Doug Brunk

PHOENIX — Patients reported less or a comparable amount of pain during needling roller treatment for upper lip rhytids when lidocaine was delivered with a jet-phoresis system, compared with an application of Emla 5% cream, results from a small study of 20 patients showed.

During a poster session at the annual meeting of the American Society for Laser Medicine and Surgery, researchers presented results from a study designed to compare administration of lidocaine with the jet-phoresis system, compared with the topical cream for pain control in patients scheduled for needling roller procedures for upper lip rhytids.

For the study, Dr. Michael Gold, a dermatologist who practices in Nashville, Tenn., and Dr. Ram Burvin, a plastic surgeon who practices in Tel-Aviv, had patients serve as their own control. The mean age of the patients was 56 years, and all were female.

The researchers treated half (left or right) of each patient's upper lip with Emla 5% cream for 45 minutes and the contralateral portion of the lip with lidocaine 3% jet phoresis for 5 minutes. They used a visual analog scale to measure pain elicited by application of a needling roller across the upper lip.

Each patient again served as her own control 12-16 weeks later when the treatments (lidocaine 3% with jet phoresis vs. Emla 5%) were repeated on the opposite lip sides for the same durations, so that in all, there were 40 full-lip applications of the two treatments. Different readings for the left and right sides were registered in some of the patients.

Of the total 40 treatments, pain control with lidocaine 3% with jet phoresis and Emla 5% was comparable in 19 applications, it was better with the lidocaine 3% with jet phoresis in 14 of the applications, and better with Emla 5% in 7 applications

The delivery device, the JetPeel 3, uses pressurized gas at supersonic velocities to deliver saline or other liquid nutrients through special handpieces into the superficial layers of the skin. It was cleared by the Food and Drug Administration in 2006 for delivery of saline into the skin.

The researchers received honoraria from TavTech Ltd., maker of the jet-phoresis system, to conduct the study.

PHOENIX — Patients reported less or a comparable amount of pain during needling roller treatment for upper lip rhytids when lidocaine was delivered with a jet-phoresis system, compared with an application of Emla 5% cream, results from a small study of 20 patients showed.

During a poster session at the annual meeting of the American Society for Laser Medicine and Surgery, researchers presented results from a study designed to compare administration of lidocaine with the jet-phoresis system, compared with the topical cream for pain control in patients scheduled for needling roller procedures for upper lip rhytids.

For the study, Dr. Michael Gold, a dermatologist who practices in Nashville, Tenn., and Dr. Ram Burvin, a plastic surgeon who practices in Tel-Aviv, had patients serve as their own control. The mean age of the patients was 56 years, and all were female.

The researchers treated half (left or right) of each patient's upper lip with Emla 5% cream for 45 minutes and the contralateral portion of the lip with lidocaine 3% jet phoresis for 5 minutes. They used a visual analog scale to measure pain elicited by application of a needling roller across the upper lip.

Each patient again served as her own control 12-16 weeks later when the treatments (lidocaine 3% with jet phoresis vs. Emla 5%) were repeated on the opposite lip sides for the same durations, so that in all, there were 40 full-lip applications of the two treatments. Different readings for the left and right sides were registered in some of the patients.

Of the total 40 treatments, pain control with lidocaine 3% with jet phoresis and Emla 5% was comparable in 19 applications, it was better with the lidocaine 3% with jet phoresis in 14 of the applications, and better with Emla 5% in 7 applications

The delivery device, the JetPeel 3, uses pressurized gas at supersonic velocities to deliver saline or other liquid nutrients through special handpieces into the superficial layers of the skin. It was cleared by the Food and Drug Administration in 2006 for delivery of saline into the skin.

The researchers received honoraria from TavTech Ltd., maker of the jet-phoresis system, to conduct the study.

PHOENIX — Patients reported less or a comparable amount of pain during needling roller treatment for upper lip rhytids when lidocaine was delivered with a jet-phoresis system, compared with an application of Emla 5% cream, results from a small study of 20 patients showed.

During a poster session at the annual meeting of the American Society for Laser Medicine and Surgery, researchers presented results from a study designed to compare administration of lidocaine with the jet-phoresis system, compared with the topical cream for pain control in patients scheduled for needling roller procedures for upper lip rhytids.

For the study, Dr. Michael Gold, a dermatologist who practices in Nashville, Tenn., and Dr. Ram Burvin, a plastic surgeon who practices in Tel-Aviv, had patients serve as their own control. The mean age of the patients was 56 years, and all were female.

The researchers treated half (left or right) of each patient's upper lip with Emla 5% cream for 45 minutes and the contralateral portion of the lip with lidocaine 3% jet phoresis for 5 minutes. They used a visual analog scale to measure pain elicited by application of a needling roller across the upper lip.

Each patient again served as her own control 12-16 weeks later when the treatments (lidocaine 3% with jet phoresis vs. Emla 5%) were repeated on the opposite lip sides for the same durations, so that in all, there were 40 full-lip applications of the two treatments. Different readings for the left and right sides were registered in some of the patients.

Of the total 40 treatments, pain control with lidocaine 3% with jet phoresis and Emla 5% was comparable in 19 applications, it was better with the lidocaine 3% with jet phoresis in 14 of the applications, and better with Emla 5% in 7 applications

The delivery device, the JetPeel 3, uses pressurized gas at supersonic velocities to deliver saline or other liquid nutrients through special handpieces into the superficial layers of the skin. It was cleared by the Food and Drug Administration in 2006 for delivery of saline into the skin.

The researchers received honoraria from TavTech Ltd., maker of the jet-phoresis system, to conduct the study.

PHOENIX — Educate darker skinned patients who seek treatment for acne scars that there is no remedy to make the scars completely disappear.

"Depending on the patient's skin type, the sensitivity of their skin, and how aggressively you treat them, the risk of hyperpigmentation can be relatively modest, or well over 50%. The expected degree of improvement, on the other hand, even with multiple modalities and multiple treatments, is 40%-50%. I think it's very important to explain that," said Dr. Murad Alam at the annual meeting of the American Society for Laser Medicine and Surgery.

Dr. Alam, chief of cutaneous and aesthetic surgery at Northwestern University, Chicago, said that clinicians face certain challenges in treating acne scars in patients of color, including the risk of exacerbation of active acne, risk of focal or diffuse hyperpigmentation or hypopigmentation, risk of nodularity or surface texture change, and risk of minimal effect.

To mitigate risks, Dr. Alam considers oral antibiotics in patients who have any degree of active acne, "even if they get one or two acne pimples once in a blue moon," he said. "If the acne is more than very mild, you may wish to target that as the primary goal and defer treatment of the acne scarring until the acne is under good control."

If the acne is mild, "you can start oral antibiotics at least 1 month before the acne scarring intervention, so they do have something on board to reduce the risk of an acne flare," he said. "You may also consider pretreatment with bleaching agents. I'm personally not that convinced that pre-treatment is that helpful, but post-treatment with bleaching agents is of definite efficacy in mitigating postinflammatory hyperpigmentation."

As for treatment, nonablative resurfacing with mid-infrared lasers, including 1320-nm, 1450-nm, and 1540-nm devices, has been shown to be effective in patients with lighter skin. "This heating process causes collagen remodeling, and can have a modest effect on so-called rolling scars, which can be quite disfiguring," he said.

Another option is ablative resurfacing with non-CO2 fractional lasers such as the 1550-nm laser. "This is one of the most gentle devices in this category, but even so you have risks of postinflammatory hyperpigmentation," Dr. Alam said. "I like to err on the side of being very modest with regard to fluences. It's much better to do more treatments than to push each individual treatment at the risk of having pigmentary abnormalities."

A more aggressive approach is ablative resurfacing with CO2 fractional lasers, which "should be restricted to patients who are of lighter skin type. If they do choose this [modality], they need to understand the significant risk of postinflammatory hyperpigmentation. I would say that virtually every patient of skin of color who undergoes this treatment will have some degree of postinflammatory hyperpigmentation. In some cases they might consider that worth it if it makes their scarring better and if it can be managed after treatment so it eventually goes away."

Perhaps the most beneficial treatment for acne scars in patients of color, Dr. Alam said, is subdermal manipulation.

In one procedure, known as subcision, clinicians insert a needle with a sphere-like tip, often an 18-guage Nokor needle, underneath the skin. "By debriding the underside of the skin, you can cause some of the acne scars to float upward," he explained. "You want to ensure very good hemostasis before doing this—lidocaine with epinephrine—because you want to avoid bruising during the procedure. If done properly, this can result in modest improvement of rolling scars, and it can be done repeatedly."

Dermal fillers can be used as an adjunct. About a month after subcision procedures Dr. Alam considers collagen for fine defects, hyaluronic acid for medium defects, and calcium hydroxylapatite for deeper defects.

The best way to develop a treatment plan for acne scarring, he said, is to assess the patient's commitment to improvement and their tolerance for adverse events.

"How much annoyance and disfigurement are they willing to tolerate?" Dr. Alam asked. "If both of these are low, you might wish to restrict yourself to subcision with or without fillers, because if done properly, that almost eliminates the risk of adverse events like hyperpigmentation, and it does provide some modest improvement with relatively little cost."

If the patient is highly committed to achieving improvement but is wary of adverse events, "then you might consider subcision and fillers, followed by nonablative laser or repeated low energy non-CO2 fractional laser treatments."

In those rare patients with a high tolerance for adverse events, he said, consider CO2 fractional laser treatments "at very modest settings."

Dr. Alam said that he had no relevant financial conflicts.

PHOENIX — Educate darker skinned patients who seek treatment for acne scars that there is no remedy to make the scars completely disappear.

"Depending on the patient's skin type, the sensitivity of their skin, and how aggressively you treat them, the risk of hyperpigmentation can be relatively modest, or well over 50%. The expected degree of improvement, on the other hand, even with multiple modalities and multiple treatments, is 40%-50%. I think it's very important to explain that," said Dr. Murad Alam at the annual meeting of the American Society for Laser Medicine and Surgery.

Dr. Alam, chief of cutaneous and aesthetic surgery at Northwestern University, Chicago, said that clinicians face certain challenges in treating acne scars in patients of color, including the risk of exacerbation of active acne, risk of focal or diffuse hyperpigmentation or hypopigmentation, risk of nodularity or surface texture change, and risk of minimal effect.

To mitigate risks, Dr. Alam considers oral antibiotics in patients who have any degree of active acne, "even if they get one or two acne pimples once in a blue moon," he said. "If the acne is more than very mild, you may wish to target that as the primary goal and defer treatment of the acne scarring until the acne is under good control."

If the acne is mild, "you can start oral antibiotics at least 1 month before the acne scarring intervention, so they do have something on board to reduce the risk of an acne flare," he said. "You may also consider pretreatment with bleaching agents. I'm personally not that convinced that pre-treatment is that helpful, but post-treatment with bleaching agents is of definite efficacy in mitigating postinflammatory hyperpigmentation."

As for treatment, nonablative resurfacing with mid-infrared lasers, including 1320-nm, 1450-nm, and 1540-nm devices, has been shown to be effective in patients with lighter skin. "This heating process causes collagen remodeling, and can have a modest effect on so-called rolling scars, which can be quite disfiguring," he said.

Another option is ablative resurfacing with non-CO2 fractional lasers such as the 1550-nm laser. "This is one of the most gentle devices in this category, but even so you have risks of postinflammatory hyperpigmentation," Dr. Alam said. "I like to err on the side of being very modest with regard to fluences. It's much better to do more treatments than to push each individual treatment at the risk of having pigmentary abnormalities."

A more aggressive approach is ablative resurfacing with CO2 fractional lasers, which "should be restricted to patients who are of lighter skin type. If they do choose this [modality], they need to understand the significant risk of postinflammatory hyperpigmentation. I would say that virtually every patient of skin of color who undergoes this treatment will have some degree of postinflammatory hyperpigmentation. In some cases they might consider that worth it if it makes their scarring better and if it can be managed after treatment so it eventually goes away."

Perhaps the most beneficial treatment for acne scars in patients of color, Dr. Alam said, is subdermal manipulation.

In one procedure, known as subcision, clinicians insert a needle with a sphere-like tip, often an 18-guage Nokor needle, underneath the skin. "By debriding the underside of the skin, you can cause some of the acne scars to float upward," he explained. "You want to ensure very good hemostasis before doing this—lidocaine with epinephrine—because you want to avoid bruising during the procedure. If done properly, this can result in modest improvement of rolling scars, and it can be done repeatedly."

Dermal fillers can be used as an adjunct. About a month after subcision procedures Dr. Alam considers collagen for fine defects, hyaluronic acid for medium defects, and calcium hydroxylapatite for deeper defects.

The best way to develop a treatment plan for acne scarring, he said, is to assess the patient's commitment to improvement and their tolerance for adverse events.

"How much annoyance and disfigurement are they willing to tolerate?" Dr. Alam asked. "If both of these are low, you might wish to restrict yourself to subcision with or without fillers, because if done properly, that almost eliminates the risk of adverse events like hyperpigmentation, and it does provide some modest improvement with relatively little cost."

If the patient is highly committed to achieving improvement but is wary of adverse events, "then you might consider subcision and fillers, followed by nonablative laser or repeated low energy non-CO2 fractional laser treatments."

In those rare patients with a high tolerance for adverse events, he said, consider CO2 fractional laser treatments "at very modest settings."

Dr. Alam said that he had no relevant financial conflicts.

PHOENIX — Educate darker skinned patients who seek treatment for acne scars that there is no remedy to make the scars completely disappear.

"Depending on the patient's skin type, the sensitivity of their skin, and how aggressively you treat them, the risk of hyperpigmentation can be relatively modest, or well over 50%. The expected degree of improvement, on the other hand, even with multiple modalities and multiple treatments, is 40%-50%. I think it's very important to explain that," said Dr. Murad Alam at the annual meeting of the American Society for Laser Medicine and Surgery.

Dr. Alam, chief of cutaneous and aesthetic surgery at Northwestern University, Chicago, said that clinicians face certain challenges in treating acne scars in patients of color, including the risk of exacerbation of active acne, risk of focal or diffuse hyperpigmentation or hypopigmentation, risk of nodularity or surface texture change, and risk of minimal effect.

To mitigate risks, Dr. Alam considers oral antibiotics in patients who have any degree of active acne, "even if they get one or two acne pimples once in a blue moon," he said. "If the acne is more than very mild, you may wish to target that as the primary goal and defer treatment of the acne scarring until the acne is under good control."

If the acne is mild, "you can start oral antibiotics at least 1 month before the acne scarring intervention, so they do have something on board to reduce the risk of an acne flare," he said. "You may also consider pretreatment with bleaching agents. I'm personally not that convinced that pre-treatment is that helpful, but post-treatment with bleaching agents is of definite efficacy in mitigating postinflammatory hyperpigmentation."

As for treatment, nonablative resurfacing with mid-infrared lasers, including 1320-nm, 1450-nm, and 1540-nm devices, has been shown to be effective in patients with lighter skin. "This heating process causes collagen remodeling, and can have a modest effect on so-called rolling scars, which can be quite disfiguring," he said.

Another option is ablative resurfacing with non-CO2 fractional lasers such as the 1550-nm laser. "This is one of the most gentle devices in this category, but even so you have risks of postinflammatory hyperpigmentation," Dr. Alam said. "I like to err on the side of being very modest with regard to fluences. It's much better to do more treatments than to push each individual treatment at the risk of having pigmentary abnormalities."

A more aggressive approach is ablative resurfacing with CO2 fractional lasers, which "should be restricted to patients who are of lighter skin type. If they do choose this [modality], they need to understand the significant risk of postinflammatory hyperpigmentation. I would say that virtually every patient of skin of color who undergoes this treatment will have some degree of postinflammatory hyperpigmentation. In some cases they might consider that worth it if it makes their scarring better and if it can be managed after treatment so it eventually goes away."

Perhaps the most beneficial treatment for acne scars in patients of color, Dr. Alam said, is subdermal manipulation.

In one procedure, known as subcision, clinicians insert a needle with a sphere-like tip, often an 18-guage Nokor needle, underneath the skin. "By debriding the underside of the skin, you can cause some of the acne scars to float upward," he explained. "You want to ensure very good hemostasis before doing this—lidocaine with epinephrine—because you want to avoid bruising during the procedure. If done properly, this can result in modest improvement of rolling scars, and it can be done repeatedly."

Dermal fillers can be used as an adjunct. About a month after subcision procedures Dr. Alam considers collagen for fine defects, hyaluronic acid for medium defects, and calcium hydroxylapatite for deeper defects.

The best way to develop a treatment plan for acne scarring, he said, is to assess the patient's commitment to improvement and their tolerance for adverse events.

"How much annoyance and disfigurement are they willing to tolerate?" Dr. Alam asked. "If both of these are low, you might wish to restrict yourself to subcision with or without fillers, because if done properly, that almost eliminates the risk of adverse events like hyperpigmentation, and it does provide some modest improvement with relatively little cost."

If the patient is highly committed to achieving improvement but is wary of adverse events, "then you might consider subcision and fillers, followed by nonablative laser or repeated low energy non-CO2 fractional laser treatments."

In those rare patients with a high tolerance for adverse events, he said, consider CO2 fractional laser treatments "at very modest settings."

Dr. Alam said that he had no relevant financial conflicts.

Major Finding: The overall diagnostic accuracy of preoperative axillary ultrasound for determining lymph node status in early-stage breast cancer patients was 73%.

Data Source: Single-center study of 319 patients with early-stage breast cancer.

Disclosures: None was reported.

ST. LOUIS — The overall diagnostic accuracy of preoperative axillary ultrasound for determining lymph node status in early-stage breast cancer patients was 73%, results from a single-center study have shown.

The method might have spared 14% of patients from having to undergo a sentinel lymph node biopsy, allowing them to proceed directly to axillary node dissection, Dr. Jonathan Cools-Lartigue reported during a poster session at the symposium.

Although sentinel lymph node biopsy is considered the standard of care in the operative management of breast cancer, it comes with its share of drawbacks, said Dr. Cools-Lartigue, a first-year resident in the department of general surgery at McGill University Health Centre, Montreal. For example, having a falsely negative sentinel lymph node biopsy on frozen section “may result in having to subject the patient to a second procedure, and the costs associated with that. Ultrasound—particularly when combined with fine-needle aspiration—provides a potential opportunity to streamline an algorithm for care of patients.”

For the study, he and his associates evaluated clinical, imaging, and laboratory data from 319 consecutive patients with early-stage breast cancer who underwent preoperative axillary ultrasound evaluation at McGill between 2005 and 2007. “All patients with primary breast cancer referred to our center routinely receive axillary ultrasound,” Dr. Cools-Lartigue said. “We didn't select patients based on the degree of disease we [thought] that they had. We took all comers.”

The median age of the 319 patients was 58 years, 67% of patients had ductal disease, 80% were estrogen-receptor positive, 61% were progesterone-receptor positive, 11% were human epidermal growth factor receptor 2 (HER2/neu) positive, and 45% had positive axillary nodes.

The sensitivity and specificity values for any ultrasound abnormality in identifying nodal metastases were 54% and 89%, respectively, while the positive and negative predictive values of ultrasound in the diagnosis of nodal metastases were 80% and 70%, respectively. The overall accuracy was 73%.

The diagnostic accuracy improved with a higher number of positive lymph nodes (greater than 3 vs. fewer than 3) and a larger size of metastatic disease (greater than 2 mm vs. less than 2 mm).

Certain clinical and pathologic factors were associated with having abnormal ultrasound findings, including the number of involved nodes, estrogen receptor and HER2/neu positivity, size of metastasis, presence of lymphovascular invasion, and tumor grade. “Those are interesting results,” Dr. Cools-Lartigue commented. “I think they reflect the biology of the malignancy. More aggressive malignancies are likely to be associated with an abnormal ultrasound, compared [with] less aggressive malignancies.”

A subset analysis of 75 patients who had undergone concomitant fine-needle aspiration revealed that 61% had nodal metastases, with a positive predictive value of 100%.

Fine-needle aspiration was more likely to be positive with increasing tumor size. It also had an accuracy of 80% when combined with ultrasound.

Dr. Cools-Lartigue acknowledged certain limitations of the study including its single-center design and that fact that it included patients with all types of early-stage breast cancer. “Because we looked at all comers, the sensitivity was lower than what has been seen in other studies.”

Major Finding: The overall diagnostic accuracy of preoperative axillary ultrasound for determining lymph node status in early-stage breast cancer patients was 73%.

Data Source: Single-center study of 319 patients with early-stage breast cancer.

Disclosures: None was reported.

ST. LOUIS — The overall diagnostic accuracy of preoperative axillary ultrasound for determining lymph node status in early-stage breast cancer patients was 73%, results from a single-center study have shown.

The method might have spared 14% of patients from having to undergo a sentinel lymph node biopsy, allowing them to proceed directly to axillary node dissection, Dr. Jonathan Cools-Lartigue reported during a poster session at the symposium.

Although sentinel lymph node biopsy is considered the standard of care in the operative management of breast cancer, it comes with its share of drawbacks, said Dr. Cools-Lartigue, a first-year resident in the department of general surgery at McGill University Health Centre, Montreal. For example, having a falsely negative sentinel lymph node biopsy on frozen section “may result in having to subject the patient to a second procedure, and the costs associated with that. Ultrasound—particularly when combined with fine-needle aspiration—provides a potential opportunity to streamline an algorithm for care of patients.”

For the study, he and his associates evaluated clinical, imaging, and laboratory data from 319 consecutive patients with early-stage breast cancer who underwent preoperative axillary ultrasound evaluation at McGill between 2005 and 2007. “All patients with primary breast cancer referred to our center routinely receive axillary ultrasound,” Dr. Cools-Lartigue said. “We didn't select patients based on the degree of disease we [thought] that they had. We took all comers.”

The median age of the 319 patients was 58 years, 67% of patients had ductal disease, 80% were estrogen-receptor positive, 61% were progesterone-receptor positive, 11% were human epidermal growth factor receptor 2 (HER2/neu) positive, and 45% had positive axillary nodes.

The sensitivity and specificity values for any ultrasound abnormality in identifying nodal metastases were 54% and 89%, respectively, while the positive and negative predictive values of ultrasound in the diagnosis of nodal metastases were 80% and 70%, respectively. The overall accuracy was 73%.

The diagnostic accuracy improved with a higher number of positive lymph nodes (greater than 3 vs. fewer than 3) and a larger size of metastatic disease (greater than 2 mm vs. less than 2 mm).

Certain clinical and pathologic factors were associated with having abnormal ultrasound findings, including the number of involved nodes, estrogen receptor and HER2/neu positivity, size of metastasis, presence of lymphovascular invasion, and tumor grade. “Those are interesting results,” Dr. Cools-Lartigue commented. “I think they reflect the biology of the malignancy. More aggressive malignancies are likely to be associated with an abnormal ultrasound, compared [with] less aggressive malignancies.”

A subset analysis of 75 patients who had undergone concomitant fine-needle aspiration revealed that 61% had nodal metastases, with a positive predictive value of 100%.

Fine-needle aspiration was more likely to be positive with increasing tumor size. It also had an accuracy of 80% when combined with ultrasound.

Dr. Cools-Lartigue acknowledged certain limitations of the study including its single-center design and that fact that it included patients with all types of early-stage breast cancer. “Because we looked at all comers, the sensitivity was lower than what has been seen in other studies.”

Major Finding: The overall diagnostic accuracy of preoperative axillary ultrasound for determining lymph node status in early-stage breast cancer patients was 73%.

Data Source: Single-center study of 319 patients with early-stage breast cancer.

Disclosures: None was reported.

ST. LOUIS — The overall diagnostic accuracy of preoperative axillary ultrasound for determining lymph node status in early-stage breast cancer patients was 73%, results from a single-center study have shown.

The method might have spared 14% of patients from having to undergo a sentinel lymph node biopsy, allowing them to proceed directly to axillary node dissection, Dr. Jonathan Cools-Lartigue reported during a poster session at the symposium.

Although sentinel lymph node biopsy is considered the standard of care in the operative management of breast cancer, it comes with its share of drawbacks, said Dr. Cools-Lartigue, a first-year resident in the department of general surgery at McGill University Health Centre, Montreal. For example, having a falsely negative sentinel lymph node biopsy on frozen section “may result in having to subject the patient to a second procedure, and the costs associated with that. Ultrasound—particularly when combined with fine-needle aspiration—provides a potential opportunity to streamline an algorithm for care of patients.”

For the study, he and his associates evaluated clinical, imaging, and laboratory data from 319 consecutive patients with early-stage breast cancer who underwent preoperative axillary ultrasound evaluation at McGill between 2005 and 2007. “All patients with primary breast cancer referred to our center routinely receive axillary ultrasound,” Dr. Cools-Lartigue said. “We didn't select patients based on the degree of disease we [thought] that they had. We took all comers.”

The median age of the 319 patients was 58 years, 67% of patients had ductal disease, 80% were estrogen-receptor positive, 61% were progesterone-receptor positive, 11% were human epidermal growth factor receptor 2 (HER2/neu) positive, and 45% had positive axillary nodes.

The sensitivity and specificity values for any ultrasound abnormality in identifying nodal metastases were 54% and 89%, respectively, while the positive and negative predictive values of ultrasound in the diagnosis of nodal metastases were 80% and 70%, respectively. The overall accuracy was 73%.

The diagnostic accuracy improved with a higher number of positive lymph nodes (greater than 3 vs. fewer than 3) and a larger size of metastatic disease (greater than 2 mm vs. less than 2 mm).

Certain clinical and pathologic factors were associated with having abnormal ultrasound findings, including the number of involved nodes, estrogen receptor and HER2/neu positivity, size of metastasis, presence of lymphovascular invasion, and tumor grade. “Those are interesting results,” Dr. Cools-Lartigue commented. “I think they reflect the biology of the malignancy. More aggressive malignancies are likely to be associated with an abnormal ultrasound, compared [with] less aggressive malignancies.”

A subset analysis of 75 patients who had undergone concomitant fine-needle aspiration revealed that 61% had nodal metastases, with a positive predictive value of 100%.

Fine-needle aspiration was more likely to be positive with increasing tumor size. It also had an accuracy of 80% when combined with ultrasound.

Dr. Cools-Lartigue acknowledged certain limitations of the study including its single-center design and that fact that it included patients with all types of early-stage breast cancer. “Because we looked at all comers, the sensitivity was lower than what has been seen in other studies.”

Major Finding: Transvaginal ultrasound missed 46% of endometrial polyps that were seen on sonohysterography.

Data Source: A single-center, blinded retrospective case study of 800 women with endometrial polyps.

Disclosures: None was reported.

SAN DIEGO — Almost half of endometrial polyps seen on sonohysterography were missed on transvaginal ultrasound, results from a large single-center study showed.

The factors associated with lack of detection on ultrasound included smaller polyp size, multiplicity, submucosal fibroids, location of polyps, and blood flow to the polyps, Dr. Alex Hartman said at the meeting.

Between January and May of 2009, Dr. Hartman and his associates performed a blinded retrospective case study of 800 consecutive patients (mean age, 48 years) diagnosed with endometrial polyps on sonohysterography who also had preliminary transvaginal ultrasound within 48 hours of the sonohysterography.

The researchers assessed multiple factors, including patient age, size of the polyp, number of polyps, submucosal fibroids, intramural fibroids, adenomyosis, location of the polyp, and blood flow. Pearson's chi-square tests and t-tests were used to compare the two samples.

Dr. Hartman, medical director of True North Imaging in Thornhill, Ont., reported that 433 patients (54%)with polyps diagnosed on ultrasound had their polyps seen on transvaginal ultrasound.

The factors significantly associated with detection of a polyp on preliminary transvaginal ultrasound included larger polyp size (in general, the larger, the more likely seen); the presence of multiple polyps; the absence of submucosal fibroids; fundal location of the polyp; and the presence of blood flow to the polyp.

“Over the years, we found that polyps that were located in the fundus were much easier to see,” Dr. Hartman commented. “The ones that were confined to the lower uterine segment and midbody were much harder to detect.”

He also noted that 39 of the 800 patients (5%) also had submucosal fibroids. “

“Interestingly, only one-third of the polyps in these patients were diagnosed in the preliminary ultrasound study,” Dr. Hartman said.

“So the presence of submucosal fibroids made it very difficult to see polyps on regular ultrasound,” he added.

Factors that were not significantly associated with the detection of a polyp on preliminary transvaginal ultrasound were age, endometrial thickness, adenomyosis, polycystic ovaries, abnormal bleeding, and fertility status.

Sonohysterogram of a polyp: The blue and red represent blood flow. A large artery goes through the polyp's center.

Source Courtesy Dr. Alex Hartman

Major Finding: Transvaginal ultrasound missed 46% of endometrial polyps that were seen on sonohysterography.

Data Source: A single-center, blinded retrospective case study of 800 women with endometrial polyps.

Disclosures: None was reported.

SAN DIEGO — Almost half of endometrial polyps seen on sonohysterography were missed on transvaginal ultrasound, results from a large single-center study showed.

The factors associated with lack of detection on ultrasound included smaller polyp size, multiplicity, submucosal fibroids, location of polyps, and blood flow to the polyps, Dr. Alex Hartman said at the meeting.

Between January and May of 2009, Dr. Hartman and his associates performed a blinded retrospective case study of 800 consecutive patients (mean age, 48 years) diagnosed with endometrial polyps on sonohysterography who also had preliminary transvaginal ultrasound within 48 hours of the sonohysterography.

The researchers assessed multiple factors, including patient age, size of the polyp, number of polyps, submucosal fibroids, intramural fibroids, adenomyosis, location of the polyp, and blood flow. Pearson's chi-square tests and t-tests were used to compare the two samples.

Dr. Hartman, medical director of True North Imaging in Thornhill, Ont., reported that 433 patients (54%)with polyps diagnosed on ultrasound had their polyps seen on transvaginal ultrasound.

The factors significantly associated with detection of a polyp on preliminary transvaginal ultrasound included larger polyp size (in general, the larger, the more likely seen); the presence of multiple polyps; the absence of submucosal fibroids; fundal location of the polyp; and the presence of blood flow to the polyp.

“Over the years, we found that polyps that were located in the fundus were much easier to see,” Dr. Hartman commented. “The ones that were confined to the lower uterine segment and midbody were much harder to detect.”

He also noted that 39 of the 800 patients (5%) also had submucosal fibroids. “

“Interestingly, only one-third of the polyps in these patients were diagnosed in the preliminary ultrasound study,” Dr. Hartman said.

“So the presence of submucosal fibroids made it very difficult to see polyps on regular ultrasound,” he added.

Factors that were not significantly associated with the detection of a polyp on preliminary transvaginal ultrasound were age, endometrial thickness, adenomyosis, polycystic ovaries, abnormal bleeding, and fertility status.

Sonohysterogram of a polyp: The blue and red represent blood flow. A large artery goes through the polyp's center.

Source Courtesy Dr. Alex Hartman

Major Finding: Transvaginal ultrasound missed 46% of endometrial polyps that were seen on sonohysterography.

Data Source: A single-center, blinded retrospective case study of 800 women with endometrial polyps.

Disclosures: None was reported.

SAN DIEGO — Almost half of endometrial polyps seen on sonohysterography were missed on transvaginal ultrasound, results from a large single-center study showed.

The factors associated with lack of detection on ultrasound included smaller polyp size, multiplicity, submucosal fibroids, location of polyps, and blood flow to the polyps, Dr. Alex Hartman said at the meeting.

Between January and May of 2009, Dr. Hartman and his associates performed a blinded retrospective case study of 800 consecutive patients (mean age, 48 years) diagnosed with endometrial polyps on sonohysterography who also had preliminary transvaginal ultrasound within 48 hours of the sonohysterography.

The researchers assessed multiple factors, including patient age, size of the polyp, number of polyps, submucosal fibroids, intramural fibroids, adenomyosis, location of the polyp, and blood flow. Pearson's chi-square tests and t-tests were used to compare the two samples.

Dr. Hartman, medical director of True North Imaging in Thornhill, Ont., reported that 433 patients (54%)with polyps diagnosed on ultrasound had their polyps seen on transvaginal ultrasound.

The factors significantly associated with detection of a polyp on preliminary transvaginal ultrasound included larger polyp size (in general, the larger, the more likely seen); the presence of multiple polyps; the absence of submucosal fibroids; fundal location of the polyp; and the presence of blood flow to the polyp.

“Over the years, we found that polyps that were located in the fundus were much easier to see,” Dr. Hartman commented. “The ones that were confined to the lower uterine segment and midbody were much harder to detect.”

He also noted that 39 of the 800 patients (5%) also had submucosal fibroids. “

“Interestingly, only one-third of the polyps in these patients were diagnosed in the preliminary ultrasound study,” Dr. Hartman said.

“So the presence of submucosal fibroids made it very difficult to see polyps on regular ultrasound,” he added.

Factors that were not significantly associated with the detection of a polyp on preliminary transvaginal ultrasound were age, endometrial thickness, adenomyosis, polycystic ovaries, abnormal bleeding, and fertility status.

Sonohysterogram of a polyp: The blue and red represent blood flow. A large artery goes through the polyp's center.

Source Courtesy Dr. Alex Hartman

Major Finding: Obese patients referred for inadequate pelvic examinations were significantly less likely than nonobese patients to have a complete ultrasound assessment (62% vs. 81%), yet they were significantly more likely to have abnormal findings detected on ultrasound (48% vs. 22%).

Data Source: A single-center study of 103 patients referred specifically for inadequate pelvic examinations.

Disclosures: None was reported.

SAN DIEGO — Ultrasound is a useful adjunct for completing difficult pelvic examinations, especially when obesity is present, results from a single-center study showed.

“Obesity is one of the leading health care concerns in the United States,” Dr. Francisco Cruz-Pachano said at the meeting. According to the Centers for Disease Control and Prevention, one-third of adults in the United States are obese, and more than 40% of childbearing women aged 15-49 years are overweight or obese. The condition has been linked multiple times to a difficult pelvic exam.

Other factors that may complicate routine pelvic exams, he said, include increasing rates of abdominal plastic surgery, extremes of age, and history of radiation to the abdomen or pelvis.

In an effort to analyze the findings encountered on sonographic evaluations done secondary to difficult pelvic examinations, Dr. Cruz-Pachano and his associates reviewed the charts of 3,400 patients who visited the ultrasound division of the department of obstetrics and gynecology at the University of Miami between August 2007 and August 2009. Of these patients, 103 (3%) were referred specifically for inadequate pelvic examinations.

“This translates into 1-10 patients per month, depending on how busy a practice is,” he said.

The mean age of the 103 patients was 50 years, 37% were black, 37% were Hispanic, and 26% were white. Their mean body mass index was 33 kg/m

When the chief complaint of patients was analyzed, 57 (55%) were seen for a routine exam while the remaining 46 (45%) had different complaints including pelvic pain, abnormal uterine bleeding, and urinary dysfunction.

Nearly two-thirds of the ultrasound exams (69%) were found to be normal. But the ovaries were not detectable on ultrasound 25% of the time. The most common findings on ultrasound were fibroids (17%) and ovarian cysts (15%).

When the researchers compared obese patients with nonobese patients, they found that obese patients were significantly less likely to have a complete ultrasound assessment (62% vs. 81%), yet they were significantly more likely to have abnormal findings detected on ultrasound (48% vs. 22%).

“We have to counsel obese patients that because of their body habitus, they have an increased chance of having an incomplete pelvic assessment and an increased chance of having findings on ultrasound,” Dr Cruz-Pachano concluded.

Major Finding: Obese patients referred for inadequate pelvic examinations were significantly less likely than nonobese patients to have a complete ultrasound assessment (62% vs. 81%), yet they were significantly more likely to have abnormal findings detected on ultrasound (48% vs. 22%).

Data Source: A single-center study of 103 patients referred specifically for inadequate pelvic examinations.

Disclosures: None was reported.

SAN DIEGO — Ultrasound is a useful adjunct for completing difficult pelvic examinations, especially when obesity is present, results from a single-center study showed.

“Obesity is one of the leading health care concerns in the United States,” Dr. Francisco Cruz-Pachano said at the meeting. According to the Centers for Disease Control and Prevention, one-third of adults in the United States are obese, and more than 40% of childbearing women aged 15-49 years are overweight or obese. The condition has been linked multiple times to a difficult pelvic exam.

Other factors that may complicate routine pelvic exams, he said, include increasing rates of abdominal plastic surgery, extremes of age, and history of radiation to the abdomen or pelvis.

In an effort to analyze the findings encountered on sonographic evaluations done secondary to difficult pelvic examinations, Dr. Cruz-Pachano and his associates reviewed the charts of 3,400 patients who visited the ultrasound division of the department of obstetrics and gynecology at the University of Miami between August 2007 and August 2009. Of these patients, 103 (3%) were referred specifically for inadequate pelvic examinations.

“This translates into 1-10 patients per month, depending on how busy a practice is,” he said.

The mean age of the 103 patients was 50 years, 37% were black, 37% were Hispanic, and 26% were white. Their mean body mass index was 33 kg/m

When the chief complaint of patients was analyzed, 57 (55%) were seen for a routine exam while the remaining 46 (45%) had different complaints including pelvic pain, abnormal uterine bleeding, and urinary dysfunction.

Nearly two-thirds of the ultrasound exams (69%) were found to be normal. But the ovaries were not detectable on ultrasound 25% of the time. The most common findings on ultrasound were fibroids (17%) and ovarian cysts (15%).

When the researchers compared obese patients with nonobese patients, they found that obese patients were significantly less likely to have a complete ultrasound assessment (62% vs. 81%), yet they were significantly more likely to have abnormal findings detected on ultrasound (48% vs. 22%).

“We have to counsel obese patients that because of their body habitus, they have an increased chance of having an incomplete pelvic assessment and an increased chance of having findings on ultrasound,” Dr Cruz-Pachano concluded.

Major Finding: Obese patients referred for inadequate pelvic examinations were significantly less likely than nonobese patients to have a complete ultrasound assessment (62% vs. 81%), yet they were significantly more likely to have abnormal findings detected on ultrasound (48% vs. 22%).

Data Source: A single-center study of 103 patients referred specifically for inadequate pelvic examinations.

Disclosures: None was reported.

SAN DIEGO — Ultrasound is a useful adjunct for completing difficult pelvic examinations, especially when obesity is present, results from a single-center study showed.

“Obesity is one of the leading health care concerns in the United States,” Dr. Francisco Cruz-Pachano said at the meeting. According to the Centers for Disease Control and Prevention, one-third of adults in the United States are obese, and more than 40% of childbearing women aged 15-49 years are overweight or obese. The condition has been linked multiple times to a difficult pelvic exam.

Other factors that may complicate routine pelvic exams, he said, include increasing rates of abdominal plastic surgery, extremes of age, and history of radiation to the abdomen or pelvis.

In an effort to analyze the findings encountered on sonographic evaluations done secondary to difficult pelvic examinations, Dr. Cruz-Pachano and his associates reviewed the charts of 3,400 patients who visited the ultrasound division of the department of obstetrics and gynecology at the University of Miami between August 2007 and August 2009. Of these patients, 103 (3%) were referred specifically for inadequate pelvic examinations.

“This translates into 1-10 patients per month, depending on how busy a practice is,” he said.

The mean age of the 103 patients was 50 years, 37% were black, 37% were Hispanic, and 26% were white. Their mean body mass index was 33 kg/m

When the chief complaint of patients was analyzed, 57 (55%) were seen for a routine exam while the remaining 46 (45%) had different complaints including pelvic pain, abnormal uterine bleeding, and urinary dysfunction.

Nearly two-thirds of the ultrasound exams (69%) were found to be normal. But the ovaries were not detectable on ultrasound 25% of the time. The most common findings on ultrasound were fibroids (17%) and ovarian cysts (15%).

When the researchers compared obese patients with nonobese patients, they found that obese patients were significantly less likely to have a complete ultrasound assessment (62% vs. 81%), yet they were significantly more likely to have abnormal findings detected on ultrasound (48% vs. 22%).

“We have to counsel obese patients that because of their body habitus, they have an increased chance of having an incomplete pelvic assessment and an increased chance of having findings on ultrasound,” Dr Cruz-Pachano concluded.

Major Finding: All seven fetuses with fetal sacral appendages had significant associated anomalies, and only one is surviving.

Data Source: A single-center study of seven fetuses with fetal sacral appendages evaluated over a 9-year period.

Disclosures: None was reported.

SAN DIEGO — A fetal sacral appendage carries a guarded prognosis, especially in the setting of associated anomalies, results from a single-center study demonstrated.

“Fetal sonography is still the primary mode for identifying the extension,” Lori J. Dobson said during the meeting. “It is important to measure fetal growth and look at the umbilical cord Doppler [scans], as well as to survey for additional anomalies. We did show that it is important to do a fetal MRI as it can help identify additional anomalies and help determine the position of the spinal cord conus.”

A fetal sacral appendage—also referred to as a fetal “tail”—is part of normal embryonic development, expected to resolve by the 8th week of gestation. While more than 30 published studies of prenatally diagnosed fetal sacral appendages have appeared in the medical literature, “the majority of cases are isolated, with no other structural anomalies reported,” said Ms. Dobson, a certified genetic counselor in the advanced fetal care center at Children's Hospital Boston. “And in most cases the appendage had resolved by the second trimester.”

She and her coinvestigators, some of whom performed fetal imaging, set out to describe the associated anomalies, etiology, and clinical outcome for a subset of the 3,641 patients evaluated at the hospital's advanced fetal care center over a 9-year period that ended in December 2009. Ms. Dobson reported that of the 3,641 patients, 7 fetuses (0.19%) had sacral appendages that ranged in size from 2.1 to 4.5 mm. The researchers assessed findings on fetal sonography and fetal MRI, results of genetic testing, and clinical outcomes.

“We noted that in all seven cases there was an extension of the coccyx causing a protrusion or a tenting of the skin,” she said. “Based on this, we propose the term sacrococcygeal extension to better describe the physical finding and its etiology. This is also a more patient-friendly term than fetal tail to use in counseling with parents.”

The average gestational age at diagnosis was 19 weeks. “Because we are a tertiary care referral center, it is not uncommon for us to only see patients in the second trimester or after,” she noted. “That may represent a bias in our sample. We did not have any cases that were diagnosed in the first or third trimester.”

All seven of the fetuses with sacral appendages had significant associated anomalies including severe growth restriction and neurologic, spinal, craniofacial, cardiac, renal, and musculoskeletal abnormalities. There were two cases of trisomy 13 and one case of Pfeiffer syndrome (craniosynostosis). “Most of our cases had multiple organ systems involved,” Ms. Dobson said.

She went on to report that three of the fetuses died in utero, two underwent elective termination, and one fetus with trisomy 13 was delivered at 36 weeks' gestation and died on the first day of life. The remaining case carried to term, and the infant is doing well at 5 months old, but does have a sacral appendage with a tethered spinal cord and an abnormal distal spine.

This sagittal view shows a fetal sacrococcygeal extension on ultrasound at 19 weeks', 4 days' gestation.

Source Courtesy Lori J. Dobson

Major Finding: All seven fetuses with fetal sacral appendages had significant associated anomalies, and only one is surviving.

Data Source: A single-center study of seven fetuses with fetal sacral appendages evaluated over a 9-year period.

Disclosures: None was reported.

SAN DIEGO — A fetal sacral appendage carries a guarded prognosis, especially in the setting of associated anomalies, results from a single-center study demonstrated.

“Fetal sonography is still the primary mode for identifying the extension,” Lori J. Dobson said during the meeting. “It is important to measure fetal growth and look at the umbilical cord Doppler [scans], as well as to survey for additional anomalies. We did show that it is important to do a fetal MRI as it can help identify additional anomalies and help determine the position of the spinal cord conus.”

A fetal sacral appendage—also referred to as a fetal “tail”—is part of normal embryonic development, expected to resolve by the 8th week of gestation. While more than 30 published studies of prenatally diagnosed fetal sacral appendages have appeared in the medical literature, “the majority of cases are isolated, with no other structural anomalies reported,” said Ms. Dobson, a certified genetic counselor in the advanced fetal care center at Children's Hospital Boston. “And in most cases the appendage had resolved by the second trimester.”

She and her coinvestigators, some of whom performed fetal imaging, set out to describe the associated anomalies, etiology, and clinical outcome for a subset of the 3,641 patients evaluated at the hospital's advanced fetal care center over a 9-year period that ended in December 2009. Ms. Dobson reported that of the 3,641 patients, 7 fetuses (0.19%) had sacral appendages that ranged in size from 2.1 to 4.5 mm. The researchers assessed findings on fetal sonography and fetal MRI, results of genetic testing, and clinical outcomes.

“We noted that in all seven cases there was an extension of the coccyx causing a protrusion or a tenting of the skin,” she said. “Based on this, we propose the term sacrococcygeal extension to better describe the physical finding and its etiology. This is also a more patient-friendly term than fetal tail to use in counseling with parents.”

The average gestational age at diagnosis was 19 weeks. “Because we are a tertiary care referral center, it is not uncommon for us to only see patients in the second trimester or after,” she noted. “That may represent a bias in our sample. We did not have any cases that were diagnosed in the first or third trimester.”

All seven of the fetuses with sacral appendages had significant associated anomalies including severe growth restriction and neurologic, spinal, craniofacial, cardiac, renal, and musculoskeletal abnormalities. There were two cases of trisomy 13 and one case of Pfeiffer syndrome (craniosynostosis). “Most of our cases had multiple organ systems involved,” Ms. Dobson said.

She went on to report that three of the fetuses died in utero, two underwent elective termination, and one fetus with trisomy 13 was delivered at 36 weeks' gestation and died on the first day of life. The remaining case carried to term, and the infant is doing well at 5 months old, but does have a sacral appendage with a tethered spinal cord and an abnormal distal spine.

This sagittal view shows a fetal sacrococcygeal extension on ultrasound at 19 weeks', 4 days' gestation.

Source Courtesy Lori J. Dobson

Major Finding: All seven fetuses with fetal sacral appendages had significant associated anomalies, and only one is surviving.

Data Source: A single-center study of seven fetuses with fetal sacral appendages evaluated over a 9-year period.

Disclosures: None was reported.

SAN DIEGO — A fetal sacral appendage carries a guarded prognosis, especially in the setting of associated anomalies, results from a single-center study demonstrated.

“Fetal sonography is still the primary mode for identifying the extension,” Lori J. Dobson said during the meeting. “It is important to measure fetal growth and look at the umbilical cord Doppler [scans], as well as to survey for additional anomalies. We did show that it is important to do a fetal MRI as it can help identify additional anomalies and help determine the position of the spinal cord conus.”

A fetal sacral appendage—also referred to as a fetal “tail”—is part of normal embryonic development, expected to resolve by the 8th week of gestation. While more than 30 published studies of prenatally diagnosed fetal sacral appendages have appeared in the medical literature, “the majority of cases are isolated, with no other structural anomalies reported,” said Ms. Dobson, a certified genetic counselor in the advanced fetal care center at Children's Hospital Boston. “And in most cases the appendage had resolved by the second trimester.”

She and her coinvestigators, some of whom performed fetal imaging, set out to describe the associated anomalies, etiology, and clinical outcome for a subset of the 3,641 patients evaluated at the hospital's advanced fetal care center over a 9-year period that ended in December 2009. Ms. Dobson reported that of the 3,641 patients, 7 fetuses (0.19%) had sacral appendages that ranged in size from 2.1 to 4.5 mm. The researchers assessed findings on fetal sonography and fetal MRI, results of genetic testing, and clinical outcomes.

“We noted that in all seven cases there was an extension of the coccyx causing a protrusion or a tenting of the skin,” she said. “Based on this, we propose the term sacrococcygeal extension to better describe the physical finding and its etiology. This is also a more patient-friendly term than fetal tail to use in counseling with parents.”

The average gestational age at diagnosis was 19 weeks. “Because we are a tertiary care referral center, it is not uncommon for us to only see patients in the second trimester or after,” she noted. “That may represent a bias in our sample. We did not have any cases that were diagnosed in the first or third trimester.”

All seven of the fetuses with sacral appendages had significant associated anomalies including severe growth restriction and neurologic, spinal, craniofacial, cardiac, renal, and musculoskeletal abnormalities. There were two cases of trisomy 13 and one case of Pfeiffer syndrome (craniosynostosis). “Most of our cases had multiple organ systems involved,” Ms. Dobson said.

She went on to report that three of the fetuses died in utero, two underwent elective termination, and one fetus with trisomy 13 was delivered at 36 weeks' gestation and died on the first day of life. The remaining case carried to term, and the infant is doing well at 5 months old, but does have a sacral appendage with a tethered spinal cord and an abnormal distal spine.

This sagittal view shows a fetal sacrococcygeal extension on ultrasound at 19 weeks', 4 days' gestation.

Source Courtesy Lori J. Dobson

SAN DIEGO — After a simple training intervention, emergency physicians at a large tertiary-care hospital performed more than twice as many focused bedside ultrasound exams on pregnant patients as before the training.

“Pregnant women who get the ultrasound by the emergency physician are usually in and out of the department in 20-30 minutes,” Dr. Michael Antonis said in an interview during a poster session.

“Basically, you're looking for a heartbeat and anything worrisome in the adnexa,” explained Dr. Antonis, ultrasound fellowship director at the Georgetown University/Washington Hospital Center's emergency medicine residency program, Washington. “With those questions answered, they're out the door in 20-30 minutes. You don't have to send them to radiology. It's something that's done right at the bedside.”

In a 9-month study led by Dr. Antonis's associate, Dr. Elizabeth Pontius, a third-year resident in the emergency medicine residency program, researchers developed a training program for attending physicians in the ED. The program consisted of two modules: an online training module on how to use the bedside ultrasound machine in general, and a second training module describing how to use the machine for transabdominal and endocavity scans during pregnancy. Next, the attending physicians were assigned to dedicated “sounding” shifts with Dr. Antonis and Dr. Carolyn Phillips, also of Washington Hospital Center, in which they learned how to perform focused ultrasound exams.

After that training, Dr. Antonis and his associates reviewed all ultrasound exams during weekly quality-assurance reviews, and the total number of scans performed by each physician during the intervention period was counted. Before the intervention period, 31 physicians had performed a total of 645 transabdominal or endocavity pregnancy ultrasound exams. After the intervention, 34 physicians had performed 2,350 exams. That translated into a 264% increase in the number of scans performed during the 9-month intervention.

Disclosures: None was reported.

SAN DIEGO — After a simple training intervention, emergency physicians at a large tertiary-care hospital performed more than twice as many focused bedside ultrasound exams on pregnant patients as before the training.

“Pregnant women who get the ultrasound by the emergency physician are usually in and out of the department in 20-30 minutes,” Dr. Michael Antonis said in an interview during a poster session.

“Basically, you're looking for a heartbeat and anything worrisome in the adnexa,” explained Dr. Antonis, ultrasound fellowship director at the Georgetown University/Washington Hospital Center's emergency medicine residency program, Washington. “With those questions answered, they're out the door in 20-30 minutes. You don't have to send them to radiology. It's something that's done right at the bedside.”

In a 9-month study led by Dr. Antonis's associate, Dr. Elizabeth Pontius, a third-year resident in the emergency medicine residency program, researchers developed a training program for attending physicians in the ED. The program consisted of two modules: an online training module on how to use the bedside ultrasound machine in general, and a second training module describing how to use the machine for transabdominal and endocavity scans during pregnancy. Next, the attending physicians were assigned to dedicated “sounding” shifts with Dr. Antonis and Dr. Carolyn Phillips, also of Washington Hospital Center, in which they learned how to perform focused ultrasound exams.

After that training, Dr. Antonis and his associates reviewed all ultrasound exams during weekly quality-assurance reviews, and the total number of scans performed by each physician during the intervention period was counted. Before the intervention period, 31 physicians had performed a total of 645 transabdominal or endocavity pregnancy ultrasound exams. After the intervention, 34 physicians had performed 2,350 exams. That translated into a 264% increase in the number of scans performed during the 9-month intervention.

Disclosures: None was reported.

SAN DIEGO — After a simple training intervention, emergency physicians at a large tertiary-care hospital performed more than twice as many focused bedside ultrasound exams on pregnant patients as before the training.

“Pregnant women who get the ultrasound by the emergency physician are usually in and out of the department in 20-30 minutes,” Dr. Michael Antonis said in an interview during a poster session.

“Basically, you're looking for a heartbeat and anything worrisome in the adnexa,” explained Dr. Antonis, ultrasound fellowship director at the Georgetown University/Washington Hospital Center's emergency medicine residency program, Washington. “With those questions answered, they're out the door in 20-30 minutes. You don't have to send them to radiology. It's something that's done right at the bedside.”

In a 9-month study led by Dr. Antonis's associate, Dr. Elizabeth Pontius, a third-year resident in the emergency medicine residency program, researchers developed a training program for attending physicians in the ED. The program consisted of two modules: an online training module on how to use the bedside ultrasound machine in general, and a second training module describing how to use the machine for transabdominal and endocavity scans during pregnancy. Next, the attending physicians were assigned to dedicated “sounding” shifts with Dr. Antonis and Dr. Carolyn Phillips, also of Washington Hospital Center, in which they learned how to perform focused ultrasound exams.

After that training, Dr. Antonis and his associates reviewed all ultrasound exams during weekly quality-assurance reviews, and the total number of scans performed by each physician during the intervention period was counted. Before the intervention period, 31 physicians had performed a total of 645 transabdominal or endocavity pregnancy ultrasound exams. After the intervention, 34 physicians had performed 2,350 exams. That translated into a 264% increase in the number of scans performed during the 9-month intervention.

Disclosures: None was reported.

A report from the American Academy of Pediatrics Task Force on Mental Health offers clinicians a comprehensive blueprint for improving delivery of mental health care services in pediatric settings.

The 135-page document, entitled “Enhancing Pediatric Mental Health Care,” describes “what pediatricians and other primary care physicians can do at the community level, what they can do at the practice level, and how they can integrate the process of providing mental health services into the primary care flow,” Dr. Jane Meschan Foy, chair of the task force, said in an interview.

Four years in the making, the report (Pediatrics 2010; 125[suppl. 3]:S1-135) builds on three key documents previously published by the task force: “Strategies for System Change in Children's Mental Health: A Chapter Action Kit” (available at www.aap.org/mentalhealth/mh2ch.html

The new report contains three main chapters followed by eight appendices and six supplemental appendices. Together with the previous reports, it addresses three main goals set by the task force: Facilitate system changes, build skills, and incrementally change practice.”

“This is really a tour de force,” said Dr. Martin T. Stein, who was not involved in developing the report. “It's an exceptionally comprehensive, well-written, and practical guideline for including psychological/psychosocial/mental health issues in the practice of primary care pediatrics. There are many practical tools such as thinking about your referral patterns, being aware of what's available in the community, and knowing the insurance sources.

“There is also a chapter on how to code for billing for mental health services, which is a critical issue in primary care. In addition, there is a practice readiness inventory, algorithms for early recognition of conditions, and good references to support the recommendations for diagnosis and screening in primary care,” Dr. Stein, professor of pediatrics in the division of child development and community health at the University of California, San Diego, said in an interview.

Dr. Foy, professor of pediatrics at Wake Forest University, Winston-Salem, N.C., called the pediatric primary care setting “a really good place to provide mental health services. It's a place where families are comfortable, a place where they have a trusting long-term relationship with a clinician. If a child has a complex or chronic illness or disability, families know that their pediatrician can help them connect with the specialty services they need and coordinate and monitor their care.”I

In the report's first chapter, “Strategies for Preparing a Community,” the task force outlines ways to gauge the mental health needs of children and youth in the community, and emphasizes the importance of developing or strengthening relationships with mental health advocates, schools, human service agencies, mental health and substance abuse providers, and developmental specialists.

For example, clinicians “might consider initiating previsit data collection from children in foster care,” the report states. “Sharing the responsibility for previsit data collection with the foster care agency increases the likelihood that adults with knowledge of the child's mental health strengths and needs provide critical information. Many states mandate that children placed in foster care receive a mental health assessment within 1 month of placement. Primary care clinicians may participate in providing this assessment.”

In the second chapter, “Strategies for Preparing a Primary Care Practice,” the task force recommends applying principles of the chronic care model to the care of children and youth with mental health problems. One critical element is a wide variety of partnerships to support and coordinate with the services in primary care.

“There are many new models of collaborative practice,” Dr. Foy said. “We are excited about those that integrate a mental health professional into the primary care setting. They show great promise. There are a number of these now around the country.”

Dr. Foy acknowledged that while chronic care model principles have worked well in primary care for medical conditions such as asthma and diabetes, less is known about how these principles will affect the delivery of mental health care to children and youth. “We are intuitively applying this model, knowing that it has been successful, knowing that pediatricians are familiar with it, and knowing that mental health conditions and concerns are often chronic in nature,” she explained.

The third chapter, “Algorithms for Primary Care,” grew out of the work of four separate teams convened by the task force, including youth and families who have had mental health problems.

The chapter proposes a clinical process for promoting mental health, identifying mental health symptoms and concerns, engaging the family as early and effectively as possible to address emerging problems, collaborating with mental health specialists when needed, and monitoring the child's progress toward recovery or further care.

For her part, Dr. Foy said she hopes the report sends a message to pediatricians that they are well positioned to provide a broad range of mental health care services to patients and their families.

As an example, she offered the case of an anxious child who resists going to school, with a family that is not willing to seek help from a mental health specialist. A technique to try in such a case is the common factors approach, which is described in the report. “It's a way to find out how the family perceives the problem; to express sympathy, support, and empathy for them; to address any barriers that they may experience in taking action-for example, conflict within the family or stigma about seeking mental health services-and then to agree on an incremental first step that they feel comfortable with and capable of taking.”

Dr. Foy noted that pediatricians and other primary care clinicians who care for children are “in a widely varied state of readiness to follow” the recommendations contained in the report. “Some are just beginning to think about expanding their mental health practice,” she said. “Others have very sophisticated multidisciplinary approaches to mental health practice, and the majority is in between. I do think that most primary care clinicians will be able to find some action steps in the wide variety of recommendations that we have made. That is our hope, that there will be something for everybody.”

The report's appendices even include appropriate billing codes.

The report was supported by the AAP, the AAP Friends of Children Fund, and the Substance Abuse and Mental Health Services Administration. ok Dr. Foy and Dr. Stein said they had no financial conflicts of interest.

“Addressing Mental Health Concerns in Primary Care: A Clinician's Toolkit” is intended to help clinicians implement action steps from the supplement and is expected to be available for purchase soon. For more information, visit http://tinyurl.aap.org/pub112382

Nurse practitoner Beth Spangle (left), teen patient Garrett Locklear, and Dr. Jane Meschan Foy, chair of the AAP Task Force on Mental Health, confer.

Source Courtesy Wake Forest University Baptist Medical Center Photography

My Take

'Brilliant and Timely'

I'm excited to see this. If it had come out in 2004 it would have been really brilliant, but before its time. In 2010 it's extremely brilliant and timely. It really points out the ongoing change in the nature of primary care of children and families. There are behavioral concerns and mental health concerns, and the state of Massachusetts has mandated that there be mental health screening at every well-child visit.

There's not a lot in the report that surprises me, but I think that when it goes to most physicians in practice, they're going to have some “Aha!” moments, and that's a good thing. This will need to be updated over time. As we learn more, we're going to learn to identify mental health problems better, we're going to learn how to treat patients better, and we're going to learn how to collaborate better with mental health professionals.

When I talk to colleagues about this issue, one of the things I always say is, 'If you have a mental health question, ask it.' For example, I always ask about divorce adjustment. Or if I think a child looks sad, I will screen him or her for depression.

The strength of this report is that it's going to encourage people to ask those kinds of questions and do that kind of screening, because now we've given them something to do with the findings. There are algorithms, and there are ways to talk about building collaborations with mental health practitioners. I think this is a real state-of-the-art good start.

JOSEPH F. HAGAN JR., M.D., is a pediatrician in private practice in Burlington, Vt. He was one of the coeditors of the AAP's “Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents,” 3rd ed. Dr. Hagan said that he had no conflicts of interest relevant to this topic.

A report from the American Academy of Pediatrics Task Force on Mental Health offers clinicians a comprehensive blueprint for improving delivery of mental health care services in pediatric settings.

The 135-page document, entitled “Enhancing Pediatric Mental Health Care,” describes “what pediatricians and other primary care physicians can do at the community level, what they can do at the practice level, and how they can integrate the process of providing mental health services into the primary care flow,” Dr. Jane Meschan Foy, chair of the task force, said in an interview.

Four years in the making, the report (Pediatrics 2010; 125[suppl. 3]:S1-135) builds on three key documents previously published by the task force: “Strategies for System Change in Children's Mental Health: A Chapter Action Kit” (available at www.aap.org/mentalhealth/mh2ch.html

The new report contains three main chapters followed by eight appendices and six supplemental appendices. Together with the previous reports, it addresses three main goals set by the task force: Facilitate system changes, build skills, and incrementally change practice.”

“This is really a tour de force,” said Dr. Martin T. Stein, who was not involved in developing the report. “It's an exceptionally comprehensive, well-written, and practical guideline for including psychological/psychosocial/mental health issues in the practice of primary care pediatrics. There are many practical tools such as thinking about your referral patterns, being aware of what's available in the community, and knowing the insurance sources.

“There is also a chapter on how to code for billing for mental health services, which is a critical issue in primary care. In addition, there is a practice readiness inventory, algorithms for early recognition of conditions, and good references to support the recommendations for diagnosis and screening in primary care,” Dr. Stein, professor of pediatrics in the division of child development and community health at the University of California, San Diego, said in an interview.

Dr. Foy, professor of pediatrics at Wake Forest University, Winston-Salem, N.C., called the pediatric primary care setting “a really good place to provide mental health services. It's a place where families are comfortable, a place where they have a trusting long-term relationship with a clinician. If a child has a complex or chronic illness or disability, families know that their pediatrician can help them connect with the specialty services they need and coordinate and monitor their care.”I

In the report's first chapter, “Strategies for Preparing a Community,” the task force outlines ways to gauge the mental health needs of children and youth in the community, and emphasizes the importance of developing or strengthening relationships with mental health advocates, schools, human service agencies, mental health and substance abuse providers, and developmental specialists.

For example, clinicians “might consider initiating previsit data collection from children in foster care,” the report states. “Sharing the responsibility for previsit data collection with the foster care agency increases the likelihood that adults with knowledge of the child's mental health strengths and needs provide critical information. Many states mandate that children placed in foster care receive a mental health assessment within 1 month of placement. Primary care clinicians may participate in providing this assessment.”

In the second chapter, “Strategies for Preparing a Primary Care Practice,” the task force recommends applying principles of the chronic care model to the care of children and youth with mental health problems. One critical element is a wide variety of partnerships to support and coordinate with the services in primary care.

“There are many new models of collaborative practice,” Dr. Foy said. “We are excited about those that integrate a mental health professional into the primary care setting. They show great promise. There are a number of these now around the country.”

Dr. Foy acknowledged that while chronic care model principles have worked well in primary care for medical conditions such as asthma and diabetes, less is known about how these principles will affect the delivery of mental health care to children and youth. “We are intuitively applying this model, knowing that it has been successful, knowing that pediatricians are familiar with it, and knowing that mental health conditions and concerns are often chronic in nature,” she explained.

The third chapter, “Algorithms for Primary Care,” grew out of the work of four separate teams convened by the task force, including youth and families who have had mental health problems.

The chapter proposes a clinical process for promoting mental health, identifying mental health symptoms and concerns, engaging the family as early and effectively as possible to address emerging problems, collaborating with mental health specialists when needed, and monitoring the child's progress toward recovery or further care.

For her part, Dr. Foy said she hopes the report sends a message to pediatricians that they are well positioned to provide a broad range of mental health care services to patients and their families.

As an example, she offered the case of an anxious child who resists going to school, with a family that is not willing to seek help from a mental health specialist. A technique to try in such a case is the common factors approach, which is described in the report. “It's a way to find out how the family perceives the problem; to express sympathy, support, and empathy for them; to address any barriers that they may experience in taking action-for example, conflict within the family or stigma about seeking mental health services-and then to agree on an incremental first step that they feel comfortable with and capable of taking.”

Dr. Foy noted that pediatricians and other primary care clinicians who care for children are “in a widely varied state of readiness to follow” the recommendations contained in the report. “Some are just beginning to think about expanding their mental health practice,” she said. “Others have very sophisticated multidisciplinary approaches to mental health practice, and the majority is in between. I do think that most primary care clinicians will be able to find some action steps in the wide variety of recommendations that we have made. That is our hope, that there will be something for everybody.”

The report's appendices even include appropriate billing codes.

The report was supported by the AAP, the AAP Friends of Children Fund, and the Substance Abuse and Mental Health Services Administration. ok Dr. Foy and Dr. Stein said they had no financial conflicts of interest.

“Addressing Mental Health Concerns in Primary Care: A Clinician's Toolkit” is intended to help clinicians implement action steps from the supplement and is expected to be available for purchase soon. For more information, visit http://tinyurl.aap.org/pub112382

Nurse practitoner Beth Spangle (left), teen patient Garrett Locklear, and Dr. Jane Meschan Foy, chair of the AAP Task Force on Mental Health, confer.

Source Courtesy Wake Forest University Baptist Medical Center Photography

My Take

'Brilliant and Timely'

I'm excited to see this. If it had come out in 2004 it would have been really brilliant, but before its time. In 2010 it's extremely brilliant and timely. It really points out the ongoing change in the nature of primary care of children and families. There are behavioral concerns and mental health concerns, and the state of Massachusetts has mandated that there be mental health screening at every well-child visit.

There's not a lot in the report that surprises me, but I think that when it goes to most physicians in practice, they're going to have some “Aha!” moments, and that's a good thing. This will need to be updated over time. As we learn more, we're going to learn to identify mental health problems better, we're going to learn how to treat patients better, and we're going to learn how to collaborate better with mental health professionals.

When I talk to colleagues about this issue, one of the things I always say is, 'If you have a mental health question, ask it.' For example, I always ask about divorce adjustment. Or if I think a child looks sad, I will screen him or her for depression.

The strength of this report is that it's going to encourage people to ask those kinds of questions and do that kind of screening, because now we've given them something to do with the findings. There are algorithms, and there are ways to talk about building collaborations with mental health practitioners. I think this is a real state-of-the-art good start.

JOSEPH F. HAGAN JR., M.D., is a pediatrician in private practice in Burlington, Vt. He was one of the coeditors of the AAP's “Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents,” 3rd ed. Dr. Hagan said that he had no conflicts of interest relevant to this topic.

A report from the American Academy of Pediatrics Task Force on Mental Health offers clinicians a comprehensive blueprint for improving delivery of mental health care services in pediatric settings.

The 135-page document, entitled “Enhancing Pediatric Mental Health Care,” describes “what pediatricians and other primary care physicians can do at the community level, what they can do at the practice level, and how they can integrate the process of providing mental health services into the primary care flow,” Dr. Jane Meschan Foy, chair of the task force, said in an interview.

Four years in the making, the report (Pediatrics 2010; 125[suppl. 3]:S1-135) builds on three key documents previously published by the task force: “Strategies for System Change in Children's Mental Health: A Chapter Action Kit” (available at www.aap.org/mentalhealth/mh2ch.html

The new report contains three main chapters followed by eight appendices and six supplemental appendices. Together with the previous reports, it addresses three main goals set by the task force: Facilitate system changes, build skills, and incrementally change practice.”

“This is really a tour de force,” said Dr. Martin T. Stein, who was not involved in developing the report. “It's an exceptionally comprehensive, well-written, and practical guideline for including psychological/psychosocial/mental health issues in the practice of primary care pediatrics. There are many practical tools such as thinking about your referral patterns, being aware of what's available in the community, and knowing the insurance sources.

“There is also a chapter on how to code for billing for mental health services, which is a critical issue in primary care. In addition, there is a practice readiness inventory, algorithms for early recognition of conditions, and good references to support the recommendations for diagnosis and screening in primary care,” Dr. Stein, professor of pediatrics in the division of child development and community health at the University of California, San Diego, said in an interview.

Dr. Foy, professor of pediatrics at Wake Forest University, Winston-Salem, N.C., called the pediatric primary care setting “a really good place to provide mental health services. It's a place where families are comfortable, a place where they have a trusting long-term relationship with a clinician. If a child has a complex or chronic illness or disability, families know that their pediatrician can help them connect with the specialty services they need and coordinate and monitor their care.”I

In the report's first chapter, “Strategies for Preparing a Community,” the task force outlines ways to gauge the mental health needs of children and youth in the community, and emphasizes the importance of developing or strengthening relationships with mental health advocates, schools, human service agencies, mental health and substance abuse providers, and developmental specialists.

For example, clinicians “might consider initiating previsit data collection from children in foster care,” the report states. “Sharing the responsibility for previsit data collection with the foster care agency increases the likelihood that adults with knowledge of the child's mental health strengths and needs provide critical information. Many states mandate that children placed in foster care receive a mental health assessment within 1 month of placement. Primary care clinicians may participate in providing this assessment.”

In the second chapter, “Strategies for Preparing a Primary Care Practice,” the task force recommends applying principles of the chronic care model to the care of children and youth with mental health problems. One critical element is a wide variety of partnerships to support and coordinate with the services in primary care.

“There are many new models of collaborative practice,” Dr. Foy said. “We are excited about those that integrate a mental health professional into the primary care setting. They show great promise. There are a number of these now around the country.”

Dr. Foy acknowledged that while chronic care model principles have worked well in primary care for medical conditions such as asthma and diabetes, less is known about how these principles will affect the delivery of mental health care to children and youth. “We are intuitively applying this model, knowing that it has been successful, knowing that pediatricians are familiar with it, and knowing that mental health conditions and concerns are often chronic in nature,” she explained.

The third chapter, “Algorithms for Primary Care,” grew out of the work of four separate teams convened by the task force, including youth and families who have had mental health problems.

The chapter proposes a clinical process for promoting mental health, identifying mental health symptoms and concerns, engaging the family as early and effectively as possible to address emerging problems, collaborating with mental health specialists when needed, and monitoring the child's progress toward recovery or further care.

For her part, Dr. Foy said she hopes the report sends a message to pediatricians that they are well positioned to provide a broad range of mental health care services to patients and their families.

As an example, she offered the case of an anxious child who resists going to school, with a family that is not willing to seek help from a mental health specialist. A technique to try in such a case is the common factors approach, which is described in the report. “It's a way to find out how the family perceives the problem; to express sympathy, support, and empathy for them; to address any barriers that they may experience in taking action-for example, conflict within the family or stigma about seeking mental health services-and then to agree on an incremental first step that they feel comfortable with and capable of taking.”

Dr. Foy noted that pediatricians and other primary care clinicians who care for children are “in a widely varied state of readiness to follow” the recommendations contained in the report. “Some are just beginning to think about expanding their mental health practice,” she said. “Others have very sophisticated multidisciplinary approaches to mental health practice, and the majority is in between. I do think that most primary care clinicians will be able to find some action steps in the wide variety of recommendations that we have made. That is our hope, that there will be something for everybody.”

The report's appendices even include appropriate billing codes.

The report was supported by the AAP, the AAP Friends of Children Fund, and the Substance Abuse and Mental Health Services Administration. ok Dr. Foy and Dr. Stein said they had no financial conflicts of interest.

“Addressing Mental Health Concerns in Primary Care: A Clinician's Toolkit” is intended to help clinicians implement action steps from the supplement and is expected to be available for purchase soon. For more information, visit http://tinyurl.aap.org/pub112382

Nurse practitoner Beth Spangle (left), teen patient Garrett Locklear, and Dr. Jane Meschan Foy, chair of the AAP Task Force on Mental Health, confer.

Source Courtesy Wake Forest University Baptist Medical Center Photography

My Take

'Brilliant and Timely'

I'm excited to see this. If it had come out in 2004 it would have been really brilliant, but before its time. In 2010 it's extremely brilliant and timely. It really points out the ongoing change in the nature of primary care of children and families. There are behavioral concerns and mental health concerns, and the state of Massachusetts has mandated that there be mental health screening at every well-child visit.

There's not a lot in the report that surprises me, but I think that when it goes to most physicians in practice, they're going to have some “Aha!” moments, and that's a good thing. This will need to be updated over time. As we learn more, we're going to learn to identify mental health problems better, we're going to learn how to treat patients better, and we're going to learn how to collaborate better with mental health professionals.

When I talk to colleagues about this issue, one of the things I always say is, 'If you have a mental health question, ask it.' For example, I always ask about divorce adjustment. Or if I think a child looks sad, I will screen him or her for depression.

The strength of this report is that it's going to encourage people to ask those kinds of questions and do that kind of screening, because now we've given them something to do with the findings. There are algorithms, and there are ways to talk about building collaborations with mental health practitioners. I think this is a real state-of-the-art good start.

JOSEPH F. HAGAN JR., M.D., is a pediatrician in private practice in Burlington, Vt. He was one of the coeditors of the AAP's “Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents,” 3rd ed. Dr. Hagan said that he had no conflicts of interest relevant to this topic.

SAN DIEGO — Almost half of endometrial polyps seen on sonohysterography were missed on transvaginal ultrasound, results from a large single-center study showed.

The factors associated with lack of detection on ultrasound included smaller polyp size, multiplicity, submucosal fibroids, location of polyps, and blood flow to the polyps, Dr. Alex Hartman said at the meeting.

Between January and May of 2009, Dr. Hartman and his associates performed a blinded retrospective case study of 800 consecutive patients (mean age, 48 years) diagnosed with endometrial polyps on sonohysterography who also had preliminary transvaginal ultrasound within 48 hours of the sonohysterography.

The researchers assessed multiple factors, including patient age, size of the polyp, number of polyps, submucosal fibroids, intramural fibroids, adenomyosis, location of the polyp, blood flow, abnormal bleeding, endometrial thickness, polycystic ovaries, and fertility status. Pearson's chi-square tests and t-tests were used to compare the two samples.

Dr. Hartman, medical director of True North Imaging in Thornhill, Ont., went on to report that 433 patients (54%) with polyps diagnosed on ultrasound had their polyps seen on transvaginal ultrasound. The factors significantly associated with detection of a polyp on preliminary transvaginal ultrasound included larger polyp size (in general, the larger, the more likely seen); the presence of multiple polyps; the absence of submucosal fibroids; fundal location of the polyp; and the presence of blood flow to the polyp.

“Over the years, we found that polyps that were located in the fundus were much easier to see,” Dr. Hartman commented. “The ones that were confined to the lower uterine segment and midbody were much harder to detect.”

He also noted that 39 of the 800 patients (5%) also had submucosal fibroids. “Interestingly, only one-third of the polyps in these patients were diagnosed in the preliminary ultrasound study,” Dr. Hartman said. “So the presence of submucosal fibroids made it very difficult to see polyps on regular ultrasound.”

A large polyp is shown on sonohysterography. The blue and red represent blood flow.

Source Courtesy Dr. Alex Hartman

SAN DIEGO — Almost half of endometrial polyps seen on sonohysterography were missed on transvaginal ultrasound, results from a large single-center study showed.

The factors associated with lack of detection on ultrasound included smaller polyp size, multiplicity, submucosal fibroids, location of polyps, and blood flow to the polyps, Dr. Alex Hartman said at the meeting.

Between January and May of 2009, Dr. Hartman and his associates performed a blinded retrospective case study of 800 consecutive patients (mean age, 48 years) diagnosed with endometrial polyps on sonohysterography who also had preliminary transvaginal ultrasound within 48 hours of the sonohysterography.

The researchers assessed multiple factors, including patient age, size of the polyp, number of polyps, submucosal fibroids, intramural fibroids, adenomyosis, location of the polyp, blood flow, abnormal bleeding, endometrial thickness, polycystic ovaries, and fertility status. Pearson's chi-square tests and t-tests were used to compare the two samples.

Dr. Hartman, medical director of True North Imaging in Thornhill, Ont., went on to report that 433 patients (54%) with polyps diagnosed on ultrasound had their polyps seen on transvaginal ultrasound. The factors significantly associated with detection of a polyp on preliminary transvaginal ultrasound included larger polyp size (in general, the larger, the more likely seen); the presence of multiple polyps; the absence of submucosal fibroids; fundal location of the polyp; and the presence of blood flow to the polyp.

“Over the years, we found that polyps that were located in the fundus were much easier to see,” Dr. Hartman commented. “The ones that were confined to the lower uterine segment and midbody were much harder to detect.”

He also noted that 39 of the 800 patients (5%) also had submucosal fibroids. “Interestingly, only one-third of the polyps in these patients were diagnosed in the preliminary ultrasound study,” Dr. Hartman said. “So the presence of submucosal fibroids made it very difficult to see polyps on regular ultrasound.”

A large polyp is shown on sonohysterography. The blue and red represent blood flow.

Source Courtesy Dr. Alex Hartman

SAN DIEGO — Almost half of endometrial polyps seen on sonohysterography were missed on transvaginal ultrasound, results from a large single-center study showed.

The factors associated with lack of detection on ultrasound included smaller polyp size, multiplicity, submucosal fibroids, location of polyps, and blood flow to the polyps, Dr. Alex Hartman said at the meeting.

Between January and May of 2009, Dr. Hartman and his associates performed a blinded retrospective case study of 800 consecutive patients (mean age, 48 years) diagnosed with endometrial polyps on sonohysterography who also had preliminary transvaginal ultrasound within 48 hours of the sonohysterography.

The researchers assessed multiple factors, including patient age, size of the polyp, number of polyps, submucosal fibroids, intramural fibroids, adenomyosis, location of the polyp, blood flow, abnormal bleeding, endometrial thickness, polycystic ovaries, and fertility status. Pearson's chi-square tests and t-tests were used to compare the two samples.

Dr. Hartman, medical director of True North Imaging in Thornhill, Ont., went on to report that 433 patients (54%) with polyps diagnosed on ultrasound had their polyps seen on transvaginal ultrasound. The factors significantly associated with detection of a polyp on preliminary transvaginal ultrasound included larger polyp size (in general, the larger, the more likely seen); the presence of multiple polyps; the absence of submucosal fibroids; fundal location of the polyp; and the presence of blood flow to the polyp.

“Over the years, we found that polyps that were located in the fundus were much easier to see,” Dr. Hartman commented. “The ones that were confined to the lower uterine segment and midbody were much harder to detect.”

He also noted that 39 of the 800 patients (5%) also had submucosal fibroids. “Interestingly, only one-third of the polyps in these patients were diagnosed in the preliminary ultrasound study,” Dr. Hartman said. “So the presence of submucosal fibroids made it very difficult to see polyps on regular ultrasound.”

A large polyp is shown on sonohysterography. The blue and red represent blood flow.

Source Courtesy Dr. Alex Hartman

PHOENIX — Burn scars rank as one of the most difficult dermatologic conditions to treat, Dr. Jill S. Waibel said at the annual meeting of the American Society for Laser Medicine and Surgery.

"Burn scars are the worst we see in clinical medicine," said Dr. Waibel, a dermatologist with a laser practice in Miami. "I believe that if we can treat a burn scar, we can treat any scar."

Under normal circumstances, wounded skin re-epithelizes from hair follicles and dermal glands, but because burn scars are often partially or completely deprived of their epidermal appendages, "healing is severely affected," she noted.

Thanks to surgical advances in the past decade, survival of burn patients has risen from about 30% to 95%. The types of scars they present with include hypertrophic, keloid, contracture, and atrophic.

Current efforts to treat burn scars fall into one of two camps: prevention of scar formation and late reconstruction of mature scars.

"We do have a model for a scarless wound," Dr. Waibel said. "A fetus in utero does not scar. We don't understand that process. There are also a number of topical applications to prevent scars at the time of the wound. Over 200 cytokines are involved in wound healing."

Research efforts are also under way on laser-assisted skin healing with a diode laser, she said, which alters the wound-healing process by thermal stress.

Current treatment for late reconstruction of mature scars includes surgery, followed by laser combination therapy. "I think fractional therapy is the … standard, but I really don't think we understand the mechanism of action in laser and scar reduction," Dr. Waibel commented. "I think we break it down into two areas: either fractional versus thermal, or probably it's fractional and thermal. The thermal effects are the most interesting. How much heat is required for the most constructive healing versus too much thermal injury? We need to look more at what that [ideal] temperature is."

She tells her burn scar patients to consider their treatment as a "work in progress" and asks them to give her a year before they start to assess efficacy. In 2005, her first burn patient underwent five treatments with a 1550-nm, nonablative, erbium-fiber fractional laser; intralesional Kenalog (triamcinolone); and a shave biopsy.

"We see functional improvement as well as cosmetic, especially with contracture scars, and we're working on some range-of-motion studies right now," Dr. Waibel said.

In a study presented at the society's 2009 meeting, Dr. Waibel and her associates presented results from a proof-of-concept study of 10 patients who had burn scars that were treated with a 1550-nm, nonablative, erbium-fiber fractional laser.

Objective scoring by blinded investigators of photos taken pretreatment and at 3 months posttreatment indicated that 78% of patients had excellent to moderate results.

Dr. Waibel acknowledged certain limitations in current efforts to improve treatment for patients with burn scars, including the need for surgery for anatomical fixes and the lack of understanding of the processes of scar formation and the laser effects on scars. "We need better technology, and we need to maximize treatment modalities," she said. "We really need to develop a scar laser. All of the lasers that we use for scars right now were invented for wrinkles."

Dr. Waibel has conducted research for Solta Medical and Sciton, and she has received honoraria from Lumenis for lectures.

PHOENIX — Burn scars rank as one of the most difficult dermatologic conditions to treat, Dr. Jill S. Waibel said at the annual meeting of the American Society for Laser Medicine and Surgery.

"Burn scars are the worst we see in clinical medicine," said Dr. Waibel, a dermatologist with a laser practice in Miami. "I believe that if we can treat a burn scar, we can treat any scar."

Under normal circumstances, wounded skin re-epithelizes from hair follicles and dermal glands, but because burn scars are often partially or completely deprived of their epidermal appendages, "healing is severely affected," she noted.

Thanks to surgical advances in the past decade, survival of burn patients has risen from about 30% to 95%. The types of scars they present with include hypertrophic, keloid, contracture, and atrophic.

Current efforts to treat burn scars fall into one of two camps: prevention of scar formation and late reconstruction of mature scars.

"We do have a model for a scarless wound," Dr. Waibel said. "A fetus in utero does not scar. We don't understand that process. There are also a number of topical applications to prevent scars at the time of the wound. Over 200 cytokines are involved in wound healing."

Research efforts are also under way on laser-assisted skin healing with a diode laser, she said, which alters the wound-healing process by thermal stress.

Current treatment for late reconstruction of mature scars includes surgery, followed by laser combination therapy. "I think fractional therapy is the … standard, but I really don't think we understand the mechanism of action in laser and scar reduction," Dr. Waibel commented. "I think we break it down into two areas: either fractional versus thermal, or probably it's fractional and thermal. The thermal effects are the most interesting. How much heat is required for the most constructive healing versus too much thermal injury? We need to look more at what that [ideal] temperature is."

She tells her burn scar patients to consider their treatment as a "work in progress" and asks them to give her a year before they start to assess efficacy. In 2005, her first burn patient underwent five treatments with a 1550-nm, nonablative, erbium-fiber fractional laser; intralesional Kenalog (triamcinolone); and a shave biopsy.

"We see functional improvement as well as cosmetic, especially with contracture scars, and we're working on some range-of-motion studies right now," Dr. Waibel said.

In a study presented at the society's 2009 meeting, Dr. Waibel and her associates presented results from a proof-of-concept study of 10 patients who had burn scars that were treated with a 1550-nm, nonablative, erbium-fiber fractional laser.

Objective scoring by blinded investigators of photos taken pretreatment and at 3 months posttreatment indicated that 78% of patients had excellent to moderate results.

Dr. Waibel acknowledged certain limitations in current efforts to improve treatment for patients with burn scars, including the need for surgery for anatomical fixes and the lack of understanding of the processes of scar formation and the laser effects on scars. "We need better technology, and we need to maximize treatment modalities," she said. "We really need to develop a scar laser. All of the lasers that we use for scars right now were invented for wrinkles."

Dr. Waibel has conducted research for Solta Medical and Sciton, and she has received honoraria from Lumenis for lectures.

PHOENIX — Burn scars rank as one of the most difficult dermatologic conditions to treat, Dr. Jill S. Waibel said at the annual meeting of the American Society for Laser Medicine and Surgery.

"Burn scars are the worst we see in clinical medicine," said Dr. Waibel, a dermatologist with a laser practice in Miami. "I believe that if we can treat a burn scar, we can treat any scar."

Under normal circumstances, wounded skin re-epithelizes from hair follicles and dermal glands, but because burn scars are often partially or completely deprived of their epidermal appendages, "healing is severely affected," she noted.

Thanks to surgical advances in the past decade, survival of burn patients has risen from about 30% to 95%. The types of scars they present with include hypertrophic, keloid, contracture, and atrophic.

Current efforts to treat burn scars fall into one of two camps: prevention of scar formation and late reconstruction of mature scars.

"We do have a model for a scarless wound," Dr. Waibel said. "A fetus in utero does not scar. We don't understand that process. There are also a number of topical applications to prevent scars at the time of the wound. Over 200 cytokines are involved in wound healing."

Research efforts are also under way on laser-assisted skin healing with a diode laser, she said, which alters the wound-healing process by thermal stress.

Current treatment for late reconstruction of mature scars includes surgery, followed by laser combination therapy. "I think fractional therapy is the … standard, but I really don't think we understand the mechanism of action in laser and scar reduction," Dr. Waibel commented. "I think we break it down into two areas: either fractional versus thermal, or probably it's fractional and thermal. The thermal effects are the most interesting. How much heat is required for the most constructive healing versus too much thermal injury? We need to look more at what that [ideal] temperature is."

She tells her burn scar patients to consider their treatment as a "work in progress" and asks them to give her a year before they start to assess efficacy. In 2005, her first burn patient underwent five treatments with a 1550-nm, nonablative, erbium-fiber fractional laser; intralesional Kenalog (triamcinolone); and a shave biopsy.

"We see functional improvement as well as cosmetic, especially with contracture scars, and we're working on some range-of-motion studies right now," Dr. Waibel said.

In a study presented at the society's 2009 meeting, Dr. Waibel and her associates presented results from a proof-of-concept study of 10 patients who had burn scars that were treated with a 1550-nm, nonablative, erbium-fiber fractional laser.

Objective scoring by blinded investigators of photos taken pretreatment and at 3 months posttreatment indicated that 78% of patients had excellent to moderate results.

Dr. Waibel acknowledged certain limitations in current efforts to improve treatment for patients with burn scars, including the need for surgery for anatomical fixes and the lack of understanding of the processes of scar formation and the laser effects on scars. "We need better technology, and we need to maximize treatment modalities," she said. "We really need to develop a scar laser. All of the lasers that we use for scars right now were invented for wrinkles."

Dr. Waibel has conducted research for Solta Medical and Sciton, and she has received honoraria from Lumenis for lectures.