Robert Finn

LAS VEGAS — Every cluster headache patient needs to be on a prophylactic drug, Todd D. Rozen, M.D., said at a symposium sponsored by the American Headache Society.

“I tell them, 'I'm not happy, and you shouldn't be happy, until you're cluster free on prevention,'” said Dr. Rozen of the Michigan Head-Pain and Neurological Institute, Ann Arbor.

There are two types of prophylaxis for cluster headache: transitional treatments, which are intended to prevent cluster headaches from occurring for a short period of time (typically 7–14 days), and maintenance preventive treatments, which are designed to keep a patient cluster free while in a cluster cycle.

Transitional treatments must kick in quickly. They're used for 10–14 days, after which they're tapered down as the maintenance preventives are tapered up to a therapeutic dose. The transitional drug and maintenance preventive drug are typically started at the same time, Dr. Rozen said.

Corticosteroids are the most commonly used transitional treatment. Start prednisone at a dosage of 60–80 mg/day, tapering down over a period of 10–12 days, he said.

Naratriptan can be used at a dosage of 2.5 mg b.i.d., but monitor the patient for rebound headaches. Ergotamine, at a dosage of 2 mg at bedtime or b.i.d., also appears useful.

Dihydroergotamine can be given by daily intramuscular injections for 1–2 weeks, or by an intravenous infusion for 3 days.

For reasons that are unclear, greater occipital nerve blocks seem to work well, giving some patients up to 13 days free of cluster headaches, even when their pain (like that of most cluster patients) is not located in the occipital area. The mechanism of action may involve decreasing afferent impulses to the spinal trigeminal nuclear complex.

For long-term prevention, a number of drugs work well, but many patients will need to be on combination therapy, taking two, three, or even four drugs to fully prevent recurrences.

“Melatonin is really my first-line choice because it is easy to get over the counter and there are no side effects,” Dr. Rozen said. “[For] a small percentage of cluster patients, the night I give them melatonin is the last time they're going to have a cluster.” The typical dosage is 9 mg at bedtime, although some patients have required higher doses.

Verapamil is the best cluster preventive currently available, Dr. Rozen said. He recommended tapering the dosage up quickly, since some patients will need up to 1 g/day. ECGs must be performed at every dosage above 480 mg to monitor for heart block.

Lithium carbonate, 300 mg t.i.d., appears to be well tolerated in cluster headache.

Valproic acid, pushed up to a dosage of 3,000 mg at bedtime, is sometimes effective.

Some small, uncontrolled studies suggest that topiramate may be effective for preventing clusters.

When trying topiramate, increase the dosage in 25-mg increments every 4–5 days until the patient is taking 75–100 mg/day. When patients do respond to topiramate, it's usually in a short period, 1–2 weeks after starting the agent, he said.

Other preventive treatments that may be effective are transdermal clonidine, tizanidine, indomethacin, nasal capsaicin, gabapentin, baclofen, and histamine desensitization.

For some patients, steroids seem to be the only thing that works, Dr. Rozen noted, and of course patients shouldn't take corticosteroids chronically.

He reported that he has had success in a single patient with mycophenolate mofetil (CellCept), the steroid-sparing immunosuppressant.

Dr. Rozen acknowledged being a member of the advisory board of Ortho-McNeil Pharmaceuticals Inc., whose products include topiramate (Topamax).

LAS VEGAS — Every cluster headache patient needs to be on a prophylactic drug, Todd D. Rozen, M.D., said at a symposium sponsored by the American Headache Society.

“I tell them, 'I'm not happy, and you shouldn't be happy, until you're cluster free on prevention,'” said Dr. Rozen of the Michigan Head-Pain and Neurological Institute, Ann Arbor.

There are two types of prophylaxis for cluster headache: transitional treatments, which are intended to prevent cluster headaches from occurring for a short period of time (typically 7–14 days), and maintenance preventive treatments, which are designed to keep a patient cluster free while in a cluster cycle.

Transitional treatments must kick in quickly. They're used for 10–14 days, after which they're tapered down as the maintenance preventives are tapered up to a therapeutic dose. The transitional drug and maintenance preventive drug are typically started at the same time, Dr. Rozen said.

Corticosteroids are the most commonly used transitional treatment. Start prednisone at a dosage of 60–80 mg/day, tapering down over a period of 10–12 days, he said.

Naratriptan can be used at a dosage of 2.5 mg b.i.d., but monitor the patient for rebound headaches. Ergotamine, at a dosage of 2 mg at bedtime or b.i.d., also appears useful.

Dihydroergotamine can be given by daily intramuscular injections for 1–2 weeks, or by an intravenous infusion for 3 days.

For reasons that are unclear, greater occipital nerve blocks seem to work well, giving some patients up to 13 days free of cluster headaches, even when their pain (like that of most cluster patients) is not located in the occipital area. The mechanism of action may involve decreasing afferent impulses to the spinal trigeminal nuclear complex.

For long-term prevention, a number of drugs work well, but many patients will need to be on combination therapy, taking two, three, or even four drugs to fully prevent recurrences.

“Melatonin is really my first-line choice because it is easy to get over the counter and there are no side effects,” Dr. Rozen said. “[For] a small percentage of cluster patients, the night I give them melatonin is the last time they're going to have a cluster.” The typical dosage is 9 mg at bedtime, although some patients have required higher doses.

Verapamil is the best cluster preventive currently available, Dr. Rozen said. He recommended tapering the dosage up quickly, since some patients will need up to 1 g/day. ECGs must be performed at every dosage above 480 mg to monitor for heart block.

Lithium carbonate, 300 mg t.i.d., appears to be well tolerated in cluster headache.

Valproic acid, pushed up to a dosage of 3,000 mg at bedtime, is sometimes effective.

Some small, uncontrolled studies suggest that topiramate may be effective for preventing clusters.

When trying topiramate, increase the dosage in 25-mg increments every 4–5 days until the patient is taking 75–100 mg/day. When patients do respond to topiramate, it's usually in a short period, 1–2 weeks after starting the agent, he said.

Other preventive treatments that may be effective are transdermal clonidine, tizanidine, indomethacin, nasal capsaicin, gabapentin, baclofen, and histamine desensitization.

For some patients, steroids seem to be the only thing that works, Dr. Rozen noted, and of course patients shouldn't take corticosteroids chronically.

He reported that he has had success in a single patient with mycophenolate mofetil (CellCept), the steroid-sparing immunosuppressant.

Dr. Rozen acknowledged being a member of the advisory board of Ortho-McNeil Pharmaceuticals Inc., whose products include topiramate (Topamax).

LAS VEGAS — Every cluster headache patient needs to be on a prophylactic drug, Todd D. Rozen, M.D., said at a symposium sponsored by the American Headache Society.

“I tell them, 'I'm not happy, and you shouldn't be happy, until you're cluster free on prevention,'” said Dr. Rozen of the Michigan Head-Pain and Neurological Institute, Ann Arbor.

There are two types of prophylaxis for cluster headache: transitional treatments, which are intended to prevent cluster headaches from occurring for a short period of time (typically 7–14 days), and maintenance preventive treatments, which are designed to keep a patient cluster free while in a cluster cycle.

Transitional treatments must kick in quickly. They're used for 10–14 days, after which they're tapered down as the maintenance preventives are tapered up to a therapeutic dose. The transitional drug and maintenance preventive drug are typically started at the same time, Dr. Rozen said.

Corticosteroids are the most commonly used transitional treatment. Start prednisone at a dosage of 60–80 mg/day, tapering down over a period of 10–12 days, he said.

Naratriptan can be used at a dosage of 2.5 mg b.i.d., but monitor the patient for rebound headaches. Ergotamine, at a dosage of 2 mg at bedtime or b.i.d., also appears useful.

Dihydroergotamine can be given by daily intramuscular injections for 1–2 weeks, or by an intravenous infusion for 3 days.

For reasons that are unclear, greater occipital nerve blocks seem to work well, giving some patients up to 13 days free of cluster headaches, even when their pain (like that of most cluster patients) is not located in the occipital area. The mechanism of action may involve decreasing afferent impulses to the spinal trigeminal nuclear complex.

For long-term prevention, a number of drugs work well, but many patients will need to be on combination therapy, taking two, three, or even four drugs to fully prevent recurrences.

“Melatonin is really my first-line choice because it is easy to get over the counter and there are no side effects,” Dr. Rozen said. “[For] a small percentage of cluster patients, the night I give them melatonin is the last time they're going to have a cluster.” The typical dosage is 9 mg at bedtime, although some patients have required higher doses.

Verapamil is the best cluster preventive currently available, Dr. Rozen said. He recommended tapering the dosage up quickly, since some patients will need up to 1 g/day. ECGs must be performed at every dosage above 480 mg to monitor for heart block.

Lithium carbonate, 300 mg t.i.d., appears to be well tolerated in cluster headache.

Valproic acid, pushed up to a dosage of 3,000 mg at bedtime, is sometimes effective.

Some small, uncontrolled studies suggest that topiramate may be effective for preventing clusters.

When trying topiramate, increase the dosage in 25-mg increments every 4–5 days until the patient is taking 75–100 mg/day. When patients do respond to topiramate, it's usually in a short period, 1–2 weeks after starting the agent, he said.

Other preventive treatments that may be effective are transdermal clonidine, tizanidine, indomethacin, nasal capsaicin, gabapentin, baclofen, and histamine desensitization.

For some patients, steroids seem to be the only thing that works, Dr. Rozen noted, and of course patients shouldn't take corticosteroids chronically.

He reported that he has had success in a single patient with mycophenolate mofetil (CellCept), the steroid-sparing immunosuppressant.

Dr. Rozen acknowledged being a member of the advisory board of Ortho-McNeil Pharmaceuticals Inc., whose products include topiramate (Topamax).

LAS VEGAS — The medical literature on surgery for cluster headaches is scant, but some patients and their neurologists are willing to chance surgery when all other treatment options have been exhausted, Todd D. Rozen, M.D., said at a symposium sponsored by the American Headache Society.

Even without the reassurance of controlled studies, several surgical techniques seem to have value despite their side effects, said Dr. Rozen of the Michigan Head-Pain and Neurological Institute, Ann Arbor.

For patients with cluster headache to be considered for surgery, they must have exhausted all medical options, or they must have a medical history that precludes the use of typical abortive and preventive medications.

The patients should be psychologically stable and be judged to have a low proclivity for addiction. Some patients may require opiates for a short period of time after surgery; also, low proclivity for addiction goes with a stable psychology. The surgery is invasive and may have long-term sequelae, so it's best done in patients who are emotionally stable.

A surgical procedure is rarely considered for patients with episodic cluster headaches because they have remission periods sometimes lasting years. These patients should not be subjected to a procedure that could cause long term side-effects possibly worse than the cluster itself, for example, anesthesia dolorosa.

And it's critical that the headaches be confined entirely to one side of the patient's head. If the patient has ever had an episode on the contralateral side, there will be a high risk of recurrence on the side opposite the site of surgery.

Most surgical approaches have targeted the sensory trigeminal nerve and the cranial parasympathetic system to turn off cluster headaches and their associated autonomic symptoms.

Interrupting the parasympathetic autonomic pathway by sectioning the superficial petrosal nerve, the nervus intermedius, or the sphenopalatine ganglion appears effective in obliterating the autonomic symptoms of cluster headache, such as lacrimation, conjunctival injection, and nasal congestion.

Unfortunately, this surgical approach is far less effective in lessening the pain associated with cluster headaches, resulting in inconsistent pain relief and high recurrence rates.

A number of procedures have been developed that target the sensory trigeminal nerve.

These include alcohol injection into the supraorbital and infraorbital nerves; alcohol injection into the Gasser's ganglion; avulsion of the infraorbital, supraorbital, and supratrochlear nerves; retrogasserian glycerol injection; radiofrequency trigeminal gangliorhyzolysis; and trigeminal root section.

Of these, thermocoagulation using radiofrequency energy appears to be the most effective, Dr. Rozen said.

Reviewing a number of small studies on this technique, he said that 50% of patients appear to do very well, 20% have fair-to-good results, and the procedure fails to provide relief in 30%.

The side effects can be severe, however. These include moderate or severe facial dysesthesia, corneal sensory loss, and anesthesia dolorosa (“painful numbness”). Rare but devastating side effects include intracranial hemorrhage, stroke, infection, and motor weakness.

A new and promising surgical approach from Italy involves implanting stimulating electrodes under stereotactic control into the posterior inferior hypothalamus, the possible “cluster generator.”

In a report involving seven patients with chronic intractable cluster, five patients have been pain free with no side effects and have needed no additional medication. The pain apparently disappears as soon as the stimulation is turned on, and returns as soon as it is turned off (Neurol. Sci. 2003;24[suppl. 2]:s143–5).

LAS VEGAS — The medical literature on surgery for cluster headaches is scant, but some patients and their neurologists are willing to chance surgery when all other treatment options have been exhausted, Todd D. Rozen, M.D., said at a symposium sponsored by the American Headache Society.

Even without the reassurance of controlled studies, several surgical techniques seem to have value despite their side effects, said Dr. Rozen of the Michigan Head-Pain and Neurological Institute, Ann Arbor.

For patients with cluster headache to be considered for surgery, they must have exhausted all medical options, or they must have a medical history that precludes the use of typical abortive and preventive medications.

The patients should be psychologically stable and be judged to have a low proclivity for addiction. Some patients may require opiates for a short period of time after surgery; also, low proclivity for addiction goes with a stable psychology. The surgery is invasive and may have long-term sequelae, so it's best done in patients who are emotionally stable.

A surgical procedure is rarely considered for patients with episodic cluster headaches because they have remission periods sometimes lasting years. These patients should not be subjected to a procedure that could cause long term side-effects possibly worse than the cluster itself, for example, anesthesia dolorosa.

And it's critical that the headaches be confined entirely to one side of the patient's head. If the patient has ever had an episode on the contralateral side, there will be a high risk of recurrence on the side opposite the site of surgery.

Most surgical approaches have targeted the sensory trigeminal nerve and the cranial parasympathetic system to turn off cluster headaches and their associated autonomic symptoms.

Interrupting the parasympathetic autonomic pathway by sectioning the superficial petrosal nerve, the nervus intermedius, or the sphenopalatine ganglion appears effective in obliterating the autonomic symptoms of cluster headache, such as lacrimation, conjunctival injection, and nasal congestion.

Unfortunately, this surgical approach is far less effective in lessening the pain associated with cluster headaches, resulting in inconsistent pain relief and high recurrence rates.

A number of procedures have been developed that target the sensory trigeminal nerve.

These include alcohol injection into the supraorbital and infraorbital nerves; alcohol injection into the Gasser's ganglion; avulsion of the infraorbital, supraorbital, and supratrochlear nerves; retrogasserian glycerol injection; radiofrequency trigeminal gangliorhyzolysis; and trigeminal root section.

Of these, thermocoagulation using radiofrequency energy appears to be the most effective, Dr. Rozen said.

Reviewing a number of small studies on this technique, he said that 50% of patients appear to do very well, 20% have fair-to-good results, and the procedure fails to provide relief in 30%.

The side effects can be severe, however. These include moderate or severe facial dysesthesia, corneal sensory loss, and anesthesia dolorosa (“painful numbness”). Rare but devastating side effects include intracranial hemorrhage, stroke, infection, and motor weakness.

A new and promising surgical approach from Italy involves implanting stimulating electrodes under stereotactic control into the posterior inferior hypothalamus, the possible “cluster generator.”

In a report involving seven patients with chronic intractable cluster, five patients have been pain free with no side effects and have needed no additional medication. The pain apparently disappears as soon as the stimulation is turned on, and returns as soon as it is turned off (Neurol. Sci. 2003;24[suppl. 2]:s143–5).

LAS VEGAS — The medical literature on surgery for cluster headaches is scant, but some patients and their neurologists are willing to chance surgery when all other treatment options have been exhausted, Todd D. Rozen, M.D., said at a symposium sponsored by the American Headache Society.

Even without the reassurance of controlled studies, several surgical techniques seem to have value despite their side effects, said Dr. Rozen of the Michigan Head-Pain and Neurological Institute, Ann Arbor.

For patients with cluster headache to be considered for surgery, they must have exhausted all medical options, or they must have a medical history that precludes the use of typical abortive and preventive medications.

The patients should be psychologically stable and be judged to have a low proclivity for addiction. Some patients may require opiates for a short period of time after surgery; also, low proclivity for addiction goes with a stable psychology. The surgery is invasive and may have long-term sequelae, so it's best done in patients who are emotionally stable.

A surgical procedure is rarely considered for patients with episodic cluster headaches because they have remission periods sometimes lasting years. These patients should not be subjected to a procedure that could cause long term side-effects possibly worse than the cluster itself, for example, anesthesia dolorosa.

And it's critical that the headaches be confined entirely to one side of the patient's head. If the patient has ever had an episode on the contralateral side, there will be a high risk of recurrence on the side opposite the site of surgery.

Most surgical approaches have targeted the sensory trigeminal nerve and the cranial parasympathetic system to turn off cluster headaches and their associated autonomic symptoms.

Interrupting the parasympathetic autonomic pathway by sectioning the superficial petrosal nerve, the nervus intermedius, or the sphenopalatine ganglion appears effective in obliterating the autonomic symptoms of cluster headache, such as lacrimation, conjunctival injection, and nasal congestion.

Unfortunately, this surgical approach is far less effective in lessening the pain associated with cluster headaches, resulting in inconsistent pain relief and high recurrence rates.

A number of procedures have been developed that target the sensory trigeminal nerve.

These include alcohol injection into the supraorbital and infraorbital nerves; alcohol injection into the Gasser's ganglion; avulsion of the infraorbital, supraorbital, and supratrochlear nerves; retrogasserian glycerol injection; radiofrequency trigeminal gangliorhyzolysis; and trigeminal root section.

Of these, thermocoagulation using radiofrequency energy appears to be the most effective, Dr. Rozen said.

Reviewing a number of small studies on this technique, he said that 50% of patients appear to do very well, 20% have fair-to-good results, and the procedure fails to provide relief in 30%.

The side effects can be severe, however. These include moderate or severe facial dysesthesia, corneal sensory loss, and anesthesia dolorosa (“painful numbness”). Rare but devastating side effects include intracranial hemorrhage, stroke, infection, and motor weakness.

A new and promising surgical approach from Italy involves implanting stimulating electrodes under stereotactic control into the posterior inferior hypothalamus, the possible “cluster generator.”

In a report involving seven patients with chronic intractable cluster, five patients have been pain free with no side effects and have needed no additional medication. The pain apparently disappears as soon as the stimulation is turned on, and returns as soon as it is turned off (Neurol. Sci. 2003;24[suppl. 2]:s143–5).

SAN FRANCISCO — A retrospective study involving 6 years of experience with microwave endometrial ablation revealed that almost 87% of 660 women were satisfied with the outcome of the procedure.

Overall, 80% of the women avoided hysterectomy over the long term, and 41% achieved amenorrhea, said Sherif Tawfeek, M.D., who acknowledged receiving grant support from Microsulis Americas Inc., which manufactures equipment for microwave endometrial ablation.

All patients were treated at Dr. Tawfeek's institution, Royal United Hospital in Bath, England, he said at the annual meeting of the American Asso- ciation of Gynecologic Laparoscopists.

When the endometrial ablation clinic at the hospital began performing the microwave procedure in 1994, all patients underwent general anesthesia. But by 2000, about half the patients were undergoing the procedure under local anesthesia.

The mean patient age was 43 years, with a range of 25-57 years. Cavity length averaged 87 mm, with a range of 50-130 mm. The average treatment time was 246 seconds, with a range of 47-810 seconds.

The treatment time was directly correlated with the cavity length, with 111- to 115-mm cavities taking more than 7 minutes, 91- to 95-mm cavities taking a bit less than 4 minutes, and 60- to 70-mm cavities taking less than 2 minutes.

Of the original group of 660 patients, 641 (97%) were followed for at least 6 months. Of those patients, five underwent incidental hysterectomy, mostly for reasons related to cancer. Of the remainder, 78% were satisfied with their first microwave endometrial ablation.

Of the patients who were dissatisfied, about half were satisfied by a second endometrial ablation procedure, for a total satisfaction rate of 87%. The remaining 13% of patients underwent hysterectomy.

SAN FRANCISCO — A retrospective study involving 6 years of experience with microwave endometrial ablation revealed that almost 87% of 660 women were satisfied with the outcome of the procedure.

Overall, 80% of the women avoided hysterectomy over the long term, and 41% achieved amenorrhea, said Sherif Tawfeek, M.D., who acknowledged receiving grant support from Microsulis Americas Inc., which manufactures equipment for microwave endometrial ablation.

All patients were treated at Dr. Tawfeek's institution, Royal United Hospital in Bath, England, he said at the annual meeting of the American Asso- ciation of Gynecologic Laparoscopists.

When the endometrial ablation clinic at the hospital began performing the microwave procedure in 1994, all patients underwent general anesthesia. But by 2000, about half the patients were undergoing the procedure under local anesthesia.

The mean patient age was 43 years, with a range of 25-57 years. Cavity length averaged 87 mm, with a range of 50-130 mm. The average treatment time was 246 seconds, with a range of 47-810 seconds.

The treatment time was directly correlated with the cavity length, with 111- to 115-mm cavities taking more than 7 minutes, 91- to 95-mm cavities taking a bit less than 4 minutes, and 60- to 70-mm cavities taking less than 2 minutes.

Of the original group of 660 patients, 641 (97%) were followed for at least 6 months. Of those patients, five underwent incidental hysterectomy, mostly for reasons related to cancer. Of the remainder, 78% were satisfied with their first microwave endometrial ablation.

Of the patients who were dissatisfied, about half were satisfied by a second endometrial ablation procedure, for a total satisfaction rate of 87%. The remaining 13% of patients underwent hysterectomy.

SAN FRANCISCO — A retrospective study involving 6 years of experience with microwave endometrial ablation revealed that almost 87% of 660 women were satisfied with the outcome of the procedure.

Overall, 80% of the women avoided hysterectomy over the long term, and 41% achieved amenorrhea, said Sherif Tawfeek, M.D., who acknowledged receiving grant support from Microsulis Americas Inc., which manufactures equipment for microwave endometrial ablation.

All patients were treated at Dr. Tawfeek's institution, Royal United Hospital in Bath, England, he said at the annual meeting of the American Asso- ciation of Gynecologic Laparoscopists.

When the endometrial ablation clinic at the hospital began performing the microwave procedure in 1994, all patients underwent general anesthesia. But by 2000, about half the patients were undergoing the procedure under local anesthesia.

The mean patient age was 43 years, with a range of 25-57 years. Cavity length averaged 87 mm, with a range of 50-130 mm. The average treatment time was 246 seconds, with a range of 47-810 seconds.

The treatment time was directly correlated with the cavity length, with 111- to 115-mm cavities taking more than 7 minutes, 91- to 95-mm cavities taking a bit less than 4 minutes, and 60- to 70-mm cavities taking less than 2 minutes.

Of the original group of 660 patients, 641 (97%) were followed for at least 6 months. Of those patients, five underwent incidental hysterectomy, mostly for reasons related to cancer. Of the remainder, 78% were satisfied with their first microwave endometrial ablation.

Of the patients who were dissatisfied, about half were satisfied by a second endometrial ablation procedure, for a total satisfaction rate of 87%. The remaining 13% of patients underwent hysterectomy.

SAN FRANCISCO — A form of depot medroxyprogesterone acetate is as effective as leuprolide for the treatment of endometriosis-associated pelvic pain, but it's significantly safer and better tolerated, Anthony A. Luciano, M.D., said at the annual meeting of the American Association of Gynecologic Laparoscopists.

Depot medroxyprogesterone acetate-subcutaneous (DMPA-SC) resulted in significantly smaller losses in bone mineral density (BMD) and significantly fewer menopausal symptoms than did leuprolide in the prospective, randomized, investigator-blinded study, said Dr. Luciano of the University of Connecticut in Farmington.

DMPA-SC was approved last December by the Food and Drug Administration and is marketed as depo-subQ provera 104. The study was funded by its manufacturer, Pharmacia Upjohn, a company that has become part of Pfizer Inc. Dr. Luciano acknowledged receiving consulting and honorarium support from Pfizer.

During the study, 274 women aged 18-49 years who had diagnoses of endometriosis-associated pelvic pain received 6 months of treatment with either DMPA-SC (104 mg every 3 months) or leuprolide (11.25 mg IM every 3 months). They were followed for an additional 12 months after completing treatment.

Women taking DMPA-SC and those taking leuprolide experienced substantial improvements in their pelvic pain, both at the end of treatment and continuing 12 months later, with no significant differences between the two groups.

Women in both groups showed some BMD declines at the end of treatment, but the mean losses were significantly less for women taking DMPA-SC than for women taking leuprolide in both the femur (0.3% vs. 1.65%) and the spine (1.1% vs. 3.95%).

The women who had been taking DMPA-SC saw their BMD return to pretreatment levels (slightly above pretreatment levels in the spine) 12 months after discontinuing treatment, whereas those who had been taking leuprolide showed continued BMD losses: 1.3% in the femur and 1.7% in the spine.

During treatment, women taking leuprolide had significant increases in their scores on the Kupperman Index (a composite score involving 11 menopausal symptoms), whereas those taking DMPA-SC showed no increase and even decreases at some time points.

This difference was particularly striking for hot flashes. Between the second and sixth month of treatment, women taking leuprolide experienced an average of 2-3 hot flashes per day. Women on DMPA-SC had almost no hot flashes.

The only adverse events seen more often in the DMPA-SC group were injection-site reactions (6.9% vs. 0%) and intermenstrual bleeding (5.4% vs. 0.7%).

SAN FRANCISCO — A form of depot medroxyprogesterone acetate is as effective as leuprolide for the treatment of endometriosis-associated pelvic pain, but it's significantly safer and better tolerated, Anthony A. Luciano, M.D., said at the annual meeting of the American Association of Gynecologic Laparoscopists.

Depot medroxyprogesterone acetate-subcutaneous (DMPA-SC) resulted in significantly smaller losses in bone mineral density (BMD) and significantly fewer menopausal symptoms than did leuprolide in the prospective, randomized, investigator-blinded study, said Dr. Luciano of the University of Connecticut in Farmington.

DMPA-SC was approved last December by the Food and Drug Administration and is marketed as depo-subQ provera 104. The study was funded by its manufacturer, Pharmacia Upjohn, a company that has become part of Pfizer Inc. Dr. Luciano acknowledged receiving consulting and honorarium support from Pfizer.

During the study, 274 women aged 18-49 years who had diagnoses of endometriosis-associated pelvic pain received 6 months of treatment with either DMPA-SC (104 mg every 3 months) or leuprolide (11.25 mg IM every 3 months). They were followed for an additional 12 months after completing treatment.

Women taking DMPA-SC and those taking leuprolide experienced substantial improvements in their pelvic pain, both at the end of treatment and continuing 12 months later, with no significant differences between the two groups.

Women in both groups showed some BMD declines at the end of treatment, but the mean losses were significantly less for women taking DMPA-SC than for women taking leuprolide in both the femur (0.3% vs. 1.65%) and the spine (1.1% vs. 3.95%).

The women who had been taking DMPA-SC saw their BMD return to pretreatment levels (slightly above pretreatment levels in the spine) 12 months after discontinuing treatment, whereas those who had been taking leuprolide showed continued BMD losses: 1.3% in the femur and 1.7% in the spine.

During treatment, women taking leuprolide had significant increases in their scores on the Kupperman Index (a composite score involving 11 menopausal symptoms), whereas those taking DMPA-SC showed no increase and even decreases at some time points.

This difference was particularly striking for hot flashes. Between the second and sixth month of treatment, women taking leuprolide experienced an average of 2-3 hot flashes per day. Women on DMPA-SC had almost no hot flashes.

The only adverse events seen more often in the DMPA-SC group were injection-site reactions (6.9% vs. 0%) and intermenstrual bleeding (5.4% vs. 0.7%).

SAN FRANCISCO — A form of depot medroxyprogesterone acetate is as effective as leuprolide for the treatment of endometriosis-associated pelvic pain, but it's significantly safer and better tolerated, Anthony A. Luciano, M.D., said at the annual meeting of the American Association of Gynecologic Laparoscopists.

Depot medroxyprogesterone acetate-subcutaneous (DMPA-SC) resulted in significantly smaller losses in bone mineral density (BMD) and significantly fewer menopausal symptoms than did leuprolide in the prospective, randomized, investigator-blinded study, said Dr. Luciano of the University of Connecticut in Farmington.

DMPA-SC was approved last December by the Food and Drug Administration and is marketed as depo-subQ provera 104. The study was funded by its manufacturer, Pharmacia Upjohn, a company that has become part of Pfizer Inc. Dr. Luciano acknowledged receiving consulting and honorarium support from Pfizer.

During the study, 274 women aged 18-49 years who had diagnoses of endometriosis-associated pelvic pain received 6 months of treatment with either DMPA-SC (104 mg every 3 months) or leuprolide (11.25 mg IM every 3 months). They were followed for an additional 12 months after completing treatment.

Women taking DMPA-SC and those taking leuprolide experienced substantial improvements in their pelvic pain, both at the end of treatment and continuing 12 months later, with no significant differences between the two groups.

Women in both groups showed some BMD declines at the end of treatment, but the mean losses were significantly less for women taking DMPA-SC than for women taking leuprolide in both the femur (0.3% vs. 1.65%) and the spine (1.1% vs. 3.95%).

The women who had been taking DMPA-SC saw their BMD return to pretreatment levels (slightly above pretreatment levels in the spine) 12 months after discontinuing treatment, whereas those who had been taking leuprolide showed continued BMD losses: 1.3% in the femur and 1.7% in the spine.

During treatment, women taking leuprolide had significant increases in their scores on the Kupperman Index (a composite score involving 11 menopausal symptoms), whereas those taking DMPA-SC showed no increase and even decreases at some time points.

This difference was particularly striking for hot flashes. Between the second and sixth month of treatment, women taking leuprolide experienced an average of 2-3 hot flashes per day. Women on DMPA-SC had almost no hot flashes.

The only adverse events seen more often in the DMPA-SC group were injection-site reactions (6.9% vs. 0%) and intermenstrual bleeding (5.4% vs. 0.7%).

Acute bacterial sinusitis is usually preceded by a viral infection of the upper respiratory tract. Because experts agree that the indiscriminate use of antibiotics for sinusitis has contributed to the emergence of resistant organisms, antibiotic therapy should be reserved for patients who have clear and severe symptoms of bacterial disease.

Signs and symptoms suggestive of bacterial sinusitis include disease that worsens after 5-7 days or persists for 7 days or more; others are nasal drainage or congestion, facial pressure or pain (especially when unilateral and focused over a sinus), hyposmia or anosmia, fever, cough, fatigue, maxillary dental pain, and ear pressure or fullness.

Studies have shown that most cases of acute bacterial sinusitis will resolve spontaneously and that, on average, antibiotic therapy will reduce the duration of symptoms by only 1 day. Nevertheless, two sets of guidelines published over the past 3 years justify the use of antibiotic therapy in some patients with severe or persistent symptoms.

These two sets of guidelines differ in important respects: The guidelines issued by the American College of Physicians in 2001 mention only three antibiotics—amoxicillin, doxycycline, and trimethoprim-sulfamethoxazole (TMP-SMX)—because these are the only three drugs that have been studied in well-controlled clinical trials in sinusitis (Ann. Intern. Med. 2001;134:495–7).

The other guidelines were issued by the Sinus and Allergy Health Partnership, a group sponsored by the American Academy of Otolaryngic Allergy, the American Academy of Otolaryngology-Head and Neck Surgery, and the American Rhinologic Society, in consultation with the Centers for Disease Control and Prevention, the Food and Drug Administration, and experts in infectious disease and other pertinent fields. The guidelines evaluated 19 antibiotics based on a theoretic analysis that incorporated pharmacokinetic and pharmacodynamic data from clinical trials, pathogen distribution, and in vitro activity of the various agents against the three predominant pathogens: Streptococcus pneumoniae, Haemophilus influenzae,andMoraxella catarrhalis (Otolaryngol. Head Neck Surg. 2004;130[suppl. 1]:1–45).

These guidelines include separate recommendations for people who have had recent antibiotic exposure (and thus are likely to harbor resistant organisms) and for people who are allergic to penicillin. Furthermore, the guidelines suggest both initial therapies and those best reserved for more severe disease or for patients who have failed first-line treatment.

Most experts agree that it's usually better to start with the simpler, less expensive antibiotics with which clinicians are likely to have the most familiarity, such as amoxicillin, amoxicillin/clavulanate, or TMP-SMX, reserving fluoroquinolones and cephalosporins for more severe or resistant disease. The macrolides have a relatively poor side effect profile and are predicted to have only a 77% clinical efficacy, and so are omitted from the list below.

Primary care physicians may consider referring patients to an otolaryngologist if symptoms persist for longer than 72 hours after the initiation of antibiotic therapy.

Amoxicillin, amoxicillin/clavulanate, and the cephalosporins are safe at any time during pregnancy or while nursing. The fluoroquinolones, rifampin plus clindamycin, and TMP-SMX are safe during nursing (avoid TMP-SMX if the infant is premature or jaundiced or has glucose-6-phosphate dehydrogenase [G6PD] deficiency), but should be avoided during the first trimester of pregnancy, although the TMP-SMX risk can be lowered with a daily multivitamin containing 1 mg folic acid. Doxycycline is contraindicated during the second and third trimesters but is safe during nursing.

More information on the diagnosis and treatment of acute bacterial sinusitis can be found in a recent review of the topic (N. Engl. J. Med. 2004;351:902–10).

Acute bacterial sinusitis is usually preceded by a viral infection of the upper respiratory tract. Because experts agree that the indiscriminate use of antibiotics for sinusitis has contributed to the emergence of resistant organisms, antibiotic therapy should be reserved for patients who have clear and severe symptoms of bacterial disease.

Signs and symptoms suggestive of bacterial sinusitis include disease that worsens after 5-7 days or persists for 7 days or more; others are nasal drainage or congestion, facial pressure or pain (especially when unilateral and focused over a sinus), hyposmia or anosmia, fever, cough, fatigue, maxillary dental pain, and ear pressure or fullness.

Studies have shown that most cases of acute bacterial sinusitis will resolve spontaneously and that, on average, antibiotic therapy will reduce the duration of symptoms by only 1 day. Nevertheless, two sets of guidelines published over the past 3 years justify the use of antibiotic therapy in some patients with severe or persistent symptoms.

These two sets of guidelines differ in important respects: The guidelines issued by the American College of Physicians in 2001 mention only three antibiotics—amoxicillin, doxycycline, and trimethoprim-sulfamethoxazole (TMP-SMX)—because these are the only three drugs that have been studied in well-controlled clinical trials in sinusitis (Ann. Intern. Med. 2001;134:495–7).

The other guidelines were issued by the Sinus and Allergy Health Partnership, a group sponsored by the American Academy of Otolaryngic Allergy, the American Academy of Otolaryngology-Head and Neck Surgery, and the American Rhinologic Society, in consultation with the Centers for Disease Control and Prevention, the Food and Drug Administration, and experts in infectious disease and other pertinent fields. The guidelines evaluated 19 antibiotics based on a theoretic analysis that incorporated pharmacokinetic and pharmacodynamic data from clinical trials, pathogen distribution, and in vitro activity of the various agents against the three predominant pathogens: Streptococcus pneumoniae, Haemophilus influenzae,andMoraxella catarrhalis (Otolaryngol. Head Neck Surg. 2004;130[suppl. 1]:1–45).

These guidelines include separate recommendations for people who have had recent antibiotic exposure (and thus are likely to harbor resistant organisms) and for people who are allergic to penicillin. Furthermore, the guidelines suggest both initial therapies and those best reserved for more severe disease or for patients who have failed first-line treatment.

Most experts agree that it's usually better to start with the simpler, less expensive antibiotics with which clinicians are likely to have the most familiarity, such as amoxicillin, amoxicillin/clavulanate, or TMP-SMX, reserving fluoroquinolones and cephalosporins for more severe or resistant disease. The macrolides have a relatively poor side effect profile and are predicted to have only a 77% clinical efficacy, and so are omitted from the list below.

Primary care physicians may consider referring patients to an otolaryngologist if symptoms persist for longer than 72 hours after the initiation of antibiotic therapy.

Amoxicillin, amoxicillin/clavulanate, and the cephalosporins are safe at any time during pregnancy or while nursing. The fluoroquinolones, rifampin plus clindamycin, and TMP-SMX are safe during nursing (avoid TMP-SMX if the infant is premature or jaundiced or has glucose-6-phosphate dehydrogenase [G6PD] deficiency), but should be avoided during the first trimester of pregnancy, although the TMP-SMX risk can be lowered with a daily multivitamin containing 1 mg folic acid. Doxycycline is contraindicated during the second and third trimesters but is safe during nursing.

More information on the diagnosis and treatment of acute bacterial sinusitis can be found in a recent review of the topic (N. Engl. J. Med. 2004;351:902–10).

Acute bacterial sinusitis is usually preceded by a viral infection of the upper respiratory tract. Because experts agree that the indiscriminate use of antibiotics for sinusitis has contributed to the emergence of resistant organisms, antibiotic therapy should be reserved for patients who have clear and severe symptoms of bacterial disease.

Signs and symptoms suggestive of bacterial sinusitis include disease that worsens after 5-7 days or persists for 7 days or more; others are nasal drainage or congestion, facial pressure or pain (especially when unilateral and focused over a sinus), hyposmia or anosmia, fever, cough, fatigue, maxillary dental pain, and ear pressure or fullness.

Studies have shown that most cases of acute bacterial sinusitis will resolve spontaneously and that, on average, antibiotic therapy will reduce the duration of symptoms by only 1 day. Nevertheless, two sets of guidelines published over the past 3 years justify the use of antibiotic therapy in some patients with severe or persistent symptoms.

These two sets of guidelines differ in important respects: The guidelines issued by the American College of Physicians in 2001 mention only three antibiotics—amoxicillin, doxycycline, and trimethoprim-sulfamethoxazole (TMP-SMX)—because these are the only three drugs that have been studied in well-controlled clinical trials in sinusitis (Ann. Intern. Med. 2001;134:495–7).

The other guidelines were issued by the Sinus and Allergy Health Partnership, a group sponsored by the American Academy of Otolaryngic Allergy, the American Academy of Otolaryngology-Head and Neck Surgery, and the American Rhinologic Society, in consultation with the Centers for Disease Control and Prevention, the Food and Drug Administration, and experts in infectious disease and other pertinent fields. The guidelines evaluated 19 antibiotics based on a theoretic analysis that incorporated pharmacokinetic and pharmacodynamic data from clinical trials, pathogen distribution, and in vitro activity of the various agents against the three predominant pathogens: Streptococcus pneumoniae, Haemophilus influenzae,andMoraxella catarrhalis (Otolaryngol. Head Neck Surg. 2004;130[suppl. 1]:1–45).

These guidelines include separate recommendations for people who have had recent antibiotic exposure (and thus are likely to harbor resistant organisms) and for people who are allergic to penicillin. Furthermore, the guidelines suggest both initial therapies and those best reserved for more severe disease or for patients who have failed first-line treatment.

Most experts agree that it's usually better to start with the simpler, less expensive antibiotics with which clinicians are likely to have the most familiarity, such as amoxicillin, amoxicillin/clavulanate, or TMP-SMX, reserving fluoroquinolones and cephalosporins for more severe or resistant disease. The macrolides have a relatively poor side effect profile and are predicted to have only a 77% clinical efficacy, and so are omitted from the list below.

Primary care physicians may consider referring patients to an otolaryngologist if symptoms persist for longer than 72 hours after the initiation of antibiotic therapy.

Amoxicillin, amoxicillin/clavulanate, and the cephalosporins are safe at any time during pregnancy or while nursing. The fluoroquinolones, rifampin plus clindamycin, and TMP-SMX are safe during nursing (avoid TMP-SMX if the infant is premature or jaundiced or has glucose-6-phosphate dehydrogenase [G6PD] deficiency), but should be avoided during the first trimester of pregnancy, although the TMP-SMX risk can be lowered with a daily multivitamin containing 1 mg folic acid. Doxycycline is contraindicated during the second and third trimesters but is safe during nursing.

More information on the diagnosis and treatment of acute bacterial sinusitis can be found in a recent review of the topic (N. Engl. J. Med. 2004;351:902–10).

SAN FRANCISCO — All official guidelines on HIV treatment either make blanket recommendations for drug-resistance testing or at least suggest that the clinician consider such testing depending on the patient's circumstances, Brad Hare, M.D., said at a meeting on HIV management sponsored by the University of California, San Francisco.

But deciding whether to use genotypic or phenotypic assays can be difficult, said Dr. Hare, a physician in the positive health program at the university.

Genotypic drug-resistance assays identify the presence of specific mutations in the HIV genome. Drug resistance is then inferred using an algorithm or a database analysis Phenotypic assays, on the other hand, use viral isolates or recombinant virus derived directly from the patient's plasma. The analysis derives from a culture-based system, and the concentration of a specific drug needed to inhibit viral replication can be quantified.

In general, genotypic testing holds the edge early in a patient's disease, before the virus has a chance to develop complex patterns of resistance. Phenotypic testing tends to be better late in a patient's infection, when the patient is likely to be experiencing more regimen failure as a result of virus with complex mutations. (See box.)

Both tests may be required in complicated patients to get the optimal information for management.

Source: Dr. King

SAN FRANCISCO — All official guidelines on HIV treatment either make blanket recommendations for drug-resistance testing or at least suggest that the clinician consider such testing depending on the patient's circumstances, Brad Hare, M.D., said at a meeting on HIV management sponsored by the University of California, San Francisco.

But deciding whether to use genotypic or phenotypic assays can be difficult, said Dr. Hare, a physician in the positive health program at the university.

Genotypic drug-resistance assays identify the presence of specific mutations in the HIV genome. Drug resistance is then inferred using an algorithm or a database analysis Phenotypic assays, on the other hand, use viral isolates or recombinant virus derived directly from the patient's plasma. The analysis derives from a culture-based system, and the concentration of a specific drug needed to inhibit viral replication can be quantified.

In general, genotypic testing holds the edge early in a patient's disease, before the virus has a chance to develop complex patterns of resistance. Phenotypic testing tends to be better late in a patient's infection, when the patient is likely to be experiencing more regimen failure as a result of virus with complex mutations. (See box.)

Both tests may be required in complicated patients to get the optimal information for management.

Source: Dr. King

SAN FRANCISCO — All official guidelines on HIV treatment either make blanket recommendations for drug-resistance testing or at least suggest that the clinician consider such testing depending on the patient's circumstances, Brad Hare, M.D., said at a meeting on HIV management sponsored by the University of California, San Francisco.

But deciding whether to use genotypic or phenotypic assays can be difficult, said Dr. Hare, a physician in the positive health program at the university.

Genotypic drug-resistance assays identify the presence of specific mutations in the HIV genome. Drug resistance is then inferred using an algorithm or a database analysis Phenotypic assays, on the other hand, use viral isolates or recombinant virus derived directly from the patient's plasma. The analysis derives from a culture-based system, and the concentration of a specific drug needed to inhibit viral replication can be quantified.

In general, genotypic testing holds the edge early in a patient's disease, before the virus has a chance to develop complex patterns of resistance. Phenotypic testing tends to be better late in a patient's infection, when the patient is likely to be experiencing more regimen failure as a result of virus with complex mutations. (See box.)

Both tests may be required in complicated patients to get the optimal information for management.

Source: Dr. King

LAS VEGAS – Even in a neurologist's office, every headache patient merits a general history and a physical examination, which may be the best tools with which to differentiate secondary from primary headaches, John G. Edmeads, M.D., said at a symposium sponsored by the American Headache Society.

“The headache never walks alone” when it is secondary to a general medical condition, said Dr. Edmeads of Sunnybrook Medical Centre, Toronto.

“There's always something on history or physical to give you a clue that there's a general medical disease going on. And once you have this clue you can diagnose them through a focused work-up that won't cost an arm and a leg,” he explained.

Dr. Edmeads offered the following suggestions:

▸ Neurologists can't assume that patients have had a thorough evaluation before reaching their offices. Dr. Edmeads said that he has had patients ask about the blood pressure cuff as if they had never seen one before.

▸ Be suspicious if the patient's signs and symptoms don't clearly meet International Headache Society criteria for primary headache. Any patient whose headache doesn't meet the society's criteria deserves additional investigation.

▸ If it's not clearly migraine or tension-type headache, look for evidence of central nervous system involvement, either in the brain or its coverings. If there's any indication of CNS involvement, the next step includes neuroimaging and possibly examination of the patient's cerebrospinal fluid.

▸ If there are no signs or symptoms of CNS involvement, then conduct a general medical screen. This should include a CBC; an erythrocyte sedimentation rate; electrolytes, including calcium and phosphate; BUN and creatinine; liver enzymes and bilirubin; thyroid function studies, including TSH, T3, and T4; and a chest x-ray. Answers will come back within a day or two and will cost less than a couple of hundred dollars, Dr. Edmeads said.

▸ If those studies are negative, consider serum protein electrophoresis and arterial blood gases. In winter, consider carbon monoxide poisoning and test for carboxyhemoglobin. Carbon monoxide poisoning from poorly maintained heaters will often present as daily, diffuse, nocturnal headaches that clear up in the morning when patients get out into the fresh air.

▸ If all results are still negative, but you still have a strong suspicion that the headache is the result of a general medical condition, consider a consultation with a general internist.

LAS VEGAS – Even in a neurologist's office, every headache patient merits a general history and a physical examination, which may be the best tools with which to differentiate secondary from primary headaches, John G. Edmeads, M.D., said at a symposium sponsored by the American Headache Society.

“The headache never walks alone” when it is secondary to a general medical condition, said Dr. Edmeads of Sunnybrook Medical Centre, Toronto.

“There's always something on history or physical to give you a clue that there's a general medical disease going on. And once you have this clue you can diagnose them through a focused work-up that won't cost an arm and a leg,” he explained.

Dr. Edmeads offered the following suggestions:

▸ Neurologists can't assume that patients have had a thorough evaluation before reaching their offices. Dr. Edmeads said that he has had patients ask about the blood pressure cuff as if they had never seen one before.

▸ Be suspicious if the patient's signs and symptoms don't clearly meet International Headache Society criteria for primary headache. Any patient whose headache doesn't meet the society's criteria deserves additional investigation.

▸ If it's not clearly migraine or tension-type headache, look for evidence of central nervous system involvement, either in the brain or its coverings. If there's any indication of CNS involvement, the next step includes neuroimaging and possibly examination of the patient's cerebrospinal fluid.

▸ If there are no signs or symptoms of CNS involvement, then conduct a general medical screen. This should include a CBC; an erythrocyte sedimentation rate; electrolytes, including calcium and phosphate; BUN and creatinine; liver enzymes and bilirubin; thyroid function studies, including TSH, T3, and T4; and a chest x-ray. Answers will come back within a day or two and will cost less than a couple of hundred dollars, Dr. Edmeads said.

▸ If those studies are negative, consider serum protein electrophoresis and arterial blood gases. In winter, consider carbon monoxide poisoning and test for carboxyhemoglobin. Carbon monoxide poisoning from poorly maintained heaters will often present as daily, diffuse, nocturnal headaches that clear up in the morning when patients get out into the fresh air.

▸ If all results are still negative, but you still have a strong suspicion that the headache is the result of a general medical condition, consider a consultation with a general internist.

LAS VEGAS – Even in a neurologist's office, every headache patient merits a general history and a physical examination, which may be the best tools with which to differentiate secondary from primary headaches, John G. Edmeads, M.D., said at a symposium sponsored by the American Headache Society.

“The headache never walks alone” when it is secondary to a general medical condition, said Dr. Edmeads of Sunnybrook Medical Centre, Toronto.

“There's always something on history or physical to give you a clue that there's a general medical disease going on. And once you have this clue you can diagnose them through a focused work-up that won't cost an arm and a leg,” he explained.

Dr. Edmeads offered the following suggestions:

▸ Neurologists can't assume that patients have had a thorough evaluation before reaching their offices. Dr. Edmeads said that he has had patients ask about the blood pressure cuff as if they had never seen one before.

▸ Be suspicious if the patient's signs and symptoms don't clearly meet International Headache Society criteria for primary headache. Any patient whose headache doesn't meet the society's criteria deserves additional investigation.

▸ If it's not clearly migraine or tension-type headache, look for evidence of central nervous system involvement, either in the brain or its coverings. If there's any indication of CNS involvement, the next step includes neuroimaging and possibly examination of the patient's cerebrospinal fluid.

▸ If there are no signs or symptoms of CNS involvement, then conduct a general medical screen. This should include a CBC; an erythrocyte sedimentation rate; electrolytes, including calcium and phosphate; BUN and creatinine; liver enzymes and bilirubin; thyroid function studies, including TSH, T3, and T4; and a chest x-ray. Answers will come back within a day or two and will cost less than a couple of hundred dollars, Dr. Edmeads said.

▸ If those studies are negative, consider serum protein electrophoresis and arterial blood gases. In winter, consider carbon monoxide poisoning and test for carboxyhemoglobin. Carbon monoxide poisoning from poorly maintained heaters will often present as daily, diffuse, nocturnal headaches that clear up in the morning when patients get out into the fresh air.

▸ If all results are still negative, but you still have a strong suspicion that the headache is the result of a general medical condition, consider a consultation with a general internist.

LAS VEGAS – The flow rate of oxygen routinely prescribed to abort cluster migraine is too low to be effective in many patients, Todd D. Rozen, M.D., said at a symposium sponsored by the American Headache Society.

Since the effectiveness of inhaled 100% oxygen for cluster headache was demonstrated in 1981, clinicians have typically prescribed flow rates of 7–10 L/min, said Dr. Rozen of the Michigan Head-Pain and Neurological Institute in Ann Arbor.

About 30% of patients fail to respond to flow rates in this range. In a recently published case series, Dr. Rozen described three patients whose headaches were apparently refractory to oxygen but who all responded well when the flow rate was pushed to 15 L/min–about the maximum flow rate delivered by most medical-grade oxygen regulators (Neurology 2004;63:593).

“I'm now telling my patients that you're not resistant to oxygen until you try 15 L/min,” Dr. Rozen said.

There are a number of caveats regarding oxygen therapy for cluster headache. The gas must be delivered through a nonrebreather face mask, and patients must be cautioned strongly about the highly flammable nature of pure oxygen. In addition, the higher flow rates may be dangerous in patients with chronic obstructive pulmonary disease.

Oxygen is thought to exert its effect on cluster headaches through cerebral arterio- and vasoconstriction. Many people whose headaches appear refractory to oxygen therapy are smokers; according to the pulmonary literature, smokers exhibit less vasoconstriction in response to 100% oxygen than do nonsmokers.

Dr. Rozen hypothesized that in some individuals, a higher oxygen flow rate is needed to obtain a clinically meaningful degree of vasoconstriction.

Cluster headache is the most severe head-pain syndrome known, and rapid abortive therapy, either at home or in the emergency department, is critical. The goal of abortive treatment is to stop the pain within 10–15 minutes.

Oxygen therapy is a good choice for patients whose cardiovascular risk factors render them unsuitable candidates for injected sumatriptan.

“I don't know how many times I've seen cluster patients who have never tried oxygen,” Dr. Rozen said. “You have to remember that they are smokers; they have cardiovascular risk factors over time. At some time, they're not going to be able to take sumatriptan injection any more, so you want to try oxygen.”

In the United States, patients must have a physician's prescription to get oxygen for home use.

LAS VEGAS – The flow rate of oxygen routinely prescribed to abort cluster migraine is too low to be effective in many patients, Todd D. Rozen, M.D., said at a symposium sponsored by the American Headache Society.

Since the effectiveness of inhaled 100% oxygen for cluster headache was demonstrated in 1981, clinicians have typically prescribed flow rates of 7–10 L/min, said Dr. Rozen of the Michigan Head-Pain and Neurological Institute in Ann Arbor.

About 30% of patients fail to respond to flow rates in this range. In a recently published case series, Dr. Rozen described three patients whose headaches were apparently refractory to oxygen but who all responded well when the flow rate was pushed to 15 L/min–about the maximum flow rate delivered by most medical-grade oxygen regulators (Neurology 2004;63:593).

“I'm now telling my patients that you're not resistant to oxygen until you try 15 L/min,” Dr. Rozen said.

There are a number of caveats regarding oxygen therapy for cluster headache. The gas must be delivered through a nonrebreather face mask, and patients must be cautioned strongly about the highly flammable nature of pure oxygen. In addition, the higher flow rates may be dangerous in patients with chronic obstructive pulmonary disease.

Oxygen is thought to exert its effect on cluster headaches through cerebral arterio- and vasoconstriction. Many people whose headaches appear refractory to oxygen therapy are smokers; according to the pulmonary literature, smokers exhibit less vasoconstriction in response to 100% oxygen than do nonsmokers.

Dr. Rozen hypothesized that in some individuals, a higher oxygen flow rate is needed to obtain a clinically meaningful degree of vasoconstriction.

Cluster headache is the most severe head-pain syndrome known, and rapid abortive therapy, either at home or in the emergency department, is critical. The goal of abortive treatment is to stop the pain within 10–15 minutes.

Oxygen therapy is a good choice for patients whose cardiovascular risk factors render them unsuitable candidates for injected sumatriptan.

“I don't know how many times I've seen cluster patients who have never tried oxygen,” Dr. Rozen said. “You have to remember that they are smokers; they have cardiovascular risk factors over time. At some time, they're not going to be able to take sumatriptan injection any more, so you want to try oxygen.”

In the United States, patients must have a physician's prescription to get oxygen for home use.

LAS VEGAS – The flow rate of oxygen routinely prescribed to abort cluster migraine is too low to be effective in many patients, Todd D. Rozen, M.D., said at a symposium sponsored by the American Headache Society.

Since the effectiveness of inhaled 100% oxygen for cluster headache was demonstrated in 1981, clinicians have typically prescribed flow rates of 7–10 L/min, said Dr. Rozen of the Michigan Head-Pain and Neurological Institute in Ann Arbor.

About 30% of patients fail to respond to flow rates in this range. In a recently published case series, Dr. Rozen described three patients whose headaches were apparently refractory to oxygen but who all responded well when the flow rate was pushed to 15 L/min–about the maximum flow rate delivered by most medical-grade oxygen regulators (Neurology 2004;63:593).

“I'm now telling my patients that you're not resistant to oxygen until you try 15 L/min,” Dr. Rozen said.

There are a number of caveats regarding oxygen therapy for cluster headache. The gas must be delivered through a nonrebreather face mask, and patients must be cautioned strongly about the highly flammable nature of pure oxygen. In addition, the higher flow rates may be dangerous in patients with chronic obstructive pulmonary disease.

Oxygen is thought to exert its effect on cluster headaches through cerebral arterio- and vasoconstriction. Many people whose headaches appear refractory to oxygen therapy are smokers; according to the pulmonary literature, smokers exhibit less vasoconstriction in response to 100% oxygen than do nonsmokers.

Dr. Rozen hypothesized that in some individuals, a higher oxygen flow rate is needed to obtain a clinically meaningful degree of vasoconstriction.

Cluster headache is the most severe head-pain syndrome known, and rapid abortive therapy, either at home or in the emergency department, is critical. The goal of abortive treatment is to stop the pain within 10–15 minutes.

Oxygen therapy is a good choice for patients whose cardiovascular risk factors render them unsuitable candidates for injected sumatriptan.

“I don't know how many times I've seen cluster patients who have never tried oxygen,” Dr. Rozen said. “You have to remember that they are smokers; they have cardiovascular risk factors over time. At some time, they're not going to be able to take sumatriptan injection any more, so you want to try oxygen.”

In the United States, patients must have a physician's prescription to get oxygen for home use.

SAN FRANCISCO — Lymphogranuloma venereum, once common among gay men but rare in the United States for the last decade, may be poised to make a comeback, Gail Bolan, M.D., said at a meeting on HIV management sponsored by the University of California, San Francisco.

The Centers for Disease Control and Prevention recently reported on an outbreak of lymphogranuloma venereum (LGV) among men who have sex with men in the Netherlands (MMWR 2004;53:985-8).

There has been one confirmed U.S. case of the opportunistic infection out of Emory University (Atlanta), and the New York City Department of Health and Mental Hygiene reported two others in February.

Another possible case from San Francisco has not yet been confirmed, said Dr. Bolan, chief of the sexually transmitted disease control branch of the California Department of Health Services, in Berkeley.

LGV is common in Africa, Southeast Asia, Central and South America, and the Caribbean but has been rare in developed countries in recent years. The outbreak in the Netherlands included 92 confirmed cases during an 18-month period in 2003 and 2004, compared with an average of 5 cases annually during previous years.

Chlamydia trachomatis is the causative organism in LGV, but the serotypes involved are not the ones responsible for garden-variety chlamydia infections.

The classic presentation includes inguinal adenopathy (buboes). These start as painless papules, nodules, or ulcers that resolve spontaneously. In the outbreak in the Netherlands, however, only one of the patients had a genital bubo. Most had GI symptoms including mucopurulent anal discharge and bloody proctitis. Other symptoms of this infection, which is sometimes mistaken for Crohn's disease, include bleeding, tenesmus, fever, and constitutional symptoms. Anoscopy shows diffuse friability and discrete ulcerations. The destructive granulomatous process can cause complications such as scarring, genital elephantiasis, fistulas, rectal strictures, and perianal abscesses.

The CDC's study of the Netherlands outbreak identified several risk factors, including unprotected receptive anal intercourse or fisting, casual-sex gatherings, and other concurrent STDs. Of the patients whose HIV status was known, 77% were HIV-positive.

A positive chlamydia test from the mucosal site or a bubo aspirate is necessary to confirm the diagnosis. For rectal lesions, it's better to get a swab under control by anoscopy than to take a blind rectal swab, Dr. Bolan said. But the available serologic tests are poorly standardized, she added. It's better, when possible, to confirm the specific LGV serotype by polymerase chain reaction sequencing or tissue culture and monoclonal antibodies.

The CDC's treatment guidelines recommend oral doxycycline, 100 mg b.i.d., for 21 days. Oral erythromycin, 500 mg four times daily for 21 days, is an alternative. Some experts also recommend oral azithromycin, 1 g weekly for 3 weeks, but this regimen has never been formally evaluated.

Partners of affected patients (within the 30 days prior to the onset of symptoms) need evaluation. If these individuals are asymptomatic, they should be treated with doxycycline, 100 mg b.i.d., for 7 days, or with a single dose of 1 g of azithromycin.

SAN FRANCISCO — Lymphogranuloma venereum, once common among gay men but rare in the United States for the last decade, may be poised to make a comeback, Gail Bolan, M.D., said at a meeting on HIV management sponsored by the University of California, San Francisco.

The Centers for Disease Control and Prevention recently reported on an outbreak of lymphogranuloma venereum (LGV) among men who have sex with men in the Netherlands (MMWR 2004;53:985-8).

There has been one confirmed U.S. case of the opportunistic infection out of Emory University (Atlanta), and the New York City Department of Health and Mental Hygiene reported two others in February.

Another possible case from San Francisco has not yet been confirmed, said Dr. Bolan, chief of the sexually transmitted disease control branch of the California Department of Health Services, in Berkeley.

LGV is common in Africa, Southeast Asia, Central and South America, and the Caribbean but has been rare in developed countries in recent years. The outbreak in the Netherlands included 92 confirmed cases during an 18-month period in 2003 and 2004, compared with an average of 5 cases annually during previous years.

Chlamydia trachomatis is the causative organism in LGV, but the serotypes involved are not the ones responsible for garden-variety chlamydia infections.

The classic presentation includes inguinal adenopathy (buboes). These start as painless papules, nodules, or ulcers that resolve spontaneously. In the outbreak in the Netherlands, however, only one of the patients had a genital bubo. Most had GI symptoms including mucopurulent anal discharge and bloody proctitis. Other symptoms of this infection, which is sometimes mistaken for Crohn's disease, include bleeding, tenesmus, fever, and constitutional symptoms. Anoscopy shows diffuse friability and discrete ulcerations. The destructive granulomatous process can cause complications such as scarring, genital elephantiasis, fistulas, rectal strictures, and perianal abscesses.

The CDC's study of the Netherlands outbreak identified several risk factors, including unprotected receptive anal intercourse or fisting, casual-sex gatherings, and other concurrent STDs. Of the patients whose HIV status was known, 77% were HIV-positive.

A positive chlamydia test from the mucosal site or a bubo aspirate is necessary to confirm the diagnosis. For rectal lesions, it's better to get a swab under control by anoscopy than to take a blind rectal swab, Dr. Bolan said. But the available serologic tests are poorly standardized, she added. It's better, when possible, to confirm the specific LGV serotype by polymerase chain reaction sequencing or tissue culture and monoclonal antibodies.

The CDC's treatment guidelines recommend oral doxycycline, 100 mg b.i.d., for 21 days. Oral erythromycin, 500 mg four times daily for 21 days, is an alternative. Some experts also recommend oral azithromycin, 1 g weekly for 3 weeks, but this regimen has never been formally evaluated.

Partners of affected patients (within the 30 days prior to the onset of symptoms) need evaluation. If these individuals are asymptomatic, they should be treated with doxycycline, 100 mg b.i.d., for 7 days, or with a single dose of 1 g of azithromycin.

SAN FRANCISCO — Lymphogranuloma venereum, once common among gay men but rare in the United States for the last decade, may be poised to make a comeback, Gail Bolan, M.D., said at a meeting on HIV management sponsored by the University of California, San Francisco.

The Centers for Disease Control and Prevention recently reported on an outbreak of lymphogranuloma venereum (LGV) among men who have sex with men in the Netherlands (MMWR 2004;53:985-8).

There has been one confirmed U.S. case of the opportunistic infection out of Emory University (Atlanta), and the New York City Department of Health and Mental Hygiene reported two others in February.

Another possible case from San Francisco has not yet been confirmed, said Dr. Bolan, chief of the sexually transmitted disease control branch of the California Department of Health Services, in Berkeley.

LGV is common in Africa, Southeast Asia, Central and South America, and the Caribbean but has been rare in developed countries in recent years. The outbreak in the Netherlands included 92 confirmed cases during an 18-month period in 2003 and 2004, compared with an average of 5 cases annually during previous years.

Chlamydia trachomatis is the causative organism in LGV, but the serotypes involved are not the ones responsible for garden-variety chlamydia infections.

The classic presentation includes inguinal adenopathy (buboes). These start as painless papules, nodules, or ulcers that resolve spontaneously. In the outbreak in the Netherlands, however, only one of the patients had a genital bubo. Most had GI symptoms including mucopurulent anal discharge and bloody proctitis. Other symptoms of this infection, which is sometimes mistaken for Crohn's disease, include bleeding, tenesmus, fever, and constitutional symptoms. Anoscopy shows diffuse friability and discrete ulcerations. The destructive granulomatous process can cause complications such as scarring, genital elephantiasis, fistulas, rectal strictures, and perianal abscesses.

The CDC's study of the Netherlands outbreak identified several risk factors, including unprotected receptive anal intercourse or fisting, casual-sex gatherings, and other concurrent STDs. Of the patients whose HIV status was known, 77% were HIV-positive.

A positive chlamydia test from the mucosal site or a bubo aspirate is necessary to confirm the diagnosis. For rectal lesions, it's better to get a swab under control by anoscopy than to take a blind rectal swab, Dr. Bolan said. But the available serologic tests are poorly standardized, she added. It's better, when possible, to confirm the specific LGV serotype by polymerase chain reaction sequencing or tissue culture and monoclonal antibodies.

The CDC's treatment guidelines recommend oral doxycycline, 100 mg b.i.d., for 21 days. Oral erythromycin, 500 mg four times daily for 21 days, is an alternative. Some experts also recommend oral azithromycin, 1 g weekly for 3 weeks, but this regimen has never been formally evaluated.

Partners of affected patients (within the 30 days prior to the onset of symptoms) need evaluation. If these individuals are asymptomatic, they should be treated with doxycycline, 100 mg b.i.d., for 7 days, or with a single dose of 1 g of azithromycin.

SAN DIEGO — A combination radiofrequency, infrared, and suction device has achieved mixed results in the treatment of cellulite according to two papers presented at the annual meeting of the American Academy of Cosmetic Surgery.

Twelve of 20 patients (60%) treated with the VelaSmooth device (Syneron Medical Ltd.) by Neil Sadick, M.D., eight times in 4 weeks achieved only mild improvement in cellulite, said Thomas W. Barnes, M.D., who delivered the paper for Dr. Sadick. Another seven patients (35%) were judged to have "good" improvement, and one patient had "very good" improvement.

The results were better among patients who were treated by R. Stephen Mulholland, M.D., 16 times over 8 weeks, said Dr. Barnes, who practices in Newport Beach, Calif. Two of 11 patients (18%) achieved excellent improvement in cellulite, 4 (36%) achieved very good improvement, 4 (36%) achieved good improvement, and in 1 patient (9%) the improvement was mild.

Already available in Europe and Canada, the VelaSmooth device has not yet been approved for sale in the United States. In January 2005, Syneron, based in Yokneam Illit, Israel, announced that the company would soon be applying to the Food and Drug Administration for marketing clearance in the United States.

The intense pulsed light and radiofrequency components of the device increase tissue temperature and are claimed to cause an increase in the available oxygen for fat metabolism, possibly also having an effect on adipocyte integrity.

The suction component is said to physically break down fat-cell clusters, stretch fibrous bands, and increase lymphatic drainage and evacuation of fat metabolism end products. The suction may also push adipocytes back into the subcutaneous compartment.

Dr. Barnes acknowledged receiving compensation from Syneron when speaking about the company's products, and Dr. Sadick acknowledged serving as a consultant to Syneron and other companies.

In two separate studies, Loek Habbema, M.D., of Medical Centre 't Gooi (Bussum, the Netherlands) treated a total of 17 patients with the VelaSmooth device. He stopped the first study, which included 8 patients, early because of an apparent lack of efficacy. Upon examining the device, the distributor noted inadequate suction, which necessitated repair.

Dr. Habbema then treated another nine patients, conducting a blinded study in which one of the patient's outer, inner, posterior, and anterior thighs and buttocks were treated. Each patient was treated eight times over 4 weeks, and was evaluated 5 days following the final treatment. An investigator scored the extent and intensity of the patient's cellulite.

At the end of the treatment period, the investigator found that none of the patients showed any left-right improvement. The patients themselves completed a survey, and none of the nine noticed any improvement. In addition, none said that they would be willing to pay for treatment.

Dr. Habbema, who declared that he had no financial conflicts of interest (although the VelaSmooth device was placed in his office at no charge) offered several possible explanations for the apparent lack of efficacy: The device may inherently lack efficacy; the treatment schedule may need to be changed; the device's output may need adjustment; or the indications for treatment and the patient selection criteria may need alteration.

Dr. Habbema noted that the device's user manual has changed recently. In July 2004 the manual read, "The VelaSmooth system is indicated for the treatment and reduction of cellulite, and the improvement of adipose tissue metabolism."

But in January 2005 he said he saw that a new version of the manual read, "The VelaSmooth Shaper system is indicated for temporary reduction in the appearance of cellulite, to relieve minor muscle aches and pain and for temporary improvement in the local blood circulation."

SAN DIEGO — A combination radiofrequency, infrared, and suction device has achieved mixed results in the treatment of cellulite according to two papers presented at the annual meeting of the American Academy of Cosmetic Surgery.

Twelve of 20 patients (60%) treated with the VelaSmooth device (Syneron Medical Ltd.) by Neil Sadick, M.D., eight times in 4 weeks achieved only mild improvement in cellulite, said Thomas W. Barnes, M.D., who delivered the paper for Dr. Sadick. Another seven patients (35%) were judged to have "good" improvement, and one patient had "very good" improvement.

The results were better among patients who were treated by R. Stephen Mulholland, M.D., 16 times over 8 weeks, said Dr. Barnes, who practices in Newport Beach, Calif. Two of 11 patients (18%) achieved excellent improvement in cellulite, 4 (36%) achieved very good improvement, 4 (36%) achieved good improvement, and in 1 patient (9%) the improvement was mild.

Already available in Europe and Canada, the VelaSmooth device has not yet been approved for sale in the United States. In January 2005, Syneron, based in Yokneam Illit, Israel, announced that the company would soon be applying to the Food and Drug Administration for marketing clearance in the United States.

The intense pulsed light and radiofrequency components of the device increase tissue temperature and are claimed to cause an increase in the available oxygen for fat metabolism, possibly also having an effect on adipocyte integrity.

The suction component is said to physically break down fat-cell clusters, stretch fibrous bands, and increase lymphatic drainage and evacuation of fat metabolism end products. The suction may also push adipocytes back into the subcutaneous compartment.

Dr. Barnes acknowledged receiving compensation from Syneron when speaking about the company's products, and Dr. Sadick acknowledged serving as a consultant to Syneron and other companies.

In two separate studies, Loek Habbema, M.D., of Medical Centre 't Gooi (Bussum, the Netherlands) treated a total of 17 patients with the VelaSmooth device. He stopped the first study, which included 8 patients, early because of an apparent lack of efficacy. Upon examining the device, the distributor noted inadequate suction, which necessitated repair.

Dr. Habbema then treated another nine patients, conducting a blinded study in which one of the patient's outer, inner, posterior, and anterior thighs and buttocks were treated. Each patient was treated eight times over 4 weeks, and was evaluated 5 days following the final treatment. An investigator scored the extent and intensity of the patient's cellulite.

At the end of the treatment period, the investigator found that none of the patients showed any left-right improvement. The patients themselves completed a survey, and none of the nine noticed any improvement. In addition, none said that they would be willing to pay for treatment.

Dr. Habbema, who declared that he had no financial conflicts of interest (although the VelaSmooth device was placed in his office at no charge) offered several possible explanations for the apparent lack of efficacy: The device may inherently lack efficacy; the treatment schedule may need to be changed; the device's output may need adjustment; or the indications for treatment and the patient selection criteria may need alteration.

Dr. Habbema noted that the device's user manual has changed recently. In July 2004 the manual read, "The VelaSmooth system is indicated for the treatment and reduction of cellulite, and the improvement of adipose tissue metabolism."

But in January 2005 he said he saw that a new version of the manual read, "The VelaSmooth Shaper system is indicated for temporary reduction in the appearance of cellulite, to relieve minor muscle aches and pain and for temporary improvement in the local blood circulation."

SAN DIEGO — A combination radiofrequency, infrared, and suction device has achieved mixed results in the treatment of cellulite according to two papers presented at the annual meeting of the American Academy of Cosmetic Surgery.

Twelve of 20 patients (60%) treated with the VelaSmooth device (Syneron Medical Ltd.) by Neil Sadick, M.D., eight times in 4 weeks achieved only mild improvement in cellulite, said Thomas W. Barnes, M.D., who delivered the paper for Dr. Sadick. Another seven patients (35%) were judged to have "good" improvement, and one patient had "very good" improvement.

The results were better among patients who were treated by R. Stephen Mulholland, M.D., 16 times over 8 weeks, said Dr. Barnes, who practices in Newport Beach, Calif. Two of 11 patients (18%) achieved excellent improvement in cellulite, 4 (36%) achieved very good improvement, 4 (36%) achieved good improvement, and in 1 patient (9%) the improvement was mild.

Already available in Europe and Canada, the VelaSmooth device has not yet been approved for sale in the United States. In January 2005, Syneron, based in Yokneam Illit, Israel, announced that the company would soon be applying to the Food and Drug Administration for marketing clearance in the United States.

The intense pulsed light and radiofrequency components of the device increase tissue temperature and are claimed to cause an increase in the available oxygen for fat metabolism, possibly also having an effect on adipocyte integrity.

The suction component is said to physically break down fat-cell clusters, stretch fibrous bands, and increase lymphatic drainage and evacuation of fat metabolism end products. The suction may also push adipocytes back into the subcutaneous compartment.

Dr. Barnes acknowledged receiving compensation from Syneron when speaking about the company's products, and Dr. Sadick acknowledged serving as a consultant to Syneron and other companies.

In two separate studies, Loek Habbema, M.D., of Medical Centre 't Gooi (Bussum, the Netherlands) treated a total of 17 patients with the VelaSmooth device. He stopped the first study, which included 8 patients, early because of an apparent lack of efficacy. Upon examining the device, the distributor noted inadequate suction, which necessitated repair.

Dr. Habbema then treated another nine patients, conducting a blinded study in which one of the patient's outer, inner, posterior, and anterior thighs and buttocks were treated. Each patient was treated eight times over 4 weeks, and was evaluated 5 days following the final treatment. An investigator scored the extent and intensity of the patient's cellulite.

At the end of the treatment period, the investigator found that none of the patients showed any left-right improvement. The patients themselves completed a survey, and none of the nine noticed any improvement. In addition, none said that they would be willing to pay for treatment.

Dr. Habbema, who declared that he had no financial conflicts of interest (although the VelaSmooth device was placed in his office at no charge) offered several possible explanations for the apparent lack of efficacy: The device may inherently lack efficacy; the treatment schedule may need to be changed; the device's output may need adjustment; or the indications for treatment and the patient selection criteria may need alteration.

Dr. Habbema noted that the device's user manual has changed recently. In July 2004 the manual read, "The VelaSmooth system is indicated for the treatment and reduction of cellulite, and the improvement of adipose tissue metabolism."

But in January 2005 he said he saw that a new version of the manual read, "The VelaSmooth Shaper system is indicated for temporary reduction in the appearance of cellulite, to relieve minor muscle aches and pain and for temporary improvement in the local blood circulation."