Timothy F. Kirn

Greater use of copayment and deductibles may be reducing the number of women seeking mammography, a study of women enrolled in Medicare managed-care plans shows.

The researchers reviewed data from 174 plans and found that, on average, 77% of women in plans with full coverage had received their biennial screening, compared with 69% of women in plans with cost sharing for their visits.

In addition, the study reviewed seven plans that instituted a copayment or a deductible in 2003 and compared them with 14 plans that did not institute a copayment or deductible. The mammography rates in those plans that adopted cost sharing declined by 5%. In contrast, mammography rates increased 3% in 14 plans that did not institute cost sharing, reported Dr. Amal N. Trivedi of the department of community health at Brown University, Providence, R.I., and colleagues (N. Engl. J. Med. 2008;358:375-83).

The study used data from the Medicare Health Plan Employer Data and Information Set from 2001 to 2004, for 174 Medicare health plans and 366,475 women aged 65-69 years.

Three of the plans had cost sharing in 2001, 9 in 2002, 10 in 2003, and 21 in 2004. The three plans with cost sharing in 2001 covered less than 1% of the women in the plans at that time. The 21 plans in 2004 covered 11%. Copayments in the plans ranged from $12.50 to $35.

The investigators found that black women and women with less education and lower incomes were more likely to be in cost-sharing plans. But the effect of cost sharing at reducing the rate of mammography was greater among whites than among blacks. Among white patients, cost-sharing plans had an 8% lower mammography rate than did plans with no cost sharing. Among black patients, cost-sharing plans had a 4% lower mammography rate.

The adoption of cost sharing is increasing among health plans generally. Mammography rates appear to have declined since 2000, after increasing greatly throughout the 1990s, Dr. Trivedi wrote in the study, which was supported by a grant from the Agency for Healthcare Research and Quality.

One study that looked at mammography rates, conducted by researchers at the National Cancer Institute using a large, national database, reported that 70% of women had received a mammography within the past 2 years in 2000 (Cancer 2007;109:2405-9). By 2005, that figure had dropped to 66%.

In an accompanying editorial, Dr. Peter B. Bach said the study by Dr. Trivedi and colleagues showed a “large” impact relative to the “modest” copayments and deductibles imposed on the patients.

“Their findings are robust, with similar findings in unadjusted analyses and in multivariable analyses adjusted for potential demographic and regional confounders,” wrote Dr. Bach of the department of epidemiology and biostatistics, and the Health Outcomes Research Group, at Memorial Sloan-Kettering Cancer Center, New York (N. Engl. J. Med. 2008;358:411-3).

Noting that Dr. Trivedi and colleagues concluded that cost-sharing strategies apparently do more harm than good in mammography and should probably be waived for this important screening procedure, Dr. Bach said the study suggests a dilemma for insurers.

ELSEVIER GLOBAL MEDICAL NEWS

Greater use of copayment and deductibles may be reducing the number of women seeking mammography, a study of women enrolled in Medicare managed-care plans shows.

The researchers reviewed data from 174 plans and found that, on average, 77% of women in plans with full coverage had received their biennial screening, compared with 69% of women in plans with cost sharing for their visits.

In addition, the study reviewed seven plans that instituted a copayment or a deductible in 2003 and compared them with 14 plans that did not institute a copayment or deductible. The mammography rates in those plans that adopted cost sharing declined by 5%. In contrast, mammography rates increased 3% in 14 plans that did not institute cost sharing, reported Dr. Amal N. Trivedi of the department of community health at Brown University, Providence, R.I., and colleagues (N. Engl. J. Med. 2008;358:375-83).

The study used data from the Medicare Health Plan Employer Data and Information Set from 2001 to 2004, for 174 Medicare health plans and 366,475 women aged 65-69 years.

Three of the plans had cost sharing in 2001, 9 in 2002, 10 in 2003, and 21 in 2004. The three plans with cost sharing in 2001 covered less than 1% of the women in the plans at that time. The 21 plans in 2004 covered 11%. Copayments in the plans ranged from $12.50 to $35.

The investigators found that black women and women with less education and lower incomes were more likely to be in cost-sharing plans. But the effect of cost sharing at reducing the rate of mammography was greater among whites than among blacks. Among white patients, cost-sharing plans had an 8% lower mammography rate than did plans with no cost sharing. Among black patients, cost-sharing plans had a 4% lower mammography rate.

The adoption of cost sharing is increasing among health plans generally. Mammography rates appear to have declined since 2000, after increasing greatly throughout the 1990s, Dr. Trivedi wrote in the study, which was supported by a grant from the Agency for Healthcare Research and Quality.

One study that looked at mammography rates, conducted by researchers at the National Cancer Institute using a large, national database, reported that 70% of women had received a mammography within the past 2 years in 2000 (Cancer 2007;109:2405-9). By 2005, that figure had dropped to 66%.

In an accompanying editorial, Dr. Peter B. Bach said the study by Dr. Trivedi and colleagues showed a “large” impact relative to the “modest” copayments and deductibles imposed on the patients.

“Their findings are robust, with similar findings in unadjusted analyses and in multivariable analyses adjusted for potential demographic and regional confounders,” wrote Dr. Bach of the department of epidemiology and biostatistics, and the Health Outcomes Research Group, at Memorial Sloan-Kettering Cancer Center, New York (N. Engl. J. Med. 2008;358:411-3).

Noting that Dr. Trivedi and colleagues concluded that cost-sharing strategies apparently do more harm than good in mammography and should probably be waived for this important screening procedure, Dr. Bach said the study suggests a dilemma for insurers.

ELSEVIER GLOBAL MEDICAL NEWS

Greater use of copayment and deductibles may be reducing the number of women seeking mammography, a study of women enrolled in Medicare managed-care plans shows.

The researchers reviewed data from 174 plans and found that, on average, 77% of women in plans with full coverage had received their biennial screening, compared with 69% of women in plans with cost sharing for their visits.

In addition, the study reviewed seven plans that instituted a copayment or a deductible in 2003 and compared them with 14 plans that did not institute a copayment or deductible. The mammography rates in those plans that adopted cost sharing declined by 5%. In contrast, mammography rates increased 3% in 14 plans that did not institute cost sharing, reported Dr. Amal N. Trivedi of the department of community health at Brown University, Providence, R.I., and colleagues (N. Engl. J. Med. 2008;358:375-83).

The study used data from the Medicare Health Plan Employer Data and Information Set from 2001 to 2004, for 174 Medicare health plans and 366,475 women aged 65-69 years.

Three of the plans had cost sharing in 2001, 9 in 2002, 10 in 2003, and 21 in 2004. The three plans with cost sharing in 2001 covered less than 1% of the women in the plans at that time. The 21 plans in 2004 covered 11%. Copayments in the plans ranged from $12.50 to $35.

The investigators found that black women and women with less education and lower incomes were more likely to be in cost-sharing plans. But the effect of cost sharing at reducing the rate of mammography was greater among whites than among blacks. Among white patients, cost-sharing plans had an 8% lower mammography rate than did plans with no cost sharing. Among black patients, cost-sharing plans had a 4% lower mammography rate.

The adoption of cost sharing is increasing among health plans generally. Mammography rates appear to have declined since 2000, after increasing greatly throughout the 1990s, Dr. Trivedi wrote in the study, which was supported by a grant from the Agency for Healthcare Research and Quality.

One study that looked at mammography rates, conducted by researchers at the National Cancer Institute using a large, national database, reported that 70% of women had received a mammography within the past 2 years in 2000 (Cancer 2007;109:2405-9). By 2005, that figure had dropped to 66%.

In an accompanying editorial, Dr. Peter B. Bach said the study by Dr. Trivedi and colleagues showed a “large” impact relative to the “modest” copayments and deductibles imposed on the patients.

“Their findings are robust, with similar findings in unadjusted analyses and in multivariable analyses adjusted for potential demographic and regional confounders,” wrote Dr. Bach of the department of epidemiology and biostatistics, and the Health Outcomes Research Group, at Memorial Sloan-Kettering Cancer Center, New York (N. Engl. J. Med. 2008;358:411-3).

Noting that Dr. Trivedi and colleagues concluded that cost-sharing strategies apparently do more harm than good in mammography and should probably be waived for this important screening procedure, Dr. Bach said the study suggests a dilemma for insurers.

ELSEVIER GLOBAL MEDICAL NEWS

A study of 81 male veterans with diabetes showed that 61% of them exhibited clinically significant apathy, a psychological condition that might predict adherence to diabetic self-care.

“Clinicians and educators may want to screen for apathy routinely in clinical care of patients with diabetes, especially in patients with poor [glycemic] control,” Dr. Prasad R. Padala, of the Veterans Affairs Medical Center, Omaha, Neb., and colleagues wrote in the January issue of Diabetes Research and Clinical Practice.

The study was conducted by recruiting 100 patients from a diabetes clinic at the medical center. Each person was tested for evidence of depression and took three psychological tests–the Apathy Evaluation Scale (clinician version), the Hamilton Rating Scale for Depression, and the Self-Care Inventory, which rates adherence to diabetes management recommendations (Diabetes Res. Clin. Pract. 2008;79:37-41). Data from those tests were then correlated with patient demographic and laboratory data.

The average age of the 81 patients analyzed for the study was 59 years. Ninety-four percent were male, 88% were white, 11% were African American, and 1 patient was Hispanic; 19 patients found to be depressed were excluded from the study.

The cross-sectional study recorded a mean score on the Apathy Evaluation Scale of 36, and 50 of the 81 patients had a score above 30, which is the cutoff for clinically significant apathy.

Apathy was associated with a higher body mass index (34 kg/m

A statistically significant association between apathy and hemoglobin A1c level was not found, though there was a trend (8.3% in those with apathy vs. 7.64% in those without), Dr. Padala added.

Studies of other conditions, such as multiple sclerosis and parkinsonism, have suggested that apathy is a common feature of several chronic illnesses.

Apathy is characterized by a lack of initiative and motivation, emotional indifference, and decreased social engagement, the study said.

For clinicians who might want to screen patients with diabetes for apathy, the test that the study used takes too long to administer in a busy office. However, there is a short set of basic screening questions from an inventory developed for neuropsychiatric evaluation that clinicians can use (Neurology 1994;44:2308-14), Dr. Padala wrote.

The questions, which can be asked of either the patient or a caregiver, are: Has the patient lost interest in the world around him/her? Has he/she lost interest in doing things or does he/she lack motivation for starting new activities? Is he/she more difficult to engage in conversation or in doing chores? Is the patient apathetic or indifferent? A yes answer to any of those questions would call for more detailed testing.

A study of 81 male veterans with diabetes showed that 61% of them exhibited clinically significant apathy, a psychological condition that might predict adherence to diabetic self-care.

“Clinicians and educators may want to screen for apathy routinely in clinical care of patients with diabetes, especially in patients with poor [glycemic] control,” Dr. Prasad R. Padala, of the Veterans Affairs Medical Center, Omaha, Neb., and colleagues wrote in the January issue of Diabetes Research and Clinical Practice.

The study was conducted by recruiting 100 patients from a diabetes clinic at the medical center. Each person was tested for evidence of depression and took three psychological tests–the Apathy Evaluation Scale (clinician version), the Hamilton Rating Scale for Depression, and the Self-Care Inventory, which rates adherence to diabetes management recommendations (Diabetes Res. Clin. Pract. 2008;79:37-41). Data from those tests were then correlated with patient demographic and laboratory data.

The average age of the 81 patients analyzed for the study was 59 years. Ninety-four percent were male, 88% were white, 11% were African American, and 1 patient was Hispanic; 19 patients found to be depressed were excluded from the study.

The cross-sectional study recorded a mean score on the Apathy Evaluation Scale of 36, and 50 of the 81 patients had a score above 30, which is the cutoff for clinically significant apathy.

Apathy was associated with a higher body mass index (34 kg/m

A statistically significant association between apathy and hemoglobin A1c level was not found, though there was a trend (8.3% in those with apathy vs. 7.64% in those without), Dr. Padala added.

Studies of other conditions, such as multiple sclerosis and parkinsonism, have suggested that apathy is a common feature of several chronic illnesses.

Apathy is characterized by a lack of initiative and motivation, emotional indifference, and decreased social engagement, the study said.

For clinicians who might want to screen patients with diabetes for apathy, the test that the study used takes too long to administer in a busy office. However, there is a short set of basic screening questions from an inventory developed for neuropsychiatric evaluation that clinicians can use (Neurology 1994;44:2308-14), Dr. Padala wrote.

The questions, which can be asked of either the patient or a caregiver, are: Has the patient lost interest in the world around him/her? Has he/she lost interest in doing things or does he/she lack motivation for starting new activities? Is he/she more difficult to engage in conversation or in doing chores? Is the patient apathetic or indifferent? A yes answer to any of those questions would call for more detailed testing.

A study of 81 male veterans with diabetes showed that 61% of them exhibited clinically significant apathy, a psychological condition that might predict adherence to diabetic self-care.

“Clinicians and educators may want to screen for apathy routinely in clinical care of patients with diabetes, especially in patients with poor [glycemic] control,” Dr. Prasad R. Padala, of the Veterans Affairs Medical Center, Omaha, Neb., and colleagues wrote in the January issue of Diabetes Research and Clinical Practice.

The study was conducted by recruiting 100 patients from a diabetes clinic at the medical center. Each person was tested for evidence of depression and took three psychological tests–the Apathy Evaluation Scale (clinician version), the Hamilton Rating Scale for Depression, and the Self-Care Inventory, which rates adherence to diabetes management recommendations (Diabetes Res. Clin. Pract. 2008;79:37-41). Data from those tests were then correlated with patient demographic and laboratory data.

The average age of the 81 patients analyzed for the study was 59 years. Ninety-four percent were male, 88% were white, 11% were African American, and 1 patient was Hispanic; 19 patients found to be depressed were excluded from the study.

The cross-sectional study recorded a mean score on the Apathy Evaluation Scale of 36, and 50 of the 81 patients had a score above 30, which is the cutoff for clinically significant apathy.

Apathy was associated with a higher body mass index (34 kg/m

A statistically significant association between apathy and hemoglobin A1c level was not found, though there was a trend (8.3% in those with apathy vs. 7.64% in those without), Dr. Padala added.

Studies of other conditions, such as multiple sclerosis and parkinsonism, have suggested that apathy is a common feature of several chronic illnesses.

Apathy is characterized by a lack of initiative and motivation, emotional indifference, and decreased social engagement, the study said.

For clinicians who might want to screen patients with diabetes for apathy, the test that the study used takes too long to administer in a busy office. However, there is a short set of basic screening questions from an inventory developed for neuropsychiatric evaluation that clinicians can use (Neurology 1994;44:2308-14), Dr. Padala wrote.

The questions, which can be asked of either the patient or a caregiver, are: Has the patient lost interest in the world around him/her? Has he/she lost interest in doing things or does he/she lack motivation for starting new activities? Is he/she more difficult to engage in conversation or in doing chores? Is the patient apathetic or indifferent? A yes answer to any of those questions would call for more detailed testing.

Five criteria for diagnosing autoimmune enteropathy are now available thanks to a compilation of 15 patients at the Mayo Clinic, which has more than doubled the number of cases in the published literature.

The researchers found that only about half of the patients had histology results that fit the typical pattern previously reported, but 80% had a predisposition to autoimmune disease, as indicated by their history or levels of circulating antibodies.

Based on the cohort, the investigators also proposed criteria that could be used for definitive diagnosis.

The first reported case of autoimmune enteropathy was that of a child in 1982, said Dr. Salma Akram, of the division of gastroenterology and hepatology at the Mayo Clinic, Rochester, Minn. More recently, a total of 11 adult-onset cases have been reported in the literature.

The Mayo cases were all patients who had protracted diarrhea leading to weight loss and malnutrition. In 13 of the 15 cases, the patients' physicians ruled out celiac disease because the patient did not respond to a gluten-free diet and did not have an HLA genotype indicative of celiac disease susceptibility.

The other two cases fulfilled diagnostic criteria for refractory sprue. However, those 2 patients were among the 13 who tested positive for antienterocyte and/or antigoblet cell antibodies; a total of 14 of the 15 patients received such testing.

The median length of time between the onset of symptoms and diagnosis was 1.5 years. Abdominal CT was unremarkable in the cohort, except for a finding of prominent mesenteric lymph nodes in six of the patients.

Dr. Akram and colleagues found that only eight patients had small-bowel biopsy histology with the features that are considered characteristic of autoimmune enteropathy—features such as minimal intraepithelial lymphocytes and dense lamina propria inflammation.

The other seven individuals had spruelike histology, and it may be that the two conditions can coexist, the investigators suggested. This theory was bolstered by the finding that five of the seven patients had elevated IgA tissue transglutaminase antibodies.

Based on the Mayo cohort, the authors suggested that the following five criteria should be considered for establishing the diagnosis of adult autoimmune enteropathy, with the first four criteria being absolutely necessary for reaching a definitive diagnosis:

▸ Adult-onset chronic diarrhea lasting longer than 6 weeks in duration.

▸ Malabsorption.

▸ Specific small-bowel histology of partial/complete villous blunting, deep crypt lymphocytosis, increased crypt apoptotic bodies, and minimal intraepithelial lymphocytosis.

▸ Exclusion of other causes of villous atrophy, including celiac disease, refractory sprue, and intestinal lymphoma.

▸ Antienterocyte and/or antigoblet cell antibodies.

Treatments for autoimmune enteropathy that have been reported in the past have included corticosteroids, cyclophosphamide, tacrolimus, and infliximab.

Most of the Mayo Clinic patients (14 of 15) were treated with immunosuppressive therapy. Four received prednisone alone, and most of the others received prednisone followed by budesonide, azathioprine, and/or 6-mercaptopurine.

Two patients received treatment with prednisone followed by either 6-mercaptopurine or azathioprine with infliximab. One patient received metronidazole for 4 weeks as well as diphenoxylate, but did not respond. Nine of the patients responded to their treatment with complete resolution of their diarrhea, and three patients had a partial response.

High-dose steroids (greater than 40 mg/day) produced a rapid clinical response in two patients, but both needed additional therapy to maintain remission within 3–11 months.

One patient responded to prednisone 10 mg/day, and remained in remission on 5 mg/day for 14 months. Five of the responders went into remission with prednisone at doses of 20–60 mg/day in 4–8 weeks, then were maintained with budesonide. Infliximab was used in two patients and produced a rapid response, the investigators said.

Five criteria for diagnosing autoimmune enteropathy are now available thanks to a compilation of 15 patients at the Mayo Clinic, which has more than doubled the number of cases in the published literature.

The researchers found that only about half of the patients had histology results that fit the typical pattern previously reported, but 80% had a predisposition to autoimmune disease, as indicated by their history or levels of circulating antibodies.

Based on the cohort, the investigators also proposed criteria that could be used for definitive diagnosis.

The first reported case of autoimmune enteropathy was that of a child in 1982, said Dr. Salma Akram, of the division of gastroenterology and hepatology at the Mayo Clinic, Rochester, Minn. More recently, a total of 11 adult-onset cases have been reported in the literature.

The Mayo cases were all patients who had protracted diarrhea leading to weight loss and malnutrition. In 13 of the 15 cases, the patients' physicians ruled out celiac disease because the patient did not respond to a gluten-free diet and did not have an HLA genotype indicative of celiac disease susceptibility.

The other two cases fulfilled diagnostic criteria for refractory sprue. However, those 2 patients were among the 13 who tested positive for antienterocyte and/or antigoblet cell antibodies; a total of 14 of the 15 patients received such testing.

The median length of time between the onset of symptoms and diagnosis was 1.5 years. Abdominal CT was unremarkable in the cohort, except for a finding of prominent mesenteric lymph nodes in six of the patients.

Dr. Akram and colleagues found that only eight patients had small-bowel biopsy histology with the features that are considered characteristic of autoimmune enteropathy—features such as minimal intraepithelial lymphocytes and dense lamina propria inflammation.

The other seven individuals had spruelike histology, and it may be that the two conditions can coexist, the investigators suggested. This theory was bolstered by the finding that five of the seven patients had elevated IgA tissue transglutaminase antibodies.

Based on the Mayo cohort, the authors suggested that the following five criteria should be considered for establishing the diagnosis of adult autoimmune enteropathy, with the first four criteria being absolutely necessary for reaching a definitive diagnosis:

▸ Adult-onset chronic diarrhea lasting longer than 6 weeks in duration.

▸ Malabsorption.

▸ Specific small-bowel histology of partial/complete villous blunting, deep crypt lymphocytosis, increased crypt apoptotic bodies, and minimal intraepithelial lymphocytosis.

▸ Exclusion of other causes of villous atrophy, including celiac disease, refractory sprue, and intestinal lymphoma.

▸ Antienterocyte and/or antigoblet cell antibodies.

Treatments for autoimmune enteropathy that have been reported in the past have included corticosteroids, cyclophosphamide, tacrolimus, and infliximab.

Most of the Mayo Clinic patients (14 of 15) were treated with immunosuppressive therapy. Four received prednisone alone, and most of the others received prednisone followed by budesonide, azathioprine, and/or 6-mercaptopurine.

Two patients received treatment with prednisone followed by either 6-mercaptopurine or azathioprine with infliximab. One patient received metronidazole for 4 weeks as well as diphenoxylate, but did not respond. Nine of the patients responded to their treatment with complete resolution of their diarrhea, and three patients had a partial response.

High-dose steroids (greater than 40 mg/day) produced a rapid clinical response in two patients, but both needed additional therapy to maintain remission within 3–11 months.

One patient responded to prednisone 10 mg/day, and remained in remission on 5 mg/day for 14 months. Five of the responders went into remission with prednisone at doses of 20–60 mg/day in 4–8 weeks, then were maintained with budesonide. Infliximab was used in two patients and produced a rapid response, the investigators said.

Five criteria for diagnosing autoimmune enteropathy are now available thanks to a compilation of 15 patients at the Mayo Clinic, which has more than doubled the number of cases in the published literature.

The researchers found that only about half of the patients had histology results that fit the typical pattern previously reported, but 80% had a predisposition to autoimmune disease, as indicated by their history or levels of circulating antibodies.

Based on the cohort, the investigators also proposed criteria that could be used for definitive diagnosis.

The first reported case of autoimmune enteropathy was that of a child in 1982, said Dr. Salma Akram, of the division of gastroenterology and hepatology at the Mayo Clinic, Rochester, Minn. More recently, a total of 11 adult-onset cases have been reported in the literature.

The Mayo cases were all patients who had protracted diarrhea leading to weight loss and malnutrition. In 13 of the 15 cases, the patients' physicians ruled out celiac disease because the patient did not respond to a gluten-free diet and did not have an HLA genotype indicative of celiac disease susceptibility.

The other two cases fulfilled diagnostic criteria for refractory sprue. However, those 2 patients were among the 13 who tested positive for antienterocyte and/or antigoblet cell antibodies; a total of 14 of the 15 patients received such testing.

The median length of time between the onset of symptoms and diagnosis was 1.5 years. Abdominal CT was unremarkable in the cohort, except for a finding of prominent mesenteric lymph nodes in six of the patients.

Dr. Akram and colleagues found that only eight patients had small-bowel biopsy histology with the features that are considered characteristic of autoimmune enteropathy—features such as minimal intraepithelial lymphocytes and dense lamina propria inflammation.

The other seven individuals had spruelike histology, and it may be that the two conditions can coexist, the investigators suggested. This theory was bolstered by the finding that five of the seven patients had elevated IgA tissue transglutaminase antibodies.

Based on the Mayo cohort, the authors suggested that the following five criteria should be considered for establishing the diagnosis of adult autoimmune enteropathy, with the first four criteria being absolutely necessary for reaching a definitive diagnosis:

▸ Adult-onset chronic diarrhea lasting longer than 6 weeks in duration.

▸ Malabsorption.

▸ Specific small-bowel histology of partial/complete villous blunting, deep crypt lymphocytosis, increased crypt apoptotic bodies, and minimal intraepithelial lymphocytosis.

▸ Exclusion of other causes of villous atrophy, including celiac disease, refractory sprue, and intestinal lymphoma.

▸ Antienterocyte and/or antigoblet cell antibodies.

Treatments for autoimmune enteropathy that have been reported in the past have included corticosteroids, cyclophosphamide, tacrolimus, and infliximab.

Most of the Mayo Clinic patients (14 of 15) were treated with immunosuppressive therapy. Four received prednisone alone, and most of the others received prednisone followed by budesonide, azathioprine, and/or 6-mercaptopurine.

Two patients received treatment with prednisone followed by either 6-mercaptopurine or azathioprine with infliximab. One patient received metronidazole for 4 weeks as well as diphenoxylate, but did not respond. Nine of the patients responded to their treatment with complete resolution of their diarrhea, and three patients had a partial response.

High-dose steroids (greater than 40 mg/day) produced a rapid clinical response in two patients, but both needed additional therapy to maintain remission within 3–11 months.

One patient responded to prednisone 10 mg/day, and remained in remission on 5 mg/day for 14 months. Five of the responders went into remission with prednisone at doses of 20–60 mg/day in 4–8 weeks, then were maintained with budesonide. Infliximab was used in two patients and produced a rapid response, the investigators said.

Greater use of copayment and deductibles may be reducing the number of women seeking mammography, a new study of women enrolled in Medicare managed-care plans shows.

The investigators reviewed data from 174 plans and found that, on average, 77% of women in plans with full coverage had received their biennial screening, compared with 69% of women in plans with cost sharing for their health care visits.

In addition, the study reviewed seven plans that instituted a copayment or a deductible in 2003 and compared them with 14 plans that did not. The mammography rates in those plans that adopted cost sharing declined by 5%. In contrast, mammography rates increased 3% in 14 plans that did not institute cost sharing, reported Dr. Amal N. Trivedi of the department of community health at Brown University, Providence, R.I., and colleagues (N. Engl. J. Med. 2008;358:375-83).

The study used data from the Medicare Health Plan Employer Data and Information Set from 2001 to 2004, for 174 Medicare health plans and 366,475 women aged 65-69.

Three of the plans had cost sharing in 2001, 9 in 2002, 10 in 2003, and 21 in 2004. The three plans with cost sharing in 2001 covered less than 1% of the women in the plans at that time. The 21 plans in 2004 covered 11%.

Copayments in the plans ranged from $12.50 to $35.

The study also found that black women and women with less education and lower incomes were more likely to be in cost-sharing plans. But the effect of cost sharing at reducing the rate of mammography was greater among whites than among blacks. Among white patients, cost-sharing plans had an 8% lower mammography rate than did plans with no cost sharing. Among black patients, cost-sharing plans had a 4% lower mammography rate.

The adoption of cost sharing is increasing among health plans generally. Mammography rates appear to have declined since 2000, after increasing greatly throughout the 1990s, Dr. Trivedi wrote in the study, which was supported by a grant from the Agency for Healthcare Research and Quality.

One study that looked at mammography rates, conducted by researchers at the National Cancer Institute using a large, national database, reported that 70% of women had received a mammography within the past 2 years in 2000 (Cancer 2007;109:2405-9). By 2005, that figure had dropped to 66%.

In an accompanying editorial, Dr. Peter B. Bach said the study by Dr. Trivedi and colleagues showed a “large” impact relative to the “modest” copayments and deductibles imposed on the patients.

“Their findings are robust, with similar findings in unadjusted analyses and in multivariable analyses adjusted for potential demographic and regional confounders,” wrote Dr. Bach of the department of epidemiology and biostatistics, and the Health Outcomes Research Group, at Memorial Sloan-Kettering Cancer Center, New York (N. Engl. J. Med. 2008;358:411-3).

Noting that Dr. Trivedi and colleagues concluded that cost-sharing strategies apparently do more harm than good in mammography and should probably be waived for this important screening procedure, Dr. Bach said the study suggests a dilemma for insurers.

Deductibles and copayments are adopted by insurers to dissuade patients from using health care services extravagantly. But in some cases, the strategy may backfire, resulting in higher costs and poorer health.

If, however, insurers choose to exempt some services from copayments or deductibles, they face the prospect of reconsidering all kinds of services and trusting that they can determine which ones are truly beneficial, he wrote.

It would be a very daunting task, he added.

The case of mammography is a particularly striking example, because mammography is a service that women tend to know is highly beneficial. Yet, the cost sharing kept 8% of consumers from seeking it out, Dr. Bach noted.

“This finding bodes poorly for the high-deductible movement, since one would expect that patients would make suboptimal decisions even more often in cases in which the health care service is more expensive, has received less publicity, has less rigorous quality control, or is more unpleasant or risky,” Dr. Bach wrote.

ELSEVIER GLOBAL MEDICAL NEWS

Greater use of copayment and deductibles may be reducing the number of women seeking mammography, a new study of women enrolled in Medicare managed-care plans shows.

The investigators reviewed data from 174 plans and found that, on average, 77% of women in plans with full coverage had received their biennial screening, compared with 69% of women in plans with cost sharing for their health care visits.

In addition, the study reviewed seven plans that instituted a copayment or a deductible in 2003 and compared them with 14 plans that did not. The mammography rates in those plans that adopted cost sharing declined by 5%. In contrast, mammography rates increased 3% in 14 plans that did not institute cost sharing, reported Dr. Amal N. Trivedi of the department of community health at Brown University, Providence, R.I., and colleagues (N. Engl. J. Med. 2008;358:375-83).

The study used data from the Medicare Health Plan Employer Data and Information Set from 2001 to 2004, for 174 Medicare health plans and 366,475 women aged 65-69.

Three of the plans had cost sharing in 2001, 9 in 2002, 10 in 2003, and 21 in 2004. The three plans with cost sharing in 2001 covered less than 1% of the women in the plans at that time. The 21 plans in 2004 covered 11%.

Copayments in the plans ranged from $12.50 to $35.

The study also found that black women and women with less education and lower incomes were more likely to be in cost-sharing plans. But the effect of cost sharing at reducing the rate of mammography was greater among whites than among blacks. Among white patients, cost-sharing plans had an 8% lower mammography rate than did plans with no cost sharing. Among black patients, cost-sharing plans had a 4% lower mammography rate.

The adoption of cost sharing is increasing among health plans generally. Mammography rates appear to have declined since 2000, after increasing greatly throughout the 1990s, Dr. Trivedi wrote in the study, which was supported by a grant from the Agency for Healthcare Research and Quality.

One study that looked at mammography rates, conducted by researchers at the National Cancer Institute using a large, national database, reported that 70% of women had received a mammography within the past 2 years in 2000 (Cancer 2007;109:2405-9). By 2005, that figure had dropped to 66%.

In an accompanying editorial, Dr. Peter B. Bach said the study by Dr. Trivedi and colleagues showed a “large” impact relative to the “modest” copayments and deductibles imposed on the patients.

“Their findings are robust, with similar findings in unadjusted analyses and in multivariable analyses adjusted for potential demographic and regional confounders,” wrote Dr. Bach of the department of epidemiology and biostatistics, and the Health Outcomes Research Group, at Memorial Sloan-Kettering Cancer Center, New York (N. Engl. J. Med. 2008;358:411-3).

Noting that Dr. Trivedi and colleagues concluded that cost-sharing strategies apparently do more harm than good in mammography and should probably be waived for this important screening procedure, Dr. Bach said the study suggests a dilemma for insurers.

Deductibles and copayments are adopted by insurers to dissuade patients from using health care services extravagantly. But in some cases, the strategy may backfire, resulting in higher costs and poorer health.

If, however, insurers choose to exempt some services from copayments or deductibles, they face the prospect of reconsidering all kinds of services and trusting that they can determine which ones are truly beneficial, he wrote.

It would be a very daunting task, he added.

The case of mammography is a particularly striking example, because mammography is a service that women tend to know is highly beneficial. Yet, the cost sharing kept 8% of consumers from seeking it out, Dr. Bach noted.

“This finding bodes poorly for the high-deductible movement, since one would expect that patients would make suboptimal decisions even more often in cases in which the health care service is more expensive, has received less publicity, has less rigorous quality control, or is more unpleasant or risky,” Dr. Bach wrote.

ELSEVIER GLOBAL MEDICAL NEWS

Greater use of copayment and deductibles may be reducing the number of women seeking mammography, a new study of women enrolled in Medicare managed-care plans shows.

The investigators reviewed data from 174 plans and found that, on average, 77% of women in plans with full coverage had received their biennial screening, compared with 69% of women in plans with cost sharing for their health care visits.

In addition, the study reviewed seven plans that instituted a copayment or a deductible in 2003 and compared them with 14 plans that did not. The mammography rates in those plans that adopted cost sharing declined by 5%. In contrast, mammography rates increased 3% in 14 plans that did not institute cost sharing, reported Dr. Amal N. Trivedi of the department of community health at Brown University, Providence, R.I., and colleagues (N. Engl. J. Med. 2008;358:375-83).

The study used data from the Medicare Health Plan Employer Data and Information Set from 2001 to 2004, for 174 Medicare health plans and 366,475 women aged 65-69.

Three of the plans had cost sharing in 2001, 9 in 2002, 10 in 2003, and 21 in 2004. The three plans with cost sharing in 2001 covered less than 1% of the women in the plans at that time. The 21 plans in 2004 covered 11%.

Copayments in the plans ranged from $12.50 to $35.

The study also found that black women and women with less education and lower incomes were more likely to be in cost-sharing plans. But the effect of cost sharing at reducing the rate of mammography was greater among whites than among blacks. Among white patients, cost-sharing plans had an 8% lower mammography rate than did plans with no cost sharing. Among black patients, cost-sharing plans had a 4% lower mammography rate.

The adoption of cost sharing is increasing among health plans generally. Mammography rates appear to have declined since 2000, after increasing greatly throughout the 1990s, Dr. Trivedi wrote in the study, which was supported by a grant from the Agency for Healthcare Research and Quality.

One study that looked at mammography rates, conducted by researchers at the National Cancer Institute using a large, national database, reported that 70% of women had received a mammography within the past 2 years in 2000 (Cancer 2007;109:2405-9). By 2005, that figure had dropped to 66%.

In an accompanying editorial, Dr. Peter B. Bach said the study by Dr. Trivedi and colleagues showed a “large” impact relative to the “modest” copayments and deductibles imposed on the patients.

“Their findings are robust, with similar findings in unadjusted analyses and in multivariable analyses adjusted for potential demographic and regional confounders,” wrote Dr. Bach of the department of epidemiology and biostatistics, and the Health Outcomes Research Group, at Memorial Sloan-Kettering Cancer Center, New York (N. Engl. J. Med. 2008;358:411-3).

Noting that Dr. Trivedi and colleagues concluded that cost-sharing strategies apparently do more harm than good in mammography and should probably be waived for this important screening procedure, Dr. Bach said the study suggests a dilemma for insurers.

Deductibles and copayments are adopted by insurers to dissuade patients from using health care services extravagantly. But in some cases, the strategy may backfire, resulting in higher costs and poorer health.

If, however, insurers choose to exempt some services from copayments or deductibles, they face the prospect of reconsidering all kinds of services and trusting that they can determine which ones are truly beneficial, he wrote.

It would be a very daunting task, he added.

The case of mammography is a particularly striking example, because mammography is a service that women tend to know is highly beneficial. Yet, the cost sharing kept 8% of consumers from seeking it out, Dr. Bach noted.

“This finding bodes poorly for the high-deductible movement, since one would expect that patients would make suboptimal decisions even more often in cases in which the health care service is more expensive, has received less publicity, has less rigorous quality control, or is more unpleasant or risky,” Dr. Bach wrote.

ELSEVIER GLOBAL MEDICAL NEWS

The idea seems simple enough, but the improvement in waiting times for lab tests for the patients of Dr. S. Germain Cassiere has been dramatic.

As in many medical offices, his patients for many years had signed in on a sheet of paper to let the receptionist and technicians know they were there, he said. Then the patients waited for an average of 25–30 minutes, and often longer on busier days, such as Monday and Tuesday.

Dr. Cassiere's solution was to put a computer terminal with a touch screen in the waiting room to replace the paper sheet. "The patients use the wall-mounted touch screen as a keyboard to enter their names and select what services are needed," said Dr. Cassiere, who works in a six-physician general internal medicine practice in Shreveport, La. "The completion of this one-page data entry generates a record in the database for that particular outpatient service center."

The technicians can see on their own computer screens the names of waiting patients and when they arrived. After patients have been called in and had their blood drawn, the technician logs them out with a click on the screen.

A program called LABRATS (Lab Registration Access Touch Screen) tracks each part of the process and can report an hourly patient count, record the number of registration technicians and phlebotomists present, and calculate the average time for every step. Monthly reports, which allow the lab staff to track trends, showed that Mondays and Tuesdays are the busiest, and therefore may require more personnel.

Because of the system, the average wait time for lab tests has declined 40%, to an average of about 18 minutes. The technicians and phlebotomists appreciate being accountable, knowing how they are doing, and showing their efficiency, Dr. Cassiere said.

He also believes the patients appreciate it. "They notice it takes less time," he said. "No one likes to wait."

After patients are finished having blood drawn for tests, they are deleted from the system, so there is no conflict with HIPAA confidentiality rules, he noted.

When Dr. Cassiere first proposed the computerized system, there was skepticism from some in administration and the information technology department at Willis-Knighton Health Systems, the health services provider he works with, regarding feasibility and patient acceptability of this process.

Dr. Cassiere took that as a challenge. He developed the system himself using the same Nexus Database System he had previously used to develop a message-tracking system to log incoming phone calls so they are returned more reliably.

The LABRATS system has worked so well that it has been adapted for use in the general admission process and is now being deployed for use in all 12 outpatient centers of the health service, he said.

The idea seems simple enough, but the improvement in waiting times for lab tests for the patients of Dr. S. Germain Cassiere has been dramatic.

As in many medical offices, his patients for many years had signed in on a sheet of paper to let the receptionist and technicians know they were there, he said. Then the patients waited for an average of 25–30 minutes, and often longer on busier days, such as Monday and Tuesday.

Dr. Cassiere's solution was to put a computer terminal with a touch screen in the waiting room to replace the paper sheet. "The patients use the wall-mounted touch screen as a keyboard to enter their names and select what services are needed," said Dr. Cassiere, who works in a six-physician general internal medicine practice in Shreveport, La. "The completion of this one-page data entry generates a record in the database for that particular outpatient service center."

The technicians can see on their own computer screens the names of waiting patients and when they arrived. After patients have been called in and had their blood drawn, the technician logs them out with a click on the screen.

A program called LABRATS (Lab Registration Access Touch Screen) tracks each part of the process and can report an hourly patient count, record the number of registration technicians and phlebotomists present, and calculate the average time for every step. Monthly reports, which allow the lab staff to track trends, showed that Mondays and Tuesdays are the busiest, and therefore may require more personnel.

Because of the system, the average wait time for lab tests has declined 40%, to an average of about 18 minutes. The technicians and phlebotomists appreciate being accountable, knowing how they are doing, and showing their efficiency, Dr. Cassiere said.

He also believes the patients appreciate it. "They notice it takes less time," he said. "No one likes to wait."

After patients are finished having blood drawn for tests, they are deleted from the system, so there is no conflict with HIPAA confidentiality rules, he noted.

When Dr. Cassiere first proposed the computerized system, there was skepticism from some in administration and the information technology department at Willis-Knighton Health Systems, the health services provider he works with, regarding feasibility and patient acceptability of this process.

Dr. Cassiere took that as a challenge. He developed the system himself using the same Nexus Database System he had previously used to develop a message-tracking system to log incoming phone calls so they are returned more reliably.

The LABRATS system has worked so well that it has been adapted for use in the general admission process and is now being deployed for use in all 12 outpatient centers of the health service, he said.

The idea seems simple enough, but the improvement in waiting times for lab tests for the patients of Dr. S. Germain Cassiere has been dramatic.

As in many medical offices, his patients for many years had signed in on a sheet of paper to let the receptionist and technicians know they were there, he said. Then the patients waited for an average of 25–30 minutes, and often longer on busier days, such as Monday and Tuesday.

Dr. Cassiere's solution was to put a computer terminal with a touch screen in the waiting room to replace the paper sheet. "The patients use the wall-mounted touch screen as a keyboard to enter their names and select what services are needed," said Dr. Cassiere, who works in a six-physician general internal medicine practice in Shreveport, La. "The completion of this one-page data entry generates a record in the database for that particular outpatient service center."

The technicians can see on their own computer screens the names of waiting patients and when they arrived. After patients have been called in and had their blood drawn, the technician logs them out with a click on the screen.

A program called LABRATS (Lab Registration Access Touch Screen) tracks each part of the process and can report an hourly patient count, record the number of registration technicians and phlebotomists present, and calculate the average time for every step. Monthly reports, which allow the lab staff to track trends, showed that Mondays and Tuesdays are the busiest, and therefore may require more personnel.

Because of the system, the average wait time for lab tests has declined 40%, to an average of about 18 minutes. The technicians and phlebotomists appreciate being accountable, knowing how they are doing, and showing their efficiency, Dr. Cassiere said.

He also believes the patients appreciate it. "They notice it takes less time," he said. "No one likes to wait."

After patients are finished having blood drawn for tests, they are deleted from the system, so there is no conflict with HIPAA confidentiality rules, he noted.

When Dr. Cassiere first proposed the computerized system, there was skepticism from some in administration and the information technology department at Willis-Knighton Health Systems, the health services provider he works with, regarding feasibility and patient acceptability of this process.

Dr. Cassiere took that as a challenge. He developed the system himself using the same Nexus Database System he had previously used to develop a message-tracking system to log incoming phone calls so they are returned more reliably.

The LABRATS system has worked so well that it has been adapted for use in the general admission process and is now being deployed for use in all 12 outpatient centers of the health service, he said.

Mumps outbreaks can occur even among highly vaccinated populations, according to a report on a summer camp outbreak in 2005.

The outbreak had 31 confirmed cases, and 55% were known to have had two doses of mumps vaccine. Analysis indicated two doses of mumps vaccine were 92% effective in preventing mumps. A single dose was 80% effective (Pediatrics 2007;120:doi:10.1542/peds.2006-3451).

Nine cases occurred in individuals who had never been vaccinated, said Dr. Joshua K. Schaffzin of the New York State Department of Health, Albany, and his colleagues.

According to a previous report on the outbreak, the index case was a 20-year-old male camp counselor from the United Kingdom who had never been vaccinated against mumps.

On June 30, 2005, about 11 days after his arrival, he was evaluated in the camp infirmary for a left-sided parotitis, sore throat, and a low-grade fever.

At the time, a mumps epidemic was occurring in the United Kingdom. But mumps was not considered, and the counselor continued work. During July 15–23, an additional 25 cases of parotitis were seen. On July 26, the New York State Department of Health became aware of the outbreak, cases were isolated, and the camp was quarantined.

According to the new report, 541 persons were at the camp that summer, including 368 campers, whose median age was 12, and 173 staff members, whose median age was 21. Of the campers, all had received at least one mumps vaccination, and all but two had two doses. Of the staff, 21 had never been vaccinated.

Thirty-one cases of mumps were identified in the camp. Twenty-six met case definitions for mumps, and six were tested for mumps IgG and IgM. Five of those six were positive for both. Only one of the six had been vaccinated, and that person had received two doses.

Twelve of the patients were campers and the rest were staff.

Of the 29 cases with certain vaccine history, 16 were individuals who had received two doses of mumps vaccine. Four had received one dose. Nine had never been vaccinated. The investigators determined that the attack rate for those who had never been vaccinated was 43%.

For those who had received one vaccine, it was 9%. Among those who had been vaccinated twice, it was 4%. The investigators also found that, among those who had been vaccinated twice, the attack rates were lowest for those who had been vaccinated within 6 years (none of 72 individuals), and those who had been vaccinated more than 15 years before the outbreak (none of 3).

Among those in the middle, the attack rate was 4% for those vaccinated 6–10 years before the outbreak, and 7% for those vaccinated 11–15 years before the outbreak.

While that finding might suggest waning immunity was playing a role in who contracted mumps, a regression analysis did not demonstrate any linearity in the attack rates by the years since last vaccination, Dr. Schaffzin said.

There was no difference in the clinical manifestations or in the duration of illness between those who had been vaccinated and those who had not, he added.

Mumps outbreaks can occur even among highly vaccinated populations, according to a report on a summer camp outbreak in 2005.

The outbreak had 31 confirmed cases, and 55% were known to have had two doses of mumps vaccine. Analysis indicated two doses of mumps vaccine were 92% effective in preventing mumps. A single dose was 80% effective (Pediatrics 2007;120:doi:10.1542/peds.2006-3451).

Nine cases occurred in individuals who had never been vaccinated, said Dr. Joshua K. Schaffzin of the New York State Department of Health, Albany, and his colleagues.

According to a previous report on the outbreak, the index case was a 20-year-old male camp counselor from the United Kingdom who had never been vaccinated against mumps.

On June 30, 2005, about 11 days after his arrival, he was evaluated in the camp infirmary for a left-sided parotitis, sore throat, and a low-grade fever.

At the time, a mumps epidemic was occurring in the United Kingdom. But mumps was not considered, and the counselor continued work. During July 15–23, an additional 25 cases of parotitis were seen. On July 26, the New York State Department of Health became aware of the outbreak, cases were isolated, and the camp was quarantined.

According to the new report, 541 persons were at the camp that summer, including 368 campers, whose median age was 12, and 173 staff members, whose median age was 21. Of the campers, all had received at least one mumps vaccination, and all but two had two doses. Of the staff, 21 had never been vaccinated.

Thirty-one cases of mumps were identified in the camp. Twenty-six met case definitions for mumps, and six were tested for mumps IgG and IgM. Five of those six were positive for both. Only one of the six had been vaccinated, and that person had received two doses.

Twelve of the patients were campers and the rest were staff.

Of the 29 cases with certain vaccine history, 16 were individuals who had received two doses of mumps vaccine. Four had received one dose. Nine had never been vaccinated. The investigators determined that the attack rate for those who had never been vaccinated was 43%.

For those who had received one vaccine, it was 9%. Among those who had been vaccinated twice, it was 4%. The investigators also found that, among those who had been vaccinated twice, the attack rates were lowest for those who had been vaccinated within 6 years (none of 72 individuals), and those who had been vaccinated more than 15 years before the outbreak (none of 3).

Among those in the middle, the attack rate was 4% for those vaccinated 6–10 years before the outbreak, and 7% for those vaccinated 11–15 years before the outbreak.

While that finding might suggest waning immunity was playing a role in who contracted mumps, a regression analysis did not demonstrate any linearity in the attack rates by the years since last vaccination, Dr. Schaffzin said.

There was no difference in the clinical manifestations or in the duration of illness between those who had been vaccinated and those who had not, he added.

Mumps outbreaks can occur even among highly vaccinated populations, according to a report on a summer camp outbreak in 2005.

The outbreak had 31 confirmed cases, and 55% were known to have had two doses of mumps vaccine. Analysis indicated two doses of mumps vaccine were 92% effective in preventing mumps. A single dose was 80% effective (Pediatrics 2007;120:doi:10.1542/peds.2006-3451).

Nine cases occurred in individuals who had never been vaccinated, said Dr. Joshua K. Schaffzin of the New York State Department of Health, Albany, and his colleagues.

According to a previous report on the outbreak, the index case was a 20-year-old male camp counselor from the United Kingdom who had never been vaccinated against mumps.

On June 30, 2005, about 11 days after his arrival, he was evaluated in the camp infirmary for a left-sided parotitis, sore throat, and a low-grade fever.

At the time, a mumps epidemic was occurring in the United Kingdom. But mumps was not considered, and the counselor continued work. During July 15–23, an additional 25 cases of parotitis were seen. On July 26, the New York State Department of Health became aware of the outbreak, cases were isolated, and the camp was quarantined.

According to the new report, 541 persons were at the camp that summer, including 368 campers, whose median age was 12, and 173 staff members, whose median age was 21. Of the campers, all had received at least one mumps vaccination, and all but two had two doses. Of the staff, 21 had never been vaccinated.

Thirty-one cases of mumps were identified in the camp. Twenty-six met case definitions for mumps, and six were tested for mumps IgG and IgM. Five of those six were positive for both. Only one of the six had been vaccinated, and that person had received two doses.

Twelve of the patients were campers and the rest were staff.

Of the 29 cases with certain vaccine history, 16 were individuals who had received two doses of mumps vaccine. Four had received one dose. Nine had never been vaccinated. The investigators determined that the attack rate for those who had never been vaccinated was 43%.

For those who had received one vaccine, it was 9%. Among those who had been vaccinated twice, it was 4%. The investigators also found that, among those who had been vaccinated twice, the attack rates were lowest for those who had been vaccinated within 6 years (none of 72 individuals), and those who had been vaccinated more than 15 years before the outbreak (none of 3).

Among those in the middle, the attack rate was 4% for those vaccinated 6–10 years before the outbreak, and 7% for those vaccinated 11–15 years before the outbreak.

While that finding might suggest waning immunity was playing a role in who contracted mumps, a regression analysis did not demonstrate any linearity in the attack rates by the years since last vaccination, Dr. Schaffzin said.

There was no difference in the clinical manifestations or in the duration of illness between those who had been vaccinated and those who had not, he added.

LAS VEGAS — Botanicals have become the new hot commodity in cosmeceuticals, as part of a larger trend that has consumers searching for natural ingredients in all kinds of products.

"Natural ingredients have become popular again," Dr. Diane Berson said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "They have always been popular, but they definitely are having a renaissance."

"Part of this is consumer driven. Patients want things that are natural, so they want botanicals," she added.

It is estimated that 40%–50% of new skin care products include a botanical agent, said Dr. Berson, who is with the department of dermatology at Cornell University, New York.

According to Dr. Berson, here are some of the currently popular botanicals:

▸ Soy. This highly potent anti-inflammatory and antioxidant contains the phytoestrogen genistein.

It may inhibit hair growth, and it probably lightens pigment, which is why it is used for lightening and brightening skin. There are also suggestions that it can stimulate collagen synthesis and initiate skin elastin repair processes. "It's also a good product for sensitive skin," Dr. Berson said.

▸ Mushroom. Several companies sell products containing shiitake mushroom, including the Aveeno Positively Ageless line. According to Johnson & Johnson Consumer Products Co., the mushroom has anti-inflammatory and antioxidant properties. It may also inhibit production of matrix metalloproteinases, which break down collagen, and it has been reported to stimulate epidermal proliferation.

"If this is true, that would be very interesting," Dr. Berson said. "It would actually be getting into retinoid territory."

As with so many cosmeceuticals that may have properties when tested in animals or culture, however, one cannot be sure—in the absence of randomized controlled trials—that the topical application actually penetrates human skin in adequate concentration, she noted.

▸ Feverfew. Feverfew PFE (parthenolide-free extract) has anti-inflammatory, antioxidant, and anti-irritant properties. It appears to inhibit tumor necrosis factor-α production, interleukin-2 and interleukin-4 production, and neutrophil chemotaxis, activities that may explain its anti-inflammatory properties, Dr. Berson said.

In fact, because feverfew naturally contains parthenolide, a compound that relieves smooth muscle spasm, it is being used orally as a prophylactic agent to prevent migraine, Dr. Berson noted.

In the skin care market, it is being sold to people with rosacea.

Feverfew (Tanacetum parthenium) is a member of the sunflower family and has been used for centuries as a folk remedy for headache, arthritis, and fevers.

▸ Coffeeberry. The extract of the husk around the coffee cherry contains quite powerful antioxidants. According to Stiefel Laboratories Inc., the company that makes the product (Revaléskin), its antioxidants have a free radical-absorbing capacity that is 10 times greater than those in green tea.

In a trial of 10 women treated in a split-face fashion for 6 weeks, the coffeeberry extract produced a 30% global improvement on the treated sides, versus 7% improvement on the control sides ("Novel Antioxidant Shows Promise as Photoaging Topical," April 2007, p. 1). The problem is that the study involved only 10 patients, Dr. Berson noted.

Even so, "I think we are going to be hearing more about this extract," she said.

▸ Witch hazel. The old folk remedy for sunburns is now included in a number of skin rejuvenation and skin toner products, such as SkinMedica Inc.'s Rejuvenative Toner.

Witch hazel (Hamamelis virginiana), it turns out, contains anti-inflammatory polyphenols, Dr. Berson said at the meeting.

"It would be great if we could see that these natural compounds do indeed do what they are supposed to do," she said. "But, even so, a lot of these products are very popular."

Dr. Berson said that she has financial conflicts of interest with many cosmeceutical manufacturers, including her service as a consultant to Medicis Pharmaceutical Corp., Kao Corp., Stiefel Laboratories, Dusa Pharmaceuticals Inc., OrthoNeutrogena, and CollaGenex Pharmaceuticals Inc.

LAS VEGAS — Botanicals have become the new hot commodity in cosmeceuticals, as part of a larger trend that has consumers searching for natural ingredients in all kinds of products.

"Natural ingredients have become popular again," Dr. Diane Berson said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "They have always been popular, but they definitely are having a renaissance."

"Part of this is consumer driven. Patients want things that are natural, so they want botanicals," she added.

It is estimated that 40%–50% of new skin care products include a botanical agent, said Dr. Berson, who is with the department of dermatology at Cornell University, New York.

According to Dr. Berson, here are some of the currently popular botanicals:

▸ Soy. This highly potent anti-inflammatory and antioxidant contains the phytoestrogen genistein.

It may inhibit hair growth, and it probably lightens pigment, which is why it is used for lightening and brightening skin. There are also suggestions that it can stimulate collagen synthesis and initiate skin elastin repair processes. "It's also a good product for sensitive skin," Dr. Berson said.

▸ Mushroom. Several companies sell products containing shiitake mushroom, including the Aveeno Positively Ageless line. According to Johnson & Johnson Consumer Products Co., the mushroom has anti-inflammatory and antioxidant properties. It may also inhibit production of matrix metalloproteinases, which break down collagen, and it has been reported to stimulate epidermal proliferation.

"If this is true, that would be very interesting," Dr. Berson said. "It would actually be getting into retinoid territory."

As with so many cosmeceuticals that may have properties when tested in animals or culture, however, one cannot be sure—in the absence of randomized controlled trials—that the topical application actually penetrates human skin in adequate concentration, she noted.

▸ Feverfew. Feverfew PFE (parthenolide-free extract) has anti-inflammatory, antioxidant, and anti-irritant properties. It appears to inhibit tumor necrosis factor-α production, interleukin-2 and interleukin-4 production, and neutrophil chemotaxis, activities that may explain its anti-inflammatory properties, Dr. Berson said.

In fact, because feverfew naturally contains parthenolide, a compound that relieves smooth muscle spasm, it is being used orally as a prophylactic agent to prevent migraine, Dr. Berson noted.

In the skin care market, it is being sold to people with rosacea.

Feverfew (Tanacetum parthenium) is a member of the sunflower family and has been used for centuries as a folk remedy for headache, arthritis, and fevers.

▸ Coffeeberry. The extract of the husk around the coffee cherry contains quite powerful antioxidants. According to Stiefel Laboratories Inc., the company that makes the product (Revaléskin), its antioxidants have a free radical-absorbing capacity that is 10 times greater than those in green tea.

In a trial of 10 women treated in a split-face fashion for 6 weeks, the coffeeberry extract produced a 30% global improvement on the treated sides, versus 7% improvement on the control sides ("Novel Antioxidant Shows Promise as Photoaging Topical," April 2007, p. 1). The problem is that the study involved only 10 patients, Dr. Berson noted.

Even so, "I think we are going to be hearing more about this extract," she said.

▸ Witch hazel. The old folk remedy for sunburns is now included in a number of skin rejuvenation and skin toner products, such as SkinMedica Inc.'s Rejuvenative Toner.

Witch hazel (Hamamelis virginiana), it turns out, contains anti-inflammatory polyphenols, Dr. Berson said at the meeting.

"It would be great if we could see that these natural compounds do indeed do what they are supposed to do," she said. "But, even so, a lot of these products are very popular."

Dr. Berson said that she has financial conflicts of interest with many cosmeceutical manufacturers, including her service as a consultant to Medicis Pharmaceutical Corp., Kao Corp., Stiefel Laboratories, Dusa Pharmaceuticals Inc., OrthoNeutrogena, and CollaGenex Pharmaceuticals Inc.

LAS VEGAS — Botanicals have become the new hot commodity in cosmeceuticals, as part of a larger trend that has consumers searching for natural ingredients in all kinds of products.

"Natural ingredients have become popular again," Dr. Diane Berson said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "They have always been popular, but they definitely are having a renaissance."

"Part of this is consumer driven. Patients want things that are natural, so they want botanicals," she added.

It is estimated that 40%–50% of new skin care products include a botanical agent, said Dr. Berson, who is with the department of dermatology at Cornell University, New York.

According to Dr. Berson, here are some of the currently popular botanicals:

▸ Soy. This highly potent anti-inflammatory and antioxidant contains the phytoestrogen genistein.

It may inhibit hair growth, and it probably lightens pigment, which is why it is used for lightening and brightening skin. There are also suggestions that it can stimulate collagen synthesis and initiate skin elastin repair processes. "It's also a good product for sensitive skin," Dr. Berson said.

▸ Mushroom. Several companies sell products containing shiitake mushroom, including the Aveeno Positively Ageless line. According to Johnson & Johnson Consumer Products Co., the mushroom has anti-inflammatory and antioxidant properties. It may also inhibit production of matrix metalloproteinases, which break down collagen, and it has been reported to stimulate epidermal proliferation.

"If this is true, that would be very interesting," Dr. Berson said. "It would actually be getting into retinoid territory."

As with so many cosmeceuticals that may have properties when tested in animals or culture, however, one cannot be sure—in the absence of randomized controlled trials—that the topical application actually penetrates human skin in adequate concentration, she noted.

▸ Feverfew. Feverfew PFE (parthenolide-free extract) has anti-inflammatory, antioxidant, and anti-irritant properties. It appears to inhibit tumor necrosis factor-α production, interleukin-2 and interleukin-4 production, and neutrophil chemotaxis, activities that may explain its anti-inflammatory properties, Dr. Berson said.

In fact, because feverfew naturally contains parthenolide, a compound that relieves smooth muscle spasm, it is being used orally as a prophylactic agent to prevent migraine, Dr. Berson noted.

In the skin care market, it is being sold to people with rosacea.

Feverfew (Tanacetum parthenium) is a member of the sunflower family and has been used for centuries as a folk remedy for headache, arthritis, and fevers.

▸ Coffeeberry. The extract of the husk around the coffee cherry contains quite powerful antioxidants. According to Stiefel Laboratories Inc., the company that makes the product (Revaléskin), its antioxidants have a free radical-absorbing capacity that is 10 times greater than those in green tea.

In a trial of 10 women treated in a split-face fashion for 6 weeks, the coffeeberry extract produced a 30% global improvement on the treated sides, versus 7% improvement on the control sides ("Novel Antioxidant Shows Promise as Photoaging Topical," April 2007, p. 1). The problem is that the study involved only 10 patients, Dr. Berson noted.

Even so, "I think we are going to be hearing more about this extract," she said.

▸ Witch hazel. The old folk remedy for sunburns is now included in a number of skin rejuvenation and skin toner products, such as SkinMedica Inc.'s Rejuvenative Toner.

Witch hazel (Hamamelis virginiana), it turns out, contains anti-inflammatory polyphenols, Dr. Berson said at the meeting.

"It would be great if we could see that these natural compounds do indeed do what they are supposed to do," she said. "But, even so, a lot of these products are very popular."

Dr. Berson said that she has financial conflicts of interest with many cosmeceutical manufacturers, including her service as a consultant to Medicis Pharmaceutical Corp., Kao Corp., Stiefel Laboratories, Dusa Pharmaceuticals Inc., OrthoNeutrogena, and CollaGenex Pharmaceuticals Inc.

LAS VEGAS — Dispensing cosmeceuticals from the office can be as lucrative as injecting fillers or performing laser procedures, said Dr. Ira Berman, a dermatologist in York, Pa., who has been dispensing products for 30 years.

With that income comes temptation, however, and the dermatologist who dispenses has to resist becoming greedy, he said. The patient's welfare must always come first, or the whole arrangement will come down like a house of cards, he said.

"Ethics is always important because the most important thing you have besides your education is your reputation," said Dr. Berman, speaking at the annual meeting of the American Society for Cosmetic Dermatology and Aesthetic Surgery.

He developed a list 10 years ago of what he considers to be the 10 commandments of ethical office dispensing. (See box.)

"If we don't follow basic ethical guidelines, we risk losing the privilege of … dispensing altogether," he added.

In his talk on this subject, Dr. Berman presented several of the lessons he has learned from his 30 years of experience. Among those lessons were:

▸ Pay your taxes. Most states require that a retail business acquire a sales tax license, Dr. Berman said.

He has a computer program at his office that figures the sales tax on items sold. "You do not want to wind up in the newspaper because your office has been raided due to a failure to pay sales tax," he said.

▸ Have adequate storage. The minimum amount of a product that a physician should keep on hand is a 1-month supply. The storage area should also be in a convenient location so members of your staff do not have to go too far to retrieve items and become resentful of the imposition. "If people come back and want refills, and you don't have them, it is an embarrassing situation," Dr. Berman said.

▸ Put one person in charge. Have one staff person assigned to keeping track of inventory. That gives that person incentive to be more attentive than they otherwise might be, and it prevents confusion about the responsibility for tracking sales and ordering.

▸ Don't offer freebies. Members of the staff need to be told clearly that they cannot take any free samples for themselves, friends, or family. Charge them cost, but make sure everyone knows that they cannot just help themselves, Dr. Berman said.

▸ Decide whether to carry name brands or use boutique labeling instead. The decision over whether to carry name-brand products or to create your own products with your own label is one that needs to be based on several factors.

For a physician who is selling small amounts of cosmeceuticals, name-brand items might be a more efficient choice, but if he or she is selling large amounts, it may behoove the office to create its own labeling.

A rule of thumb is that dermatologists can price the items they sell at twice their cost, but this can be trickier with brand-name items, he said.

"The one thing with carrying [a] brand-name item is that you must remember you are going to be competing with some people who are selling it on the Internet, and that affects how you can price it," he pointed out.

▸ Determine whether employees will receive a commission. Decide whether the members of your staff are going to get a percentage of the product sales before you start selling, and remember that if you consider the sales of items to be a low priority so will your staff, Dr. Berman said.

His office has two separate reception areas, one for cosmetic patients and one for medical patients.

Members of the staff who work in the medical area earn a straight salary, while those in the cosmetic area earn commissions. Be sure that the members of your staff understand the office is not a retail store and that they should not engage in high-pressure sales tactics, he added.

Dr. Berman noted that the American Academy of Dermatology has articulated the position that selling products is an appropriate practice. But the position statement says that those products should have proven benefit.

Office Dispensing Commandments

1. The best interests of the patient come first.

2. There must be a legitimate basis for the patient's use of the product.

3. There must be valid scientific evidence for the product.

4. The cost should be reasonable and be of true value to the patient.

5. Office staff should maintain the same values as the physician—that the patient comes first.

6. Office staff should also maintain an unconditional money-back guarantee.

7. The dispensing physician should not charge for a consultation when any product causes problems.

8. The physician should obtain the products from responsible manufacturers who carry insurance.

9. The product labeling should provide full disclosure of what is in the product.

10. The office should never sell outdated, damaged, or chemically altered products.

LAS VEGAS — Dispensing cosmeceuticals from the office can be as lucrative as injecting fillers or performing laser procedures, said Dr. Ira Berman, a dermatologist in York, Pa., who has been dispensing products for 30 years.

With that income comes temptation, however, and the dermatologist who dispenses has to resist becoming greedy, he said. The patient's welfare must always come first, or the whole arrangement will come down like a house of cards, he said.

"Ethics is always important because the most important thing you have besides your education is your reputation," said Dr. Berman, speaking at the annual meeting of the American Society for Cosmetic Dermatology and Aesthetic Surgery.

He developed a list 10 years ago of what he considers to be the 10 commandments of ethical office dispensing. (See box.)

"If we don't follow basic ethical guidelines, we risk losing the privilege of … dispensing altogether," he added.

In his talk on this subject, Dr. Berman presented several of the lessons he has learned from his 30 years of experience. Among those lessons were:

▸ Pay your taxes. Most states require that a retail business acquire a sales tax license, Dr. Berman said.

He has a computer program at his office that figures the sales tax on items sold. "You do not want to wind up in the newspaper because your office has been raided due to a failure to pay sales tax," he said.

▸ Have adequate storage. The minimum amount of a product that a physician should keep on hand is a 1-month supply. The storage area should also be in a convenient location so members of your staff do not have to go too far to retrieve items and become resentful of the imposition. "If people come back and want refills, and you don't have them, it is an embarrassing situation," Dr. Berman said.

▸ Put one person in charge. Have one staff person assigned to keeping track of inventory. That gives that person incentive to be more attentive than they otherwise might be, and it prevents confusion about the responsibility for tracking sales and ordering.

▸ Don't offer freebies. Members of the staff need to be told clearly that they cannot take any free samples for themselves, friends, or family. Charge them cost, but make sure everyone knows that they cannot just help themselves, Dr. Berman said.

▸ Decide whether to carry name brands or use boutique labeling instead. The decision over whether to carry name-brand products or to create your own products with your own label is one that needs to be based on several factors.

For a physician who is selling small amounts of cosmeceuticals, name-brand items might be a more efficient choice, but if he or she is selling large amounts, it may behoove the office to create its own labeling.

A rule of thumb is that dermatologists can price the items they sell at twice their cost, but this can be trickier with brand-name items, he said.

"The one thing with carrying [a] brand-name item is that you must remember you are going to be competing with some people who are selling it on the Internet, and that affects how you can price it," he pointed out.

▸ Determine whether employees will receive a commission. Decide whether the members of your staff are going to get a percentage of the product sales before you start selling, and remember that if you consider the sales of items to be a low priority so will your staff, Dr. Berman said.

His office has two separate reception areas, one for cosmetic patients and one for medical patients.

Members of the staff who work in the medical area earn a straight salary, while those in the cosmetic area earn commissions. Be sure that the members of your staff understand the office is not a retail store and that they should not engage in high-pressure sales tactics, he added.

Dr. Berman noted that the American Academy of Dermatology has articulated the position that selling products is an appropriate practice. But the position statement says that those products should have proven benefit.

Office Dispensing Commandments

1. The best interests of the patient come first.

2. There must be a legitimate basis for the patient's use of the product.

3. There must be valid scientific evidence for the product.

4. The cost should be reasonable and be of true value to the patient.

5. Office staff should maintain the same values as the physician—that the patient comes first.

6. Office staff should also maintain an unconditional money-back guarantee.

7. The dispensing physician should not charge for a consultation when any product causes problems.

8. The physician should obtain the products from responsible manufacturers who carry insurance.

9. The product labeling should provide full disclosure of what is in the product.

10. The office should never sell outdated, damaged, or chemically altered products.

LAS VEGAS — Dispensing cosmeceuticals from the office can be as lucrative as injecting fillers or performing laser procedures, said Dr. Ira Berman, a dermatologist in York, Pa., who has been dispensing products for 30 years.

With that income comes temptation, however, and the dermatologist who dispenses has to resist becoming greedy, he said. The patient's welfare must always come first, or the whole arrangement will come down like a house of cards, he said.

"Ethics is always important because the most important thing you have besides your education is your reputation," said Dr. Berman, speaking at the annual meeting of the American Society for Cosmetic Dermatology and Aesthetic Surgery.

He developed a list 10 years ago of what he considers to be the 10 commandments of ethical office dispensing. (See box.)

"If we don't follow basic ethical guidelines, we risk losing the privilege of … dispensing altogether," he added.

In his talk on this subject, Dr. Berman presented several of the lessons he has learned from his 30 years of experience. Among those lessons were:

▸ Pay your taxes. Most states require that a retail business acquire a sales tax license, Dr. Berman said.

He has a computer program at his office that figures the sales tax on items sold. "You do not want to wind up in the newspaper because your office has been raided due to a failure to pay sales tax," he said.

▸ Have adequate storage. The minimum amount of a product that a physician should keep on hand is a 1-month supply. The storage area should also be in a convenient location so members of your staff do not have to go too far to retrieve items and become resentful of the imposition. "If people come back and want refills, and you don't have them, it is an embarrassing situation," Dr. Berman said.

▸ Put one person in charge. Have one staff person assigned to keeping track of inventory. That gives that person incentive to be more attentive than they otherwise might be, and it prevents confusion about the responsibility for tracking sales and ordering.

▸ Don't offer freebies. Members of the staff need to be told clearly that they cannot take any free samples for themselves, friends, or family. Charge them cost, but make sure everyone knows that they cannot just help themselves, Dr. Berman said.

▸ Decide whether to carry name brands or use boutique labeling instead. The decision over whether to carry name-brand products or to create your own products with your own label is one that needs to be based on several factors.

For a physician who is selling small amounts of cosmeceuticals, name-brand items might be a more efficient choice, but if he or she is selling large amounts, it may behoove the office to create its own labeling.

A rule of thumb is that dermatologists can price the items they sell at twice their cost, but this can be trickier with brand-name items, he said.

"The one thing with carrying [a] brand-name item is that you must remember you are going to be competing with some people who are selling it on the Internet, and that affects how you can price it," he pointed out.

▸ Determine whether employees will receive a commission. Decide whether the members of your staff are going to get a percentage of the product sales before you start selling, and remember that if you consider the sales of items to be a low priority so will your staff, Dr. Berman said.

His office has two separate reception areas, one for cosmetic patients and one for medical patients.

Members of the staff who work in the medical area earn a straight salary, while those in the cosmetic area earn commissions. Be sure that the members of your staff understand the office is not a retail store and that they should not engage in high-pressure sales tactics, he added.

Dr. Berman noted that the American Academy of Dermatology has articulated the position that selling products is an appropriate practice. But the position statement says that those products should have proven benefit.

Office Dispensing Commandments

1. The best interests of the patient come first.

2. There must be a legitimate basis for the patient's use of the product.

3. There must be valid scientific evidence for the product.

4. The cost should be reasonable and be of true value to the patient.

5. Office staff should maintain the same values as the physician—that the patient comes first.

6. Office staff should also maintain an unconditional money-back guarantee.

7. The dispensing physician should not charge for a consultation when any product causes problems.

8. The physician should obtain the products from responsible manufacturers who carry insurance.

9. The product labeling should provide full disclosure of what is in the product.

10. The office should never sell outdated, damaged, or chemically altered products.

LAS VEGAS — Poly-L-lactic acid needs to be used somewhat differently than other cosmetic fillers to correct nasolabial folds and wrinkles, and it requires more technique and more real familiarity with the product, a number of speakers said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

"I think Sculptra [poly-L-lactic acid] is the most interesting filler and the most difficult to use," said Dr. David Duffy, a dermatologist who practices in Torrance, Calif., and is a clinical faculty member at the University of Southern California, Los Angeles.

"You really have to learn how to use this. I suggest that someone starts with injecting the hyalurons, then Radiesse [calcium hydroxylapatite], and then tries Sculptra," said Dr. Duffy, who is a consultant for Aventis, the maker of Sculptra.

Dr. Duffy and the others who discussed poly-L-lactic acid at the meeting talked about what they have learned in the first few years since the filler was approved for the treatment of lipoatrophy in patients with HIV and gave some pointers they have picked up.

"Sculptra has shown us a whole new venue and approach," said Dr. Gary Monheit of the University of Alabama, Birmingham.

"We're creating almost a cheek implant with Sculptra these days," added Dr. Cherie M. Ditre, director of the University of Pennsylvania's Cosmetic Dermatology and Skin Enhancement Center in Radnor.

The speakers offered a number of tips:

▸ Make it painless. The frequently recommended dilution of poly-L-lactic acid is to take the vial, which contains 150 mg of material, and dilute it with 5 mL of sterile water. Dr. Ditre said that she adds another 2 mL of lidocaine anesthetic and then gives patients about 3 mL in each cheek per session.

Dr. Duffy said he actually uses nerve blocks, and that he often uses smaller injections of lidocaine and epinephrine to help map his poly-L-lactic acid injections since the epinephrine leaves areas slightly blanched.

▸ Put it deep. Although many recommendations suggest that poly-L-lactic acid should be injected into the deep dermis, Dr. Monheit said he goes deeper, just into the subcutaneous tissue.

"For me, it is all injected in the subcutaneous now," he said. "I use little aliquots, at least four sessions, each 6 weeks apart. And we see new collagen in 4–6 months."

He injects in a crisscross pattern, with a tunneling technique. One advantage of injecting into the subcutaneous space is that the material spreads out more easily, Dr. Monheit said.

▸ Tap the syringe. The material does not stay in solution, so it is necessary to tap the syringe periodically when injecting to prevent the material from accumulating at the bottom, Dr. Duffy said.

"You really have to keep snapping the syringe," he said.

Dr. Monheit said he shakes the syringe well. A 25-gauge or 26-gauge needle is recommended, but he uses a larger one to prevent clogging.

▸ Massage, massage, massage. Each of the physicians stressed that the treating physician must massage the area after injection, and that patients must massage every day, a few times a day, for about a week after injection. The massaging spreads the material out, almost into a sheet, and prevents nodule formation, which is not uncommon otherwise, Dr. Monheit said.

▸ Rejuvenate gradually. A patient should get three separate treatments, spaced 4–6 weeks apart, and then wait before any more, Dr. Ditre said. With poly-L-lactic acid there is gradual improvement, which often takes 6 months or more to fully appear as collagen remodeling occurs.

Because of the gradual, continued improvement that patients have, it is important not to use too much and overcorrect, Dr. Monheit said.

▸ What to treat. Poly-L-lactic acid can be injected into the cheeks, the chin, and the temple, but one should be careful to avoid superficial injection, to not treat the folds themselves, and to spread the material out evenly, Dr. Monheit said.

He noted that he has used it successfully to reduce the appearance of acne scars.

The corrections associated with poly-L-lactic acid treatment are thought to last 18–24 months for most patients, but there are reports of patients having adequate correction that has lasted 5 years and more, Dr. Ditre said.

Dr. Ditre and Dr. Monheit have no relevant disclosures to report.

Because ofthe gradual improvement that patients have, itis important notto overcorrect. DR. MONHEIT

LAS VEGAS — Poly-L-lactic acid needs to be used somewhat differently than other cosmetic fillers to correct nasolabial folds and wrinkles, and it requires more technique and more real familiarity with the product, a number of speakers said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

"I think Sculptra [poly-L-lactic acid] is the most interesting filler and the most difficult to use," said Dr. David Duffy, a dermatologist who practices in Torrance, Calif., and is a clinical faculty member at the University of Southern California, Los Angeles.

"You really have to learn how to use this. I suggest that someone starts with injecting the hyalurons, then Radiesse [calcium hydroxylapatite], and then tries Sculptra," said Dr. Duffy, who is a consultant for Aventis, the maker of Sculptra.

Dr. Duffy and the others who discussed poly-L-lactic acid at the meeting talked about what they have learned in the first few years since the filler was approved for the treatment of lipoatrophy in patients with HIV and gave some pointers they have picked up.

"Sculptra has shown us a whole new venue and approach," said Dr. Gary Monheit of the University of Alabama, Birmingham.

"We're creating almost a cheek implant with Sculptra these days," added Dr. Cherie M. Ditre, director of the University of Pennsylvania's Cosmetic Dermatology and Skin Enhancement Center in Radnor.

The speakers offered a number of tips:

▸ Make it painless. The frequently recommended dilution of poly-L-lactic acid is to take the vial, which contains 150 mg of material, and dilute it with 5 mL of sterile water. Dr. Ditre said that she adds another 2 mL of lidocaine anesthetic and then gives patients about 3 mL in each cheek per session.

Dr. Duffy said he actually uses nerve blocks, and that he often uses smaller injections of lidocaine and epinephrine to help map his poly-L-lactic acid injections since the epinephrine leaves areas slightly blanched.

▸ Put it deep. Although many recommendations suggest that poly-L-lactic acid should be injected into the deep dermis, Dr. Monheit said he goes deeper, just into the subcutaneous tissue.

"For me, it is all injected in the subcutaneous now," he said. "I use little aliquots, at least four sessions, each 6 weeks apart. And we see new collagen in 4–6 months."

He injects in a crisscross pattern, with a tunneling technique. One advantage of injecting into the subcutaneous space is that the material spreads out more easily, Dr. Monheit said.

▸ Tap the syringe. The material does not stay in solution, so it is necessary to tap the syringe periodically when injecting to prevent the material from accumulating at the bottom, Dr. Duffy said.

"You really have to keep snapping the syringe," he said.

Dr. Monheit said he shakes the syringe well. A 25-gauge or 26-gauge needle is recommended, but he uses a larger one to prevent clogging.

▸ Massage, massage, massage. Each of the physicians stressed that the treating physician must massage the area after injection, and that patients must massage every day, a few times a day, for about a week after injection. The massaging spreads the material out, almost into a sheet, and prevents nodule formation, which is not uncommon otherwise, Dr. Monheit said.

▸ Rejuvenate gradually. A patient should get three separate treatments, spaced 4–6 weeks apart, and then wait before any more, Dr. Ditre said. With poly-L-lactic acid there is gradual improvement, which often takes 6 months or more to fully appear as collagen remodeling occurs.

Because of the gradual, continued improvement that patients have, it is important not to use too much and overcorrect, Dr. Monheit said.

▸ What to treat. Poly-L-lactic acid can be injected into the cheeks, the chin, and the temple, but one should be careful to avoid superficial injection, to not treat the folds themselves, and to spread the material out evenly, Dr. Monheit said.

He noted that he has used it successfully to reduce the appearance of acne scars.

The corrections associated with poly-L-lactic acid treatment are thought to last 18–24 months for most patients, but there are reports of patients having adequate correction that has lasted 5 years and more, Dr. Ditre said.

Dr. Ditre and Dr. Monheit have no relevant disclosures to report.

Because ofthe gradual improvement that patients have, itis important notto overcorrect. DR. MONHEIT

LAS VEGAS — Poly-L-lactic acid needs to be used somewhat differently than other cosmetic fillers to correct nasolabial folds and wrinkles, and it requires more technique and more real familiarity with the product, a number of speakers said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

"I think Sculptra [poly-L-lactic acid] is the most interesting filler and the most difficult to use," said Dr. David Duffy, a dermatologist who practices in Torrance, Calif., and is a clinical faculty member at the University of Southern California, Los Angeles.

"You really have to learn how to use this. I suggest that someone starts with injecting the hyalurons, then Radiesse [calcium hydroxylapatite], and then tries Sculptra," said Dr. Duffy, who is a consultant for Aventis, the maker of Sculptra.

Dr. Duffy and the others who discussed poly-L-lactic acid at the meeting talked about what they have learned in the first few years since the filler was approved for the treatment of lipoatrophy in patients with HIV and gave some pointers they have picked up.

"Sculptra has shown us a whole new venue and approach," said Dr. Gary Monheit of the University of Alabama, Birmingham.

"We're creating almost a cheek implant with Sculptra these days," added Dr. Cherie M. Ditre, director of the University of Pennsylvania's Cosmetic Dermatology and Skin Enhancement Center in Radnor.

The speakers offered a number of tips:

▸ Make it painless. The frequently recommended dilution of poly-L-lactic acid is to take the vial, which contains 150 mg of material, and dilute it with 5 mL of sterile water. Dr. Ditre said that she adds another 2 mL of lidocaine anesthetic and then gives patients about 3 mL in each cheek per session.

Dr. Duffy said he actually uses nerve blocks, and that he often uses smaller injections of lidocaine and epinephrine to help map his poly-L-lactic acid injections since the epinephrine leaves areas slightly blanched.

▸ Put it deep. Although many recommendations suggest that poly-L-lactic acid should be injected into the deep dermis, Dr. Monheit said he goes deeper, just into the subcutaneous tissue.

"For me, it is all injected in the subcutaneous now," he said. "I use little aliquots, at least four sessions, each 6 weeks apart. And we see new collagen in 4–6 months."

He injects in a crisscross pattern, with a tunneling technique. One advantage of injecting into the subcutaneous space is that the material spreads out more easily, Dr. Monheit said.

▸ Tap the syringe. The material does not stay in solution, so it is necessary to tap the syringe periodically when injecting to prevent the material from accumulating at the bottom, Dr. Duffy said.

"You really have to keep snapping the syringe," he said.

Dr. Monheit said he shakes the syringe well. A 25-gauge or 26-gauge needle is recommended, but he uses a larger one to prevent clogging.

▸ Massage, massage, massage. Each of the physicians stressed that the treating physician must massage the area after injection, and that patients must massage every day, a few times a day, for about a week after injection. The massaging spreads the material out, almost into a sheet, and prevents nodule formation, which is not uncommon otherwise, Dr. Monheit said.

▸ Rejuvenate gradually. A patient should get three separate treatments, spaced 4–6 weeks apart, and then wait before any more, Dr. Ditre said. With poly-L-lactic acid there is gradual improvement, which often takes 6 months or more to fully appear as collagen remodeling occurs.

Because of the gradual, continued improvement that patients have, it is important not to use too much and overcorrect, Dr. Monheit said.

▸ What to treat. Poly-L-lactic acid can be injected into the cheeks, the chin, and the temple, but one should be careful to avoid superficial injection, to not treat the folds themselves, and to spread the material out evenly, Dr. Monheit said.

He noted that he has used it successfully to reduce the appearance of acne scars.

The corrections associated with poly-L-lactic acid treatment are thought to last 18–24 months for most patients, but there are reports of patients having adequate correction that has lasted 5 years and more, Dr. Ditre said.

Dr. Ditre and Dr. Monheit have no relevant disclosures to report.

Because ofthe gradual improvement that patients have, itis important notto overcorrect. DR. MONHEIT

LAS VEGAS — More than half of the dermatologists in the United States now spend at least part of their patient-care time providing cosmetic services, according to a survey conducted by the American Academy of Dermatology in 2007.

"You can see that it is becoming a more important part of the general dermatologist's practice," Dr. Diane R. Baker, president of the academy, said in presenting some of the survey results at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

The survey was sent to 3,600 AAD members who are in private practice, of whom 1,146 (32%) responded, said Dr. Baker of Oregon Health and Science University, Portland, where she is also in private practice.

Fifty-five percent of respondents said that they spend at least some time practicing cosmetic dermatology.

Perhaps the most significant finding from the survery regarding cosmetic dermatology was that 3.5% of the respondents spend 50% or more of their patient-care time doing cosmetic care, which is up from 2.7% who reported the same in 2005, Dr. Baker said.

The mean amount of time that the dermatologists reported spending in direct patient care was 38 hr/wk, and 10% of that time overall was spent providing cosmetic care.

In addition, 3.7% of the dermatologists said that they spend no time doing medical dermatology, and the majority of those are Mohs surgeons, Dr. Baker said.

The cosmetic procedure performed by the most dermatologists was a chemical peel, reported by 51% of the responding dermatologists. The next most common procedure was botulinum toxin (botox) injection, which was performed by 49% of the respondents.

Other procedures that are commonly offered included UV light therapy (47%), collagen or filler injections (44%), sclerotherapy (44%), laser surgery (38%), and photodynamic therapy (24%).

Liposuction was performed by 6%, and hair transplants were performed by 2%, she said.

As a way of saying that the AAD tries to support dermatologists who provide cosmetic services as part of their practices, Dr. Baker noted that 18% of all the presentations given at the academy's last annual meeting were on cosmetic dermatology topics.

ELSEVIER GLOBAL MEDICAL NEWS

LAS VEGAS — More than half of the dermatologists in the United States now spend at least part of their patient-care time providing cosmetic services, according to a survey conducted by the American Academy of Dermatology in 2007.

"You can see that it is becoming a more important part of the general dermatologist's practice," Dr. Diane R. Baker, president of the academy, said in presenting some of the survey results at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

The survey was sent to 3,600 AAD members who are in private practice, of whom 1,146 (32%) responded, said Dr. Baker of Oregon Health and Science University, Portland, where she is also in private practice.

Fifty-five percent of respondents said that they spend at least some time practicing cosmetic dermatology.

Perhaps the most significant finding from the survery regarding cosmetic dermatology was that 3.5% of the respondents spend 50% or more of their patient-care time doing cosmetic care, which is up from 2.7% who reported the same in 2005, Dr. Baker said.

The mean amount of time that the dermatologists reported spending in direct patient care was 38 hr/wk, and 10% of that time overall was spent providing cosmetic care.

In addition, 3.7% of the dermatologists said that they spend no time doing medical dermatology, and the majority of those are Mohs surgeons, Dr. Baker said.

The cosmetic procedure performed by the most dermatologists was a chemical peel, reported by 51% of the responding dermatologists. The next most common procedure was botulinum toxin (botox) injection, which was performed by 49% of the respondents.

Other procedures that are commonly offered included UV light therapy (47%), collagen or filler injections (44%), sclerotherapy (44%), laser surgery (38%), and photodynamic therapy (24%).

Liposuction was performed by 6%, and hair transplants were performed by 2%, she said.

As a way of saying that the AAD tries to support dermatologists who provide cosmetic services as part of their practices, Dr. Baker noted that 18% of all the presentations given at the academy's last annual meeting were on cosmetic dermatology topics.

ELSEVIER GLOBAL MEDICAL NEWS

LAS VEGAS — More than half of the dermatologists in the United States now spend at least part of their patient-care time providing cosmetic services, according to a survey conducted by the American Academy of Dermatology in 2007.

"You can see that it is becoming a more important part of the general dermatologist's practice," Dr. Diane R. Baker, president of the academy, said in presenting some of the survey results at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

The survey was sent to 3,600 AAD members who are in private practice, of whom 1,146 (32%) responded, said Dr. Baker of Oregon Health and Science University, Portland, where she is also in private practice.

Fifty-five percent of respondents said that they spend at least some time practicing cosmetic dermatology.

Perhaps the most significant finding from the survery regarding cosmetic dermatology was that 3.5% of the respondents spend 50% or more of their patient-care time doing cosmetic care, which is up from 2.7% who reported the same in 2005, Dr. Baker said.

The mean amount of time that the dermatologists reported spending in direct patient care was 38 hr/wk, and 10% of that time overall was spent providing cosmetic care.

In addition, 3.7% of the dermatologists said that they spend no time doing medical dermatology, and the majority of those are Mohs surgeons, Dr. Baker said.

The cosmetic procedure performed by the most dermatologists was a chemical peel, reported by 51% of the responding dermatologists. The next most common procedure was botulinum toxin (botox) injection, which was performed by 49% of the respondents.

Other procedures that are commonly offered included UV light therapy (47%), collagen or filler injections (44%), sclerotherapy (44%), laser surgery (38%), and photodynamic therapy (24%).

Liposuction was performed by 6%, and hair transplants were performed by 2%, she said.

As a way of saying that the AAD tries to support dermatologists who provide cosmetic services as part of their practices, Dr. Baker noted that 18% of all the presentations given at the academy's last annual meeting were on cosmetic dermatology topics.

ELSEVIER GLOBAL MEDICAL NEWS