia repair (five), excision of melanoma (three), cholecystectomy (three), and lower limb amputation (three).

A trained mechanical circulatory support member attended each surgery to monitor the function of the LVAD. All surgeries also involved a cardiac anesthesiologist.

WASHINGTON — Patients with left ventricular assist devices who undergo surgery that is unrelated to their device can safely manage the operation without device complications, according to results achieved at a single center.

The likelihood that a patient with a left ventricular assist device (LVAD) will require surgery unrelated to the LVAD is increasing as a result of growing clinical experience with such devices, the development of longer-lasting LVADs, and growth in indications for permanent devices, Devin M. Nelson said during a moderated poster session at the annual conference of the American Society for Artificial Internal Organs.

A total of 16 patients underwent 24 surgical procedures during 1998–2005 at LDS Hospital, Salt Lake City, without any deaths or complications related to the LVAD. Five patients underwent more than one surgery on separate occasions, and two of the patients had two procedures performed during the same surgical session, Mr. Nelson reported.

Most (86%) of the surgical sessions occurred after the patient's hospital discharge for LVAD implantation. LVADs supported the patients for a range of 9–1,511 days before surgery and continued to do so for range of 21–991 days after surgery, said Mr. Nelson, a bioengineering research assistant with the Utah Artificial Heart Program at the hospital.

The most common surgical procedures included hernia repair (five), excision of melanoma (three), cholecystectomy (three), and lower limb amputation (three).

A trained mechanical circulatory support member attended each surgery to monitor the function of the LVAD. All surgeries also involved a cardiac anesthesiologist.

WASHINGTON — Patients with left ventricular assist devices who undergo surgery that is unrelated to their device can safely manage the operation without device complications, according to results achieved at a single center.

The likelihood that a patient with a left ventricular assist device (LVAD) will require surgery unrelated to the LVAD is increasing as a result of growing clinical experience with such devices, the development of longer-lasting LVADs, and growth in indications for permanent devices, Devin M. Nelson said during a moderated poster session at the annual conference of the American Society for Artificial Internal Organs.

A total of 16 patients underwent 24 surgical procedures during 1998–2005 at LDS Hospital, Salt Lake City, without any deaths or complications related to the LVAD. Five patients underwent more than one surgery on separate occasions, and two of the patients had two procedures performed during the same surgical session, Mr. Nelson reported.

Most (86%) of the surgical sessions occurred after the patient's hospital discharge for LVAD implantation. LVADs supported the patients for a range of 9–1,511 days before surgery and continued to do so for range of 21–991 days after surgery, said Mr. Nelson, a bioengineering research assistant with the Utah Artificial Heart Program at the hospital.

The most common surgical procedures included hernia repair (five), excision of melanoma (three), cholecystectomy (three), and lower limb amputation (three).

A trained mechanical circulatory support member attended each surgery to monitor the function of the LVAD. All surgeries also involved a cardiac anesthesiologist.

BETHESDA, MD. — Calcitonin nasal spray appears to preserve trabecular bone microarchitecture at the distal radius without substantially altering bone mineral density, Charles H. Chestnut III, M.D., reported during a meeting on bone quality.

In a 2-year, randomized, double-blind trial involving 91 women with an average age of 67 years, high-resolution MRI analysis of the distal radius showed that calcitonin nasal spray preserved significantly more trabecular bone architecture than placebo.

Calcitonin's effects included preservation of the volume, number, spacing, and thickness of trabecular bone, Dr. Chestnut wrote in a poster presentation at the meeting, which was sponsored by the National Institute for Arthritis and Musculoskeletal and Skin Diseases and the American Society for Bone and Mineral Research.

Trabecular bone microarchitecture was significantly preserved—if not reinforced—in calcitonin patients, compared with placebo patients, despite loss in bone mineral density (BMD) at the distal radius or lumbar spine during the same period, Dr. Chestnut said.

In placebo patients, the number of trabeculae declined slightly at those sites even if the women had gained BMD.

The results are consistent with earlier reports showing that calcitonin spray was associated with reductions in osteoporotic fractures in postmenopausal women with a history of vertebral fracture, despite producing minimal increases in BMD, said Dr. Chestnut, professor of medicine and radiology at the University of Washington, Seattle.

Almost none of the measurements of BMD in the lumbar spine or midradius were significantly correlated with measures of trabecular microarchitecture change as shown on high-resolution MRI, suggesting that “BMD is a poor marker for trabecular microarchitecture,” Dr. Chestnut wrote.

In the calcitonin group, trabecular microarchitecture in the lower trochanter was preserved, according to T2-MRI findings, regardless of whether patients lost or gained total hip BMD.

By comparison, trabecular microarchitecture deteriorated in the placebo group.

All women in the trial received calcium supplementation.

Dr. Chestnut reported that he has received research grants and consulting fees from Novartis Pharmaceuticals Corp., which funded the trial and manufactures calcitonin-salmon nasal spray, marketed as Miacalcin.

BETHESDA, MD. — Calcitonin nasal spray appears to preserve trabecular bone microarchitecture at the distal radius without substantially altering bone mineral density, Charles H. Chestnut III, M.D., reported during a meeting on bone quality.

In a 2-year, randomized, double-blind trial involving 91 women with an average age of 67 years, high-resolution MRI analysis of the distal radius showed that calcitonin nasal spray preserved significantly more trabecular bone architecture than placebo.

Calcitonin's effects included preservation of the volume, number, spacing, and thickness of trabecular bone, Dr. Chestnut wrote in a poster presentation at the meeting, which was sponsored by the National Institute for Arthritis and Musculoskeletal and Skin Diseases and the American Society for Bone and Mineral Research.

Trabecular bone microarchitecture was significantly preserved—if not reinforced—in calcitonin patients, compared with placebo patients, despite loss in bone mineral density (BMD) at the distal radius or lumbar spine during the same period, Dr. Chestnut said.

In placebo patients, the number of trabeculae declined slightly at those sites even if the women had gained BMD.

The results are consistent with earlier reports showing that calcitonin spray was associated with reductions in osteoporotic fractures in postmenopausal women with a history of vertebral fracture, despite producing minimal increases in BMD, said Dr. Chestnut, professor of medicine and radiology at the University of Washington, Seattle.

Almost none of the measurements of BMD in the lumbar spine or midradius were significantly correlated with measures of trabecular microarchitecture change as shown on high-resolution MRI, suggesting that “BMD is a poor marker for trabecular microarchitecture,” Dr. Chestnut wrote.

In the calcitonin group, trabecular microarchitecture in the lower trochanter was preserved, according to T2-MRI findings, regardless of whether patients lost or gained total hip BMD.

By comparison, trabecular microarchitecture deteriorated in the placebo group.

All women in the trial received calcium supplementation.

Dr. Chestnut reported that he has received research grants and consulting fees from Novartis Pharmaceuticals Corp., which funded the trial and manufactures calcitonin-salmon nasal spray, marketed as Miacalcin.

BETHESDA, MD. — Calcitonin nasal spray appears to preserve trabecular bone microarchitecture at the distal radius without substantially altering bone mineral density, Charles H. Chestnut III, M.D., reported during a meeting on bone quality.

In a 2-year, randomized, double-blind trial involving 91 women with an average age of 67 years, high-resolution MRI analysis of the distal radius showed that calcitonin nasal spray preserved significantly more trabecular bone architecture than placebo.

Calcitonin's effects included preservation of the volume, number, spacing, and thickness of trabecular bone, Dr. Chestnut wrote in a poster presentation at the meeting, which was sponsored by the National Institute for Arthritis and Musculoskeletal and Skin Diseases and the American Society for Bone and Mineral Research.

Trabecular bone microarchitecture was significantly preserved—if not reinforced—in calcitonin patients, compared with placebo patients, despite loss in bone mineral density (BMD) at the distal radius or lumbar spine during the same period, Dr. Chestnut said.

In placebo patients, the number of trabeculae declined slightly at those sites even if the women had gained BMD.

The results are consistent with earlier reports showing that calcitonin spray was associated with reductions in osteoporotic fractures in postmenopausal women with a history of vertebral fracture, despite producing minimal increases in BMD, said Dr. Chestnut, professor of medicine and radiology at the University of Washington, Seattle.

Almost none of the measurements of BMD in the lumbar spine or midradius were significantly correlated with measures of trabecular microarchitecture change as shown on high-resolution MRI, suggesting that “BMD is a poor marker for trabecular microarchitecture,” Dr. Chestnut wrote.

In the calcitonin group, trabecular microarchitecture in the lower trochanter was preserved, according to T2-MRI findings, regardless of whether patients lost or gained total hip BMD.

By comparison, trabecular microarchitecture deteriorated in the placebo group.

All women in the trial received calcium supplementation.

Dr. Chestnut reported that he has received research grants and consulting fees from Novartis Pharmaceuticals Corp., which funded the trial and manufactures calcitonin-salmon nasal spray, marketed as Miacalcin.

WASHINGTON — Measuring markers of inflammation and neurohumoral activation in candidates for implantation with a left ventricular assist device may help predict the probability of right ventricular failure, Evgenij V. Potapov, M.D., reported at the annual conference of the American Society for Artificial Internal Organs.

“The problem is that up to 20% of patients receiving a left ventricular assist device [LVAD] develop right heart failure,” Dr. Potapov, a cardiothoracic surgeon at the Deutsches Herzzentrum Berlin, said in an interview.

Dr. Potapov and his colleagues reviewed the records of patients with chronic end-stage heart failure who received an LVAD during 2002-2004.

They found no differences in preoperative echocardiographic findings or laboratory or hemodynamic parameters between the 102 patients who had normal right ventricular function after LVAD implantation and the 9 patients with right ventricular failure, defined as having at least two of the following within 24 hours of LVAD implantation: mean arterial pressure less than 55 mm Hg, central venous pressure less than 16 mm Hg, mixed venous oxygen saturation less than 55%, cardiac index less than 2 L/min per square meter, and more than 20 inotropic equivalents of inotropic support.

But a subsequent prospective study of 40 patients found that people with normal right ventricular function after left ventricular assist device implantation had significantly lower levels of markers of inflammation (procalcitonin and neopterin) and neurohumoral activation (N-terminal pro-B-type natriuretic peptide and big endothelin-1) than did those who would later develop right ventricular failure, he said in a poster session at the conference.

Patients who are identified as having a high probability of right ventricular failure after implantation of a left ventricular assist device could instead undergo implantation of a biventricular support device or a total artificial heart, Dr. Potapov suggested.

None of the patients who were in either study required a left ventricular assist device for postcardiotomy heart failure.

WASHINGTON — Measuring markers of inflammation and neurohumoral activation in candidates for implantation with a left ventricular assist device may help predict the probability of right ventricular failure, Evgenij V. Potapov, M.D., reported at the annual conference of the American Society for Artificial Internal Organs.

“The problem is that up to 20% of patients receiving a left ventricular assist device [LVAD] develop right heart failure,” Dr. Potapov, a cardiothoracic surgeon at the Deutsches Herzzentrum Berlin, said in an interview.

Dr. Potapov and his colleagues reviewed the records of patients with chronic end-stage heart failure who received an LVAD during 2002-2004.

They found no differences in preoperative echocardiographic findings or laboratory or hemodynamic parameters between the 102 patients who had normal right ventricular function after LVAD implantation and the 9 patients with right ventricular failure, defined as having at least two of the following within 24 hours of LVAD implantation: mean arterial pressure less than 55 mm Hg, central venous pressure less than 16 mm Hg, mixed venous oxygen saturation less than 55%, cardiac index less than 2 L/min per square meter, and more than 20 inotropic equivalents of inotropic support.

But a subsequent prospective study of 40 patients found that people with normal right ventricular function after left ventricular assist device implantation had significantly lower levels of markers of inflammation (procalcitonin and neopterin) and neurohumoral activation (N-terminal pro-B-type natriuretic peptide and big endothelin-1) than did those who would later develop right ventricular failure, he said in a poster session at the conference.

Patients who are identified as having a high probability of right ventricular failure after implantation of a left ventricular assist device could instead undergo implantation of a biventricular support device or a total artificial heart, Dr. Potapov suggested.

None of the patients who were in either study required a left ventricular assist device for postcardiotomy heart failure.

WASHINGTON — Measuring markers of inflammation and neurohumoral activation in candidates for implantation with a left ventricular assist device may help predict the probability of right ventricular failure, Evgenij V. Potapov, M.D., reported at the annual conference of the American Society for Artificial Internal Organs.

“The problem is that up to 20% of patients receiving a left ventricular assist device [LVAD] develop right heart failure,” Dr. Potapov, a cardiothoracic surgeon at the Deutsches Herzzentrum Berlin, said in an interview.

Dr. Potapov and his colleagues reviewed the records of patients with chronic end-stage heart failure who received an LVAD during 2002-2004.

They found no differences in preoperative echocardiographic findings or laboratory or hemodynamic parameters between the 102 patients who had normal right ventricular function after LVAD implantation and the 9 patients with right ventricular failure, defined as having at least two of the following within 24 hours of LVAD implantation: mean arterial pressure less than 55 mm Hg, central venous pressure less than 16 mm Hg, mixed venous oxygen saturation less than 55%, cardiac index less than 2 L/min per square meter, and more than 20 inotropic equivalents of inotropic support.

But a subsequent prospective study of 40 patients found that people with normal right ventricular function after left ventricular assist device implantation had significantly lower levels of markers of inflammation (procalcitonin and neopterin) and neurohumoral activation (N-terminal pro-B-type natriuretic peptide and big endothelin-1) than did those who would later develop right ventricular failure, he said in a poster session at the conference.

Patients who are identified as having a high probability of right ventricular failure after implantation of a left ventricular assist device could instead undergo implantation of a biventricular support device or a total artificial heart, Dr. Potapov suggested.

None of the patients who were in either study required a left ventricular assist device for postcardiotomy heart failure.