Sherry Boschert

Major Finding: Irrespective of HPV type, the vaccine reduced the risk for ASCUS by 8%, the risk for LSILs by 14%, and the risk for HSILs by 41%. The risk for CIN2 and CIN3 was 30% and 33% lower than in the control group.

Data Source: Secondary analysis of data on 17,347 women from a phase III efficacy trial in 14 countries.

Disclosures: Dr. Martens has been a consultant for and received research funds, honoraria, and conference sponsorship from Merck & Co. and from GlaxoSmithKline Biologicals, which makes the vaccine and funded the study.

SAN FRANCISCO — A vaccine for human papillomavirus decreased the risk for cytologic abnormalities over a 3-year period by 56%-68%, compared with placebo vaccine, a secondary analysis of data on 17,347 women in a phase III clinical trial found.

The analysis looked at vaccination with all three doses of Cervarix, the atropine sulfate–adjuvanted vaccine for human papillomavirus types 16 and 18 (HPV-16/18), in 8,665 young, predominantly sexually active women compared with a control group of 8,682 women who got hepatitis A vaccine.

The primary results of the Papilloma Trial Against Cancer in Young Adults (PATRICIA), reported last year, showed the vaccine was highly prophylactic against grade II cervical intraepithelial neoplasia (CIN2) associated with HPV-16/18 and against several oncogenic non-vaccine types of HPV (Lancet 2009;374:301-14).

Dr. Mark G. Martens reported on a secondary end point built into the PATRICIA trial to assess vaccine efficacy in preventing abnormal Pap smear results and subsequent reduction in colposcopy referrals and cervical excision procedures.

Cervical samples were collected every 6 months for HPV DNA genotyping, and the women underwent yearly gynecology and cytologic examinations. The rate of atypical squamous cells of undetermined significance (ASCUS) with HPV-16/18 was 57% lower in the vaccine group compared with the control group during 3 years of follow-up, said Dr. Martens, who conducted the analysis while at Oklahoma State University, Tulsa, and now practices at Jersey Shore University Medical Center, Neptune, N.J.

The rate of low-grade squamous intraepithelial lesions (LSILs) with HPV-16/18 was 68% lower than in the control group, and the rate of high-grade squamous intraepithelial lesions (HSILs) with HPV-16/18 was 56% lower than in the control group, he said at the meeting.

Absolute rates of ASCUS with HPV-16/18 were about 2% in the vaccine group and 4% in the control group. LSILs with HPV-16/18 were detected in 2% of the vaccine group and 6% of the control group. HSILs with HPV-16/18 were present in 0.2% of the vaccine group and 0.5% of the control group.

There was a statistically significant difference between groups for HSILs with HPV-16 (0.1% in the vaccine group vs. 0.4% in the control group) but not for HSILs with HPV-18 (0.05% and 0.1%).

Irrespective of HPV type, the vaccine reduced the risk for ASCUS by 8%, the risk for LSILs by 14%, and the risk for HSILs by 41%, he added.

The risk for CIN2 and CIN3 was 30% and 33% lower than in the control group. “That means the lesions we're going to act upon”—HSILs, CIN2, and CIN3— “were 30%-40% lower with the vaccine,” Dr. Martens said.

HSILs were found in 0.5% of the vaccine group, irrespective of HPV type, and 0.9% of the control group. CIN2 was detected in 2.5% of the vaccine group and 3.7% of the control group. The rate of CIN3 was 0.8% in the vaccine group and 1.3% in the control group.

Compared with the control group, colposcopy referrals were reduced by 10% and cervical excision procedures were reduced by 25% in the vaccine group, he reported.

Dr. Martens said he did an extra calculation for one state—Ohio—and estimated that each physician performing Pap smears in the state would see 20 fewer cases of CIN2/3 per year if patients were vaccinated. Nationally, the vaccine could result in 5 million fewer Pap smears per year because there would be less abnormal cytology, he added.

Women were included in the analysis regardless of their HPV DNA status, HPV serostatus, or cytology at baseline. Evidence of past or current infection with HPV-16/18 was present at baseline in 26% of women, but only 98 participants (less than 1%) were DNA positive for both HPV-16 and HPV-18.

Major Finding: Irrespective of HPV type, the vaccine reduced the risk for ASCUS by 8%, the risk for LSILs by 14%, and the risk for HSILs by 41%. The risk for CIN2 and CIN3 was 30% and 33% lower than in the control group.

Data Source: Secondary analysis of data on 17,347 women from a phase III efficacy trial in 14 countries.

Disclosures: Dr. Martens has been a consultant for and received research funds, honoraria, and conference sponsorship from Merck & Co. and from GlaxoSmithKline Biologicals, which makes the vaccine and funded the study.

SAN FRANCISCO — A vaccine for human papillomavirus decreased the risk for cytologic abnormalities over a 3-year period by 56%-68%, compared with placebo vaccine, a secondary analysis of data on 17,347 women in a phase III clinical trial found.

The analysis looked at vaccination with all three doses of Cervarix, the atropine sulfate–adjuvanted vaccine for human papillomavirus types 16 and 18 (HPV-16/18), in 8,665 young, predominantly sexually active women compared with a control group of 8,682 women who got hepatitis A vaccine.

The primary results of the Papilloma Trial Against Cancer in Young Adults (PATRICIA), reported last year, showed the vaccine was highly prophylactic against grade II cervical intraepithelial neoplasia (CIN2) associated with HPV-16/18 and against several oncogenic non-vaccine types of HPV (Lancet 2009;374:301-14).

Dr. Mark G. Martens reported on a secondary end point built into the PATRICIA trial to assess vaccine efficacy in preventing abnormal Pap smear results and subsequent reduction in colposcopy referrals and cervical excision procedures.

Cervical samples were collected every 6 months for HPV DNA genotyping, and the women underwent yearly gynecology and cytologic examinations. The rate of atypical squamous cells of undetermined significance (ASCUS) with HPV-16/18 was 57% lower in the vaccine group compared with the control group during 3 years of follow-up, said Dr. Martens, who conducted the analysis while at Oklahoma State University, Tulsa, and now practices at Jersey Shore University Medical Center, Neptune, N.J.

The rate of low-grade squamous intraepithelial lesions (LSILs) with HPV-16/18 was 68% lower than in the control group, and the rate of high-grade squamous intraepithelial lesions (HSILs) with HPV-16/18 was 56% lower than in the control group, he said at the meeting.

Absolute rates of ASCUS with HPV-16/18 were about 2% in the vaccine group and 4% in the control group. LSILs with HPV-16/18 were detected in 2% of the vaccine group and 6% of the control group. HSILs with HPV-16/18 were present in 0.2% of the vaccine group and 0.5% of the control group.

There was a statistically significant difference between groups for HSILs with HPV-16 (0.1% in the vaccine group vs. 0.4% in the control group) but not for HSILs with HPV-18 (0.05% and 0.1%).

Irrespective of HPV type, the vaccine reduced the risk for ASCUS by 8%, the risk for LSILs by 14%, and the risk for HSILs by 41%, he added.

The risk for CIN2 and CIN3 was 30% and 33% lower than in the control group. “That means the lesions we're going to act upon”—HSILs, CIN2, and CIN3— “were 30%-40% lower with the vaccine,” Dr. Martens said.

HSILs were found in 0.5% of the vaccine group, irrespective of HPV type, and 0.9% of the control group. CIN2 was detected in 2.5% of the vaccine group and 3.7% of the control group. The rate of CIN3 was 0.8% in the vaccine group and 1.3% in the control group.

Compared with the control group, colposcopy referrals were reduced by 10% and cervical excision procedures were reduced by 25% in the vaccine group, he reported.

Dr. Martens said he did an extra calculation for one state—Ohio—and estimated that each physician performing Pap smears in the state would see 20 fewer cases of CIN2/3 per year if patients were vaccinated. Nationally, the vaccine could result in 5 million fewer Pap smears per year because there would be less abnormal cytology, he added.

Women were included in the analysis regardless of their HPV DNA status, HPV serostatus, or cytology at baseline. Evidence of past or current infection with HPV-16/18 was present at baseline in 26% of women, but only 98 participants (less than 1%) were DNA positive for both HPV-16 and HPV-18.

Major Finding: Irrespective of HPV type, the vaccine reduced the risk for ASCUS by 8%, the risk for LSILs by 14%, and the risk for HSILs by 41%. The risk for CIN2 and CIN3 was 30% and 33% lower than in the control group.

Data Source: Secondary analysis of data on 17,347 women from a phase III efficacy trial in 14 countries.

Disclosures: Dr. Martens has been a consultant for and received research funds, honoraria, and conference sponsorship from Merck & Co. and from GlaxoSmithKline Biologicals, which makes the vaccine and funded the study.

SAN FRANCISCO — A vaccine for human papillomavirus decreased the risk for cytologic abnormalities over a 3-year period by 56%-68%, compared with placebo vaccine, a secondary analysis of data on 17,347 women in a phase III clinical trial found.

The analysis looked at vaccination with all three doses of Cervarix, the atropine sulfate–adjuvanted vaccine for human papillomavirus types 16 and 18 (HPV-16/18), in 8,665 young, predominantly sexually active women compared with a control group of 8,682 women who got hepatitis A vaccine.

The primary results of the Papilloma Trial Against Cancer in Young Adults (PATRICIA), reported last year, showed the vaccine was highly prophylactic against grade II cervical intraepithelial neoplasia (CIN2) associated with HPV-16/18 and against several oncogenic non-vaccine types of HPV (Lancet 2009;374:301-14).

Dr. Mark G. Martens reported on a secondary end point built into the PATRICIA trial to assess vaccine efficacy in preventing abnormal Pap smear results and subsequent reduction in colposcopy referrals and cervical excision procedures.

Cervical samples were collected every 6 months for HPV DNA genotyping, and the women underwent yearly gynecology and cytologic examinations. The rate of atypical squamous cells of undetermined significance (ASCUS) with HPV-16/18 was 57% lower in the vaccine group compared with the control group during 3 years of follow-up, said Dr. Martens, who conducted the analysis while at Oklahoma State University, Tulsa, and now practices at Jersey Shore University Medical Center, Neptune, N.J.

The rate of low-grade squamous intraepithelial lesions (LSILs) with HPV-16/18 was 68% lower than in the control group, and the rate of high-grade squamous intraepithelial lesions (HSILs) with HPV-16/18 was 56% lower than in the control group, he said at the meeting.

Absolute rates of ASCUS with HPV-16/18 were about 2% in the vaccine group and 4% in the control group. LSILs with HPV-16/18 were detected in 2% of the vaccine group and 6% of the control group. HSILs with HPV-16/18 were present in 0.2% of the vaccine group and 0.5% of the control group.

There was a statistically significant difference between groups for HSILs with HPV-16 (0.1% in the vaccine group vs. 0.4% in the control group) but not for HSILs with HPV-18 (0.05% and 0.1%).

Irrespective of HPV type, the vaccine reduced the risk for ASCUS by 8%, the risk for LSILs by 14%, and the risk for HSILs by 41%, he added.

The risk for CIN2 and CIN3 was 30% and 33% lower than in the control group. “That means the lesions we're going to act upon”—HSILs, CIN2, and CIN3— “were 30%-40% lower with the vaccine,” Dr. Martens said.

HSILs were found in 0.5% of the vaccine group, irrespective of HPV type, and 0.9% of the control group. CIN2 was detected in 2.5% of the vaccine group and 3.7% of the control group. The rate of CIN3 was 0.8% in the vaccine group and 1.3% in the control group.

Compared with the control group, colposcopy referrals were reduced by 10% and cervical excision procedures were reduced by 25% in the vaccine group, he reported.

Dr. Martens said he did an extra calculation for one state—Ohio—and estimated that each physician performing Pap smears in the state would see 20 fewer cases of CIN2/3 per year if patients were vaccinated. Nationally, the vaccine could result in 5 million fewer Pap smears per year because there would be less abnormal cytology, he added.

Women were included in the analysis regardless of their HPV DNA status, HPV serostatus, or cytology at baseline. Evidence of past or current infection with HPV-16/18 was present at baseline in 26% of women, but only 98 participants (less than 1%) were DNA positive for both HPV-16 and HPV-18.

SAN FRANCISCO — Results of nonstress tests in 112 pregnant women being treated for chronic hypertension during 2003-2007 did not differ significantly in patients on labetalol, compared with those on methyldopa, results of a retrospective study found.

“Physicians should feel comfortable using labetalol or methyldopa for pregnant patients with hypertension. Those medications have no effect on the baby,” Dr. Ramata Niangan, an ob.gyn. at the University of Illinois at Chicago, said in an interview at the meeting.

Nonstress tests were reactive in 84% of 76 patients on labetalol and in 81% of 36 patients on methyldopa, a difference that was not statistically significant, she said.

Traditionally, methyldopa has been used to treat hypertension during pregnancy, but in recent years more physicians have begun using beta-blockers or other medications.

Labetalol is both a selective alpha-blocker and a nonselective beta-blocker that decreases systemic vascular resistance without changing maternal cardiac output.

The study included 112 women treated for hypertension during pregnancy and excluded women with multiple-gestation pregnancies or other antihypertensive treatment.

Among secondary outcomes, there were no significant differences between the two treatment groups in maternal age, gestational age at delivery, birth weight, or the rate of preeclampsia, said Dr. Niang, who did not report any financial disclosures.

SAN FRANCISCO — Results of nonstress tests in 112 pregnant women being treated for chronic hypertension during 2003-2007 did not differ significantly in patients on labetalol, compared with those on methyldopa, results of a retrospective study found.

“Physicians should feel comfortable using labetalol or methyldopa for pregnant patients with hypertension. Those medications have no effect on the baby,” Dr. Ramata Niangan, an ob.gyn. at the University of Illinois at Chicago, said in an interview at the meeting.

Nonstress tests were reactive in 84% of 76 patients on labetalol and in 81% of 36 patients on methyldopa, a difference that was not statistically significant, she said.

Traditionally, methyldopa has been used to treat hypertension during pregnancy, but in recent years more physicians have begun using beta-blockers or other medications.

Labetalol is both a selective alpha-blocker and a nonselective beta-blocker that decreases systemic vascular resistance without changing maternal cardiac output.

The study included 112 women treated for hypertension during pregnancy and excluded women with multiple-gestation pregnancies or other antihypertensive treatment.

Among secondary outcomes, there were no significant differences between the two treatment groups in maternal age, gestational age at delivery, birth weight, or the rate of preeclampsia, said Dr. Niang, who did not report any financial disclosures.

SAN FRANCISCO — Results of nonstress tests in 112 pregnant women being treated for chronic hypertension during 2003-2007 did not differ significantly in patients on labetalol, compared with those on methyldopa, results of a retrospective study found.

“Physicians should feel comfortable using labetalol or methyldopa for pregnant patients with hypertension. Those medications have no effect on the baby,” Dr. Ramata Niangan, an ob.gyn. at the University of Illinois at Chicago, said in an interview at the meeting.

Nonstress tests were reactive in 84% of 76 patients on labetalol and in 81% of 36 patients on methyldopa, a difference that was not statistically significant, she said.

Traditionally, methyldopa has been used to treat hypertension during pregnancy, but in recent years more physicians have begun using beta-blockers or other medications.

Labetalol is both a selective alpha-blocker and a nonselective beta-blocker that decreases systemic vascular resistance without changing maternal cardiac output.

The study included 112 women treated for hypertension during pregnancy and excluded women with multiple-gestation pregnancies or other antihypertensive treatment.

Among secondary outcomes, there were no significant differences between the two treatment groups in maternal age, gestational age at delivery, birth weight, or the rate of preeclampsia, said Dr. Niang, who did not report any financial disclosures.

MONTEREY, CALIF. — Have you searched for your name on the Internet? Your patients have.

“Your patients are Googling you,” and some of them probably are rating your performance as a doctor on one of the many physician-rating sites or generic rating sites, Dr. Clifford Warren Lober said at the meeting.

Here's the problem: The patients most likely to rate you are those who are livid or those who think you walk on water. And it's not just patients who are posting comments about you, but previous patients, ex-employees, former spouses, or anyone else who knows you, said Dr. Lober, a dermatologist and attorney in Kissimmee, Fla.

Online comments may be made anonymously, may persist for years on the Internet, may be accessed by anyone with a computer, and may be replicated on other Web sites beyond the original.

If you discover comments about you that you think are harmful to your reputation, your attempts to remedy the situation may backfire and instead “optimize” the content by bringing more attention to the posted statement, amplifying its negativity, Dr. Lober pointed out.

Legal remedies are few and complicated. “There is a morass of legal defenses and privileges that protect the offending person,” Dr. Lober said.

So what is the best way to manage your online reputation? One strategy is to minimize the impact of negative online information through search-engine optimization, he suggested.

In practice, this means blitzing the Web with your own content to crowd out comments by others.

“You want to occupy the first three pages of the rating sites” and the search-engine results pages, if possible, Dr. Lober said, adding that most people do not look beyond the first three pages of results.

This can be accomplished by establishing multiple Web sites, each with numerous internal page links, external high-traffic links, significant content on each of your home pages, and other features that make these the sites that show up when someone searches your name.

Establishing a deep social network presence helps, too. Dr. Lober suggests creating accounts on Facebook, Twitter, LinkedIn, ZoomInfo, Connectbeam, Yahoo Profile, Google Profile, MSN Profile, Wetpaint, Naymz, Jigsaw, Ning, and others, he suggested. Ideally, get on sites that feature RSS (Really Simple Syndication) feeds so that information posted on one site transfers to others.

Other prongs in this strategy include issuing press releases by using Internet publication sites, establishing one or more blogs in your name, and using pay-per-click advertising.

Sound overwhelming? Innovative entrepreneurs thought that it might, so a number of Internet reputation-management companies have formed to do some of this work for you—for a fee, of course. These include companies such as Reputation Repair & Management, Internet Reputation Management, and Reputation-Defender, Dr. Lober said.

If, instead, you want to make an attempt to get a specific offensive statement removed from the Web, seek legal counsel to guide you, he advised.

First, the statement must be determined to meet the legal definition of defamation. If it does, the next step is to determine if the person who wrote it is covered by any one of several standard legal defenses. If that's not an issue, check the terms and conditions listed by the Internet service provider (ISP) of the site where the comment appeared, to see if the ISP made any promises or assurances about the content on the site. If you contact the ISP, it may take the comment down.

Normally, ISPs are immune from lawsuits over statements made by others on its service; they resemble telephone companies more than newspapers in that respect, he said.

You or your lawyer can request that the courts issue a subpoena to try to compel the person who made the statement (even an anonymous poster) to remedy the situation, but this process is time consuming and expensive, and the person who posted the comment may be difficult to locate, Dr. Lober cautioned.

And if you sue, the defendant may try to frame your action as a SLAPP (strategic litigation against public participation) suit intended to muzzle critics and restrict freedom of speech.

Some states have anti-SLAPP laws that could leave you paying the defendant's attorney fees and costs, and make you vulnerable to a countersuit by the defendant.

Better to try to “manage” your online reputation than to try to legally defend it, Dr. Lober suggested.

Disclosures: Dr. Lober reported having no pertinent conflicts of interest.

MONTEREY, CALIF. — Have you searched for your name on the Internet? Your patients have.

“Your patients are Googling you,” and some of them probably are rating your performance as a doctor on one of the many physician-rating sites or generic rating sites, Dr. Clifford Warren Lober said at the meeting.

Here's the problem: The patients most likely to rate you are those who are livid or those who think you walk on water. And it's not just patients who are posting comments about you, but previous patients, ex-employees, former spouses, or anyone else who knows you, said Dr. Lober, a dermatologist and attorney in Kissimmee, Fla.

Online comments may be made anonymously, may persist for years on the Internet, may be accessed by anyone with a computer, and may be replicated on other Web sites beyond the original.

If you discover comments about you that you think are harmful to your reputation, your attempts to remedy the situation may backfire and instead “optimize” the content by bringing more attention to the posted statement, amplifying its negativity, Dr. Lober pointed out.

Legal remedies are few and complicated. “There is a morass of legal defenses and privileges that protect the offending person,” Dr. Lober said.

So what is the best way to manage your online reputation? One strategy is to minimize the impact of negative online information through search-engine optimization, he suggested.

In practice, this means blitzing the Web with your own content to crowd out comments by others.

“You want to occupy the first three pages of the rating sites” and the search-engine results pages, if possible, Dr. Lober said, adding that most people do not look beyond the first three pages of results.

This can be accomplished by establishing multiple Web sites, each with numerous internal page links, external high-traffic links, significant content on each of your home pages, and other features that make these the sites that show up when someone searches your name.

Establishing a deep social network presence helps, too. Dr. Lober suggests creating accounts on Facebook, Twitter, LinkedIn, ZoomInfo, Connectbeam, Yahoo Profile, Google Profile, MSN Profile, Wetpaint, Naymz, Jigsaw, Ning, and others, he suggested. Ideally, get on sites that feature RSS (Really Simple Syndication) feeds so that information posted on one site transfers to others.

Other prongs in this strategy include issuing press releases by using Internet publication sites, establishing one or more blogs in your name, and using pay-per-click advertising.

Sound overwhelming? Innovative entrepreneurs thought that it might, so a number of Internet reputation-management companies have formed to do some of this work for you—for a fee, of course. These include companies such as Reputation Repair & Management, Internet Reputation Management, and Reputation-Defender, Dr. Lober said.

If, instead, you want to make an attempt to get a specific offensive statement removed from the Web, seek legal counsel to guide you, he advised.

First, the statement must be determined to meet the legal definition of defamation. If it does, the next step is to determine if the person who wrote it is covered by any one of several standard legal defenses. If that's not an issue, check the terms and conditions listed by the Internet service provider (ISP) of the site where the comment appeared, to see if the ISP made any promises or assurances about the content on the site. If you contact the ISP, it may take the comment down.

Normally, ISPs are immune from lawsuits over statements made by others on its service; they resemble telephone companies more than newspapers in that respect, he said.

You or your lawyer can request that the courts issue a subpoena to try to compel the person who made the statement (even an anonymous poster) to remedy the situation, but this process is time consuming and expensive, and the person who posted the comment may be difficult to locate, Dr. Lober cautioned.

And if you sue, the defendant may try to frame your action as a SLAPP (strategic litigation against public participation) suit intended to muzzle critics and restrict freedom of speech.

Some states have anti-SLAPP laws that could leave you paying the defendant's attorney fees and costs, and make you vulnerable to a countersuit by the defendant.

Better to try to “manage” your online reputation than to try to legally defend it, Dr. Lober suggested.

Disclosures: Dr. Lober reported having no pertinent conflicts of interest.

MONTEREY, CALIF. — Have you searched for your name on the Internet? Your patients have.

“Your patients are Googling you,” and some of them probably are rating your performance as a doctor on one of the many physician-rating sites or generic rating sites, Dr. Clifford Warren Lober said at the meeting.

Here's the problem: The patients most likely to rate you are those who are livid or those who think you walk on water. And it's not just patients who are posting comments about you, but previous patients, ex-employees, former spouses, or anyone else who knows you, said Dr. Lober, a dermatologist and attorney in Kissimmee, Fla.

Online comments may be made anonymously, may persist for years on the Internet, may be accessed by anyone with a computer, and may be replicated on other Web sites beyond the original.

If you discover comments about you that you think are harmful to your reputation, your attempts to remedy the situation may backfire and instead “optimize” the content by bringing more attention to the posted statement, amplifying its negativity, Dr. Lober pointed out.

Legal remedies are few and complicated. “There is a morass of legal defenses and privileges that protect the offending person,” Dr. Lober said.

So what is the best way to manage your online reputation? One strategy is to minimize the impact of negative online information through search-engine optimization, he suggested.

In practice, this means blitzing the Web with your own content to crowd out comments by others.

“You want to occupy the first three pages of the rating sites” and the search-engine results pages, if possible, Dr. Lober said, adding that most people do not look beyond the first three pages of results.

This can be accomplished by establishing multiple Web sites, each with numerous internal page links, external high-traffic links, significant content on each of your home pages, and other features that make these the sites that show up when someone searches your name.

Establishing a deep social network presence helps, too. Dr. Lober suggests creating accounts on Facebook, Twitter, LinkedIn, ZoomInfo, Connectbeam, Yahoo Profile, Google Profile, MSN Profile, Wetpaint, Naymz, Jigsaw, Ning, and others, he suggested. Ideally, get on sites that feature RSS (Really Simple Syndication) feeds so that information posted on one site transfers to others.

Other prongs in this strategy include issuing press releases by using Internet publication sites, establishing one or more blogs in your name, and using pay-per-click advertising.

Sound overwhelming? Innovative entrepreneurs thought that it might, so a number of Internet reputation-management companies have formed to do some of this work for you—for a fee, of course. These include companies such as Reputation Repair & Management, Internet Reputation Management, and Reputation-Defender, Dr. Lober said.

If, instead, you want to make an attempt to get a specific offensive statement removed from the Web, seek legal counsel to guide you, he advised.

First, the statement must be determined to meet the legal definition of defamation. If it does, the next step is to determine if the person who wrote it is covered by any one of several standard legal defenses. If that's not an issue, check the terms and conditions listed by the Internet service provider (ISP) of the site where the comment appeared, to see if the ISP made any promises or assurances about the content on the site. If you contact the ISP, it may take the comment down.

Normally, ISPs are immune from lawsuits over statements made by others on its service; they resemble telephone companies more than newspapers in that respect, he said.

You or your lawyer can request that the courts issue a subpoena to try to compel the person who made the statement (even an anonymous poster) to remedy the situation, but this process is time consuming and expensive, and the person who posted the comment may be difficult to locate, Dr. Lober cautioned.

And if you sue, the defendant may try to frame your action as a SLAPP (strategic litigation against public participation) suit intended to muzzle critics and restrict freedom of speech.

Some states have anti-SLAPP laws that could leave you paying the defendant's attorney fees and costs, and make you vulnerable to a countersuit by the defendant.

Better to try to “manage” your online reputation than to try to legally defend it, Dr. Lober suggested.

Disclosures: Dr. Lober reported having no pertinent conflicts of interest.

Major Finding: The atropine sulfate–adjuvanted vaccine for human papillomavirus types 16 and 18 (Cervarix) significantly reduced the risk of abnormal Pap test results over a 3-year period by 56%–68% depending on the type of abnormality.

Data Source: Secondary analysis of data on 17,347 women from a phase III efficacy trial in 14 countries.

Disclosures: Dr. Martens has been a consultant for and received research funds, honoraria, and conference sponsorship from Merck & Co. and from GlaxoSmithKline Biologicals, which makes the vaccine and funded the study.

SAN FRANCISCO — A vaccine for human papillomavirus decreased the risk for cytologic abnormalities over a 3-year period by 56%–68%, compared with placebo vaccine, a secondary analysis of data on 17,347 women in a phase III clinical trial found.

The analysis looked at vaccination with all three doses of Cervarix, the atropine sulfate–adjuvanted vaccine for human papillomavirus types 16 and 18 (HPV-16/18), in 8,665 young, predominantly sexually active women compared with a control group of 8,682 women who got hepatitis A vaccine.

The primary results of the Papilloma Trial Against Cancer in Young Adults (PATRICIA), reported last year, showed that the vaccine was highly prophylactic against grade II cervical intraepithelial neoplasia (CIN2) associated with HPV-16/18 and against several oncogenic nonvaccine types of HPV (Lancet 2009;374:301-14).

Dr. Mark G. Martens reported at the meeting on a secondary end point built into the PATRICIA trial to assess vaccine efficacy in preventing abnormal Pap smear results and subsequent reduction in colposcopy referrals and cervical excision procedures.

Cervical samples were collected every 6 months for HPV DNA genotyping, and the women underwent yearly gynecology and cytologic examinations. The rate of atypical squamous cells of undetermined significance (ASCUS) with HPV-16/18 was 57% lower in the vaccine group compared with the control group during 3 years of follow-up, said Dr. Martens, who conducted the analysis while at Oklahoma State University, Tulsa, and now practices at Jersey Shore University Medical Center, Neptune, N.J.

The rate of low-grade squamous intraepithelial lesions (LSILs) with HPV-16/18 was 68% lower than in the control group, and the rate of high-grade squamous intraepithelial lesions (HSILs) with HPV-16/18 was 56% lower than in the control group, he said.

Absolute rates of ASCUS with HPV-16/18 were 2% in the vaccine group and 4% in the control group (percentages are rounded). LSILs with HPV-16/18 were detected in 2% of the vaccine group and 6% of the control group. HSILs with HPV-16/18 were present in 0.2% of the vaccine group and 0.5% of the control group.

There was a statistically significant difference between groups for HSILs with HPV-16 (0.1% in the vaccine group vs. 0.4% in the control group) but not for HSILs with HPV-18 (0.05% and 0.1%).

Irrespective of HPV type, the vaccine reduced the risk for ASCUS by 8%, the risk for LSILs by 14%, and the risk for HSILs by 41%, he added.

The risk for CIN2 and CIN3 was 30% and 33% lower than in the control group. “That means the lesions we're going to act upon”—HSILs, CIN2, and CIN3—“were 30%–40% lower with the vaccine,” Dr. Martens said.

HSILs were found in 0.5% of the vaccine group, irrespective of HPV type, and 0.9% of the control group. CIN2 was detected in 2.5% of the vaccine group and 3.7% of the control group. The rate of CIN3 was 0.8% in the vaccine group and 1.3% in the control group.

Compared with the control group, colposcopy referrals were reduced by 10% and cervical excision procedures were reduced by 25% in the vaccine group, he reported.

Dr. Martens said he did an extra calculation for one state—Ohio—and estimated that each physician performing Pap smears in the state would see 20 fewer cases of CIN2/3 per year if patients were vaccinated. Nationally, the vaccine could result in 5 million fewer Pap smears per year because there would be less abnormal cytology, he added.

Women were included in the analysis regardless of their HPV DNA status, HPV serostatus, or cytology at baseline. Evidence of past or current infection with HPV-16/18 was present at baseline in 26% of women, but only 98 participants (less than 1%) were DNA positive for both HPV-16 and HPV-18.

Major Finding: The atropine sulfate–adjuvanted vaccine for human papillomavirus types 16 and 18 (Cervarix) significantly reduced the risk of abnormal Pap test results over a 3-year period by 56%–68% depending on the type of abnormality.

Data Source: Secondary analysis of data on 17,347 women from a phase III efficacy trial in 14 countries.

Disclosures: Dr. Martens has been a consultant for and received research funds, honoraria, and conference sponsorship from Merck & Co. and from GlaxoSmithKline Biologicals, which makes the vaccine and funded the study.

SAN FRANCISCO — A vaccine for human papillomavirus decreased the risk for cytologic abnormalities over a 3-year period by 56%–68%, compared with placebo vaccine, a secondary analysis of data on 17,347 women in a phase III clinical trial found.

The analysis looked at vaccination with all three doses of Cervarix, the atropine sulfate–adjuvanted vaccine for human papillomavirus types 16 and 18 (HPV-16/18), in 8,665 young, predominantly sexually active women compared with a control group of 8,682 women who got hepatitis A vaccine.

The primary results of the Papilloma Trial Against Cancer in Young Adults (PATRICIA), reported last year, showed that the vaccine was highly prophylactic against grade II cervical intraepithelial neoplasia (CIN2) associated with HPV-16/18 and against several oncogenic nonvaccine types of HPV (Lancet 2009;374:301-14).

Dr. Mark G. Martens reported at the meeting on a secondary end point built into the PATRICIA trial to assess vaccine efficacy in preventing abnormal Pap smear results and subsequent reduction in colposcopy referrals and cervical excision procedures.

Cervical samples were collected every 6 months for HPV DNA genotyping, and the women underwent yearly gynecology and cytologic examinations. The rate of atypical squamous cells of undetermined significance (ASCUS) with HPV-16/18 was 57% lower in the vaccine group compared with the control group during 3 years of follow-up, said Dr. Martens, who conducted the analysis while at Oklahoma State University, Tulsa, and now practices at Jersey Shore University Medical Center, Neptune, N.J.

The rate of low-grade squamous intraepithelial lesions (LSILs) with HPV-16/18 was 68% lower than in the control group, and the rate of high-grade squamous intraepithelial lesions (HSILs) with HPV-16/18 was 56% lower than in the control group, he said.

Absolute rates of ASCUS with HPV-16/18 were 2% in the vaccine group and 4% in the control group (percentages are rounded). LSILs with HPV-16/18 were detected in 2% of the vaccine group and 6% of the control group. HSILs with HPV-16/18 were present in 0.2% of the vaccine group and 0.5% of the control group.

There was a statistically significant difference between groups for HSILs with HPV-16 (0.1% in the vaccine group vs. 0.4% in the control group) but not for HSILs with HPV-18 (0.05% and 0.1%).

Irrespective of HPV type, the vaccine reduced the risk for ASCUS by 8%, the risk for LSILs by 14%, and the risk for HSILs by 41%, he added.

The risk for CIN2 and CIN3 was 30% and 33% lower than in the control group. “That means the lesions we're going to act upon”—HSILs, CIN2, and CIN3—“were 30%–40% lower with the vaccine,” Dr. Martens said.

HSILs were found in 0.5% of the vaccine group, irrespective of HPV type, and 0.9% of the control group. CIN2 was detected in 2.5% of the vaccine group and 3.7% of the control group. The rate of CIN3 was 0.8% in the vaccine group and 1.3% in the control group.

Compared with the control group, colposcopy referrals were reduced by 10% and cervical excision procedures were reduced by 25% in the vaccine group, he reported.

Dr. Martens said he did an extra calculation for one state—Ohio—and estimated that each physician performing Pap smears in the state would see 20 fewer cases of CIN2/3 per year if patients were vaccinated. Nationally, the vaccine could result in 5 million fewer Pap smears per year because there would be less abnormal cytology, he added.

Women were included in the analysis regardless of their HPV DNA status, HPV serostatus, or cytology at baseline. Evidence of past or current infection with HPV-16/18 was present at baseline in 26% of women, but only 98 participants (less than 1%) were DNA positive for both HPV-16 and HPV-18.

Major Finding: The atropine sulfate–adjuvanted vaccine for human papillomavirus types 16 and 18 (Cervarix) significantly reduced the risk of abnormal Pap test results over a 3-year period by 56%–68% depending on the type of abnormality.

Data Source: Secondary analysis of data on 17,347 women from a phase III efficacy trial in 14 countries.

Disclosures: Dr. Martens has been a consultant for and received research funds, honoraria, and conference sponsorship from Merck & Co. and from GlaxoSmithKline Biologicals, which makes the vaccine and funded the study.

SAN FRANCISCO — A vaccine for human papillomavirus decreased the risk for cytologic abnormalities over a 3-year period by 56%–68%, compared with placebo vaccine, a secondary analysis of data on 17,347 women in a phase III clinical trial found.

The analysis looked at vaccination with all three doses of Cervarix, the atropine sulfate–adjuvanted vaccine for human papillomavirus types 16 and 18 (HPV-16/18), in 8,665 young, predominantly sexually active women compared with a control group of 8,682 women who got hepatitis A vaccine.

The primary results of the Papilloma Trial Against Cancer in Young Adults (PATRICIA), reported last year, showed that the vaccine was highly prophylactic against grade II cervical intraepithelial neoplasia (CIN2) associated with HPV-16/18 and against several oncogenic nonvaccine types of HPV (Lancet 2009;374:301-14).

Dr. Mark G. Martens reported at the meeting on a secondary end point built into the PATRICIA trial to assess vaccine efficacy in preventing abnormal Pap smear results and subsequent reduction in colposcopy referrals and cervical excision procedures.

Cervical samples were collected every 6 months for HPV DNA genotyping, and the women underwent yearly gynecology and cytologic examinations. The rate of atypical squamous cells of undetermined significance (ASCUS) with HPV-16/18 was 57% lower in the vaccine group compared with the control group during 3 years of follow-up, said Dr. Martens, who conducted the analysis while at Oklahoma State University, Tulsa, and now practices at Jersey Shore University Medical Center, Neptune, N.J.

The rate of low-grade squamous intraepithelial lesions (LSILs) with HPV-16/18 was 68% lower than in the control group, and the rate of high-grade squamous intraepithelial lesions (HSILs) with HPV-16/18 was 56% lower than in the control group, he said.

Absolute rates of ASCUS with HPV-16/18 were 2% in the vaccine group and 4% in the control group (percentages are rounded). LSILs with HPV-16/18 were detected in 2% of the vaccine group and 6% of the control group. HSILs with HPV-16/18 were present in 0.2% of the vaccine group and 0.5% of the control group.

There was a statistically significant difference between groups for HSILs with HPV-16 (0.1% in the vaccine group vs. 0.4% in the control group) but not for HSILs with HPV-18 (0.05% and 0.1%).

Irrespective of HPV type, the vaccine reduced the risk for ASCUS by 8%, the risk for LSILs by 14%, and the risk for HSILs by 41%, he added.

The risk for CIN2 and CIN3 was 30% and 33% lower than in the control group. “That means the lesions we're going to act upon”—HSILs, CIN2, and CIN3—“were 30%–40% lower with the vaccine,” Dr. Martens said.

HSILs were found in 0.5% of the vaccine group, irrespective of HPV type, and 0.9% of the control group. CIN2 was detected in 2.5% of the vaccine group and 3.7% of the control group. The rate of CIN3 was 0.8% in the vaccine group and 1.3% in the control group.

Compared with the control group, colposcopy referrals were reduced by 10% and cervical excision procedures were reduced by 25% in the vaccine group, he reported.

Dr. Martens said he did an extra calculation for one state—Ohio—and estimated that each physician performing Pap smears in the state would see 20 fewer cases of CIN2/3 per year if patients were vaccinated. Nationally, the vaccine could result in 5 million fewer Pap smears per year because there would be less abnormal cytology, he added.

Women were included in the analysis regardless of their HPV DNA status, HPV serostatus, or cytology at baseline. Evidence of past or current infection with HPV-16/18 was present at baseline in 26% of women, but only 98 participants (less than 1%) were DNA positive for both HPV-16 and HPV-18.

LOS ANGELES — Marijuana use was more common among 139 French patients with cluster headaches than among the general population, but their reports of the effect of the drug on headaches were variable and uncertain.

Dr. Elizabeth Leroux and her associates surveyed 115 male and 24 female patients presenting with cluster headaches at the Emergency Headache Center in Paris and the Headache Clinic in Marseille, France.

On questionnaires, 45% of the patients described themselves as cannabis (marijuana) users, which the investigators defined as any repeated use of cannabis except for isolated trials during their teenage years.

In the previous 6 months, a total of 32% of the patients had used cannabis.

Those rates were significantly higher than the rates of use among the general French population, Dr. Leroux of Lariboisière Hospital, Paris, reported in a poster presentation at the meeting.

Previous data from other investigators suggest that 12% of men and 5% of women in France had used cannabis in 2006.

Clinicians should address substance use when caring for patients with cluster headaches, in order to prevent complications from drug use and potential interactions with prescription medications, Dr. Leroux advised.

The 63 cannabis users in the current study were more likely to be young men and tobacco smokers than were the 73 headache patients who didn't use cannabis. (Three other patients who had once used cannabis to try to treat a cluster headache attack did not describe themselves as users and were excluded from some analyses.)

The mean age was 36 years for cannabis users and 45 years for nonusers. Males made up 59 of the 63 cannabis users and 54 of the 73 nonusers. Among the cannabis users, a total of 58 (92%) reported that they smoke tobacco, compared with 43 (60%) of the nonusers.

The effects of cannabis on cluster headaches were no clearer than a smoke-filled room, with 27% of patients saying that they think cannabis could provoke a cluster headache attack, 59% saying they do not think so, and no response from the rest.

Four patients (3% of the cohort) said they believe that cannabis could either provoke or abort cluster headache attacks.

Among the 63 cannabis users, 27 (43%) said they avoid cannabis during an attack of cluster headaches, 24 patients (38%) said they do not avoid cannabis during attack periods, and 12 patients (19%) didn't answer the question.

A total of 27 patients had tried cannabis specifically to treat their cluster headache attacks, and 20 of them had tried this more than twice.

Their reports of the effect of cannabis on headaches were variable as well.

One patient (3%) said that cannabis was “very efficient” in treating cluster headache, 6 patients (22%) said cannabis gave them more than 50% relief from headache pain, 6 patients (22%) said cannabis was not helpful or made the headache worse, and 14 patients (53%) said the drug's effects on cluster headache were “variable or uncertain.”

The study provides some of the first data on cannabis use in this population.

Cannabis contains the compound delta-9-tetrahydrocannabinol, an agonist of cannabinoid receptors, which have antinociceptive properties and effects on cerebral arteries, the investigators noted.

Disclosures: The investigators reported having no pertinent conflicts of interest.

LOS ANGELES — Marijuana use was more common among 139 French patients with cluster headaches than among the general population, but their reports of the effect of the drug on headaches were variable and uncertain.

Dr. Elizabeth Leroux and her associates surveyed 115 male and 24 female patients presenting with cluster headaches at the Emergency Headache Center in Paris and the Headache Clinic in Marseille, France.

On questionnaires, 45% of the patients described themselves as cannabis (marijuana) users, which the investigators defined as any repeated use of cannabis except for isolated trials during their teenage years.

In the previous 6 months, a total of 32% of the patients had used cannabis.

Those rates were significantly higher than the rates of use among the general French population, Dr. Leroux of Lariboisière Hospital, Paris, reported in a poster presentation at the meeting.

Previous data from other investigators suggest that 12% of men and 5% of women in France had used cannabis in 2006.

Clinicians should address substance use when caring for patients with cluster headaches, in order to prevent complications from drug use and potential interactions with prescription medications, Dr. Leroux advised.

The 63 cannabis users in the current study were more likely to be young men and tobacco smokers than were the 73 headache patients who didn't use cannabis. (Three other patients who had once used cannabis to try to treat a cluster headache attack did not describe themselves as users and were excluded from some analyses.)

The mean age was 36 years for cannabis users and 45 years for nonusers. Males made up 59 of the 63 cannabis users and 54 of the 73 nonusers. Among the cannabis users, a total of 58 (92%) reported that they smoke tobacco, compared with 43 (60%) of the nonusers.

The effects of cannabis on cluster headaches were no clearer than a smoke-filled room, with 27% of patients saying that they think cannabis could provoke a cluster headache attack, 59% saying they do not think so, and no response from the rest.

Four patients (3% of the cohort) said they believe that cannabis could either provoke or abort cluster headache attacks.

Among the 63 cannabis users, 27 (43%) said they avoid cannabis during an attack of cluster headaches, 24 patients (38%) said they do not avoid cannabis during attack periods, and 12 patients (19%) didn't answer the question.

A total of 27 patients had tried cannabis specifically to treat their cluster headache attacks, and 20 of them had tried this more than twice.

Their reports of the effect of cannabis on headaches were variable as well.

One patient (3%) said that cannabis was “very efficient” in treating cluster headache, 6 patients (22%) said cannabis gave them more than 50% relief from headache pain, 6 patients (22%) said cannabis was not helpful or made the headache worse, and 14 patients (53%) said the drug's effects on cluster headache were “variable or uncertain.”

The study provides some of the first data on cannabis use in this population.

Cannabis contains the compound delta-9-tetrahydrocannabinol, an agonist of cannabinoid receptors, which have antinociceptive properties and effects on cerebral arteries, the investigators noted.

Disclosures: The investigators reported having no pertinent conflicts of interest.

LOS ANGELES — Marijuana use was more common among 139 French patients with cluster headaches than among the general population, but their reports of the effect of the drug on headaches were variable and uncertain.

Dr. Elizabeth Leroux and her associates surveyed 115 male and 24 female patients presenting with cluster headaches at the Emergency Headache Center in Paris and the Headache Clinic in Marseille, France.

On questionnaires, 45% of the patients described themselves as cannabis (marijuana) users, which the investigators defined as any repeated use of cannabis except for isolated trials during their teenage years.

In the previous 6 months, a total of 32% of the patients had used cannabis.

Those rates were significantly higher than the rates of use among the general French population, Dr. Leroux of Lariboisière Hospital, Paris, reported in a poster presentation at the meeting.

Previous data from other investigators suggest that 12% of men and 5% of women in France had used cannabis in 2006.

Clinicians should address substance use when caring for patients with cluster headaches, in order to prevent complications from drug use and potential interactions with prescription medications, Dr. Leroux advised.

The 63 cannabis users in the current study were more likely to be young men and tobacco smokers than were the 73 headache patients who didn't use cannabis. (Three other patients who had once used cannabis to try to treat a cluster headache attack did not describe themselves as users and were excluded from some analyses.)

The mean age was 36 years for cannabis users and 45 years for nonusers. Males made up 59 of the 63 cannabis users and 54 of the 73 nonusers. Among the cannabis users, a total of 58 (92%) reported that they smoke tobacco, compared with 43 (60%) of the nonusers.

The effects of cannabis on cluster headaches were no clearer than a smoke-filled room, with 27% of patients saying that they think cannabis could provoke a cluster headache attack, 59% saying they do not think so, and no response from the rest.

Four patients (3% of the cohort) said they believe that cannabis could either provoke or abort cluster headache attacks.

Among the 63 cannabis users, 27 (43%) said they avoid cannabis during an attack of cluster headaches, 24 patients (38%) said they do not avoid cannabis during attack periods, and 12 patients (19%) didn't answer the question.

A total of 27 patients had tried cannabis specifically to treat their cluster headache attacks, and 20 of them had tried this more than twice.

Their reports of the effect of cannabis on headaches were variable as well.

One patient (3%) said that cannabis was “very efficient” in treating cluster headache, 6 patients (22%) said cannabis gave them more than 50% relief from headache pain, 6 patients (22%) said cannabis was not helpful or made the headache worse, and 14 patients (53%) said the drug's effects on cluster headache were “variable or uncertain.”

The study provides some of the first data on cannabis use in this population.

Cannabis contains the compound delta-9-tetrahydrocannabinol, an agonist of cannabinoid receptors, which have antinociceptive properties and effects on cerebral arteries, the investigators noted.

Disclosures: The investigators reported having no pertinent conflicts of interest.

Major Finding: Headaches, initially reported by 46% of patients soon after injury, still occurred in 48% at 3 months, 44% at 6 months, and 46% at 12 months.

Data Source: Prospective study of 377 consecutive admissions to acute rehabilitation facilities for traumatic brain injury.

Disclosures: Dr. Lucas said she has no relevant conflicts of interest. The National Institute on Disability and Rehabilitation Research funded the study.

LOS ANGELES — Nearly half of 377 patients with traumatic brain injury reported postinjury headaches that persisted during a year of follow-up in a prospective study.

The prevalence of headaches in the cohort increased from 18% before the injury to 46% soon after injury, according to patient reports during rehabilitation hospitalization for traumatic brain injury (TBI).

In phone interviews after discharge at 3, 6, and 12 months post injury, headaches were reported by 48%, 44% and 46%, respectively.

The persistence of the headaches took senior investigator Dr. Sylvia Lucas and her colleagues by surprise, because previous data have suggested that 18%-22% of posttraumatic headaches are chronic problems.

Dr. Lucas said that she and her associates also were surprised that most of the headaches in the current study were classified as migraine or tension-type headache.

They were also surprised to find that the presence of preinjury headache seemed to be a risk factor for postinjury headache, and that women were at higher risk for postinjury headache.

The findings on types of headache and their persistence could have “important implications for treatment” of posttraumatic headache, said Dr. Lucas, founder and director of the headache center at the University of Washington, Seattle.

Posttraumatic headache is one of the most common persisting symptoms after TBI, occurring in 30%-90% of patients, previous studies suggest. Although most familiar as a salient symptom in soldiers who were exposed to explosive blasts, “it's becoming of great interest in adolescent children who've been in sports concussion injuries,” she said.

The study included consecutive admissions of patients older than 16 years at seven acute rehabilitation facilities for TBI, excluding 79 patients who could not provide consent or answer questions themselves without their families' acting as proxy.

The cause of injury was vehicular trauma in approximately 56%, falls or impacts with flying objects in 28%, violence in 9%, and sports or pedestrian accidents in 4% each. (Percentages were rounded.)

Based on descriptions of symptoms by patients who reported headache, 60% of preinjury headaches were classified as migraine or probable migraine, compared with 48% soon after injury and 54% a year later.

Although 25% of preinjury headaches and 37% of headaches soon after injury were deemed “unclassifiable” by investigators using patients' descriptions, over time they gained features that allowed them to be classified in one of the primary headache classifications, so that the proportion of “unclassified” headache fell to 19% by 12 months post injury.

“Mostly, patients were classified as migraine with or without aura, or tension-type headache, which is also surprising given the fact that most of these were vehicular injuries,” she said.

“There was not a high prevalence of cervicogenic headache,” Dr. Lucas added.

Headaches were classified as tension-type in 12% before injury, in 7% soon after injury, and in 19% at 12 months. Headaches were classified as cervicogenic in 4% before injury, in 8% soon after injury, and in 5% at 12 months.

Among patients who said they suffered headaches before the injury, 48% reported postinjury headache, compared with 23% of patients who said they did not have headaches before the injury.

“Preinjury headache may be a risk factor for posttraumatic headache. This may argue for a common underlying mechanism,” Dr. Lucas said.

The cohort was 71% male and 75% white. Patients were average age 43 years, and 84% of patients were able to be discharged to home.

The injury caused posttraumatic amnesia for less than a day in 7% (indicative of a milder head injury), for 1-7 days in 21%, for 8-28 days in 42%, and for 29 or more days in 30%.

“This was primarily a male group; however, all the way along—at baseline, 3 months, 6 months, and 12 months—there was a statistically significant difference in women having more posttraumatic headache than men,” as well as a higher incidence of preinjury headache, Dr. Lucas said at the meeting.

About 40% of men reported headache at all follow-up time points after injury, compared with approximately 60% of women.

A physician in the audience asked if there was any relationship between insurance claims and reports that the headaches were persisting. “That's a good question, but at the time of our study, that information was not available,” she responded.

Preinjury headache may be a risk factor for posttraumatic headache, especially among women.

Source DR. LUCAS

Major Finding: Headaches, initially reported by 46% of patients soon after injury, still occurred in 48% at 3 months, 44% at 6 months, and 46% at 12 months.

Data Source: Prospective study of 377 consecutive admissions to acute rehabilitation facilities for traumatic brain injury.

Disclosures: Dr. Lucas said she has no relevant conflicts of interest. The National Institute on Disability and Rehabilitation Research funded the study.

LOS ANGELES — Nearly half of 377 patients with traumatic brain injury reported postinjury headaches that persisted during a year of follow-up in a prospective study.

The prevalence of headaches in the cohort increased from 18% before the injury to 46% soon after injury, according to patient reports during rehabilitation hospitalization for traumatic brain injury (TBI).

In phone interviews after discharge at 3, 6, and 12 months post injury, headaches were reported by 48%, 44% and 46%, respectively.

The persistence of the headaches took senior investigator Dr. Sylvia Lucas and her colleagues by surprise, because previous data have suggested that 18%-22% of posttraumatic headaches are chronic problems.

Dr. Lucas said that she and her associates also were surprised that most of the headaches in the current study were classified as migraine or tension-type headache.

They were also surprised to find that the presence of preinjury headache seemed to be a risk factor for postinjury headache, and that women were at higher risk for postinjury headache.

The findings on types of headache and their persistence could have “important implications for treatment” of posttraumatic headache, said Dr. Lucas, founder and director of the headache center at the University of Washington, Seattle.

Posttraumatic headache is one of the most common persisting symptoms after TBI, occurring in 30%-90% of patients, previous studies suggest. Although most familiar as a salient symptom in soldiers who were exposed to explosive blasts, “it's becoming of great interest in adolescent children who've been in sports concussion injuries,” she said.

The study included consecutive admissions of patients older than 16 years at seven acute rehabilitation facilities for TBI, excluding 79 patients who could not provide consent or answer questions themselves without their families' acting as proxy.

The cause of injury was vehicular trauma in approximately 56%, falls or impacts with flying objects in 28%, violence in 9%, and sports or pedestrian accidents in 4% each. (Percentages were rounded.)

Based on descriptions of symptoms by patients who reported headache, 60% of preinjury headaches were classified as migraine or probable migraine, compared with 48% soon after injury and 54% a year later.

Although 25% of preinjury headaches and 37% of headaches soon after injury were deemed “unclassifiable” by investigators using patients' descriptions, over time they gained features that allowed them to be classified in one of the primary headache classifications, so that the proportion of “unclassified” headache fell to 19% by 12 months post injury.

“Mostly, patients were classified as migraine with or without aura, or tension-type headache, which is also surprising given the fact that most of these were vehicular injuries,” she said.

“There was not a high prevalence of cervicogenic headache,” Dr. Lucas added.

Headaches were classified as tension-type in 12% before injury, in 7% soon after injury, and in 19% at 12 months. Headaches were classified as cervicogenic in 4% before injury, in 8% soon after injury, and in 5% at 12 months.

Among patients who said they suffered headaches before the injury, 48% reported postinjury headache, compared with 23% of patients who said they did not have headaches before the injury.

“Preinjury headache may be a risk factor for posttraumatic headache. This may argue for a common underlying mechanism,” Dr. Lucas said.

The cohort was 71% male and 75% white. Patients were average age 43 years, and 84% of patients were able to be discharged to home.

The injury caused posttraumatic amnesia for less than a day in 7% (indicative of a milder head injury), for 1-7 days in 21%, for 8-28 days in 42%, and for 29 or more days in 30%.

“This was primarily a male group; however, all the way along—at baseline, 3 months, 6 months, and 12 months—there was a statistically significant difference in women having more posttraumatic headache than men,” as well as a higher incidence of preinjury headache, Dr. Lucas said at the meeting.

About 40% of men reported headache at all follow-up time points after injury, compared with approximately 60% of women.

A physician in the audience asked if there was any relationship between insurance claims and reports that the headaches were persisting. “That's a good question, but at the time of our study, that information was not available,” she responded.

Preinjury headache may be a risk factor for posttraumatic headache, especially among women.

Source DR. LUCAS

Major Finding: Headaches, initially reported by 46% of patients soon after injury, still occurred in 48% at 3 months, 44% at 6 months, and 46% at 12 months.

Data Source: Prospective study of 377 consecutive admissions to acute rehabilitation facilities for traumatic brain injury.

Disclosures: Dr. Lucas said she has no relevant conflicts of interest. The National Institute on Disability and Rehabilitation Research funded the study.

LOS ANGELES — Nearly half of 377 patients with traumatic brain injury reported postinjury headaches that persisted during a year of follow-up in a prospective study.

The prevalence of headaches in the cohort increased from 18% before the injury to 46% soon after injury, according to patient reports during rehabilitation hospitalization for traumatic brain injury (TBI).

In phone interviews after discharge at 3, 6, and 12 months post injury, headaches were reported by 48%, 44% and 46%, respectively.

The persistence of the headaches took senior investigator Dr. Sylvia Lucas and her colleagues by surprise, because previous data have suggested that 18%-22% of posttraumatic headaches are chronic problems.

Dr. Lucas said that she and her associates also were surprised that most of the headaches in the current study were classified as migraine or tension-type headache.

They were also surprised to find that the presence of preinjury headache seemed to be a risk factor for postinjury headache, and that women were at higher risk for postinjury headache.

The findings on types of headache and their persistence could have “important implications for treatment” of posttraumatic headache, said Dr. Lucas, founder and director of the headache center at the University of Washington, Seattle.

Posttraumatic headache is one of the most common persisting symptoms after TBI, occurring in 30%-90% of patients, previous studies suggest. Although most familiar as a salient symptom in soldiers who were exposed to explosive blasts, “it's becoming of great interest in adolescent children who've been in sports concussion injuries,” she said.

The study included consecutive admissions of patients older than 16 years at seven acute rehabilitation facilities for TBI, excluding 79 patients who could not provide consent or answer questions themselves without their families' acting as proxy.

The cause of injury was vehicular trauma in approximately 56%, falls or impacts with flying objects in 28%, violence in 9%, and sports or pedestrian accidents in 4% each. (Percentages were rounded.)

Based on descriptions of symptoms by patients who reported headache, 60% of preinjury headaches were classified as migraine or probable migraine, compared with 48% soon after injury and 54% a year later.

Although 25% of preinjury headaches and 37% of headaches soon after injury were deemed “unclassifiable” by investigators using patients' descriptions, over time they gained features that allowed them to be classified in one of the primary headache classifications, so that the proportion of “unclassified” headache fell to 19% by 12 months post injury.

“Mostly, patients were classified as migraine with or without aura, or tension-type headache, which is also surprising given the fact that most of these were vehicular injuries,” she said.

“There was not a high prevalence of cervicogenic headache,” Dr. Lucas added.

Headaches were classified as tension-type in 12% before injury, in 7% soon after injury, and in 19% at 12 months. Headaches were classified as cervicogenic in 4% before injury, in 8% soon after injury, and in 5% at 12 months.

Among patients who said they suffered headaches before the injury, 48% reported postinjury headache, compared with 23% of patients who said they did not have headaches before the injury.

“Preinjury headache may be a risk factor for posttraumatic headache. This may argue for a common underlying mechanism,” Dr. Lucas said.

The cohort was 71% male and 75% white. Patients were average age 43 years, and 84% of patients were able to be discharged to home.

The injury caused posttraumatic amnesia for less than a day in 7% (indicative of a milder head injury), for 1-7 days in 21%, for 8-28 days in 42%, and for 29 or more days in 30%.

“This was primarily a male group; however, all the way along—at baseline, 3 months, 6 months, and 12 months—there was a statistically significant difference in women having more posttraumatic headache than men,” as well as a higher incidence of preinjury headache, Dr. Lucas said at the meeting.

About 40% of men reported headache at all follow-up time points after injury, compared with approximately 60% of women.

A physician in the audience asked if there was any relationship between insurance claims and reports that the headaches were persisting. “That's a good question, but at the time of our study, that information was not available,” she responded.

Preinjury headache may be a risk factor for posttraumatic headache, especially among women.

Source DR. LUCAS

SAN FRANCISCO — People with HIV infection tend to have more risk factors for bone loss than do people without HIV, and antiretroviral medications may be adding to that risk.

The specific role of antiretroviral therapy in bone loss has been controversial: Some studies say there is no association, but others suggest that the drugs do contribute to bone loss. Results of two small but well-conducted studies recently tipped the emphasis toward concern about the differential effects of antiretrovirals on bone mineral density, Dr. Dolores Shoback said.

“I think it's very provocative. We certainly need more data, and this needs to be confirmed,” she said at the meeting, which was sponsored by the University of California, San Francisco.

One randomized, controlled trial of 71 HIV-infected patients suggested that antiretroviral regimens that contain a protease inhibitor booster have a greater negative impact on spinal bone density than do regimens without a boosted protease inhibitor, said Dr. Shoback, professor of medicine at UCSF.

At baseline, 31% of the patients were osteopenic and 3% were osteoporotic. Bone densities were retested after 48 weeks of combination HIV therapy with a nonnucleoside reverse transcriptase inhibitor (NNRTI) and nucleoside reverse transcriptase inhibitors (NRTIs), or an NNRTI and a boosted protease inhibitor, or two NRTIs and a boosted protease inhibitor. On average, the cohort as a whole lost 4% of lumbar spine bone mineral density and 3% of hip bone density during those 48 weeks (AIDS 2009;23:817-24). The groups treated with boosted protease inhibitors lost significantly more spinal density—4.4% when combined with an NNRTI and 5.8% when combined with NRTIs—compared with the NNRTI-plus-NRTI arm (1.5%). Changes in hip bone density did not differ significantly by treatment group.

The second study randomized 50 HIV-infected patients to treatment with lopinavir/ritonavir plus zidovudine/lamivudine (ZDV/3TC) or lopinavir/ritonavir plus nevirapine, with bone densities compared at baseline and 2 years. At the start, up to 31% were osteopenic and up to 4% were osteoporotic. The ZDV/3TC group lost 6.3% of bone mineral density in the hip and 5.1% in the spine, compared with smaller losses of 2.3% in the hip and 2.6% in the spine in the nevirapine group. Spinal density decreased mainly in the first year and then stabilized, but hip density continued to fall in the second year (AIDS 2009;23:1367-76).

The investigators speculated that ZDV/3TC increased osteoclastic activity.

There are not enough data yet to support changing antiretroviral regimens if bone mineral density is low, she added, but physicians should pay attention to nutrition (especially calcium and vitamin D), lifestyle factors, and weight-bearing exercise in patients with HIV.

Ongoing immune activation in HIV infection leads to high levels of cytokines. “There pretty much isn't a cytokine that doesn't have a negative effect on bone,” she said.

Many other risk factors for bone loss and fractures are more common in the setting of HIV. Five of six cross-sectional studies found low levels of hydroxyvitamin D in patients with HIV. Compared with the HIV-negative population, people with HIV have higher rates of smoking and alcohol use, are more likely to be treated with steroids, and are more likely to have periods of immobilization and illness, bouts of weight loss, hypogonadism (in men), and amenorrhea (in women).

Disclosures: Dr. Shoback has been a speaker for Novartis.

Antiretroviral regimens that contain a protease inhibitor booster have a greater impact on spinal bone density.

Source DR. SHOBACK

SAN FRANCISCO — People with HIV infection tend to have more risk factors for bone loss than do people without HIV, and antiretroviral medications may be adding to that risk.

The specific role of antiretroviral therapy in bone loss has been controversial: Some studies say there is no association, but others suggest that the drugs do contribute to bone loss. Results of two small but well-conducted studies recently tipped the emphasis toward concern about the differential effects of antiretrovirals on bone mineral density, Dr. Dolores Shoback said.

“I think it's very provocative. We certainly need more data, and this needs to be confirmed,” she said at the meeting, which was sponsored by the University of California, San Francisco.

One randomized, controlled trial of 71 HIV-infected patients suggested that antiretroviral regimens that contain a protease inhibitor booster have a greater negative impact on spinal bone density than do regimens without a boosted protease inhibitor, said Dr. Shoback, professor of medicine at UCSF.

At baseline, 31% of the patients were osteopenic and 3% were osteoporotic. Bone densities were retested after 48 weeks of combination HIV therapy with a nonnucleoside reverse transcriptase inhibitor (NNRTI) and nucleoside reverse transcriptase inhibitors (NRTIs), or an NNRTI and a boosted protease inhibitor, or two NRTIs and a boosted protease inhibitor. On average, the cohort as a whole lost 4% of lumbar spine bone mineral density and 3% of hip bone density during those 48 weeks (AIDS 2009;23:817-24). The groups treated with boosted protease inhibitors lost significantly more spinal density—4.4% when combined with an NNRTI and 5.8% when combined with NRTIs—compared with the NNRTI-plus-NRTI arm (1.5%). Changes in hip bone density did not differ significantly by treatment group.

The second study randomized 50 HIV-infected patients to treatment with lopinavir/ritonavir plus zidovudine/lamivudine (ZDV/3TC) or lopinavir/ritonavir plus nevirapine, with bone densities compared at baseline and 2 years. At the start, up to 31% were osteopenic and up to 4% were osteoporotic. The ZDV/3TC group lost 6.3% of bone mineral density in the hip and 5.1% in the spine, compared with smaller losses of 2.3% in the hip and 2.6% in the spine in the nevirapine group. Spinal density decreased mainly in the first year and then stabilized, but hip density continued to fall in the second year (AIDS 2009;23:1367-76).

The investigators speculated that ZDV/3TC increased osteoclastic activity.

There are not enough data yet to support changing antiretroviral regimens if bone mineral density is low, she added, but physicians should pay attention to nutrition (especially calcium and vitamin D), lifestyle factors, and weight-bearing exercise in patients with HIV.

Ongoing immune activation in HIV infection leads to high levels of cytokines. “There pretty much isn't a cytokine that doesn't have a negative effect on bone,” she said.

Many other risk factors for bone loss and fractures are more common in the setting of HIV. Five of six cross-sectional studies found low levels of hydroxyvitamin D in patients with HIV. Compared with the HIV-negative population, people with HIV have higher rates of smoking and alcohol use, are more likely to be treated with steroids, and are more likely to have periods of immobilization and illness, bouts of weight loss, hypogonadism (in men), and amenorrhea (in women).

Disclosures: Dr. Shoback has been a speaker for Novartis.

Antiretroviral regimens that contain a protease inhibitor booster have a greater impact on spinal bone density.

Source DR. SHOBACK

SAN FRANCISCO — People with HIV infection tend to have more risk factors for bone loss than do people without HIV, and antiretroviral medications may be adding to that risk.

The specific role of antiretroviral therapy in bone loss has been controversial: Some studies say there is no association, but others suggest that the drugs do contribute to bone loss. Results of two small but well-conducted studies recently tipped the emphasis toward concern about the differential effects of antiretrovirals on bone mineral density, Dr. Dolores Shoback said.

“I think it's very provocative. We certainly need more data, and this needs to be confirmed,” she said at the meeting, which was sponsored by the University of California, San Francisco.

One randomized, controlled trial of 71 HIV-infected patients suggested that antiretroviral regimens that contain a protease inhibitor booster have a greater negative impact on spinal bone density than do regimens without a boosted protease inhibitor, said Dr. Shoback, professor of medicine at UCSF.

At baseline, 31% of the patients were osteopenic and 3% were osteoporotic. Bone densities were retested after 48 weeks of combination HIV therapy with a nonnucleoside reverse transcriptase inhibitor (NNRTI) and nucleoside reverse transcriptase inhibitors (NRTIs), or an NNRTI and a boosted protease inhibitor, or two NRTIs and a boosted protease inhibitor. On average, the cohort as a whole lost 4% of lumbar spine bone mineral density and 3% of hip bone density during those 48 weeks (AIDS 2009;23:817-24). The groups treated with boosted protease inhibitors lost significantly more spinal density—4.4% when combined with an NNRTI and 5.8% when combined with NRTIs—compared with the NNRTI-plus-NRTI arm (1.5%). Changes in hip bone density did not differ significantly by treatment group.

The second study randomized 50 HIV-infected patients to treatment with lopinavir/ritonavir plus zidovudine/lamivudine (ZDV/3TC) or lopinavir/ritonavir plus nevirapine, with bone densities compared at baseline and 2 years. At the start, up to 31% were osteopenic and up to 4% were osteoporotic. The ZDV/3TC group lost 6.3% of bone mineral density in the hip and 5.1% in the spine, compared with smaller losses of 2.3% in the hip and 2.6% in the spine in the nevirapine group. Spinal density decreased mainly in the first year and then stabilized, but hip density continued to fall in the second year (AIDS 2009;23:1367-76).

The investigators speculated that ZDV/3TC increased osteoclastic activity.

There are not enough data yet to support changing antiretroviral regimens if bone mineral density is low, she added, but physicians should pay attention to nutrition (especially calcium and vitamin D), lifestyle factors, and weight-bearing exercise in patients with HIV.

Ongoing immune activation in HIV infection leads to high levels of cytokines. “There pretty much isn't a cytokine that doesn't have a negative effect on bone,” she said.

Many other risk factors for bone loss and fractures are more common in the setting of HIV. Five of six cross-sectional studies found low levels of hydroxyvitamin D in patients with HIV. Compared with the HIV-negative population, people with HIV have higher rates of smoking and alcohol use, are more likely to be treated with steroids, and are more likely to have periods of immobilization and illness, bouts of weight loss, hypogonadism (in men), and amenorrhea (in women).

Disclosures: Dr. Shoback has been a speaker for Novartis.

Antiretroviral regimens that contain a protease inhibitor booster have a greater impact on spinal bone density.

Source DR. SHOBACK

MONTEREY, CALIF. - When things go horribly wrong for patients, physicians must ask themselves some delicate questions in the art of management.

Should I apologize? How do I deal with the patient? Am I legally obligated to tell the patient what I know about what happened? How do I deal with myself?

Medical negligence may be a factor in some cases, but bad results can happen even when there is no breach of duty, Dr. Clifford Warren Lober noted at the American Society for Mohs Surgery meeting. Especially in cosmetic procedures, the problem may be unmet expectations.

The best thing to do is to anticipate the possibility of a bad outcome to be in the best position to deal with it. Be prepared by maintaining appropriate training and experience. Comply with office surgery rules and develop a good rapport with colleagues. Give the patient a realistic description of expected results. Obtain informed consent from patients and dismiss selected patients if necessary to stay out of trouble, he suggested.

Should the physician apologize when there's a bad outcome? "It depends," said Dr. Lober, a dermatologist in Kissimmee, Fla., who is also an attorney.

Make an effort to show concern, compassion, and empathy. Patients are more likely to sue doctors they perceive as callous or unconcerned but "do not readily sue doctors they like," he said. Some states prohibit expressions of regret, sympathy, or benevolence from being entered into evidence, so apologizing won't necessarily help if a subsequent suit goes to trial. Plus, physicians should ask themselves how effective they are at communicating, because some may come across as arrogant instead of sympathetic.

An apology may deflate the patient's anger and make negotiations possible instead of a lawsuit. Patients may expect an apology--many claim they would not have sued if only the doctor had apologized, Dr. Lober said. Apologizing may be the ethically correct thing to do, help put closure on the problem for both patient and physician, and decrease physician feelings of guilt or distance from the patient.

On the other hand, an apology may be misconstrued as legal weakness and encourage a lawsuit. It could be entered into evidence as an admission of guilt in some states, and malpractice insurers may consider it a breach of contract, so physicians should consult their attorney and malpractice insurer before apologizing.

A physician who chooses to apologize should do it soon after the injury and should be the one who apologizes instead of delegating it to a nurse, attorney, or someone else, Dr. Lober stressed. Sincere expressions of sympathy or remorse are okay, but a physician should never admit guilt, he added.

Seven states--California, Florida, Nevada, New Jersey, Oregon, Pennsylvania, and Vermont--require physicians to notify patients of adverse incidents that seriously harm the patient but specify that this cannot be introduced as evidence or construed as an acknowledgment of liability.

When things go horribly wrong for a patient, the physician may experience anger, self-doubt, or depression. Discuss the situation with your attorney, Dr. Lober advised, but be careful about discussing the circumstances with colleagues, a spouse, or others. Consider psychological counseling if the emotional response is strong or persistent, he added.

Dr. Lober stressed that his comments were for educational purposes only, and he advised physicians to seek legal counsel if an adverse situation arose.n

Dr. Lober reported having no pertinent conflicts of interest.

MONTEREY, CALIF. - When things go horribly wrong for patients, physicians must ask themselves some delicate questions in the art of management.

Should I apologize? How do I deal with the patient? Am I legally obligated to tell the patient what I know about what happened? How do I deal with myself?

Medical negligence may be a factor in some cases, but bad results can happen even when there is no breach of duty, Dr. Clifford Warren Lober noted at the American Society for Mohs Surgery meeting. Especially in cosmetic procedures, the problem may be unmet expectations.

The best thing to do is to anticipate the possibility of a bad outcome to be in the best position to deal with it. Be prepared by maintaining appropriate training and experience. Comply with office surgery rules and develop a good rapport with colleagues. Give the patient a realistic description of expected results. Obtain informed consent from patients and dismiss selected patients if necessary to stay out of trouble, he suggested.

Should the physician apologize when there's a bad outcome? "It depends," said Dr. Lober, a dermatologist in Kissimmee, Fla., who is also an attorney.

Make an effort to show concern, compassion, and empathy. Patients are more likely to sue doctors they perceive as callous or unconcerned but "do not readily sue doctors they like," he said. Some states prohibit expressions of regret, sympathy, or benevolence from being entered into evidence, so apologizing won't necessarily help if a subsequent suit goes to trial. Plus, physicians should ask themselves how effective they are at communicating, because some may come across as arrogant instead of sympathetic.

An apology may deflate the patient's anger and make negotiations possible instead of a lawsuit. Patients may expect an apology--many claim they would not have sued if only the doctor had apologized, Dr. Lober said. Apologizing may be the ethically correct thing to do, help put closure on the problem for both patient and physician, and decrease physician feelings of guilt or distance from the patient.

On the other hand, an apology may be misconstrued as legal weakness and encourage a lawsuit. It could be entered into evidence as an admission of guilt in some states, and malpractice insurers may consider it a breach of contract, so physicians should consult their attorney and malpractice insurer before apologizing.

A physician who chooses to apologize should do it soon after the injury and should be the one who apologizes instead of delegating it to a nurse, attorney, or someone else, Dr. Lober stressed. Sincere expressions of sympathy or remorse are okay, but a physician should never admit guilt, he added.

Seven states--California, Florida, Nevada, New Jersey, Oregon, Pennsylvania, and Vermont--require physicians to notify patients of adverse incidents that seriously harm the patient but specify that this cannot be introduced as evidence or construed as an acknowledgment of liability.

When things go horribly wrong for a patient, the physician may experience anger, self-doubt, or depression. Discuss the situation with your attorney, Dr. Lober advised, but be careful about discussing the circumstances with colleagues, a spouse, or others. Consider psychological counseling if the emotional response is strong or persistent, he added.

Dr. Lober stressed that his comments were for educational purposes only, and he advised physicians to seek legal counsel if an adverse situation arose.n

Dr. Lober reported having no pertinent conflicts of interest.

MONTEREY, CALIF. - When things go horribly wrong for patients, physicians must ask themselves some delicate questions in the art of management.

Should I apologize? How do I deal with the patient? Am I legally obligated to tell the patient what I know about what happened? How do I deal with myself?

Medical negligence may be a factor in some cases, but bad results can happen even when there is no breach of duty, Dr. Clifford Warren Lober noted at the American Society for Mohs Surgery meeting. Especially in cosmetic procedures, the problem may be unmet expectations.

The best thing to do is to anticipate the possibility of a bad outcome to be in the best position to deal with it. Be prepared by maintaining appropriate training and experience. Comply with office surgery rules and develop a good rapport with colleagues. Give the patient a realistic description of expected results. Obtain informed consent from patients and dismiss selected patients if necessary to stay out of trouble, he suggested.

Should the physician apologize when there's a bad outcome? "It depends," said Dr. Lober, a dermatologist in Kissimmee, Fla., who is also an attorney.

Make an effort to show concern, compassion, and empathy. Patients are more likely to sue doctors they perceive as callous or unconcerned but "do not readily sue doctors they like," he said. Some states prohibit expressions of regret, sympathy, or benevolence from being entered into evidence, so apologizing won't necessarily help if a subsequent suit goes to trial. Plus, physicians should ask themselves how effective they are at communicating, because some may come across as arrogant instead of sympathetic.

An apology may deflate the patient's anger and make negotiations possible instead of a lawsuit. Patients may expect an apology--many claim they would not have sued if only the doctor had apologized, Dr. Lober said. Apologizing may be the ethically correct thing to do, help put closure on the problem for both patient and physician, and decrease physician feelings of guilt or distance from the patient.

On the other hand, an apology may be misconstrued as legal weakness and encourage a lawsuit. It could be entered into evidence as an admission of guilt in some states, and malpractice insurers may consider it a breach of contract, so physicians should consult their attorney and malpractice insurer before apologizing.

A physician who chooses to apologize should do it soon after the injury and should be the one who apologizes instead of delegating it to a nurse, attorney, or someone else, Dr. Lober stressed. Sincere expressions of sympathy or remorse are okay, but a physician should never admit guilt, he added.

Seven states--California, Florida, Nevada, New Jersey, Oregon, Pennsylvania, and Vermont--require physicians to notify patients of adverse incidents that seriously harm the patient but specify that this cannot be introduced as evidence or construed as an acknowledgment of liability.

When things go horribly wrong for a patient, the physician may experience anger, self-doubt, or depression. Discuss the situation with your attorney, Dr. Lober advised, but be careful about discussing the circumstances with colleagues, a spouse, or others. Consider psychological counseling if the emotional response is strong or persistent, he added.

Dr. Lober stressed that his comments were for educational purposes only, and he advised physicians to seek legal counsel if an adverse situation arose.n

Dr. Lober reported having no pertinent conflicts of interest.

MONTEREY, CALIF. - Have you searched for your name on the Internet? Your patients have.

"Your patients are Googling you," and some of them probably are rating your performance as a doctor on one of the many physician-rating sites or generic rating sites, Dr. Clifford Warren Lober said at the annual meeting of the American Society for Mohs Surgery.

Here's the problem: The patients most likely to rate you are those who are livid at you, or those who think you walk on water. And it's not just patients who are posting comments about you, but previous patients, ex-employees, former spouses, or anyone else who knows you, said Dr. Lober, a dermatologist and attorney in Kissimmee, Fla.

Online comments may be made anonymously, persist for years on the Internet, be accessed by anyone with a computer, and be replicated on other Web sites beyond the original. If you discover comments about you that you think are harmful to your reputation, your attempts to remedy the situation may backfire and instead "optimize" the content by bringing more attention to the posted statement, amplifying its negativity, he said.

Legal remedies are few and complicated. "There is a morass of legal defenses and privileges that protect the offending person," Dr. Lober said.

So how best to manage your online reputation? One strategy is to minimize the impact of negative online information through search-engine optimization, he suggested.

In practice, this means blitzing the Web with your own content to crowd out comments by others. "You want to occupy the first three pages of the rating sites" and the search-engine results pages if possible, Dr. Lober said, adding that most people don't look beyond the first three pages of results.

This can be done by establishing multiple Web sites, each with numerous internal page links, external high-traffic links, significant content on each of your home pages, and other features that make these the sites that show up when someone searches your name.

Establishing a deep social network presence helps, too. Create accounts on Facebook, Twitter, LinkedIn, ZoomInfo, Connectbeam, Yahoo profile, Google Profile, MSN Profile, Wetpaint, Naymz, Jigsaw, Ning, and others, he suggested.

Ideally, get on sites that feature RSS (Really Simple Syndication) feeds so that information posted on one site transfers to others.

Other prongs in this strategy include issuing press releases by using Internet publication sites, establishing one or more blogs in your name, and using pay-per-click advertising.

Sound overwhelming? Innovative entrepreneurs thought that it might, so a number of Internet reputation-management companies have formed to do some of this work for you--for a fee, of course. These include companies like Reputation Repair & Management, Internet Reputation Management, and ReputationDefender, Dr. Lober said.

If, instead, you want to try to get a specific offensive statement removed from the Web, seek legal counsel to guide you, he advised.

First, the statement must be determined to meet the legal definition of defamation.

If it does, the next step is to determine if the person who wrote it is covered by any one of several standard legal defenses. If that's not an issue, check the terms and conditions listed by the Internet service provider (ISP) of the site where the comment appeared, to see if the ISP made any promises or assurances about the content on the site. If you contact the ISP, it may take the comment down.

Normally, ISPs are immune from lawsuits over statements made by others on its service; they resemble telephone companies more than newspapers in that respect, he said.

You or your lawyer can request that the courts issue a subpoena to try to compel the person who made the statement (even an anonymous poster) to remedy the situation, but this process is time consuming and expensive, and the person who posted the comment may be difficult to locate, Dr. Lober cautioned.

And if you sue, the defendant may try to frame your action as a SLAPP (strategic litigation against public participation) suit intended to muzzle critics and restrict freedom of speech. Some states have anti-SLAPP laws that could leave you paying the defendant's attorney fees and costs, and make you vulnerable to a countersuit by the defendant.

Better to try to "manage" your online reputation than to try to legally defend it, he suggested.

Dr. Lober reported having no pertinent conflicts of interest.

MONTEREY, CALIF. - Have you searched for your name on the Internet? Your patients have.

"Your patients are Googling you," and some of them probably are rating your performance as a doctor on one of the many physician-rating sites or generic rating sites, Dr. Clifford Warren Lober said at the annual meeting of the American Society for Mohs Surgery.

Here's the problem: The patients most likely to rate you are those who are livid at you, or those who think you walk on water. And it's not just patients who are posting comments about you, but previous patients, ex-employees, former spouses, or anyone else who knows you, said Dr. Lober, a dermatologist and attorney in Kissimmee, Fla.

Online comments may be made anonymously, persist for years on the Internet, be accessed by anyone with a computer, and be replicated on other Web sites beyond the original. If you discover comments about you that you think are harmful to your reputation, your attempts to remedy the situation may backfire and instead "optimize" the content by bringing more attention to the posted statement, amplifying its negativity, he said.

Legal remedies are few and complicated. "There is a morass of legal defenses and privileges that protect the offending person," Dr. Lober said.

So how best to manage your online reputation? One strategy is to minimize the impact of negative online information through search-engine optimization, he suggested.

In practice, this means blitzing the Web with your own content to crowd out comments by others. "You want to occupy the first three pages of the rating sites" and the search-engine results pages if possible, Dr. Lober said, adding that most people don't look beyond the first three pages of results.

This can be done by establishing multiple Web sites, each with numerous internal page links, external high-traffic links, significant content on each of your home pages, and other features that make these the sites that show up when someone searches your name.

Establishing a deep social network presence helps, too. Create accounts on Facebook, Twitter, LinkedIn, ZoomInfo, Connectbeam, Yahoo profile, Google Profile, MSN Profile, Wetpaint, Naymz, Jigsaw, Ning, and others, he suggested.

Ideally, get on sites that feature RSS (Really Simple Syndication) feeds so that information posted on one site transfers to others.

Other prongs in this strategy include issuing press releases by using Internet publication sites, establishing one or more blogs in your name, and using pay-per-click advertising.

Sound overwhelming? Innovative entrepreneurs thought that it might, so a number of Internet reputation-management companies have formed to do some of this work for you--for a fee, of course. These include companies like Reputation Repair & Management, Internet Reputation Management, and ReputationDefender, Dr. Lober said.

If, instead, you want to try to get a specific offensive statement removed from the Web, seek legal counsel to guide you, he advised.

First, the statement must be determined to meet the legal definition of defamation.

If it does, the next step is to determine if the person who wrote it is covered by any one of several standard legal defenses. If that's not an issue, check the terms and conditions listed by the Internet service provider (ISP) of the site where the comment appeared, to see if the ISP made any promises or assurances about the content on the site. If you contact the ISP, it may take the comment down.

Normally, ISPs are immune from lawsuits over statements made by others on its service; they resemble telephone companies more than newspapers in that respect, he said.

You or your lawyer can request that the courts issue a subpoena to try to compel the person who made the statement (even an anonymous poster) to remedy the situation, but this process is time consuming and expensive, and the person who posted the comment may be difficult to locate, Dr. Lober cautioned.

And if you sue, the defendant may try to frame your action as a SLAPP (strategic litigation against public participation) suit intended to muzzle critics and restrict freedom of speech. Some states have anti-SLAPP laws that could leave you paying the defendant's attorney fees and costs, and make you vulnerable to a countersuit by the defendant.

Better to try to "manage" your online reputation than to try to legally defend it, he suggested.

Dr. Lober reported having no pertinent conflicts of interest.

MONTEREY, CALIF. - Have you searched for your name on the Internet? Your patients have.

"Your patients are Googling you," and some of them probably are rating your performance as a doctor on one of the many physician-rating sites or generic rating sites, Dr. Clifford Warren Lober said at the annual meeting of the American Society for Mohs Surgery.

Here's the problem: The patients most likely to rate you are those who are livid at you, or those who think you walk on water. And it's not just patients who are posting comments about you, but previous patients, ex-employees, former spouses, or anyone else who knows you, said Dr. Lober, a dermatologist and attorney in Kissimmee, Fla.

Online comments may be made anonymously, persist for years on the Internet, be accessed by anyone with a computer, and be replicated on other Web sites beyond the original. If you discover comments about you that you think are harmful to your reputation, your attempts to remedy the situation may backfire and instead "optimize" the content by bringing more attention to the posted statement, amplifying its negativity, he said.

Legal remedies are few and complicated. "There is a morass of legal defenses and privileges that protect the offending person," Dr. Lober said.

So how best to manage your online reputation? One strategy is to minimize the impact of negative online information through search-engine optimization, he suggested.

In practice, this means blitzing the Web with your own content to crowd out comments by others. "You want to occupy the first three pages of the rating sites" and the search-engine results pages if possible, Dr. Lober said, adding that most people don't look beyond the first three pages of results.

This can be done by establishing multiple Web sites, each with numerous internal page links, external high-traffic links, significant content on each of your home pages, and other features that make these the sites that show up when someone searches your name.

Establishing a deep social network presence helps, too. Create accounts on Facebook, Twitter, LinkedIn, ZoomInfo, Connectbeam, Yahoo profile, Google Profile, MSN Profile, Wetpaint, Naymz, Jigsaw, Ning, and others, he suggested.

Ideally, get on sites that feature RSS (Really Simple Syndication) feeds so that information posted on one site transfers to others.

Other prongs in this strategy include issuing press releases by using Internet publication sites, establishing one or more blogs in your name, and using pay-per-click advertising.

Sound overwhelming? Innovative entrepreneurs thought that it might, so a number of Internet reputation-management companies have formed to do some of this work for you--for a fee, of course. These include companies like Reputation Repair & Management, Internet Reputation Management, and ReputationDefender, Dr. Lober said.

If, instead, you want to try to get a specific offensive statement removed from the Web, seek legal counsel to guide you, he advised.

First, the statement must be determined to meet the legal definition of defamation.

If it does, the next step is to determine if the person who wrote it is covered by any one of several standard legal defenses. If that's not an issue, check the terms and conditions listed by the Internet service provider (ISP) of the site where the comment appeared, to see if the ISP made any promises or assurances about the content on the site. If you contact the ISP, it may take the comment down.

Normally, ISPs are immune from lawsuits over statements made by others on its service; they resemble telephone companies more than newspapers in that respect, he said.

You or your lawyer can request that the courts issue a subpoena to try to compel the person who made the statement (even an anonymous poster) to remedy the situation, but this process is time consuming and expensive, and the person who posted the comment may be difficult to locate, Dr. Lober cautioned.

And if you sue, the defendant may try to frame your action as a SLAPP (strategic litigation against public participation) suit intended to muzzle critics and restrict freedom of speech. Some states have anti-SLAPP laws that could leave you paying the defendant's attorney fees and costs, and make you vulnerable to a countersuit by the defendant.

Better to try to "manage" your online reputation than to try to legally defend it, he suggested.

Dr. Lober reported having no pertinent conflicts of interest.

MONTEREY, Calif. — Stainless steel embedding wells may be the best of several mechanisms available to flatten or “conform” tissue specimens for sectioning in Mohs surgery, in one expert’s opinion.

Sectioning of the peripheral/epidermal margin of the lesion is essential for Mohs surgery to ensure complete margin assessment. Most Mohs surgeons require that 90% or more of the epidermis be present to feel that they’re assessing an adequate epidermal margin, Dr. David F. Butler explained at a meeting of the American Society for Mohs Surgery.

Photo courtesy Dr. David F. Butler

Only two mechanisms can flatten multiple tissue specimens at once: the $20,000 CryoHist machine, or the $529 stainless steel embedding wells, said Dr. Butler, chair of dermatology at the Scott and White Hospital and Clinic and professor of medicine at Texas A&M University, both in Temple, Tex.

Lower cost, convenience, and quality results make him a fan of the stainless steel embedding wells, which consist of 1-inch steel bars with wells cut out in different sizes and depths. The bars reside within a cryostat, which provides a heat sink for the rapid freezing of the specimen.

The surgeon or other operator places a specimen facedown on the smooth surface of a well and presses down on the peripheral edge of the specimen with a gloved finger. “Like putting your tongue to a cold flagpole in Wisconsin in winter, it sticks,” he said.

Optimal cutting temperature (OCT) compound—a cryopreservation medium—is then applied over the specimen, and a metal chuck with a cross-grid pattern to better hold onto frozen OCT is applied to the OCT. A freezing block that’s been kept cold within the cryostat can be placed over the stem of the chuck to freeze the specimen more quickly.

As Dr. Butler described it, one of the sets includes one freezing bar with a 24-mm well, a 36-mm chuck, and the overchuck freezing block. He described the complete set as three bars with different well sizes, six small chucks, four large chucks, four overchuck freezing blocks, a chuck bin, an elevated embedding block, and angled freezing forceps.

The stainless steel embedding wells are available from Dr. Stephen R. Peters, the pathologist who designed them, Dr. Butler said. Dr. Peters is at Hackensack (N.J.) University Medical Center and can be reached through his Web site or via e-mail.

In using the stainless steel embedding wells for seven consecutive specimens, Dr. Butler found that five of the seven specimens (71%) met the goal of having more than 90% of the epidermis present by the sixth retained section.

He compared the time needed to freeze a specimen and mount the block using several mechanisms. It took 105 seconds with the embedding wells, 56 seconds with the CryoHist, 68 seconds with the Miami Special, and 91 seconds with the Cryocup. Only the embedding wells and CryoHist could freeze and mount multiple specimens at the same time “so the overall process doesn’t take very long,” he said.

The CryoHist is a large machine, plumbed for liquid nitrogen that flattens specimens via a vacuum suction. Compared with embedding wells, its disadvantages include the high cost and the need for greater space, external power and liquid nitrogen, and consumables such as a plastic film that is used in the process, Dr. Butler said.

The Miami Special is a long-handled clamp with flat metal plates at the end on which partially frozen OCT and a chuck are placed. The specimen is placed on the OCT and the clamp is closed and dipped in liquid nitrogen to freeze. “The problem is that it’s very cumbersome and can only do one at a time,” he said.

The Davidson Cryocup is a metal device with a long handle and a cup at one end in which tissue is placed facedown and covered with OCT and a chuck. The cup is lowered into liquid nitrogen to freeze. “It has the same problem as the Miami Special: You can only process one specimen at a time,” he said.

Other mechanisms include the inexpensive cryomold, small plastic trays of different sizes and depths on which specimens are placed facedown and covered with OCT and a chuck before placement in a cryostat. The plastic cryomold is peeled back before sectioning, one specimen at a time.

An older technique employs a heat extractor that resides within some cryostats and remains cold. A chuck is placed on the rack within the cryostat, OCT is applied, and the specimen is placed “deep side up” on the OCT, he said. A cold round bar of the heat extractor is pressed down on the specimen and OCT until frozen.

Dr. Butler said he has no pertinent conflicts of interest.

MONTEREY, Calif. — Stainless steel embedding wells may be the best of several mechanisms available to flatten or “conform” tissue specimens for sectioning in Mohs surgery, in one expert’s opinion.

Sectioning of the peripheral/epidermal margin of the lesion is essential for Mohs surgery to ensure complete margin assessment. Most Mohs surgeons require that 90% or more of the epidermis be present to feel that they’re assessing an adequate epidermal margin, Dr. David F. Butler explained at a meeting of the American Society for Mohs Surgery.

Photo courtesy Dr. David F. Butler

Only two mechanisms can flatten multiple tissue specimens at once: the $20,000 CryoHist machine, or the $529 stainless steel embedding wells, said Dr. Butler, chair of dermatology at the Scott and White Hospital and Clinic and professor of medicine at Texas A&M University, both in Temple, Tex.

Lower cost, convenience, and quality results make him a fan of the stainless steel embedding wells, which consist of 1-inch steel bars with wells cut out in different sizes and depths. The bars reside within a cryostat, which provides a heat sink for the rapid freezing of the specimen.

The surgeon or other operator places a specimen facedown on the smooth surface of a well and presses down on the peripheral edge of the specimen with a gloved finger. “Like putting your tongue to a cold flagpole in Wisconsin in winter, it sticks,” he said.

Optimal cutting temperature (OCT) compound—a cryopreservation medium—is then applied over the specimen, and a metal chuck with a cross-grid pattern to better hold onto frozen OCT is applied to the OCT. A freezing block that’s been kept cold within the cryostat can be placed over the stem of the chuck to freeze the specimen more quickly.

As Dr. Butler described it, one of the sets includes one freezing bar with a 24-mm well, a 36-mm chuck, and the overchuck freezing block. He described the complete set as three bars with different well sizes, six small chucks, four large chucks, four overchuck freezing blocks, a chuck bin, an elevated embedding block, and angled freezing forceps.

The stainless steel embedding wells are available from Dr. Stephen R. Peters, the pathologist who designed them, Dr. Butler said. Dr. Peters is at Hackensack (N.J.) University Medical Center and can be reached through his Web site or via e-mail.

In using the stainless steel embedding wells for seven consecutive specimens, Dr. Butler found that five of the seven specimens (71%) met the goal of having more than 90% of the epidermis present by the sixth retained section.

He compared the time needed to freeze a specimen and mount the block using several mechanisms. It took 105 seconds with the embedding wells, 56 seconds with the CryoHist, 68 seconds with the Miami Special, and 91 seconds with the Cryocup. Only the embedding wells and CryoHist could freeze and mount multiple specimens at the same time “so the overall process doesn’t take very long,” he said.

The CryoHist is a large machine, plumbed for liquid nitrogen that flattens specimens via a vacuum suction. Compared with embedding wells, its disadvantages include the high cost and the need for greater space, external power and liquid nitrogen, and consumables such as a plastic film that is used in the process, Dr. Butler said.

The Miami Special is a long-handled clamp with flat metal plates at the end on which partially frozen OCT and a chuck are placed. The specimen is placed on the OCT and the clamp is closed and dipped in liquid nitrogen to freeze. “The problem is that it’s very cumbersome and can only do one at a time,” he said.

The Davidson Cryocup is a metal device with a long handle and a cup at one end in which tissue is placed facedown and covered with OCT and a chuck. The cup is lowered into liquid nitrogen to freeze. “It has the same problem as the Miami Special: You can only process one specimen at a time,” he said.

Other mechanisms include the inexpensive cryomold, small plastic trays of different sizes and depths on which specimens are placed facedown and covered with OCT and a chuck before placement in a cryostat. The plastic cryomold is peeled back before sectioning, one specimen at a time.

An older technique employs a heat extractor that resides within some cryostats and remains cold. A chuck is placed on the rack within the cryostat, OCT is applied, and the specimen is placed “deep side up” on the OCT, he said. A cold round bar of the heat extractor is pressed down on the specimen and OCT until frozen.

Dr. Butler said he has no pertinent conflicts of interest.

MONTEREY, Calif. — Stainless steel embedding wells may be the best of several mechanisms available to flatten or “conform” tissue specimens for sectioning in Mohs surgery, in one expert’s opinion.

Sectioning of the peripheral/epidermal margin of the lesion is essential for Mohs surgery to ensure complete margin assessment. Most Mohs surgeons require that 90% or more of the epidermis be present to feel that they’re assessing an adequate epidermal margin, Dr. David F. Butler explained at a meeting of the American Society for Mohs Surgery.

Photo courtesy Dr. David F. Butler

Only two mechanisms can flatten multiple tissue specimens at once: the $20,000 CryoHist machine, or the $529 stainless steel embedding wells, said Dr. Butler, chair of dermatology at the Scott and White Hospital and Clinic and professor of medicine at Texas A&M University, both in Temple, Tex.

Lower cost, convenience, and quality results make him a fan of the stainless steel embedding wells, which consist of 1-inch steel bars with wells cut out in different sizes and depths. The bars reside within a cryostat, which provides a heat sink for the rapid freezing of the specimen.

The surgeon or other operator places a specimen facedown on the smooth surface of a well and presses down on the peripheral edge of the specimen with a gloved finger. “Like putting your tongue to a cold flagpole in Wisconsin in winter, it sticks,” he said.

Optimal cutting temperature (OCT) compound—a cryopreservation medium—is then applied over the specimen, and a metal chuck with a cross-grid pattern to better hold onto frozen OCT is applied to the OCT. A freezing block that’s been kept cold within the cryostat can be placed over the stem of the chuck to freeze the specimen more quickly.

As Dr. Butler described it, one of the sets includes one freezing bar with a 24-mm well, a 36-mm chuck, and the overchuck freezing block. He described the complete set as three bars with different well sizes, six small chucks, four large chucks, four overchuck freezing blocks, a chuck bin, an elevated embedding block, and angled freezing forceps.

The stainless steel embedding wells are available from Dr. Stephen R. Peters, the pathologist who designed them, Dr. Butler said. Dr. Peters is at Hackensack (N.J.) University Medical Center and can be reached through his Web site or via e-mail.

In using the stainless steel embedding wells for seven consecutive specimens, Dr. Butler found that five of the seven specimens (71%) met the goal of having more than 90% of the epidermis present by the sixth retained section.

He compared the time needed to freeze a specimen and mount the block using several mechanisms. It took 105 seconds with the embedding wells, 56 seconds with the CryoHist, 68 seconds with the Miami Special, and 91 seconds with the Cryocup. Only the embedding wells and CryoHist could freeze and mount multiple specimens at the same time “so the overall process doesn’t take very long,” he said.

The CryoHist is a large machine, plumbed for liquid nitrogen that flattens specimens via a vacuum suction. Compared with embedding wells, its disadvantages include the high cost and the need for greater space, external power and liquid nitrogen, and consumables such as a plastic film that is used in the process, Dr. Butler said.

The Miami Special is a long-handled clamp with flat metal plates at the end on which partially frozen OCT and a chuck are placed. The specimen is placed on the OCT and the clamp is closed and dipped in liquid nitrogen to freeze. “The problem is that it’s very cumbersome and can only do one at a time,” he said.

The Davidson Cryocup is a metal device with a long handle and a cup at one end in which tissue is placed facedown and covered with OCT and a chuck. The cup is lowered into liquid nitrogen to freeze. “It has the same problem as the Miami Special: You can only process one specimen at a time,” he said.

Other mechanisms include the inexpensive cryomold, small plastic trays of different sizes and depths on which specimens are placed facedown and covered with OCT and a chuck before placement in a cryostat. The plastic cryomold is peeled back before sectioning, one specimen at a time.

An older technique employs a heat extractor that resides within some cryostats and remains cold. A chuck is placed on the rack within the cryostat, OCT is applied, and the specimen is placed “deep side up” on the OCT, he said. A cold round bar of the heat extractor is pressed down on the specimen and OCT until frozen.

Dr. Butler said he has no pertinent conflicts of interest.