Sherry Boschert

SAN FRANCISCO — When it comes to alternative therapies for osteoporosis, data are sparse and most do not point to efficacy.

Speaking at the annual meeting of the International Society for Clinical Densitometry, Rogene Tesar, Ph.D., reported available data based on her review:

▸ Strontium. The form that is studied most of 20 supplement compounds is strontium ranelate, which consists of about 340 mg strontium in 1 g of compound.

The Food and Drug Administration is considering approval of strontium ranelate for the treatment of osteoporosis because in two large phase III studies it promoted bone formation, decreased resorption, and reduced fracture risk in postmenopausal women, said Dr. Tesar, who is in private practice in Austin, Texas. The Spinal Osteoporosis Therapeutic Intervention (SOTI) trial of 1,649 patients with a previous vertebral fracture found a 41% reduction in vertebral fracture risk after 3 years of taking strontium ranelate 2 g/day, compared with placebo. Bone mineral density (BMD) increased in the spine by 14% and in the hip by 8% in the strontium group, compared with placebo. The Treatment of Peripheral Osteoporosis (TROPOS) study of 5,091 patients with low hip BMD showed a 39% reduction in vertebral fractures and a 16% reduction in non-vertebral fractures, compared with placebo, over a 3-year period.

A related product, OsteoValin, has strontium carbonate as its main ingredient and is licensed in Europe as a prescription drug to treat osteoporosis. OsteoValin is available in the U.S. over the counter for around $27 for 30 capsules, Dr. Tesar said. Efficacy data, however, are based on only six patients and no control group. In addition, the product is not regulated well enough to ensure its quality and safety.

▸ Soy isoflavones. Although there is solid evidence for prevention of bone loss in animals given soy isoflavones, human data are mixed, Dr. Tesar said.

A double-blind, randomized, placebo-controlled study of 203 women within a decade of menopause reported in 2005 that high-dose isoflavones (80 mg) produced a mild but significant preservation of hip BMD over 1 year. A separate randomized, placebo-controlled study found that 2 years of soy milk with isoflavones prevented spine bone loss in postmenopausal women. The study concluded that two glasses of soy milk containing 76 mg isoflavones per day prevent lumbar spine bone loss.

▸ Vitamin K2. Positive evidence comes mainly from Japan, where a vitamin K2 compound called menatetrenone is standard treatment for osteopenia, Dr. Tesar said. A 2-year study of 241 osteoporotic women reported in 2000 that those taking 45 mg/day of a menatetrenone product called Gla-kay, plus calcium lactate, lost 1% of lumbar spine BMD, compared with a 3% loss in patients taking calcium supplements alone. A separate 2-year study of 172 postmenopausal women found a slight (0.1%) increase in lumbar spine density with vitamin K2 and a more marked (5%) increase with vitamin K2 plus vitamin D3.

▸ Tai Chi. A 1-year study of 34 postmenopausal women in 2002 found generalized bone loss in the 17 women who did 3.5 hours/week of tai chi and in the 17 who did not exercise, but the tai chi group had a lower rate of bone loss. A separate randomized study of 132 menopausal, sedentary women in 2004 also showed a lower rate of bone loss in those who practiced tai chi for 45 minutes a day, 5 days a week, compared with sedentary controls.

There is evidence for prevention of bone loss in animals given soy isoflavones, but human data are mixed. DR. TESAR

SAN FRANCISCO — When it comes to alternative therapies for osteoporosis, data are sparse and most do not point to efficacy.

Speaking at the annual meeting of the International Society for Clinical Densitometry, Rogene Tesar, Ph.D., reported available data based on her review:

▸ Strontium. The form that is studied most of 20 supplement compounds is strontium ranelate, which consists of about 340 mg strontium in 1 g of compound.

The Food and Drug Administration is considering approval of strontium ranelate for the treatment of osteoporosis because in two large phase III studies it promoted bone formation, decreased resorption, and reduced fracture risk in postmenopausal women, said Dr. Tesar, who is in private practice in Austin, Texas. The Spinal Osteoporosis Therapeutic Intervention (SOTI) trial of 1,649 patients with a previous vertebral fracture found a 41% reduction in vertebral fracture risk after 3 years of taking strontium ranelate 2 g/day, compared with placebo. Bone mineral density (BMD) increased in the spine by 14% and in the hip by 8% in the strontium group, compared with placebo. The Treatment of Peripheral Osteoporosis (TROPOS) study of 5,091 patients with low hip BMD showed a 39% reduction in vertebral fractures and a 16% reduction in non-vertebral fractures, compared with placebo, over a 3-year period.

A related product, OsteoValin, has strontium carbonate as its main ingredient and is licensed in Europe as a prescription drug to treat osteoporosis. OsteoValin is available in the U.S. over the counter for around $27 for 30 capsules, Dr. Tesar said. Efficacy data, however, are based on only six patients and no control group. In addition, the product is not regulated well enough to ensure its quality and safety.

▸ Soy isoflavones. Although there is solid evidence for prevention of bone loss in animals given soy isoflavones, human data are mixed, Dr. Tesar said.

A double-blind, randomized, placebo-controlled study of 203 women within a decade of menopause reported in 2005 that high-dose isoflavones (80 mg) produced a mild but significant preservation of hip BMD over 1 year. A separate randomized, placebo-controlled study found that 2 years of soy milk with isoflavones prevented spine bone loss in postmenopausal women. The study concluded that two glasses of soy milk containing 76 mg isoflavones per day prevent lumbar spine bone loss.

▸ Vitamin K2. Positive evidence comes mainly from Japan, where a vitamin K2 compound called menatetrenone is standard treatment for osteopenia, Dr. Tesar said. A 2-year study of 241 osteoporotic women reported in 2000 that those taking 45 mg/day of a menatetrenone product called Gla-kay, plus calcium lactate, lost 1% of lumbar spine BMD, compared with a 3% loss in patients taking calcium supplements alone. A separate 2-year study of 172 postmenopausal women found a slight (0.1%) increase in lumbar spine density with vitamin K2 and a more marked (5%) increase with vitamin K2 plus vitamin D3.

▸ Tai Chi. A 1-year study of 34 postmenopausal women in 2002 found generalized bone loss in the 17 women who did 3.5 hours/week of tai chi and in the 17 who did not exercise, but the tai chi group had a lower rate of bone loss. A separate randomized study of 132 menopausal, sedentary women in 2004 also showed a lower rate of bone loss in those who practiced tai chi for 45 minutes a day, 5 days a week, compared with sedentary controls.

There is evidence for prevention of bone loss in animals given soy isoflavones, but human data are mixed. DR. TESAR

SAN FRANCISCO — When it comes to alternative therapies for osteoporosis, data are sparse and most do not point to efficacy.

Speaking at the annual meeting of the International Society for Clinical Densitometry, Rogene Tesar, Ph.D., reported available data based on her review:

▸ Strontium. The form that is studied most of 20 supplement compounds is strontium ranelate, which consists of about 340 mg strontium in 1 g of compound.

The Food and Drug Administration is considering approval of strontium ranelate for the treatment of osteoporosis because in two large phase III studies it promoted bone formation, decreased resorption, and reduced fracture risk in postmenopausal women, said Dr. Tesar, who is in private practice in Austin, Texas. The Spinal Osteoporosis Therapeutic Intervention (SOTI) trial of 1,649 patients with a previous vertebral fracture found a 41% reduction in vertebral fracture risk after 3 years of taking strontium ranelate 2 g/day, compared with placebo. Bone mineral density (BMD) increased in the spine by 14% and in the hip by 8% in the strontium group, compared with placebo. The Treatment of Peripheral Osteoporosis (TROPOS) study of 5,091 patients with low hip BMD showed a 39% reduction in vertebral fractures and a 16% reduction in non-vertebral fractures, compared with placebo, over a 3-year period.

A related product, OsteoValin, has strontium carbonate as its main ingredient and is licensed in Europe as a prescription drug to treat osteoporosis. OsteoValin is available in the U.S. over the counter for around $27 for 30 capsules, Dr. Tesar said. Efficacy data, however, are based on only six patients and no control group. In addition, the product is not regulated well enough to ensure its quality and safety.

▸ Soy isoflavones. Although there is solid evidence for prevention of bone loss in animals given soy isoflavones, human data are mixed, Dr. Tesar said.

A double-blind, randomized, placebo-controlled study of 203 women within a decade of menopause reported in 2005 that high-dose isoflavones (80 mg) produced a mild but significant preservation of hip BMD over 1 year. A separate randomized, placebo-controlled study found that 2 years of soy milk with isoflavones prevented spine bone loss in postmenopausal women. The study concluded that two glasses of soy milk containing 76 mg isoflavones per day prevent lumbar spine bone loss.

▸ Vitamin K2. Positive evidence comes mainly from Japan, where a vitamin K2 compound called menatetrenone is standard treatment for osteopenia, Dr. Tesar said. A 2-year study of 241 osteoporotic women reported in 2000 that those taking 45 mg/day of a menatetrenone product called Gla-kay, plus calcium lactate, lost 1% of lumbar spine BMD, compared with a 3% loss in patients taking calcium supplements alone. A separate 2-year study of 172 postmenopausal women found a slight (0.1%) increase in lumbar spine density with vitamin K2 and a more marked (5%) increase with vitamin K2 plus vitamin D3.

▸ Tai Chi. A 1-year study of 34 postmenopausal women in 2002 found generalized bone loss in the 17 women who did 3.5 hours/week of tai chi and in the 17 who did not exercise, but the tai chi group had a lower rate of bone loss. A separate randomized study of 132 menopausal, sedentary women in 2004 also showed a lower rate of bone loss in those who practiced tai chi for 45 minutes a day, 5 days a week, compared with sedentary controls.

There is evidence for prevention of bone loss in animals given soy isoflavones, but human data are mixed. DR. TESAR

STANFORD, CALIF. — Bacteria are no longer just resistant, but have learned how to live on antibiotics as their only food source, according to the first study to analyze bacterial resistance in soil samples.

Dr. Alan Greene, a pediatrician with a special interest in the environment, found this study in Science while reviewing journals for articles that affected the practice of pediatrics. This article revealed that antibiotics excreted from humans and livestock are plentiful in soil (Science 2008;320:100-3).

“We're treating not just our patients but the environment, and it's beginning to have an impact,” Dr. Greene said at a pediatric update sponsored by Stanford University.

Reducing U.S. beef consumption by 10% or replacing 10% of conventional livestock with organic beef sources would eliminate 2.5 million pounds of antibiotics from the environment and soil, more than twice the amount of antibiotics prescribed by U.S. physicians each year, said Dr. Greene of the university.

About 40% of health care dollars spent on drugs in pediatrics buy antibiotics, which has got to change, Dr. Greene said. He reported having no financial relationships relevant to his presentation.

A subsequent issue of Science devoted entirely to drug resistance recommended drastically reducing the prescribing of antibiotics, and saving them for when they are really needed (2008;321:313-423). Rather than completing a 7- to 10-day course of antibiotics, it may be better to treat for a day or two until the patient is feeling better, then stop the drug and rely on the immune system, some of the authors suggested.

“I'm not ready to say that we should do that,” but antibiotic prophylaxis is being deemphasized for some pediatric medical problems, Dr. Greene said. Recent guidelines recommend limiting antibiotic prophylaxis for infective endocarditis to select patients, and say prophylaxis will not prevent pyelonephritis and renal scars in children with vesicoureteral reflux.

'We're treating not just our patients but the environment, and it's beginning to have an impact.' DR. GREENE

STANFORD, CALIF. — Bacteria are no longer just resistant, but have learned how to live on antibiotics as their only food source, according to the first study to analyze bacterial resistance in soil samples.

Dr. Alan Greene, a pediatrician with a special interest in the environment, found this study in Science while reviewing journals for articles that affected the practice of pediatrics. This article revealed that antibiotics excreted from humans and livestock are plentiful in soil (Science 2008;320:100-3).

“We're treating not just our patients but the environment, and it's beginning to have an impact,” Dr. Greene said at a pediatric update sponsored by Stanford University.

Reducing U.S. beef consumption by 10% or replacing 10% of conventional livestock with organic beef sources would eliminate 2.5 million pounds of antibiotics from the environment and soil, more than twice the amount of antibiotics prescribed by U.S. physicians each year, said Dr. Greene of the university.

About 40% of health care dollars spent on drugs in pediatrics buy antibiotics, which has got to change, Dr. Greene said. He reported having no financial relationships relevant to his presentation.

A subsequent issue of Science devoted entirely to drug resistance recommended drastically reducing the prescribing of antibiotics, and saving them for when they are really needed (2008;321:313-423). Rather than completing a 7- to 10-day course of antibiotics, it may be better to treat for a day or two until the patient is feeling better, then stop the drug and rely on the immune system, some of the authors suggested.

“I'm not ready to say that we should do that,” but antibiotic prophylaxis is being deemphasized for some pediatric medical problems, Dr. Greene said. Recent guidelines recommend limiting antibiotic prophylaxis for infective endocarditis to select patients, and say prophylaxis will not prevent pyelonephritis and renal scars in children with vesicoureteral reflux.

'We're treating not just our patients but the environment, and it's beginning to have an impact.' DR. GREENE

STANFORD, CALIF. — Bacteria are no longer just resistant, but have learned how to live on antibiotics as their only food source, according to the first study to analyze bacterial resistance in soil samples.

Dr. Alan Greene, a pediatrician with a special interest in the environment, found this study in Science while reviewing journals for articles that affected the practice of pediatrics. This article revealed that antibiotics excreted from humans and livestock are plentiful in soil (Science 2008;320:100-3).

“We're treating not just our patients but the environment, and it's beginning to have an impact,” Dr. Greene said at a pediatric update sponsored by Stanford University.

Reducing U.S. beef consumption by 10% or replacing 10% of conventional livestock with organic beef sources would eliminate 2.5 million pounds of antibiotics from the environment and soil, more than twice the amount of antibiotics prescribed by U.S. physicians each year, said Dr. Greene of the university.

About 40% of health care dollars spent on drugs in pediatrics buy antibiotics, which has got to change, Dr. Greene said. He reported having no financial relationships relevant to his presentation.

A subsequent issue of Science devoted entirely to drug resistance recommended drastically reducing the prescribing of antibiotics, and saving them for when they are really needed (2008;321:313-423). Rather than completing a 7- to 10-day course of antibiotics, it may be better to treat for a day or two until the patient is feeling better, then stop the drug and rely on the immune system, some of the authors suggested.

“I'm not ready to say that we should do that,” but antibiotic prophylaxis is being deemphasized for some pediatric medical problems, Dr. Greene said. Recent guidelines recommend limiting antibiotic prophylaxis for infective endocarditis to select patients, and say prophylaxis will not prevent pyelonephritis and renal scars in children with vesicoureteral reflux.

'We're treating not just our patients but the environment, and it's beginning to have an impact.' DR. GREENE

SAN FRANCISCO — Remote interrogation of pacemakers detected more cardiac events that might require a clinical response, compared with traditional pacemaker follow-up, but did not alter clinical response rates in a study of 897 patients.

The results suggest that remote interrogation of pacemakers has the potential to identify problems earlier and to reduce the time to starting therapy if needed, but further studies are necessary to verify whether enhanced detection affects clinician response, Dr. Bruce L. Wilkoff said at the annual meeting of the Heart Rhythm Society.

Internet-based remote monitoring systems have been studied in patients with implantable cardioverter defibrillators, but this is one of the first studies of remote interrogation in patients with pacemakers.

The prospective Pacemaker Remote Follow-Up Evaluation and Review (PREFER) trial randomized 295 patients with pacemakers to conventional monitoring using transtelephonic rhythm strip evaluations and 602 patients to remote interrogation of pacemakers over a 12-month period. Remote interrogations were done at 3, 6, and 9 months, with a live visit at 12 months. Transtelephonic monitoring was performed every 2 months, with live visits at 12 months for patients with single-chamber pacemakers and at 6 and 12 months for patients with dual-chamber pacemakers.

During the 1-year follow-up, a total of 45% of patients in the remote interrogation group and 38% in the transtelephonic monitoring group had evidence of one or more predefined “clinically actionable events.” These were events that would be likely to trigger clinician response, such as nonsustained ventricular tachycardia, new onset of atrial tachyarrhythmias or atrial fibrillation (AT/AF), electric replacement of the pacemaker indicated, or end of life of the device.

Remote interrogation identified 66% of the clinically actionable events before the live follow-up visit, compared with only 2% of clinically actionable events identified remotely by transtelephonic monitoring (and the rest identified later at live follow-ups), reported Dr. Wilkoff, director of cardiac pacing and tachyarrhythmia devices at the Cleveland Clinic, and his associates.

Early detection of new onset AT/AF was significantly more likely with remote interrogation than with transtelephonic monitoring, which could lead to earlier initiation of therapy and a reduction in risk for stroke, Dr. Wilkoff said.

In this study, however, the significant difference in remote detection of events did not lead to a significant difference in overall clinical response. Of events detected, clinicians acted on 19% in the remote interrogation group and on 15% in the transtelephonic monitoring group.

The study was funded by Medtronic Inc., which makes the remote interrogation system used in the study. Dr. Wilkoff is a consultant for Medtronic. He also has received research funds from or is a consultant to several device makers.

Because of its low yield, “The value of transtelephonic monitoring is limited and may be of clinical significance mostly for the detection of battery depletion,” Dr. Wilkoff suggested. With remote interrogation, in contrast, “rate, duration, electrograms—everything that's in the pacemaker, you can see,” he explained.

He did not have data on the specificity of remote interrogation and how many detected events led to further work-ups that were not necessary.

Dr. Wilkoff noted that the pacemaker monitoring technology is only a part of follow-up plans, which should emphasize communication with patients. By communicating more detailed information to patients with each remote interrogation, “we don't have less of a relationship with them. We actually have more of a relationship.”

The newer remote interrogation technology seemed as acceptable to patients as the older transtelephonic monitoring technology, which has been in use since the 1970s, he added.

Remote interrogation has the potential to identify problems earlier and to reduce the time to therapy, if needed. DR. WILKOFF

SAN FRANCISCO — Remote interrogation of pacemakers detected more cardiac events that might require a clinical response, compared with traditional pacemaker follow-up, but did not alter clinical response rates in a study of 897 patients.

The results suggest that remote interrogation of pacemakers has the potential to identify problems earlier and to reduce the time to starting therapy if needed, but further studies are necessary to verify whether enhanced detection affects clinician response, Dr. Bruce L. Wilkoff said at the annual meeting of the Heart Rhythm Society.

Internet-based remote monitoring systems have been studied in patients with implantable cardioverter defibrillators, but this is one of the first studies of remote interrogation in patients with pacemakers.

The prospective Pacemaker Remote Follow-Up Evaluation and Review (PREFER) trial randomized 295 patients with pacemakers to conventional monitoring using transtelephonic rhythm strip evaluations and 602 patients to remote interrogation of pacemakers over a 12-month period. Remote interrogations were done at 3, 6, and 9 months, with a live visit at 12 months. Transtelephonic monitoring was performed every 2 months, with live visits at 12 months for patients with single-chamber pacemakers and at 6 and 12 months for patients with dual-chamber pacemakers.

During the 1-year follow-up, a total of 45% of patients in the remote interrogation group and 38% in the transtelephonic monitoring group had evidence of one or more predefined “clinically actionable events.” These were events that would be likely to trigger clinician response, such as nonsustained ventricular tachycardia, new onset of atrial tachyarrhythmias or atrial fibrillation (AT/AF), electric replacement of the pacemaker indicated, or end of life of the device.

Remote interrogation identified 66% of the clinically actionable events before the live follow-up visit, compared with only 2% of clinically actionable events identified remotely by transtelephonic monitoring (and the rest identified later at live follow-ups), reported Dr. Wilkoff, director of cardiac pacing and tachyarrhythmia devices at the Cleveland Clinic, and his associates.

Early detection of new onset AT/AF was significantly more likely with remote interrogation than with transtelephonic monitoring, which could lead to earlier initiation of therapy and a reduction in risk for stroke, Dr. Wilkoff said.

In this study, however, the significant difference in remote detection of events did not lead to a significant difference in overall clinical response. Of events detected, clinicians acted on 19% in the remote interrogation group and on 15% in the transtelephonic monitoring group.

The study was funded by Medtronic Inc., which makes the remote interrogation system used in the study. Dr. Wilkoff is a consultant for Medtronic. He also has received research funds from or is a consultant to several device makers.

Because of its low yield, “The value of transtelephonic monitoring is limited and may be of clinical significance mostly for the detection of battery depletion,” Dr. Wilkoff suggested. With remote interrogation, in contrast, “rate, duration, electrograms—everything that's in the pacemaker, you can see,” he explained.

He did not have data on the specificity of remote interrogation and how many detected events led to further work-ups that were not necessary.

Dr. Wilkoff noted that the pacemaker monitoring technology is only a part of follow-up plans, which should emphasize communication with patients. By communicating more detailed information to patients with each remote interrogation, “we don't have less of a relationship with them. We actually have more of a relationship.”

The newer remote interrogation technology seemed as acceptable to patients as the older transtelephonic monitoring technology, which has been in use since the 1970s, he added.

Remote interrogation has the potential to identify problems earlier and to reduce the time to therapy, if needed. DR. WILKOFF

SAN FRANCISCO — Remote interrogation of pacemakers detected more cardiac events that might require a clinical response, compared with traditional pacemaker follow-up, but did not alter clinical response rates in a study of 897 patients.

The results suggest that remote interrogation of pacemakers has the potential to identify problems earlier and to reduce the time to starting therapy if needed, but further studies are necessary to verify whether enhanced detection affects clinician response, Dr. Bruce L. Wilkoff said at the annual meeting of the Heart Rhythm Society.

Internet-based remote monitoring systems have been studied in patients with implantable cardioverter defibrillators, but this is one of the first studies of remote interrogation in patients with pacemakers.

The prospective Pacemaker Remote Follow-Up Evaluation and Review (PREFER) trial randomized 295 patients with pacemakers to conventional monitoring using transtelephonic rhythm strip evaluations and 602 patients to remote interrogation of pacemakers over a 12-month period. Remote interrogations were done at 3, 6, and 9 months, with a live visit at 12 months. Transtelephonic monitoring was performed every 2 months, with live visits at 12 months for patients with single-chamber pacemakers and at 6 and 12 months for patients with dual-chamber pacemakers.

During the 1-year follow-up, a total of 45% of patients in the remote interrogation group and 38% in the transtelephonic monitoring group had evidence of one or more predefined “clinically actionable events.” These were events that would be likely to trigger clinician response, such as nonsustained ventricular tachycardia, new onset of atrial tachyarrhythmias or atrial fibrillation (AT/AF), electric replacement of the pacemaker indicated, or end of life of the device.

Remote interrogation identified 66% of the clinically actionable events before the live follow-up visit, compared with only 2% of clinically actionable events identified remotely by transtelephonic monitoring (and the rest identified later at live follow-ups), reported Dr. Wilkoff, director of cardiac pacing and tachyarrhythmia devices at the Cleveland Clinic, and his associates.

Early detection of new onset AT/AF was significantly more likely with remote interrogation than with transtelephonic monitoring, which could lead to earlier initiation of therapy and a reduction in risk for stroke, Dr. Wilkoff said.

In this study, however, the significant difference in remote detection of events did not lead to a significant difference in overall clinical response. Of events detected, clinicians acted on 19% in the remote interrogation group and on 15% in the transtelephonic monitoring group.

The study was funded by Medtronic Inc., which makes the remote interrogation system used in the study. Dr. Wilkoff is a consultant for Medtronic. He also has received research funds from or is a consultant to several device makers.

Because of its low yield, “The value of transtelephonic monitoring is limited and may be of clinical significance mostly for the detection of battery depletion,” Dr. Wilkoff suggested. With remote interrogation, in contrast, “rate, duration, electrograms—everything that's in the pacemaker, you can see,” he explained.

He did not have data on the specificity of remote interrogation and how many detected events led to further work-ups that were not necessary.

Dr. Wilkoff noted that the pacemaker monitoring technology is only a part of follow-up plans, which should emphasize communication with patients. By communicating more detailed information to patients with each remote interrogation, “we don't have less of a relationship with them. We actually have more of a relationship.”

The newer remote interrogation technology seemed as acceptable to patients as the older transtelephonic monitoring technology, which has been in use since the 1970s, he added.

Remote interrogation has the potential to identify problems earlier and to reduce the time to therapy, if needed. DR. WILKOFF

SAN FRANCISCO — Developing rapport with someone who seeks cosmetic surgery—first as a person and then as a patient—can help weed out potentially problematic patients.

Dr. Roberta D. Sengelmann enters the room for a patient's first consultation "without any preconceived notion about what they're here for," and spends a few minutes asking the patient about herself before moving on to cosmetic topics, she said. "I want to know who I'm embarking on this journey with," said Dr. Sengelmann, a dermatologist in Santa Barbara, Calif. and St. Louis, Mo.

She and three other cosmetic surgeons practicing in California offered tips for managing cosmetic patients in a panel discussion at the annual meeting of the Pacific Dermatologic Association.

Have a mirror handy at that first visit, because often patients do not have a very good idea of what they want done, said Dr. David R. Harris of Campbell, Calif. Help them focus by asking, "If I were a genie, and could pop out of a bottle and satisfy one problem that you have, what would that problem be?" he suggested.

Dr. Ronald L. Moy of Los Angeles agreed that listening to patients is extremely important. He added that listing the main categories of procedures offered, for resurfacing, lifting or tightening, filling, or Botox (botulinum toxin type A) treatments, may help the patient focus.

In addition to developing rapport with patients and helping them decide which treatment to get, the panelists discussed:

▸ Care coordinators. Dr. Greg S. Morganroth of Mountain View, Calif., relies on cosmetic consultants to explain his philosophy, background, and approaches, so when he enters the room, the patient already is feeling good about being there. "It's not just your rapport with them" that matters, he said. "Make them aware it's a team that's taking care of them."

In Dr. Morganroth's practice, the cosmetic consultants not only help during the consultation by handling preoperative education and through extensive "hand-holding" in the postoperative phase. "They're the liaison for the patient throughout the entire process," he said.

The role can be filled by a dedicated cosmetic consultant, or by a nurse, medical assistant, or receptionist. "They all can be trained to do it," he said.

Dr. Sengelmann employs a nurse to fill this role of patient advocate, liaison and care provider.

If a consultant screens cosmetic patients for you, it's still important for you to get acquainted with the patient to decide whether to proceed, Dr. Harris cautioned.

▸ Duration of the consultation. Dr. Sengelmann charges for initial consultations, which last 30 minutes or as long as she thinks is needed. "This all boils down to really getting to know who you're working with and may eventually be operating on. It's just like dating," she said. Many times a patient needs to return for a second or even third consultation, or she will start with more minor treatments prior to scheduling a more involved procedure.

Before he accepts patients, Dr. Moy meets with them two or three times and makes himself accessible by e-mail.

Another strategy is to offer to take care of smaller problems such as dyschromia, an unsightly mole, telangiectasias, lumps, or bumps, and see how the patient handles that before agreeing to do a larger procedure, Dr. Harris said.

▸ Red flags. Patients treated for general dermatologic problems such as psoriasis or acne may become dissatisfied, frustrated, or unhappy with the results, but cosmetic patients in addition can become terribly angry, especially if they have unjustified expectations, Dr. Harris cautioned.

Watch out for patients who complain about every other dermatologist they've seen, or someone who complains about a previous surgeon's work that seems well done to you. "They're going to hate you next," he warned. If the horrible problem a patient complains of is a nearly imperceptible defect, don't treat it. If a patient doesn't listen well and can't focus or make eye contact, be cautious.

▸ Rejections. If you do not want to work with a patient, speak as you would in other troubled relationships, Dr. Sengelmann suggested. Start sentences with "I don't feel that I will be able to meet your expectations …" or "I'm concerned you will not be satisfied with what think I can accomplish for you."

SAN FRANCISCO — Developing rapport with someone who seeks cosmetic surgery—first as a person and then as a patient—can help weed out potentially problematic patients.

Dr. Roberta D. Sengelmann enters the room for a patient's first consultation "without any preconceived notion about what they're here for," and spends a few minutes asking the patient about herself before moving on to cosmetic topics, she said. "I want to know who I'm embarking on this journey with," said Dr. Sengelmann, a dermatologist in Santa Barbara, Calif. and St. Louis, Mo.

She and three other cosmetic surgeons practicing in California offered tips for managing cosmetic patients in a panel discussion at the annual meeting of the Pacific Dermatologic Association.

Have a mirror handy at that first visit, because often patients do not have a very good idea of what they want done, said Dr. David R. Harris of Campbell, Calif. Help them focus by asking, "If I were a genie, and could pop out of a bottle and satisfy one problem that you have, what would that problem be?" he suggested.

Dr. Ronald L. Moy of Los Angeles agreed that listening to patients is extremely important. He added that listing the main categories of procedures offered, for resurfacing, lifting or tightening, filling, or Botox (botulinum toxin type A) treatments, may help the patient focus.

In addition to developing rapport with patients and helping them decide which treatment to get, the panelists discussed:

▸ Care coordinators. Dr. Greg S. Morganroth of Mountain View, Calif., relies on cosmetic consultants to explain his philosophy, background, and approaches, so when he enters the room, the patient already is feeling good about being there. "It's not just your rapport with them" that matters, he said. "Make them aware it's a team that's taking care of them."

In Dr. Morganroth's practice, the cosmetic consultants not only help during the consultation by handling preoperative education and through extensive "hand-holding" in the postoperative phase. "They're the liaison for the patient throughout the entire process," he said.

The role can be filled by a dedicated cosmetic consultant, or by a nurse, medical assistant, or receptionist. "They all can be trained to do it," he said.

Dr. Sengelmann employs a nurse to fill this role of patient advocate, liaison and care provider.

If a consultant screens cosmetic patients for you, it's still important for you to get acquainted with the patient to decide whether to proceed, Dr. Harris cautioned.

▸ Duration of the consultation. Dr. Sengelmann charges for initial consultations, which last 30 minutes or as long as she thinks is needed. "This all boils down to really getting to know who you're working with and may eventually be operating on. It's just like dating," she said. Many times a patient needs to return for a second or even third consultation, or she will start with more minor treatments prior to scheduling a more involved procedure.

Before he accepts patients, Dr. Moy meets with them two or three times and makes himself accessible by e-mail.

Another strategy is to offer to take care of smaller problems such as dyschromia, an unsightly mole, telangiectasias, lumps, or bumps, and see how the patient handles that before agreeing to do a larger procedure, Dr. Harris said.

▸ Red flags. Patients treated for general dermatologic problems such as psoriasis or acne may become dissatisfied, frustrated, or unhappy with the results, but cosmetic patients in addition can become terribly angry, especially if they have unjustified expectations, Dr. Harris cautioned.

Watch out for patients who complain about every other dermatologist they've seen, or someone who complains about a previous surgeon's work that seems well done to you. "They're going to hate you next," he warned. If the horrible problem a patient complains of is a nearly imperceptible defect, don't treat it. If a patient doesn't listen well and can't focus or make eye contact, be cautious.

▸ Rejections. If you do not want to work with a patient, speak as you would in other troubled relationships, Dr. Sengelmann suggested. Start sentences with "I don't feel that I will be able to meet your expectations …" or "I'm concerned you will not be satisfied with what think I can accomplish for you."

SAN FRANCISCO — Developing rapport with someone who seeks cosmetic surgery—first as a person and then as a patient—can help weed out potentially problematic patients.

Dr. Roberta D. Sengelmann enters the room for a patient's first consultation "without any preconceived notion about what they're here for," and spends a few minutes asking the patient about herself before moving on to cosmetic topics, she said. "I want to know who I'm embarking on this journey with," said Dr. Sengelmann, a dermatologist in Santa Barbara, Calif. and St. Louis, Mo.

She and three other cosmetic surgeons practicing in California offered tips for managing cosmetic patients in a panel discussion at the annual meeting of the Pacific Dermatologic Association.

Have a mirror handy at that first visit, because often patients do not have a very good idea of what they want done, said Dr. David R. Harris of Campbell, Calif. Help them focus by asking, "If I were a genie, and could pop out of a bottle and satisfy one problem that you have, what would that problem be?" he suggested.

Dr. Ronald L. Moy of Los Angeles agreed that listening to patients is extremely important. He added that listing the main categories of procedures offered, for resurfacing, lifting or tightening, filling, or Botox (botulinum toxin type A) treatments, may help the patient focus.

In addition to developing rapport with patients and helping them decide which treatment to get, the panelists discussed:

▸ Care coordinators. Dr. Greg S. Morganroth of Mountain View, Calif., relies on cosmetic consultants to explain his philosophy, background, and approaches, so when he enters the room, the patient already is feeling good about being there. "It's not just your rapport with them" that matters, he said. "Make them aware it's a team that's taking care of them."

In Dr. Morganroth's practice, the cosmetic consultants not only help during the consultation by handling preoperative education and through extensive "hand-holding" in the postoperative phase. "They're the liaison for the patient throughout the entire process," he said.

The role can be filled by a dedicated cosmetic consultant, or by a nurse, medical assistant, or receptionist. "They all can be trained to do it," he said.

Dr. Sengelmann employs a nurse to fill this role of patient advocate, liaison and care provider.

If a consultant screens cosmetic patients for you, it's still important for you to get acquainted with the patient to decide whether to proceed, Dr. Harris cautioned.

▸ Duration of the consultation. Dr. Sengelmann charges for initial consultations, which last 30 minutes or as long as she thinks is needed. "This all boils down to really getting to know who you're working with and may eventually be operating on. It's just like dating," she said. Many times a patient needs to return for a second or even third consultation, or she will start with more minor treatments prior to scheduling a more involved procedure.

Before he accepts patients, Dr. Moy meets with them two or three times and makes himself accessible by e-mail.

Another strategy is to offer to take care of smaller problems such as dyschromia, an unsightly mole, telangiectasias, lumps, or bumps, and see how the patient handles that before agreeing to do a larger procedure, Dr. Harris said.

▸ Red flags. Patients treated for general dermatologic problems such as psoriasis or acne may become dissatisfied, frustrated, or unhappy with the results, but cosmetic patients in addition can become terribly angry, especially if they have unjustified expectations, Dr. Harris cautioned.

Watch out for patients who complain about every other dermatologist they've seen, or someone who complains about a previous surgeon's work that seems well done to you. "They're going to hate you next," he warned. If the horrible problem a patient complains of is a nearly imperceptible defect, don't treat it. If a patient doesn't listen well and can't focus or make eye contact, be cautious.

▸ Rejections. If you do not want to work with a patient, speak as you would in other troubled relationships, Dr. Sengelmann suggested. Start sentences with "I don't feel that I will be able to meet your expectations …" or "I'm concerned you will not be satisfied with what think I can accomplish for you."

SAN FRANCISCO — Dermatologists who perform cosmetic surgery take a variety of approaches to obtain a patient's informed consent, with differing views on the best method to do so.

Some try to list every possible complication of a procedure on informed consent forms. Others see that as a trap if they omit the one problem that the patient develops, and prefer more generic references to potential complications.

Four experts in private cosmetic surgery practices shared best practices in obtaining informed consent on a panel at the annual meeting of the Pacific Dermatologic Association. All agreed that there should be two copies of consent forms—one for the patient's chart, and the other to go home with the patient.

Dr. Roberta D. Sengelmann uses a fairly generic consent form in her current practice in Santa Barbara, Calif., and St. Louis, Mo., and after a thorough discussion with the patient, documents specific pertinent risks in their medical record.

In her experience as an expert witness for dermatologic procedures, she has found that the danger of itemizing every possible risk is that should something occur that was not listed, problems will arise.

Dr. Sengelmann said that important phrases to include in consent forms are that "No guarantee can be made" for specific results, and "Sometimes additional procedures are needed to obtain the desired result."

Dr. Ronald L. Moy of Los Angeles takes a different approach, influenced by his 8 years of service on the Medical Board of California. Many of the cases handled by the board involved patients who said they were not aware that they were at risk for a particular complication.

"It's true that you're not going to include everything, but you can include 99.9%" of potential complications on the form, he said, adding that an extensive list is best.

Dr. David R. Harris, who is from Campbell, Calif., agreed, and added that the form also should point out the cost of additional procedures; otherwise, patients might assume that the work is free.

His office developed an easy-to-understand format that uses bullets and short explanations on the consent form instead of "legal mumbo jumbo." He asks patients to sign a clause saying they will go to arbitration rather than file a lawsuit if they end up in a conflict over the results, even knowing that an arbitration clause is not binding.

Dr. Moy takes a different tack, asking patients to sign a statement saying that if they were to take legal action, they would use an expert witness from one of the four medical specialty societies in which Dr. Moy is a member. This would exclude expert witnesses from specialties that have had turf wars with dermatologic surgeons.

Dr. Greg S. Morganroth of Mountain View, Calif., asks patients to sign an arbitration agreement and tells them it is not binding. He uses the discussion primarily to develop a mindset that he and the patient are collaborators working together.

Malpractice carriers tend to frown on arbitration agreements, he noted, because physicians are more likely to win a case in a court of law than with an arbitration panel. The nonbinding nature of these agreements cut both ways, however, so that he could opt out of the agreement if it ever came to that.

His informed consent form includes a checklist of items that patients must initial. Patients must acknowledge, for example, that they are aware of how long healing may take, that Dr. Morganroth is not a plastic surgeon, and that some physicians would be critical of a dermatologic surgeon doing cosmetic surgery.

For larger facial surgeries, he numbers them, telling a patient that she is the third case he will have done for a particular procedure, or number 364. "I go a little bit overboard," but it avoids a patient getting angry later if he learns of this fact, he said.

The danger of itemizing every risk is that should something occur that was not listed, problems will arise. DR. SENGELMANN

SAN FRANCISCO — Dermatologists who perform cosmetic surgery take a variety of approaches to obtain a patient's informed consent, with differing views on the best method to do so.

Some try to list every possible complication of a procedure on informed consent forms. Others see that as a trap if they omit the one problem that the patient develops, and prefer more generic references to potential complications.

Four experts in private cosmetic surgery practices shared best practices in obtaining informed consent on a panel at the annual meeting of the Pacific Dermatologic Association. All agreed that there should be two copies of consent forms—one for the patient's chart, and the other to go home with the patient.

Dr. Roberta D. Sengelmann uses a fairly generic consent form in her current practice in Santa Barbara, Calif., and St. Louis, Mo., and after a thorough discussion with the patient, documents specific pertinent risks in their medical record.

In her experience as an expert witness for dermatologic procedures, she has found that the danger of itemizing every possible risk is that should something occur that was not listed, problems will arise.

Dr. Sengelmann said that important phrases to include in consent forms are that "No guarantee can be made" for specific results, and "Sometimes additional procedures are needed to obtain the desired result."

Dr. Ronald L. Moy of Los Angeles takes a different approach, influenced by his 8 years of service on the Medical Board of California. Many of the cases handled by the board involved patients who said they were not aware that they were at risk for a particular complication.

"It's true that you're not going to include everything, but you can include 99.9%" of potential complications on the form, he said, adding that an extensive list is best.

Dr. David R. Harris, who is from Campbell, Calif., agreed, and added that the form also should point out the cost of additional procedures; otherwise, patients might assume that the work is free.

His office developed an easy-to-understand format that uses bullets and short explanations on the consent form instead of "legal mumbo jumbo." He asks patients to sign a clause saying they will go to arbitration rather than file a lawsuit if they end up in a conflict over the results, even knowing that an arbitration clause is not binding.

Dr. Moy takes a different tack, asking patients to sign a statement saying that if they were to take legal action, they would use an expert witness from one of the four medical specialty societies in which Dr. Moy is a member. This would exclude expert witnesses from specialties that have had turf wars with dermatologic surgeons.

Dr. Greg S. Morganroth of Mountain View, Calif., asks patients to sign an arbitration agreement and tells them it is not binding. He uses the discussion primarily to develop a mindset that he and the patient are collaborators working together.

Malpractice carriers tend to frown on arbitration agreements, he noted, because physicians are more likely to win a case in a court of law than with an arbitration panel. The nonbinding nature of these agreements cut both ways, however, so that he could opt out of the agreement if it ever came to that.

His informed consent form includes a checklist of items that patients must initial. Patients must acknowledge, for example, that they are aware of how long healing may take, that Dr. Morganroth is not a plastic surgeon, and that some physicians would be critical of a dermatologic surgeon doing cosmetic surgery.

For larger facial surgeries, he numbers them, telling a patient that she is the third case he will have done for a particular procedure, or number 364. "I go a little bit overboard," but it avoids a patient getting angry later if he learns of this fact, he said.

The danger of itemizing every risk is that should something occur that was not listed, problems will arise. DR. SENGELMANN

SAN FRANCISCO — Dermatologists who perform cosmetic surgery take a variety of approaches to obtain a patient's informed consent, with differing views on the best method to do so.

Some try to list every possible complication of a procedure on informed consent forms. Others see that as a trap if they omit the one problem that the patient develops, and prefer more generic references to potential complications.

Four experts in private cosmetic surgery practices shared best practices in obtaining informed consent on a panel at the annual meeting of the Pacific Dermatologic Association. All agreed that there should be two copies of consent forms—one for the patient's chart, and the other to go home with the patient.

Dr. Roberta D. Sengelmann uses a fairly generic consent form in her current practice in Santa Barbara, Calif., and St. Louis, Mo., and after a thorough discussion with the patient, documents specific pertinent risks in their medical record.

In her experience as an expert witness for dermatologic procedures, she has found that the danger of itemizing every possible risk is that should something occur that was not listed, problems will arise.

Dr. Sengelmann said that important phrases to include in consent forms are that "No guarantee can be made" for specific results, and "Sometimes additional procedures are needed to obtain the desired result."

Dr. Ronald L. Moy of Los Angeles takes a different approach, influenced by his 8 years of service on the Medical Board of California. Many of the cases handled by the board involved patients who said they were not aware that they were at risk for a particular complication.

"It's true that you're not going to include everything, but you can include 99.9%" of potential complications on the form, he said, adding that an extensive list is best.

Dr. David R. Harris, who is from Campbell, Calif., agreed, and added that the form also should point out the cost of additional procedures; otherwise, patients might assume that the work is free.

His office developed an easy-to-understand format that uses bullets and short explanations on the consent form instead of "legal mumbo jumbo." He asks patients to sign a clause saying they will go to arbitration rather than file a lawsuit if they end up in a conflict over the results, even knowing that an arbitration clause is not binding.

Dr. Moy takes a different tack, asking patients to sign a statement saying that if they were to take legal action, they would use an expert witness from one of the four medical specialty societies in which Dr. Moy is a member. This would exclude expert witnesses from specialties that have had turf wars with dermatologic surgeons.

Dr. Greg S. Morganroth of Mountain View, Calif., asks patients to sign an arbitration agreement and tells them it is not binding. He uses the discussion primarily to develop a mindset that he and the patient are collaborators working together.

Malpractice carriers tend to frown on arbitration agreements, he noted, because physicians are more likely to win a case in a court of law than with an arbitration panel. The nonbinding nature of these agreements cut both ways, however, so that he could opt out of the agreement if it ever came to that.

His informed consent form includes a checklist of items that patients must initial. Patients must acknowledge, for example, that they are aware of how long healing may take, that Dr. Morganroth is not a plastic surgeon, and that some physicians would be critical of a dermatologic surgeon doing cosmetic surgery.

For larger facial surgeries, he numbers them, telling a patient that she is the third case he will have done for a particular procedure, or number 364. "I go a little bit overboard," but it avoids a patient getting angry later if he learns of this fact, he said.

The danger of itemizing every risk is that should something occur that was not listed, problems will arise. DR. SENGELMANN

SAN FRANCISCO — Three techniques can help make nasal reconstruction surgery easier while providing positive results.

Dr. Hayes B. Gladstone recommends using a more diamond-shaped bilobed flap instead of curved incisions, doing a shave contour instead of defatting a staged melolabial flap, and dividing a paramedian forehead flap after 1 week instead of 3 weeks.

The diamond bilobed flap results in less stress and tension during healing and may reduce the risk of pincushioning, also called trap-door deformity. A shave division of a staged melolabial flap is much easier than defatting, and patients seem pleased to shorten the time to division of a paramedian forehead flap, he said at the annual meeting of the Pacific Dermatologic Association.

▸ Bilobed flap. The original design for a bilobed flap was modified in 1989 to change the angles in order to reduce pincushioning, in which the flap raises up. "If you look in the literature, there is still about a 5%–10% risk" of pincushioning with a bilobed flap, probably caused by wound contraction, said Dr. Gladstone of Stanford (Calif.) University.

By using more angular incision lines (instead of curved lines) to give the flap more of a diamond shape, only 2 mm of undermining is needed instead of the 3 mm needed with a conventional bilobed flap. "It's more of an advancement flap in its angular design," he said.

Computer modeling suggests that the diamond bilobed flap reduces strain on the closure points by 85%, compared with a conventional bilobed flap.

"With angles you're going to get less compression and less contraction, and therefore you're going to get less risk of pincushioning," Dr. Gladstone said.

▸ Melolabial flap. He follows the conventional technique for most patients with thin, nonlobular alar rims who undergo a staged melolabial flap for nasal reconstruction, but after 3 weeks, instead of defatting the flap, he does a shave contour that takes around 3–4 minutes. He lets that heal by second intent.

"It seems a little counterintuitive, but it actually heals very well," accompanied by closure of a small cheek defect when needed, he said.

The key to shave contouring the melolabial flap is to not be too aggressive, which can result in a divot or raising of the alar rim, he added.

▸ Paramedian forehead flap. Most patients dislike waiting 3 weeks to divide a paramedian forehead flap because the flap disrupts vision, making it difficult to read or drive; decreases quality of life; and can cause psychological stress.

One patient tore off his flap after 4 days but healed well. "That's how I decided to start doing this" division earlier, Dr. Gladstone said.

He plans to submit for publication the results for 35 patients who underwent division of a paramedian forehead flap after 1 week.

A survey of the first 15 patients found that all preferred to have the procedure done after 1 week instead of 3 weeks. Tests showed good blood flow, and only three patients required small revisions, he said.

One 95-year-old patient with an active dating life was a prime candidate for the 1-week division of the paramedian forehead flap because "he wasn't going to tolerate 3 weeks," Dr. Gladstone said. The patient healed well.

SAN FRANCISCO — Three techniques can help make nasal reconstruction surgery easier while providing positive results.

Dr. Hayes B. Gladstone recommends using a more diamond-shaped bilobed flap instead of curved incisions, doing a shave contour instead of defatting a staged melolabial flap, and dividing a paramedian forehead flap after 1 week instead of 3 weeks.

The diamond bilobed flap results in less stress and tension during healing and may reduce the risk of pincushioning, also called trap-door deformity. A shave division of a staged melolabial flap is much easier than defatting, and patients seem pleased to shorten the time to division of a paramedian forehead flap, he said at the annual meeting of the Pacific Dermatologic Association.

▸ Bilobed flap. The original design for a bilobed flap was modified in 1989 to change the angles in order to reduce pincushioning, in which the flap raises up. "If you look in the literature, there is still about a 5%–10% risk" of pincushioning with a bilobed flap, probably caused by wound contraction, said Dr. Gladstone of Stanford (Calif.) University.

By using more angular incision lines (instead of curved lines) to give the flap more of a diamond shape, only 2 mm of undermining is needed instead of the 3 mm needed with a conventional bilobed flap. "It's more of an advancement flap in its angular design," he said.

Computer modeling suggests that the diamond bilobed flap reduces strain on the closure points by 85%, compared with a conventional bilobed flap.

"With angles you're going to get less compression and less contraction, and therefore you're going to get less risk of pincushioning," Dr. Gladstone said.

▸ Melolabial flap. He follows the conventional technique for most patients with thin, nonlobular alar rims who undergo a staged melolabial flap for nasal reconstruction, but after 3 weeks, instead of defatting the flap, he does a shave contour that takes around 3–4 minutes. He lets that heal by second intent.

"It seems a little counterintuitive, but it actually heals very well," accompanied by closure of a small cheek defect when needed, he said.

The key to shave contouring the melolabial flap is to not be too aggressive, which can result in a divot or raising of the alar rim, he added.

▸ Paramedian forehead flap. Most patients dislike waiting 3 weeks to divide a paramedian forehead flap because the flap disrupts vision, making it difficult to read or drive; decreases quality of life; and can cause psychological stress.

One patient tore off his flap after 4 days but healed well. "That's how I decided to start doing this" division earlier, Dr. Gladstone said.

He plans to submit for publication the results for 35 patients who underwent division of a paramedian forehead flap after 1 week.

A survey of the first 15 patients found that all preferred to have the procedure done after 1 week instead of 3 weeks. Tests showed good blood flow, and only three patients required small revisions, he said.

One 95-year-old patient with an active dating life was a prime candidate for the 1-week division of the paramedian forehead flap because "he wasn't going to tolerate 3 weeks," Dr. Gladstone said. The patient healed well.

SAN FRANCISCO — Three techniques can help make nasal reconstruction surgery easier while providing positive results.

Dr. Hayes B. Gladstone recommends using a more diamond-shaped bilobed flap instead of curved incisions, doing a shave contour instead of defatting a staged melolabial flap, and dividing a paramedian forehead flap after 1 week instead of 3 weeks.

The diamond bilobed flap results in less stress and tension during healing and may reduce the risk of pincushioning, also called trap-door deformity. A shave division of a staged melolabial flap is much easier than defatting, and patients seem pleased to shorten the time to division of a paramedian forehead flap, he said at the annual meeting of the Pacific Dermatologic Association.

▸ Bilobed flap. The original design for a bilobed flap was modified in 1989 to change the angles in order to reduce pincushioning, in which the flap raises up. "If you look in the literature, there is still about a 5%–10% risk" of pincushioning with a bilobed flap, probably caused by wound contraction, said Dr. Gladstone of Stanford (Calif.) University.

By using more angular incision lines (instead of curved lines) to give the flap more of a diamond shape, only 2 mm of undermining is needed instead of the 3 mm needed with a conventional bilobed flap. "It's more of an advancement flap in its angular design," he said.

Computer modeling suggests that the diamond bilobed flap reduces strain on the closure points by 85%, compared with a conventional bilobed flap.

"With angles you're going to get less compression and less contraction, and therefore you're going to get less risk of pincushioning," Dr. Gladstone said.

▸ Melolabial flap. He follows the conventional technique for most patients with thin, nonlobular alar rims who undergo a staged melolabial flap for nasal reconstruction, but after 3 weeks, instead of defatting the flap, he does a shave contour that takes around 3–4 minutes. He lets that heal by second intent.

"It seems a little counterintuitive, but it actually heals very well," accompanied by closure of a small cheek defect when needed, he said.

The key to shave contouring the melolabial flap is to not be too aggressive, which can result in a divot or raising of the alar rim, he added.

▸ Paramedian forehead flap. Most patients dislike waiting 3 weeks to divide a paramedian forehead flap because the flap disrupts vision, making it difficult to read or drive; decreases quality of life; and can cause psychological stress.

One patient tore off his flap after 4 days but healed well. "That's how I decided to start doing this" division earlier, Dr. Gladstone said.

He plans to submit for publication the results for 35 patients who underwent division of a paramedian forehead flap after 1 week.

A survey of the first 15 patients found that all preferred to have the procedure done after 1 week instead of 3 weeks. Tests showed good blood flow, and only three patients required small revisions, he said.

One 95-year-old patient with an active dating life was a prime candidate for the 1-week division of the paramedian forehead flap because "he wasn't going to tolerate 3 weeks," Dr. Gladstone said. The patient healed well.

SAN FRANCISCO — Respect the nasolabial folds, vermilion border, and mental crease to get the most natural-looking results from reconstructive surgery around the mouth.

Put linear surgical scars into those lines—not across them—to avoid a noticeable asymmetry that "gets very exaggerated during movement" of the mouth, Dr. Ken K. Lee said at the annual meeting of the Pacific Dermatologic Association. Even respecting the lines of current or future rhytids can help hide a scar.

Surgeons commonly used to use a transition flap from the cheek to repair surgical defects on the upper cutaneous lip, but this would blunt the entire nasolabial fold. "If the crease is completely gone, it looks unnatural," so surgeons today shy away from that technique, said Dr. Lee, director of dermatologic and laser surgery at Oregon Health and Science University, Portland.

Perioral surgical defects on the upper lip tend to leave indented scars unless the surgeon hypereverts the incision. "The natural tendency—the reason we get wrinkles in this area—is it wants to invert. So you really have to do an exaggerated eversion to prevent this type of indented scar," he said. The creation of a little ridge when a defect is closed helps produce a nearly invisible scar instead of an indented one.

Closing in a linear fashion may not suffice for larger defects, but the surgeon still should respect the cosmetic lines when using other techniques for closure. Aligning the closure of a rotation flap with the nasolabial fold, rhytids, mental crease, or vermilion border will help hide a scar.

For larger defects, the island pedicle flap becomes the surgeon's work horse, in all its variations. "It allows me to bring skin in from outside the lip unit to fill in larger defects in the lip," Dr. Lee said.

He used a pedicle flap from outside the nasolabial fold to help close a complex defect in the upper cutaneous lip, nose, and cheek in one patient, closing along the nasolabial fold and advancing the cheek. "Recreating all the cosmetic borders is important," he said.

For a young woman in her 30s with little extra skin compared with older patients, it is difficult to repair a defect that takes up a large portion of the upper cutaneous lip just by using the skin inside of the nasolabial fold. It's okay to tap the reservoir of cheek skin for an island pedicle flap to repair this, but "the important thing is that when you zip up the island pedicle—the defect behind it—that line needs to follow the nasolabial fold," he said.

The downside of island pedicle flaps is potential "pincushioning," he added, but if the incision has been adequately undermined and the edges everted, resulting in a good-looking scar, pincushioning will go away in time.

'The natural tendency—the reason we get wrinkles in this area—is it wants to invert.' DR. LEE

An island pedicle flap can utilize skin from outside the perioral borders to fill a defect in the upper lip, with closure along the nasolabial fold for a good cosmetic result as demonstrated in the patient above. The patient is shown before and after surgery (left and middle, respectively), and after the wound had healed (right). Photos courtesy Dr. Ken K. Lee

SAN FRANCISCO — Respect the nasolabial folds, vermilion border, and mental crease to get the most natural-looking results from reconstructive surgery around the mouth.

Put linear surgical scars into those lines—not across them—to avoid a noticeable asymmetry that "gets very exaggerated during movement" of the mouth, Dr. Ken K. Lee said at the annual meeting of the Pacific Dermatologic Association. Even respecting the lines of current or future rhytids can help hide a scar.

Surgeons commonly used to use a transition flap from the cheek to repair surgical defects on the upper cutaneous lip, but this would blunt the entire nasolabial fold. "If the crease is completely gone, it looks unnatural," so surgeons today shy away from that technique, said Dr. Lee, director of dermatologic and laser surgery at Oregon Health and Science University, Portland.

Perioral surgical defects on the upper lip tend to leave indented scars unless the surgeon hypereverts the incision. "The natural tendency—the reason we get wrinkles in this area—is it wants to invert. So you really have to do an exaggerated eversion to prevent this type of indented scar," he said. The creation of a little ridge when a defect is closed helps produce a nearly invisible scar instead of an indented one.

Closing in a linear fashion may not suffice for larger defects, but the surgeon still should respect the cosmetic lines when using other techniques for closure. Aligning the closure of a rotation flap with the nasolabial fold, rhytids, mental crease, or vermilion border will help hide a scar.

For larger defects, the island pedicle flap becomes the surgeon's work horse, in all its variations. "It allows me to bring skin in from outside the lip unit to fill in larger defects in the lip," Dr. Lee said.

He used a pedicle flap from outside the nasolabial fold to help close a complex defect in the upper cutaneous lip, nose, and cheek in one patient, closing along the nasolabial fold and advancing the cheek. "Recreating all the cosmetic borders is important," he said.

For a young woman in her 30s with little extra skin compared with older patients, it is difficult to repair a defect that takes up a large portion of the upper cutaneous lip just by using the skin inside of the nasolabial fold. It's okay to tap the reservoir of cheek skin for an island pedicle flap to repair this, but "the important thing is that when you zip up the island pedicle—the defect behind it—that line needs to follow the nasolabial fold," he said.

The downside of island pedicle flaps is potential "pincushioning," he added, but if the incision has been adequately undermined and the edges everted, resulting in a good-looking scar, pincushioning will go away in time.

'The natural tendency—the reason we get wrinkles in this area—is it wants to invert.' DR. LEE

An island pedicle flap can utilize skin from outside the perioral borders to fill a defect in the upper lip, with closure along the nasolabial fold for a good cosmetic result as demonstrated in the patient above. The patient is shown before and after surgery (left and middle, respectively), and after the wound had healed (right). Photos courtesy Dr. Ken K. Lee

SAN FRANCISCO — Respect the nasolabial folds, vermilion border, and mental crease to get the most natural-looking results from reconstructive surgery around the mouth.

Put linear surgical scars into those lines—not across them—to avoid a noticeable asymmetry that "gets very exaggerated during movement" of the mouth, Dr. Ken K. Lee said at the annual meeting of the Pacific Dermatologic Association. Even respecting the lines of current or future rhytids can help hide a scar.

Surgeons commonly used to use a transition flap from the cheek to repair surgical defects on the upper cutaneous lip, but this would blunt the entire nasolabial fold. "If the crease is completely gone, it looks unnatural," so surgeons today shy away from that technique, said Dr. Lee, director of dermatologic and laser surgery at Oregon Health and Science University, Portland.

Perioral surgical defects on the upper lip tend to leave indented scars unless the surgeon hypereverts the incision. "The natural tendency—the reason we get wrinkles in this area—is it wants to invert. So you really have to do an exaggerated eversion to prevent this type of indented scar," he said. The creation of a little ridge when a defect is closed helps produce a nearly invisible scar instead of an indented one.

Closing in a linear fashion may not suffice for larger defects, but the surgeon still should respect the cosmetic lines when using other techniques for closure. Aligning the closure of a rotation flap with the nasolabial fold, rhytids, mental crease, or vermilion border will help hide a scar.

For larger defects, the island pedicle flap becomes the surgeon's work horse, in all its variations. "It allows me to bring skin in from outside the lip unit to fill in larger defects in the lip," Dr. Lee said.

He used a pedicle flap from outside the nasolabial fold to help close a complex defect in the upper cutaneous lip, nose, and cheek in one patient, closing along the nasolabial fold and advancing the cheek. "Recreating all the cosmetic borders is important," he said.

For a young woman in her 30s with little extra skin compared with older patients, it is difficult to repair a defect that takes up a large portion of the upper cutaneous lip just by using the skin inside of the nasolabial fold. It's okay to tap the reservoir of cheek skin for an island pedicle flap to repair this, but "the important thing is that when you zip up the island pedicle—the defect behind it—that line needs to follow the nasolabial fold," he said.

The downside of island pedicle flaps is potential "pincushioning," he added, but if the incision has been adequately undermined and the edges everted, resulting in a good-looking scar, pincushioning will go away in time.

'The natural tendency—the reason we get wrinkles in this area—is it wants to invert.' DR. LEE

An island pedicle flap can utilize skin from outside the perioral borders to fill a defect in the upper lip, with closure along the nasolabial fold for a good cosmetic result as demonstrated in the patient above. The patient is shown before and after surgery (left and middle, respectively), and after the wound had healed (right). Photos courtesy Dr. Ken K. Lee

SAN FRANCISCO — Having a history of melanoma should not preclude a patient from receiving an organ transplant, according to Dr. Daniel Berg.

Roughly half of the approximately 100,000 new cases of melanoma diagnosed in the United States each year are in situ melanomas, and there is no reason these patients should not proceed to organ transplantation, but "the transplant docs don't necessarily separate these out" from other melanomas, Dr. Berg said at the annual meeting of the Pacific Dermatologic Association.

Patients with a history of stage T1a melanoma probably can safely undergo organ transplantation if they have gone 2 years without a recurrence of the melanoma, he said. At least 5 years without recurrence should be required in patients with melanoma stage greater than T1a or with tumor stage b before considering organ transplantation, added Dr. Berg, director of dermatologic surgery at the University of Washington, Seattle. Transplantation should be avoided if there is a history of metastatic melanoma.

Should a new melanoma in a posttransplant patient be found, treatment is the same as for other melanoma patients, with a couple of exceptions. For more aggressive melanoma (with a tumor larger than 1 mm in diameter, or a positive sentinel node), consider reducing immunosuppressive therapy, Dr. Berg suggested. If a posttransplant patient develops metastatic melanoma, try to determine if the melanoma originated in the patient's own body or in the organ donor. Metastatic melanoma that came from transplant should prompt you to notify other recipients of organs from the same donor. Their risk for metastatic melanoma is very high.

One study of 20 recipients of organs from 11 donors who retrospectively were diagnosed with metastatic melanoma found that 17 recipients developed to stage IV, and most died. Ceasing immunosuppression produced complete remission in five organ recipients (Transplantation 1996;61:274–8).

If an organ recipient gets metastatic melanoma from a donor, consider withdrawing immunosuppression, an allograft explantation, or retransplantation to improve the chance of survival, Dr. Berg said. The medical literature recommends against using organs from donors with any history of melanoma, but this may be overkill, he suggested. A review of data on 140 transplant patients who unwittingly received organs in 2000–2005 from donors with a history of melanoma found that one organ recipient died of metastatic melanoma (Transplantation 2007;84:272–4).

The organ in the recipient who died came from a donor who had been diagnosed with melanoma 32 years earlier. Another 27% of donors were diagnosed with melanoma within 5 years of their deaths, but none of those recipients died of melanoma.

"So, what do you do with a patient who has a sister who's willing to give him a kidney, and that sister had an in situ melanoma?" Dr. Berg asked. "You should be prepared to be an advocate for them" to proceed with transplantation.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — Having a history of melanoma should not preclude a patient from receiving an organ transplant, according to Dr. Daniel Berg.

Roughly half of the approximately 100,000 new cases of melanoma diagnosed in the United States each year are in situ melanomas, and there is no reason these patients should not proceed to organ transplantation, but "the transplant docs don't necessarily separate these out" from other melanomas, Dr. Berg said at the annual meeting of the Pacific Dermatologic Association.

Patients with a history of stage T1a melanoma probably can safely undergo organ transplantation if they have gone 2 years without a recurrence of the melanoma, he said. At least 5 years without recurrence should be required in patients with melanoma stage greater than T1a or with tumor stage b before considering organ transplantation, added Dr. Berg, director of dermatologic surgery at the University of Washington, Seattle. Transplantation should be avoided if there is a history of metastatic melanoma.

Should a new melanoma in a posttransplant patient be found, treatment is the same as for other melanoma patients, with a couple of exceptions. For more aggressive melanoma (with a tumor larger than 1 mm in diameter, or a positive sentinel node), consider reducing immunosuppressive therapy, Dr. Berg suggested. If a posttransplant patient develops metastatic melanoma, try to determine if the melanoma originated in the patient's own body or in the organ donor. Metastatic melanoma that came from transplant should prompt you to notify other recipients of organs from the same donor. Their risk for metastatic melanoma is very high.

One study of 20 recipients of organs from 11 donors who retrospectively were diagnosed with metastatic melanoma found that 17 recipients developed to stage IV, and most died. Ceasing immunosuppression produced complete remission in five organ recipients (Transplantation 1996;61:274–8).

If an organ recipient gets metastatic melanoma from a donor, consider withdrawing immunosuppression, an allograft explantation, or retransplantation to improve the chance of survival, Dr. Berg said. The medical literature recommends against using organs from donors with any history of melanoma, but this may be overkill, he suggested. A review of data on 140 transplant patients who unwittingly received organs in 2000–2005 from donors with a history of melanoma found that one organ recipient died of metastatic melanoma (Transplantation 2007;84:272–4).

The organ in the recipient who died came from a donor who had been diagnosed with melanoma 32 years earlier. Another 27% of donors were diagnosed with melanoma within 5 years of their deaths, but none of those recipients died of melanoma.

"So, what do you do with a patient who has a sister who's willing to give him a kidney, and that sister had an in situ melanoma?" Dr. Berg asked. "You should be prepared to be an advocate for them" to proceed with transplantation.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — Having a history of melanoma should not preclude a patient from receiving an organ transplant, according to Dr. Daniel Berg.

Roughly half of the approximately 100,000 new cases of melanoma diagnosed in the United States each year are in situ melanomas, and there is no reason these patients should not proceed to organ transplantation, but "the transplant docs don't necessarily separate these out" from other melanomas, Dr. Berg said at the annual meeting of the Pacific Dermatologic Association.

Patients with a history of stage T1a melanoma probably can safely undergo organ transplantation if they have gone 2 years without a recurrence of the melanoma, he said. At least 5 years without recurrence should be required in patients with melanoma stage greater than T1a or with tumor stage b before considering organ transplantation, added Dr. Berg, director of dermatologic surgery at the University of Washington, Seattle. Transplantation should be avoided if there is a history of metastatic melanoma.

Should a new melanoma in a posttransplant patient be found, treatment is the same as for other melanoma patients, with a couple of exceptions. For more aggressive melanoma (with a tumor larger than 1 mm in diameter, or a positive sentinel node), consider reducing immunosuppressive therapy, Dr. Berg suggested. If a posttransplant patient develops metastatic melanoma, try to determine if the melanoma originated in the patient's own body or in the organ donor. Metastatic melanoma that came from transplant should prompt you to notify other recipients of organs from the same donor. Their risk for metastatic melanoma is very high.

One study of 20 recipients of organs from 11 donors who retrospectively were diagnosed with metastatic melanoma found that 17 recipients developed to stage IV, and most died. Ceasing immunosuppression produced complete remission in five organ recipients (Transplantation 1996;61:274–8).

If an organ recipient gets metastatic melanoma from a donor, consider withdrawing immunosuppression, an allograft explantation, or retransplantation to improve the chance of survival, Dr. Berg said. The medical literature recommends against using organs from donors with any history of melanoma, but this may be overkill, he suggested. A review of data on 140 transplant patients who unwittingly received organs in 2000–2005 from donors with a history of melanoma found that one organ recipient died of metastatic melanoma (Transplantation 2007;84:272–4).

The organ in the recipient who died came from a donor who had been diagnosed with melanoma 32 years earlier. Another 27% of donors were diagnosed with melanoma within 5 years of their deaths, but none of those recipients died of melanoma.

"So, what do you do with a patient who has a sister who's willing to give him a kidney, and that sister had an in situ melanoma?" Dr. Berg asked. "You should be prepared to be an advocate for them" to proceed with transplantation.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — Traditional radiographic assessment of osteoarthritis in the medial compartment of the knee should be combined with scintigraphic data for the most accurate evaluation, according to a poster presentation at the annual meeting of the American Academy of Orthopaedic Surgeons.

By providing information on the metabolic activity of bone, scintigraphy enables degenerative changes in the knee to be detected early, before joint disease shows up in x-rays, said Dr. Scott F. Dye of the orthopedic surgery department at the University of California, San Francisco.

An anterior-posterior technetium bone scan provides a window into the metabolic activity of living bone, according to Dr. Dye and his associates. Knees can be metabolically worse or better than the x-ray results suggest. Combining the structural (x-ray) and metabolic (scintigraphy) studies provides a better assessment of the status of the knee and response to therapies.

The earliest stages of medial compartment osteoarthritis of the knee often are secondary to meniscal tears, and 80% of patients with medial meniscus tears will show loss of osseous homeostasis on scintigraphy despite normal x-ray results. This allows for identification of joints at risk of degenerative disease “at a time when the process can be fully reversed,” said Dr. Dye, who has no association with companies that make scintigraphic equipment.

SAN FRANCISCO — Traditional radiographic assessment of osteoarthritis in the medial compartment of the knee should be combined with scintigraphic data for the most accurate evaluation, according to a poster presentation at the annual meeting of the American Academy of Orthopaedic Surgeons.

By providing information on the metabolic activity of bone, scintigraphy enables degenerative changes in the knee to be detected early, before joint disease shows up in x-rays, said Dr. Scott F. Dye of the orthopedic surgery department at the University of California, San Francisco.

An anterior-posterior technetium bone scan provides a window into the metabolic activity of living bone, according to Dr. Dye and his associates. Knees can be metabolically worse or better than the x-ray results suggest. Combining the structural (x-ray) and metabolic (scintigraphy) studies provides a better assessment of the status of the knee and response to therapies.

The earliest stages of medial compartment osteoarthritis of the knee often are secondary to meniscal tears, and 80% of patients with medial meniscus tears will show loss of osseous homeostasis on scintigraphy despite normal x-ray results. This allows for identification of joints at risk of degenerative disease “at a time when the process can be fully reversed,” said Dr. Dye, who has no association with companies that make scintigraphic equipment.

SAN FRANCISCO — Traditional radiographic assessment of osteoarthritis in the medial compartment of the knee should be combined with scintigraphic data for the most accurate evaluation, according to a poster presentation at the annual meeting of the American Academy of Orthopaedic Surgeons.

By providing information on the metabolic activity of bone, scintigraphy enables degenerative changes in the knee to be detected early, before joint disease shows up in x-rays, said Dr. Scott F. Dye of the orthopedic surgery department at the University of California, San Francisco.

An anterior-posterior technetium bone scan provides a window into the metabolic activity of living bone, according to Dr. Dye and his associates. Knees can be metabolically worse or better than the x-ray results suggest. Combining the structural (x-ray) and metabolic (scintigraphy) studies provides a better assessment of the status of the knee and response to therapies.

The earliest stages of medial compartment osteoarthritis of the knee often are secondary to meniscal tears, and 80% of patients with medial meniscus tears will show loss of osseous homeostasis on scintigraphy despite normal x-ray results. This allows for identification of joints at risk of degenerative disease “at a time when the process can be fully reversed,” said Dr. Dye, who has no association with companies that make scintigraphic equipment.

PHOENIX — The proportion of clinic visits to psychiatrists involving antidepressants for youths fell compared with the proportion of visits to primary care physicians after the black box warning linking antidepressant use to suicidality in youths.

However, visits by adults for antidepressants did not change by specialty during the same time period—suggesting that the Food and Drug Administration's suicidality warning of 2004 caused the change in pediatric prescriptions.

Results of an analysis of data from the National Ambulatory Medical Care Survey seem to show that the FDA warning “had a greater impact on the prescribing of antidepressants to youth by psychiatrists than by primary care physicians,” Julie M. Zito, Ph.D., said at a poster presentation at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.

Dr. Zito and her associates compared the national ambulatory trend data from the years 2000–2001 and 2002–2003 (before the FDA warning) with data from 2004–2005 (after the warning).

The proportion of visits by youth (aged under 18 years) to psychiatrists for antidepressants changed little between 2000 (63%) and 2003 (62%), but fell after the FDA warning to 54% in 2004 and 41% in 2005, reported Dr. Zito, professor of pharmacoepidemiology and psychotherapeutics at the University of Maryland, Baltimore.

The proportion of visits by youths to primary care physicians (pediatricians, internists, and family physicians) for antidepressants was 31% in both 2000 and 2003, but increased to 42% in 2004 and to 45% in 2005. Visits by youth to other specialties for antidepressants comprised 6% in 2000, 8% in 2003, 4% in 2004, and 14% in 2005.

The proportion of visits by adults, in comparison, changed relatively little by specialty, with visits to psychiatrists for antidepressants comprising 21% in 2003 and 20% in 2005. Primary care physicians handled 54% of adult visits for antidepressants in 2003 and 53% in 2005. Other specialties covered 22% of adult visits for antidepressants in 2003 and 27% in 2005.

In each year, the share of antidepressant visits by youth to psychiatrists was larger than the share of antidepressant visits by adults to psychiatrists. Adults were more likely to be treated by primary care physicians.

Among the visits for antidepressant prescriptions for youths during 2004–2005, 67% were for selective serotonin reuptake inhibitors, 36% were for tricyclic antidepressants, and 26% were for other medications.

Dr. Zito has no association with companies that manufacture antidepressants.

In 2003, 31% of vists by youths to PCPs were for for antidepressants, versus 42% in 2004 and 45% in 2005. DR. ZITO

PHOENIX — The proportion of clinic visits to psychiatrists involving antidepressants for youths fell compared with the proportion of visits to primary care physicians after the black box warning linking antidepressant use to suicidality in youths.

However, visits by adults for antidepressants did not change by specialty during the same time period—suggesting that the Food and Drug Administration's suicidality warning of 2004 caused the change in pediatric prescriptions.

Results of an analysis of data from the National Ambulatory Medical Care Survey seem to show that the FDA warning “had a greater impact on the prescribing of antidepressants to youth by psychiatrists than by primary care physicians,” Julie M. Zito, Ph.D., said at a poster presentation at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.

Dr. Zito and her associates compared the national ambulatory trend data from the years 2000–2001 and 2002–2003 (before the FDA warning) with data from 2004–2005 (after the warning).

The proportion of visits by youth (aged under 18 years) to psychiatrists for antidepressants changed little between 2000 (63%) and 2003 (62%), but fell after the FDA warning to 54% in 2004 and 41% in 2005, reported Dr. Zito, professor of pharmacoepidemiology and psychotherapeutics at the University of Maryland, Baltimore.

The proportion of visits by youths to primary care physicians (pediatricians, internists, and family physicians) for antidepressants was 31% in both 2000 and 2003, but increased to 42% in 2004 and to 45% in 2005. Visits by youth to other specialties for antidepressants comprised 6% in 2000, 8% in 2003, 4% in 2004, and 14% in 2005.

The proportion of visits by adults, in comparison, changed relatively little by specialty, with visits to psychiatrists for antidepressants comprising 21% in 2003 and 20% in 2005. Primary care physicians handled 54% of adult visits for antidepressants in 2003 and 53% in 2005. Other specialties covered 22% of adult visits for antidepressants in 2003 and 27% in 2005.

In each year, the share of antidepressant visits by youth to psychiatrists was larger than the share of antidepressant visits by adults to psychiatrists. Adults were more likely to be treated by primary care physicians.

Among the visits for antidepressant prescriptions for youths during 2004–2005, 67% were for selective serotonin reuptake inhibitors, 36% were for tricyclic antidepressants, and 26% were for other medications.

Dr. Zito has no association with companies that manufacture antidepressants.

In 2003, 31% of vists by youths to PCPs were for for antidepressants, versus 42% in 2004 and 45% in 2005. DR. ZITO

PHOENIX — The proportion of clinic visits to psychiatrists involving antidepressants for youths fell compared with the proportion of visits to primary care physicians after the black box warning linking antidepressant use to suicidality in youths.

However, visits by adults for antidepressants did not change by specialty during the same time period—suggesting that the Food and Drug Administration's suicidality warning of 2004 caused the change in pediatric prescriptions.

Results of an analysis of data from the National Ambulatory Medical Care Survey seem to show that the FDA warning “had a greater impact on the prescribing of antidepressants to youth by psychiatrists than by primary care physicians,” Julie M. Zito, Ph.D., said at a poster presentation at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.

Dr. Zito and her associates compared the national ambulatory trend data from the years 2000–2001 and 2002–2003 (before the FDA warning) with data from 2004–2005 (after the warning).

The proportion of visits by youth (aged under 18 years) to psychiatrists for antidepressants changed little between 2000 (63%) and 2003 (62%), but fell after the FDA warning to 54% in 2004 and 41% in 2005, reported Dr. Zito, professor of pharmacoepidemiology and psychotherapeutics at the University of Maryland, Baltimore.

The proportion of visits by youths to primary care physicians (pediatricians, internists, and family physicians) for antidepressants was 31% in both 2000 and 2003, but increased to 42% in 2004 and to 45% in 2005. Visits by youth to other specialties for antidepressants comprised 6% in 2000, 8% in 2003, 4% in 2004, and 14% in 2005.

The proportion of visits by adults, in comparison, changed relatively little by specialty, with visits to psychiatrists for antidepressants comprising 21% in 2003 and 20% in 2005. Primary care physicians handled 54% of adult visits for antidepressants in 2003 and 53% in 2005. Other specialties covered 22% of adult visits for antidepressants in 2003 and 27% in 2005.

In each year, the share of antidepressant visits by youth to psychiatrists was larger than the share of antidepressant visits by adults to psychiatrists. Adults were more likely to be treated by primary care physicians.

Among the visits for antidepressant prescriptions for youths during 2004–2005, 67% were for selective serotonin reuptake inhibitors, 36% were for tricyclic antidepressants, and 26% were for other medications.

Dr. Zito has no association with companies that manufacture antidepressants.

In 2003, 31% of vists by youths to PCPs were for for antidepressants, versus 42% in 2004 and 45% in 2005. DR. ZITO