Betsy Bates

Histiocytoid Sweet Syndrome

At first glance, it appeared that a straightforward diagnosis was in order, said Dr. Paul A. Krusinski at the annual meeting of the Noah Worcester Dermatological Society.

“We thought it looked pretty good for Sweet syndrome,” he said, referencing the patient's characteristic fever and joint pain. “Often, Sweet syndrome has a prodrome associated with it and she had her—quote—sinus infection,” he said.

A second differential diagnosis was drug hypersensitivity reaction, noted Dr. Krusinski, professor and director of the division of dermatology at the University of Vermont, Burlington.

Histologically, edema could be seen in the upper papillary dermis. A perivascular infiltrate was evident in the dermis. At higher power, however, the Sweet syndrome diagnosis seemed less likely. “When you get a little closer, you say, 'Where are the polys [polymorphonuclear neutrophils]? Where are the neutrophils?'” he said. In their place appeared to be large histiocytes.

A dermatopathology report on an initial biopsy specimen identified “a moderately dense dermal inflammatory infiltrate that is of mixed composition but predominated by mononuclear cells,” and went on to note that “only rare neutrophils are present, thus militating against Sweet syndrome.” Immunostaining was positive for CD68 and myeloid precursors.

Classic Sweet syndrome, first described in 1964, is characterized by its female predominance, abrupt onset, fever, painful erythematous plaques or nodules, and abnormal laboratory values such as elevated erythrocyte sedimentation rate and positive C-reactive protein, just as in this case.

Neutrophilic infiltrate conventionally heralds classic Sweet syndrome, either in the absence of vasculitis or, rarely, with secondary vasculitis. Three subtypes are classically described, including idiopathic Sweet syndrome associated with other inflammatory diseases, cases related to hematologic malignancies, and cases associated with solid malignant neoplasms.

A literature review revealed a study from Spanish researchers detailing 41 cases of a previously undescribed entity: histiocytoid Sweet syndrome. In this series, 26 women and 15 men aged 29–79 years had lesions typical of Sweet syndrome but failed to meet conventional histopathologic criteria for the disease (Arch. Dermatol. 2005;141:834–42).

Biopsies showed dense, bandlike infiltrate in the superficial dermis and mid-dermis that was predominated by large mononuclear cells with “eccentric” nuclei and irregular contours. Few neutrophils, lymphocytes, or small histiocytes were present. Moderate to intense superficial dermal edema was present and there was no appreciable vasculitis.

Findings align with the monocytic histiocytic lineage, with positive staining for CD15, CD43, CD45, CD68, MAC-386, HAM56, and lysozyme.

The authors of a recent article detailing six clinically and microscopically diverse cases thought to be Sweet syndrome, drug eruptions, erythema nodosum, or Wells's syndrome hypothesized that histiocytoid neutrophilic dermatoses and panniculitides are “variations on a theme” and proposed three new disease classifications: Sweetlike neutrophilic dermatoses, histiocytoid; subcutaneous Sweet syndrome, histiocytoid; and histiocytoid neutrophilic dermatosis, unspecified (Am. J. Dermatopathol. 2007;29:334–41).

The case patient had age-appropriate cancer screening, with negative results, and responded well to prednisone 40 mg daily followed by a tapering of the drug.

Dr. Kathryn Schwarzenberger was the physician at the University of Vermont who made the diagnosis.

Histology shows dense dermal inflam-matory infiltrate of mononuclear cells. Courtesy Dr. Paul A. Krusinski

Histiocytoid Sweet Syndrome

At first glance, it appeared that a straightforward diagnosis was in order, said Dr. Paul A. Krusinski at the annual meeting of the Noah Worcester Dermatological Society.

“We thought it looked pretty good for Sweet syndrome,” he said, referencing the patient's characteristic fever and joint pain. “Often, Sweet syndrome has a prodrome associated with it and she had her—quote—sinus infection,” he said.

A second differential diagnosis was drug hypersensitivity reaction, noted Dr. Krusinski, professor and director of the division of dermatology at the University of Vermont, Burlington.

Histologically, edema could be seen in the upper papillary dermis. A perivascular infiltrate was evident in the dermis. At higher power, however, the Sweet syndrome diagnosis seemed less likely. “When you get a little closer, you say, 'Where are the polys [polymorphonuclear neutrophils]? Where are the neutrophils?'” he said. In their place appeared to be large histiocytes.

A dermatopathology report on an initial biopsy specimen identified “a moderately dense dermal inflammatory infiltrate that is of mixed composition but predominated by mononuclear cells,” and went on to note that “only rare neutrophils are present, thus militating against Sweet syndrome.” Immunostaining was positive for CD68 and myeloid precursors.

Classic Sweet syndrome, first described in 1964, is characterized by its female predominance, abrupt onset, fever, painful erythematous plaques or nodules, and abnormal laboratory values such as elevated erythrocyte sedimentation rate and positive C-reactive protein, just as in this case.

Neutrophilic infiltrate conventionally heralds classic Sweet syndrome, either in the absence of vasculitis or, rarely, with secondary vasculitis. Three subtypes are classically described, including idiopathic Sweet syndrome associated with other inflammatory diseases, cases related to hematologic malignancies, and cases associated with solid malignant neoplasms.

A literature review revealed a study from Spanish researchers detailing 41 cases of a previously undescribed entity: histiocytoid Sweet syndrome. In this series, 26 women and 15 men aged 29–79 years had lesions typical of Sweet syndrome but failed to meet conventional histopathologic criteria for the disease (Arch. Dermatol. 2005;141:834–42).

Biopsies showed dense, bandlike infiltrate in the superficial dermis and mid-dermis that was predominated by large mononuclear cells with “eccentric” nuclei and irregular contours. Few neutrophils, lymphocytes, or small histiocytes were present. Moderate to intense superficial dermal edema was present and there was no appreciable vasculitis.

Findings align with the monocytic histiocytic lineage, with positive staining for CD15, CD43, CD45, CD68, MAC-386, HAM56, and lysozyme.

The authors of a recent article detailing six clinically and microscopically diverse cases thought to be Sweet syndrome, drug eruptions, erythema nodosum, or Wells's syndrome hypothesized that histiocytoid neutrophilic dermatoses and panniculitides are “variations on a theme” and proposed three new disease classifications: Sweetlike neutrophilic dermatoses, histiocytoid; subcutaneous Sweet syndrome, histiocytoid; and histiocytoid neutrophilic dermatosis, unspecified (Am. J. Dermatopathol. 2007;29:334–41).

The case patient had age-appropriate cancer screening, with negative results, and responded well to prednisone 40 mg daily followed by a tapering of the drug.

Dr. Kathryn Schwarzenberger was the physician at the University of Vermont who made the diagnosis.

Histology shows dense dermal inflam-matory infiltrate of mononuclear cells. Courtesy Dr. Paul A. Krusinski

Histiocytoid Sweet Syndrome

At first glance, it appeared that a straightforward diagnosis was in order, said Dr. Paul A. Krusinski at the annual meeting of the Noah Worcester Dermatological Society.

“We thought it looked pretty good for Sweet syndrome,” he said, referencing the patient's characteristic fever and joint pain. “Often, Sweet syndrome has a prodrome associated with it and she had her—quote—sinus infection,” he said.

A second differential diagnosis was drug hypersensitivity reaction, noted Dr. Krusinski, professor and director of the division of dermatology at the University of Vermont, Burlington.

Histologically, edema could be seen in the upper papillary dermis. A perivascular infiltrate was evident in the dermis. At higher power, however, the Sweet syndrome diagnosis seemed less likely. “When you get a little closer, you say, 'Where are the polys [polymorphonuclear neutrophils]? Where are the neutrophils?'” he said. In their place appeared to be large histiocytes.

A dermatopathology report on an initial biopsy specimen identified “a moderately dense dermal inflammatory infiltrate that is of mixed composition but predominated by mononuclear cells,” and went on to note that “only rare neutrophils are present, thus militating against Sweet syndrome.” Immunostaining was positive for CD68 and myeloid precursors.

Classic Sweet syndrome, first described in 1964, is characterized by its female predominance, abrupt onset, fever, painful erythematous plaques or nodules, and abnormal laboratory values such as elevated erythrocyte sedimentation rate and positive C-reactive protein, just as in this case.

Neutrophilic infiltrate conventionally heralds classic Sweet syndrome, either in the absence of vasculitis or, rarely, with secondary vasculitis. Three subtypes are classically described, including idiopathic Sweet syndrome associated with other inflammatory diseases, cases related to hematologic malignancies, and cases associated with solid malignant neoplasms.

A literature review revealed a study from Spanish researchers detailing 41 cases of a previously undescribed entity: histiocytoid Sweet syndrome. In this series, 26 women and 15 men aged 29–79 years had lesions typical of Sweet syndrome but failed to meet conventional histopathologic criteria for the disease (Arch. Dermatol. 2005;141:834–42).

Biopsies showed dense, bandlike infiltrate in the superficial dermis and mid-dermis that was predominated by large mononuclear cells with “eccentric” nuclei and irregular contours. Few neutrophils, lymphocytes, or small histiocytes were present. Moderate to intense superficial dermal edema was present and there was no appreciable vasculitis.

Findings align with the monocytic histiocytic lineage, with positive staining for CD15, CD43, CD45, CD68, MAC-386, HAM56, and lysozyme.

The authors of a recent article detailing six clinically and microscopically diverse cases thought to be Sweet syndrome, drug eruptions, erythema nodosum, or Wells's syndrome hypothesized that histiocytoid neutrophilic dermatoses and panniculitides are “variations on a theme” and proposed three new disease classifications: Sweetlike neutrophilic dermatoses, histiocytoid; subcutaneous Sweet syndrome, histiocytoid; and histiocytoid neutrophilic dermatosis, unspecified (Am. J. Dermatopathol. 2007;29:334–41).

The case patient had age-appropriate cancer screening, with negative results, and responded well to prednisone 40 mg daily followed by a tapering of the drug.

Dr. Kathryn Schwarzenberger was the physician at the University of Vermont who made the diagnosis.

Histology shows dense dermal inflam-matory infiltrate of mononuclear cells. Courtesy Dr. Paul A. Krusinski

LOS ANGELES – Today's adolescents are so immersed in technology they multitask in their cyberspace lives, texting while listening to their iPods, talking on cell phones as they scope out each other's Facebook pages.

Even for adolescent medicine specialists, their worlds move fast–so fast, in fact, it's difficult for researchers to keep up with what teens are doing, what it all means, and whether these technologies can be tapped for the betterment of teen health.

Researchers at the annual meeting of the Society for Adolescent Medicine offered a mixed picture of teens and technology, but all agreed that the topic is a moving target.

“As soon as we figure out what they're doing, they're on to something else,” said Amy B. Jordan, Ph.D., director of the media and the developing child sector of the Annenberg Public Policy Center at the University of Pennsylvania in Philadelphia.

As of this moment, texting and instant messaging are in; e-mailing is out–the latter now just a relic “used to communicate with adults and institutions,” said Patti M. Valkenburg, Ph.D., director of the center for research on children, adolescents, and the media at the University of Amsterdam.

“Sexting” is also a hot topic, with 20% of 12- to 17-year-olds texting messages with sexual content and/or explicit photographs of themselves, Dr. Jordan said.

Younger adolescents quickly “appropriated” the social networking site Facebook from college students, but now there are indications that the teens are moving on.

In an aside, Dr. Jordan described her own 14-year-old daughter's horror at learning that her 74-year-old grandmother had a Facebook page and 11 “friends,” “8 of whom she does not know!”

Dr. Valkenburg noted that American and European teenagers are virtually identical in their ravenous consumption of technology, with more than 90% of U.S. and Dutch teens logging onto the Internet.

Much of the appeal is understandable within the context of the developmental tasks of adolescence, including the need to develop self-esteem and social competency, she said.

In her research, one-third of teens said they prefer online self-disclosure to face-to-face conversations, finding a measure of comfort in a medium that doesn't expose their awkward facial and auditory cues (not to mention zits and blushing).

But while new media can provide a kinder, gentler avenue to budding teen friendships, there are pitfalls as well.

The reality of online life for teens means they are “one click away” from pornography, drug and alcohol messages, and hard-bitten marketing schemes bent on capitalizing on their impulsivity, Dr. Valkenburg said.

With that perspective in mind, it is useful to note that researchers are discovering that American and Dutch teenagers are fairly transparent on social networking sites.

A Pew Research Center study found that 82% of U.S. teenagers reveal their first names and 29%, their last names, on such sites.

Nearly 80% provide photos of themselves, and 61% reveal the city where they live.

Dr. Valkenburg found Dutch teenagers are even more sanguine, with 92% revealing their first names and 62% their last names.

Another technology expert, Kaveri Subrahmanyam, Ph.D., reported that, despite “exaggerated” online behaviors, few adolescents tread deeply into out-of-character, risky territory when they log on.

Troubled teens are troubled in all domains of their lives, while well-adjusted teens connect online with friends and those with similar interests.

“It does appear that teens' offline and online world are connected,” said Dr. Subrahmanyam, director of the media and language lab at California State University, Los Angeles.

Her studies of cyberbullying, for example, reveal highly creative bullying techniques, from slam books to embedded pictures to sexting.

But the cast of characters holds few surprises.

“The majority of bullies know their victims. Their victims are victims of offline bullying at school,” she said.

Indeed, for some victims, the Internet may provide a buffer in which they can avoid social rejection by connecting with online friends.

On the other hand, Dr. Subrahmanyam warned that some children and teens are vulnerable to harmful influences and manipulation online, often marked by a solitary retreat to the online world.

“For those of us who work with teenagers, it's important to consider that a discrepancy between offline and online life is probably a red flag,” she said.

From a professional standpoint, it would behoove adolescent medicine professionals to get immersed in the fast-moving technological culture of adolescence in order to understand its influence on the teens they see, said Dr. Ellen Wartella, executive vice chancellor and provost for the University of California, Riverside.

From a public policy standpoint, physician voices are needed in the effort to monitor and control content, she maintained.

“You really need to experience it, not just listen to someone like me talk about it. Bring in some college students or teens … to actually walk you through Twitter and take you into Second Life [an online virtual world],” she advised.

Immersion in these environments can “go a long way” in gaining insight into how these new forms of communication are so very different from previous forms of adolescent communication, she said.

To view a video interview with Dr. Subrahmanyam, go to www.youtube.com/ClinPsychNews

LOS ANGELES – Today's adolescents are so immersed in technology they multitask in their cyberspace lives, texting while listening to their iPods, talking on cell phones as they scope out each other's Facebook pages.

Even for adolescent medicine specialists, their worlds move fast–so fast, in fact, it's difficult for researchers to keep up with what teens are doing, what it all means, and whether these technologies can be tapped for the betterment of teen health.

Researchers at the annual meeting of the Society for Adolescent Medicine offered a mixed picture of teens and technology, but all agreed that the topic is a moving target.

“As soon as we figure out what they're doing, they're on to something else,” said Amy B. Jordan, Ph.D., director of the media and the developing child sector of the Annenberg Public Policy Center at the University of Pennsylvania in Philadelphia.

As of this moment, texting and instant messaging are in; e-mailing is out–the latter now just a relic “used to communicate with adults and institutions,” said Patti M. Valkenburg, Ph.D., director of the center for research on children, adolescents, and the media at the University of Amsterdam.

“Sexting” is also a hot topic, with 20% of 12- to 17-year-olds texting messages with sexual content and/or explicit photographs of themselves, Dr. Jordan said.

Younger adolescents quickly “appropriated” the social networking site Facebook from college students, but now there are indications that the teens are moving on.

In an aside, Dr. Jordan described her own 14-year-old daughter's horror at learning that her 74-year-old grandmother had a Facebook page and 11 “friends,” “8 of whom she does not know!”

Dr. Valkenburg noted that American and European teenagers are virtually identical in their ravenous consumption of technology, with more than 90% of U.S. and Dutch teens logging onto the Internet.

Much of the appeal is understandable within the context of the developmental tasks of adolescence, including the need to develop self-esteem and social competency, she said.

In her research, one-third of teens said they prefer online self-disclosure to face-to-face conversations, finding a measure of comfort in a medium that doesn't expose their awkward facial and auditory cues (not to mention zits and blushing).

But while new media can provide a kinder, gentler avenue to budding teen friendships, there are pitfalls as well.

The reality of online life for teens means they are “one click away” from pornography, drug and alcohol messages, and hard-bitten marketing schemes bent on capitalizing on their impulsivity, Dr. Valkenburg said.

With that perspective in mind, it is useful to note that researchers are discovering that American and Dutch teenagers are fairly transparent on social networking sites.

A Pew Research Center study found that 82% of U.S. teenagers reveal their first names and 29%, their last names, on such sites.

Nearly 80% provide photos of themselves, and 61% reveal the city where they live.

Dr. Valkenburg found Dutch teenagers are even more sanguine, with 92% revealing their first names and 62% their last names.

Another technology expert, Kaveri Subrahmanyam, Ph.D., reported that, despite “exaggerated” online behaviors, few adolescents tread deeply into out-of-character, risky territory when they log on.

Troubled teens are troubled in all domains of their lives, while well-adjusted teens connect online with friends and those with similar interests.

“It does appear that teens' offline and online world are connected,” said Dr. Subrahmanyam, director of the media and language lab at California State University, Los Angeles.

Her studies of cyberbullying, for example, reveal highly creative bullying techniques, from slam books to embedded pictures to sexting.

But the cast of characters holds few surprises.

“The majority of bullies know their victims. Their victims are victims of offline bullying at school,” she said.

Indeed, for some victims, the Internet may provide a buffer in which they can avoid social rejection by connecting with online friends.

On the other hand, Dr. Subrahmanyam warned that some children and teens are vulnerable to harmful influences and manipulation online, often marked by a solitary retreat to the online world.

“For those of us who work with teenagers, it's important to consider that a discrepancy between offline and online life is probably a red flag,” she said.

From a professional standpoint, it would behoove adolescent medicine professionals to get immersed in the fast-moving technological culture of adolescence in order to understand its influence on the teens they see, said Dr. Ellen Wartella, executive vice chancellor and provost for the University of California, Riverside.

From a public policy standpoint, physician voices are needed in the effort to monitor and control content, she maintained.

“You really need to experience it, not just listen to someone like me talk about it. Bring in some college students or teens … to actually walk you through Twitter and take you into Second Life [an online virtual world],” she advised.

Immersion in these environments can “go a long way” in gaining insight into how these new forms of communication are so very different from previous forms of adolescent communication, she said.

To view a video interview with Dr. Subrahmanyam, go to www.youtube.com/ClinPsychNews

LOS ANGELES – Today's adolescents are so immersed in technology they multitask in their cyberspace lives, texting while listening to their iPods, talking on cell phones as they scope out each other's Facebook pages.

Even for adolescent medicine specialists, their worlds move fast–so fast, in fact, it's difficult for researchers to keep up with what teens are doing, what it all means, and whether these technologies can be tapped for the betterment of teen health.

Researchers at the annual meeting of the Society for Adolescent Medicine offered a mixed picture of teens and technology, but all agreed that the topic is a moving target.

“As soon as we figure out what they're doing, they're on to something else,” said Amy B. Jordan, Ph.D., director of the media and the developing child sector of the Annenberg Public Policy Center at the University of Pennsylvania in Philadelphia.

As of this moment, texting and instant messaging are in; e-mailing is out–the latter now just a relic “used to communicate with adults and institutions,” said Patti M. Valkenburg, Ph.D., director of the center for research on children, adolescents, and the media at the University of Amsterdam.

“Sexting” is also a hot topic, with 20% of 12- to 17-year-olds texting messages with sexual content and/or explicit photographs of themselves, Dr. Jordan said.

Younger adolescents quickly “appropriated” the social networking site Facebook from college students, but now there are indications that the teens are moving on.

In an aside, Dr. Jordan described her own 14-year-old daughter's horror at learning that her 74-year-old grandmother had a Facebook page and 11 “friends,” “8 of whom she does not know!”

Dr. Valkenburg noted that American and European teenagers are virtually identical in their ravenous consumption of technology, with more than 90% of U.S. and Dutch teens logging onto the Internet.

Much of the appeal is understandable within the context of the developmental tasks of adolescence, including the need to develop self-esteem and social competency, she said.

In her research, one-third of teens said they prefer online self-disclosure to face-to-face conversations, finding a measure of comfort in a medium that doesn't expose their awkward facial and auditory cues (not to mention zits and blushing).

But while new media can provide a kinder, gentler avenue to budding teen friendships, there are pitfalls as well.

The reality of online life for teens means they are “one click away” from pornography, drug and alcohol messages, and hard-bitten marketing schemes bent on capitalizing on their impulsivity, Dr. Valkenburg said.

With that perspective in mind, it is useful to note that researchers are discovering that American and Dutch teenagers are fairly transparent on social networking sites.

A Pew Research Center study found that 82% of U.S. teenagers reveal their first names and 29%, their last names, on such sites.

Nearly 80% provide photos of themselves, and 61% reveal the city where they live.

Dr. Valkenburg found Dutch teenagers are even more sanguine, with 92% revealing their first names and 62% their last names.

Another technology expert, Kaveri Subrahmanyam, Ph.D., reported that, despite “exaggerated” online behaviors, few adolescents tread deeply into out-of-character, risky territory when they log on.

Troubled teens are troubled in all domains of their lives, while well-adjusted teens connect online with friends and those with similar interests.

“It does appear that teens' offline and online world are connected,” said Dr. Subrahmanyam, director of the media and language lab at California State University, Los Angeles.

Her studies of cyberbullying, for example, reveal highly creative bullying techniques, from slam books to embedded pictures to sexting.

But the cast of characters holds few surprises.

“The majority of bullies know their victims. Their victims are victims of offline bullying at school,” she said.

Indeed, for some victims, the Internet may provide a buffer in which they can avoid social rejection by connecting with online friends.

On the other hand, Dr. Subrahmanyam warned that some children and teens are vulnerable to harmful influences and manipulation online, often marked by a solitary retreat to the online world.

“For those of us who work with teenagers, it's important to consider that a discrepancy between offline and online life is probably a red flag,” she said.

From a professional standpoint, it would behoove adolescent medicine professionals to get immersed in the fast-moving technological culture of adolescence in order to understand its influence on the teens they see, said Dr. Ellen Wartella, executive vice chancellor and provost for the University of California, Riverside.

From a public policy standpoint, physician voices are needed in the effort to monitor and control content, she maintained.

“You really need to experience it, not just listen to someone like me talk about it. Bring in some college students or teens … to actually walk you through Twitter and take you into Second Life [an online virtual world],” she advised.

Immersion in these environments can “go a long way” in gaining insight into how these new forms of communication are so very different from previous forms of adolescent communication, she said.

To view a video interview with Dr. Subrahmanyam, go to www.youtube.com/ClinPsychNews

Pain and depression are common bedfellows, entwined in a complex relationship of situational and neurophysiologic connections that are not yet fully understood.

Numerous studies point to frequent comorbidity, yet physicians treating patients who present with chronic pain often fail to assess for depression and anxiety.

The opposite also can prove true, with psychiatrists failing to diagnose chronic pain in a significant percentage of their patients—particularly those with depression, said Dr. Alan Schatzberg, chairman and chief of psychiatry at Stanford (Calif.) University, in an interview.

“Pain is not commonly asked about in assessing depressed patients but is extremely commonly present,” he said.

In a cross-sectional international interview study of 18,980 subjects, nearly half of those with major depression also reported having a chronic pain condition (such as back pain, joint/articular pain, or headaches)—a fourfold elevation over people who were not depressed, reported Dr. Schatzberg and Dr. Maurice M. Ohayon, also of Stanford (Arch. Gen. Psychiatry 2003;60:39-47).

On the flip side, in people whose presenting problem is chronic pain, the prevalence of depression in the literature has ranged from 30% to 60%.

It remains unknown whether depression is the “cause or the consequence” of chronic pain, said Dr. Michael Clark, a psychiatrist who directs the Johns Hopkins Pain Treatment Program in Baltimore.

Intuitively, living with chronic pain puts significant stresses on a person's life and relationships. But increasing evidence points to multiple pathways of shared neurobiology as well, explaining the long-appreciated analgesic effects of tricyclic antidepressants, Dr. Clark said.

Today's armamentarium holds a wide variety of medications for chronic pain, starting with the anticonvulsant pregabalin (Lyrica), a GABA analogue, and the serotonin-norepinephrine reuptake inhibitor duloxetine (Cymbalta). Both have received Food and Drug Administration approval for fibromyalgia, and duloxetine also has garnered approval for the treatment of generalized anxiety disorder, depression, and diabetic peripheral neuropathy. Despite the on-label specifics, these drugs are cited by many experts as cornerstones of therapy for a wide range of patients with pain and comorbid psychiatric diagnoses, especially depression and anxiety.

“If I have a patient with both an emotional disorder and a pain disorder, I very well may put them on Cymbalta or on the combination of Lyrica and Cymbalta, which act through different mechanisms and have a synergistic effect in some patients,” said Dr. Gerald M. Aronoff, a psychiatrist and medical director of Carolina Pain Associates in Charlotte, N.C.

The strategy, along with a fervent belief in coordinated nonpharmacologic adjunct treatments that include supervised exercise, physical and occupational therapy, and cognitive-behavioral psychotherapy, allows Dr. Aronoff to reduce doses of opioids, which are central to management in many pain programs, especially those directed by nonpsychiatrists.

“My desire is not to have people on opioids indefinitely, but to get people through a difficult phase in their lives,” he said.

Numbing a patient's sensations may do nothing for the ripples of distress that can accompany pain: depression, relationship problems, and a crisis of self-efficacy and self-esteem.

Although tricyclic antidepressants are viewed as “old school” by some physicians treating chronic pain, Dr. Clark disagrees.

By the time patients see him, they may have been prescribed an array of the newer, more expensive drug choices, so he may turn to a tricyclic antidepressant (such as amitriptyline or doxepin) or an antiseizure medication such as divalproex (Depakote) or lamotrigine (Lamictal).

“Often, no one else has tried these medications in these patients,” he said, explaining that rare side effects, careful titration, and blood monitoring are not daunting once one is familiar with them.

Dr. Jon Mark Streltzer, professor of psychiatry at the University of Hawaii, Honolulu, maintains that the controversy surrounding long-term, high-dose opioid use for chronic pain is a matter of difference among individuals, rather than a specialty-specific perspective. “There are practitioners on both sides of the issue in all specialties,” he said. “There are competitive schools of thought.”

Dr. Streltzer generally opposes the use of high-dose opioids for chronic pain management, preferring to maintain patients (where possible) on acetaminophen (1 g, 4 times daily) while using a program aimed at function, activity through functionally directed therapy, and cognitive-behavioral psychotherapy.

That said, acetaminophen “won't work on opioid-dependent patients,” he warned. “Almost nothing will work until the dependence is treated.”

Dr. Clark said decreasing efficacy of opioids at standard doses results in patients on extremely high doses by the time they arrive at a tertiary pain clinic.

For example, patients commonly present to his clinic on doses of 600 mg/day of morphine or oxycodone, and individuals on 1,000 mg/day are not unheard of.

“At that point, you have to say, 'Is this really helping your problem? If it was, you probably wouldn't be here. Could it be hurting you?' Well, yeah, probably it is, in terms of some cognitive impairment, and a whole host of effects on autoimmune and endocrine function. Like anything else, you have to look judiciously at the specific risks and benefits for an individual patient,” he said.

Dr. Aronoff advises “erring on the conservative side” when treating any chronic pain patient with opioids or any other medications, since he considers these patients to be at high-risk for self-harm.

“I can't overemphasize that it is very important to do a very thorough mental status examination before prescribing any of these medications that have toxicity at low doses,” he said.

Within the larger context of chronic pain, patients with generalized pain syndromes deserve special consideration, Dr. Clark said.

Central sensitization appears to be the common denominator among fibromyalgia, interstitial cystitis, diffuse low back pain, chronic fatigue syndrome, irritable bowel syndrome, and headache syndromes, with resulting amplified pain sensations.

Depression itself may be a problem of central sensitization, he added. Such patients describe vague symptoms with a lack of clearcut etiology and a seemingly disproportionate degree of disability.

“The most important thing is you don't want to give these patients a little bit of everything and think that's the answer: a little bit of occupational therapy, a little bit of physical therapy, a little bit of psychotherapy and psychopharmacology.

“Throwing ingredients into a soup without a recipe is not the answer. These patients need to have someone design a rational plan for their care,” Dr. Clark said.

Dr. Schatzberg and Dr. Streltzer reported no relevant financial conflicts with regard to this story. Dr. Aronoff and Dr. Clark have both served on the speakers bureau or as consultants for Lilly Pharmaceuticals, maker of Cymbalta, and Pfizer Inc., maker of Lyrica. Dr. Aronoff also has been a speaker and/or consultant for Cephalon Inc., maker of several pain medications, and Endo Pharmaceuticals, maker of several opioids.

'You don't want to give these patients a little bit of everything and think that's the answer.' DR. CLARK

Pain and depression are common bedfellows, entwined in a complex relationship of situational and neurophysiologic connections that are not yet fully understood.

Numerous studies point to frequent comorbidity, yet physicians treating patients who present with chronic pain often fail to assess for depression and anxiety.

The opposite also can prove true, with psychiatrists failing to diagnose chronic pain in a significant percentage of their patients—particularly those with depression, said Dr. Alan Schatzberg, chairman and chief of psychiatry at Stanford (Calif.) University, in an interview.

“Pain is not commonly asked about in assessing depressed patients but is extremely commonly present,” he said.

In a cross-sectional international interview study of 18,980 subjects, nearly half of those with major depression also reported having a chronic pain condition (such as back pain, joint/articular pain, or headaches)—a fourfold elevation over people who were not depressed, reported Dr. Schatzberg and Dr. Maurice M. Ohayon, also of Stanford (Arch. Gen. Psychiatry 2003;60:39-47).

On the flip side, in people whose presenting problem is chronic pain, the prevalence of depression in the literature has ranged from 30% to 60%.

It remains unknown whether depression is the “cause or the consequence” of chronic pain, said Dr. Michael Clark, a psychiatrist who directs the Johns Hopkins Pain Treatment Program in Baltimore.

Intuitively, living with chronic pain puts significant stresses on a person's life and relationships. But increasing evidence points to multiple pathways of shared neurobiology as well, explaining the long-appreciated analgesic effects of tricyclic antidepressants, Dr. Clark said.

Today's armamentarium holds a wide variety of medications for chronic pain, starting with the anticonvulsant pregabalin (Lyrica), a GABA analogue, and the serotonin-norepinephrine reuptake inhibitor duloxetine (Cymbalta). Both have received Food and Drug Administration approval for fibromyalgia, and duloxetine also has garnered approval for the treatment of generalized anxiety disorder, depression, and diabetic peripheral neuropathy. Despite the on-label specifics, these drugs are cited by many experts as cornerstones of therapy for a wide range of patients with pain and comorbid psychiatric diagnoses, especially depression and anxiety.

“If I have a patient with both an emotional disorder and a pain disorder, I very well may put them on Cymbalta or on the combination of Lyrica and Cymbalta, which act through different mechanisms and have a synergistic effect in some patients,” said Dr. Gerald M. Aronoff, a psychiatrist and medical director of Carolina Pain Associates in Charlotte, N.C.

The strategy, along with a fervent belief in coordinated nonpharmacologic adjunct treatments that include supervised exercise, physical and occupational therapy, and cognitive-behavioral psychotherapy, allows Dr. Aronoff to reduce doses of opioids, which are central to management in many pain programs, especially those directed by nonpsychiatrists.

“My desire is not to have people on opioids indefinitely, but to get people through a difficult phase in their lives,” he said.

Numbing a patient's sensations may do nothing for the ripples of distress that can accompany pain: depression, relationship problems, and a crisis of self-efficacy and self-esteem.

Although tricyclic antidepressants are viewed as “old school” by some physicians treating chronic pain, Dr. Clark disagrees.

By the time patients see him, they may have been prescribed an array of the newer, more expensive drug choices, so he may turn to a tricyclic antidepressant (such as amitriptyline or doxepin) or an antiseizure medication such as divalproex (Depakote) or lamotrigine (Lamictal).

“Often, no one else has tried these medications in these patients,” he said, explaining that rare side effects, careful titration, and blood monitoring are not daunting once one is familiar with them.

Dr. Jon Mark Streltzer, professor of psychiatry at the University of Hawaii, Honolulu, maintains that the controversy surrounding long-term, high-dose opioid use for chronic pain is a matter of difference among individuals, rather than a specialty-specific perspective. “There are practitioners on both sides of the issue in all specialties,” he said. “There are competitive schools of thought.”

Dr. Streltzer generally opposes the use of high-dose opioids for chronic pain management, preferring to maintain patients (where possible) on acetaminophen (1 g, 4 times daily) while using a program aimed at function, activity through functionally directed therapy, and cognitive-behavioral psychotherapy.

That said, acetaminophen “won't work on opioid-dependent patients,” he warned. “Almost nothing will work until the dependence is treated.”

Dr. Clark said decreasing efficacy of opioids at standard doses results in patients on extremely high doses by the time they arrive at a tertiary pain clinic.

For example, patients commonly present to his clinic on doses of 600 mg/day of morphine or oxycodone, and individuals on 1,000 mg/day are not unheard of.

“At that point, you have to say, 'Is this really helping your problem? If it was, you probably wouldn't be here. Could it be hurting you?' Well, yeah, probably it is, in terms of some cognitive impairment, and a whole host of effects on autoimmune and endocrine function. Like anything else, you have to look judiciously at the specific risks and benefits for an individual patient,” he said.

Dr. Aronoff advises “erring on the conservative side” when treating any chronic pain patient with opioids or any other medications, since he considers these patients to be at high-risk for self-harm.

“I can't overemphasize that it is very important to do a very thorough mental status examination before prescribing any of these medications that have toxicity at low doses,” he said.

Within the larger context of chronic pain, patients with generalized pain syndromes deserve special consideration, Dr. Clark said.

Central sensitization appears to be the common denominator among fibromyalgia, interstitial cystitis, diffuse low back pain, chronic fatigue syndrome, irritable bowel syndrome, and headache syndromes, with resulting amplified pain sensations.

Depression itself may be a problem of central sensitization, he added. Such patients describe vague symptoms with a lack of clearcut etiology and a seemingly disproportionate degree of disability.

“The most important thing is you don't want to give these patients a little bit of everything and think that's the answer: a little bit of occupational therapy, a little bit of physical therapy, a little bit of psychotherapy and psychopharmacology.

“Throwing ingredients into a soup without a recipe is not the answer. These patients need to have someone design a rational plan for their care,” Dr. Clark said.

Dr. Schatzberg and Dr. Streltzer reported no relevant financial conflicts with regard to this story. Dr. Aronoff and Dr. Clark have both served on the speakers bureau or as consultants for Lilly Pharmaceuticals, maker of Cymbalta, and Pfizer Inc., maker of Lyrica. Dr. Aronoff also has been a speaker and/or consultant for Cephalon Inc., maker of several pain medications, and Endo Pharmaceuticals, maker of several opioids.

'You don't want to give these patients a little bit of everything and think that's the answer.' DR. CLARK

Pain and depression are common bedfellows, entwined in a complex relationship of situational and neurophysiologic connections that are not yet fully understood.

Numerous studies point to frequent comorbidity, yet physicians treating patients who present with chronic pain often fail to assess for depression and anxiety.

The opposite also can prove true, with psychiatrists failing to diagnose chronic pain in a significant percentage of their patients—particularly those with depression, said Dr. Alan Schatzberg, chairman and chief of psychiatry at Stanford (Calif.) University, in an interview.

“Pain is not commonly asked about in assessing depressed patients but is extremely commonly present,” he said.

In a cross-sectional international interview study of 18,980 subjects, nearly half of those with major depression also reported having a chronic pain condition (such as back pain, joint/articular pain, or headaches)—a fourfold elevation over people who were not depressed, reported Dr. Schatzberg and Dr. Maurice M. Ohayon, also of Stanford (Arch. Gen. Psychiatry 2003;60:39-47).

On the flip side, in people whose presenting problem is chronic pain, the prevalence of depression in the literature has ranged from 30% to 60%.

It remains unknown whether depression is the “cause or the consequence” of chronic pain, said Dr. Michael Clark, a psychiatrist who directs the Johns Hopkins Pain Treatment Program in Baltimore.

Intuitively, living with chronic pain puts significant stresses on a person's life and relationships. But increasing evidence points to multiple pathways of shared neurobiology as well, explaining the long-appreciated analgesic effects of tricyclic antidepressants, Dr. Clark said.

Today's armamentarium holds a wide variety of medications for chronic pain, starting with the anticonvulsant pregabalin (Lyrica), a GABA analogue, and the serotonin-norepinephrine reuptake inhibitor duloxetine (Cymbalta). Both have received Food and Drug Administration approval for fibromyalgia, and duloxetine also has garnered approval for the treatment of generalized anxiety disorder, depression, and diabetic peripheral neuropathy. Despite the on-label specifics, these drugs are cited by many experts as cornerstones of therapy for a wide range of patients with pain and comorbid psychiatric diagnoses, especially depression and anxiety.

“If I have a patient with both an emotional disorder and a pain disorder, I very well may put them on Cymbalta or on the combination of Lyrica and Cymbalta, which act through different mechanisms and have a synergistic effect in some patients,” said Dr. Gerald M. Aronoff, a psychiatrist and medical director of Carolina Pain Associates in Charlotte, N.C.

The strategy, along with a fervent belief in coordinated nonpharmacologic adjunct treatments that include supervised exercise, physical and occupational therapy, and cognitive-behavioral psychotherapy, allows Dr. Aronoff to reduce doses of opioids, which are central to management in many pain programs, especially those directed by nonpsychiatrists.

“My desire is not to have people on opioids indefinitely, but to get people through a difficult phase in their lives,” he said.

Numbing a patient's sensations may do nothing for the ripples of distress that can accompany pain: depression, relationship problems, and a crisis of self-efficacy and self-esteem.

Although tricyclic antidepressants are viewed as “old school” by some physicians treating chronic pain, Dr. Clark disagrees.

By the time patients see him, they may have been prescribed an array of the newer, more expensive drug choices, so he may turn to a tricyclic antidepressant (such as amitriptyline or doxepin) or an antiseizure medication such as divalproex (Depakote) or lamotrigine (Lamictal).

“Often, no one else has tried these medications in these patients,” he said, explaining that rare side effects, careful titration, and blood monitoring are not daunting once one is familiar with them.

Dr. Jon Mark Streltzer, professor of psychiatry at the University of Hawaii, Honolulu, maintains that the controversy surrounding long-term, high-dose opioid use for chronic pain is a matter of difference among individuals, rather than a specialty-specific perspective. “There are practitioners on both sides of the issue in all specialties,” he said. “There are competitive schools of thought.”

Dr. Streltzer generally opposes the use of high-dose opioids for chronic pain management, preferring to maintain patients (where possible) on acetaminophen (1 g, 4 times daily) while using a program aimed at function, activity through functionally directed therapy, and cognitive-behavioral psychotherapy.

That said, acetaminophen “won't work on opioid-dependent patients,” he warned. “Almost nothing will work until the dependence is treated.”

Dr. Clark said decreasing efficacy of opioids at standard doses results in patients on extremely high doses by the time they arrive at a tertiary pain clinic.

For example, patients commonly present to his clinic on doses of 600 mg/day of morphine or oxycodone, and individuals on 1,000 mg/day are not unheard of.

“At that point, you have to say, 'Is this really helping your problem? If it was, you probably wouldn't be here. Could it be hurting you?' Well, yeah, probably it is, in terms of some cognitive impairment, and a whole host of effects on autoimmune and endocrine function. Like anything else, you have to look judiciously at the specific risks and benefits for an individual patient,” he said.

Dr. Aronoff advises “erring on the conservative side” when treating any chronic pain patient with opioids or any other medications, since he considers these patients to be at high-risk for self-harm.

“I can't overemphasize that it is very important to do a very thorough mental status examination before prescribing any of these medications that have toxicity at low doses,” he said.

Within the larger context of chronic pain, patients with generalized pain syndromes deserve special consideration, Dr. Clark said.

Central sensitization appears to be the common denominator among fibromyalgia, interstitial cystitis, diffuse low back pain, chronic fatigue syndrome, irritable bowel syndrome, and headache syndromes, with resulting amplified pain sensations.

Depression itself may be a problem of central sensitization, he added. Such patients describe vague symptoms with a lack of clearcut etiology and a seemingly disproportionate degree of disability.

“The most important thing is you don't want to give these patients a little bit of everything and think that's the answer: a little bit of occupational therapy, a little bit of physical therapy, a little bit of psychotherapy and psychopharmacology.

“Throwing ingredients into a soup without a recipe is not the answer. These patients need to have someone design a rational plan for their care,” Dr. Clark said.

Dr. Schatzberg and Dr. Streltzer reported no relevant financial conflicts with regard to this story. Dr. Aronoff and Dr. Clark have both served on the speakers bureau or as consultants for Lilly Pharmaceuticals, maker of Cymbalta, and Pfizer Inc., maker of Lyrica. Dr. Aronoff also has been a speaker and/or consultant for Cephalon Inc., maker of several pain medications, and Endo Pharmaceuticals, maker of several opioids.

'You don't want to give these patients a little bit of everything and think that's the answer.' DR. CLARK

SANTA MONICA, CALIF. — Pre-existing medical or psychiatric conditions are not necessarily contraindications to liposuction, but they must be carefully evaluated in the preoperative period, Dr. Roberta D. Sengelmann said.

"This is an elective procedure that should be done only on healthy patients in an office setting," she emphasized. In general, patients should meet American Surgical Association Class I (normal, healthy) or II (mild systemic disease without functional compromise) criteria.

"Sometimes patients downplay their medical conditions because they want this operation," she said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF). "I would really be cautious if someone doesn't tell you the truth."

Dr. Sengelmann's previously low threshold for requesting medical clearance has become even lower in recent years, she said.

"I do this on every patient, even my young patients who have never had a physical exam because they've never had a medical problem," she said.

She asks for a letter from a primary care physician who has seen the patient in the previous 2 years to clear a patient for liposuction, but also conducts her own thorough physical examination and obtains a personal and family history.

Some conditions deserve special consideration, said Dr. Sengelmann, a dermatologist in private practice in Santa Barbara, Calif., and St. Louis.

▸ Hypercoagulable state/bleeding disorders. Anticipate potential complications in any patient with a history of clotting or bleeding conditions, including thrombophlebitis, deep vein thrombosis, high-dose estrogen therapy, tobacco use, protein C or S deficiency, frequent miscarriages, or any personal or family history of recurrent epistaxis or heavy bleeding with menses or tooth extractions.

"Don't rely on blood work alone," she said. Laboratory results will not detect a family history of hemophilia A or B, von Willebrand disease, or other important hereditary conditions.

▸ Impaired liver function. A history of chemotherapy, chronic alcohol or illegal drug use, hepatitis, cytomegalovirus, or HIV may be a tip-off to impaired liver function, said Dr. Sengelmann.

"I am very cautious about treating these patients, and [if I do] I usually cut their dose of anesthesia in half," she explained.

Patients with HIV pose a special risk, not only to themselves due to an increased potential for infection and possible impaired liver function due to antiretroviral medications, but also to the medical staff due to biohazards.

▸ Previous surgery. A lengthy history of cosmetic procedures, particularly if the patient was unhappy with results, looms large as a warning flag, said Dr. Sengelmann.

Previous scars, including hypertrophic scars or keloids, may be a problem, as may be previous abdominal surgery complicated by hernia, dehiscence, or infection (which may suggest an incomplete rectus muscle). Adhesions may make liposuction difficult.

▸ Psychiatric history. "Be really careful of those with psychiatric conditions, especially if they've been hospitalized within the last year," she said.

Much information can be gleaned in the initial consultation by getting to know the patient and discussing the reasons they are considering liposuction at this time, she said.

Patients with well-controlled depression may be liposuction candidates, but only on an individualized basis in consultation with their psychiatrist or internist, said Dr. Sengelmann, who reported no conflicts of interest.

SDEF and this news organization are owned by Elsevier.

'Sometimes patients downplay their medical conditions because they want this operation.' DR. SENGELMANN

SANTA MONICA, CALIF. — Pre-existing medical or psychiatric conditions are not necessarily contraindications to liposuction, but they must be carefully evaluated in the preoperative period, Dr. Roberta D. Sengelmann said.

"This is an elective procedure that should be done only on healthy patients in an office setting," she emphasized. In general, patients should meet American Surgical Association Class I (normal, healthy) or II (mild systemic disease without functional compromise) criteria.

"Sometimes patients downplay their medical conditions because they want this operation," she said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF). "I would really be cautious if someone doesn't tell you the truth."

Dr. Sengelmann's previously low threshold for requesting medical clearance has become even lower in recent years, she said.

"I do this on every patient, even my young patients who have never had a physical exam because they've never had a medical problem," she said.

She asks for a letter from a primary care physician who has seen the patient in the previous 2 years to clear a patient for liposuction, but also conducts her own thorough physical examination and obtains a personal and family history.

Some conditions deserve special consideration, said Dr. Sengelmann, a dermatologist in private practice in Santa Barbara, Calif., and St. Louis.

▸ Hypercoagulable state/bleeding disorders. Anticipate potential complications in any patient with a history of clotting or bleeding conditions, including thrombophlebitis, deep vein thrombosis, high-dose estrogen therapy, tobacco use, protein C or S deficiency, frequent miscarriages, or any personal or family history of recurrent epistaxis or heavy bleeding with menses or tooth extractions.

"Don't rely on blood work alone," she said. Laboratory results will not detect a family history of hemophilia A or B, von Willebrand disease, or other important hereditary conditions.

▸ Impaired liver function. A history of chemotherapy, chronic alcohol or illegal drug use, hepatitis, cytomegalovirus, or HIV may be a tip-off to impaired liver function, said Dr. Sengelmann.

"I am very cautious about treating these patients, and [if I do] I usually cut their dose of anesthesia in half," she explained.

Patients with HIV pose a special risk, not only to themselves due to an increased potential for infection and possible impaired liver function due to antiretroviral medications, but also to the medical staff due to biohazards.

▸ Previous surgery. A lengthy history of cosmetic procedures, particularly if the patient was unhappy with results, looms large as a warning flag, said Dr. Sengelmann.

Previous scars, including hypertrophic scars or keloids, may be a problem, as may be previous abdominal surgery complicated by hernia, dehiscence, or infection (which may suggest an incomplete rectus muscle). Adhesions may make liposuction difficult.

▸ Psychiatric history. "Be really careful of those with psychiatric conditions, especially if they've been hospitalized within the last year," she said.

Much information can be gleaned in the initial consultation by getting to know the patient and discussing the reasons they are considering liposuction at this time, she said.

Patients with well-controlled depression may be liposuction candidates, but only on an individualized basis in consultation with their psychiatrist or internist, said Dr. Sengelmann, who reported no conflicts of interest.

SDEF and this news organization are owned by Elsevier.

'Sometimes patients downplay their medical conditions because they want this operation.' DR. SENGELMANN

SANTA MONICA, CALIF. — Pre-existing medical or psychiatric conditions are not necessarily contraindications to liposuction, but they must be carefully evaluated in the preoperative period, Dr. Roberta D. Sengelmann said.

"This is an elective procedure that should be done only on healthy patients in an office setting," she emphasized. In general, patients should meet American Surgical Association Class I (normal, healthy) or II (mild systemic disease without functional compromise) criteria.

"Sometimes patients downplay their medical conditions because they want this operation," she said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF). "I would really be cautious if someone doesn't tell you the truth."

Dr. Sengelmann's previously low threshold for requesting medical clearance has become even lower in recent years, she said.

"I do this on every patient, even my young patients who have never had a physical exam because they've never had a medical problem," she said.

She asks for a letter from a primary care physician who has seen the patient in the previous 2 years to clear a patient for liposuction, but also conducts her own thorough physical examination and obtains a personal and family history.

Some conditions deserve special consideration, said Dr. Sengelmann, a dermatologist in private practice in Santa Barbara, Calif., and St. Louis.

▸ Hypercoagulable state/bleeding disorders. Anticipate potential complications in any patient with a history of clotting or bleeding conditions, including thrombophlebitis, deep vein thrombosis, high-dose estrogen therapy, tobacco use, protein C or S deficiency, frequent miscarriages, or any personal or family history of recurrent epistaxis or heavy bleeding with menses or tooth extractions.

"Don't rely on blood work alone," she said. Laboratory results will not detect a family history of hemophilia A or B, von Willebrand disease, or other important hereditary conditions.

▸ Impaired liver function. A history of chemotherapy, chronic alcohol or illegal drug use, hepatitis, cytomegalovirus, or HIV may be a tip-off to impaired liver function, said Dr. Sengelmann.

"I am very cautious about treating these patients, and [if I do] I usually cut their dose of anesthesia in half," she explained.

Patients with HIV pose a special risk, not only to themselves due to an increased potential for infection and possible impaired liver function due to antiretroviral medications, but also to the medical staff due to biohazards.

▸ Previous surgery. A lengthy history of cosmetic procedures, particularly if the patient was unhappy with results, looms large as a warning flag, said Dr. Sengelmann.

Previous scars, including hypertrophic scars or keloids, may be a problem, as may be previous abdominal surgery complicated by hernia, dehiscence, or infection (which may suggest an incomplete rectus muscle). Adhesions may make liposuction difficult.

▸ Psychiatric history. "Be really careful of those with psychiatric conditions, especially if they've been hospitalized within the last year," she said.

Much information can be gleaned in the initial consultation by getting to know the patient and discussing the reasons they are considering liposuction at this time, she said.

Patients with well-controlled depression may be liposuction candidates, but only on an individualized basis in consultation with their psychiatrist or internist, said Dr. Sengelmann, who reported no conflicts of interest.

SDEF and this news organization are owned by Elsevier.

'Sometimes patients downplay their medical conditions because they want this operation.' DR. SENGELMANN

SANTA MONICA, CALIF. — Dysport is on its way; ArteFill won't be gone for long; and Juvéderm will soon be available in a formulation with lidocaine.

The already rapidly evolving array of cosmetic dermatology products is about to expand again, and in a big way, speakers said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF). "Dysport is going to be here as soon as it gets through customs," said Dr. Christopher B. Zachary, professor and chair of dermatology at the University of California, Irvine.

The agent, approved by the Food and Drug Administration on April 30 for the temporary treatment of glabellar lines, represents the first widely available U.S. competitor to Allergan's botulinum toxin type A, Botox.

Many studies comparing Botox and Dysport have been hampered by disparate methodology, including the timelines for results and means of assessment, explained Dr. David Goldberg, clinical professor of dermatology and director of laser research at Mount Sinai School of Medicine in New York.

"It's going to be very interesting to see what happens when thousands of injections are given [and we'll] see if there are real differences," said Dr. Goldberg.

Two more botulinum toxin type A formulations are on the horizon, although they have yet to receive FDA approval: Xeomin from Merz Pharmaceuticals of Germany, and PurTox from Mentor Corp.

In other breaking news, Dr. Goldberg said dermatologists will not have to wait long for new shipments of ArteFill, the only filler FDA approved for cosmetic use.

The manufacturer of ArteFill, Artes Medical Inc., of San Diego, declared bankruptcy in December, but a new company, Suneva Medical Inc., was formed in April to take over the manufacturing and distribution of the deep dermal filler made of microspheres of polymethylmethacrylate (PMMA) in bovine collagen.

Juvéderm, a mid-dermal filler made of cross-linked hyaluronic acid, will soon be available in a formulation containing lidocaine, in line with its only FDA-approved hyaluronic acid competitor, Prevelle Silk by Mentor Corp., said Dr. Goldberg.

The hyaluronic acid filler market is poised to grow and perhaps will even spur a price war, he added.

"You can be sure there will be so many more. My prediction is that if the filler market is not glutted already now, it will be incredibly glutted over the next few years. All you have to do is to go to Europe and see 20, 25 different hyaluronic acid products," he said.

Not all fillers seem immediately destined for the U.S. market, however.

Isolagen Inc., which has created a permanent natural filler derived from a patient's autologous fibroblasts grown in culture, is reportedly in financial trouble and may file for bankruptcy, according to media reports, said Dr. Goldberg.

The company's biologicals license application for the product was accepted for full review by the FDA in May, but the company appears to be struggling, he said. While novel and intriguing, the product is "extraordinarily expensive" in Europe.

Dr. Zachary reported no relevant disclosures. Dr. Goldberg has received research grants, served as a consultant for, or been on a speakers bureau for numerous filler manufacturers, including Allergan, Mentor Corp., and Coapt Systems Inc.

SDEF and this news organization are owned by Elsevier.

Watch a video interview with Dr. Goldberg at http://www.youtube.com/SkinAndAllergyNews

'Dysport isgoing to be here as soon as itgets through customs,' bringing Botox its first competitor. DR. ZACHARY

SANTA MONICA, CALIF. — Dysport is on its way; ArteFill won't be gone for long; and Juvéderm will soon be available in a formulation with lidocaine.

The already rapidly evolving array of cosmetic dermatology products is about to expand again, and in a big way, speakers said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF). "Dysport is going to be here as soon as it gets through customs," said Dr. Christopher B. Zachary, professor and chair of dermatology at the University of California, Irvine.

The agent, approved by the Food and Drug Administration on April 30 for the temporary treatment of glabellar lines, represents the first widely available U.S. competitor to Allergan's botulinum toxin type A, Botox.

Many studies comparing Botox and Dysport have been hampered by disparate methodology, including the timelines for results and means of assessment, explained Dr. David Goldberg, clinical professor of dermatology and director of laser research at Mount Sinai School of Medicine in New York.

"It's going to be very interesting to see what happens when thousands of injections are given [and we'll] see if there are real differences," said Dr. Goldberg.

Two more botulinum toxin type A formulations are on the horizon, although they have yet to receive FDA approval: Xeomin from Merz Pharmaceuticals of Germany, and PurTox from Mentor Corp.

In other breaking news, Dr. Goldberg said dermatologists will not have to wait long for new shipments of ArteFill, the only filler FDA approved for cosmetic use.

The manufacturer of ArteFill, Artes Medical Inc., of San Diego, declared bankruptcy in December, but a new company, Suneva Medical Inc., was formed in April to take over the manufacturing and distribution of the deep dermal filler made of microspheres of polymethylmethacrylate (PMMA) in bovine collagen.

Juvéderm, a mid-dermal filler made of cross-linked hyaluronic acid, will soon be available in a formulation containing lidocaine, in line with its only FDA-approved hyaluronic acid competitor, Prevelle Silk by Mentor Corp., said Dr. Goldberg.

The hyaluronic acid filler market is poised to grow and perhaps will even spur a price war, he added.

"You can be sure there will be so many more. My prediction is that if the filler market is not glutted already now, it will be incredibly glutted over the next few years. All you have to do is to go to Europe and see 20, 25 different hyaluronic acid products," he said.

Not all fillers seem immediately destined for the U.S. market, however.

Isolagen Inc., which has created a permanent natural filler derived from a patient's autologous fibroblasts grown in culture, is reportedly in financial trouble and may file for bankruptcy, according to media reports, said Dr. Goldberg.

The company's biologicals license application for the product was accepted for full review by the FDA in May, but the company appears to be struggling, he said. While novel and intriguing, the product is "extraordinarily expensive" in Europe.

Dr. Zachary reported no relevant disclosures. Dr. Goldberg has received research grants, served as a consultant for, or been on a speakers bureau for numerous filler manufacturers, including Allergan, Mentor Corp., and Coapt Systems Inc.

SDEF and this news organization are owned by Elsevier.

Watch a video interview with Dr. Goldberg at http://www.youtube.com/SkinAndAllergyNews

'Dysport isgoing to be here as soon as itgets through customs,' bringing Botox its first competitor. DR. ZACHARY

SANTA MONICA, CALIF. — Dysport is on its way; ArteFill won't be gone for long; and Juvéderm will soon be available in a formulation with lidocaine.

The already rapidly evolving array of cosmetic dermatology products is about to expand again, and in a big way, speakers said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF). "Dysport is going to be here as soon as it gets through customs," said Dr. Christopher B. Zachary, professor and chair of dermatology at the University of California, Irvine.

The agent, approved by the Food and Drug Administration on April 30 for the temporary treatment of glabellar lines, represents the first widely available U.S. competitor to Allergan's botulinum toxin type A, Botox.

Many studies comparing Botox and Dysport have been hampered by disparate methodology, including the timelines for results and means of assessment, explained Dr. David Goldberg, clinical professor of dermatology and director of laser research at Mount Sinai School of Medicine in New York.

"It's going to be very interesting to see what happens when thousands of injections are given [and we'll] see if there are real differences," said Dr. Goldberg.

Two more botulinum toxin type A formulations are on the horizon, although they have yet to receive FDA approval: Xeomin from Merz Pharmaceuticals of Germany, and PurTox from Mentor Corp.

In other breaking news, Dr. Goldberg said dermatologists will not have to wait long for new shipments of ArteFill, the only filler FDA approved for cosmetic use.

The manufacturer of ArteFill, Artes Medical Inc., of San Diego, declared bankruptcy in December, but a new company, Suneva Medical Inc., was formed in April to take over the manufacturing and distribution of the deep dermal filler made of microspheres of polymethylmethacrylate (PMMA) in bovine collagen.

Juvéderm, a mid-dermal filler made of cross-linked hyaluronic acid, will soon be available in a formulation containing lidocaine, in line with its only FDA-approved hyaluronic acid competitor, Prevelle Silk by Mentor Corp., said Dr. Goldberg.

The hyaluronic acid filler market is poised to grow and perhaps will even spur a price war, he added.

"You can be sure there will be so many more. My prediction is that if the filler market is not glutted already now, it will be incredibly glutted over the next few years. All you have to do is to go to Europe and see 20, 25 different hyaluronic acid products," he said.

Not all fillers seem immediately destined for the U.S. market, however.

Isolagen Inc., which has created a permanent natural filler derived from a patient's autologous fibroblasts grown in culture, is reportedly in financial trouble and may file for bankruptcy, according to media reports, said Dr. Goldberg.

The company's biologicals license application for the product was accepted for full review by the FDA in May, but the company appears to be struggling, he said. While novel and intriguing, the product is "extraordinarily expensive" in Europe.

Dr. Zachary reported no relevant disclosures. Dr. Goldberg has received research grants, served as a consultant for, or been on a speakers bureau for numerous filler manufacturers, including Allergan, Mentor Corp., and Coapt Systems Inc.

SDEF and this news organization are owned by Elsevier.

Watch a video interview with Dr. Goldberg at http://www.youtube.com/SkinAndAllergyNews

'Dysport isgoing to be here as soon as itgets through customs,' bringing Botox its first competitor. DR. ZACHARY

The murder last month of Dr. George Tiller, a family physician and one of the nation's only providers of late-term abortions, has deepened the anxiety and apprehension of physicians who provide family planning services, especially abortion, according to providers and physicians' organizations.

There is nothing new about the fear that pervades abortion services in the United States, with Dr. Tiller's murder only the latest in a long string of murders, attempted murders, and bombings. Dr. Tiller himself had been shot in both arms in 1993, and his clinic in Wichita, Kan., had been bombed in 1985.

But “when there is a pro-choice [presidential] administration, the fringe violence movement becomes more desperate and acts out,” Dr. Nancy L. Stanwood, a board member of Physicians for Reproductive Choice and Health, said in an interview.

“We knew violence would probably go up. Of course, we are horrified that a murderous act happened so quickly,” said Dr. Stanwood of the department of obstetrics and gynecology at the University of Rochester (N.Y.).

The loss of Dr. Tiller, who Dr. Stanwood described as a careful, compassionate physician, poses a real blow to providers of prenatal care who depended on him for referral of difficult and tragic cases, she said.

“We've all had that dreadful ultrasound result. We all do screening amniocentesis, [chorionic villus sampling], and anatomic ultrasounds, and we know we're going to find terrible things now and then. We could refer patients to him and know he was a colleague with the medical skill and compassion to help these patients at a time of desperate need,” she said.

Dr. Stanwood added that an increase in the number of residency programs and fellowships that train physicians in safe abortion procedures gives her hope that intimidation will not further undermine the availability of family planning services to American women.

But a study by the National Abortion Federation and the American College of Obstetricians and Gynecologists (ACOG) found that anti-abortion harassment and violence has been a top contributor to a precipitous decline in the number of abortion providers over the years.

Social stigma and marginalization, professional isolation, and peer pressure also factor into the decline, the study found.

Echoing Dr. Stanwood's predictions, many observers believe that extremist anti-abortion rhetoric, as well as more mainstream protests, has escalated in the past few months, following the election of President Obama, who advocated abortion rights during his campaign.

Abortion clinics reported a sharp increase in the number of harassing telephone calls they received during the first 4 months of Mr. Obama's presidency, 1,401, compared with 396 during the last full year of George W. Bush's presidency.

Just weeks before the murder, buses carrying physicians to ACOG's annual meeting in Chicago negotiated a daily gauntlet of protesters lining the route, each displaying oversized, gruesome photographs of purported aborted fetuses. Billboard trucks circled the convention hotels.

“Why do you hate babies, doctor?” one sign read.

At the ACOG meeting, researchers from the University of California at San Francisco reported on findings from interviews with 30 ob.gyns. who had received abortion training at four residency programs 5–10 years previously.

The surveyed physicians detailed a highly adversarial culture surrounding abortion services, identifying professional barriers that included threats from other physicians and administrative hurdles, reported Dr. Jody Steinauer, Lori R. Freedman, Ph.D., and researcher Mitchel Hawkins.

Providing such services “is a great way to make no friends amongst the ob.gyns. and to have no family practice docs refer to you,” said one physician interviewed during the study.

One ob.gyn. recalled a partner asking him to sign a contract with a group that said, “I would not do terminations on certain genetic problems, like trisomy 21.”

Several others received direct intimidation. One potential employer told a candidate for an ob.gyn. position, “If I ever find out you did elective abortions … you'll never practice in [this state] again.”

Against this backdrop of nonviolent pressure, Dr. Tiller's murder may be an anomaly or may signal a return to violence that reached new heights during the 1990s, when President Clinton, another pro-choice advocate, was in office.

In all, there have been 8 murders and 17 attempted murders of physicians and allied health care workers involved in abortion services since 1977, according to statistics from the National Abortion Federation, a membership organization of abortion providers.

Professional organizations reacted swiftly to the murder in Kansas.

“There is no excuse, no explanation, and no justification for this brutal slaying of a courageous and honorable physician who provided safe and legal reproductive health care to women who otherwise might not have received it,” ACOG said in a statement.

The statement called the killing “chilling and deeply disturbing,” noting that it occurred as the nation's leaders are searching for a “middle ground” on the topic of abortion. “There is no middle ground when it comes to violence of this nature,” the statement read.

A Kansas man with ties to antigovernment groups and anti-abortion protests, Scott Roeder, 51, has been charged with murder and aggravated assault in Dr. Tiller's slaying.

Following the shooting, U.S. Attorney Eric Holder activated the U.S. Marshals Service to increase security for “clinics and individuals” providing abortion services.

The number of U.S. abortion providers has been declining for many years, resulting in a situation in which 87% of U.S. counties (97% of nonmetropolitan counties) had no abortion provider as of 2005, reported the Alan Guttmacher Institute, a policy and research organization.

More than half of abortion providers experienced harassment in 2000, with abortion care depending on individuals like Dr. Tiller, who “risked his life on a daily basis,” said Guttmacher president Sharon Camp, Ph.D.

“For the women he helped over the years, as well as those who will now have nowhere else to turn, this is an incalculable loss,” she said.

The majority of recognized anti-abortion groups condemned the killing as incompatible with their pro-life stance.

“We denounce vigilantism and the cowardly act that took place this morning,” said Troy Newman, director of Operation Rescue, a Kansas-based activist anti-abortion group. The group also distanced itself from former Operation Rescue leader Randall Terry, who said that Dr. Tiller was a “mass murderer … [who] reaped what he sowed.”

Other individuals, many in anonymous Web postings, expressed satisfaction following the murder, equating it with abortion.

Kansas community activist Regina Dinwiddie, who had protested at Dr. Tiller's clinic, told the Los Angeles Times, “If anybody needed killing, George Tiller needed killing. The gut reaction from everybody who doesn't have their thoughts filtered by fear is 'Yahoo!'”

The National Task Force on Violence Against Health Care Providers, formed by then-Attorney General Janet Reno following the 1998 murder of abortion provider Dr. Barnett A. Slepian, lists nearly 60 safety tips for providers, including “Do not allow your vehicle to be boxed in. Maintain at least 8 feet between you and the vehicle in front, and avoid the inner lanes.”

Dr. Stanwood said that several physicians had vowed to reopen and staff Dr. Tiller's clinic in Wichita. However at press time, Dr. Tiller's family announced in a statement that the clinic would be closed permanently.

The murder last month of Dr. George Tiller, a family physician and one of the nation's only providers of late-term abortions, has deepened the anxiety and apprehension of physicians who provide family planning services, especially abortion, according to providers and physicians' organizations.

There is nothing new about the fear that pervades abortion services in the United States, with Dr. Tiller's murder only the latest in a long string of murders, attempted murders, and bombings. Dr. Tiller himself had been shot in both arms in 1993, and his clinic in Wichita, Kan., had been bombed in 1985.

But “when there is a pro-choice [presidential] administration, the fringe violence movement becomes more desperate and acts out,” Dr. Nancy L. Stanwood, a board member of Physicians for Reproductive Choice and Health, said in an interview.

“We knew violence would probably go up. Of course, we are horrified that a murderous act happened so quickly,” said Dr. Stanwood of the department of obstetrics and gynecology at the University of Rochester (N.Y.).

The loss of Dr. Tiller, who Dr. Stanwood described as a careful, compassionate physician, poses a real blow to providers of prenatal care who depended on him for referral of difficult and tragic cases, she said.

“We've all had that dreadful ultrasound result. We all do screening amniocentesis, [chorionic villus sampling], and anatomic ultrasounds, and we know we're going to find terrible things now and then. We could refer patients to him and know he was a colleague with the medical skill and compassion to help these patients at a time of desperate need,” she said.

Dr. Stanwood added that an increase in the number of residency programs and fellowships that train physicians in safe abortion procedures gives her hope that intimidation will not further undermine the availability of family planning services to American women.

But a study by the National Abortion Federation and the American College of Obstetricians and Gynecologists (ACOG) found that anti-abortion harassment and violence has been a top contributor to a precipitous decline in the number of abortion providers over the years.

Social stigma and marginalization, professional isolation, and peer pressure also factor into the decline, the study found.

Echoing Dr. Stanwood's predictions, many observers believe that extremist anti-abortion rhetoric, as well as more mainstream protests, has escalated in the past few months, following the election of President Obama, who advocated abortion rights during his campaign.

Abortion clinics reported a sharp increase in the number of harassing telephone calls they received during the first 4 months of Mr. Obama's presidency, 1,401, compared with 396 during the last full year of George W. Bush's presidency.

Just weeks before the murder, buses carrying physicians to ACOG's annual meeting in Chicago negotiated a daily gauntlet of protesters lining the route, each displaying oversized, gruesome photographs of purported aborted fetuses. Billboard trucks circled the convention hotels.

“Why do you hate babies, doctor?” one sign read.

At the ACOG meeting, researchers from the University of California at San Francisco reported on findings from interviews with 30 ob.gyns. who had received abortion training at four residency programs 5–10 years previously.

The surveyed physicians detailed a highly adversarial culture surrounding abortion services, identifying professional barriers that included threats from other physicians and administrative hurdles, reported Dr. Jody Steinauer, Lori R. Freedman, Ph.D., and researcher Mitchel Hawkins.

Providing such services “is a great way to make no friends amongst the ob.gyns. and to have no family practice docs refer to you,” said one physician interviewed during the study.

One ob.gyn. recalled a partner asking him to sign a contract with a group that said, “I would not do terminations on certain genetic problems, like trisomy 21.”

Several others received direct intimidation. One potential employer told a candidate for an ob.gyn. position, “If I ever find out you did elective abortions … you'll never practice in [this state] again.”

Against this backdrop of nonviolent pressure, Dr. Tiller's murder may be an anomaly or may signal a return to violence that reached new heights during the 1990s, when President Clinton, another pro-choice advocate, was in office.

In all, there have been 8 murders and 17 attempted murders of physicians and allied health care workers involved in abortion services since 1977, according to statistics from the National Abortion Federation, a membership organization of abortion providers.

Professional organizations reacted swiftly to the murder in Kansas.

“There is no excuse, no explanation, and no justification for this brutal slaying of a courageous and honorable physician who provided safe and legal reproductive health care to women who otherwise might not have received it,” ACOG said in a statement.

The statement called the killing “chilling and deeply disturbing,” noting that it occurred as the nation's leaders are searching for a “middle ground” on the topic of abortion. “There is no middle ground when it comes to violence of this nature,” the statement read.

A Kansas man with ties to antigovernment groups and anti-abortion protests, Scott Roeder, 51, has been charged with murder and aggravated assault in Dr. Tiller's slaying.

Following the shooting, U.S. Attorney Eric Holder activated the U.S. Marshals Service to increase security for “clinics and individuals” providing abortion services.

The number of U.S. abortion providers has been declining for many years, resulting in a situation in which 87% of U.S. counties (97% of nonmetropolitan counties) had no abortion provider as of 2005, reported the Alan Guttmacher Institute, a policy and research organization.

More than half of abortion providers experienced harassment in 2000, with abortion care depending on individuals like Dr. Tiller, who “risked his life on a daily basis,” said Guttmacher president Sharon Camp, Ph.D.

“For the women he helped over the years, as well as those who will now have nowhere else to turn, this is an incalculable loss,” she said.

The majority of recognized anti-abortion groups condemned the killing as incompatible with their pro-life stance.

“We denounce vigilantism and the cowardly act that took place this morning,” said Troy Newman, director of Operation Rescue, a Kansas-based activist anti-abortion group. The group also distanced itself from former Operation Rescue leader Randall Terry, who said that Dr. Tiller was a “mass murderer … [who] reaped what he sowed.”

Other individuals, many in anonymous Web postings, expressed satisfaction following the murder, equating it with abortion.

Kansas community activist Regina Dinwiddie, who had protested at Dr. Tiller's clinic, told the Los Angeles Times, “If anybody needed killing, George Tiller needed killing. The gut reaction from everybody who doesn't have their thoughts filtered by fear is 'Yahoo!'”

The National Task Force on Violence Against Health Care Providers, formed by then-Attorney General Janet Reno following the 1998 murder of abortion provider Dr. Barnett A. Slepian, lists nearly 60 safety tips for providers, including “Do not allow your vehicle to be boxed in. Maintain at least 8 feet between you and the vehicle in front, and avoid the inner lanes.”

Dr. Stanwood said that several physicians had vowed to reopen and staff Dr. Tiller's clinic in Wichita. However at press time, Dr. Tiller's family announced in a statement that the clinic would be closed permanently.

The murder last month of Dr. George Tiller, a family physician and one of the nation's only providers of late-term abortions, has deepened the anxiety and apprehension of physicians who provide family planning services, especially abortion, according to providers and physicians' organizations.

There is nothing new about the fear that pervades abortion services in the United States, with Dr. Tiller's murder only the latest in a long string of murders, attempted murders, and bombings. Dr. Tiller himself had been shot in both arms in 1993, and his clinic in Wichita, Kan., had been bombed in 1985.

But “when there is a pro-choice [presidential] administration, the fringe violence movement becomes more desperate and acts out,” Dr. Nancy L. Stanwood, a board member of Physicians for Reproductive Choice and Health, said in an interview.

“We knew violence would probably go up. Of course, we are horrified that a murderous act happened so quickly,” said Dr. Stanwood of the department of obstetrics and gynecology at the University of Rochester (N.Y.).

The loss of Dr. Tiller, who Dr. Stanwood described as a careful, compassionate physician, poses a real blow to providers of prenatal care who depended on him for referral of difficult and tragic cases, she said.

“We've all had that dreadful ultrasound result. We all do screening amniocentesis, [chorionic villus sampling], and anatomic ultrasounds, and we know we're going to find terrible things now and then. We could refer patients to him and know he was a colleague with the medical skill and compassion to help these patients at a time of desperate need,” she said.

Dr. Stanwood added that an increase in the number of residency programs and fellowships that train physicians in safe abortion procedures gives her hope that intimidation will not further undermine the availability of family planning services to American women.

But a study by the National Abortion Federation and the American College of Obstetricians and Gynecologists (ACOG) found that anti-abortion harassment and violence has been a top contributor to a precipitous decline in the number of abortion providers over the years.

Social stigma and marginalization, professional isolation, and peer pressure also factor into the decline, the study found.

Echoing Dr. Stanwood's predictions, many observers believe that extremist anti-abortion rhetoric, as well as more mainstream protests, has escalated in the past few months, following the election of President Obama, who advocated abortion rights during his campaign.

Abortion clinics reported a sharp increase in the number of harassing telephone calls they received during the first 4 months of Mr. Obama's presidency, 1,401, compared with 396 during the last full year of George W. Bush's presidency.

Just weeks before the murder, buses carrying physicians to ACOG's annual meeting in Chicago negotiated a daily gauntlet of protesters lining the route, each displaying oversized, gruesome photographs of purported aborted fetuses. Billboard trucks circled the convention hotels.

“Why do you hate babies, doctor?” one sign read.

At the ACOG meeting, researchers from the University of California at San Francisco reported on findings from interviews with 30 ob.gyns. who had received abortion training at four residency programs 5–10 years previously.

The surveyed physicians detailed a highly adversarial culture surrounding abortion services, identifying professional barriers that included threats from other physicians and administrative hurdles, reported Dr. Jody Steinauer, Lori R. Freedman, Ph.D., and researcher Mitchel Hawkins.

Providing such services “is a great way to make no friends amongst the ob.gyns. and to have no family practice docs refer to you,” said one physician interviewed during the study.

One ob.gyn. recalled a partner asking him to sign a contract with a group that said, “I would not do terminations on certain genetic problems, like trisomy 21.”

Several others received direct intimidation. One potential employer told a candidate for an ob.gyn. position, “If I ever find out you did elective abortions … you'll never practice in [this state] again.”

Against this backdrop of nonviolent pressure, Dr. Tiller's murder may be an anomaly or may signal a return to violence that reached new heights during the 1990s, when President Clinton, another pro-choice advocate, was in office.

In all, there have been 8 murders and 17 attempted murders of physicians and allied health care workers involved in abortion services since 1977, according to statistics from the National Abortion Federation, a membership organization of abortion providers.

Professional organizations reacted swiftly to the murder in Kansas.

“There is no excuse, no explanation, and no justification for this brutal slaying of a courageous and honorable physician who provided safe and legal reproductive health care to women who otherwise might not have received it,” ACOG said in a statement.

The statement called the killing “chilling and deeply disturbing,” noting that it occurred as the nation's leaders are searching for a “middle ground” on the topic of abortion. “There is no middle ground when it comes to violence of this nature,” the statement read.

A Kansas man with ties to antigovernment groups and anti-abortion protests, Scott Roeder, 51, has been charged with murder and aggravated assault in Dr. Tiller's slaying.

Following the shooting, U.S. Attorney Eric Holder activated the U.S. Marshals Service to increase security for “clinics and individuals” providing abortion services.

The number of U.S. abortion providers has been declining for many years, resulting in a situation in which 87% of U.S. counties (97% of nonmetropolitan counties) had no abortion provider as of 2005, reported the Alan Guttmacher Institute, a policy and research organization.

More than half of abortion providers experienced harassment in 2000, with abortion care depending on individuals like Dr. Tiller, who “risked his life on a daily basis,” said Guttmacher president Sharon Camp, Ph.D.

“For the women he helped over the years, as well as those who will now have nowhere else to turn, this is an incalculable loss,” she said.

The majority of recognized anti-abortion groups condemned the killing as incompatible with their pro-life stance.

“We denounce vigilantism and the cowardly act that took place this morning,” said Troy Newman, director of Operation Rescue, a Kansas-based activist anti-abortion group. The group also distanced itself from former Operation Rescue leader Randall Terry, who said that Dr. Tiller was a “mass murderer … [who] reaped what he sowed.”

Other individuals, many in anonymous Web postings, expressed satisfaction following the murder, equating it with abortion.

Kansas community activist Regina Dinwiddie, who had protested at Dr. Tiller's clinic, told the Los Angeles Times, “If anybody needed killing, George Tiller needed killing. The gut reaction from everybody who doesn't have their thoughts filtered by fear is 'Yahoo!'”

The National Task Force on Violence Against Health Care Providers, formed by then-Attorney General Janet Reno following the 1998 murder of abortion provider Dr. Barnett A. Slepian, lists nearly 60 safety tips for providers, including “Do not allow your vehicle to be boxed in. Maintain at least 8 feet between you and the vehicle in front, and avoid the inner lanes.”

Dr. Stanwood said that several physicians had vowed to reopen and staff Dr. Tiller's clinic in Wichita. However at press time, Dr. Tiller's family announced in a statement that the clinic would be closed permanently.

Specific neural signatures of posttraumatic stress disorder in brain centers involved in cognition and emotions have been identified on imaging studies of recently returned veterans of the wars in Iraq and Afghanistan, a finding that may advance efforts to objectively diagnose individuals with the disorder.

Functional magnetic resonance imaging (fMRI) studies of 22 American soldiers diagnosed with PTSD demonstrated heightened activity in three regions of the brain during a working memory task, compared with 20 soldiers exposed to similar combat situations who did not develop PTSD, reported Florin Dolcos, Ph.D., of the University of Alberta, Edmonton.

The study, which was presented at the World Psychiatry Association International Congress in Florence, Italy, provides early evidence of specific functional neuroanatomy biomarkers of PTSD in conjunction with a working memory task (J. Psychiatric Res. 2009;43:809–17).

During fMRI, soldiers were shown photographs of three faces and later asked whether another photograph was one of the three they had previously seen.

However, during a delay period before the cognitive memory challenge, participants were shown random images of combat or noncombat (neutral) scenes. The noncombat photographs included such images as a man playing a trombone.

The investigators hypothesized that soldiers who have PTSD might process cognitive information differently when they are simultaneously distracted by exposure to a combat image. Indeed, activation of three specific brain regions distinguished participants meeting PTSD criteria and those who did not, said lead investigator Dr. Rajendra A. Morey, a Duke University psychiatrist and director of the Neuroimaging Core at the Durham (N.C.) Veterans Affairs Medical Center.

Among the investigators' specific findings:

▸ As expected from previous imaging studies, soldiers with PTSD reacted to combat photos with significantly elevated activation in emotion processing centers of the brain, including the amygdala (P less than .05), fusiform gyrus (P less than .005), and ventrolateral prefrontal cortex (P less than .001), compared with soldiers without PTSD.

▸ In the dorsal medial prefrontal cortex, a region associated with an individual's sense of self and self-reflection, soldiers with PTSD exhibited significantly higher brain activity (P less than .004) than those without PTSD when exposed to combat photos, perhaps suggesting a tendency to relate the scenes to their own experience (although actual combat exposure was similar in both groups).

▸ In the dorsal lateral prefrontal cortex, a region associated with focus and concentration, soldiers without PTSD showed significant (P less than .05) disruption of cognitive activity (and memory performance) when distracted by combat photos, but not when shown distracting photos of neutral scenes. In contrast, soldiers with PTSD responded with reduced activity in the dorsal lateral prefrontal cortex and a decline in memory task performance—regardless of whether the distracting images depicted combat or noncombat scenes.

The latter finding “may fit with what we see clinically in people with PTSD, who often misinterpret things in the environment, reacting to nontraumatic events as if they were traumatic,” Dr. Morey said in an interview.

Hypervigilance, then, may lead to the difficulty in focusing that is “one of the biggest impairments in everyday life for people with PTSD,” he said.

Dr. Dolcos, a psychologist who directs a clinical neuroscience laboratory at the University of Alberta, said that a portrait of the PTSD brain is gradually evolving.

“As technology improves, imaging research is increasingly providing insights into the brains of people with PTSD, pointing to potential biological markers distinguishing the PTSD brain,” he said in a statement.

“The field is still in its infancy, but this raises the possibility that one day we may be able to see the disorder in the body as plainly as we now can see conditions such as heart disease and cancer,” Dr. Dolcos said.

The investigators are currently studying episodic memory and brain function in soldiers with and without PTSD and plan a larger study to evaluate how genetic differences may impact brain activity in the same groups, Dr. Morey said.

Funding for the research was provided by the Department of Veterans Affairs.

When soldiers were shown combat photos, fMRI revealed differences in activation in the brain region governing personal relevance of information. Images courtesy Dr. Rajendra Morey/Duke University

Specific neural signatures of posttraumatic stress disorder in brain centers involved in cognition and emotions have been identified on imaging studies of recently returned veterans of the wars in Iraq and Afghanistan, a finding that may advance efforts to objectively diagnose individuals with the disorder.

Functional magnetic resonance imaging (fMRI) studies of 22 American soldiers diagnosed with PTSD demonstrated heightened activity in three regions of the brain during a working memory task, compared with 20 soldiers exposed to similar combat situations who did not develop PTSD, reported Florin Dolcos, Ph.D., of the University of Alberta, Edmonton.

The study, which was presented at the World Psychiatry Association International Congress in Florence, Italy, provides early evidence of specific functional neuroanatomy biomarkers of PTSD in conjunction with a working memory task (J. Psychiatric Res. 2009;43:809–17).

During fMRI, soldiers were shown photographs of three faces and later asked whether another photograph was one of the three they had previously seen.

However, during a delay period before the cognitive memory challenge, participants were shown random images of combat or noncombat (neutral) scenes. The noncombat photographs included such images as a man playing a trombone.

The investigators hypothesized that soldiers who have PTSD might process cognitive information differently when they are simultaneously distracted by exposure to a combat image. Indeed, activation of three specific brain regions distinguished participants meeting PTSD criteria and those who did not, said lead investigator Dr. Rajendra A. Morey, a Duke University psychiatrist and director of the Neuroimaging Core at the Durham (N.C.) Veterans Affairs Medical Center.

Among the investigators' specific findings:

▸ As expected from previous imaging studies, soldiers with PTSD reacted to combat photos with significantly elevated activation in emotion processing centers of the brain, including the amygdala (P less than .05), fusiform gyrus (P less than .005), and ventrolateral prefrontal cortex (P less than .001), compared with soldiers without PTSD.

▸ In the dorsal medial prefrontal cortex, a region associated with an individual's sense of self and self-reflection, soldiers with PTSD exhibited significantly higher brain activity (P less than .004) than those without PTSD when exposed to combat photos, perhaps suggesting a tendency to relate the scenes to their own experience (although actual combat exposure was similar in both groups).

▸ In the dorsal lateral prefrontal cortex, a region associated with focus and concentration, soldiers without PTSD showed significant (P less than .05) disruption of cognitive activity (and memory performance) when distracted by combat photos, but not when shown distracting photos of neutral scenes. In contrast, soldiers with PTSD responded with reduced activity in the dorsal lateral prefrontal cortex and a decline in memory task performance—regardless of whether the distracting images depicted combat or noncombat scenes.

The latter finding “may fit with what we see clinically in people with PTSD, who often misinterpret things in the environment, reacting to nontraumatic events as if they were traumatic,” Dr. Morey said in an interview.

Hypervigilance, then, may lead to the difficulty in focusing that is “one of the biggest impairments in everyday life for people with PTSD,” he said.

Dr. Dolcos, a psychologist who directs a clinical neuroscience laboratory at the University of Alberta, said that a portrait of the PTSD brain is gradually evolving.

“As technology improves, imaging research is increasingly providing insights into the brains of people with PTSD, pointing to potential biological markers distinguishing the PTSD brain,” he said in a statement.

“The field is still in its infancy, but this raises the possibility that one day we may be able to see the disorder in the body as plainly as we now can see conditions such as heart disease and cancer,” Dr. Dolcos said.

The investigators are currently studying episodic memory and brain function in soldiers with and without PTSD and plan a larger study to evaluate how genetic differences may impact brain activity in the same groups, Dr. Morey said.

Funding for the research was provided by the Department of Veterans Affairs.

When soldiers were shown combat photos, fMRI revealed differences in activation in the brain region governing personal relevance of information. Images courtesy Dr. Rajendra Morey/Duke University

Specific neural signatures of posttraumatic stress disorder in brain centers involved in cognition and emotions have been identified on imaging studies of recently returned veterans of the wars in Iraq and Afghanistan, a finding that may advance efforts to objectively diagnose individuals with the disorder.

Functional magnetic resonance imaging (fMRI) studies of 22 American soldiers diagnosed with PTSD demonstrated heightened activity in three regions of the brain during a working memory task, compared with 20 soldiers exposed to similar combat situations who did not develop PTSD, reported Florin Dolcos, Ph.D., of the University of Alberta, Edmonton.

The study, which was presented at the World Psychiatry Association International Congress in Florence, Italy, provides early evidence of specific functional neuroanatomy biomarkers of PTSD in conjunction with a working memory task (J. Psychiatric Res. 2009;43:809–17).

During fMRI, soldiers were shown photographs of three faces and later asked whether another photograph was one of the three they had previously seen.

However, during a delay period before the cognitive memory challenge, participants were shown random images of combat or noncombat (neutral) scenes. The noncombat photographs included such images as a man playing a trombone.

The investigators hypothesized that soldiers who have PTSD might process cognitive information differently when they are simultaneously distracted by exposure to a combat image. Indeed, activation of three specific brain regions distinguished participants meeting PTSD criteria and those who did not, said lead investigator Dr. Rajendra A. Morey, a Duke University psychiatrist and director of the Neuroimaging Core at the Durham (N.C.) Veterans Affairs Medical Center.

Among the investigators' specific findings:

▸ As expected from previous imaging studies, soldiers with PTSD reacted to combat photos with significantly elevated activation in emotion processing centers of the brain, including the amygdala (P less than .05), fusiform gyrus (P less than .005), and ventrolateral prefrontal cortex (P less than .001), compared with soldiers without PTSD.

▸ In the dorsal medial prefrontal cortex, a region associated with an individual's sense of self and self-reflection, soldiers with PTSD exhibited significantly higher brain activity (P less than .004) than those without PTSD when exposed to combat photos, perhaps suggesting a tendency to relate the scenes to their own experience (although actual combat exposure was similar in both groups).

▸ In the dorsal lateral prefrontal cortex, a region associated with focus and concentration, soldiers without PTSD showed significant (P less than .05) disruption of cognitive activity (and memory performance) when distracted by combat photos, but not when shown distracting photos of neutral scenes. In contrast, soldiers with PTSD responded with reduced activity in the dorsal lateral prefrontal cortex and a decline in memory task performance—regardless of whether the distracting images depicted combat or noncombat scenes.

The latter finding “may fit with what we see clinically in people with PTSD, who often misinterpret things in the environment, reacting to nontraumatic events as if they were traumatic,” Dr. Morey said in an interview.

Hypervigilance, then, may lead to the difficulty in focusing that is “one of the biggest impairments in everyday life for people with PTSD,” he said.

Dr. Dolcos, a psychologist who directs a clinical neuroscience laboratory at the University of Alberta, said that a portrait of the PTSD brain is gradually evolving.

“As technology improves, imaging research is increasingly providing insights into the brains of people with PTSD, pointing to potential biological markers distinguishing the PTSD brain,” he said in a statement.

“The field is still in its infancy, but this raises the possibility that one day we may be able to see the disorder in the body as plainly as we now can see conditions such as heart disease and cancer,” Dr. Dolcos said.

The investigators are currently studying episodic memory and brain function in soldiers with and without PTSD and plan a larger study to evaluate how genetic differences may impact brain activity in the same groups, Dr. Morey said.

Funding for the research was provided by the Department of Veterans Affairs.

When soldiers were shown combat photos, fMRI revealed differences in activation in the brain region governing personal relevance of information. Images courtesy Dr. Rajendra Morey/Duke University

CHICAGO — Virtually any weight gain during pregnancy by obese women with gestational diabetes resulted in high rates of large-for-gestational-age infants, according to a study released at the annual meeting of the American College of Obstetricians and Gynecologists.

Obese women in the study who either lost weight or maintained their prepregnancy weight during pregnancy while on a medically supervised low-carbohydrate diet gave birth to babies with “close to normal” birth weights. They also had the lowest cesarean delivery rates (10.5%) in the study.

In contrast, more than one in five obese women who gained a modest amount of weight during pregnancy—1-14 pounds—had large-for-gestational-age (LGA) infants.

The LGA rate increased with more weight gain, accounting for 36% of infants born to women who gained 26–35 pounds, and nearly 40% of those born to women who gained more than 35 pounds, said Dr. Deborah L. Conway of the University of Texas Health Science Center at San Antonio.

Dr. Conway explained that her institution carefully monitors women with gestational diabetes and places them on a calorie-controlled, low-carbohydrate diet that includes nutritional counseling. They also receive glyburide or insulin as necessary to achieve euglycemia.

“Although it wasn't the intention, we noticed that some of these women didn't gain weight as you might expect during pregnancy. We weren't sure that was such a bad thing,” said Dr. Conway during an interview at the meeting, where her study was presented in poster form.

The Institute of Medicine is still recommending an 11- to 20 -lb weight gain for obese women during pregnancy in its recently released new guidelines. “What we saw in our study was that under nutritional supervision, it did not appear necessary for obese women with gestational diabetes to gain weight to have normal obstetrical rates of outcome and normal fetal size,” she said in a later interview.

To better understand gestational weight changes in this group, Dr. Poornima Kaul, a fourth-year resident, analyzed birth weights and pregnancy complications among 302 women with gestational diabetes who had a mean prepregnancy body mass index of 35.6 kg/m

The LGA rate among those who lost weight or maintained their prepregnancy weight was 11.8%.

The macrosomia rate (weight greater than 4,000 g) among their infants was 8.8%, and the rate of small-for-gestational-age infants was 8.8%.

These rates are “pretty close to normal,” Dr. Conway said.

Infants born to women who gained a small amount of weight (1–14 pounds) had a 27.3% LGA rate and a 13.6% rate of macrosomia. These women had a 15.1% cesarean delivery rate.

Women who gained 15–25 pounds had rates of LGA, macrosomia, and cesarean delivery of 27.6%, 13.2%, and 23.4%, respectively.

Those who gained 26–35 pounds had rates of LGA, macrosomia, and cesarean delivery of 36.4%, 21.8%, and 26.7%, while rates in women who gained more than 35 pounds were 39.6%, 25%, and 17.2%.

Dr. Kaul and Dr. Conway reported no disclosures.

Dr. Deborah L. Conway (right) and Dr. Poornima Kaul found that more than one in five obese women who gained a modest amount of weight during pregnancy—1–14 pounds—had LGA infants. The LGA rate increased with more weight gain. COURTESY LESTER ROSEBROCK/UT HEALTH SCIENCE CENTER SAN ANTONIO

CHICAGO — Virtually any weight gain during pregnancy by obese women with gestational diabetes resulted in high rates of large-for-gestational-age infants, according to a study released at the annual meeting of the American College of Obstetricians and Gynecologists.

Obese women in the study who either lost weight or maintained their prepregnancy weight during pregnancy while on a medically supervised low-carbohydrate diet gave birth to babies with “close to normal” birth weights. They also had the lowest cesarean delivery rates (10.5%) in the study.

In contrast, more than one in five obese women who gained a modest amount of weight during pregnancy—1-14 pounds—had large-for-gestational-age (LGA) infants.

The LGA rate increased with more weight gain, accounting for 36% of infants born to women who gained 26–35 pounds, and nearly 40% of those born to women who gained more than 35 pounds, said Dr. Deborah L. Conway of the University of Texas Health Science Center at San Antonio.

Dr. Conway explained that her institution carefully monitors women with gestational diabetes and places them on a calorie-controlled, low-carbohydrate diet that includes nutritional counseling. They also receive glyburide or insulin as necessary to achieve euglycemia.

“Although it wasn't the intention, we noticed that some of these women didn't gain weight as you might expect during pregnancy. We weren't sure that was such a bad thing,” said Dr. Conway during an interview at the meeting, where her study was presented in poster form.

The Institute of Medicine is still recommending an 11- to 20 -lb weight gain for obese women during pregnancy in its recently released new guidelines. “What we saw in our study was that under nutritional supervision, it did not appear necessary for obese women with gestational diabetes to gain weight to have normal obstetrical rates of outcome and normal fetal size,” she said in a later interview.

To better understand gestational weight changes in this group, Dr. Poornima Kaul, a fourth-year resident, analyzed birth weights and pregnancy complications among 302 women with gestational diabetes who had a mean prepregnancy body mass index of 35.6 kg/m

The LGA rate among those who lost weight or maintained their prepregnancy weight was 11.8%.

The macrosomia rate (weight greater than 4,000 g) among their infants was 8.8%, and the rate of small-for-gestational-age infants was 8.8%.

These rates are “pretty close to normal,” Dr. Conway said.

Infants born to women who gained a small amount of weight (1–14 pounds) had a 27.3% LGA rate and a 13.6% rate of macrosomia. These women had a 15.1% cesarean delivery rate.

Women who gained 15–25 pounds had rates of LGA, macrosomia, and cesarean delivery of 27.6%, 13.2%, and 23.4%, respectively.

Those who gained 26–35 pounds had rates of LGA, macrosomia, and cesarean delivery of 36.4%, 21.8%, and 26.7%, while rates in women who gained more than 35 pounds were 39.6%, 25%, and 17.2%.

Dr. Kaul and Dr. Conway reported no disclosures.

Dr. Deborah L. Conway (right) and Dr. Poornima Kaul found that more than one in five obese women who gained a modest amount of weight during pregnancy—1–14 pounds—had LGA infants. The LGA rate increased with more weight gain. COURTESY LESTER ROSEBROCK/UT HEALTH SCIENCE CENTER SAN ANTONIO

CHICAGO — Virtually any weight gain during pregnancy by obese women with gestational diabetes resulted in high rates of large-for-gestational-age infants, according to a study released at the annual meeting of the American College of Obstetricians and Gynecologists.

Obese women in the study who either lost weight or maintained their prepregnancy weight during pregnancy while on a medically supervised low-carbohydrate diet gave birth to babies with “close to normal” birth weights. They also had the lowest cesarean delivery rates (10.5%) in the study.

In contrast, more than one in five obese women who gained a modest amount of weight during pregnancy—1-14 pounds—had large-for-gestational-age (LGA) infants.

The LGA rate increased with more weight gain, accounting for 36% of infants born to women who gained 26–35 pounds, and nearly 40% of those born to women who gained more than 35 pounds, said Dr. Deborah L. Conway of the University of Texas Health Science Center at San Antonio.

Dr. Conway explained that her institution carefully monitors women with gestational diabetes and places them on a calorie-controlled, low-carbohydrate diet that includes nutritional counseling. They also receive glyburide or insulin as necessary to achieve euglycemia.

“Although it wasn't the intention, we noticed that some of these women didn't gain weight as you might expect during pregnancy. We weren't sure that was such a bad thing,” said Dr. Conway during an interview at the meeting, where her study was presented in poster form.

The Institute of Medicine is still recommending an 11- to 20 -lb weight gain for obese women during pregnancy in its recently released new guidelines. “What we saw in our study was that under nutritional supervision, it did not appear necessary for obese women with gestational diabetes to gain weight to have normal obstetrical rates of outcome and normal fetal size,” she said in a later interview.

To better understand gestational weight changes in this group, Dr. Poornima Kaul, a fourth-year resident, analyzed birth weights and pregnancy complications among 302 women with gestational diabetes who had a mean prepregnancy body mass index of 35.6 kg/m

The LGA rate among those who lost weight or maintained their prepregnancy weight was 11.8%.

The macrosomia rate (weight greater than 4,000 g) among their infants was 8.8%, and the rate of small-for-gestational-age infants was 8.8%.

These rates are “pretty close to normal,” Dr. Conway said.

Infants born to women who gained a small amount of weight (1–14 pounds) had a 27.3% LGA rate and a 13.6% rate of macrosomia. These women had a 15.1% cesarean delivery rate.

Women who gained 15–25 pounds had rates of LGA, macrosomia, and cesarean delivery of 27.6%, 13.2%, and 23.4%, respectively.

Those who gained 26–35 pounds had rates of LGA, macrosomia, and cesarean delivery of 36.4%, 21.8%, and 26.7%, while rates in women who gained more than 35 pounds were 39.6%, 25%, and 17.2%.

Dr. Kaul and Dr. Conway reported no disclosures.

Dr. Deborah L. Conway (right) and Dr. Poornima Kaul found that more than one in five obese women who gained a modest amount of weight during pregnancy—1–14 pounds—had LGA infants. The LGA rate increased with more weight gain. COURTESY LESTER ROSEBROCK/UT HEALTH SCIENCE CENTER SAN ANTONIO

LOS ANGELES — Perhaps not surprisingly, sixth graders who demonstrated an aggressive temperament and/or symptoms of depression were more likely than their peers to begin using alcohol and other drugs by eighth grade, in a longitudinal study performed by researchers at the University of Washington, Seattle.

It was the third independent risk factor researchers detected—an early onset of puberty—that was less predictable, and it might serve as an early red flag for physicians.

Dr. Carolyn A. McCarty and her associates in the university's departments of pediatrics and psychology recruited 521 sixth graders from four public schools in the Seattle area, interviewing them every 6 months for 2.5 years, until they entered the eighth grade.

Children with conduct problems in school and/or depressive symptoms on a psychological instrument were oversampled in the survey supported by grants from the National Institute of Mental Health. At the study's onset, just 5.4% of sixth graders were using any substance, the most common being alcohol at 4.2%. By the study's conclusion, 16.7% of the teens—who had now reached eighth grade—reported using alcohol (13.2%), tobacco (4.2%), marijuana (6.8%), and/or other illicit substances (1.5%).

Sex, race, frustrated temperament, and externalizing symptoms were not significantly, independently associated with initiation of substance use over the course of the study, but several factors were, after adjustment for other variables. Most pronounced were aggressive temperament (hazard ratio, 1.61), pubertal status (HR, 1.42), and depressive symptoms, (HR, 1.04).

The link to early puberty (by sixth grade) “doesn't seem to be a blip,” since it is consistent with previous research that only examined initiation of alcohol use, said Dr. McCarty, a psychologist who has a dual appointment in pediatrics and psychology at the university.

The reason for the apparent link is still unclear, but several theories have been proposed, she said in an interview at the annual meeting of the Society for Adolescent Medicine, where the study was presented in poster form. “Some of the literature suggests that kids who go through puberty early associate with more deviant peers. It could also be that biologically, morphologically, they look older, so people treat them as if they're older. People might be more willing to offer them substances that they wouldn't [offer] to someone who looks younger.”

Dr. McCarty suggested that pediatricians, family physicians, ob.gyns., and endocrinologists take note when a girl or boy enters puberty early (by sixth grade), or shows signs of aggression and/or depression. “I would recommend doing a more thorough risk assessment of behavior so that they can know whether [alcohol and/or substance use] may or may not be an issue for a particular child.” In the case of early puberty, physicians need to consider possible behavioral implications of the physiological change. “Are they feeling older than their peers? And what does that mean for them?” she said.

LOS ANGELES — Perhaps not surprisingly, sixth graders who demonstrated an aggressive temperament and/or symptoms of depression were more likely than their peers to begin using alcohol and other drugs by eighth grade, in a longitudinal study performed by researchers at the University of Washington, Seattle.

It was the third independent risk factor researchers detected—an early onset of puberty—that was less predictable, and it might serve as an early red flag for physicians.

Dr. Carolyn A. McCarty and her associates in the university's departments of pediatrics and psychology recruited 521 sixth graders from four public schools in the Seattle area, interviewing them every 6 months for 2.5 years, until they entered the eighth grade.

Children with conduct problems in school and/or depressive symptoms on a psychological instrument were oversampled in the survey supported by grants from the National Institute of Mental Health. At the study's onset, just 5.4% of sixth graders were using any substance, the most common being alcohol at 4.2%. By the study's conclusion, 16.7% of the teens—who had now reached eighth grade—reported using alcohol (13.2%), tobacco (4.2%), marijuana (6.8%), and/or other illicit substances (1.5%).

Sex, race, frustrated temperament, and externalizing symptoms were not significantly, independently associated with initiation of substance use over the course of the study, but several factors were, after adjustment for other variables. Most pronounced were aggressive temperament (hazard ratio, 1.61), pubertal status (HR, 1.42), and depressive symptoms, (HR, 1.04).

The link to early puberty (by sixth grade) “doesn't seem to be a blip,” since it is consistent with previous research that only examined initiation of alcohol use, said Dr. McCarty, a psychologist who has a dual appointment in pediatrics and psychology at the university.

The reason for the apparent link is still unclear, but several theories have been proposed, she said in an interview at the annual meeting of the Society for Adolescent Medicine, where the study was presented in poster form. “Some of the literature suggests that kids who go through puberty early associate with more deviant peers. It could also be that biologically, morphologically, they look older, so people treat them as if they're older. People might be more willing to offer them substances that they wouldn't [offer] to someone who looks younger.”

Dr. McCarty suggested that pediatricians, family physicians, ob.gyns., and endocrinologists take note when a girl or boy enters puberty early (by sixth grade), or shows signs of aggression and/or depression. “I would recommend doing a more thorough risk assessment of behavior so that they can know whether [alcohol and/or substance use] may or may not be an issue for a particular child.” In the case of early puberty, physicians need to consider possible behavioral implications of the physiological change. “Are they feeling older than their peers? And what does that mean for them?” she said.

LOS ANGELES — Perhaps not surprisingly, sixth graders who demonstrated an aggressive temperament and/or symptoms of depression were more likely than their peers to begin using alcohol and other drugs by eighth grade, in a longitudinal study performed by researchers at the University of Washington, Seattle.

It was the third independent risk factor researchers detected—an early onset of puberty—that was less predictable, and it might serve as an early red flag for physicians.

Dr. Carolyn A. McCarty and her associates in the university's departments of pediatrics and psychology recruited 521 sixth graders from four public schools in the Seattle area, interviewing them every 6 months for 2.5 years, until they entered the eighth grade.

Children with conduct problems in school and/or depressive symptoms on a psychological instrument were oversampled in the survey supported by grants from the National Institute of Mental Health. At the study's onset, just 5.4% of sixth graders were using any substance, the most common being alcohol at 4.2%. By the study's conclusion, 16.7% of the teens—who had now reached eighth grade—reported using alcohol (13.2%), tobacco (4.2%), marijuana (6.8%), and/or other illicit substances (1.5%).

Sex, race, frustrated temperament, and externalizing symptoms were not significantly, independently associated with initiation of substance use over the course of the study, but several factors were, after adjustment for other variables. Most pronounced were aggressive temperament (hazard ratio, 1.61), pubertal status (HR, 1.42), and depressive symptoms, (HR, 1.04).

The link to early puberty (by sixth grade) “doesn't seem to be a blip,” since it is consistent with previous research that only examined initiation of alcohol use, said Dr. McCarty, a psychologist who has a dual appointment in pediatrics and psychology at the university.

The reason for the apparent link is still unclear, but several theories have been proposed, she said in an interview at the annual meeting of the Society for Adolescent Medicine, where the study was presented in poster form. “Some of the literature suggests that kids who go through puberty early associate with more deviant peers. It could also be that biologically, morphologically, they look older, so people treat them as if they're older. People might be more willing to offer them substances that they wouldn't [offer] to someone who looks younger.”

Dr. McCarty suggested that pediatricians, family physicians, ob.gyns., and endocrinologists take note when a girl or boy enters puberty early (by sixth grade), or shows signs of aggression and/or depression. “I would recommend doing a more thorough risk assessment of behavior so that they can know whether [alcohol and/or substance use] may or may not be an issue for a particular child.” In the case of early puberty, physicians need to consider possible behavioral implications of the physiological change. “Are they feeling older than their peers? And what does that mean for them?” she said.

LOS ANGELES — Teenagers cruising mainstream Web sites can hardly be faulted for thinking that emergency contraception is difficult to obtain, birth control pills will make them fat, and IUDs are meant for older women, not adolescents.

That's because incomplete and inaccurate information abounds on the Internet, even within very well-known Web sites, according to an analysis performed in 2008 by Stanford (Calif.) University researchers.

“We found a lot of myths about IUDs, emergency contraception, birth control, and when women should be getting Pap smears, especially their first one,” said Alisha T. Tolani, a student in the human biology program at the university.

Ms. Tolani and her research mentor, Dr. Sophia Yen of the division of adolescent medicine at Stanford's Lucile Packard Children's Hospital, presented their findings in a poster at the annual meeting of the Society of Adolescent Medicine.

Web sites were selected for analysis based on practitioner recommendations and Google searches of key terms, such as “birth control,” “morning after pill,” and “sexually transmitted disease.” The top 10–15 results for each search term were included. The 35 Web sites examined were assessed for accuracy on 26 topics.

In general, sites provided “fairly accurate” information on STDs, Ms. Tolani and Dr. Yen reported in their poster. For example, 100% of Web sites addressing STDs correctly noted that most sexually transmitted diseases are asymptomatic and that when symptoms are present, they may include burning with urination and discharge.

However, information about transmission was often vague or incomplete. Just 9 of 29 (31%) STD Web sites informed adolescents that herpes can be transmitted by kissing, and 14 of 29 (48%) mentioned skin-to-skin contact as a possible source of transmission.

Some contraception information was uniformly accurate, with Web sites making it clear that withdrawal is not a very effective means of preventing pregnancy, and noting that hormonal contraception does not protect against STDs.

On other topics, however, the information gleaned on Web sites was inaccurate or incomplete. More than half of the Web sites that addressed contraception listed weight gain as a possible side effect of birth control pills, a myth contradicted by 47 randomized, controlled trials. Five Web sites incorrectly stated that the calendar/rhythm method is effective at preventing pregnancy, and three misstated the effectiveness of emergency contraception.

Often, the Web sites omitted important information, considering that approximately a quarter of teens use the Internet to answer “some or a lot” of their questions about sexual health, Ms. Tolani said in an interview.

Although 16 of 34 (47%) Web sites noted that minors need a prescription for emergency contraception, they failed to mention that in many states, minors can obtain those prescriptions directly from authorized pharmacists. Very few sites explained exactly where emergency contraception can be obtained by minors or adults. (The Web sites may soon require more revisions, because a federal judge recently ordered the Food and Drug Administration to allow 17-year-olds to obtain emergency contraception without a prescription, and asked the agency to consider extending the option to younger girls.) Nearly a third of Web sites failed to debunk common myths about emergency contraception by explaining that is not an abortifacient, and making a distinction between emergency contraception and RU-486, mifepristone.

Just 5 of 27 (19%) Web sites dealing with contraception reflected 2007 American College of Obstetricians and Gynecologists guidelines recommending IUDs as a safe means of contraception in adolescents. Many were neutral, failing to mention adolescents and IUDs. But three sites incorrectly stated that IUDs should be reserved for parous women, they found.

Most Web sites offering information on Pap smears were updated in the past few years. Nonetheless, their recommendations for when women should have Pap smears “were all over the place,” with 40% offering advice that contradicted ACOG's 2003 guidelines, which state that women should begin receiving Pap smears at age 21 years or 3 years post coitarche, said Ms. Tolani.

She said adolescents will undoubtedly continue to rely heavily on Web sites to obtain sexual health information, but that doesn't mean physicians can't have a voice. “I think physicians need to specifically debunk the myths that we know are out there.”

Neither Ms. Tolani nor Dr. Yen had any conflicts of interest to disclose.

Recommended Sites for Teens

▸ Go Ask Alice! at

www.goaskalice.columbia.edu

▸ Center for Young Women's Health at

www.youngwomenshealth.org

▸ TeenWire at

www.teenwire.com

▸ TeensHealth at

http://kidshealth.org/teen

Sources: Ms. Tolani and Dr. Yen

Six Common Myths About Sex on the Internet That Physicians Can Debunk

Myth: Emergency contraception is difficult to obtain.

Reality: Emergency contraception is over the counter for women 17 and older and may be available OTC soon for younger minors as well. Minors can currently receive prescriptions directly from authorized pharmacists in nine states: Alaska, California, Hawaii, Maine, Massachusetts, New Hampshire, New Mexico, Vermont, and Washington.

Myth: Emergency contraception induces an abortion.

Reality: Emergency contraception does not cause an abortion and is not RU-486.

Myth: IUDs are for multiparous women.

Reality: IUDs are safe for use in adolescents, including the nulliparous and serially monogamous.

Myth: Oral contraceptives cause weight gain.

Reality: A review of 47 randomized, controlled trials found no evidence that combined hormonal contraceptives caused weight gain.

Myth: Women should have Pap smears with each change of sexual partner, at age 18 years, or immediately following coitarche.

Reality: The American College of Obstetricians and Gynecologists recommends that women have a Pap smears beginning at age 21 years or 3 years post coitarche.

Myth: Kissing is safe, even if your partner has herpes.

Reality: Herpes can be transmitted by kissing an infected individual.

Source: Dr. Yen

LOS ANGELES — Teenagers cruising mainstream Web sites can hardly be faulted for thinking that emergency contraception is difficult to obtain, birth control pills will make them fat, and IUDs are meant for older women, not adolescents.

That's because incomplete and inaccurate information abounds on the Internet, even within very well-known Web sites, according to an analysis performed in 2008 by Stanford (Calif.) University researchers.

“We found a lot of myths about IUDs, emergency contraception, birth control, and when women should be getting Pap smears, especially their first one,” said Alisha T. Tolani, a student in the human biology program at the university.

Ms. Tolani and her research mentor, Dr. Sophia Yen of the division of adolescent medicine at Stanford's Lucile Packard Children's Hospital, presented their findings in a poster at the annual meeting of the Society of Adolescent Medicine.

Web sites were selected for analysis based on practitioner recommendations and Google searches of key terms, such as “birth control,” “morning after pill,” and “sexually transmitted disease.” The top 10–15 results for each search term were included. The 35 Web sites examined were assessed for accuracy on 26 topics.

In general, sites provided “fairly accurate” information on STDs, Ms. Tolani and Dr. Yen reported in their poster. For example, 100% of Web sites addressing STDs correctly noted that most sexually transmitted diseases are asymptomatic and that when symptoms are present, they may include burning with urination and discharge.

However, information about transmission was often vague or incomplete. Just 9 of 29 (31%) STD Web sites informed adolescents that herpes can be transmitted by kissing, and 14 of 29 (48%) mentioned skin-to-skin contact as a possible source of transmission.

Some contraception information was uniformly accurate, with Web sites making it clear that withdrawal is not a very effective means of preventing pregnancy, and noting that hormonal contraception does not protect against STDs.

On other topics, however, the information gleaned on Web sites was inaccurate or incomplete. More than half of the Web sites that addressed contraception listed weight gain as a possible side effect of birth control pills, a myth contradicted by 47 randomized, controlled trials. Five Web sites incorrectly stated that the calendar/rhythm method is effective at preventing pregnancy, and three misstated the effectiveness of emergency contraception.

Often, the Web sites omitted important information, considering that approximately a quarter of teens use the Internet to answer “some or a lot” of their questions about sexual health, Ms. Tolani said in an interview.

Although 16 of 34 (47%) Web sites noted that minors need a prescription for emergency contraception, they failed to mention that in many states, minors can obtain those prescriptions directly from authorized pharmacists. Very few sites explained exactly where emergency contraception can be obtained by minors or adults. (The Web sites may soon require more revisions, because a federal judge recently ordered the Food and Drug Administration to allow 17-year-olds to obtain emergency contraception without a prescription, and asked the agency to consider extending the option to younger girls.) Nearly a third of Web sites failed to debunk common myths about emergency contraception by explaining that is not an abortifacient, and making a distinction between emergency contraception and RU-486, mifepristone.

Just 5 of 27 (19%) Web sites dealing with contraception reflected 2007 American College of Obstetricians and Gynecologists guidelines recommending IUDs as a safe means of contraception in adolescents. Many were neutral, failing to mention adolescents and IUDs. But three sites incorrectly stated that IUDs should be reserved for parous women, they found.

Most Web sites offering information on Pap smears were updated in the past few years. Nonetheless, their recommendations for when women should have Pap smears “were all over the place,” with 40% offering advice that contradicted ACOG's 2003 guidelines, which state that women should begin receiving Pap smears at age 21 years or 3 years post coitarche, said Ms. Tolani.

She said adolescents will undoubtedly continue to rely heavily on Web sites to obtain sexual health information, but that doesn't mean physicians can't have a voice. “I think physicians need to specifically debunk the myths that we know are out there.”

Neither Ms. Tolani nor Dr. Yen had any conflicts of interest to disclose.

Recommended Sites for Teens

▸ Go Ask Alice! at

www.goaskalice.columbia.edu

▸ Center for Young Women's Health at

www.youngwomenshealth.org

▸ TeenWire at

www.teenwire.com

▸ TeensHealth at

http://kidshealth.org/teen

Sources: Ms. Tolani and Dr. Yen

Six Common Myths About Sex on the Internet That Physicians Can Debunk

Myth: Emergency contraception is difficult to obtain.

Reality: Emergency contraception is over the counter for women 17 and older and may be available OTC soon for younger minors as well. Minors can currently receive prescriptions directly from authorized pharmacists in nine states: Alaska, California, Hawaii, Maine, Massachusetts, New Hampshire, New Mexico, Vermont, and Washington.

Myth: Emergency contraception induces an abortion.

Reality: Emergency contraception does not cause an abortion and is not RU-486.

Myth: IUDs are for multiparous women.

Reality: IUDs are safe for use in adolescents, including the nulliparous and serially monogamous.

Myth: Oral contraceptives cause weight gain.

Reality: A review of 47 randomized, controlled trials found no evidence that combined hormonal contraceptives caused weight gain.

Myth: Women should have Pap smears with each change of sexual partner, at age 18 years, or immediately following coitarche.

Reality: The American College of Obstetricians and Gynecologists recommends that women have a Pap smears beginning at age 21 years or 3 years post coitarche.

Myth: Kissing is safe, even if your partner has herpes.

Reality: Herpes can be transmitted by kissing an infected individual.

Source: Dr. Yen

LOS ANGELES — Teenagers cruising mainstream Web sites can hardly be faulted for thinking that emergency contraception is difficult to obtain, birth control pills will make them fat, and IUDs are meant for older women, not adolescents.

That's because incomplete and inaccurate information abounds on the Internet, even within very well-known Web sites, according to an analysis performed in 2008 by Stanford (Calif.) University researchers.

“We found a lot of myths about IUDs, emergency contraception, birth control, and when women should be getting Pap smears, especially their first one,” said Alisha T. Tolani, a student in the human biology program at the university.

Ms. Tolani and her research mentor, Dr. Sophia Yen of the division of adolescent medicine at Stanford's Lucile Packard Children's Hospital, presented their findings in a poster at the annual meeting of the Society of Adolescent Medicine.

Web sites were selected for analysis based on practitioner recommendations and Google searches of key terms, such as “birth control,” “morning after pill,” and “sexually transmitted disease.” The top 10–15 results for each search term were included. The 35 Web sites examined were assessed for accuracy on 26 topics.

In general, sites provided “fairly accurate” information on STDs, Ms. Tolani and Dr. Yen reported in their poster. For example, 100% of Web sites addressing STDs correctly noted that most sexually transmitted diseases are asymptomatic and that when symptoms are present, they may include burning with urination and discharge.

However, information about transmission was often vague or incomplete. Just 9 of 29 (31%) STD Web sites informed adolescents that herpes can be transmitted by kissing, and 14 of 29 (48%) mentioned skin-to-skin contact as a possible source of transmission.

Some contraception information was uniformly accurate, with Web sites making it clear that withdrawal is not a very effective means of preventing pregnancy, and noting that hormonal contraception does not protect against STDs.

On other topics, however, the information gleaned on Web sites was inaccurate or incomplete. More than half of the Web sites that addressed contraception listed weight gain as a possible side effect of birth control pills, a myth contradicted by 47 randomized, controlled trials. Five Web sites incorrectly stated that the calendar/rhythm method is effective at preventing pregnancy, and three misstated the effectiveness of emergency contraception.

Often, the Web sites omitted important information, considering that approximately a quarter of teens use the Internet to answer “some or a lot” of their questions about sexual health, Ms. Tolani said in an interview.

Although 16 of 34 (47%) Web sites noted that minors need a prescription for emergency contraception, they failed to mention that in many states, minors can obtain those prescriptions directly from authorized pharmacists. Very few sites explained exactly where emergency contraception can be obtained by minors or adults. (The Web sites may soon require more revisions, because a federal judge recently ordered the Food and Drug Administration to allow 17-year-olds to obtain emergency contraception without a prescription, and asked the agency to consider extending the option to younger girls.) Nearly a third of Web sites failed to debunk common myths about emergency contraception by explaining that is not an abortifacient, and making a distinction between emergency contraception and RU-486, mifepristone.

Just 5 of 27 (19%) Web sites dealing with contraception reflected 2007 American College of Obstetricians and Gynecologists guidelines recommending IUDs as a safe means of contraception in adolescents. Many were neutral, failing to mention adolescents and IUDs. But three sites incorrectly stated that IUDs should be reserved for parous women, they found.

Most Web sites offering information on Pap smears were updated in the past few years. Nonetheless, their recommendations for when women should have Pap smears “were all over the place,” with 40% offering advice that contradicted ACOG's 2003 guidelines, which state that women should begin receiving Pap smears at age 21 years or 3 years post coitarche, said Ms. Tolani.

She said adolescents will undoubtedly continue to rely heavily on Web sites to obtain sexual health information, but that doesn't mean physicians can't have a voice. “I think physicians need to specifically debunk the myths that we know are out there.”

Neither Ms. Tolani nor Dr. Yen had any conflicts of interest to disclose.

Recommended Sites for Teens

▸ Go Ask Alice! at

www.goaskalice.columbia.edu

▸ Center for Young Women's Health at

www.youngwomenshealth.org

▸ TeenWire at

www.teenwire.com

▸ TeensHealth at

http://kidshealth.org/teen

Sources: Ms. Tolani and Dr. Yen

Six Common Myths About Sex on the Internet That Physicians Can Debunk

Myth: Emergency contraception is difficult to obtain.

Reality: Emergency contraception is over the counter for women 17 and older and may be available OTC soon for younger minors as well. Minors can currently receive prescriptions directly from authorized pharmacists in nine states: Alaska, California, Hawaii, Maine, Massachusetts, New Hampshire, New Mexico, Vermont, and Washington.

Myth: Emergency contraception induces an abortion.

Reality: Emergency contraception does not cause an abortion and is not RU-486.

Myth: IUDs are for multiparous women.

Reality: IUDs are safe for use in adolescents, including the nulliparous and serially monogamous.

Myth: Oral contraceptives cause weight gain.

Reality: A review of 47 randomized, controlled trials found no evidence that combined hormonal contraceptives caused weight gain.

Myth: Women should have Pap smears with each change of sexual partner, at age 18 years, or immediately following coitarche.

Reality: The American College of Obstetricians and Gynecologists recommends that women have a Pap smears beginning at age 21 years or 3 years post coitarche.

Myth: Kissing is safe, even if your partner has herpes.

Reality: Herpes can be transmitted by kissing an infected individual.

Source: Dr. Yen