Greg Muirhead

WAIKOLOA, HAWAII — The look of an ancient royal Egyptian female statue—referred to as "Nefertiti"—can be achieved with well-placed injections of Botox, according to Dr. David J. Goldberg.

"It's called the 'Nefertiti lift,'" Dr. Goldberg said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation. (Nefertiti was the wife of the pharaoh Akhenaten; she lived from 1370 to 1330 BC.)

"It's a softening of the chin by getting the bands of the platysma as they insert along the mandible. It's a way of recontouring the jawline." He described the look as a "liquid facelift."

Dr. Phillip M. Levy first described the Nefertiti lift and reported the results of injecting Botox (Allergan Inc.) using this method into the lower chin (J. Cosmet. Laser Ther. 2007;9:249–52). Of 130 patients who were treated over a 6-month period, 126 achieved immediate results with minimum adverse events.

The patients, all female, with a median age of 47 years, had noticeable recontouring of the chin and elevation of the skin at the jawline.

"The success of this technique is due to manipulation of the opposing effects of the platysmal complex" with Botox, wrote Dr. Levy, of Geneva.

Injected in this area, the substance will improve the definition of the mandibular border and angle, while elevating the corners of the mouth, said Dr. Goldberg. And you are able to get to the platysma and its small bands. It gives the visual effect of a minilift.

"It really drapes the skin of the jawline," he added. "It's amazing how much we can accomplish without surgery," said Dr. Goldberg, director of laser research and Mohs surgery at Mount Sinai School of Medicine, New York.

The patients received 2–3 U of Botox injected along and under each mandible, and to the upper part of the posterior platysmal band. Patients were asked to contract their platysmal muscle during injection.

"You have to see those bands inserted along the mandible. You can't just haphazardly inject," he said.

The total amount of Botox used was 15–20 U per side.

Dr. Goldberg recommended following up with patients at 2 weeks but described the results as being "really quite impressive."

Touch-ups can be performed at follow-up if needed, he added.

Dr. Levy has been a consultant to Allergan. Dr. Goldberg disclosed no relevant financial conflicts of interest.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

Nefertiti has been said to have the perfect mandibular contour. ©Aurelio/Fotolia

WAIKOLOA, HAWAII — The look of an ancient royal Egyptian female statue—referred to as "Nefertiti"—can be achieved with well-placed injections of Botox, according to Dr. David J. Goldberg.

"It's called the 'Nefertiti lift,'" Dr. Goldberg said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation. (Nefertiti was the wife of the pharaoh Akhenaten; she lived from 1370 to 1330 BC.)

"It's a softening of the chin by getting the bands of the platysma as they insert along the mandible. It's a way of recontouring the jawline." He described the look as a "liquid facelift."

Dr. Phillip M. Levy first described the Nefertiti lift and reported the results of injecting Botox (Allergan Inc.) using this method into the lower chin (J. Cosmet. Laser Ther. 2007;9:249–52). Of 130 patients who were treated over a 6-month period, 126 achieved immediate results with minimum adverse events.

The patients, all female, with a median age of 47 years, had noticeable recontouring of the chin and elevation of the skin at the jawline.

"The success of this technique is due to manipulation of the opposing effects of the platysmal complex" with Botox, wrote Dr. Levy, of Geneva.

Injected in this area, the substance will improve the definition of the mandibular border and angle, while elevating the corners of the mouth, said Dr. Goldberg. And you are able to get to the platysma and its small bands. It gives the visual effect of a minilift.

"It really drapes the skin of the jawline," he added. "It's amazing how much we can accomplish without surgery," said Dr. Goldberg, director of laser research and Mohs surgery at Mount Sinai School of Medicine, New York.

The patients received 2–3 U of Botox injected along and under each mandible, and to the upper part of the posterior platysmal band. Patients were asked to contract their platysmal muscle during injection.

"You have to see those bands inserted along the mandible. You can't just haphazardly inject," he said.

The total amount of Botox used was 15–20 U per side.

Dr. Goldberg recommended following up with patients at 2 weeks but described the results as being "really quite impressive."

Touch-ups can be performed at follow-up if needed, he added.

Dr. Levy has been a consultant to Allergan. Dr. Goldberg disclosed no relevant financial conflicts of interest.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

Nefertiti has been said to have the perfect mandibular contour. ©Aurelio/Fotolia

WAIKOLOA, HAWAII — The look of an ancient royal Egyptian female statue—referred to as "Nefertiti"—can be achieved with well-placed injections of Botox, according to Dr. David J. Goldberg.

"It's called the 'Nefertiti lift,'" Dr. Goldberg said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation. (Nefertiti was the wife of the pharaoh Akhenaten; she lived from 1370 to 1330 BC.)

"It's a softening of the chin by getting the bands of the platysma as they insert along the mandible. It's a way of recontouring the jawline." He described the look as a "liquid facelift."

Dr. Phillip M. Levy first described the Nefertiti lift and reported the results of injecting Botox (Allergan Inc.) using this method into the lower chin (J. Cosmet. Laser Ther. 2007;9:249–52). Of 130 patients who were treated over a 6-month period, 126 achieved immediate results with minimum adverse events.

The patients, all female, with a median age of 47 years, had noticeable recontouring of the chin and elevation of the skin at the jawline.

"The success of this technique is due to manipulation of the opposing effects of the platysmal complex" with Botox, wrote Dr. Levy, of Geneva.

Injected in this area, the substance will improve the definition of the mandibular border and angle, while elevating the corners of the mouth, said Dr. Goldberg. And you are able to get to the platysma and its small bands. It gives the visual effect of a minilift.

"It really drapes the skin of the jawline," he added. "It's amazing how much we can accomplish without surgery," said Dr. Goldberg, director of laser research and Mohs surgery at Mount Sinai School of Medicine, New York.

The patients received 2–3 U of Botox injected along and under each mandible, and to the upper part of the posterior platysmal band. Patients were asked to contract their platysmal muscle during injection.

"You have to see those bands inserted along the mandible. You can't just haphazardly inject," he said.

The total amount of Botox used was 15–20 U per side.

Dr. Goldberg recommended following up with patients at 2 weeks but described the results as being "really quite impressive."

Touch-ups can be performed at follow-up if needed, he added.

Dr. Levy has been a consultant to Allergan. Dr. Goldberg disclosed no relevant financial conflicts of interest.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

Nefertiti has been said to have the perfect mandibular contour. ©Aurelio/Fotolia

MAUI, HAWAII — An as-yet unpublished white paper on the appropriate use of nonsteroidal anti-inflammatory drugs by the American College of Rheumatology contains common sense advice such as using the lowest possible dose and the least costly agent when treating the pain of patients with osteoarthritis.

Controversy centers on whether to use naproxen in patients taking low-dose aspirin for cardioprotection.

The white paper sanctions the use of either acetaminophen or naproxen in such patients, Dr. John Cush, an author of the white paper as well as director of clinical rheumatology, Baylor Research Institute, and professor of medicine and rheumatology, Baylor University Medical Center, Dallas, reported at a symposium sponsored by Excellence in Rheumatology Education. However, Dr. Vibeke Strand of Stanford (Calif.) University, an audience member, criticized the ACR's support of the use of naproxen in patients with, or at risk of developing, cardiovascular disease. She argued that there is no statistically significant evidence to support its use.

When aspirin is required, Dr. Cush said that a gastroprotective drug or a proton pump inhibitor should be used. For patients who are at GI risk, a selective cyclooxygenase-2 inhibitor is recommended, he continued. “But if you're going to use a nonselective nonsteroidal, you should use a PPI or misoprostol with it.”

ACR based its recommendations on evidence culled from existing ACR/osteoarthritis guidelines, osteoarthritis guidelines from the European League Against Rheumatism, and reviews by the Cochrane Collaboration, Dr. Cush said.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the preferable choice to acetaminophen for relieving pain. Patients on long-term NSAIDs require close monitoring of the complete blood count, liver function, and blood pressure. Physicians should avoid nonselective NSAIDs and cyclooxygenase-2 inhibitors in patients with renal or liver disease. Dr. Cush disclosed that he is a clinical investigator and/or consultant/adviser for Abbot, Biogen/Idec, Genentech, Pfizer, Targeted Genetics, UCB, Wyeth, Centocor, and Novartis.

'If you're going to use a nonselective nonsteroidal, you should use a PPI or misoprostol with it.' DR. CUSH

MAUI, HAWAII — An as-yet unpublished white paper on the appropriate use of nonsteroidal anti-inflammatory drugs by the American College of Rheumatology contains common sense advice such as using the lowest possible dose and the least costly agent when treating the pain of patients with osteoarthritis.

Controversy centers on whether to use naproxen in patients taking low-dose aspirin for cardioprotection.

The white paper sanctions the use of either acetaminophen or naproxen in such patients, Dr. John Cush, an author of the white paper as well as director of clinical rheumatology, Baylor Research Institute, and professor of medicine and rheumatology, Baylor University Medical Center, Dallas, reported at a symposium sponsored by Excellence in Rheumatology Education. However, Dr. Vibeke Strand of Stanford (Calif.) University, an audience member, criticized the ACR's support of the use of naproxen in patients with, or at risk of developing, cardiovascular disease. She argued that there is no statistically significant evidence to support its use.

When aspirin is required, Dr. Cush said that a gastroprotective drug or a proton pump inhibitor should be used. For patients who are at GI risk, a selective cyclooxygenase-2 inhibitor is recommended, he continued. “But if you're going to use a nonselective nonsteroidal, you should use a PPI or misoprostol with it.”

ACR based its recommendations on evidence culled from existing ACR/osteoarthritis guidelines, osteoarthritis guidelines from the European League Against Rheumatism, and reviews by the Cochrane Collaboration, Dr. Cush said.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the preferable choice to acetaminophen for relieving pain. Patients on long-term NSAIDs require close monitoring of the complete blood count, liver function, and blood pressure. Physicians should avoid nonselective NSAIDs and cyclooxygenase-2 inhibitors in patients with renal or liver disease. Dr. Cush disclosed that he is a clinical investigator and/or consultant/adviser for Abbot, Biogen/Idec, Genentech, Pfizer, Targeted Genetics, UCB, Wyeth, Centocor, and Novartis.

'If you're going to use a nonselective nonsteroidal, you should use a PPI or misoprostol with it.' DR. CUSH

MAUI, HAWAII — An as-yet unpublished white paper on the appropriate use of nonsteroidal anti-inflammatory drugs by the American College of Rheumatology contains common sense advice such as using the lowest possible dose and the least costly agent when treating the pain of patients with osteoarthritis.

Controversy centers on whether to use naproxen in patients taking low-dose aspirin for cardioprotection.

The white paper sanctions the use of either acetaminophen or naproxen in such patients, Dr. John Cush, an author of the white paper as well as director of clinical rheumatology, Baylor Research Institute, and professor of medicine and rheumatology, Baylor University Medical Center, Dallas, reported at a symposium sponsored by Excellence in Rheumatology Education. However, Dr. Vibeke Strand of Stanford (Calif.) University, an audience member, criticized the ACR's support of the use of naproxen in patients with, or at risk of developing, cardiovascular disease. She argued that there is no statistically significant evidence to support its use.

When aspirin is required, Dr. Cush said that a gastroprotective drug or a proton pump inhibitor should be used. For patients who are at GI risk, a selective cyclooxygenase-2 inhibitor is recommended, he continued. “But if you're going to use a nonselective nonsteroidal, you should use a PPI or misoprostol with it.”

ACR based its recommendations on evidence culled from existing ACR/osteoarthritis guidelines, osteoarthritis guidelines from the European League Against Rheumatism, and reviews by the Cochrane Collaboration, Dr. Cush said.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the preferable choice to acetaminophen for relieving pain. Patients on long-term NSAIDs require close monitoring of the complete blood count, liver function, and blood pressure. Physicians should avoid nonselective NSAIDs and cyclooxygenase-2 inhibitors in patients with renal or liver disease. Dr. Cush disclosed that he is a clinical investigator and/or consultant/adviser for Abbot, Biogen/Idec, Genentech, Pfizer, Targeted Genetics, UCB, Wyeth, Centocor, and Novartis.

'If you're going to use a nonselective nonsteroidal, you should use a PPI or misoprostol with it.' DR. CUSH

MAUI, HAWAII – An as-yet unpublished white paper on the appropriate use of nonsteroidal anti-inflammatory drugs contains mostly common sense advice, save for a small controversy over whether to use naproxen in patients taking low-dose aspirin for cardioprotection.

The white paper, from the American College of Rheumatology, sanctions acetaminophen or naproxen in such patients, said co-author Dr. John Cush, director of clinical rheumatology, Baylor Research Institute, and professor of medicine and rheumatology, Baylor University Medical Center, Dallas, at a symposium sponsored by Excellence in Rheumatology Education. But Dr. Vibeke Strand of Stanford (Calif.) University, an audience member, said there is no statistically significant evidence to support its use.

Dr. Cush said: “If aspirin is required for any patient for cardioprotection, you should seriously consider avoiding nonsteroidals of all kinds, including [cyclooxygenase-2s].”

When aspirin is needed, a gastroprotective drug like misoprostol or a proton pump inhibitor like esomeprazole should be used. For patients at GI risk, a selective cyclooxygenase-2 inhibitor is best, he said. But, “if you're going to use a nonselective nonsteroidal, you should use a PPI or misoprostol with it.”

Dr. Cush said that the white paper is based on existing osteoarthritis guidelines from the ACR, OA guidelines from EULAR (the European League Against Rheumatism), and reviews by the Cochrane Collaboration.

Other tenets of the white paper hold that patients on long-term NSAIDs require close monitoring of the complete blood count, liver function, and blood pressure. Physicians should avoid nonselective NSAIDs and cyclooxygenase-2 inhibitors in patients with renal or liver disease. and avoid nonselective NSAID use in patients on anticoagulants or who have chronic thrombocytopenia.

Dr. Cush has financial ties to: Abbot, Biogen/Idec, Genentech, Pfizer, Targeted Genetics, UCB, Wyeth, Centocor, and Novartis.

If a patient takes aspirin for heart protection, 'you should seriously consider avoiding nonsteroidals of all kinds.' DR. CUSH

MAUI, HAWAII – An as-yet unpublished white paper on the appropriate use of nonsteroidal anti-inflammatory drugs contains mostly common sense advice, save for a small controversy over whether to use naproxen in patients taking low-dose aspirin for cardioprotection.

The white paper, from the American College of Rheumatology, sanctions acetaminophen or naproxen in such patients, said co-author Dr. John Cush, director of clinical rheumatology, Baylor Research Institute, and professor of medicine and rheumatology, Baylor University Medical Center, Dallas, at a symposium sponsored by Excellence in Rheumatology Education. But Dr. Vibeke Strand of Stanford (Calif.) University, an audience member, said there is no statistically significant evidence to support its use.

Dr. Cush said: “If aspirin is required for any patient for cardioprotection, you should seriously consider avoiding nonsteroidals of all kinds, including [cyclooxygenase-2s].”

When aspirin is needed, a gastroprotective drug like misoprostol or a proton pump inhibitor like esomeprazole should be used. For patients at GI risk, a selective cyclooxygenase-2 inhibitor is best, he said. But, “if you're going to use a nonselective nonsteroidal, you should use a PPI or misoprostol with it.”

Dr. Cush said that the white paper is based on existing osteoarthritis guidelines from the ACR, OA guidelines from EULAR (the European League Against Rheumatism), and reviews by the Cochrane Collaboration.

Other tenets of the white paper hold that patients on long-term NSAIDs require close monitoring of the complete blood count, liver function, and blood pressure. Physicians should avoid nonselective NSAIDs and cyclooxygenase-2 inhibitors in patients with renal or liver disease. and avoid nonselective NSAID use in patients on anticoagulants or who have chronic thrombocytopenia.

Dr. Cush has financial ties to: Abbot, Biogen/Idec, Genentech, Pfizer, Targeted Genetics, UCB, Wyeth, Centocor, and Novartis.

If a patient takes aspirin for heart protection, 'you should seriously consider avoiding nonsteroidals of all kinds.' DR. CUSH

MAUI, HAWAII – An as-yet unpublished white paper on the appropriate use of nonsteroidal anti-inflammatory drugs contains mostly common sense advice, save for a small controversy over whether to use naproxen in patients taking low-dose aspirin for cardioprotection.

The white paper, from the American College of Rheumatology, sanctions acetaminophen or naproxen in such patients, said co-author Dr. John Cush, director of clinical rheumatology, Baylor Research Institute, and professor of medicine and rheumatology, Baylor University Medical Center, Dallas, at a symposium sponsored by Excellence in Rheumatology Education. But Dr. Vibeke Strand of Stanford (Calif.) University, an audience member, said there is no statistically significant evidence to support its use.

Dr. Cush said: “If aspirin is required for any patient for cardioprotection, you should seriously consider avoiding nonsteroidals of all kinds, including [cyclooxygenase-2s].”

When aspirin is needed, a gastroprotective drug like misoprostol or a proton pump inhibitor like esomeprazole should be used. For patients at GI risk, a selective cyclooxygenase-2 inhibitor is best, he said. But, “if you're going to use a nonselective nonsteroidal, you should use a PPI or misoprostol with it.”

Dr. Cush said that the white paper is based on existing osteoarthritis guidelines from the ACR, OA guidelines from EULAR (the European League Against Rheumatism), and reviews by the Cochrane Collaboration.

Other tenets of the white paper hold that patients on long-term NSAIDs require close monitoring of the complete blood count, liver function, and blood pressure. Physicians should avoid nonselective NSAIDs and cyclooxygenase-2 inhibitors in patients with renal or liver disease. and avoid nonselective NSAID use in patients on anticoagulants or who have chronic thrombocytopenia.

Dr. Cush has financial ties to: Abbot, Biogen/Idec, Genentech, Pfizer, Targeted Genetics, UCB, Wyeth, Centocor, and Novartis.

If a patient takes aspirin for heart protection, 'you should seriously consider avoiding nonsteroidals of all kinds.' DR. CUSH

MAUI, HAWAII – Rheumatologists and physicians in other specialties are needlessly resisting the inevitability of electronic medical records, said Dr. Martin J. Bergman.

As of 2005, about 23% of office-based physicians used electronic medical records (EMRs), said Dr. Bergman, citing statistics from the Centers for Disease Control and Prevention's National Center for Health Statistics that were reported in 2006. In contrast, almost 80% of office-based physicians used billing software, he added.

Reasons for resistance include complaints that EMRs are difficult to complete, interrupt the office flow, and take too much time to administer and review, said Dr. Bergman, chief of rheumatology at Taylor Hospital, Ridley Park, Pa.

“The first obstacle is cost,” he noted. The cost of getting EMR software can range from $5,000 to more than $30,000, although the better software doesn't necessarily cost more. Once EMRs are established in the practice, rheumatologists can expect significant savings associated with their use. The practice will save on transcription fees, and dictation will no longer be needed. “My example is 12 years ago, when I went into electronic records, I was paying just under $20,000 a year for transcriptions,” he recalled. “I no longer use a transcriptionist. Over 12 years, I've saved close to $250,000 on transcription fees alone.”

As for time difficulties, there is a “steep learning curve” in getting used to using EMRs. “Those first 3 months are ugly,” he said. “After that, your productivity doubles.”

Dr. Bergman pointed out that rheumatologists can use EMRs to track metrics–measures of patients' progress–which is difficult to do with paper files. Metrics can quickly help gauge the success of the practice, and the news is not always good. “Until you start doing metrics, you think you are doing better than you are,” he said. “The majority of us are not using any form of metric.”

Other benefits of EMRs include:

▸ An increase in productivity. Dr. Bergman observed that, now, paper records slow him down. EMRs give him instant access to entire histories, including lab tests and drugs used.

▸ Easy creation of referral letters. Print them by pressing a couple of buttons.

▸ A tool for research. Patient data can be graphed to show results of treatment over time, which provides a good source of private practice research.

▸ Access to databases. Data extracted from the EMR database can readily be shared with existing databases, such as the Consortium of Rheumatology Researchers of North America (CORRONA), and the National Data Bank for Rheumatic Diseases.

Patient data typically collected in an EMR include demographic information, active and comorbid diagnoses, currently and formerly used medications, lab reports, DAS28 findings, both physician and patient global scores, Rheumatology Assessment Patient Index Data (RAPID) findings, and patient-reported measures such as pain, functionality, fatigue, and tender and swollen joint counts, he said during his presentation at a symposium sponsored by Excellence in Rheumatology Education.

EMR software offers two basic options: template software or database software. The choice might depend on whether the rheumatologist is in a solo or group practice.

The solo rheumatologist will be better served by database software, which is flexible and can be altered on the fly to fit special information-gathering needs. But a group practice or hospital will more likely want template software, which is more rigid, and requires all users to fill in the same kinds of information in the same format.

Free, month-long demos of software are available that allow rheumatologists to decide which is best for them.

Although patients can enter data directly into their EMRs at an office computer kiosk, older arthritic patients who have limited dexterity might find doing so difficult. A personal digital assistant (PDA), which is often used by physicians to enter patient data in hospitals, also presents problems for older arthritic patients to use at the office. A laptop is another option; however, because it may need to be replaced every few years, it may be a costly one.

Dr. Bergman gives his patients paper questionnaires; the answers are entered into the EMRs. By filling out the questionnaires, patients become more focused on their disease, which helps focus the physician-patient encounter. His questionnaire comprises mostly check-off questions, which are easy for patients to fill it out quickly and for office staff to enter electronically. After the patient's questionnaire information has been entered into an EMR, Dr. Bergman can quickly open the patient's record, see the new information, and easily review information from the previous visit.

Dr. Bergman said that he has been using EMR software from Stat Systems for 12 years. He is neither a spokesman for nor an owner of the company.

MAUI, HAWAII – Rheumatologists and physicians in other specialties are needlessly resisting the inevitability of electronic medical records, said Dr. Martin J. Bergman.

As of 2005, about 23% of office-based physicians used electronic medical records (EMRs), said Dr. Bergman, citing statistics from the Centers for Disease Control and Prevention's National Center for Health Statistics that were reported in 2006. In contrast, almost 80% of office-based physicians used billing software, he added.

Reasons for resistance include complaints that EMRs are difficult to complete, interrupt the office flow, and take too much time to administer and review, said Dr. Bergman, chief of rheumatology at Taylor Hospital, Ridley Park, Pa.

“The first obstacle is cost,” he noted. The cost of getting EMR software can range from $5,000 to more than $30,000, although the better software doesn't necessarily cost more. Once EMRs are established in the practice, rheumatologists can expect significant savings associated with their use. The practice will save on transcription fees, and dictation will no longer be needed. “My example is 12 years ago, when I went into electronic records, I was paying just under $20,000 a year for transcriptions,” he recalled. “I no longer use a transcriptionist. Over 12 years, I've saved close to $250,000 on transcription fees alone.”

As for time difficulties, there is a “steep learning curve” in getting used to using EMRs. “Those first 3 months are ugly,” he said. “After that, your productivity doubles.”

Dr. Bergman pointed out that rheumatologists can use EMRs to track metrics–measures of patients' progress–which is difficult to do with paper files. Metrics can quickly help gauge the success of the practice, and the news is not always good. “Until you start doing metrics, you think you are doing better than you are,” he said. “The majority of us are not using any form of metric.”

Other benefits of EMRs include:

▸ An increase in productivity. Dr. Bergman observed that, now, paper records slow him down. EMRs give him instant access to entire histories, including lab tests and drugs used.

▸ Easy creation of referral letters. Print them by pressing a couple of buttons.

▸ A tool for research. Patient data can be graphed to show results of treatment over time, which provides a good source of private practice research.

▸ Access to databases. Data extracted from the EMR database can readily be shared with existing databases, such as the Consortium of Rheumatology Researchers of North America (CORRONA), and the National Data Bank for Rheumatic Diseases.

Patient data typically collected in an EMR include demographic information, active and comorbid diagnoses, currently and formerly used medications, lab reports, DAS28 findings, both physician and patient global scores, Rheumatology Assessment Patient Index Data (RAPID) findings, and patient-reported measures such as pain, functionality, fatigue, and tender and swollen joint counts, he said during his presentation at a symposium sponsored by Excellence in Rheumatology Education.

EMR software offers two basic options: template software or database software. The choice might depend on whether the rheumatologist is in a solo or group practice.

The solo rheumatologist will be better served by database software, which is flexible and can be altered on the fly to fit special information-gathering needs. But a group practice or hospital will more likely want template software, which is more rigid, and requires all users to fill in the same kinds of information in the same format.

Free, month-long demos of software are available that allow rheumatologists to decide which is best for them.

Although patients can enter data directly into their EMRs at an office computer kiosk, older arthritic patients who have limited dexterity might find doing so difficult. A personal digital assistant (PDA), which is often used by physicians to enter patient data in hospitals, also presents problems for older arthritic patients to use at the office. A laptop is another option; however, because it may need to be replaced every few years, it may be a costly one.

Dr. Bergman gives his patients paper questionnaires; the answers are entered into the EMRs. By filling out the questionnaires, patients become more focused on their disease, which helps focus the physician-patient encounter. His questionnaire comprises mostly check-off questions, which are easy for patients to fill it out quickly and for office staff to enter electronically. After the patient's questionnaire information has been entered into an EMR, Dr. Bergman can quickly open the patient's record, see the new information, and easily review information from the previous visit.

Dr. Bergman said that he has been using EMR software from Stat Systems for 12 years. He is neither a spokesman for nor an owner of the company.

MAUI, HAWAII – Rheumatologists and physicians in other specialties are needlessly resisting the inevitability of electronic medical records, said Dr. Martin J. Bergman.

As of 2005, about 23% of office-based physicians used electronic medical records (EMRs), said Dr. Bergman, citing statistics from the Centers for Disease Control and Prevention's National Center for Health Statistics that were reported in 2006. In contrast, almost 80% of office-based physicians used billing software, he added.

Reasons for resistance include complaints that EMRs are difficult to complete, interrupt the office flow, and take too much time to administer and review, said Dr. Bergman, chief of rheumatology at Taylor Hospital, Ridley Park, Pa.

“The first obstacle is cost,” he noted. The cost of getting EMR software can range from $5,000 to more than $30,000, although the better software doesn't necessarily cost more. Once EMRs are established in the practice, rheumatologists can expect significant savings associated with their use. The practice will save on transcription fees, and dictation will no longer be needed. “My example is 12 years ago, when I went into electronic records, I was paying just under $20,000 a year for transcriptions,” he recalled. “I no longer use a transcriptionist. Over 12 years, I've saved close to $250,000 on transcription fees alone.”

As for time difficulties, there is a “steep learning curve” in getting used to using EMRs. “Those first 3 months are ugly,” he said. “After that, your productivity doubles.”

Dr. Bergman pointed out that rheumatologists can use EMRs to track metrics–measures of patients' progress–which is difficult to do with paper files. Metrics can quickly help gauge the success of the practice, and the news is not always good. “Until you start doing metrics, you think you are doing better than you are,” he said. “The majority of us are not using any form of metric.”

Other benefits of EMRs include:

▸ An increase in productivity. Dr. Bergman observed that, now, paper records slow him down. EMRs give him instant access to entire histories, including lab tests and drugs used.

▸ Easy creation of referral letters. Print them by pressing a couple of buttons.

▸ A tool for research. Patient data can be graphed to show results of treatment over time, which provides a good source of private practice research.

▸ Access to databases. Data extracted from the EMR database can readily be shared with existing databases, such as the Consortium of Rheumatology Researchers of North America (CORRONA), and the National Data Bank for Rheumatic Diseases.

Patient data typically collected in an EMR include demographic information, active and comorbid diagnoses, currently and formerly used medications, lab reports, DAS28 findings, both physician and patient global scores, Rheumatology Assessment Patient Index Data (RAPID) findings, and patient-reported measures such as pain, functionality, fatigue, and tender and swollen joint counts, he said during his presentation at a symposium sponsored by Excellence in Rheumatology Education.

EMR software offers two basic options: template software or database software. The choice might depend on whether the rheumatologist is in a solo or group practice.

The solo rheumatologist will be better served by database software, which is flexible and can be altered on the fly to fit special information-gathering needs. But a group practice or hospital will more likely want template software, which is more rigid, and requires all users to fill in the same kinds of information in the same format.

Free, month-long demos of software are available that allow rheumatologists to decide which is best for them.

Although patients can enter data directly into their EMRs at an office computer kiosk, older arthritic patients who have limited dexterity might find doing so difficult. A personal digital assistant (PDA), which is often used by physicians to enter patient data in hospitals, also presents problems for older arthritic patients to use at the office. A laptop is another option; however, because it may need to be replaced every few years, it may be a costly one.

Dr. Bergman gives his patients paper questionnaires; the answers are entered into the EMRs. By filling out the questionnaires, patients become more focused on their disease, which helps focus the physician-patient encounter. His questionnaire comprises mostly check-off questions, which are easy for patients to fill it out quickly and for office staff to enter electronically. After the patient's questionnaire information has been entered into an EMR, Dr. Bergman can quickly open the patient's record, see the new information, and easily review information from the previous visit.

Dr. Bergman said that he has been using EMR software from Stat Systems for 12 years. He is neither a spokesman for nor an owner of the company.

MAUI, HAWAII — Physicians are needlessly resisting the inevitability of electronic medical records, according to Dr. Martin J. Bergman.

As of 2005, about 23% of office-based physicians used electronic medical records (EMRs), said Dr. Bergman, citing statistics from the Centers for Disease Control and Prevention's National Center for Health Statistics that were reported in 2006. In contrast, almost 80% of office-based physicians used billing software, he added.

Reasons for resistance include complaints that EMRs are difficult to complete, interrupt the office flow, and take too much time to administer and review, said Dr. Bergman, chief of rheumatology at Taylor Hospital, Ridley Park, Pa.

The first obstacle is cost, he noted. EMRsoftware can run $5,000 to more than $30,000. Still, the better software does not necessarily cost more. Once EMRs are established in the practice, physicians can expect significant savings, especially on transcription fees.

Twelve years ago, Dr. Bergman said he was paying just under $20,000 a year for transcriptions. "I no longer use a transcriptionist. Over 12 years, I've saved close to $250,000" on those fees alone.

However, there is a "steep learning curve" in getting used to using EMRs; it takes about 3 months to become familiar enough with the software that it no longer slows the physician's practice. But after that, he said, "your productivity doubles."

Dr. Bergman pointed out that physicians can use EMRs to track metrics—measures of patients' progress—which is difficult to do with paper files. Metrics can quickly help gauge the success of the practice, and the news is not always good. "Until you start doing metrics, you think you are doing better than you are," he said.

Benefits of EMRs include:

▸ An increase in productivity. Dr. Bergman observed that, now, paper records slow him down. EMRs give him instant access to entire histories, including lab tests and drugs used.

▸ Easy creation of referral letters. Print them by pressing a couple of buttons, and upon leaving the computer, he said, "I'm done when I'm done."

▸ A tool for research. Patient data can be graphed to show results of treatment over time, which provides a good source of private practice research.

▸ Access to databases. Data extracted from the database can readily be shared with existing databases.

Patient data typically collected in an EMR include demographic information, active and comorbid diagnoses, current and formerly used medications, lab reports, DAS28 findings, both physician and patient global scores, and patient-reported measures such as pain, functionality, fatigue, and tender and swollen joint counts, Dr. Bergman said during his presentation at a symposium sponsored by Excellence in Rheumatology Education.

EMR software offers two basic options: template or database software. The choice might depend on whether the physician is in a solo or group practice.

The solo dermatologist will be better served by database software, which is flexible and can be altered on the fly to fit special information-gathering needs. But a group practice or hospital will more likely want template software, which requires all users to fill in the same kinds of information in the same format.

Dr. Bergman said although he has been using EMR software from Stat Systems for 12 years, he is not a spokesman for nor an owner of the company.

MAUI, HAWAII — Physicians are needlessly resisting the inevitability of electronic medical records, according to Dr. Martin J. Bergman.

As of 2005, about 23% of office-based physicians used electronic medical records (EMRs), said Dr. Bergman, citing statistics from the Centers for Disease Control and Prevention's National Center for Health Statistics that were reported in 2006. In contrast, almost 80% of office-based physicians used billing software, he added.

Reasons for resistance include complaints that EMRs are difficult to complete, interrupt the office flow, and take too much time to administer and review, said Dr. Bergman, chief of rheumatology at Taylor Hospital, Ridley Park, Pa.

The first obstacle is cost, he noted. EMRsoftware can run $5,000 to more than $30,000. Still, the better software does not necessarily cost more. Once EMRs are established in the practice, physicians can expect significant savings, especially on transcription fees.

Twelve years ago, Dr. Bergman said he was paying just under $20,000 a year for transcriptions. "I no longer use a transcriptionist. Over 12 years, I've saved close to $250,000" on those fees alone.

However, there is a "steep learning curve" in getting used to using EMRs; it takes about 3 months to become familiar enough with the software that it no longer slows the physician's practice. But after that, he said, "your productivity doubles."

Dr. Bergman pointed out that physicians can use EMRs to track metrics—measures of patients' progress—which is difficult to do with paper files. Metrics can quickly help gauge the success of the practice, and the news is not always good. "Until you start doing metrics, you think you are doing better than you are," he said.

Benefits of EMRs include:

▸ An increase in productivity. Dr. Bergman observed that, now, paper records slow him down. EMRs give him instant access to entire histories, including lab tests and drugs used.

▸ Easy creation of referral letters. Print them by pressing a couple of buttons, and upon leaving the computer, he said, "I'm done when I'm done."

▸ A tool for research. Patient data can be graphed to show results of treatment over time, which provides a good source of private practice research.

▸ Access to databases. Data extracted from the database can readily be shared with existing databases.

Patient data typically collected in an EMR include demographic information, active and comorbid diagnoses, current and formerly used medications, lab reports, DAS28 findings, both physician and patient global scores, and patient-reported measures such as pain, functionality, fatigue, and tender and swollen joint counts, Dr. Bergman said during his presentation at a symposium sponsored by Excellence in Rheumatology Education.

EMR software offers two basic options: template or database software. The choice might depend on whether the physician is in a solo or group practice.

The solo dermatologist will be better served by database software, which is flexible and can be altered on the fly to fit special information-gathering needs. But a group practice or hospital will more likely want template software, which requires all users to fill in the same kinds of information in the same format.

Dr. Bergman said although he has been using EMR software from Stat Systems for 12 years, he is not a spokesman for nor an owner of the company.

MAUI, HAWAII — Physicians are needlessly resisting the inevitability of electronic medical records, according to Dr. Martin J. Bergman.

As of 2005, about 23% of office-based physicians used electronic medical records (EMRs), said Dr. Bergman, citing statistics from the Centers for Disease Control and Prevention's National Center for Health Statistics that were reported in 2006. In contrast, almost 80% of office-based physicians used billing software, he added.

Reasons for resistance include complaints that EMRs are difficult to complete, interrupt the office flow, and take too much time to administer and review, said Dr. Bergman, chief of rheumatology at Taylor Hospital, Ridley Park, Pa.

The first obstacle is cost, he noted. EMRsoftware can run $5,000 to more than $30,000. Still, the better software does not necessarily cost more. Once EMRs are established in the practice, physicians can expect significant savings, especially on transcription fees.

Twelve years ago, Dr. Bergman said he was paying just under $20,000 a year for transcriptions. "I no longer use a transcriptionist. Over 12 years, I've saved close to $250,000" on those fees alone.

However, there is a "steep learning curve" in getting used to using EMRs; it takes about 3 months to become familiar enough with the software that it no longer slows the physician's practice. But after that, he said, "your productivity doubles."

Dr. Bergman pointed out that physicians can use EMRs to track metrics—measures of patients' progress—which is difficult to do with paper files. Metrics can quickly help gauge the success of the practice, and the news is not always good. "Until you start doing metrics, you think you are doing better than you are," he said.

Benefits of EMRs include:

▸ An increase in productivity. Dr. Bergman observed that, now, paper records slow him down. EMRs give him instant access to entire histories, including lab tests and drugs used.

▸ Easy creation of referral letters. Print them by pressing a couple of buttons, and upon leaving the computer, he said, "I'm done when I'm done."

▸ A tool for research. Patient data can be graphed to show results of treatment over time, which provides a good source of private practice research.

▸ Access to databases. Data extracted from the database can readily be shared with existing databases.

Patient data typically collected in an EMR include demographic information, active and comorbid diagnoses, current and formerly used medications, lab reports, DAS28 findings, both physician and patient global scores, and patient-reported measures such as pain, functionality, fatigue, and tender and swollen joint counts, Dr. Bergman said during his presentation at a symposium sponsored by Excellence in Rheumatology Education.

EMR software offers two basic options: template or database software. The choice might depend on whether the physician is in a solo or group practice.

The solo dermatologist will be better served by database software, which is flexible and can be altered on the fly to fit special information-gathering needs. But a group practice or hospital will more likely want template software, which requires all users to fill in the same kinds of information in the same format.

Dr. Bergman said although he has been using EMR software from Stat Systems for 12 years, he is not a spokesman for nor an owner of the company.

MAUI, HAWAII — Physicians are needlessly resisting the inevitability of electronic medical records, according to Dr. Martin J. Bergman.

As of 2005, about 23% of office-based physicians used electronic medical records (EMRs), said Dr. Bergman, citing statistics from the Centers for Disease Control and Prevention's National Center for Health Statistics that were reported in 2006. In contrast, almost 80% of office-based physicians used billing software, he added.

Reasons for resistance include complaints that EMRs are difficult to complete, interrupt the office flow, and take too much time to administer and review, said Dr. Bergman of Taylor Hospital, Ridley Park, Pa.

“The first obstacle is cost,” he noted. The cost of getting EMR software can range from $5,000 to more than $30,000, although the better software doesn't necessarily cost more.

Once EMRs are established in the practice, physicians can expect significant savings associated with their use. The practice will save on transcription fees, and dictation will no longer be needed.

“My example is 12 years ago, when I went into electronic records, I was paying just under $20,000 a year for transcriptions,” he recalled. “I no longer use a transcriptionist. Over 12 years, I've saved close to $250,000 on transcription fees alone.”

As for time difficulties, there is a “steep learning curve” in getting used to using EMRs; it takes about 3 months to become familiar enough with the software that it no longer slows down the physician's practice.

“Those first 3 months are ugly,” he said. “After that, your productivity doubles.”

Dr. Bergman pointed out that EMRs can be used to track metrics—measures of patients' progress—which is difficult to do with paper files.

Metrics can quickly help gauge the success of the practice, and the news is not always good. “Until you start doing metrics, you think you are doing better than you are,” he said. “The majority of us are not using any form of metric.”

Other benefits of EMRs include:

▸ An increase in productivity. Dr. Bergman observed that, now, paper records slow him down. EMRs give him instant access to entire histories, including lab tests and drugs used.

▸ Easy creation of referral letters. Print them by pressing a couple of buttons, and upon leaving the computer, he said, “I'm done when I'm done.”

▸ A tool for research. Patient data can be graphed to show results of treatment over time, which provides a good source of private practice research.

▸ Access to databases. Data extracted from the EMR database can readily be shared with existing databases.

Patient data typically collected in an EMR include demographic information, active and comorbid diagnoses, currently and formerly used medications, and lab reports, he said during his presentation at a symposium sponsored by Excellence in Rheumatology Education.

EMR software offers two basic options: template software and database software. The choice might depend on whether the purchaser is in a solo practice or a group practice.

The solo practice will be better served by database software, which is flexible and can be altered on the fly to fit special information-gathering needs. But a group practice or hospital will more likely want template software, which is more rigid, and requires all users to fill in the same kinds of information in the same format.

Solo practitioners, Dr. Berman said, will probably not like working with rigid template software; they should look at flexible database software instead.

There are free, month-long demos of software available that allow determination of which one is appropriate for the practice.

Although patients can enter data directly into their EMRs at an office computer kiosk, some patients might find doing so difficult.

A personal digital assistant (PDA), which is often used by physicians to enter patient data in hospitals, also presents problems for some patients. A laptop is another option; however, because it may need to be replaced every few years, it may be a costly one.

Dr. Bergman gives his patients paper questionnaires; the answers are entered into the EMRs. His questionnaire comprises mostly check-off questions, which are easy for patients to fill it out quickly and for office staff to enter electronically.

After the patient's questionnaire information has been entered into an EMR at the office, Dr. Bergman can quickly open the patient's record, see the new information, and easily review information from the previous visit.

Dr. Bergman said that although he has been using EMR software from Stat Systems for 12 years, he is neither a spokesman for nor an owner of the company.

MAUI, HAWAII — Physicians are needlessly resisting the inevitability of electronic medical records, according to Dr. Martin J. Bergman.

As of 2005, about 23% of office-based physicians used electronic medical records (EMRs), said Dr. Bergman, citing statistics from the Centers for Disease Control and Prevention's National Center for Health Statistics that were reported in 2006. In contrast, almost 80% of office-based physicians used billing software, he added.

Reasons for resistance include complaints that EMRs are difficult to complete, interrupt the office flow, and take too much time to administer and review, said Dr. Bergman of Taylor Hospital, Ridley Park, Pa.

“The first obstacle is cost,” he noted. The cost of getting EMR software can range from $5,000 to more than $30,000, although the better software doesn't necessarily cost more.

Once EMRs are established in the practice, physicians can expect significant savings associated with their use. The practice will save on transcription fees, and dictation will no longer be needed.

“My example is 12 years ago, when I went into electronic records, I was paying just under $20,000 a year for transcriptions,” he recalled. “I no longer use a transcriptionist. Over 12 years, I've saved close to $250,000 on transcription fees alone.”

As for time difficulties, there is a “steep learning curve” in getting used to using EMRs; it takes about 3 months to become familiar enough with the software that it no longer slows down the physician's practice.

“Those first 3 months are ugly,” he said. “After that, your productivity doubles.”

Dr. Bergman pointed out that EMRs can be used to track metrics—measures of patients' progress—which is difficult to do with paper files.

Metrics can quickly help gauge the success of the practice, and the news is not always good. “Until you start doing metrics, you think you are doing better than you are,” he said. “The majority of us are not using any form of metric.”

Other benefits of EMRs include:

▸ An increase in productivity. Dr. Bergman observed that, now, paper records slow him down. EMRs give him instant access to entire histories, including lab tests and drugs used.

▸ Easy creation of referral letters. Print them by pressing a couple of buttons, and upon leaving the computer, he said, “I'm done when I'm done.”

▸ A tool for research. Patient data can be graphed to show results of treatment over time, which provides a good source of private practice research.

▸ Access to databases. Data extracted from the EMR database can readily be shared with existing databases.

Patient data typically collected in an EMR include demographic information, active and comorbid diagnoses, currently and formerly used medications, and lab reports, he said during his presentation at a symposium sponsored by Excellence in Rheumatology Education.

EMR software offers two basic options: template software and database software. The choice might depend on whether the purchaser is in a solo practice or a group practice.

The solo practice will be better served by database software, which is flexible and can be altered on the fly to fit special information-gathering needs. But a group practice or hospital will more likely want template software, which is more rigid, and requires all users to fill in the same kinds of information in the same format.

Solo practitioners, Dr. Berman said, will probably not like working with rigid template software; they should look at flexible database software instead.

There are free, month-long demos of software available that allow determination of which one is appropriate for the practice.

Although patients can enter data directly into their EMRs at an office computer kiosk, some patients might find doing so difficult.

A personal digital assistant (PDA), which is often used by physicians to enter patient data in hospitals, also presents problems for some patients. A laptop is another option; however, because it may need to be replaced every few years, it may be a costly one.

Dr. Bergman gives his patients paper questionnaires; the answers are entered into the EMRs. His questionnaire comprises mostly check-off questions, which are easy for patients to fill it out quickly and for office staff to enter electronically.

After the patient's questionnaire information has been entered into an EMR at the office, Dr. Bergman can quickly open the patient's record, see the new information, and easily review information from the previous visit.

Dr. Bergman said that although he has been using EMR software from Stat Systems for 12 years, he is neither a spokesman for nor an owner of the company.

MAUI, HAWAII — Physicians are needlessly resisting the inevitability of electronic medical records, according to Dr. Martin J. Bergman.

As of 2005, about 23% of office-based physicians used electronic medical records (EMRs), said Dr. Bergman, citing statistics from the Centers for Disease Control and Prevention's National Center for Health Statistics that were reported in 2006. In contrast, almost 80% of office-based physicians used billing software, he added.

Reasons for resistance include complaints that EMRs are difficult to complete, interrupt the office flow, and take too much time to administer and review, said Dr. Bergman of Taylor Hospital, Ridley Park, Pa.

“The first obstacle is cost,” he noted. The cost of getting EMR software can range from $5,000 to more than $30,000, although the better software doesn't necessarily cost more.

Once EMRs are established in the practice, physicians can expect significant savings associated with their use. The practice will save on transcription fees, and dictation will no longer be needed.

“My example is 12 years ago, when I went into electronic records, I was paying just under $20,000 a year for transcriptions,” he recalled. “I no longer use a transcriptionist. Over 12 years, I've saved close to $250,000 on transcription fees alone.”

As for time difficulties, there is a “steep learning curve” in getting used to using EMRs; it takes about 3 months to become familiar enough with the software that it no longer slows down the physician's practice.

“Those first 3 months are ugly,” he said. “After that, your productivity doubles.”

Dr. Bergman pointed out that EMRs can be used to track metrics—measures of patients' progress—which is difficult to do with paper files.

Metrics can quickly help gauge the success of the practice, and the news is not always good. “Until you start doing metrics, you think you are doing better than you are,” he said. “The majority of us are not using any form of metric.”

Other benefits of EMRs include:

▸ An increase in productivity. Dr. Bergman observed that, now, paper records slow him down. EMRs give him instant access to entire histories, including lab tests and drugs used.

▸ Easy creation of referral letters. Print them by pressing a couple of buttons, and upon leaving the computer, he said, “I'm done when I'm done.”

▸ A tool for research. Patient data can be graphed to show results of treatment over time, which provides a good source of private practice research.

▸ Access to databases. Data extracted from the EMR database can readily be shared with existing databases.

Patient data typically collected in an EMR include demographic information, active and comorbid diagnoses, currently and formerly used medications, and lab reports, he said during his presentation at a symposium sponsored by Excellence in Rheumatology Education.

EMR software offers two basic options: template software and database software. The choice might depend on whether the purchaser is in a solo practice or a group practice.

The solo practice will be better served by database software, which is flexible and can be altered on the fly to fit special information-gathering needs. But a group practice or hospital will more likely want template software, which is more rigid, and requires all users to fill in the same kinds of information in the same format.

Solo practitioners, Dr. Berman said, will probably not like working with rigid template software; they should look at flexible database software instead.

There are free, month-long demos of software available that allow determination of which one is appropriate for the practice.

Although patients can enter data directly into their EMRs at an office computer kiosk, some patients might find doing so difficult.

A personal digital assistant (PDA), which is often used by physicians to enter patient data in hospitals, also presents problems for some patients. A laptop is another option; however, because it may need to be replaced every few years, it may be a costly one.

Dr. Bergman gives his patients paper questionnaires; the answers are entered into the EMRs. His questionnaire comprises mostly check-off questions, which are easy for patients to fill it out quickly and for office staff to enter electronically.

After the patient's questionnaire information has been entered into an EMR at the office, Dr. Bergman can quickly open the patient's record, see the new information, and easily review information from the previous visit.

Dr. Bergman said that although he has been using EMR software from Stat Systems for 12 years, he is neither a spokesman for nor an owner of the company.

WAIKOLOA, HAWAII — Patients with low to moderate cardiac risk who receive targeted β-blocker therapy may not need to undergo preoperative stress testing before undergoing major vascular surgery/amputation, according to a new study presented at the annual meeting of the Western Vascular Society.

Anesthesiologists typically require a preoperative stress test in patients at low to intermediate risk of cardiac events, although recent evidence has found that such testing does not provide a benefit for such patients.

“Despite the literature, the American Heart Association has published a series of guidelines for preoperative cardiac risk assessment; it continues to recommend stress testing for a significant number of patients,” said Dr. Arezou Yaghoubian, a resident in the department of surgery at Harbor-UCLA Medical Center, Torrance, Calif. “As a result, many anesthesiologists won't take patients to surgery unless they are cardiac cleared, and many cardiologists won't clear patients for surgery without stress testing.”

The purpose of this study was to assess whether preoperative cardiac stress testing is needed in low- to intermediate-risk patients who receive targeted β-blocker therapy prior to major vascular surgery or lower extremity amputation. The primary end point was a composite measure of adverse cardiac outcomes. The study had both prospective and retrospective components.

Between the years 2004 and 2006, 100 consecutive prospectively enrolled patients who were scheduled to undergo major vascular surgery/lower-extremity amputation were given targeted β-blocker therapy but no preoperative cardiac stress testing or coronary revascularization.

“[Patients] were given metoprolol at 25 mg b.i.d. and had their dose titrated to an ideal target heart rate of 50–60 beats per minute,” Dr. Yaghoubian said. This was achieved in 24% of patients. Failure to achieve the target did not preclude surgery.

Another 80 control patients who had undergone similar procedures between 1999 and 2003 were identified retrospectively, she explained, adding: “Preoperative cardiac stress testing was utilized in 14% of the retrospective patients.” β-Blockade was given to 61% of retrospective patients.

“The primary outcome of this study was an adverse cardiac event,” she said, “either within the hospital or within 30 days of discharge.”

As for results, prospectively enrolled patients had a cardiac complication rate of 2%, compared with 10% of retrospective patients, a significant difference (P = .02).

Nobody died in either group. Multivariate analysis of the data found a significantly lower rate of cardiac complications in prospective patients, compared with retrospective ones (P = .003).

“In conclusion, in low- to intermediate-risk patients undergoing major vascular surgery and lower-extremity amputation, preoperative, targeted β-blockade is feasible in a short period of time,” Dr. Yaghoubian said.

“The findings of this study suggest that routine use of targeted β-blockade lowers cardiac morbidity and may even obviate the need for preoperative stress testing,” she said.

WAIKOLOA, HAWAII — Patients with low to moderate cardiac risk who receive targeted β-blocker therapy may not need to undergo preoperative stress testing before undergoing major vascular surgery/amputation, according to a new study presented at the annual meeting of the Western Vascular Society.

Anesthesiologists typically require a preoperative stress test in patients at low to intermediate risk of cardiac events, although recent evidence has found that such testing does not provide a benefit for such patients.

“Despite the literature, the American Heart Association has published a series of guidelines for preoperative cardiac risk assessment; it continues to recommend stress testing for a significant number of patients,” said Dr. Arezou Yaghoubian, a resident in the department of surgery at Harbor-UCLA Medical Center, Torrance, Calif. “As a result, many anesthesiologists won't take patients to surgery unless they are cardiac cleared, and many cardiologists won't clear patients for surgery without stress testing.”

The purpose of this study was to assess whether preoperative cardiac stress testing is needed in low- to intermediate-risk patients who receive targeted β-blocker therapy prior to major vascular surgery or lower extremity amputation. The primary end point was a composite measure of adverse cardiac outcomes. The study had both prospective and retrospective components.

Between the years 2004 and 2006, 100 consecutive prospectively enrolled patients who were scheduled to undergo major vascular surgery/lower-extremity amputation were given targeted β-blocker therapy but no preoperative cardiac stress testing or coronary revascularization.

“[Patients] were given metoprolol at 25 mg b.i.d. and had their dose titrated to an ideal target heart rate of 50–60 beats per minute,” Dr. Yaghoubian said. This was achieved in 24% of patients. Failure to achieve the target did not preclude surgery.

Another 80 control patients who had undergone similar procedures between 1999 and 2003 were identified retrospectively, she explained, adding: “Preoperative cardiac stress testing was utilized in 14% of the retrospective patients.” β-Blockade was given to 61% of retrospective patients.

“The primary outcome of this study was an adverse cardiac event,” she said, “either within the hospital or within 30 days of discharge.”

As for results, prospectively enrolled patients had a cardiac complication rate of 2%, compared with 10% of retrospective patients, a significant difference (P = .02).

Nobody died in either group. Multivariate analysis of the data found a significantly lower rate of cardiac complications in prospective patients, compared with retrospective ones (P = .003).

“In conclusion, in low- to intermediate-risk patients undergoing major vascular surgery and lower-extremity amputation, preoperative, targeted β-blockade is feasible in a short period of time,” Dr. Yaghoubian said.

“The findings of this study suggest that routine use of targeted β-blockade lowers cardiac morbidity and may even obviate the need for preoperative stress testing,” she said.

WAIKOLOA, HAWAII — Patients with low to moderate cardiac risk who receive targeted β-blocker therapy may not need to undergo preoperative stress testing before undergoing major vascular surgery/amputation, according to a new study presented at the annual meeting of the Western Vascular Society.

Anesthesiologists typically require a preoperative stress test in patients at low to intermediate risk of cardiac events, although recent evidence has found that such testing does not provide a benefit for such patients.

“Despite the literature, the American Heart Association has published a series of guidelines for preoperative cardiac risk assessment; it continues to recommend stress testing for a significant number of patients,” said Dr. Arezou Yaghoubian, a resident in the department of surgery at Harbor-UCLA Medical Center, Torrance, Calif. “As a result, many anesthesiologists won't take patients to surgery unless they are cardiac cleared, and many cardiologists won't clear patients for surgery without stress testing.”

The purpose of this study was to assess whether preoperative cardiac stress testing is needed in low- to intermediate-risk patients who receive targeted β-blocker therapy prior to major vascular surgery or lower extremity amputation. The primary end point was a composite measure of adverse cardiac outcomes. The study had both prospective and retrospective components.

Between the years 2004 and 2006, 100 consecutive prospectively enrolled patients who were scheduled to undergo major vascular surgery/lower-extremity amputation were given targeted β-blocker therapy but no preoperative cardiac stress testing or coronary revascularization.

“[Patients] were given metoprolol at 25 mg b.i.d. and had their dose titrated to an ideal target heart rate of 50–60 beats per minute,” Dr. Yaghoubian said. This was achieved in 24% of patients. Failure to achieve the target did not preclude surgery.

Another 80 control patients who had undergone similar procedures between 1999 and 2003 were identified retrospectively, she explained, adding: “Preoperative cardiac stress testing was utilized in 14% of the retrospective patients.” β-Blockade was given to 61% of retrospective patients.

“The primary outcome of this study was an adverse cardiac event,” she said, “either within the hospital or within 30 days of discharge.”

As for results, prospectively enrolled patients had a cardiac complication rate of 2%, compared with 10% of retrospective patients, a significant difference (P = .02).

Nobody died in either group. Multivariate analysis of the data found a significantly lower rate of cardiac complications in prospective patients, compared with retrospective ones (P = .003).

“In conclusion, in low- to intermediate-risk patients undergoing major vascular surgery and lower-extremity amputation, preoperative, targeted β-blockade is feasible in a short period of time,” Dr. Yaghoubian said.

“The findings of this study suggest that routine use of targeted β-blockade lowers cardiac morbidity and may even obviate the need for preoperative stress testing,” she said.

MAUI, HAWAII – Because tinea capitis in children can be mistaken for a number of other diseases, Dr. Sheila Fallon Friedlander urged physicians, “I want you to culture.”

“Classically, people have thought that you look for hair loss and scaling, but my experience has been that most scalps that scale are not tinea capitis,” she said at a meeting sponsored by the University Children's Medical Group and the American Academy of Pediatrics.

Although with some presentations tinea capitis can be easy to diagnose, the infection can look unusual and be harder to detect, she said at the meeting, also sponsored by California Chapter 2 of the AAP.

Diseases and conditions that can be mistaken for tinea capitis include seborrheic dermatitis, eczema, psoriasis, alopecia areata, cradle cap, traction folliculitis leading to traction alopecia, and the effects of head lice.

In their study, Dr. Friedlander and a colleague examined 200 children, with half in her organization's clinic and half in other pediatric practices in San Diego. “What we found is a heck of a lot of kids have scale on their scalp,” she said. “And a heck of a lot of kids–if you look for it–have [enlarged] lymph nodes in their neck.” Based on these two symptoms plus hair loss, many pediatricians have been trained to diagnose tinea capitis, said Dr. Friedlander, director of the fellowship training program in pediatric and adolescent dermatology at Rady Children's Hospital, San Diego.

“But that's inaccurate,” she said. “That's not appropriate. In our study, we found that 22% of kids just walking into the pediatrician's office had scale, and 55% of them had [enlarged] lymph nodes. Very few of those kids had tinea capitis” (Pediatrics 2005;115:e1-6). She encouraged checking the lymph nodes, however. “If a child comes in who has scaling and has hair loss and has large lymph nodes, then you are very likely to be dealing with tinea capitis.” But the child needs to be cultured to confirm the diagnosis.

Dr. Friedlander said her center has done a study that supports taking cultures with a cotton swab and transport medium otherwise used for strep throat. She instructed the audience to swab all four quadrants of the patient's scalp and send it out to a lab. Even if the sample swab sits at room temperature in the office for a couple of days before delivery to the lab, the results still should be good.

“Ninety-five percent of tinea capitis in this country is caused by Trichophyton tonsurans,” she said, which is believed to have come from Central and South America. Tinea capitis is the most common dermatophyte infection in children, frequently affecting those who are aged 3-7 years. “It commonly affects the preschool age group.”

“The prevalence is somewhere between 0% and 8% in any given place, depending on the city you're looking at,” she said, and it's even higher in some urban populations and among African Americans. Prevalence appears to be relatively higher in immigrants from Africa.

While taking the history, Dr. Friedlander continued, also ask about family members, “because often there will be somebody else in the house who is scaling.”

As for treatment, a meta-analysis of six studies found that a 2- to 4-week course of terbinafine is “at least as effective” as a 6- to 8-week course of griseofulvin for Trichophyton. But for Microsporum infections, griseofulvin is likely the better treatment (Pediatrics 2004;114:1312-5).

“High-dose griseofulvin, for the moment, is the drug of choice; it's FDA approved,” she said. It should be given with food to aid absorption. Keep in mind that children clear the drug faster than do adults and, therefore, need a high dose. Patients should be rechecked in 4 weeks. Most of Dr. Friedlander's patients are treated for 8 weeks. Lab tests are not needed if patients use the drug for 8 weeks or less.

“Consider off-label use of terbinafine if there is griseofulvin failure,” she said.

As an aid to therapy, the use of antifungal lotions and shampoos help decrease the time of infectivity, Dr. Friedlander said.

She has her patients use Nizoral shampoo twice a week. Selenium sulfite is another option.

Dr. Friedlander disclosed that she is a speaker on the speakers bureau, a consultant, and/or involved with clinical research trials for Novartis AG, Pfizer Inc., and Dermik Laboratories.

MAUI, HAWAII – Because tinea capitis in children can be mistaken for a number of other diseases, Dr. Sheila Fallon Friedlander urged physicians, “I want you to culture.”

“Classically, people have thought that you look for hair loss and scaling, but my experience has been that most scalps that scale are not tinea capitis,” she said at a meeting sponsored by the University Children's Medical Group and the American Academy of Pediatrics.

Although with some presentations tinea capitis can be easy to diagnose, the infection can look unusual and be harder to detect, she said at the meeting, also sponsored by California Chapter 2 of the AAP.

Diseases and conditions that can be mistaken for tinea capitis include seborrheic dermatitis, eczema, psoriasis, alopecia areata, cradle cap, traction folliculitis leading to traction alopecia, and the effects of head lice.

In their study, Dr. Friedlander and a colleague examined 200 children, with half in her organization's clinic and half in other pediatric practices in San Diego. “What we found is a heck of a lot of kids have scale on their scalp,” she said. “And a heck of a lot of kids–if you look for it–have [enlarged] lymph nodes in their neck.” Based on these two symptoms plus hair loss, many pediatricians have been trained to diagnose tinea capitis, said Dr. Friedlander, director of the fellowship training program in pediatric and adolescent dermatology at Rady Children's Hospital, San Diego.

“But that's inaccurate,” she said. “That's not appropriate. In our study, we found that 22% of kids just walking into the pediatrician's office had scale, and 55% of them had [enlarged] lymph nodes. Very few of those kids had tinea capitis” (Pediatrics 2005;115:e1-6). She encouraged checking the lymph nodes, however. “If a child comes in who has scaling and has hair loss and has large lymph nodes, then you are very likely to be dealing with tinea capitis.” But the child needs to be cultured to confirm the diagnosis.

Dr. Friedlander said her center has done a study that supports taking cultures with a cotton swab and transport medium otherwise used for strep throat. She instructed the audience to swab all four quadrants of the patient's scalp and send it out to a lab. Even if the sample swab sits at room temperature in the office for a couple of days before delivery to the lab, the results still should be good.

“Ninety-five percent of tinea capitis in this country is caused by Trichophyton tonsurans,” she said, which is believed to have come from Central and South America. Tinea capitis is the most common dermatophyte infection in children, frequently affecting those who are aged 3-7 years. “It commonly affects the preschool age group.”

“The prevalence is somewhere between 0% and 8% in any given place, depending on the city you're looking at,” she said, and it's even higher in some urban populations and among African Americans. Prevalence appears to be relatively higher in immigrants from Africa.

While taking the history, Dr. Friedlander continued, also ask about family members, “because often there will be somebody else in the house who is scaling.”

As for treatment, a meta-analysis of six studies found that a 2- to 4-week course of terbinafine is “at least as effective” as a 6- to 8-week course of griseofulvin for Trichophyton. But for Microsporum infections, griseofulvin is likely the better treatment (Pediatrics 2004;114:1312-5).

“High-dose griseofulvin, for the moment, is the drug of choice; it's FDA approved,” she said. It should be given with food to aid absorption. Keep in mind that children clear the drug faster than do adults and, therefore, need a high dose. Patients should be rechecked in 4 weeks. Most of Dr. Friedlander's patients are treated for 8 weeks. Lab tests are not needed if patients use the drug for 8 weeks or less.

“Consider off-label use of terbinafine if there is griseofulvin failure,” she said.

As an aid to therapy, the use of antifungal lotions and shampoos help decrease the time of infectivity, Dr. Friedlander said.

She has her patients use Nizoral shampoo twice a week. Selenium sulfite is another option.

Dr. Friedlander disclosed that she is a speaker on the speakers bureau, a consultant, and/or involved with clinical research trials for Novartis AG, Pfizer Inc., and Dermik Laboratories.

MAUI, HAWAII – Because tinea capitis in children can be mistaken for a number of other diseases, Dr. Sheila Fallon Friedlander urged physicians, “I want you to culture.”

“Classically, people have thought that you look for hair loss and scaling, but my experience has been that most scalps that scale are not tinea capitis,” she said at a meeting sponsored by the University Children's Medical Group and the American Academy of Pediatrics.

Although with some presentations tinea capitis can be easy to diagnose, the infection can look unusual and be harder to detect, she said at the meeting, also sponsored by California Chapter 2 of the AAP.

Diseases and conditions that can be mistaken for tinea capitis include seborrheic dermatitis, eczema, psoriasis, alopecia areata, cradle cap, traction folliculitis leading to traction alopecia, and the effects of head lice.

In their study, Dr. Friedlander and a colleague examined 200 children, with half in her organization's clinic and half in other pediatric practices in San Diego. “What we found is a heck of a lot of kids have scale on their scalp,” she said. “And a heck of a lot of kids–if you look for it–have [enlarged] lymph nodes in their neck.” Based on these two symptoms plus hair loss, many pediatricians have been trained to diagnose tinea capitis, said Dr. Friedlander, director of the fellowship training program in pediatric and adolescent dermatology at Rady Children's Hospital, San Diego.

“But that's inaccurate,” she said. “That's not appropriate. In our study, we found that 22% of kids just walking into the pediatrician's office had scale, and 55% of them had [enlarged] lymph nodes. Very few of those kids had tinea capitis” (Pediatrics 2005;115:e1-6). She encouraged checking the lymph nodes, however. “If a child comes in who has scaling and has hair loss and has large lymph nodes, then you are very likely to be dealing with tinea capitis.” But the child needs to be cultured to confirm the diagnosis.

Dr. Friedlander said her center has done a study that supports taking cultures with a cotton swab and transport medium otherwise used for strep throat. She instructed the audience to swab all four quadrants of the patient's scalp and send it out to a lab. Even if the sample swab sits at room temperature in the office for a couple of days before delivery to the lab, the results still should be good.

“Ninety-five percent of tinea capitis in this country is caused by Trichophyton tonsurans,” she said, which is believed to have come from Central and South America. Tinea capitis is the most common dermatophyte infection in children, frequently affecting those who are aged 3-7 years. “It commonly affects the preschool age group.”

“The prevalence is somewhere between 0% and 8% in any given place, depending on the city you're looking at,” she said, and it's even higher in some urban populations and among African Americans. Prevalence appears to be relatively higher in immigrants from Africa.

While taking the history, Dr. Friedlander continued, also ask about family members, “because often there will be somebody else in the house who is scaling.”

As for treatment, a meta-analysis of six studies found that a 2- to 4-week course of terbinafine is “at least as effective” as a 6- to 8-week course of griseofulvin for Trichophyton. But for Microsporum infections, griseofulvin is likely the better treatment (Pediatrics 2004;114:1312-5).

“High-dose griseofulvin, for the moment, is the drug of choice; it's FDA approved,” she said. It should be given with food to aid absorption. Keep in mind that children clear the drug faster than do adults and, therefore, need a high dose. Patients should be rechecked in 4 weeks. Most of Dr. Friedlander's patients are treated for 8 weeks. Lab tests are not needed if patients use the drug for 8 weeks or less.

“Consider off-label use of terbinafine if there is griseofulvin failure,” she said.

As an aid to therapy, the use of antifungal lotions and shampoos help decrease the time of infectivity, Dr. Friedlander said.

She has her patients use Nizoral shampoo twice a week. Selenium sulfite is another option.

Dr. Friedlander disclosed that she is a speaker on the speakers bureau, a consultant, and/or involved with clinical research trials for Novartis AG, Pfizer Inc., and Dermik Laboratories.

HONOLULU — Bazedoxifene is effective in preventing osteoporosis in postmenopausal women, according to the results of a 2-year, phase III, placebo-controlled trial presented at the annual meeting of the American Society for Bone and Mineral Research.

Participants were postmenopausal women aged 45 years, whose femoral neck bone or lumbar spine T scores were above −2.5. Women with vasomotor symptoms, bone diseases, prior vertebral fractures, or endometrial hyperplasia, were excluded.

A total of 1,583 postmenopausal women were randomized to daily bazedoxifene regimens of 10 mg, 20 mg, or 40 mg, or to raloxifene (60 mg), or to placebo. All received a daily 600-mg calcium supplement.

Of the total, 1,113 (70%) completed the study. More than 90% in each group were white. Mean range in body mass index (kg/m

By month 24, BMD loss was prevented in all groups except in women using placebo, who had a significant decline in BMD. The percent change in lumbar spine BMD from baseline (relative to placebo) was 1.1%, 1.4%, and 1.5%, for bazedoxifene 10 mg, 20 mg, and 40 mg, respectively; it was 1.5% for raloxifene 60 mg. Similar dose-response results were found at other skeletal sites for those on bazedoxifene. Adverse event rates were similar among the groups. The study was supported by Wyeth Research and Wyeth Pharmaceuticals.

HONOLULU — Bazedoxifene is effective in preventing osteoporosis in postmenopausal women, according to the results of a 2-year, phase III, placebo-controlled trial presented at the annual meeting of the American Society for Bone and Mineral Research.

Participants were postmenopausal women aged 45 years, whose femoral neck bone or lumbar spine T scores were above −2.5. Women with vasomotor symptoms, bone diseases, prior vertebral fractures, or endometrial hyperplasia, were excluded.

A total of 1,583 postmenopausal women were randomized to daily bazedoxifene regimens of 10 mg, 20 mg, or 40 mg, or to raloxifene (60 mg), or to placebo. All received a daily 600-mg calcium supplement.

Of the total, 1,113 (70%) completed the study. More than 90% in each group were white. Mean range in body mass index (kg/m

By month 24, BMD loss was prevented in all groups except in women using placebo, who had a significant decline in BMD. The percent change in lumbar spine BMD from baseline (relative to placebo) was 1.1%, 1.4%, and 1.5%, for bazedoxifene 10 mg, 20 mg, and 40 mg, respectively; it was 1.5% for raloxifene 60 mg. Similar dose-response results were found at other skeletal sites for those on bazedoxifene. Adverse event rates were similar among the groups. The study was supported by Wyeth Research and Wyeth Pharmaceuticals.

HONOLULU — Bazedoxifene is effective in preventing osteoporosis in postmenopausal women, according to the results of a 2-year, phase III, placebo-controlled trial presented at the annual meeting of the American Society for Bone and Mineral Research.

Participants were postmenopausal women aged 45 years, whose femoral neck bone or lumbar spine T scores were above −2.5. Women with vasomotor symptoms, bone diseases, prior vertebral fractures, or endometrial hyperplasia, were excluded.

A total of 1,583 postmenopausal women were randomized to daily bazedoxifene regimens of 10 mg, 20 mg, or 40 mg, or to raloxifene (60 mg), or to placebo. All received a daily 600-mg calcium supplement.

Of the total, 1,113 (70%) completed the study. More than 90% in each group were white. Mean range in body mass index (kg/m

By month 24, BMD loss was prevented in all groups except in women using placebo, who had a significant decline in BMD. The percent change in lumbar spine BMD from baseline (relative to placebo) was 1.1%, 1.4%, and 1.5%, for bazedoxifene 10 mg, 20 mg, and 40 mg, respectively; it was 1.5% for raloxifene 60 mg. Similar dose-response results were found at other skeletal sites for those on bazedoxifene. Adverse event rates were similar among the groups. The study was supported by Wyeth Research and Wyeth Pharmaceuticals.

HONOLULU — Though vegans do not eat dairy, they have surprisingly good bone health, according to results from a study presented at the annual meeting of the American Society for Bone and Mineral Research.

Heather J. Hinkley, Ph.D., of the British College of Osteopathic Medicine, in London, recruited 60 white females. Age ranged from 20 to 44 years, and all had been vegan for a minimum of 5 years. Exclusion criteria included use of hormone therapy, use of corticosteroids or thyroxine for more than 6 months, onset of menopause before age 45, lactation in the previous year, presence of rheumatoid arthritis, or previous osteoporosis-related fracture.

Broadband ultrasound attenuation of the calcaneum was examined for all women to assess bone mineral density. The results were compared with ultrasound attenuation data on 110 age-matched white female omnivores.

Though the vegan women had a slightly lower mean ultrasound attenuation, the difference was not significant. Weight also was not significantly different in vegan women, and no significant difference in body mass index was seen. There was no link between the duration of the vegan diet and ultrasound attenuation results.

The researchers observed that 66% of the vegans took calcium supplements, which may have benefited their bone density.

In addition, a lack of dietary animal protein in the vegan's diet may actually benefit the acid/base balance, resulting in less movement of bone mineral and decreasing calcium excretion, preserving bone health and integrity, they suggested.

HONOLULU — Though vegans do not eat dairy, they have surprisingly good bone health, according to results from a study presented at the annual meeting of the American Society for Bone and Mineral Research.

Heather J. Hinkley, Ph.D., of the British College of Osteopathic Medicine, in London, recruited 60 white females. Age ranged from 20 to 44 years, and all had been vegan for a minimum of 5 years. Exclusion criteria included use of hormone therapy, use of corticosteroids or thyroxine for more than 6 months, onset of menopause before age 45, lactation in the previous year, presence of rheumatoid arthritis, or previous osteoporosis-related fracture.

Broadband ultrasound attenuation of the calcaneum was examined for all women to assess bone mineral density. The results were compared with ultrasound attenuation data on 110 age-matched white female omnivores.

Though the vegan women had a slightly lower mean ultrasound attenuation, the difference was not significant. Weight also was not significantly different in vegan women, and no significant difference in body mass index was seen. There was no link between the duration of the vegan diet and ultrasound attenuation results.

The researchers observed that 66% of the vegans took calcium supplements, which may have benefited their bone density.

In addition, a lack of dietary animal protein in the vegan's diet may actually benefit the acid/base balance, resulting in less movement of bone mineral and decreasing calcium excretion, preserving bone health and integrity, they suggested.

HONOLULU — Though vegans do not eat dairy, they have surprisingly good bone health, according to results from a study presented at the annual meeting of the American Society for Bone and Mineral Research.

Heather J. Hinkley, Ph.D., of the British College of Osteopathic Medicine, in London, recruited 60 white females. Age ranged from 20 to 44 years, and all had been vegan for a minimum of 5 years. Exclusion criteria included use of hormone therapy, use of corticosteroids or thyroxine for more than 6 months, onset of menopause before age 45, lactation in the previous year, presence of rheumatoid arthritis, or previous osteoporosis-related fracture.

Broadband ultrasound attenuation of the calcaneum was examined for all women to assess bone mineral density. The results were compared with ultrasound attenuation data on 110 age-matched white female omnivores.

Though the vegan women had a slightly lower mean ultrasound attenuation, the difference was not significant. Weight also was not significantly different in vegan women, and no significant difference in body mass index was seen. There was no link between the duration of the vegan diet and ultrasound attenuation results.

The researchers observed that 66% of the vegans took calcium supplements, which may have benefited their bone density.

In addition, a lack of dietary animal protein in the vegan's diet may actually benefit the acid/base balance, resulting in less movement of bone mineral and decreasing calcium excretion, preserving bone health and integrity, they suggested.