Timothy F. Kirn

LAS VEGAS — Dermatologists do not often think of using Botox in the lower face, but they should, Dr. Roberta D. Sengelmann said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

It is possible to treat and improve perioral rhytids, an asymmetric smile, a gummy smile, and even "apple-dumpling" chin, said Dr. Sengelmann of Santa Barbara, Calif.

The key to using botulinum toxin type A in the lower face is to be extremely careful not to use too much since those muscles are used for so many different functions. Also, the botulinum toxin option probably should be reserved for patients with mild to moderate aging changes, as there are better alternatives for serious rhytids of the lower face, she said.

Botulinum toxin "is a different animal when you get below the canthus," Dr. Sengelmann said. "Volume loss and soft-tissue ptosis play a large role in the lower face, and this cannot always be remedied by botulinum toxin injections. The lower face and neck are functionally important as well.

"The goal when we are treating the lower face is to soften dynamic lines and not to completely freeze," she added.

In treating perioral rhytids, inject into the orbicularis oris. The injections should be fairly superficial, into just the first layer of what is a "very thick and robust muscle," Dr. Sengelmann said.

The injections should be given right above the vermilion border, evenly spaced, and they need to be symmetric.

She gives 1–3 U per injection, with a maximum of 6 U in the upper lip and 4 U in the lower lip, so there is not too much deadening of function. She advised against injecting only the upper lip because treated lips lengthen and can protrude over the lower lip.

Results in the lower face often do not last as long as treatment of the glabella because less botulinum toxin is used. Dr. Sengelmann said that her treatments of perioral rhytids usually last 2–3 months.

Downturned lips can be treated with injections to the depressor labii inferioris—she gives 2–4 U into the mid-muscle. Radial perioral rhytids, or marionette lines, can be treated with injections to the depressor anguli oris. She does two injections per side, in the middle and lower third of the muscle, starting about 1 cm below the oral commissure and injecting 3–5 U per side.

Apple-dumpling chin, or a chin that gets lumpy when someone smiles or tightens their lips, is treated with an injection to the mentalis, at the mental crease, of about 5 U. "You want to be fairly inferior so you don't knock out the depressor labii, and it is a deep muscle," Dr. Sengelmann said.

Finally, patients with smiles that they don't like because they get a lot of upper gum showing can be treated with equal injections of 1–2 units into the levator labii superioris on each side of the nasal prominence.

Dr. Sengelmann also said that she always takes photographs before she does lower face treatments, that she marks her injection sites when she identifies the muscle before giving the actual injections, and that she often uses ice for the patients since lower face injections can be quite painful.

Dr. Sengelmann is on the advisory board and the speakers bureau for Allergan Inc., maker of Botox.

'The goal when we are treating the lower face is to soften dynamic lines and not to completely freeze.' DR. SENGELMANN

LAS VEGAS — Dermatologists do not often think of using Botox in the lower face, but they should, Dr. Roberta D. Sengelmann said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

It is possible to treat and improve perioral rhytids, an asymmetric smile, a gummy smile, and even "apple-dumpling" chin, said Dr. Sengelmann of Santa Barbara, Calif.

The key to using botulinum toxin type A in the lower face is to be extremely careful not to use too much since those muscles are used for so many different functions. Also, the botulinum toxin option probably should be reserved for patients with mild to moderate aging changes, as there are better alternatives for serious rhytids of the lower face, she said.

Botulinum toxin "is a different animal when you get below the canthus," Dr. Sengelmann said. "Volume loss and soft-tissue ptosis play a large role in the lower face, and this cannot always be remedied by botulinum toxin injections. The lower face and neck are functionally important as well.

"The goal when we are treating the lower face is to soften dynamic lines and not to completely freeze," she added.

In treating perioral rhytids, inject into the orbicularis oris. The injections should be fairly superficial, into just the first layer of what is a "very thick and robust muscle," Dr. Sengelmann said.

The injections should be given right above the vermilion border, evenly spaced, and they need to be symmetric.

She gives 1–3 U per injection, with a maximum of 6 U in the upper lip and 4 U in the lower lip, so there is not too much deadening of function. She advised against injecting only the upper lip because treated lips lengthen and can protrude over the lower lip.

Results in the lower face often do not last as long as treatment of the glabella because less botulinum toxin is used. Dr. Sengelmann said that her treatments of perioral rhytids usually last 2–3 months.

Downturned lips can be treated with injections to the depressor labii inferioris—she gives 2–4 U into the mid-muscle. Radial perioral rhytids, or marionette lines, can be treated with injections to the depressor anguli oris. She does two injections per side, in the middle and lower third of the muscle, starting about 1 cm below the oral commissure and injecting 3–5 U per side.

Apple-dumpling chin, or a chin that gets lumpy when someone smiles or tightens their lips, is treated with an injection to the mentalis, at the mental crease, of about 5 U. "You want to be fairly inferior so you don't knock out the depressor labii, and it is a deep muscle," Dr. Sengelmann said.

Finally, patients with smiles that they don't like because they get a lot of upper gum showing can be treated with equal injections of 1–2 units into the levator labii superioris on each side of the nasal prominence.

Dr. Sengelmann also said that she always takes photographs before she does lower face treatments, that she marks her injection sites when she identifies the muscle before giving the actual injections, and that she often uses ice for the patients since lower face injections can be quite painful.

Dr. Sengelmann is on the advisory board and the speakers bureau for Allergan Inc., maker of Botox.

'The goal when we are treating the lower face is to soften dynamic lines and not to completely freeze.' DR. SENGELMANN

LAS VEGAS — Dermatologists do not often think of using Botox in the lower face, but they should, Dr. Roberta D. Sengelmann said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

It is possible to treat and improve perioral rhytids, an asymmetric smile, a gummy smile, and even "apple-dumpling" chin, said Dr. Sengelmann of Santa Barbara, Calif.

The key to using botulinum toxin type A in the lower face is to be extremely careful not to use too much since those muscles are used for so many different functions. Also, the botulinum toxin option probably should be reserved for patients with mild to moderate aging changes, as there are better alternatives for serious rhytids of the lower face, she said.

Botulinum toxin "is a different animal when you get below the canthus," Dr. Sengelmann said. "Volume loss and soft-tissue ptosis play a large role in the lower face, and this cannot always be remedied by botulinum toxin injections. The lower face and neck are functionally important as well.

"The goal when we are treating the lower face is to soften dynamic lines and not to completely freeze," she added.

In treating perioral rhytids, inject into the orbicularis oris. The injections should be fairly superficial, into just the first layer of what is a "very thick and robust muscle," Dr. Sengelmann said.

The injections should be given right above the vermilion border, evenly spaced, and they need to be symmetric.

She gives 1–3 U per injection, with a maximum of 6 U in the upper lip and 4 U in the lower lip, so there is not too much deadening of function. She advised against injecting only the upper lip because treated lips lengthen and can protrude over the lower lip.

Results in the lower face often do not last as long as treatment of the glabella because less botulinum toxin is used. Dr. Sengelmann said that her treatments of perioral rhytids usually last 2–3 months.

Downturned lips can be treated with injections to the depressor labii inferioris—she gives 2–4 U into the mid-muscle. Radial perioral rhytids, or marionette lines, can be treated with injections to the depressor anguli oris. She does two injections per side, in the middle and lower third of the muscle, starting about 1 cm below the oral commissure and injecting 3–5 U per side.

Apple-dumpling chin, or a chin that gets lumpy when someone smiles or tightens their lips, is treated with an injection to the mentalis, at the mental crease, of about 5 U. "You want to be fairly inferior so you don't knock out the depressor labii, and it is a deep muscle," Dr. Sengelmann said.

Finally, patients with smiles that they don't like because they get a lot of upper gum showing can be treated with equal injections of 1–2 units into the levator labii superioris on each side of the nasal prominence.

Dr. Sengelmann also said that she always takes photographs before she does lower face treatments, that she marks her injection sites when she identifies the muscle before giving the actual injections, and that she often uses ice for the patients since lower face injections can be quite painful.

Dr. Sengelmann is on the advisory board and the speakers bureau for Allergan Inc., maker of Botox.

'The goal when we are treating the lower face is to soften dynamic lines and not to completely freeze.' DR. SENGELMANN

LAS VEGAS — Recurrence can be a problem when aminolevulinic acid and light are used to treat patients with nodular basal cell carcinomas, largely because the drug does not penetrate to the deeper nodules, Dr. E. Victor Ross Jr. said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Photodynamic therapy using aminolevulinic acid "is somewhat unpredictable with some of these skin cancers, particularly the nodular ones in the absence of curettage prior to the application," said Dr. Ross, director of the laser and cosmetic dermatology unit at the Scripps Clinic in San Diego.

In a recent study that compared surgical excision to photodynamic therapy at 5 years after treatment in 97 patients who had primary nodular basal cell carcinoma, investigators found a 14% recurrence rate with the light-activated therapy, versus a 4% rate with surgical excision (Arch. Dermatol. 2007;143:1131–6).

"We find the relapse rate is reasonably high, so you have to be careful in interpreting the statistics sometimes," he said. Paying attention to certain aspects of treatment, however, can probably improve the results.

In treating skin cancers, the aminolevulinic acid must be applied and left on for at least 4–6 hours before the light application.

For nodular basal cell carcinoma, curettage should be performed on the lesion before applying the aminolevulinic acid, Dr. Ross said.

Removing the stratum corneum, at the very least, is important before applying aminolevulinic acid because it greatly inhibits penetration of the cream, he pointed out.

Use of red light (630 nm) may be better than using blue light (400–450 nm) because it penetrates deeper.

The trade-off, however, is that it does not activate the protoporphyrin-9 created from the aminolevulinic acid as well as blue light, he said at the meeting.

From his experience working with a red-light, potassium-titanyl-phosphate (KTP) pump-dye laser, Dr. Ross has found that the red light is preferable.

It is not as much better as it should be, but it is a little better. "Blue light does not work for those lesions that are further than about a millimeter down," he commented.

"Theoretically, red light should work a lot better, despite the fact that [it] does not activate the protoporphyrin-9 as well, simply because it penetrates a lot better," he added.

Dr. Ross said that he uses a cream base for the aminolevulinic acid (specifically Eucerin lotion) instead of the ethanol/water solution that is contained in Levulan Kerastick.

"We get better fluorescence in the basal cells at the treatment time," said Dr. Ross, who reported relevant conflicts of interest involving Palomar Medical Technologies and Alma Laser.

'Blue light does not work for those lesions that are further than about a millimeter down.' DR. ROSS

LAS VEGAS — Recurrence can be a problem when aminolevulinic acid and light are used to treat patients with nodular basal cell carcinomas, largely because the drug does not penetrate to the deeper nodules, Dr. E. Victor Ross Jr. said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Photodynamic therapy using aminolevulinic acid "is somewhat unpredictable with some of these skin cancers, particularly the nodular ones in the absence of curettage prior to the application," said Dr. Ross, director of the laser and cosmetic dermatology unit at the Scripps Clinic in San Diego.

In a recent study that compared surgical excision to photodynamic therapy at 5 years after treatment in 97 patients who had primary nodular basal cell carcinoma, investigators found a 14% recurrence rate with the light-activated therapy, versus a 4% rate with surgical excision (Arch. Dermatol. 2007;143:1131–6).

"We find the relapse rate is reasonably high, so you have to be careful in interpreting the statistics sometimes," he said. Paying attention to certain aspects of treatment, however, can probably improve the results.

In treating skin cancers, the aminolevulinic acid must be applied and left on for at least 4–6 hours before the light application.

For nodular basal cell carcinoma, curettage should be performed on the lesion before applying the aminolevulinic acid, Dr. Ross said.

Removing the stratum corneum, at the very least, is important before applying aminolevulinic acid because it greatly inhibits penetration of the cream, he pointed out.

Use of red light (630 nm) may be better than using blue light (400–450 nm) because it penetrates deeper.

The trade-off, however, is that it does not activate the protoporphyrin-9 created from the aminolevulinic acid as well as blue light, he said at the meeting.

From his experience working with a red-light, potassium-titanyl-phosphate (KTP) pump-dye laser, Dr. Ross has found that the red light is preferable.

It is not as much better as it should be, but it is a little better. "Blue light does not work for those lesions that are further than about a millimeter down," he commented.

"Theoretically, red light should work a lot better, despite the fact that [it] does not activate the protoporphyrin-9 as well, simply because it penetrates a lot better," he added.

Dr. Ross said that he uses a cream base for the aminolevulinic acid (specifically Eucerin lotion) instead of the ethanol/water solution that is contained in Levulan Kerastick.

"We get better fluorescence in the basal cells at the treatment time," said Dr. Ross, who reported relevant conflicts of interest involving Palomar Medical Technologies and Alma Laser.

'Blue light does not work for those lesions that are further than about a millimeter down.' DR. ROSS

LAS VEGAS — Recurrence can be a problem when aminolevulinic acid and light are used to treat patients with nodular basal cell carcinomas, largely because the drug does not penetrate to the deeper nodules, Dr. E. Victor Ross Jr. said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Photodynamic therapy using aminolevulinic acid "is somewhat unpredictable with some of these skin cancers, particularly the nodular ones in the absence of curettage prior to the application," said Dr. Ross, director of the laser and cosmetic dermatology unit at the Scripps Clinic in San Diego.

In a recent study that compared surgical excision to photodynamic therapy at 5 years after treatment in 97 patients who had primary nodular basal cell carcinoma, investigators found a 14% recurrence rate with the light-activated therapy, versus a 4% rate with surgical excision (Arch. Dermatol. 2007;143:1131–6).

"We find the relapse rate is reasonably high, so you have to be careful in interpreting the statistics sometimes," he said. Paying attention to certain aspects of treatment, however, can probably improve the results.

In treating skin cancers, the aminolevulinic acid must be applied and left on for at least 4–6 hours before the light application.

For nodular basal cell carcinoma, curettage should be performed on the lesion before applying the aminolevulinic acid, Dr. Ross said.

Removing the stratum corneum, at the very least, is important before applying aminolevulinic acid because it greatly inhibits penetration of the cream, he pointed out.

Use of red light (630 nm) may be better than using blue light (400–450 nm) because it penetrates deeper.

The trade-off, however, is that it does not activate the protoporphyrin-9 created from the aminolevulinic acid as well as blue light, he said at the meeting.

From his experience working with a red-light, potassium-titanyl-phosphate (KTP) pump-dye laser, Dr. Ross has found that the red light is preferable.

It is not as much better as it should be, but it is a little better. "Blue light does not work for those lesions that are further than about a millimeter down," he commented.

"Theoretically, red light should work a lot better, despite the fact that [it] does not activate the protoporphyrin-9 as well, simply because it penetrates a lot better," he added.

Dr. Ross said that he uses a cream base for the aminolevulinic acid (specifically Eucerin lotion) instead of the ethanol/water solution that is contained in Levulan Kerastick.

"We get better fluorescence in the basal cells at the treatment time," said Dr. Ross, who reported relevant conflicts of interest involving Palomar Medical Technologies and Alma Laser.

'Blue light does not work for those lesions that are further than about a millimeter down.' DR. ROSS

Chronic proximal hamstring ruptures that are repaired surgically with a reconstruction technique that involves an Achilles allograft and interference screw fixation can result in patients' return to full activity, according to a report on 26 patients.

Hamstring strains account for 25%-30% of all muscle strains, and–often after a lengthy convalescence–recovery is complete and uneventful. Complete rupture of the proximal hamstring tendon, however, is more serious and often requires surgical treatment, whether the rupture is acute or chronic. Although two prior studies on reconstructions in chronic injuries have shown “less than optimal results,” the investigators, Dr. Greg J. Folsom and Dr. Christopher M. Larson, who are orthopedic surgeons in Eden Prairie, Minn., note that prior published reports on chronic ruptures are retrospective and have small sample sizes because this injury is rare.

In this study, 26 patients with a mean age of 44 years (range, 16-58 years) were randomized as having an acute or chronic rupture.

A total of five patients had ruptures that had occurred 4-116 months prior to surgery, and thus qualified as chronic ruptures.

At follow-up, some of those patients had limitations, but all reported being more active and feeling stronger than before surgery. Three of the patients in the chronic group had a complete recovery and returned to athletic endeavors. Of those, two were classified as recreational athletes (defined as engaging in a highly physical activity at least once a week), and one was classified as an elite athlete.

One patient returned to sporting activities but was unable to jog long distances. The final patient complained of pain with vigorous activity and reported being unable to jog.

All patients reported satisfaction with the results, but one indicated the intention to decline the surgery a second time (Am. J. Sports Med. 2007 [Epub doi:10.1177/0363546507312167]).

The mean time of follow-up in the chronic patients was 17 months (range, 6-33 months).

In the group of 21 patients who underwent surgery acutely (defined as within 4 weeks of the injury), 9 patients returned to full activity and 15 returned to sports activity. Five patients did not return to sporting activity because of their injury, and one patient was lost to follow-up.

Four of the acute surgery patients reported pain with activity, six reported muscle spasms, one reported poor leg control, and one reported that the leg was giving way.

Mean follow-up in the acute group was 14 months (range, 5-43 months).

No adverse events occurred in the chronic-rupture group, but three major adverse events occurred in the acute group. One patient fell 4 months after surgery and reinjured the hamstring, one developed a complex regional pain syndrome with frequent spasms, and one developed a deep infection.

Chronic proximal hamstring ruptures that are repaired surgically with a reconstruction technique that involves an Achilles allograft and interference screw fixation can result in patients' return to full activity, according to a report on 26 patients.

Hamstring strains account for 25%-30% of all muscle strains, and–often after a lengthy convalescence–recovery is complete and uneventful. Complete rupture of the proximal hamstring tendon, however, is more serious and often requires surgical treatment, whether the rupture is acute or chronic. Although two prior studies on reconstructions in chronic injuries have shown “less than optimal results,” the investigators, Dr. Greg J. Folsom and Dr. Christopher M. Larson, who are orthopedic surgeons in Eden Prairie, Minn., note that prior published reports on chronic ruptures are retrospective and have small sample sizes because this injury is rare.

In this study, 26 patients with a mean age of 44 years (range, 16-58 years) were randomized as having an acute or chronic rupture.

A total of five patients had ruptures that had occurred 4-116 months prior to surgery, and thus qualified as chronic ruptures.

At follow-up, some of those patients had limitations, but all reported being more active and feeling stronger than before surgery. Three of the patients in the chronic group had a complete recovery and returned to athletic endeavors. Of those, two were classified as recreational athletes (defined as engaging in a highly physical activity at least once a week), and one was classified as an elite athlete.

One patient returned to sporting activities but was unable to jog long distances. The final patient complained of pain with vigorous activity and reported being unable to jog.

All patients reported satisfaction with the results, but one indicated the intention to decline the surgery a second time (Am. J. Sports Med. 2007 [Epub doi:10.1177/0363546507312167]).

The mean time of follow-up in the chronic patients was 17 months (range, 6-33 months).

In the group of 21 patients who underwent surgery acutely (defined as within 4 weeks of the injury), 9 patients returned to full activity and 15 returned to sports activity. Five patients did not return to sporting activity because of their injury, and one patient was lost to follow-up.

Four of the acute surgery patients reported pain with activity, six reported muscle spasms, one reported poor leg control, and one reported that the leg was giving way.

Mean follow-up in the acute group was 14 months (range, 5-43 months).

No adverse events occurred in the chronic-rupture group, but three major adverse events occurred in the acute group. One patient fell 4 months after surgery and reinjured the hamstring, one developed a complex regional pain syndrome with frequent spasms, and one developed a deep infection.

Chronic proximal hamstring ruptures that are repaired surgically with a reconstruction technique that involves an Achilles allograft and interference screw fixation can result in patients' return to full activity, according to a report on 26 patients.

Hamstring strains account for 25%-30% of all muscle strains, and–often after a lengthy convalescence–recovery is complete and uneventful. Complete rupture of the proximal hamstring tendon, however, is more serious and often requires surgical treatment, whether the rupture is acute or chronic. Although two prior studies on reconstructions in chronic injuries have shown “less than optimal results,” the investigators, Dr. Greg J. Folsom and Dr. Christopher M. Larson, who are orthopedic surgeons in Eden Prairie, Minn., note that prior published reports on chronic ruptures are retrospective and have small sample sizes because this injury is rare.

In this study, 26 patients with a mean age of 44 years (range, 16-58 years) were randomized as having an acute or chronic rupture.

A total of five patients had ruptures that had occurred 4-116 months prior to surgery, and thus qualified as chronic ruptures.

At follow-up, some of those patients had limitations, but all reported being more active and feeling stronger than before surgery. Three of the patients in the chronic group had a complete recovery and returned to athletic endeavors. Of those, two were classified as recreational athletes (defined as engaging in a highly physical activity at least once a week), and one was classified as an elite athlete.

One patient returned to sporting activities but was unable to jog long distances. The final patient complained of pain with vigorous activity and reported being unable to jog.

All patients reported satisfaction with the results, but one indicated the intention to decline the surgery a second time (Am. J. Sports Med. 2007 [Epub doi:10.1177/0363546507312167]).

The mean time of follow-up in the chronic patients was 17 months (range, 6-33 months).

In the group of 21 patients who underwent surgery acutely (defined as within 4 weeks of the injury), 9 patients returned to full activity and 15 returned to sports activity. Five patients did not return to sporting activity because of their injury, and one patient was lost to follow-up.

Four of the acute surgery patients reported pain with activity, six reported muscle spasms, one reported poor leg control, and one reported that the leg was giving way.

Mean follow-up in the acute group was 14 months (range, 5-43 months).

No adverse events occurred in the chronic-rupture group, but three major adverse events occurred in the acute group. One patient fell 4 months after surgery and reinjured the hamstring, one developed a complex regional pain syndrome with frequent spasms, and one developed a deep infection.

The public were agog over the new study suggesting that a teaspoon of honey helps a child with nighttime cold and cough, but the experts' reaction was more nuanced and varied.

Dr. Lawrence Rosen said that if he had not already known about the study, his patients would have made sure he heard about it.

The study, published in the December issue of the Archives of Pediatric and Adolescent Medicine, received tremendous attention from the public and the press when it was released.

A bedtime dose of buckwheat honey was more effective than was dextromethorphan or no treatment at all for quieting cough and facilitating sleep in children aged 2-17 who had upper respiratory infection (Arch. Pediatr. Adolesc. Med. 2007;161:1140-6).

The study came out shortly after a Food and Drug Administration advisory panel voted that over-the-counter cough and cold medications should not be recommended for children under age 5 years, and many major manufacturers voluntarily pulled from the stores their cough and cold products aimed at infants and toddlers.

“What perfect timing,” said Dr. Rosen, a pediatrician who practices in Old Tappan, N.J., and who is a member of the provisional section on complementary, holistic, and integrative medicine of the American Academy of Pediatrics.

Dr. Rosen said he thought the study was well designed and compelling, and that he already recommended honey, with tea, before the study, but the study gives him more reason to do so, particularly since honey is benign for children over 1 year of age.

Parents “are just happy to know there are things that they can do,” he said. “They just want to be able to do something.”

Some other experts, however, do not have such a high regard for the findings.

“I think it is reasonable to recommend honey for treatment in cough for children over 2 years old based on these results,” said Dr. James Taylor, a professor of pediatrics at the University of Washington, Seattle. But “In my own practice I will probably not yet widely recommend honey because the benefits are relatively small, and the appropriate dose and form of honey to use are not well standardized,” he said in an interview.

The mechanism of action involved with the honey treatment might only be its demulcent properties, said Dr. Taylor, who has an interest in complementary medicines. “If that is the case, any soothing cough drop might work equally well.”

Dr. J. Owen Hendley said he was not impressed with the study, but he probably would recommend honey to patients.

“It is not a knock your socks off kind of study,” said Dr. Hendley, a professor of pediatrics in the division of pediatric infectious diseases at the University of Virginia, Charlottesville, who has studied rhinovirus and colds since the 1960s.

The study used parental recall to measure cold improvement, rather than a more objective and definitive measure, noted Dr. Hendley. Moreover, all of the groups in the study had improvement in their cough, even those who received no treatment.

Dr. Hendley said he does not recommend much for a cold since nothing has been shown to have a definite benefit, but he would recommend honey. “I happen to like honey–the price is right. I can't think of anything bad about having a 1-year-old use honey,” he added.

The public were agog over the new study suggesting that a teaspoon of honey helps a child with nighttime cold and cough, but the experts' reaction was more nuanced and varied.

Dr. Lawrence Rosen said that if he had not already known about the study, his patients would have made sure he heard about it.

The study, published in the December issue of the Archives of Pediatric and Adolescent Medicine, received tremendous attention from the public and the press when it was released.

A bedtime dose of buckwheat honey was more effective than was dextromethorphan or no treatment at all for quieting cough and facilitating sleep in children aged 2-17 who had upper respiratory infection (Arch. Pediatr. Adolesc. Med. 2007;161:1140-6).

The study came out shortly after a Food and Drug Administration advisory panel voted that over-the-counter cough and cold medications should not be recommended for children under age 5 years, and many major manufacturers voluntarily pulled from the stores their cough and cold products aimed at infants and toddlers.

“What perfect timing,” said Dr. Rosen, a pediatrician who practices in Old Tappan, N.J., and who is a member of the provisional section on complementary, holistic, and integrative medicine of the American Academy of Pediatrics.

Dr. Rosen said he thought the study was well designed and compelling, and that he already recommended honey, with tea, before the study, but the study gives him more reason to do so, particularly since honey is benign for children over 1 year of age.

Parents “are just happy to know there are things that they can do,” he said. “They just want to be able to do something.”

Some other experts, however, do not have such a high regard for the findings.

“I think it is reasonable to recommend honey for treatment in cough for children over 2 years old based on these results,” said Dr. James Taylor, a professor of pediatrics at the University of Washington, Seattle. But “In my own practice I will probably not yet widely recommend honey because the benefits are relatively small, and the appropriate dose and form of honey to use are not well standardized,” he said in an interview.

The mechanism of action involved with the honey treatment might only be its demulcent properties, said Dr. Taylor, who has an interest in complementary medicines. “If that is the case, any soothing cough drop might work equally well.”

Dr. J. Owen Hendley said he was not impressed with the study, but he probably would recommend honey to patients.

“It is not a knock your socks off kind of study,” said Dr. Hendley, a professor of pediatrics in the division of pediatric infectious diseases at the University of Virginia, Charlottesville, who has studied rhinovirus and colds since the 1960s.

The study used parental recall to measure cold improvement, rather than a more objective and definitive measure, noted Dr. Hendley. Moreover, all of the groups in the study had improvement in their cough, even those who received no treatment.

Dr. Hendley said he does not recommend much for a cold since nothing has been shown to have a definite benefit, but he would recommend honey. “I happen to like honey–the price is right. I can't think of anything bad about having a 1-year-old use honey,” he added.

The public were agog over the new study suggesting that a teaspoon of honey helps a child with nighttime cold and cough, but the experts' reaction was more nuanced and varied.

Dr. Lawrence Rosen said that if he had not already known about the study, his patients would have made sure he heard about it.

The study, published in the December issue of the Archives of Pediatric and Adolescent Medicine, received tremendous attention from the public and the press when it was released.

A bedtime dose of buckwheat honey was more effective than was dextromethorphan or no treatment at all for quieting cough and facilitating sleep in children aged 2-17 who had upper respiratory infection (Arch. Pediatr. Adolesc. Med. 2007;161:1140-6).

The study came out shortly after a Food and Drug Administration advisory panel voted that over-the-counter cough and cold medications should not be recommended for children under age 5 years, and many major manufacturers voluntarily pulled from the stores their cough and cold products aimed at infants and toddlers.

“What perfect timing,” said Dr. Rosen, a pediatrician who practices in Old Tappan, N.J., and who is a member of the provisional section on complementary, holistic, and integrative medicine of the American Academy of Pediatrics.

Dr. Rosen said he thought the study was well designed and compelling, and that he already recommended honey, with tea, before the study, but the study gives him more reason to do so, particularly since honey is benign for children over 1 year of age.

Parents “are just happy to know there are things that they can do,” he said. “They just want to be able to do something.”

Some other experts, however, do not have such a high regard for the findings.

“I think it is reasonable to recommend honey for treatment in cough for children over 2 years old based on these results,” said Dr. James Taylor, a professor of pediatrics at the University of Washington, Seattle. But “In my own practice I will probably not yet widely recommend honey because the benefits are relatively small, and the appropriate dose and form of honey to use are not well standardized,” he said in an interview.

The mechanism of action involved with the honey treatment might only be its demulcent properties, said Dr. Taylor, who has an interest in complementary medicines. “If that is the case, any soothing cough drop might work equally well.”

Dr. J. Owen Hendley said he was not impressed with the study, but he probably would recommend honey to patients.

“It is not a knock your socks off kind of study,” said Dr. Hendley, a professor of pediatrics in the division of pediatric infectious diseases at the University of Virginia, Charlottesville, who has studied rhinovirus and colds since the 1960s.

The study used parental recall to measure cold improvement, rather than a more objective and definitive measure, noted Dr. Hendley. Moreover, all of the groups in the study had improvement in their cough, even those who received no treatment.

Dr. Hendley said he does not recommend much for a cold since nothing has been shown to have a definite benefit, but he would recommend honey. “I happen to like honey–the price is right. I can't think of anything bad about having a 1-year-old use honey,” he added.

Sulfonylureas, alpha-glucosidase inhibitors, and possibly glinides have similar efficacy when added on to failing metformin therapy in patients with type 2 diabetes, according to a new a meta-analysis.

Thiazolidinediones (TZDs) have less efficacy as an add-on to metformin—that is, less effect in lowering hemoglobin A_1c—in the first 6 months, but may become more efficacious over the long term. And insulin as an add-on to failing metformin therapy is not clearly superior to adding on a sulfonylurea, the meta-analysis indicated.

Those results aside, there are few studies on the subject, and the choice of which drug to add for a patient failing metformin cannot clearly be made based on evidence of differences in hypoglycemic efficacy, commented Dr. Matteo Monami and colleagues from the department of critical care medicine and surgery at the University of Florence (Italy). Differences are not definitively confirmed by the clinical trials, the researchers noted.

The researchers conducted their analysis by searching the U.S. National Library of Medicine's Medline database for randomized clinical trials investigating the efficacy of add-on therapy in patients failing either metformin or another oral antihypoglycemic agent. Limiting their selection to trials that lasted at least 16 weeks, they identified 27 studies that fit their criteria (Diab. Res. Clin. Pract. [2007], doi:10.1016/j.diabres.2007.08.024).

In all, 16 of those trials compared an add-on drug with placebo in patients on metformin; 5 of the trials added on a sulfonylurea; 5 trials, an alpha-glucosidase inhibitor; 3 trials, a thiazolidinedione; 2 trials, a glinide; and 1 trial, the glucagon-like peptide 1 agonist exenatide.

Combining data from those trials showed that adding on a sulfonylurea reduced the hemoglobin A_1c (HbA_1c) level by an average of 0.85%; adding on a thiazolidinedione reduced HbA_1c by 0.42%; and adding on an alpha-glucosidase inhibitor reduced HbA_1c by 0.61%.

Adjusting for baseline HbA_1c level, the investigators found that the reduction from adding a sulfonylurea was greater than the reduction obtained by adding a TZD. But they also found that the difference between a sulfonylurea and an alpha-glucosidase inhibitor was not statistically significant; neither was the difference between an alpha-glucosidase inhibitor and a TZD.

A total of 11 trials were found that compared different agents added on to existing therapy. Combining data from the trials that directly compared a sulfonylurea add-on with a TZD add-on, the sulfonylurea add-on was found to produce the greater reduction in HbA_1c, of 0.17%. In direct comparison of sulfonylurea with insulin, there was no significant difference in the reduction obtained.

Six of the trials were conducted in patients failing metformin therapy. In data from those trials, the sulfonylurea add-on had greater efficacy than the TZD add-on, with a difference in HbA_1c of 0.24%.

The data suggesting equivalence between a sulfonylurea and insulin should be viewed with caution, the authors said. The meta-analysis included only two studies addressing that issue; each was only 16 weeks long, they noted.

Sulfonylureas, alpha-glucosidase inhibitors, and possibly glinides have similar efficacy when added on to failing metformin therapy in patients with type 2 diabetes, according to a new a meta-analysis.

Thiazolidinediones (TZDs) have less efficacy as an add-on to metformin—that is, less effect in lowering hemoglobin A_1c—in the first 6 months, but may become more efficacious over the long term. And insulin as an add-on to failing metformin therapy is not clearly superior to adding on a sulfonylurea, the meta-analysis indicated.

Those results aside, there are few studies on the subject, and the choice of which drug to add for a patient failing metformin cannot clearly be made based on evidence of differences in hypoglycemic efficacy, commented Dr. Matteo Monami and colleagues from the department of critical care medicine and surgery at the University of Florence (Italy). Differences are not definitively confirmed by the clinical trials, the researchers noted.

The researchers conducted their analysis by searching the U.S. National Library of Medicine's Medline database for randomized clinical trials investigating the efficacy of add-on therapy in patients failing either metformin or another oral antihypoglycemic agent. Limiting their selection to trials that lasted at least 16 weeks, they identified 27 studies that fit their criteria (Diab. Res. Clin. Pract. [2007], doi:10.1016/j.diabres.2007.08.024).

In all, 16 of those trials compared an add-on drug with placebo in patients on metformin; 5 of the trials added on a sulfonylurea; 5 trials, an alpha-glucosidase inhibitor; 3 trials, a thiazolidinedione; 2 trials, a glinide; and 1 trial, the glucagon-like peptide 1 agonist exenatide.

Combining data from those trials showed that adding on a sulfonylurea reduced the hemoglobin A_1c (HbA_1c) level by an average of 0.85%; adding on a thiazolidinedione reduced HbA_1c by 0.42%; and adding on an alpha-glucosidase inhibitor reduced HbA_1c by 0.61%.

Adjusting for baseline HbA_1c level, the investigators found that the reduction from adding a sulfonylurea was greater than the reduction obtained by adding a TZD. But they also found that the difference between a sulfonylurea and an alpha-glucosidase inhibitor was not statistically significant; neither was the difference between an alpha-glucosidase inhibitor and a TZD.

A total of 11 trials were found that compared different agents added on to existing therapy. Combining data from the trials that directly compared a sulfonylurea add-on with a TZD add-on, the sulfonylurea add-on was found to produce the greater reduction in HbA_1c, of 0.17%. In direct comparison of sulfonylurea with insulin, there was no significant difference in the reduction obtained.

Six of the trials were conducted in patients failing metformin therapy. In data from those trials, the sulfonylurea add-on had greater efficacy than the TZD add-on, with a difference in HbA_1c of 0.24%.

The data suggesting equivalence between a sulfonylurea and insulin should be viewed with caution, the authors said. The meta-analysis included only two studies addressing that issue; each was only 16 weeks long, they noted.

Sulfonylureas, alpha-glucosidase inhibitors, and possibly glinides have similar efficacy when added on to failing metformin therapy in patients with type 2 diabetes, according to a new a meta-analysis.

Thiazolidinediones (TZDs) have less efficacy as an add-on to metformin—that is, less effect in lowering hemoglobin A_1c—in the first 6 months, but may become more efficacious over the long term. And insulin as an add-on to failing metformin therapy is not clearly superior to adding on a sulfonylurea, the meta-analysis indicated.

Those results aside, there are few studies on the subject, and the choice of which drug to add for a patient failing metformin cannot clearly be made based on evidence of differences in hypoglycemic efficacy, commented Dr. Matteo Monami and colleagues from the department of critical care medicine and surgery at the University of Florence (Italy). Differences are not definitively confirmed by the clinical trials, the researchers noted.

The researchers conducted their analysis by searching the U.S. National Library of Medicine's Medline database for randomized clinical trials investigating the efficacy of add-on therapy in patients failing either metformin or another oral antihypoglycemic agent. Limiting their selection to trials that lasted at least 16 weeks, they identified 27 studies that fit their criteria (Diab. Res. Clin. Pract. [2007], doi:10.1016/j.diabres.2007.08.024).

In all, 16 of those trials compared an add-on drug with placebo in patients on metformin; 5 of the trials added on a sulfonylurea; 5 trials, an alpha-glucosidase inhibitor; 3 trials, a thiazolidinedione; 2 trials, a glinide; and 1 trial, the glucagon-like peptide 1 agonist exenatide.

Combining data from those trials showed that adding on a sulfonylurea reduced the hemoglobin A_1c (HbA_1c) level by an average of 0.85%; adding on a thiazolidinedione reduced HbA_1c by 0.42%; and adding on an alpha-glucosidase inhibitor reduced HbA_1c by 0.61%.

Adjusting for baseline HbA_1c level, the investigators found that the reduction from adding a sulfonylurea was greater than the reduction obtained by adding a TZD. But they also found that the difference between a sulfonylurea and an alpha-glucosidase inhibitor was not statistically significant; neither was the difference between an alpha-glucosidase inhibitor and a TZD.

A total of 11 trials were found that compared different agents added on to existing therapy. Combining data from the trials that directly compared a sulfonylurea add-on with a TZD add-on, the sulfonylurea add-on was found to produce the greater reduction in HbA_1c, of 0.17%. In direct comparison of sulfonylurea with insulin, there was no significant difference in the reduction obtained.

Six of the trials were conducted in patients failing metformin therapy. In data from those trials, the sulfonylurea add-on had greater efficacy than the TZD add-on, with a difference in HbA_1c of 0.24%.

The data suggesting equivalence between a sulfonylurea and insulin should be viewed with caution, the authors said. The meta-analysis included only two studies addressing that issue; each was only 16 weeks long, they noted.

SEATTLE — Despite the government's push to encourage the development of the electronic medical record system, only a quarter of physicians keep medical records electronically, and only 11% of hospitals have fully implemented them, according to Dr. Karen M. Bell, director of the federal government's Office of Health IT Adoption.

In addition, of the electronic record systems in use, probably fewer than half are fully operational, that is, able to take notes, make lab and pharmacy orders, and get lab results, said Dr. Bell at the annual meeting of the American Geriatrics Society. “The reality of it is that adoption of really good functionality is really very low,” she said.

The barriers to widespread adoption continue to be the lack of good, accepted computer applications, and the time and cost, said Dr. Bell.

While it is thought that the use of electronic health records eventually would result in financial savings, start-up costs continue to be prohibitive, she said.

The cost to get every record interface—every office, laboratory, pharmacy, etc.—up to speed with appropriate software and hardware may be $5,000 for each one, and for the nation as a whole it may cost $50 billion, Dr. Bell said.

At the same time, those who are using electronic medical records are finding they aren't exactly time saving. There is a learning curve involved. And, the records generally require more data than what were previously recorded.

The government currently has public policy advisory committees to encourage more adoption and to deal with privacy issues—significant challenges, Dr. Bell said.

In the meantime, her office is continuing to develop an exact definition of what is going to be needed in an electronic health record, she added. “There are no standard definitions for any of this stuff.”

Added Challenge for LTC

Other speakers at the meeting described the significant hardship they went through acquiring a system specifically for geriatrics.

The electronic health record industry and its products are geared to the acute care environment, and when they can be used for a facility that cares for older persons, they need to be modified significantly, the speakers said.

“As I was trying to figure out which electronic health records system we would use for geriatrics, I really ran into a lot of roadblocks,” said Dr. Irene Hamrick of the division of geriatrics at East Carolina University, Greenville, N.C.

“There really is nothing out there that is very good,” she added.

Her institution finally chose General Electric Company's Centricity system because it can be used in many locations, such as the home for health care visits.

However, the institution found that it needed to tailor the system for specific geriatric needs, adding records of diet and activities of daily living. Changes also needed to be made to the physical exam form to include sections for foot and mental status exams.

“Very little out-of-the-box software is user friendly for geriatrics. None is totally acceptable to my mind. If you want to use them, you have to adapt them,” Dr. Hamrick said.

When the Gurwin Jewish Geriatric Center of Commack, N.Y., began to look for an electronic medical record system, the institution had no idea it would take so long to find and implement one, said Dr. Suzanne Fields, the medical director.

The center found that there are Web sites (such as www.providersedge.com/ehr_links_products_services.htm

And, the center found a number of products for long-term care. But, the center has both outpatient day care and clinics, and inpatient beds, and none of the products adequately accommodated both, Dr. Fields said.

Dr. Fields and her colleagues also found that they had to adapt a system to their needs. In the end, the center combined two products, one for long-term care and another for physician care. The system is not yet up and running.

“It has to be individualized. That's what I didn't realize,” she said.

SEATTLE — Despite the government's push to encourage the development of the electronic medical record system, only a quarter of physicians keep medical records electronically, and only 11% of hospitals have fully implemented them, according to Dr. Karen M. Bell, director of the federal government's Office of Health IT Adoption.

In addition, of the electronic record systems in use, probably fewer than half are fully operational, that is, able to take notes, make lab and pharmacy orders, and get lab results, said Dr. Bell at the annual meeting of the American Geriatrics Society. “The reality of it is that adoption of really good functionality is really very low,” she said.

The barriers to widespread adoption continue to be the lack of good, accepted computer applications, and the time and cost, said Dr. Bell.

While it is thought that the use of electronic health records eventually would result in financial savings, start-up costs continue to be prohibitive, she said.

The cost to get every record interface—every office, laboratory, pharmacy, etc.—up to speed with appropriate software and hardware may be $5,000 for each one, and for the nation as a whole it may cost $50 billion, Dr. Bell said.

At the same time, those who are using electronic medical records are finding they aren't exactly time saving. There is a learning curve involved. And, the records generally require more data than what were previously recorded.

The government currently has public policy advisory committees to encourage more adoption and to deal with privacy issues—significant challenges, Dr. Bell said.

In the meantime, her office is continuing to develop an exact definition of what is going to be needed in an electronic health record, she added. “There are no standard definitions for any of this stuff.”

Added Challenge for LTC

Other speakers at the meeting described the significant hardship they went through acquiring a system specifically for geriatrics.

The electronic health record industry and its products are geared to the acute care environment, and when they can be used for a facility that cares for older persons, they need to be modified significantly, the speakers said.

“As I was trying to figure out which electronic health records system we would use for geriatrics, I really ran into a lot of roadblocks,” said Dr. Irene Hamrick of the division of geriatrics at East Carolina University, Greenville, N.C.

“There really is nothing out there that is very good,” she added.

Her institution finally chose General Electric Company's Centricity system because it can be used in many locations, such as the home for health care visits.

However, the institution found that it needed to tailor the system for specific geriatric needs, adding records of diet and activities of daily living. Changes also needed to be made to the physical exam form to include sections for foot and mental status exams.

“Very little out-of-the-box software is user friendly for geriatrics. None is totally acceptable to my mind. If you want to use them, you have to adapt them,” Dr. Hamrick said.

When the Gurwin Jewish Geriatric Center of Commack, N.Y., began to look for an electronic medical record system, the institution had no idea it would take so long to find and implement one, said Dr. Suzanne Fields, the medical director.

The center found that there are Web sites (such as www.providersedge.com/ehr_links_products_services.htm

And, the center found a number of products for long-term care. But, the center has both outpatient day care and clinics, and inpatient beds, and none of the products adequately accommodated both, Dr. Fields said.

Dr. Fields and her colleagues also found that they had to adapt a system to their needs. In the end, the center combined two products, one for long-term care and another for physician care. The system is not yet up and running.

“It has to be individualized. That's what I didn't realize,” she said.

SEATTLE — Despite the government's push to encourage the development of the electronic medical record system, only a quarter of physicians keep medical records electronically, and only 11% of hospitals have fully implemented them, according to Dr. Karen M. Bell, director of the federal government's Office of Health IT Adoption.

In addition, of the electronic record systems in use, probably fewer than half are fully operational, that is, able to take notes, make lab and pharmacy orders, and get lab results, said Dr. Bell at the annual meeting of the American Geriatrics Society. “The reality of it is that adoption of really good functionality is really very low,” she said.

The barriers to widespread adoption continue to be the lack of good, accepted computer applications, and the time and cost, said Dr. Bell.

While it is thought that the use of electronic health records eventually would result in financial savings, start-up costs continue to be prohibitive, she said.

The cost to get every record interface—every office, laboratory, pharmacy, etc.—up to speed with appropriate software and hardware may be $5,000 for each one, and for the nation as a whole it may cost $50 billion, Dr. Bell said.

At the same time, those who are using electronic medical records are finding they aren't exactly time saving. There is a learning curve involved. And, the records generally require more data than what were previously recorded.

The government currently has public policy advisory committees to encourage more adoption and to deal with privacy issues—significant challenges, Dr. Bell said.

In the meantime, her office is continuing to develop an exact definition of what is going to be needed in an electronic health record, she added. “There are no standard definitions for any of this stuff.”

Added Challenge for LTC

Other speakers at the meeting described the significant hardship they went through acquiring a system specifically for geriatrics.

The electronic health record industry and its products are geared to the acute care environment, and when they can be used for a facility that cares for older persons, they need to be modified significantly, the speakers said.

“As I was trying to figure out which electronic health records system we would use for geriatrics, I really ran into a lot of roadblocks,” said Dr. Irene Hamrick of the division of geriatrics at East Carolina University, Greenville, N.C.

“There really is nothing out there that is very good,” she added.

Her institution finally chose General Electric Company's Centricity system because it can be used in many locations, such as the home for health care visits.

However, the institution found that it needed to tailor the system for specific geriatric needs, adding records of diet and activities of daily living. Changes also needed to be made to the physical exam form to include sections for foot and mental status exams.

“Very little out-of-the-box software is user friendly for geriatrics. None is totally acceptable to my mind. If you want to use them, you have to adapt them,” Dr. Hamrick said.

When the Gurwin Jewish Geriatric Center of Commack, N.Y., began to look for an electronic medical record system, the institution had no idea it would take so long to find and implement one, said Dr. Suzanne Fields, the medical director.

The center found that there are Web sites (such as www.providersedge.com/ehr_links_products_services.htm

And, the center found a number of products for long-term care. But, the center has both outpatient day care and clinics, and inpatient beds, and none of the products adequately accommodated both, Dr. Fields said.

Dr. Fields and her colleagues also found that they had to adapt a system to their needs. In the end, the center combined two products, one for long-term care and another for physician care. The system is not yet up and running.

“It has to be individualized. That's what I didn't realize,” she said.

SALT LAKE CITY — A young child who has a bacterial gastrointestinal infection may have a 30 times higher risk of intussusception in the following 6 months, according to a study of cases from a large military database.

“There is a significant increased risk of intussusception in patients with a recent gastrointestinal infection,” said Capt. Cade M. Nylund, MC, USAF, at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

The potential association between bacterial gastroenteritis and intussusception had not been investigated before, although there had been case reports, Dr. Nylund said. He was prompted to look into the possibility of an association by the case of a 17-month-old girl with an intussusception who had had bloody diarrhea 2 weeks previously.

He searched the military's Patient Administration System and Biostatistics Activity database for all children 5 years old or younger who were seen with bacterial gastroenteritis at a military medical facility between January 2002 and December 2005. The search was conducted to find an ICD diagnostic-related group (DRG) code specifically for infection with Yersinia enterocolitica, Escherichia coli, Campylobacter, Shigella species, and Salmonella species.

Dr. Nylund, of the San Antonio Military Pediatric Center, also searched the records for a DRG code or a current procedural terminology code for an intussusception within 6 months after the infection.

He reviewed 387,514 persons, in which there were 1,412 infections and 293 intussusceptions. The overall rate for intussusception in the reviewed patients, therefore, was 7.6 cases per 10,000 population, a rate that is consistent with previous population reports, Dr. Nylund said. Of the 293 intussusception cases, 37 were in patients who had been seen for bacterial gastroenteritis in the previous 6 months.

The analysis showed that the odds ratio for a case of intussusception in those with a previous bacterial gastrointestinal infection was 40. The increase in absolute risk was 30, he said.

The odds ratio in infants less than 1 year of age was 16, and the odds ratio for children between 1 year and 5 years was 56.

The organism with the most frequent association was Salmonella, which accounted for 18 of the cases and had an odds ratio of 46. The second most frequent association was with E. coli, which accounted for 12 cases and had an odds ratio of 33.

Five cases were associated with a Shigella infection and two with a Campylobacter infection.

No cases were associated with a Yersinia infection, but that may have been because it was so rare; the database included only four cases of Yersinia infection.

Most of the intussusceptions occurred within 8 days of the infection, although some occurred months afterward. Dr. Nylund said it was not possible to know whether there was increased risk beyond 6 months, because he looked only for an association within 6 months, a period of time he chose arbitrarily.

The association between infection and intussusception could be related to hyperplasia caused by the infection, or could be linked to changes in motility, he said.

SALT LAKE CITY — A young child who has a bacterial gastrointestinal infection may have a 30 times higher risk of intussusception in the following 6 months, according to a study of cases from a large military database.

“There is a significant increased risk of intussusception in patients with a recent gastrointestinal infection,” said Capt. Cade M. Nylund, MC, USAF, at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

The potential association between bacterial gastroenteritis and intussusception had not been investigated before, although there had been case reports, Dr. Nylund said. He was prompted to look into the possibility of an association by the case of a 17-month-old girl with an intussusception who had had bloody diarrhea 2 weeks previously.

He searched the military's Patient Administration System and Biostatistics Activity database for all children 5 years old or younger who were seen with bacterial gastroenteritis at a military medical facility between January 2002 and December 2005. The search was conducted to find an ICD diagnostic-related group (DRG) code specifically for infection with Yersinia enterocolitica, Escherichia coli, Campylobacter, Shigella species, and Salmonella species.

Dr. Nylund, of the San Antonio Military Pediatric Center, also searched the records for a DRG code or a current procedural terminology code for an intussusception within 6 months after the infection.

He reviewed 387,514 persons, in which there were 1,412 infections and 293 intussusceptions. The overall rate for intussusception in the reviewed patients, therefore, was 7.6 cases per 10,000 population, a rate that is consistent with previous population reports, Dr. Nylund said. Of the 293 intussusception cases, 37 were in patients who had been seen for bacterial gastroenteritis in the previous 6 months.

The analysis showed that the odds ratio for a case of intussusception in those with a previous bacterial gastrointestinal infection was 40. The increase in absolute risk was 30, he said.

The odds ratio in infants less than 1 year of age was 16, and the odds ratio for children between 1 year and 5 years was 56.

The organism with the most frequent association was Salmonella, which accounted for 18 of the cases and had an odds ratio of 46. The second most frequent association was with E. coli, which accounted for 12 cases and had an odds ratio of 33.

Five cases were associated with a Shigella infection and two with a Campylobacter infection.

No cases were associated with a Yersinia infection, but that may have been because it was so rare; the database included only four cases of Yersinia infection.

Most of the intussusceptions occurred within 8 days of the infection, although some occurred months afterward. Dr. Nylund said it was not possible to know whether there was increased risk beyond 6 months, because he looked only for an association within 6 months, a period of time he chose arbitrarily.

The association between infection and intussusception could be related to hyperplasia caused by the infection, or could be linked to changes in motility, he said.

SALT LAKE CITY — A young child who has a bacterial gastrointestinal infection may have a 30 times higher risk of intussusception in the following 6 months, according to a study of cases from a large military database.

“There is a significant increased risk of intussusception in patients with a recent gastrointestinal infection,” said Capt. Cade M. Nylund, MC, USAF, at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

The potential association between bacterial gastroenteritis and intussusception had not been investigated before, although there had been case reports, Dr. Nylund said. He was prompted to look into the possibility of an association by the case of a 17-month-old girl with an intussusception who had had bloody diarrhea 2 weeks previously.

He searched the military's Patient Administration System and Biostatistics Activity database for all children 5 years old or younger who were seen with bacterial gastroenteritis at a military medical facility between January 2002 and December 2005. The search was conducted to find an ICD diagnostic-related group (DRG) code specifically for infection with Yersinia enterocolitica, Escherichia coli, Campylobacter, Shigella species, and Salmonella species.

Dr. Nylund, of the San Antonio Military Pediatric Center, also searched the records for a DRG code or a current procedural terminology code for an intussusception within 6 months after the infection.

He reviewed 387,514 persons, in which there were 1,412 infections and 293 intussusceptions. The overall rate for intussusception in the reviewed patients, therefore, was 7.6 cases per 10,000 population, a rate that is consistent with previous population reports, Dr. Nylund said. Of the 293 intussusception cases, 37 were in patients who had been seen for bacterial gastroenteritis in the previous 6 months.

The analysis showed that the odds ratio for a case of intussusception in those with a previous bacterial gastrointestinal infection was 40. The increase in absolute risk was 30, he said.

The odds ratio in infants less than 1 year of age was 16, and the odds ratio for children between 1 year and 5 years was 56.

The organism with the most frequent association was Salmonella, which accounted for 18 of the cases and had an odds ratio of 46. The second most frequent association was with E. coli, which accounted for 12 cases and had an odds ratio of 33.

Five cases were associated with a Shigella infection and two with a Campylobacter infection.

No cases were associated with a Yersinia infection, but that may have been because it was so rare; the database included only four cases of Yersinia infection.

Most of the intussusceptions occurred within 8 days of the infection, although some occurred months afterward. Dr. Nylund said it was not possible to know whether there was increased risk beyond 6 months, because he looked only for an association within 6 months, a period of time he chose arbitrarily.

The association between infection and intussusception could be related to hyperplasia caused by the infection, or could be linked to changes in motility, he said.

SALT LAKE CITY — Narcotic bowel syndrome is a problem that physicians have been sweeping under the rug, and it may be growing in frequency, Dr. Douglas A. Drossman said at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

Physicians have ignored this syndrome, since many are loathe to undertake the arduous task of weaning their patients from narcotics, said Dr. Drossman, codirector of the University of North Carolina Center for Functional Gastrointestinal and Motility Disorders.

But this reluctance is not necessary, because patients can be helped to break the “vicious cycle,” he said. There is a very effective protocol that can be used to withdraw patients from narcotics, using clonidine for the physical withdrawal symptoms and lorazepam for the anxiety, while switching them to an antidepressant for pain control.

This syndrome was first noted and described in the 1980s, but very little was written about it until Dr. Drossman and his colleagues published a paper (Clin. Gastroenterol. Hepatol. 2007;5:1126–39). He has seen at least 100 patients with narcotic bowel syndrome in his clinic.

Typically, the patient with narcotic bowel syndrome was started on an opiate because of a functional bowel disorder, or after surgery, or even for an acute painful condition. The patient then developed chronic or intermittent colicky abdominal pain, often due to delayed motility.

At first, the narcotic helps this pain, but over time tachyphylaxis and hyperalgesia set in, rendering the narcotic less and less effective and making the patient dependent on ever-escalating doses.

Dr. Drossman, who is a gastroenterologist but also is trained in psychosomatic medicine, said narcotic bowel syndrome occurs often enough that most gastroenterologists are aware that it occurs and have a pretty good intuitive sense when they see patients with it. But often, in practice, they push the idea to the background and prescribe more narcotics because that is what the patient wants, and clinics and hospitals pressure physicians to move patients through the system fast.

The doctors do not have the time or the motivation to address such a complex problem in a medical system that dictates quick processing of patients, Dr. Drossman said.

Narcotic bowel syndrome is probably a U.S. phenomenon because about 80% of the world's medical use of narcotics occurs in the United States, and physicians here are using opiates more and more, he said.

According to the protocol Dr. Drossman recommends, physicians who want to detoxify a patient should start with a tricyclic antidepressant or a serotonin-noradrenergic inhibitor, which is begun about 2 days before the withdrawal is initiated. Of the tricyclics, desipramine or nortriptyline are better than imipramine or amitriptyline because they have fewer side effects, he said.

A low dose is used for pain control—for example, 50 mg per day of desipramine taken at bedtime, titrated up to 150 mg per day. One day before narcotic withdrawal begins, lorazepam is started in order to ease anxiety, at a dose of 1 mg every 6–8 hours, continued throughout the entire withdrawal.

The narcotic can be withdrawn at a rate of 10%–33% per day, meaning the detoxification can take anywhere from 3 to 10 days.

On the second or third day of withdrawal, clonidine is begun to treat the sympathetic-related symptoms, such as muscle pains and chills. Both lorazepam and clonidine can be tapered and discontinued once the withdrawal is complete.

If the patient is constipated, he or she can be treated with polyethylene glycol. The antidepressant is continued indefinitely, as needed, for pain control.

Dr. Drossman is on the speaker's bureau for Sucampo Pharmaceuticals, Takeda Pharmaceutical North America, Novartis, and Microbia.

About 80% of the world's medical use of narcotics occurs in the United States. DR. DROSSMAN

SALT LAKE CITY — Narcotic bowel syndrome is a problem that physicians have been sweeping under the rug, and it may be growing in frequency, Dr. Douglas A. Drossman said at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

Physicians have ignored this syndrome, since many are loathe to undertake the arduous task of weaning their patients from narcotics, said Dr. Drossman, codirector of the University of North Carolina Center for Functional Gastrointestinal and Motility Disorders.

But this reluctance is not necessary, because patients can be helped to break the “vicious cycle,” he said. There is a very effective protocol that can be used to withdraw patients from narcotics, using clonidine for the physical withdrawal symptoms and lorazepam for the anxiety, while switching them to an antidepressant for pain control.

This syndrome was first noted and described in the 1980s, but very little was written about it until Dr. Drossman and his colleagues published a paper (Clin. Gastroenterol. Hepatol. 2007;5:1126–39). He has seen at least 100 patients with narcotic bowel syndrome in his clinic.

Typically, the patient with narcotic bowel syndrome was started on an opiate because of a functional bowel disorder, or after surgery, or even for an acute painful condition. The patient then developed chronic or intermittent colicky abdominal pain, often due to delayed motility.

At first, the narcotic helps this pain, but over time tachyphylaxis and hyperalgesia set in, rendering the narcotic less and less effective and making the patient dependent on ever-escalating doses.

Dr. Drossman, who is a gastroenterologist but also is trained in psychosomatic medicine, said narcotic bowel syndrome occurs often enough that most gastroenterologists are aware that it occurs and have a pretty good intuitive sense when they see patients with it. But often, in practice, they push the idea to the background and prescribe more narcotics because that is what the patient wants, and clinics and hospitals pressure physicians to move patients through the system fast.

The doctors do not have the time or the motivation to address such a complex problem in a medical system that dictates quick processing of patients, Dr. Drossman said.

Narcotic bowel syndrome is probably a U.S. phenomenon because about 80% of the world's medical use of narcotics occurs in the United States, and physicians here are using opiates more and more, he said.

According to the protocol Dr. Drossman recommends, physicians who want to detoxify a patient should start with a tricyclic antidepressant or a serotonin-noradrenergic inhibitor, which is begun about 2 days before the withdrawal is initiated. Of the tricyclics, desipramine or nortriptyline are better than imipramine or amitriptyline because they have fewer side effects, he said.

A low dose is used for pain control—for example, 50 mg per day of desipramine taken at bedtime, titrated up to 150 mg per day. One day before narcotic withdrawal begins, lorazepam is started in order to ease anxiety, at a dose of 1 mg every 6–8 hours, continued throughout the entire withdrawal.

The narcotic can be withdrawn at a rate of 10%–33% per day, meaning the detoxification can take anywhere from 3 to 10 days.

On the second or third day of withdrawal, clonidine is begun to treat the sympathetic-related symptoms, such as muscle pains and chills. Both lorazepam and clonidine can be tapered and discontinued once the withdrawal is complete.

If the patient is constipated, he or she can be treated with polyethylene glycol. The antidepressant is continued indefinitely, as needed, for pain control.

Dr. Drossman is on the speaker's bureau for Sucampo Pharmaceuticals, Takeda Pharmaceutical North America, Novartis, and Microbia.

About 80% of the world's medical use of narcotics occurs in the United States. DR. DROSSMAN

SALT LAKE CITY — Narcotic bowel syndrome is a problem that physicians have been sweeping under the rug, and it may be growing in frequency, Dr. Douglas A. Drossman said at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

Physicians have ignored this syndrome, since many are loathe to undertake the arduous task of weaning their patients from narcotics, said Dr. Drossman, codirector of the University of North Carolina Center for Functional Gastrointestinal and Motility Disorders.

But this reluctance is not necessary, because patients can be helped to break the “vicious cycle,” he said. There is a very effective protocol that can be used to withdraw patients from narcotics, using clonidine for the physical withdrawal symptoms and lorazepam for the anxiety, while switching them to an antidepressant for pain control.

This syndrome was first noted and described in the 1980s, but very little was written about it until Dr. Drossman and his colleagues published a paper (Clin. Gastroenterol. Hepatol. 2007;5:1126–39). He has seen at least 100 patients with narcotic bowel syndrome in his clinic.

Typically, the patient with narcotic bowel syndrome was started on an opiate because of a functional bowel disorder, or after surgery, or even for an acute painful condition. The patient then developed chronic or intermittent colicky abdominal pain, often due to delayed motility.

At first, the narcotic helps this pain, but over time tachyphylaxis and hyperalgesia set in, rendering the narcotic less and less effective and making the patient dependent on ever-escalating doses.

Dr. Drossman, who is a gastroenterologist but also is trained in psychosomatic medicine, said narcotic bowel syndrome occurs often enough that most gastroenterologists are aware that it occurs and have a pretty good intuitive sense when they see patients with it. But often, in practice, they push the idea to the background and prescribe more narcotics because that is what the patient wants, and clinics and hospitals pressure physicians to move patients through the system fast.

The doctors do not have the time or the motivation to address such a complex problem in a medical system that dictates quick processing of patients, Dr. Drossman said.

Narcotic bowel syndrome is probably a U.S. phenomenon because about 80% of the world's medical use of narcotics occurs in the United States, and physicians here are using opiates more and more, he said.

According to the protocol Dr. Drossman recommends, physicians who want to detoxify a patient should start with a tricyclic antidepressant or a serotonin-noradrenergic inhibitor, which is begun about 2 days before the withdrawal is initiated. Of the tricyclics, desipramine or nortriptyline are better than imipramine or amitriptyline because they have fewer side effects, he said.

A low dose is used for pain control—for example, 50 mg per day of desipramine taken at bedtime, titrated up to 150 mg per day. One day before narcotic withdrawal begins, lorazepam is started in order to ease anxiety, at a dose of 1 mg every 6–8 hours, continued throughout the entire withdrawal.

The narcotic can be withdrawn at a rate of 10%–33% per day, meaning the detoxification can take anywhere from 3 to 10 days.

On the second or third day of withdrawal, clonidine is begun to treat the sympathetic-related symptoms, such as muscle pains and chills. Both lorazepam and clonidine can be tapered and discontinued once the withdrawal is complete.

If the patient is constipated, he or she can be treated with polyethylene glycol. The antidepressant is continued indefinitely, as needed, for pain control.

Dr. Drossman is on the speaker's bureau for Sucampo Pharmaceuticals, Takeda Pharmaceutical North America, Novartis, and Microbia.

About 80% of the world's medical use of narcotics occurs in the United States. DR. DROSSMAN

LAS VEGAS — Beware the cosmeceutical claims about green tea and its antiaging properties.

Although there is strong evidence that green tea contains substances that may ward off UVA-related skin damage, it is all from in vitro experiments, Dr. Cherie Ditre said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

None of it comes from actual patient trials.

"This is all done with artificial skin and artificial-skin substrates. More work needs to be done," said Dr. Ditre, director of the University of Pennsylvania Health System's Cosmetic Dermatology and Skin Enhancement Center in Radnor.

With that caveat, Dr. Ditre said that green tea has been shown to have strong antioncogenic properties and may work in a complementary fashion to retinoids.

The most important, active component of green tea is considered to be epigallocatechin-3-gallate, or ECGC, which is a polyphenolic compound. It appears to inhibit the generation of intracellular hydrogen peroxide, one of the most active DNA-damaging oxygen species, and the formation of cyclobutane pyrimidine dimer, another source of DNA damage.

In experiments with hairless mice prone to squamous cell carcinoma, application of green tea reduced the development of tumors by 60%, relative to controls (Neoplasia 2003;5:555-65), she said.

In the skin culture systems, topical application of green tea extract of ECGC, at practical doses, has been shown to increase the expression of tissue inhibitors of matrix metalloproteinases (TIMPs). Matrix metalloproteinases contribute to the degradation of collagen, and their levels increase after UV exposure, so they may be an important pathway for sun-induced aging, Dr. Ditre said.

In particular, ECGC was shown to increase production of TIMPs in dermal fibroblasts in response to UVA exposure (J. Dermatol. Sci. 2005;40:195-204).

This is different from how retinoids work, she added. Retinoids upregulate collagen synthesis and downregulate matrix metalloproteinase expression. Matrix metalloproteinase expression is mostly increased as a result of UVB exposure.

These differences suggest that using green tea and a retinoid together could be advantageous.

"There is some harmony between these agents," Dr. Ditre said. "Perhaps the combination of retinoids with green tea could give us the maximum benefit for collagen preservation and perhaps collagen upregulation."

Dr. Ditre disclosed that she serves on the speakers' bureau and is an adviser for Topix Pharmaceuticals Inc., maker of Replenix, a skin-care line containing green tea.

LAS VEGAS — Beware the cosmeceutical claims about green tea and its antiaging properties.

Although there is strong evidence that green tea contains substances that may ward off UVA-related skin damage, it is all from in vitro experiments, Dr. Cherie Ditre said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

None of it comes from actual patient trials.

"This is all done with artificial skin and artificial-skin substrates. More work needs to be done," said Dr. Ditre, director of the University of Pennsylvania Health System's Cosmetic Dermatology and Skin Enhancement Center in Radnor.

With that caveat, Dr. Ditre said that green tea has been shown to have strong antioncogenic properties and may work in a complementary fashion to retinoids.

The most important, active component of green tea is considered to be epigallocatechin-3-gallate, or ECGC, which is a polyphenolic compound. It appears to inhibit the generation of intracellular hydrogen peroxide, one of the most active DNA-damaging oxygen species, and the formation of cyclobutane pyrimidine dimer, another source of DNA damage.

In experiments with hairless mice prone to squamous cell carcinoma, application of green tea reduced the development of tumors by 60%, relative to controls (Neoplasia 2003;5:555-65), she said.

In the skin culture systems, topical application of green tea extract of ECGC, at practical doses, has been shown to increase the expression of tissue inhibitors of matrix metalloproteinases (TIMPs). Matrix metalloproteinases contribute to the degradation of collagen, and their levels increase after UV exposure, so they may be an important pathway for sun-induced aging, Dr. Ditre said.

In particular, ECGC was shown to increase production of TIMPs in dermal fibroblasts in response to UVA exposure (J. Dermatol. Sci. 2005;40:195-204).

This is different from how retinoids work, she added. Retinoids upregulate collagen synthesis and downregulate matrix metalloproteinase expression. Matrix metalloproteinase expression is mostly increased as a result of UVB exposure.

These differences suggest that using green tea and a retinoid together could be advantageous.

"There is some harmony between these agents," Dr. Ditre said. "Perhaps the combination of retinoids with green tea could give us the maximum benefit for collagen preservation and perhaps collagen upregulation."

Dr. Ditre disclosed that she serves on the speakers' bureau and is an adviser for Topix Pharmaceuticals Inc., maker of Replenix, a skin-care line containing green tea.

LAS VEGAS — Beware the cosmeceutical claims about green tea and its antiaging properties.

Although there is strong evidence that green tea contains substances that may ward off UVA-related skin damage, it is all from in vitro experiments, Dr. Cherie Ditre said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

None of it comes from actual patient trials.

"This is all done with artificial skin and artificial-skin substrates. More work needs to be done," said Dr. Ditre, director of the University of Pennsylvania Health System's Cosmetic Dermatology and Skin Enhancement Center in Radnor.

With that caveat, Dr. Ditre said that green tea has been shown to have strong antioncogenic properties and may work in a complementary fashion to retinoids.

The most important, active component of green tea is considered to be epigallocatechin-3-gallate, or ECGC, which is a polyphenolic compound. It appears to inhibit the generation of intracellular hydrogen peroxide, one of the most active DNA-damaging oxygen species, and the formation of cyclobutane pyrimidine dimer, another source of DNA damage.

In experiments with hairless mice prone to squamous cell carcinoma, application of green tea reduced the development of tumors by 60%, relative to controls (Neoplasia 2003;5:555-65), she said.

In the skin culture systems, topical application of green tea extract of ECGC, at practical doses, has been shown to increase the expression of tissue inhibitors of matrix metalloproteinases (TIMPs). Matrix metalloproteinases contribute to the degradation of collagen, and their levels increase after UV exposure, so they may be an important pathway for sun-induced aging, Dr. Ditre said.

In particular, ECGC was shown to increase production of TIMPs in dermal fibroblasts in response to UVA exposure (J. Dermatol. Sci. 2005;40:195-204).

This is different from how retinoids work, she added. Retinoids upregulate collagen synthesis and downregulate matrix metalloproteinase expression. Matrix metalloproteinase expression is mostly increased as a result of UVB exposure.

These differences suggest that using green tea and a retinoid together could be advantageous.

"There is some harmony between these agents," Dr. Ditre said. "Perhaps the combination of retinoids with green tea could give us the maximum benefit for collagen preservation and perhaps collagen upregulation."

Dr. Ditre disclosed that she serves on the speakers' bureau and is an adviser for Topix Pharmaceuticals Inc., maker of Replenix, a skin-care line containing green tea.

LAS VEGAS — The new approach in the cosmetic treatment of the aging face is to look beyond simply using fillers for wrinkles and to think about restoring volume in the upper face and cheeks, Dr. W. Philip Werschler said.

"We are moving from using fillers as wrinkle and line fillers, to facial shaping agents," said Dr. Werschler, at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "And we divide the face into facial treatment zones in which certain facial shaping agents might be more suited."

A young face, from below the eyes, has an inverted triangle shape with the broad base of the triangle extending across from the top of the malar zygomas and the point extending down to the muscularis mentalis of the chin. As the face ages, the volume descends. Jowls form and muscle atrophies, and the face takes on an upright triangle shape with the sides framed by the marionette lines and the top at the narrowing of the nasal bone, said Dr. Werschler, who has a private dermatology practice and conducts research in Spokane, Wash.

In a recent study, researchers performed dissections on the faces of 30 cadavers, and found that the subcutaneous fat in the face is divided into distinct compartments. Malar fat, for example, is divided into three compartments. The researchers also suggested that the different compartments of fat in the face probably change differently with age, with the divergent fat pads changing location and proportion (Plast. Reconstr. Surg. 2007;119:2219-27).

A short while ago, there was a limited repertoire of fillers, said Dr. Werschler. One could use a temporary filler (bovine collagen) or a permanent filler (silicone). Now there is a broad palette of fillers, with properties that defy easy classification, such as poly-L-lactic acid (Sculptra) and calcium hydroxylapatite microspheres (Radiesse). Poly-L-lactic acid can be molded and shaped under the skin for a short while after injection, while calcium hydroxylapatite stimulates collagen growth around the implanted material and persists for over a year. Both can be used to build volume and they last much longer than collagen.

A "facial shaping artist" will plan out the rejuvenation procedure by taking into account the different properties of fillers, he said. The plan should be informed by the triangle concept, and by the concept that the face has three zones. The top zone extends roughly from the hairline to the upper eyelids. The middle zone goes roughly from the eyebrows to the upper lip. The bottom zone falls roughly from the base of the nose to include the anterior neck.

The goal should be to create balance and symmetry within each zone, and balance and proportion between the zones. The treatment concept embracing these ideas is known as RAVE, or regional aesthetic volume enhancement.

Many simply look to reduce nasolabial folds, oftentimes injecting too much and concentrating on just that one area. Patients may have fewer lines, but they can lose balance and proportion between the zones and can end up looking like "someone who has just stepped off the set of 'Planet of the Apes,'" he said.

"You have to look at facial balance," Dr. Werschler said. "Our approach now has to be more about global balance of the face. Lines and wrinkles do not necessarily define someone's age."

Dr. Werschler has served as a consultant to many companies, including Sanofi Aventis, maker of Sculptra, and BioForm Medical Inc., maker of Radiesse.

LAS VEGAS — The new approach in the cosmetic treatment of the aging face is to look beyond simply using fillers for wrinkles and to think about restoring volume in the upper face and cheeks, Dr. W. Philip Werschler said.

"We are moving from using fillers as wrinkle and line fillers, to facial shaping agents," said Dr. Werschler, at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "And we divide the face into facial treatment zones in which certain facial shaping agents might be more suited."

A young face, from below the eyes, has an inverted triangle shape with the broad base of the triangle extending across from the top of the malar zygomas and the point extending down to the muscularis mentalis of the chin. As the face ages, the volume descends. Jowls form and muscle atrophies, and the face takes on an upright triangle shape with the sides framed by the marionette lines and the top at the narrowing of the nasal bone, said Dr. Werschler, who has a private dermatology practice and conducts research in Spokane, Wash.

In a recent study, researchers performed dissections on the faces of 30 cadavers, and found that the subcutaneous fat in the face is divided into distinct compartments. Malar fat, for example, is divided into three compartments. The researchers also suggested that the different compartments of fat in the face probably change differently with age, with the divergent fat pads changing location and proportion (Plast. Reconstr. Surg. 2007;119:2219-27).

A short while ago, there was a limited repertoire of fillers, said Dr. Werschler. One could use a temporary filler (bovine collagen) or a permanent filler (silicone). Now there is a broad palette of fillers, with properties that defy easy classification, such as poly-L-lactic acid (Sculptra) and calcium hydroxylapatite microspheres (Radiesse). Poly-L-lactic acid can be molded and shaped under the skin for a short while after injection, while calcium hydroxylapatite stimulates collagen growth around the implanted material and persists for over a year. Both can be used to build volume and they last much longer than collagen.

A "facial shaping artist" will plan out the rejuvenation procedure by taking into account the different properties of fillers, he said. The plan should be informed by the triangle concept, and by the concept that the face has three zones. The top zone extends roughly from the hairline to the upper eyelids. The middle zone goes roughly from the eyebrows to the upper lip. The bottom zone falls roughly from the base of the nose to include the anterior neck.

The goal should be to create balance and symmetry within each zone, and balance and proportion between the zones. The treatment concept embracing these ideas is known as RAVE, or regional aesthetic volume enhancement.

Many simply look to reduce nasolabial folds, oftentimes injecting too much and concentrating on just that one area. Patients may have fewer lines, but they can lose balance and proportion between the zones and can end up looking like "someone who has just stepped off the set of 'Planet of the Apes,'" he said.

"You have to look at facial balance," Dr. Werschler said. "Our approach now has to be more about global balance of the face. Lines and wrinkles do not necessarily define someone's age."

Dr. Werschler has served as a consultant to many companies, including Sanofi Aventis, maker of Sculptra, and BioForm Medical Inc., maker of Radiesse.

LAS VEGAS — The new approach in the cosmetic treatment of the aging face is to look beyond simply using fillers for wrinkles and to think about restoring volume in the upper face and cheeks, Dr. W. Philip Werschler said.

"We are moving from using fillers as wrinkle and line fillers, to facial shaping agents," said Dr. Werschler, at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "And we divide the face into facial treatment zones in which certain facial shaping agents might be more suited."

A young face, from below the eyes, has an inverted triangle shape with the broad base of the triangle extending across from the top of the malar zygomas and the point extending down to the muscularis mentalis of the chin. As the face ages, the volume descends. Jowls form and muscle atrophies, and the face takes on an upright triangle shape with the sides framed by the marionette lines and the top at the narrowing of the nasal bone, said Dr. Werschler, who has a private dermatology practice and conducts research in Spokane, Wash.

In a recent study, researchers performed dissections on the faces of 30 cadavers, and found that the subcutaneous fat in the face is divided into distinct compartments. Malar fat, for example, is divided into three compartments. The researchers also suggested that the different compartments of fat in the face probably change differently with age, with the divergent fat pads changing location and proportion (Plast. Reconstr. Surg. 2007;119:2219-27).

A short while ago, there was a limited repertoire of fillers, said Dr. Werschler. One could use a temporary filler (bovine collagen) or a permanent filler (silicone). Now there is a broad palette of fillers, with properties that defy easy classification, such as poly-L-lactic acid (Sculptra) and calcium hydroxylapatite microspheres (Radiesse). Poly-L-lactic acid can be molded and shaped under the skin for a short while after injection, while calcium hydroxylapatite stimulates collagen growth around the implanted material and persists for over a year. Both can be used to build volume and they last much longer than collagen.

A "facial shaping artist" will plan out the rejuvenation procedure by taking into account the different properties of fillers, he said. The plan should be informed by the triangle concept, and by the concept that the face has three zones. The top zone extends roughly from the hairline to the upper eyelids. The middle zone goes roughly from the eyebrows to the upper lip. The bottom zone falls roughly from the base of the nose to include the anterior neck.

The goal should be to create balance and symmetry within each zone, and balance and proportion between the zones. The treatment concept embracing these ideas is known as RAVE, or regional aesthetic volume enhancement.

Many simply look to reduce nasolabial folds, oftentimes injecting too much and concentrating on just that one area. Patients may have fewer lines, but they can lose balance and proportion between the zones and can end up looking like "someone who has just stepped off the set of 'Planet of the Apes,'" he said.

"You have to look at facial balance," Dr. Werschler said. "Our approach now has to be more about global balance of the face. Lines and wrinkles do not necessarily define someone's age."

Dr. Werschler has served as a consultant to many companies, including Sanofi Aventis, maker of Sculptra, and BioForm Medical Inc., maker of Radiesse.