Volume 11 | Issue 9
Maritza I.Perez MD|No abstract details for the moment.
No abstract details for the moment.
Five-Year Retrospective Review of Safety, Injected Volumes, and Longevity of the Hyaluronic Acid Belotero Basic for Facial Treatments in 317 PatientsBackground: Hyaluronic acids (HA) fillers abound in the European community, many with different names in different countries. One such HA is Belotero Basic, recently approved by the FDA in the United States.
Objective: The objective of this article is to report on use of this HA in a German clinic, over a period of 5+ years, in 317 patients (668 treatments).
Methods and Materials: Authors retrospectively examined patient charts of 317 patients (312 females), aged 24 to 87 years. Chart review showed areas treated, range of volumes per area, and mean volumes. Patient satisfaction data was collected anecdotally over the five years.
Results: Volumes of the HA injected ranged from 0.2 mL to 3.0 mL, depending on the area being treated. No serious adverse events were noted in the chart review, nor was any Tyndall effect observed in the treated areas. Anecdotal information suggests high patient satisfaction with results, based on the return of these patients to the clinic for other treatments over the more than five years.
Conclusion: Belotero Basic provides aesthetically pleasing results for treatment of facial defects, without carrying a risk of serious adverse events. North American physicians now have a new HA to consider as part of their treatment protocols.
J Drugs Dermatol. 2012;11(9):1032-1035.
Histologic Improvement in Photodamage After 12 Months of Treatment With Tretinoin Emollient Cream (0.02%)Background and Objective: Topical retinoids, such as tretinoin, have been established as the gold standard for the treatment of photodamaged skin. This was a single-center, open-label, single-group, observational histologic subanalysis of 3 of 19 patients participating in a study of the efficacy and safety of tretinoin emollient cream 0.02% for the treatment of moderate to severe facial photodamage.
Methods: Subjects were female, 18 years of age or older, and instructed to apply tretinoin 0.02% to the treatment areas for 12 months. Histology was undertaken using facial photographs and 2-mm biopsies of the lateral canthus area that were obtained from 3 subjects at baseline and 12 months.
Results: Histopathologic analyses revealed evidence of extensive solar elastosis at baseline for 2 of the 3 subjects who were white, with moderate elastosis observed for the third subject who was African American. Histologic improvements in photodamage following 12 months of treatment with tretinoin 0.02% were observed for each subject. Improvements included smoothing of the epidermis, a slightly thinner keratin layer, and thin, comparatively straight elastic and collagen fibers in the mid- to deep-dermal layer.
Conclusions: The histologic changes in all subjects could be attributed to a remodeling (elastin) or repair (collagen) process that affected the connective tissue fibers in all layers of the dermis. These results suggest that tretinoin 0.02% may be an effective treatment for photodamage, and additional evaluation is warranted in future studies.
J Drugs Dermatol. 2012;11(9):1036-1040.
The introduction of botulinum neurotoxin type A (BoNTA) for the treatment of glabellar lines marked a revolution in aesthetic medicine, allowing for noninvasive facial rejuvenation and sculpting. Treatment of the glabellar area requires a thorough understanding of facial anatomy and the interaction of adjacent muscle groups with respect to facial expression. Because the muscles underlying the glabella are among the larger muscles commonly treated with BoNTA, they may require higher doses than other facial sites. In addition, men typically have a greater glabellar muscle mass than women and require larger BoNTA doses. For optimal outcomes, it is necessary to account for individual variation in muscle mass, anatomy, and function to determine the proper dose, number, and location of injections. The validated Medicis Glabellar Muscle Mass Scale was developed to facilitate research on dose adjustment for muscle mass in the glabella and can be applied as a clinical tool. This review will discuss techniques for optimizing BoNTA treatment of the glabella, with emphasis on the need to assess muscle mass in individual patients and adjust BoNTA dosing and technique accordingly.
J Drugs Dermatol. 2012;11(9):1041-1045.
Objective: Aesthetic fillers aim to rejuvenate the aging face, but the true end goal is to help patients feel better about their appearance. Cheek augmentation seems to elicit immediate recognition of an improved appearance. This study aims to quantify that impression.
Methods:10 women aged 40 to 60 years were not preselected but were the first 10 women willing to undergo the study who fit the inclusion and exclusion criteria. Prior to receiving the filler, participants were asked to rate on a visual analog scale (VAS) from 1 to 6 how they felt about their appearance. Each woman received 1.0 cc of hyaluronic acid filler (Perlane, Medicis Corporation, Phoenix, AZ) into each cheek. Two weeks later they returned for photos and to complete the same VAS scale.
Results: Seven of ten women felt 0.5 to 2 points better about their appearance as measured by their VAS responses.
Conclusion:Cheek augmentation improves how a woman feels about her attractiveness.
J Drugs Dermatol. 2012;11(9):1077-1080.
Poly-L-lactic acid (PLLA) is a biostimulatory agent that can correct bony and soft tissue facial deficiencies by producing gradual volume restoration. Proper patient selection and clear expectations are important to treatment success. Correct product preparation, injection technique, and patient follow-up correlates with increased patient safety, outcomes, and satisfaction. Alone, or in combination with other rejuvenative procedures, Sculptra® provides longer-lasting improvement to signs of facial aging.
J Drugs Dermatol. 2012;11(9):1046-1052.
Facial wrinkles are the most visible morphological change of the aging process. Therefore, several rejuvenation methods have been developed to cure these unloved signs of the times, such as botulinum toxin, laser treatments as well as topical active ingredients. Recently, dermal fillers have become a popular means of addressing contour defects and soft-tissue augmentation. Although this aesthetic treatment is considered to be relatively safe, the use of injectable dermal fillers is a minimally-invasive treatment, and as with any medical procedure, there is a risk for unwanted side effects.
J Drugs Dermatol. 2012;11(9):1053-1058.
Dermal fillers have provided a safe and effective means for aesthetic soft tissue augmentation, and have experienced a dramatic increase in popularity during the past 10 years. Much focus has been placed upon filler technique and patient outcomes. However, there is a relative lack of literature reviewing the basic science of dermal fillers, which is vital to a physician's understanding of how each product behaves in vivo. Part I of this article reviews the basic science and evolution of both historical and contemporary dermal fillers; Part II examines their adverse effects. We endeavor to provide the physician with a practical approach to choosing products that maximize both aesthetic outcome and safety.
J Drugs Dermatol. 2012;11(9):1059-1068.
The ideal dermal filler should offer long-lasting aesthetic improvement with a minimal side-effect profile. It should be biocompatible and stable within the injection site, with the risk of only transient undesirable effects from injection alone. However, all dermal fillers can induce serious and potentially long-lasting adverse effects. In Part II of this paper, we review the most common adverse effects related to dermal filler use.
J Drugs Dermatol. 2012;11(9):1069-1079.
Full lips have always been associated with youth and beauty. Because of this, lip enhancement is one of the most frequently requested procedures in a cosmetic practice. For novice injectors, we recommend hyaluronic acid (HA) as the filler of choice. There is no skin test required; it is an easily obtainable, “off-the-shelf” product that is natural feeling when skillfully implanted in the soft tissues. Hyaluronic acid is easily reversible with hyaluronidase and, therefore, has an excellent safety profile. While Restylane® is the only FDA-approved HA filler with a specific indication for lip augmentation, one can use the following HA products off-label: Juvéderm® Ultra, Juvéderm Ultra Plus, Juvéderm Ultra XC, Juvéderm Ultra PLUS XC, Restylane-L®, Perlane®, Perlane-L®, and Belotero®. We present our six steps to achieve aesthetically pleasing augmented lips. While there is no single prescription for a “perfect” lip, nor a “one size fits all” approach for lip augmentation, these 6 steps can be used as a basic template for achieving a natural look. For more comprehensive, global perioral rejuvenation, our 6-step technique can be combined with the injection of neuromodulating agents and fractional laser skin resurfacing during the same treatment session.
J Drugs Dermatol. 2012;11(9):1081-1088.
This manuscript is intended to give one an international perspective on the use of fillers around the world—what makes some of them special and what is the need and what is the purpose of having so many fillers in this global dermatologic community we live in. In the US, we have a finite number of fillers and only a handful more currently going through FDA testing. We demand much from our fillers in terms of safety and efficacy, and for all of us in the US, this is a very good reason to keep the numbers of fillers available to a reasonable number.
J Drugs Dermatol. 2012;11(9):1089-1093.
Brighter Eyes: Combined Upper Cheek and Tear Trough Augmentation: A Systematic Approach Utilizing Two Complementary Hyaluronic Acid FillersNon-surgical rejuvenation of the periorbital-cheek complex can be effectively and safely accomplished using a combination of two hyaluronic acid (HA) fillers with distinct viscosities. We present a series of 21 patients with mild to moderate tear trough deformities who were treated with concomitant injection of two dermal fillers (Restylane® and Perlane®). Procedural technique entailed micro-depot injections of the finer viscosity HA into the sub-muscular plane along the orbital rim followed by manual massage. Secondly, injections of the thicker, more firm HA were placed in the sub-muscular and/or deep dermal spaces in the upper malar and lateral zygomatic areas and in the medial aspect of the temporal fossa. On average 0.5 mL Restylane and 0.5 mL Perlane were used per side. Statistically significant improvement in modified Wrinkle Severity Rating Scale scores was seen at 20 weeks. Overall improvement in modified Global Aesthetic Improvement Scale scores occurred in 20 out of 21 patients. Mean patient satisfaction scores increased by 2 grades relative to baseline. Patients' self-reported overall mean improvement was 2.23, indicating moderate (26% to 50%) to good (51% to 75%) improvement. Side effects were limited to transient bruising and swelling. No patients required dissolution of injectant with hyaluronidase. Overall, this combination filler procedure was found to produce both statistically significant and clinically apparent improvement and was associated with an extremely high degree of patient satisfaction.
J Drugs Dermatol. 2012;11(9):1094-1097.
Background:Microcannulas with blunt tips for filler injections have recently been developed for use with dermal fillers. Their utility, ease of use, cosmetic outcomes, perceived pain, and satisfaction ratings amongst patients in terms of comfort and aesthetic outcomes when compared to sharp hypodermic needles has not previously been investigated.
Objective: To compare injections of filler with microcannulas versus hypodermic needles in terms of ease of use, amount of filler required to achieve desired aesthetic outcome, perceived pain by patient, adverse events such as bleeding and bruising and to demonstrate the advantages of single-port injection technique with the blunt-tip microcannula.
Materials and Methods:Ninety-five patients aged 30 to 76 years with a desire to augment facial, décolleté, and hand features were enrolled in the study. Subjects were recruited in a consecutive manner from patients interested in receiving dermal filler augmentation. Each site was cleaned with alcohol before injection. Anesthesia was obtained with a topical anesthesia peel off mask of lidocaine/tetracaine. Cross-linked hyaluronic acid (20 mg to 28 mg per mL) was injected into the mid-dermis. The microcannula or a hypodermic needle was inserted the entire length of the fold, depression or lip and the filler was injected in a linear retrograde fashion. The volume injected was variable, depending on the depth and the extent of the defect. The injecting physician assessed the ease of injection. Subjects used the Visual Analog Scale (0-10) for pain assessment. Clinical efficacy was assessed by the patients and the investigators immediately after injection, and at one and six months after injection using the Global Aesthetic Improvement Scale (GAIS) and digital photography.
Results: Overall, the Global Aesthetic Improvements Scale (GAIS) results were excellent (55%), moderate (35%), and somewhat improved (10%) one month after the procedure, decreasing to 23%, 44%, and 33%, respectively, at the six month evaluation. There was no significant differences in the GAIS score between the microcannula and the hypodermic needle. However, the Visual Analog Scale for pain assessment during the injections was quite different. The pain was described as 3 (mild) for injections with the microcannula, increasing to 6 (moderate) for injections with the hypodermic needle. Bruising and ecchymosis was more marked following use of the hypodermic needle.
Conclusion:Using the blunt-tip microcannula as an alternative to the hypodermic needles has simplified filler injections and produced less bruising, echymosis, and pain with faster recovery.
J Drugs Dermatol. 2012;11(9):1098-1103.
Adjunctive Use of a Facial Moisturizer SPF 30 Containing Ceramide Precursor Improves Tolerability of Topical Tretinoin 0.05%: A Randomized, Investigator-Blinded, Split-Face StudyObjectives: To assess the benefit of adjunctive use of a SPF 30 moisturizing lotion in reducing local side effects associated with atopical tretinoin cream.
Methods:This was a randomized, investigator/evaluator-blinded, split-face comparison in subjects with healthy skin. Subjects applied tretinoin cream 0.05% once daily to the whole face and Cetaphil® Dermacontrol Moisturizer (CDM) once daily to one side of the face based on randomization. Tolerability, perference and skin hydration were evaluated at each week, and a cosmetic acceptability questionnaire regarding CDM was completed at the end of the study.
Results: The majority (about 83% to 86%) of subjects experienced skin irritations on both sides of their face, though predominantly mild for the CDM + tretinoin treated side. Tolerability preferences favored the CDM+tretinoin sides. Adjunctive use of CDM with a topical tretinoin cream improves tolerance of the treatment.
J Drugs Dermatol. 2012;11(9):1104-1107.
Most dermatologists agree that antioxidants help fight free radical damage and can help maintain healthy skin. They do so by affecting intracellular signaling pathways involved in skin damage and protecting against photodamage, as well as preventing wrinkles and inflammation. In today's modern world of the rising nutraceutical industry, many people, in addition to applying topical skin care products, turn to supplementation of the nutrients missing in their diets by taking multivitamins or isolated, man-made nutraceuticals, in what is known as the “Inside-Out” approach to skin care. However, ingestion of large quantities of isolated, fragmented nutrients can be harmful and is a poor representation of the kind of nutrition that can be obtained from whole food sources. In this comprehensive review, it was found that few studies on oral antioxidants benefiting the skin have been done using whole foods, and that the vast majority of current research is focused on the study of compounds in isolation. However, the public stands to benefit greatly if more research were to be devoted toward the impact that physiologic doses of antioxidants (obtained from fruits, vegetables, and whole grains) can have on skin health, and on health in general.
J Drugs Dermatol. 2012;11(9):e1-e4.
Microdermabrasion (MDA) remains a common in-office procedure for many dermatologic practices.The procedure offers minimal downtime with a low incidence of side effects, making it a relatively desirable option for skin rejuvenation. Investigators have identified many of the molecular mechanisms behind this technology in an attempt to optimize clinical results. In particular, activation of the wound healing response plays a key role in the remodeling of post-MDA treated skin, although this response varies based on the type of MDA employed.While many studies discuss the clinical applications of MDA and their relation to histologic changes found after treatment, few address the basic science behind the technology.Our review covers progress made in the last 10 years of research, with an emphasis on the molecular mechanisms.
J Drugs Dermatol. 2012;11(9):e5-e9.
Microdermabrasion (MDA) remains a common in-office procedure for many dermatologic practices. The procedure offers minimal downtime with a low incidence of side effects, making it a relatively desirable option for skin rejuvenation. Investigators have identified many of the molecular mechanisms behind this technology in an attempt to optimize clinical results. In particular, activation of the wound healing response plays a key role in the remodeling of post-MDA treated skin, although this response varies based on the type of MDA employed. In addition, advances in MDA technology offer new and promising ways to enhance transcutaneous penetration of active ingredients to improve clinical outcomes. Our review addresses innovative applications of MDA in the last 10 years of research.
J Drugs Dermatol. 2012;11(9):e10-e17.
Objective: To examine white coat hypertension (WCHTN) in patients presenting for Mohs micrographic surgery (MMS) to determine whether it should be a concern.
Methods:In this prospective study, blood pressure (BP) was recorded in 100 consecutive patients who presented for MMS consultation and a subsequent MMS procedure, and compared on both days. Statistical analysis was performed using the paired Student t test and the significance of the findings was determined based on the corresponding P values. Progression from normotensive to hypertensive state while the doctor was in the room was stratified based on the patient's age, gender, and histories of smoking, hypertension (HTN), diabetes, and hyperlipidemia; as well as whether the doctor was wearing a white lab coat over blue surgical scrubs (50 patients) or blue surgical scrubs alone (50 patients).
Results: BP increased from baseline when the doctor entered the room and then decreased towards baseline after five minutes of the doctor being present. Elevation in BP was more evident in younger people, males, and those with HTN and hyperlipidemia. BP was slightly higher on the day of the consultation than on the day of the procedure. A higher number of patients became hypertensive when the doctor wore a white lab coat over blue surgical scrubs vs blue surgical scrubs alone. However, these changes in BP did not prove to be statistically significant.
Conclusion: Brief periods of WCHTN were seen on both days. However, these elevations in BP were not statistically significant and decreased towards baseline after five minutes. There were no cases in which elevation in BP associated with WCHTN was sufficient to result in the need to postpone or cancel MMS.
J Drugs Dermatol. 2012;11(9):e18-e22.
Objective: Acne vulgaris is one of the most common skin disorders, and oral isotretinoin has widely been used as a treatment for severe and resistant cases in recent years. This article considers the controversy over systemic isotretinoin's effect on the serum level of folic acid and its implications for health.
Methods: This study was conducted to assess the effect of systemic isotretinoin on the serum level of folic acid. Sixty-one patients, including 38 women and 23 men (mean age 23.6 ± 6 years) with severe or moderate acne that was resistant to conventional treatments, were supplemented with 0.5 mg/kg/d of oral isotretinoin for 30 days. They were instructed not to use any other drugs having an effect on the folic acid level nor change their diet. The serum levels of folic acid were measured at the baseline and at the end of the treatment period. Statistical analyses were carried out using the paired t test.
Results: Mean levels of folic acid were 26.75 ± 9.42 nmol/L at baseline, and and 23.6 ± 8.42 nmol/L after 30 days of isotretinoin supplementation. This showed a significant decrease in the serum level of folic acid (P=.008).
Conclusion: Given the significant decrease in the serum level of folic acid following a 30-day use of oral isotretinoin in acne patients, and considering the important role of folic acid in metabolic functions, we recommend further studies to assess the effect of longer periods of isotretinoin treatment, in addition to studies including other relevant factors in folic acid metabolism (e.g., serum homocysteine levels). Moreover, folic acid supplementation in acne patients using isotretinoin is recommended.
J Drugs Dermatol. 2012;11(9):e23-e24.
Topical Pimecrolimus 1% Reverses Long-term Suberythemal Ultraviolet B—induced Epidermal Langerhans Cell Reduction and Morphologic Changes in MiceObjective: Some literature reported that topical calcineurin inhibitors (TCIs) did not accelerate photocarcinogenesis in hairless mice after long-term simulated solar radiation. In this work, we investigate the effects of topical pimecrolimus 1% on long-term suberythemal ultraviolet B (UVB)—irradiated epidermal Langerhans cells (LCs) in mice.
Methods:Thirty female mice were randomly divided into two groups, including four subgroups: (1A) control, (1B) pimecrolimus 1% only, (2A) 25 mJ/cm2 UVB only, (2B) UVB plus pimecrolimus. After being treated for 60 days, the dorsal skin was collected and given immunohistochemical staining of active caspase 3, and immunofluorescence staining for cluster of differentiation 1a (CD1a).
Results:Our results show that, compared with the control subgroup, the CD1a+ LC number in the epidermal sheet of the UVB-only subgroup decreased substantially from 578.6 per mm2 to 227 per mm2 (P<.001). Compared with the UVB-only subgroup, the UVB plus pimecrolimus subgroup significantly restored the LC number from 227 per mm2 to 475.7 per mm2 (P<.001). Compared with other subgroups, the LC morphology of the UVB-only subgroup became rounder, and the LC dendrites became shorter. There were no significant active caspase 3-positive cells in the epidermis in any of the four subgroups.
Conclusion:Our results show that topical pimecrolimus 1% reverses long-term UVB-induced epidermal LC reduction and morphologic changes in mice, where the exact mechanism is likely not related to apoptosis.
J Drugs Dermatol. 2012;11(9):e25-e27.
Local flaps may be required to reconstruct defects on the face, neck, and scalp. Occasionally, delay techniques are indicated to reduce the risk for flap ischemia and subsequent necrosis. Delay may be employed before the flap is raised, as done to improve blood supply to a random flap when length to breadth proportions are not ideal, or after the flap is raised and before separation of the pedicle in the final reconstructive step to improve vascularity in the distal end of an interpolation flap. We present our techniques and results of delay procedures for interpolation and similar flaps.
J Drugs Dermatol. 2012;11(9):1108-1110.
Resident Rounds is a section of the JDD dedicated to highlighting various dermatology departments with residency training programs. Resident Rounds includes three sections: (1) a program spotlight, highlighting pertinent information about the department and residency training program; (2) a section presenting study materials used by residents at the program; and (3) a section designed to highlight recent interesting cases seen at the institution. This issue of Resident Rounds features the Duke Dermatology Residency Training Program. The editor of Resident Rounds is Omar A. Ibrahimi MD PhD. He is currently the Director of Cutaneous Laser and Cosmetic Surgery and a Mohs surgeon at the University of Connecticut. Dr. Ibrahimi is also a Visiting Scientist at the Wellman Center for Photomedicine at Massachusetts General Hospital/Harvard Medical School. If you are interested in highlighting your training program in a future issue, please contact Dr. Ibrahimi at OIbrahimi@jddonline.com.
No abstract details for the moment.
No abstract details for the moment.
No abstract details for the moment.
Pipeline Previews brings to you information on the newest drugs and medical products as they become available to the dermatologic community. This department may include additional information from the manufacturers, plus reports from physicians who wish to share their clinical experience with these new products. In addition, we will inform our readers about the latest drugs receiving Food and Drug Administration (FDA) approval.
Clinical Trial Review is a JDD department designed to provide physicians with information on drugs and devices undergoing clinical testing. It is our goal to inform the reader of the status of select drug and device studies relevant to the practice of dermatology before this information is available through standard channels. To participate in or learn more about these and additional trials, visit www.clinicaltrials.gov.
Background: Discoid lupus erythematosus (DLE) is an inflammatory condition characterized by round demarcated lesions with varying amounts of erythema, telangiectasia, scaling, follicular plugging, dyspigmentation, atrophy, and scarring. Clinical diagnosis can be confirmed through biopsy samples; reflectance confocal microscopy (RCM) is also emerging as an accurate diagnostic tool.
Objective and Methods:Our objective was to examine the features of discoid lupus erythematosus on reflectance confocal microscopy. Two patients presenting with discoid lupus erythematosus were imaged using RCM. Features seen in RCM were correlated with those seen in histopathology.
Results:Reflectance confocal microscopy images of discoid lupus erythematosus yielded features characteristically seen in histopathological samples including inflammatory cells, inflammation at the dermo-epidermal junction, pigment incontinence, and vacuolar degeneration.
Conclusion:Reflectance confocal microscopy is a useful tool in the diagnosis of discoid lupus erythematosus. Features described in these two cases as well as prior research have yielded sufficient data to allow for the formulation of useful RCM diagnostic algorithms. Further studies with a larger patient population will help in confirming and describing new features of DLE on RCM.
J Drugs Dermatol. 2012;11(9):1111-1113.
Antiphospholipid antibody syndrome (APS) results from autoantibodies to cell surface phospholipids or phospholipid-binding proteins resulting in clotting anomalies and can have devastating sequelae, including stroke, deep venous thrombosis, pulmonary embolism, and recurrent spontaneous abortions. However, cutaneous manifestations are the first sign of APS in up to 41% of patients. We present a case report of APS that developed several days after taking trimethoprim/sulfamethoxazole. The clinical and pathological features of this unique presentation, differential diagnoses, and treatments are discussed.
J Drugs Dermatol. 2012;11(9):1117-1118.
Pathergy is a nonspecific response to stimuli seen in a multitude of disease states. We present what we feel is a unique variant of this phenomenon, a case of multiple keratoacanthomas developing following treatment with Fractional CO2. This state of acute tumor emergence, which is similar to an isomorphic response, is believed to be related to changes in both the inflammatory and immune response. It is imperative that one keeps this process in their differential when evaluating a patient that has not only a potential predisposing disease, but also a history of traumatic exposure.
J Drugs Dermatol. 2012;11(9):1122-1123.
Whitney P. Bowe MD, Magdalene A. Dohil MD, Alan C. Logan ND, Andrew F. Alexis MD MPH|This CME supplement reviews the science behind a select group of natural ingredients in the context of treating cosmetic and medical conditions. Dr. Magdalene A. Dohil discusses the data supporting certain natural ingredients in the treatment of atopic dermatitis and a defective skin barrier. Drs. Whitney P. Bowe and Alan C. Logan address the role of antioxidants in acne vulgaris and aging and discuss biologically active ingredients as they relate to the skin. Finally, Dr. Andrew F. Alexis focuses on skin of color and the use of natural ingredients to aid in the management of hyperpigmentation. After reviewing this publication, practitioners should be in a better position to help their patients discriminate potentially effective over-the-counter products from those that lack any scientific basis for their claims. This is a CME supplement; visit the JDD Medical Education Library to participate in this activity and earn 1 AMA PRA Category 1 Credits.