Doug Brunk

SAN DIEGO — Brain development at birth is significantly delayed in full-term neonates with complex congenital heart defects, both on magnetic resonance imaging and by mean head circumference.

These observations “should stimulate discussion on the optimal timing of labor induction for those infants with prenatally diagnosed heart defects,” Dr. Daniel J. Licht said at the annual meeting of the American Association for Thoracic Surgery.

“Historically, the timing of delivery for neonates with prenatally diagnosed congenital heart disease was determined by lung maturity and surgical logistics. The current study suggests neonates with complex CHD should be delivered as close to term as possible,” said Dr. Licht, a child neurologist at Children's Hospital of Philadelphia.

Previous studies have shown that at birth, term infants with complex congenital heart defects have smaller head circumferences and, on MRI, have been shown to have structural simplicity of the brain as seen by open operculum. These infants “also have an unexpectedly high proportion of preoperative and postoperative white matter injury in the form of periventricular leukomalacia,” he said.

This finding has been corroborated by a report of biochemical immaturity of the white matter in infants with congenital heart defects as shown by MR spectroscopy (N. Engl. J. Med. 2007;357:1928–38).

Dr. Licht and his associates hypothesized that term infants with complex forms of congenital heart defects have structurally delayed brain development as measured by smaller head circumferences and a lower total maturation score (TMS), a validated MRI metric for assessing full brain maturity. The TMS is composed of four MRI characteristics: myelination, cortical folding, germinal matrix, and migrating bands of glial cells.

A 3-Tesla MRI was used to evaluate 29 full-term infants with hypoplastic left heart syndrome (HLHS) and 13 with transposition of the great arteries (TGA) just prior to heart surgery. Infants with evidence of perinatal distress, shock, or intrauterine growth retardation were excluded from the study “as these were felt to be independent risks for brain injury,” Dr. Licht said.

Clinical studies were reviewed by a single neuroradiologist who was blinded to the clinical data, and TMS was rated by two MRI readers who also were blinded to the data. Findings were compared with published normative data of similar gestational age. The mean gestational age of the 42 infants was 39 weeks and 64% were boys. Average birth weight was 3.4 kg.

The average head circumference for infants in the study was 34.5 cm, which is a full standard deviation below the expected normal of 35.5 cm. In addition, open operculum was seen on MRI in 36 of the infants (86%), and would be expected in less than 5%–10% of normal full-term infants

The average TMS for infants in the study was just over 10, which is significantly lower than reported normative TMS of 11.1 in noncardiac infants with a gestational age of 36–37 weeks.

“This average TMS … places our term infants with congenital heart defects at 35 weeks of gestational age, when white matter remains vulnerable and myelination is just beginning,” Dr. Licht said. “We conclude that this group of otherwise healthy term babies with congenital heart defects has immature brains as evidenced by the high prevalence of small head circumferences and open opercula and corroborated with the finding of reduced TMS scores, suggesting a delay in brain maturity of a full month.”

He noted that the relative immaturity of the central nervous system in these term neonates “may provide the substrate for the vulnerability to white matter injury in the pre-, intra-, and postoperative periods.”

The study was funded by the National Institute of Neurological Disorders and Stroke and by the Dana Foundation. Dr. Licht had no conflicts to disclose.

Open operculum, indicating structural simplicity of the brain, was seen in 86% of neonates with complex congenital heart defects on magnetic resonance imaging. Images courtesy Dr. Daniel J. Licht

SAN DIEGO — Brain development at birth is significantly delayed in full-term neonates with complex congenital heart defects, both on magnetic resonance imaging and by mean head circumference.

These observations “should stimulate discussion on the optimal timing of labor induction for those infants with prenatally diagnosed heart defects,” Dr. Daniel J. Licht said at the annual meeting of the American Association for Thoracic Surgery.

“Historically, the timing of delivery for neonates with prenatally diagnosed congenital heart disease was determined by lung maturity and surgical logistics. The current study suggests neonates with complex CHD should be delivered as close to term as possible,” said Dr. Licht, a child neurologist at Children's Hospital of Philadelphia.

Previous studies have shown that at birth, term infants with complex congenital heart defects have smaller head circumferences and, on MRI, have been shown to have structural simplicity of the brain as seen by open operculum. These infants “also have an unexpectedly high proportion of preoperative and postoperative white matter injury in the form of periventricular leukomalacia,” he said.

This finding has been corroborated by a report of biochemical immaturity of the white matter in infants with congenital heart defects as shown by MR spectroscopy (N. Engl. J. Med. 2007;357:1928–38).

Dr. Licht and his associates hypothesized that term infants with complex forms of congenital heart defects have structurally delayed brain development as measured by smaller head circumferences and a lower total maturation score (TMS), a validated MRI metric for assessing full brain maturity. The TMS is composed of four MRI characteristics: myelination, cortical folding, germinal matrix, and migrating bands of glial cells.

A 3-Tesla MRI was used to evaluate 29 full-term infants with hypoplastic left heart syndrome (HLHS) and 13 with transposition of the great arteries (TGA) just prior to heart surgery. Infants with evidence of perinatal distress, shock, or intrauterine growth retardation were excluded from the study “as these were felt to be independent risks for brain injury,” Dr. Licht said.

Clinical studies were reviewed by a single neuroradiologist who was blinded to the clinical data, and TMS was rated by two MRI readers who also were blinded to the data. Findings were compared with published normative data of similar gestational age. The mean gestational age of the 42 infants was 39 weeks and 64% were boys. Average birth weight was 3.4 kg.

The average head circumference for infants in the study was 34.5 cm, which is a full standard deviation below the expected normal of 35.5 cm. In addition, open operculum was seen on MRI in 36 of the infants (86%), and would be expected in less than 5%–10% of normal full-term infants

The average TMS for infants in the study was just over 10, which is significantly lower than reported normative TMS of 11.1 in noncardiac infants with a gestational age of 36–37 weeks.

“This average TMS … places our term infants with congenital heart defects at 35 weeks of gestational age, when white matter remains vulnerable and myelination is just beginning,” Dr. Licht said. “We conclude that this group of otherwise healthy term babies with congenital heart defects has immature brains as evidenced by the high prevalence of small head circumferences and open opercula and corroborated with the finding of reduced TMS scores, suggesting a delay in brain maturity of a full month.”

He noted that the relative immaturity of the central nervous system in these term neonates “may provide the substrate for the vulnerability to white matter injury in the pre-, intra-, and postoperative periods.”

The study was funded by the National Institute of Neurological Disorders and Stroke and by the Dana Foundation. Dr. Licht had no conflicts to disclose.

Open operculum, indicating structural simplicity of the brain, was seen in 86% of neonates with complex congenital heart defects on magnetic resonance imaging. Images courtesy Dr. Daniel J. Licht

SAN DIEGO — Brain development at birth is significantly delayed in full-term neonates with complex congenital heart defects, both on magnetic resonance imaging and by mean head circumference.

These observations “should stimulate discussion on the optimal timing of labor induction for those infants with prenatally diagnosed heart defects,” Dr. Daniel J. Licht said at the annual meeting of the American Association for Thoracic Surgery.

“Historically, the timing of delivery for neonates with prenatally diagnosed congenital heart disease was determined by lung maturity and surgical logistics. The current study suggests neonates with complex CHD should be delivered as close to term as possible,” said Dr. Licht, a child neurologist at Children's Hospital of Philadelphia.

Previous studies have shown that at birth, term infants with complex congenital heart defects have smaller head circumferences and, on MRI, have been shown to have structural simplicity of the brain as seen by open operculum. These infants “also have an unexpectedly high proportion of preoperative and postoperative white matter injury in the form of periventricular leukomalacia,” he said.

This finding has been corroborated by a report of biochemical immaturity of the white matter in infants with congenital heart defects as shown by MR spectroscopy (N. Engl. J. Med. 2007;357:1928–38).

Dr. Licht and his associates hypothesized that term infants with complex forms of congenital heart defects have structurally delayed brain development as measured by smaller head circumferences and a lower total maturation score (TMS), a validated MRI metric for assessing full brain maturity. The TMS is composed of four MRI characteristics: myelination, cortical folding, germinal matrix, and migrating bands of glial cells.

A 3-Tesla MRI was used to evaluate 29 full-term infants with hypoplastic left heart syndrome (HLHS) and 13 with transposition of the great arteries (TGA) just prior to heart surgery. Infants with evidence of perinatal distress, shock, or intrauterine growth retardation were excluded from the study “as these were felt to be independent risks for brain injury,” Dr. Licht said.

Clinical studies were reviewed by a single neuroradiologist who was blinded to the clinical data, and TMS was rated by two MRI readers who also were blinded to the data. Findings were compared with published normative data of similar gestational age. The mean gestational age of the 42 infants was 39 weeks and 64% were boys. Average birth weight was 3.4 kg.

The average head circumference for infants in the study was 34.5 cm, which is a full standard deviation below the expected normal of 35.5 cm. In addition, open operculum was seen on MRI in 36 of the infants (86%), and would be expected in less than 5%–10% of normal full-term infants

The average TMS for infants in the study was just over 10, which is significantly lower than reported normative TMS of 11.1 in noncardiac infants with a gestational age of 36–37 weeks.

“This average TMS … places our term infants with congenital heart defects at 35 weeks of gestational age, when white matter remains vulnerable and myelination is just beginning,” Dr. Licht said. “We conclude that this group of otherwise healthy term babies with congenital heart defects has immature brains as evidenced by the high prevalence of small head circumferences and open opercula and corroborated with the finding of reduced TMS scores, suggesting a delay in brain maturity of a full month.”

He noted that the relative immaturity of the central nervous system in these term neonates “may provide the substrate for the vulnerability to white matter injury in the pre-, intra-, and postoperative periods.”

The study was funded by the National Institute of Neurological Disorders and Stroke and by the Dana Foundation. Dr. Licht had no conflicts to disclose.

Open operculum, indicating structural simplicity of the brain, was seen in 86% of neonates with complex congenital heart defects on magnetic resonance imaging. Images courtesy Dr. Daniel J. Licht

SAN DIEGO — Parents of children newly diagnosed with atopic dermatitis can be riddled with angst.

Some gravitate to guilt and self-blame, figuring "we did something wrong to our child" or "it must be something we're giving him" that's causing the atopic dermatitis, Dr. Magdalene A. Dohil said at a meeting sponsored by Rady Children's Hospital.

Others believe that baths are bad for their child, and many are frightened to use topical steroids to treat the disease. "They may say things like, 'there are so many creams, we can't remember what goes on and where it goes,'" said Dr. Dohil, a pediatric dermatologist at Rady Children's Hospital, San Diego. "They want a simple and easy cure so they can control the disease."

Many parents find it hard to accept the fact that there is no treatment that completely cures atopic dermatitis. That is why she practices "extreme parent education" from the get-go.

"We have to battle myths and misperceptions," said Dr. Dohil, also of the University of California, San Diego. "We have some good safety data on atopic dermatitis treatments out there. It's just not common knowledge, and they are not that easy to explain."

Patient Resources

Web-based resources she points parents and patients to include The Eczema Center at Rady Children's Hospital (

www.eczemacenter.org

www.nationaleczema.org

www.undermyskin.com

Management of atopic dermatitis is currently based on the number, location, and intensity of lesions, persistence of disease, frequency of flares, patient age, and quality of life and emotional issues.

Dr. Dohil focused her discussion on topical corticosteroids and topical calcineurin inhibitors. "We have to stress for our patients that this is what it boils down to; this is our primary anti-inflammatory armamentarium right now," she said.

Topical Corticosteroids

Topical corticosteroids have been a mainstay of inflammatory atopic dermatitis treatment for decades. They are also used to manage acute flares and as maintenance therapy.

"We can start as low potency as needed or start high, control, and go back to low potency as needed," she said.

"This is my preference because I feel it gives you that initial trust and compliance if parents see their child getting better. It allows you to taper down and reassure parents that you are no longer at that very potent level of topical steroids," Dr. Dohil added.

The choice of topical corticosteroid is influenced by what prior agents have been used, the age of the patient, severity and localization of dermatitis, formularies, and parental steroid phobia. The anti-inflammatory effects of topical corticosteroids come at a price, Dr. Dohil said, including the potential for skin atrophy, telangiectasia, acne, perioral dermatitis, as well as hypothalamic-pituitary-adrenal axis suppression.

"This really scares parents. We need to take this parent fear factor into account at every step along the way because if you don't, you set yourself up for noncompliance. The eczema's not going to get better. The parents will get confused, and there is so much input from non-health professionals, such as 'this worked for my child. Why don't you try this?' and so on," she said.

Previous research has demonstrated that the anti-inflammatory effects of topical corticosteroids stem from a pathway of transrepression, while its side effects stem from a pathway of transactivation.

"Current research is focusing on trying to separate these two pathways," Dr. Dohil said.

"In the meantime we have great data down to 3 months of age that give us a sense of how safe they are, [and] how long we can use these agents. Most of these studies have run over a period of 4 weeks. I think it's important to share this information with parents, to help them feel comfortable about the treatment," she said.

Topical Calcineurin Inhibitors

The topical calcineurin inhibitors, tacrolimus ointment (Protopic) and pimecrolimus cream (Elidel), are popular second-line treatment options for treatment of moderate to severe disease.

According to labeling information, these agents are indicated in nonimmunocompromised adults and children 2 years of age and older, who have failed to respond adequately to other topical prescription treatments, or when those treatments are not advisable.

After a Food and Drug Administration black box warning was issued in January 2006 related to concerns about skin malignancies and lymphoma from the use of topical calcineurin inhibitors, several case-control studies, long-term registries, ongoing clinical studies, and data safety monitoring boards were launched to continue to assess their safety.

A 10-year study, A Prospective Pediatric Longitudinal Evaluation Study, will examine 8,000 pediatric subjects treated for at least 6 weeks.

Another 10-year trial, The Pediatric Eczema Elective Registry, is an observational parent-report registry designed to assess the risk of malignancies in 5,000 children aged 2–17 years who were treated with pimecrolimus for at least 6 weeks.

One recent study found that the patients with severe atopic dermatitis were 2.4 times more likely to develop lymphoma, compared with controls. However, use of pimecrolimus and tacrolimus conferred a protective effect, with odds ratios of 0.8 each (J. Invest. Dermatol. 2007;127:808–16).

A separate case-control study of patients with inflammatory dermatitis found that those who used pimecrolimus and tacrolimus had almost a 50% reduction in the risk of developing nonmelanoma skin cancer (Dermatology 2007;214:289–95).

The odds ratio of association for nonmelanoma skin cancer decreased as the number of tubes used and the potency of the agent increased. "There was no clear explanation for this," Dr. Dohil said. "There's still a lot of discussion going on."

She added that studies of the blood levels of topical calcineurin inhibitors indicate that they "appear to be negligible when used appropriately."

In clinical practice these agents are commonly used for the face and genital area and for other so-called hot spots with high risk of atrophy.

They are often used in patients with concerns about steroids due to quantity of use in delicate locations, need for constant or near constant therapy, or in those with an adverse event history such as striae or systemic effects.

"Many people feel that topical calcineurin inhibitors can help patients experience a longer flare-free interval and then further transition from this maintenance treatment to maybe just a topical moisturizer if you give enough time for the skin to settle down," Dr. Dohil said.

Dr. Dohil disclosed that the department at Rady has received grant and research support from Hill Pharmaceuticals. She has also received honoraria from Medicis and Dermik.

Many parents find it hard to accept the fact that there is no treatment that completely cures atopic dermatitis. DR. DOHIL

SAN DIEGO — Parents of children newly diagnosed with atopic dermatitis can be riddled with angst.

Some gravitate to guilt and self-blame, figuring "we did something wrong to our child" or "it must be something we're giving him" that's causing the atopic dermatitis, Dr. Magdalene A. Dohil said at a meeting sponsored by Rady Children's Hospital.

Others believe that baths are bad for their child, and many are frightened to use topical steroids to treat the disease. "They may say things like, 'there are so many creams, we can't remember what goes on and where it goes,'" said Dr. Dohil, a pediatric dermatologist at Rady Children's Hospital, San Diego. "They want a simple and easy cure so they can control the disease."

Many parents find it hard to accept the fact that there is no treatment that completely cures atopic dermatitis. That is why she practices "extreme parent education" from the get-go.

"We have to battle myths and misperceptions," said Dr. Dohil, also of the University of California, San Diego. "We have some good safety data on atopic dermatitis treatments out there. It's just not common knowledge, and they are not that easy to explain."

Patient Resources

Web-based resources she points parents and patients to include The Eczema Center at Rady Children's Hospital (

www.eczemacenter.org

www.nationaleczema.org

www.undermyskin.com

Management of atopic dermatitis is currently based on the number, location, and intensity of lesions, persistence of disease, frequency of flares, patient age, and quality of life and emotional issues.

Dr. Dohil focused her discussion on topical corticosteroids and topical calcineurin inhibitors. "We have to stress for our patients that this is what it boils down to; this is our primary anti-inflammatory armamentarium right now," she said.

Topical Corticosteroids

Topical corticosteroids have been a mainstay of inflammatory atopic dermatitis treatment for decades. They are also used to manage acute flares and as maintenance therapy.

"We can start as low potency as needed or start high, control, and go back to low potency as needed," she said.

"This is my preference because I feel it gives you that initial trust and compliance if parents see their child getting better. It allows you to taper down and reassure parents that you are no longer at that very potent level of topical steroids," Dr. Dohil added.

The choice of topical corticosteroid is influenced by what prior agents have been used, the age of the patient, severity and localization of dermatitis, formularies, and parental steroid phobia. The anti-inflammatory effects of topical corticosteroids come at a price, Dr. Dohil said, including the potential for skin atrophy, telangiectasia, acne, perioral dermatitis, as well as hypothalamic-pituitary-adrenal axis suppression.

"This really scares parents. We need to take this parent fear factor into account at every step along the way because if you don't, you set yourself up for noncompliance. The eczema's not going to get better. The parents will get confused, and there is so much input from non-health professionals, such as 'this worked for my child. Why don't you try this?' and so on," she said.

Previous research has demonstrated that the anti-inflammatory effects of topical corticosteroids stem from a pathway of transrepression, while its side effects stem from a pathway of transactivation.

"Current research is focusing on trying to separate these two pathways," Dr. Dohil said.

"In the meantime we have great data down to 3 months of age that give us a sense of how safe they are, [and] how long we can use these agents. Most of these studies have run over a period of 4 weeks. I think it's important to share this information with parents, to help them feel comfortable about the treatment," she said.

Topical Calcineurin Inhibitors

The topical calcineurin inhibitors, tacrolimus ointment (Protopic) and pimecrolimus cream (Elidel), are popular second-line treatment options for treatment of moderate to severe disease.

According to labeling information, these agents are indicated in nonimmunocompromised adults and children 2 years of age and older, who have failed to respond adequately to other topical prescription treatments, or when those treatments are not advisable.

After a Food and Drug Administration black box warning was issued in January 2006 related to concerns about skin malignancies and lymphoma from the use of topical calcineurin inhibitors, several case-control studies, long-term registries, ongoing clinical studies, and data safety monitoring boards were launched to continue to assess their safety.

A 10-year study, A Prospective Pediatric Longitudinal Evaluation Study, will examine 8,000 pediatric subjects treated for at least 6 weeks.

Another 10-year trial, The Pediatric Eczema Elective Registry, is an observational parent-report registry designed to assess the risk of malignancies in 5,000 children aged 2–17 years who were treated with pimecrolimus for at least 6 weeks.

One recent study found that the patients with severe atopic dermatitis were 2.4 times more likely to develop lymphoma, compared with controls. However, use of pimecrolimus and tacrolimus conferred a protective effect, with odds ratios of 0.8 each (J. Invest. Dermatol. 2007;127:808–16).

A separate case-control study of patients with inflammatory dermatitis found that those who used pimecrolimus and tacrolimus had almost a 50% reduction in the risk of developing nonmelanoma skin cancer (Dermatology 2007;214:289–95).

The odds ratio of association for nonmelanoma skin cancer decreased as the number of tubes used and the potency of the agent increased. "There was no clear explanation for this," Dr. Dohil said. "There's still a lot of discussion going on."

She added that studies of the blood levels of topical calcineurin inhibitors indicate that they "appear to be negligible when used appropriately."

In clinical practice these agents are commonly used for the face and genital area and for other so-called hot spots with high risk of atrophy.

They are often used in patients with concerns about steroids due to quantity of use in delicate locations, need for constant or near constant therapy, or in those with an adverse event history such as striae or systemic effects.

"Many people feel that topical calcineurin inhibitors can help patients experience a longer flare-free interval and then further transition from this maintenance treatment to maybe just a topical moisturizer if you give enough time for the skin to settle down," Dr. Dohil said.

Dr. Dohil disclosed that the department at Rady has received grant and research support from Hill Pharmaceuticals. She has also received honoraria from Medicis and Dermik.

Many parents find it hard to accept the fact that there is no treatment that completely cures atopic dermatitis. DR. DOHIL

SAN DIEGO — Parents of children newly diagnosed with atopic dermatitis can be riddled with angst.

Some gravitate to guilt and self-blame, figuring "we did something wrong to our child" or "it must be something we're giving him" that's causing the atopic dermatitis, Dr. Magdalene A. Dohil said at a meeting sponsored by Rady Children's Hospital.

Others believe that baths are bad for their child, and many are frightened to use topical steroids to treat the disease. "They may say things like, 'there are so many creams, we can't remember what goes on and where it goes,'" said Dr. Dohil, a pediatric dermatologist at Rady Children's Hospital, San Diego. "They want a simple and easy cure so they can control the disease."

Many parents find it hard to accept the fact that there is no treatment that completely cures atopic dermatitis. That is why she practices "extreme parent education" from the get-go.

"We have to battle myths and misperceptions," said Dr. Dohil, also of the University of California, San Diego. "We have some good safety data on atopic dermatitis treatments out there. It's just not common knowledge, and they are not that easy to explain."

Patient Resources

Web-based resources she points parents and patients to include The Eczema Center at Rady Children's Hospital (

www.eczemacenter.org

www.nationaleczema.org

www.undermyskin.com

Management of atopic dermatitis is currently based on the number, location, and intensity of lesions, persistence of disease, frequency of flares, patient age, and quality of life and emotional issues.

Dr. Dohil focused her discussion on topical corticosteroids and topical calcineurin inhibitors. "We have to stress for our patients that this is what it boils down to; this is our primary anti-inflammatory armamentarium right now," she said.

Topical Corticosteroids

Topical corticosteroids have been a mainstay of inflammatory atopic dermatitis treatment for decades. They are also used to manage acute flares and as maintenance therapy.

"We can start as low potency as needed or start high, control, and go back to low potency as needed," she said.

"This is my preference because I feel it gives you that initial trust and compliance if parents see their child getting better. It allows you to taper down and reassure parents that you are no longer at that very potent level of topical steroids," Dr. Dohil added.

The choice of topical corticosteroid is influenced by what prior agents have been used, the age of the patient, severity and localization of dermatitis, formularies, and parental steroid phobia. The anti-inflammatory effects of topical corticosteroids come at a price, Dr. Dohil said, including the potential for skin atrophy, telangiectasia, acne, perioral dermatitis, as well as hypothalamic-pituitary-adrenal axis suppression.

"This really scares parents. We need to take this parent fear factor into account at every step along the way because if you don't, you set yourself up for noncompliance. The eczema's not going to get better. The parents will get confused, and there is so much input from non-health professionals, such as 'this worked for my child. Why don't you try this?' and so on," she said.

Previous research has demonstrated that the anti-inflammatory effects of topical corticosteroids stem from a pathway of transrepression, while its side effects stem from a pathway of transactivation.

"Current research is focusing on trying to separate these two pathways," Dr. Dohil said.

"In the meantime we have great data down to 3 months of age that give us a sense of how safe they are, [and] how long we can use these agents. Most of these studies have run over a period of 4 weeks. I think it's important to share this information with parents, to help them feel comfortable about the treatment," she said.

Topical Calcineurin Inhibitors

The topical calcineurin inhibitors, tacrolimus ointment (Protopic) and pimecrolimus cream (Elidel), are popular second-line treatment options for treatment of moderate to severe disease.

According to labeling information, these agents are indicated in nonimmunocompromised adults and children 2 years of age and older, who have failed to respond adequately to other topical prescription treatments, or when those treatments are not advisable.

After a Food and Drug Administration black box warning was issued in January 2006 related to concerns about skin malignancies and lymphoma from the use of topical calcineurin inhibitors, several case-control studies, long-term registries, ongoing clinical studies, and data safety monitoring boards were launched to continue to assess their safety.

A 10-year study, A Prospective Pediatric Longitudinal Evaluation Study, will examine 8,000 pediatric subjects treated for at least 6 weeks.

Another 10-year trial, The Pediatric Eczema Elective Registry, is an observational parent-report registry designed to assess the risk of malignancies in 5,000 children aged 2–17 years who were treated with pimecrolimus for at least 6 weeks.

One recent study found that the patients with severe atopic dermatitis were 2.4 times more likely to develop lymphoma, compared with controls. However, use of pimecrolimus and tacrolimus conferred a protective effect, with odds ratios of 0.8 each (J. Invest. Dermatol. 2007;127:808–16).

A separate case-control study of patients with inflammatory dermatitis found that those who used pimecrolimus and tacrolimus had almost a 50% reduction in the risk of developing nonmelanoma skin cancer (Dermatology 2007;214:289–95).

The odds ratio of association for nonmelanoma skin cancer decreased as the number of tubes used and the potency of the agent increased. "There was no clear explanation for this," Dr. Dohil said. "There's still a lot of discussion going on."

She added that studies of the blood levels of topical calcineurin inhibitors indicate that they "appear to be negligible when used appropriately."

In clinical practice these agents are commonly used for the face and genital area and for other so-called hot spots with high risk of atrophy.

They are often used in patients with concerns about steroids due to quantity of use in delicate locations, need for constant or near constant therapy, or in those with an adverse event history such as striae or systemic effects.

"Many people feel that topical calcineurin inhibitors can help patients experience a longer flare-free interval and then further transition from this maintenance treatment to maybe just a topical moisturizer if you give enough time for the skin to settle down," Dr. Dohil said.

Dr. Dohil disclosed that the department at Rady has received grant and research support from Hill Pharmaceuticals. She has also received honoraria from Medicis and Dermik.

Many parents find it hard to accept the fact that there is no treatment that completely cures atopic dermatitis. DR. DOHIL

SAN DIEGO — While the number of patients diagnosed with atopic disease is on the rise, the general public might be overestimating the prevalence of food allergy, according to Dr. Jonathan M. Spergel.

At a meeting on skin disorders sponsored by Rady Children's Hospital, Dr. Spergel said that Americans perceive the prevalence of food allergy to be in the range of 20%–25%, whereas the actual prevalence ranges from 6%–8% in infants and young children and 2%–3.5% in adults.

The prevalence is higher in those with atopic dermatitis, certain pollen allergens, and latex allergies. "And [as with] all atopic diseases, the prevalence has risen," said Dr. Spergel, allergy section chief in the division of allergy and immunology at the Children's Hospital of Philadelphia. "It probably has quadrupled in the last 20 years."

Conducting a thorough history is vital and should include asking about symptoms, reproducibility, diet, concurrent exercise, use of nonsteroidal anti-inflammatory medications, and timing of reaction. "The timing is an important thing," he said. "If you eat a food and then react 12 hours later, that's not an IgE-mediated reaction. It may be a non-IgE-mediated reaction."

If you suspect an IgE-mediated allergy, broad screening should not be done without supporting history because of the high rate of false positives. Skin prick tests indicate the presence of IgE antibody but not clinical reactivity. They have a sensitivity rate of 90%, a specificity rate of 50%, and a false-positive rate of 20%–60%, depending on the individual food.

"When you do a skin prick test, look for a wheal or a flare about 15 minutes later," Dr. Spergel said. "They work very well. They're relatively painless … and they're safe. The youngest I've done it was on a 1-week-old. He was a newborn in the nursery. They gave him a bottle of milk and he got hives."

Milk, egg, and peanut account for 85% of food allergies, he said. A predictive value on whether a child will react is based on the size of the wheal from the skin test. The age of the child also affects the size. For example, 95% of children aged 0–2 years with a wheal size of 5 mm or greater will react to egg, while a wheal size of 7 mm or greater is the 95% cutoff for older children.

Unproven or experimental tests for food allergy include intradermal skin tests, "which should never be done," Dr. Spergel warned. "It has a risk of systemic reactions and death. And in people who don't have IgE reactions, there is a fair amount of false positives."

Other unproven tests include provocation/neutralization tests, cytotoxic test, applied kinesiology, hair analysis, electrodermal testing, and food-specific IgG or IgG4. "Some of these tests cost a fortune," he said. "They make some labs very rich but they don't work. Do not recommend them."

Elimination diets for 1–6 weeks might be the most useful for patients with atopic dermatitis, gastrointestinal syndromes, or other chronic diseases.

"For food allergy, the 100% test is an oral food challenge where you give a food and see what happens," Dr. Spergel said. "This may need to be supervised by a physician, and you might need emergency medications available."

If testing for specific IgE antibody is negative, reintroduce the food unless a convincing history warrants a supervised challenge. If it is positive, start the patient on an elimination diet, he said.

If the elimination diet is associated with no resolution, reintroduce the food unless a convincing history warrants a supervised challenge. If the elimination diet is associated with resolution, conduct open or single-blind challenge testing, or double-blind, placebo-controlled testing for equivocal open challenges.

Dr. Spergel disclosed that he has received grant support from Novartis and Ception Therapeutics Inc. and speaker fees from GlaxoSmithKline and Astra-Zeneca Pharmaceuticals LP.

SAN DIEGO — While the number of patients diagnosed with atopic disease is on the rise, the general public might be overestimating the prevalence of food allergy, according to Dr. Jonathan M. Spergel.

At a meeting on skin disorders sponsored by Rady Children's Hospital, Dr. Spergel said that Americans perceive the prevalence of food allergy to be in the range of 20%–25%, whereas the actual prevalence ranges from 6%–8% in infants and young children and 2%–3.5% in adults.

The prevalence is higher in those with atopic dermatitis, certain pollen allergens, and latex allergies. "And [as with] all atopic diseases, the prevalence has risen," said Dr. Spergel, allergy section chief in the division of allergy and immunology at the Children's Hospital of Philadelphia. "It probably has quadrupled in the last 20 years."

Conducting a thorough history is vital and should include asking about symptoms, reproducibility, diet, concurrent exercise, use of nonsteroidal anti-inflammatory medications, and timing of reaction. "The timing is an important thing," he said. "If you eat a food and then react 12 hours later, that's not an IgE-mediated reaction. It may be a non-IgE-mediated reaction."

If you suspect an IgE-mediated allergy, broad screening should not be done without supporting history because of the high rate of false positives. Skin prick tests indicate the presence of IgE antibody but not clinical reactivity. They have a sensitivity rate of 90%, a specificity rate of 50%, and a false-positive rate of 20%–60%, depending on the individual food.

"When you do a skin prick test, look for a wheal or a flare about 15 minutes later," Dr. Spergel said. "They work very well. They're relatively painless … and they're safe. The youngest I've done it was on a 1-week-old. He was a newborn in the nursery. They gave him a bottle of milk and he got hives."

Milk, egg, and peanut account for 85% of food allergies, he said. A predictive value on whether a child will react is based on the size of the wheal from the skin test. The age of the child also affects the size. For example, 95% of children aged 0–2 years with a wheal size of 5 mm or greater will react to egg, while a wheal size of 7 mm or greater is the 95% cutoff for older children.

Unproven or experimental tests for food allergy include intradermal skin tests, "which should never be done," Dr. Spergel warned. "It has a risk of systemic reactions and death. And in people who don't have IgE reactions, there is a fair amount of false positives."

Other unproven tests include provocation/neutralization tests, cytotoxic test, applied kinesiology, hair analysis, electrodermal testing, and food-specific IgG or IgG4. "Some of these tests cost a fortune," he said. "They make some labs very rich but they don't work. Do not recommend them."

Elimination diets for 1–6 weeks might be the most useful for patients with atopic dermatitis, gastrointestinal syndromes, or other chronic diseases.

"For food allergy, the 100% test is an oral food challenge where you give a food and see what happens," Dr. Spergel said. "This may need to be supervised by a physician, and you might need emergency medications available."

If testing for specific IgE antibody is negative, reintroduce the food unless a convincing history warrants a supervised challenge. If it is positive, start the patient on an elimination diet, he said.

If the elimination diet is associated with no resolution, reintroduce the food unless a convincing history warrants a supervised challenge. If the elimination diet is associated with resolution, conduct open or single-blind challenge testing, or double-blind, placebo-controlled testing for equivocal open challenges.

Dr. Spergel disclosed that he has received grant support from Novartis and Ception Therapeutics Inc. and speaker fees from GlaxoSmithKline and Astra-Zeneca Pharmaceuticals LP.

SAN DIEGO — While the number of patients diagnosed with atopic disease is on the rise, the general public might be overestimating the prevalence of food allergy, according to Dr. Jonathan M. Spergel.

At a meeting on skin disorders sponsored by Rady Children's Hospital, Dr. Spergel said that Americans perceive the prevalence of food allergy to be in the range of 20%–25%, whereas the actual prevalence ranges from 6%–8% in infants and young children and 2%–3.5% in adults.

The prevalence is higher in those with atopic dermatitis, certain pollen allergens, and latex allergies. "And [as with] all atopic diseases, the prevalence has risen," said Dr. Spergel, allergy section chief in the division of allergy and immunology at the Children's Hospital of Philadelphia. "It probably has quadrupled in the last 20 years."

Conducting a thorough history is vital and should include asking about symptoms, reproducibility, diet, concurrent exercise, use of nonsteroidal anti-inflammatory medications, and timing of reaction. "The timing is an important thing," he said. "If you eat a food and then react 12 hours later, that's not an IgE-mediated reaction. It may be a non-IgE-mediated reaction."

If you suspect an IgE-mediated allergy, broad screening should not be done without supporting history because of the high rate of false positives. Skin prick tests indicate the presence of IgE antibody but not clinical reactivity. They have a sensitivity rate of 90%, a specificity rate of 50%, and a false-positive rate of 20%–60%, depending on the individual food.

"When you do a skin prick test, look for a wheal or a flare about 15 minutes later," Dr. Spergel said. "They work very well. They're relatively painless … and they're safe. The youngest I've done it was on a 1-week-old. He was a newborn in the nursery. They gave him a bottle of milk and he got hives."

Milk, egg, and peanut account for 85% of food allergies, he said. A predictive value on whether a child will react is based on the size of the wheal from the skin test. The age of the child also affects the size. For example, 95% of children aged 0–2 years with a wheal size of 5 mm or greater will react to egg, while a wheal size of 7 mm or greater is the 95% cutoff for older children.

Unproven or experimental tests for food allergy include intradermal skin tests, "which should never be done," Dr. Spergel warned. "It has a risk of systemic reactions and death. And in people who don't have IgE reactions, there is a fair amount of false positives."

Other unproven tests include provocation/neutralization tests, cytotoxic test, applied kinesiology, hair analysis, electrodermal testing, and food-specific IgG or IgG4. "Some of these tests cost a fortune," he said. "They make some labs very rich but they don't work. Do not recommend them."

Elimination diets for 1–6 weeks might be the most useful for patients with atopic dermatitis, gastrointestinal syndromes, or other chronic diseases.

"For food allergy, the 100% test is an oral food challenge where you give a food and see what happens," Dr. Spergel said. "This may need to be supervised by a physician, and you might need emergency medications available."

If testing for specific IgE antibody is negative, reintroduce the food unless a convincing history warrants a supervised challenge. If it is positive, start the patient on an elimination diet, he said.

If the elimination diet is associated with no resolution, reintroduce the food unless a convincing history warrants a supervised challenge. If the elimination diet is associated with resolution, conduct open or single-blind challenge testing, or double-blind, placebo-controlled testing for equivocal open challenges.

Dr. Spergel disclosed that he has received grant support from Novartis and Ception Therapeutics Inc. and speaker fees from GlaxoSmithKline and Astra-Zeneca Pharmaceuticals LP.

CALGARY, ALTA. — Menopause provides the ideal opportunity to review with patients their risk for heart disease and stroke, and to reinforce heart-healthy behaviors.

“Although it's a bit of a paradigm shift, we need to start talking about heart-healthy behavior in [our] offices,” said Dr. Beth L. Abramson at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada. “There is no doubt that risk of heart disease increases with menopause.”

In Canada, one in three women dies from heart disease and stroke, which makes these two conditions the leading causes of death among women, greater than all forms of cancer combined

“For the first time in 30 years, women have caught up to men when it comes to the number of deaths from cardiovascular disease,” said Dr. Abramson, a cardiologist who directs the cardiac prevention and rehabilitation center at St. Michael's Hospital and is a spokesperson for the Heart and Stroke Foundation of Ontario, both in Toronto.

Moreover, the risk of dying within the first 30 days of a myocardial infarction is 16% higher for women compared with men. The same goes for stroke, which confers an 11% higher risk of death within 30 days for women compared with men. “Women are less likely to be treated by a specialist, are less likely to be transferred to another facility for treatment, and are less likely to undergo cardiac catheterization or revascularization,” she noted.

Despite the well-known risks, awareness of heart disease risk among women is generally poor. According to Dr. Abramson, only one in eight Canadian women understands that heart disease and stroke are her most serious health concerns, whereas only one woman in three knows that the conditions are the leading causes of death.

In an effort to improve the current knowledge gap, Dr. Abramson and her associates at St. Michael's are teaching primary care physicians to administer a Framingham risk calculation as a way to assess a woman's risk of developing coronary artery disease.

A software program calculates the woman's 10-year risk of a heart attack based on factors including age, blood pressure, smoking status, lipids, fasting blood glucose, and family history. The score “may underestimate some risk, but it's what we are using,” she said.

(The assessment is similar to the National Heart, Lung, and Blood Institute's tool for estimating the 10-year risk of having a heart attack, which can be found at http://hp2010.nhlbihin.net/atpiii/calculator.asp

Dr. Abramson also recommends a discussion of risk reduction strategies—including smoking cessation, healthful eating choices, exercise, and weight-loss tips when needed—during each office visit.

“It's very hard to make lifestyle changes,” she acknowledged. “I encourage people to make small changes over time. Most heart attacks aren't sudden; they take many years of preparation.”

Most smokers want to quit, she said, yet only about one-third of smokers report receiving smoking-cessation advice from their physician. She often uses this script, which can be delivered in about 20 seconds: “Do you smoke? I know you understand it's bad for you. It's the worst thing for your health. I can help you quit smoking if you want to.”

Finding a way to personalize the effects of smoking cessation is also key. “Tell the women their skin will look better and younger if they quit,” she said. “That's an important motivator.” So is the phrase, “Your children want you to quit so you can be around for your grandchildren.”

Dr. Abramson pointed out that visceral obesity is associated with conditions that lead to heart disease, including increased LDL cholesterol, decreased HDL cholesterol, high triglycerides, diabetes, insulin resistance, increased insulin levels, abnormal blood clotting, glucose intolerance, and poor blood-vessel function.

“In menopause, the fat distribution of women changes,” she said. “They are more likely to take on an apple-shaped figure than a pear-shaped one.”

The Heart and Stroke Foundation of Canada has launched “The Heart Truth” campaign aimed at educating women about their risk for coronary heart disease.

The campaign includes a dedicated Web site (www.thehearttruth.ca

The campaign advises women to take action and talk with health care professionals about treatment options for risk factors such as high cholesterol, high blood pressure, and smoking.

“You have a role to play,” Dr. Abramson said. “You have an opportunity to take care of women around the time of menopause and try to reduce their risk factors.”

Dr. Abramson disclosed that she receives ongoing research funds from Astra Zeneca Pharmaceuticals LP, Boehringer-Ingelheim Pharmaceuticals Inc., and Merck & Co., and that she has been a speaker for several other pharmaceutical companies.

The presentation was part of a session sponsored by Bayer Healthcare Pharmaceuticals.

Women have caught up to men when it comes to the number of deaths from cardiovascular disease DR. ABRAMSON

CALGARY, ALTA. — Menopause provides the ideal opportunity to review with patients their risk for heart disease and stroke, and to reinforce heart-healthy behaviors.

“Although it's a bit of a paradigm shift, we need to start talking about heart-healthy behavior in [our] offices,” said Dr. Beth L. Abramson at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada. “There is no doubt that risk of heart disease increases with menopause.”

In Canada, one in three women dies from heart disease and stroke, which makes these two conditions the leading causes of death among women, greater than all forms of cancer combined

“For the first time in 30 years, women have caught up to men when it comes to the number of deaths from cardiovascular disease,” said Dr. Abramson, a cardiologist who directs the cardiac prevention and rehabilitation center at St. Michael's Hospital and is a spokesperson for the Heart and Stroke Foundation of Ontario, both in Toronto.

Moreover, the risk of dying within the first 30 days of a myocardial infarction is 16% higher for women compared with men. The same goes for stroke, which confers an 11% higher risk of death within 30 days for women compared with men. “Women are less likely to be treated by a specialist, are less likely to be transferred to another facility for treatment, and are less likely to undergo cardiac catheterization or revascularization,” she noted.

Despite the well-known risks, awareness of heart disease risk among women is generally poor. According to Dr. Abramson, only one in eight Canadian women understands that heart disease and stroke are her most serious health concerns, whereas only one woman in three knows that the conditions are the leading causes of death.

In an effort to improve the current knowledge gap, Dr. Abramson and her associates at St. Michael's are teaching primary care physicians to administer a Framingham risk calculation as a way to assess a woman's risk of developing coronary artery disease.

A software program calculates the woman's 10-year risk of a heart attack based on factors including age, blood pressure, smoking status, lipids, fasting blood glucose, and family history. The score “may underestimate some risk, but it's what we are using,” she said.

(The assessment is similar to the National Heart, Lung, and Blood Institute's tool for estimating the 10-year risk of having a heart attack, which can be found at http://hp2010.nhlbihin.net/atpiii/calculator.asp

Dr. Abramson also recommends a discussion of risk reduction strategies—including smoking cessation, healthful eating choices, exercise, and weight-loss tips when needed—during each office visit.

“It's very hard to make lifestyle changes,” she acknowledged. “I encourage people to make small changes over time. Most heart attacks aren't sudden; they take many years of preparation.”

Most smokers want to quit, she said, yet only about one-third of smokers report receiving smoking-cessation advice from their physician. She often uses this script, which can be delivered in about 20 seconds: “Do you smoke? I know you understand it's bad for you. It's the worst thing for your health. I can help you quit smoking if you want to.”

Finding a way to personalize the effects of smoking cessation is also key. “Tell the women their skin will look better and younger if they quit,” she said. “That's an important motivator.” So is the phrase, “Your children want you to quit so you can be around for your grandchildren.”

Dr. Abramson pointed out that visceral obesity is associated with conditions that lead to heart disease, including increased LDL cholesterol, decreased HDL cholesterol, high triglycerides, diabetes, insulin resistance, increased insulin levels, abnormal blood clotting, glucose intolerance, and poor blood-vessel function.

“In menopause, the fat distribution of women changes,” she said. “They are more likely to take on an apple-shaped figure than a pear-shaped one.”

The Heart and Stroke Foundation of Canada has launched “The Heart Truth” campaign aimed at educating women about their risk for coronary heart disease.

The campaign includes a dedicated Web site (www.thehearttruth.ca

The campaign advises women to take action and talk with health care professionals about treatment options for risk factors such as high cholesterol, high blood pressure, and smoking.

“You have a role to play,” Dr. Abramson said. “You have an opportunity to take care of women around the time of menopause and try to reduce their risk factors.”

Dr. Abramson disclosed that she receives ongoing research funds from Astra Zeneca Pharmaceuticals LP, Boehringer-Ingelheim Pharmaceuticals Inc., and Merck & Co., and that she has been a speaker for several other pharmaceutical companies.

The presentation was part of a session sponsored by Bayer Healthcare Pharmaceuticals.

Women have caught up to men when it comes to the number of deaths from cardiovascular disease DR. ABRAMSON

CALGARY, ALTA. — Menopause provides the ideal opportunity to review with patients their risk for heart disease and stroke, and to reinforce heart-healthy behaviors.

“Although it's a bit of a paradigm shift, we need to start talking about heart-healthy behavior in [our] offices,” said Dr. Beth L. Abramson at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada. “There is no doubt that risk of heart disease increases with menopause.”

In Canada, one in three women dies from heart disease and stroke, which makes these two conditions the leading causes of death among women, greater than all forms of cancer combined

“For the first time in 30 years, women have caught up to men when it comes to the number of deaths from cardiovascular disease,” said Dr. Abramson, a cardiologist who directs the cardiac prevention and rehabilitation center at St. Michael's Hospital and is a spokesperson for the Heart and Stroke Foundation of Ontario, both in Toronto.

Moreover, the risk of dying within the first 30 days of a myocardial infarction is 16% higher for women compared with men. The same goes for stroke, which confers an 11% higher risk of death within 30 days for women compared with men. “Women are less likely to be treated by a specialist, are less likely to be transferred to another facility for treatment, and are less likely to undergo cardiac catheterization or revascularization,” she noted.

Despite the well-known risks, awareness of heart disease risk among women is generally poor. According to Dr. Abramson, only one in eight Canadian women understands that heart disease and stroke are her most serious health concerns, whereas only one woman in three knows that the conditions are the leading causes of death.

In an effort to improve the current knowledge gap, Dr. Abramson and her associates at St. Michael's are teaching primary care physicians to administer a Framingham risk calculation as a way to assess a woman's risk of developing coronary artery disease.

A software program calculates the woman's 10-year risk of a heart attack based on factors including age, blood pressure, smoking status, lipids, fasting blood glucose, and family history. The score “may underestimate some risk, but it's what we are using,” she said.

(The assessment is similar to the National Heart, Lung, and Blood Institute's tool for estimating the 10-year risk of having a heart attack, which can be found at http://hp2010.nhlbihin.net/atpiii/calculator.asp

Dr. Abramson also recommends a discussion of risk reduction strategies—including smoking cessation, healthful eating choices, exercise, and weight-loss tips when needed—during each office visit.

“It's very hard to make lifestyle changes,” she acknowledged. “I encourage people to make small changes over time. Most heart attacks aren't sudden; they take many years of preparation.”

Most smokers want to quit, she said, yet only about one-third of smokers report receiving smoking-cessation advice from their physician. She often uses this script, which can be delivered in about 20 seconds: “Do you smoke? I know you understand it's bad for you. It's the worst thing for your health. I can help you quit smoking if you want to.”

Finding a way to personalize the effects of smoking cessation is also key. “Tell the women their skin will look better and younger if they quit,” she said. “That's an important motivator.” So is the phrase, “Your children want you to quit so you can be around for your grandchildren.”

Dr. Abramson pointed out that visceral obesity is associated with conditions that lead to heart disease, including increased LDL cholesterol, decreased HDL cholesterol, high triglycerides, diabetes, insulin resistance, increased insulin levels, abnormal blood clotting, glucose intolerance, and poor blood-vessel function.

“In menopause, the fat distribution of women changes,” she said. “They are more likely to take on an apple-shaped figure than a pear-shaped one.”

The Heart and Stroke Foundation of Canada has launched “The Heart Truth” campaign aimed at educating women about their risk for coronary heart disease.

The campaign includes a dedicated Web site (www.thehearttruth.ca

The campaign advises women to take action and talk with health care professionals about treatment options for risk factors such as high cholesterol, high blood pressure, and smoking.

“You have a role to play,” Dr. Abramson said. “You have an opportunity to take care of women around the time of menopause and try to reduce their risk factors.”

Dr. Abramson disclosed that she receives ongoing research funds from Astra Zeneca Pharmaceuticals LP, Boehringer-Ingelheim Pharmaceuticals Inc., and Merck & Co., and that she has been a speaker for several other pharmaceutical companies.

The presentation was part of a session sponsored by Bayer Healthcare Pharmaceuticals.

Women have caught up to men when it comes to the number of deaths from cardiovascular disease DR. ABRAMSON

Twenty-one percent of internationally adopted children demonstrated evidence of latent tuberculosis infection on their first tuberculin skin test, according to results from a single-center study.

And the rate of latent TB infection in those retested at least 3 months after a second tuberculin skin test (TST) was 20%.

The findings underscore the need for internationally adopted children to be tested for TB when they arrive in the United States, according to investigators Dr. Indi Trehan of the department of pediatrics at Cincinnati Children's Hospital Medical Center and his associates.

“TB screening is important, and it should be viewed in the context of postinstitutionalized children,” Dr. Todd J. Ochs, a Chicago-based adoption pediatrician who was not affiliated with the study, said in an interview. “Intestinal parasites, especially Giardia lamblia, potential exposure to HIV, hepatitis B and C, syphilis, malnutrition (kwashiorkor and marasmus), developmental delays, and emotional and psychological problems, all are seen in these children. The mantra when assessing them should be 'remember who I was, not who I am.'”

Dr. Trehan and his associates evaluated 527 children at the University of Cincinnati's International Adoption Center who had an initial TST within 2 months of arriving in the United States (Pediatrics 2008;122:e7-e14 [doi:10.1542/peds. 2007–1338]). A repeat TST at least 3 months after the initial one was recommended for those whose initial test was negative or not read.

The mean age of the children was 23 months and 54% were female. Most were from Russia, China, Guatemala, Ka-zakhstan, and South Korea.

Of the 527 children, 111 (21%) had evidence of latent TB infection after their initial TST.

Of the 416 children with an initially negative TST, only 191 (46%) had a repeat test performed and read at least 3 months after their initial TST, even though the researchers recommended repeat testing to adoptive parents and their primary care physicians. Of these, 38 (20%) had evidence of latent TB infection.

“Presumably, these children were not exposed to TB in the United States but instead, at this later date, were better able to mount an appropriate delayed hypersensitivity response to the TST,” the researchers commented.

“The hypothesis that this is perhaps a result of improved nutrition is supported by our data showing that those with an initially positive TST result had a higher weight-for-age z score (−1.13 vs. −1.38),” they wrote.

Dr. Ochs, who is the father of four internationally adopted daughters and one biological daughter, noted that when most internationally adopted children present to physician offices “it's very rare that there is family history, so we're seeing children who we know nothing about their history, and we're trying to assess their health. They all need infectious diseases screening. They all need eye exams, hearing exams, developmental evaluations. Many of them also need psychological support. We need to be meticulous with these kids.”

He recommends administering a repeat TST 6 months after the initial test in internationally adopted children as well as in foster children, “who may have had multiple placements. They may have entered the health care system because they were being handed off from one caregiver to another and may have been exposed to tuberculosis.”

Children should be considered a high-priority group for treatment of TB not only because of their risk for severe disease and lifetime risk for reactivation of disease, but also because they often serve as index cases for widespread transmission of TB, the investigators commented.

Twenty-one percent of internationally adopted children demonstrated evidence of latent tuberculosis infection on their first tuberculin skin test, according to results from a single-center study.

And the rate of latent TB infection in those retested at least 3 months after a second tuberculin skin test (TST) was 20%.

The findings underscore the need for internationally adopted children to be tested for TB when they arrive in the United States, according to investigators Dr. Indi Trehan of the department of pediatrics at Cincinnati Children's Hospital Medical Center and his associates.

“TB screening is important, and it should be viewed in the context of postinstitutionalized children,” Dr. Todd J. Ochs, a Chicago-based adoption pediatrician who was not affiliated with the study, said in an interview. “Intestinal parasites, especially Giardia lamblia, potential exposure to HIV, hepatitis B and C, syphilis, malnutrition (kwashiorkor and marasmus), developmental delays, and emotional and psychological problems, all are seen in these children. The mantra when assessing them should be 'remember who I was, not who I am.'”

Dr. Trehan and his associates evaluated 527 children at the University of Cincinnati's International Adoption Center who had an initial TST within 2 months of arriving in the United States (Pediatrics 2008;122:e7-e14 [doi:10.1542/peds. 2007–1338]). A repeat TST at least 3 months after the initial one was recommended for those whose initial test was negative or not read.

The mean age of the children was 23 months and 54% were female. Most were from Russia, China, Guatemala, Ka-zakhstan, and South Korea.

Of the 527 children, 111 (21%) had evidence of latent TB infection after their initial TST.

Of the 416 children with an initially negative TST, only 191 (46%) had a repeat test performed and read at least 3 months after their initial TST, even though the researchers recommended repeat testing to adoptive parents and their primary care physicians. Of these, 38 (20%) had evidence of latent TB infection.

“Presumably, these children were not exposed to TB in the United States but instead, at this later date, were better able to mount an appropriate delayed hypersensitivity response to the TST,” the researchers commented.

“The hypothesis that this is perhaps a result of improved nutrition is supported by our data showing that those with an initially positive TST result had a higher weight-for-age z score (−1.13 vs. −1.38),” they wrote.

Dr. Ochs, who is the father of four internationally adopted daughters and one biological daughter, noted that when most internationally adopted children present to physician offices “it's very rare that there is family history, so we're seeing children who we know nothing about their history, and we're trying to assess their health. They all need infectious diseases screening. They all need eye exams, hearing exams, developmental evaluations. Many of them also need psychological support. We need to be meticulous with these kids.”

He recommends administering a repeat TST 6 months after the initial test in internationally adopted children as well as in foster children, “who may have had multiple placements. They may have entered the health care system because they were being handed off from one caregiver to another and may have been exposed to tuberculosis.”

Children should be considered a high-priority group for treatment of TB not only because of their risk for severe disease and lifetime risk for reactivation of disease, but also because they often serve as index cases for widespread transmission of TB, the investigators commented.

Twenty-one percent of internationally adopted children demonstrated evidence of latent tuberculosis infection on their first tuberculin skin test, according to results from a single-center study.

And the rate of latent TB infection in those retested at least 3 months after a second tuberculin skin test (TST) was 20%.

The findings underscore the need for internationally adopted children to be tested for TB when they arrive in the United States, according to investigators Dr. Indi Trehan of the department of pediatrics at Cincinnati Children's Hospital Medical Center and his associates.

“TB screening is important, and it should be viewed in the context of postinstitutionalized children,” Dr. Todd J. Ochs, a Chicago-based adoption pediatrician who was not affiliated with the study, said in an interview. “Intestinal parasites, especially Giardia lamblia, potential exposure to HIV, hepatitis B and C, syphilis, malnutrition (kwashiorkor and marasmus), developmental delays, and emotional and psychological problems, all are seen in these children. The mantra when assessing them should be 'remember who I was, not who I am.'”

Dr. Trehan and his associates evaluated 527 children at the University of Cincinnati's International Adoption Center who had an initial TST within 2 months of arriving in the United States (Pediatrics 2008;122:e7-e14 [doi:10.1542/peds. 2007–1338]). A repeat TST at least 3 months after the initial one was recommended for those whose initial test was negative or not read.

The mean age of the children was 23 months and 54% were female. Most were from Russia, China, Guatemala, Ka-zakhstan, and South Korea.

Of the 527 children, 111 (21%) had evidence of latent TB infection after their initial TST.

Of the 416 children with an initially negative TST, only 191 (46%) had a repeat test performed and read at least 3 months after their initial TST, even though the researchers recommended repeat testing to adoptive parents and their primary care physicians. Of these, 38 (20%) had evidence of latent TB infection.

“Presumably, these children were not exposed to TB in the United States but instead, at this later date, were better able to mount an appropriate delayed hypersensitivity response to the TST,” the researchers commented.

“The hypothesis that this is perhaps a result of improved nutrition is supported by our data showing that those with an initially positive TST result had a higher weight-for-age z score (−1.13 vs. −1.38),” they wrote.

Dr. Ochs, who is the father of four internationally adopted daughters and one biological daughter, noted that when most internationally adopted children present to physician offices “it's very rare that there is family history, so we're seeing children who we know nothing about their history, and we're trying to assess their health. They all need infectious diseases screening. They all need eye exams, hearing exams, developmental evaluations. Many of them also need psychological support. We need to be meticulous with these kids.”

He recommends administering a repeat TST 6 months after the initial test in internationally adopted children as well as in foster children, “who may have had multiple placements. They may have entered the health care system because they were being handed off from one caregiver to another and may have been exposed to tuberculosis.”

Children should be considered a high-priority group for treatment of TB not only because of their risk for severe disease and lifetime risk for reactivation of disease, but also because they often serve as index cases for widespread transmission of TB, the investigators commented.

Well before he attended medical school at Columbia University, New York, Dr. Daniel C. Bryant had been captivated by reading and writing, underscored by an undergraduate degree in French literature that he earned from Princeton (N.J.) University in 1961.

In the 1980s, he began to notice that scores of physicians both past and present had written books on nonmedical topics, so he started combing through reference books and secondhand book shops to collect them in earnest.

“The original motivation to collect these books was a combination of my own interest in writing and vicarious writing in a way,” explained Dr. Bryant, who practiced internal medicine for 28 years in Portland, Maine, before retiring in 1999. “But also it occurred to me in my practice that doctors are so privileged in their access to human experience. They generally have such wonderful educations and wonderful opportunities to see all sorts of people and to travel and to have cultural experiences. They are the ideal people, it seemed to me, to comment on human experience.”

Names of physician writers such as Dr. William Carlos Williams (1883-1963), a pediatrician and poet, came to mind right away, Dr. Bryant said. To locate nonmedical works by other physicians, he tapped into a number of sources, including the reference guide “Contemporary Authors”; “Poetry and the Doctors” by Charles L. Dana (Woodstock, N.Y.: The Elm Tree Press, 1916); “Literature and Medicine: An Annotated Bibliography” by Joanne Trautmann and Carol Pollard (Pittsburgh: University of Pittsburgh Press, 1982); and secondhand book shops in the United States and abroad.

During occasional trips to England with his wife he located many books in Hay-on-Wye in Wales, which is “just a village in Wales, but it's almost entirely book shops,” Dr. Bryant said. “We would often spend a few days there, and I'd get a backpack full of books.”

Before the Internet, “the only way to really find out who had what books was through catalogues,” he said. “I was on the mailing list of many secondhand book shops. I'd get these lists in the mail and spend a few hours a week going through them.”

Favorite books he collected include Dr. William Carlos Williams's first editions and “The Silver River” (out of print, 1938), the first book by Dr. Alex Comfort, who is perhaps best known for “The Joy of Sex” (New York: Crown, 1972).

Dr. Bryant also became a fan of the poet Dannie Abse, a radiologist in Wales who writes poetry and plays, and has penned five novels. “He did incorporate his medical experience into his work somewhat,” Dr. Bryant said. “He represents what I was hoping to find: using the medical experience as a window into the bigger human experience and commenting on human experience as a doctor.”

By 2004, his collection grew to more than 1,100 physician-penned books, so he donated them to New York University's Ehrman Medical Library, which established the Bryant Collection of Physician Writers, a permanent collection that is believed to be the largest of its kind (library.med.nyu.edu/library/eresources/featuredcollections/bryant

“I always liked the idea that physicians have a little bigger perspective and humanistic outlook on things and figured that if these books were in an area where medical students, residents, and staff passed by, they would think about that,” said Dr. Bryant, who lives in Cape Elizabeth, Maine. “I thought that a medical library would be a good place for them.”

Over the course of his 20-plus years of collecting the books, he came to realize that he's not alone in his high regard for the craft of writing. “I've had many e-mails and contacts from doctors who write or try to write,” said Dr. Bryant, who has published poems and essays in medical journals, written half a dozen short stories for literary magazines, and written crossword puzzles for the New York Times and Los Angeles Times. “It does seem that a lot of doctors write about medical subjects; there's a lot of interest in medical thrillers. That seems to be a common theme.”

His interest in collecting more physician-penned books “has waned a bit in the last few years, but occasionally I'll send a few more to the Erhman Library that I come across.”

He called the avocation “an escape into something that I quite enjoyed. It was my golf, I guess.”

As for the Bryant Collection of Physician Writers, he hopes that “it will be added to, that it will inspire medical students and other medical people to take down a book and look at it or even spur them on to do a little writing themselves.”

Dr. Daniel C. Bryant donated his collection of physician-penned books to New York University's Ehrman Medical Library. Courtesy Dr. Daniel C. Bryant

Well before he attended medical school at Columbia University, New York, Dr. Daniel C. Bryant had been captivated by reading and writing, underscored by an undergraduate degree in French literature that he earned from Princeton (N.J.) University in 1961.

In the 1980s, he began to notice that scores of physicians both past and present had written books on nonmedical topics, so he started combing through reference books and secondhand book shops to collect them in earnest.

“The original motivation to collect these books was a combination of my own interest in writing and vicarious writing in a way,” explained Dr. Bryant, who practiced internal medicine for 28 years in Portland, Maine, before retiring in 1999. “But also it occurred to me in my practice that doctors are so privileged in their access to human experience. They generally have such wonderful educations and wonderful opportunities to see all sorts of people and to travel and to have cultural experiences. They are the ideal people, it seemed to me, to comment on human experience.”

Names of physician writers such as Dr. William Carlos Williams (1883-1963), a pediatrician and poet, came to mind right away, Dr. Bryant said. To locate nonmedical works by other physicians, he tapped into a number of sources, including the reference guide “Contemporary Authors”; “Poetry and the Doctors” by Charles L. Dana (Woodstock, N.Y.: The Elm Tree Press, 1916); “Literature and Medicine: An Annotated Bibliography” by Joanne Trautmann and Carol Pollard (Pittsburgh: University of Pittsburgh Press, 1982); and secondhand book shops in the United States and abroad.

During occasional trips to England with his wife he located many books in Hay-on-Wye in Wales, which is “just a village in Wales, but it's almost entirely book shops,” Dr. Bryant said. “We would often spend a few days there, and I'd get a backpack full of books.”

Before the Internet, “the only way to really find out who had what books was through catalogues,” he said. “I was on the mailing list of many secondhand book shops. I'd get these lists in the mail and spend a few hours a week going through them.”

Favorite books he collected include Dr. William Carlos Williams's first editions and “The Silver River” (out of print, 1938), the first book by Dr. Alex Comfort, who is perhaps best known for “The Joy of Sex” (New York: Crown, 1972).

Dr. Bryant also became a fan of the poet Dannie Abse, a radiologist in Wales who writes poetry and plays, and has penned five novels. “He did incorporate his medical experience into his work somewhat,” Dr. Bryant said. “He represents what I was hoping to find: using the medical experience as a window into the bigger human experience and commenting on human experience as a doctor.”

By 2004, his collection grew to more than 1,100 physician-penned books, so he donated them to New York University's Ehrman Medical Library, which established the Bryant Collection of Physician Writers, a permanent collection that is believed to be the largest of its kind (library.med.nyu.edu/library/eresources/featuredcollections/bryant

“I always liked the idea that physicians have a little bigger perspective and humanistic outlook on things and figured that if these books were in an area where medical students, residents, and staff passed by, they would think about that,” said Dr. Bryant, who lives in Cape Elizabeth, Maine. “I thought that a medical library would be a good place for them.”

Over the course of his 20-plus years of collecting the books, he came to realize that he's not alone in his high regard for the craft of writing. “I've had many e-mails and contacts from doctors who write or try to write,” said Dr. Bryant, who has published poems and essays in medical journals, written half a dozen short stories for literary magazines, and written crossword puzzles for the New York Times and Los Angeles Times. “It does seem that a lot of doctors write about medical subjects; there's a lot of interest in medical thrillers. That seems to be a common theme.”

His interest in collecting more physician-penned books “has waned a bit in the last few years, but occasionally I'll send a few more to the Erhman Library that I come across.”

He called the avocation “an escape into something that I quite enjoyed. It was my golf, I guess.”

As for the Bryant Collection of Physician Writers, he hopes that “it will be added to, that it will inspire medical students and other medical people to take down a book and look at it or even spur them on to do a little writing themselves.”

Dr. Daniel C. Bryant donated his collection of physician-penned books to New York University's Ehrman Medical Library. Courtesy Dr. Daniel C. Bryant

Well before he attended medical school at Columbia University, New York, Dr. Daniel C. Bryant had been captivated by reading and writing, underscored by an undergraduate degree in French literature that he earned from Princeton (N.J.) University in 1961.

In the 1980s, he began to notice that scores of physicians both past and present had written books on nonmedical topics, so he started combing through reference books and secondhand book shops to collect them in earnest.

“The original motivation to collect these books was a combination of my own interest in writing and vicarious writing in a way,” explained Dr. Bryant, who practiced internal medicine for 28 years in Portland, Maine, before retiring in 1999. “But also it occurred to me in my practice that doctors are so privileged in their access to human experience. They generally have such wonderful educations and wonderful opportunities to see all sorts of people and to travel and to have cultural experiences. They are the ideal people, it seemed to me, to comment on human experience.”

Names of physician writers such as Dr. William Carlos Williams (1883-1963), a pediatrician and poet, came to mind right away, Dr. Bryant said. To locate nonmedical works by other physicians, he tapped into a number of sources, including the reference guide “Contemporary Authors”; “Poetry and the Doctors” by Charles L. Dana (Woodstock, N.Y.: The Elm Tree Press, 1916); “Literature and Medicine: An Annotated Bibliography” by Joanne Trautmann and Carol Pollard (Pittsburgh: University of Pittsburgh Press, 1982); and secondhand book shops in the United States and abroad.

During occasional trips to England with his wife he located many books in Hay-on-Wye in Wales, which is “just a village in Wales, but it's almost entirely book shops,” Dr. Bryant said. “We would often spend a few days there, and I'd get a backpack full of books.”

Before the Internet, “the only way to really find out who had what books was through catalogues,” he said. “I was on the mailing list of many secondhand book shops. I'd get these lists in the mail and spend a few hours a week going through them.”

Favorite books he collected include Dr. William Carlos Williams's first editions and “The Silver River” (out of print, 1938), the first book by Dr. Alex Comfort, who is perhaps best known for “The Joy of Sex” (New York: Crown, 1972).

Dr. Bryant also became a fan of the poet Dannie Abse, a radiologist in Wales who writes poetry and plays, and has penned five novels. “He did incorporate his medical experience into his work somewhat,” Dr. Bryant said. “He represents what I was hoping to find: using the medical experience as a window into the bigger human experience and commenting on human experience as a doctor.”

By 2004, his collection grew to more than 1,100 physician-penned books, so he donated them to New York University's Ehrman Medical Library, which established the Bryant Collection of Physician Writers, a permanent collection that is believed to be the largest of its kind (library.med.nyu.edu/library/eresources/featuredcollections/bryant

“I always liked the idea that physicians have a little bigger perspective and humanistic outlook on things and figured that if these books were in an area where medical students, residents, and staff passed by, they would think about that,” said Dr. Bryant, who lives in Cape Elizabeth, Maine. “I thought that a medical library would be a good place for them.”

Over the course of his 20-plus years of collecting the books, he came to realize that he's not alone in his high regard for the craft of writing. “I've had many e-mails and contacts from doctors who write or try to write,” said Dr. Bryant, who has published poems and essays in medical journals, written half a dozen short stories for literary magazines, and written crossword puzzles for the New York Times and Los Angeles Times. “It does seem that a lot of doctors write about medical subjects; there's a lot of interest in medical thrillers. That seems to be a common theme.”

His interest in collecting more physician-penned books “has waned a bit in the last few years, but occasionally I'll send a few more to the Erhman Library that I come across.”

He called the avocation “an escape into something that I quite enjoyed. It was my golf, I guess.”

As for the Bryant Collection of Physician Writers, he hopes that “it will be added to, that it will inspire medical students and other medical people to take down a book and look at it or even spur them on to do a little writing themselves.”

Dr. Daniel C. Bryant donated his collection of physician-penned books to New York University's Ehrman Medical Library. Courtesy Dr. Daniel C. Bryant

CALGARY, ALTA. — Reassurance, relief, and reassessment are hallmark factors in providing practical management of menopausal symptoms.

“We need to remind women that menopausal symptoms are normal,” Dr. Cynthia Stuenkel said at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada. “For many women, vasomotor symptoms are self-limited. There is a small percentage of women in whom these symptoms go on for a very long period of time. But for most women these symptoms will abate within a number of years.”

Dr. Stuenkel of the division of endocrinology and metabolism at the University of California, San Diego, also emphasized the importance of reassuring women that vaginal symptoms are easy to treat. “I'm surprised that I still encounter women who don't know that there is a whole aisle at their drugstore with vaginal moisturizers and vaginal lubricants, or the fact that we can just use vaginal estrogens,” she commented.

Another key factor in the practical management of menopausal symptoms is providing “relief.” Dr. Stuenkel makes it a point to tell healthy menopausal women that short-term hormone therapy is relatively safe, noting that use of hormone therapy has switched from an emphasis on prevention of heart disease and other disorders to a focus on symptom relief if necessary.

Women opposed to hormone therapy can try alternative strategies for relief of hot flashes, such as lowering their core temperature; getting regular exercise; and avoiding hot flash triggers such as coffee, alcohol, and spicy foods. Nonprescriptive remedies such as soy foods, isoflavones, black cohosh, and vitamin E may work for some women, “though in randomized clinical trials these have not been of particular benefit,” said Dr. Stuenkel, who is a member of the Board of Trustees of the North American Menopause Society.

Clinical trials of paroxetine, fluoxetine, venlafaxine, gabapentin, and clonidine have shown some positive effect on hot flashes. However, the consensus is that for women who are able to take it, hormone therapy most effectively treats vasomotor and vaginal symptoms.

Dr. Stuenkel and other experts advocate initiating hormone therapy at lower doses than those used in the Women's Health Initiative. For example, low-dose forms of oral estrogen found to be effective for treatment of vasomotor symptoms include conjugated equine estrogens 0.3 mg, micronized 17-β-estradiol 0.5 mg, and ethinyl estradiol 2.5 mcg. Low-dose transdermal preparations found to be effective include the 17-β-estradiol patch 25 mcg, cutaneous gel 1–1.25 g, and estrogen lotion (one packet).

Compared with oral preparations of estrogen, Dr. Stuenkel said, transdermal preparations possibly lower levels of venous thromboembolic events, triglycerides, C-reactive protein, and sex hormone-binding globulin.

Another hallmark factor in the practical management of menopausal symptoms is reassessment. “We don't just make a plan and then put these women on autopilot forever,” she said. “Have the symptoms been relieved? With the low-dose therapies it may take longer, and there may not be a complete obliteration of all symptoms, but there should be an improvement.”

If you're giving hormone therapy and symptoms aren't improving at all, “there's a rare woman who may have an absorption problem, but remember to think about other possibilities, such as thyroid disease,” Dr. Stuenkel advised.

How long a woman should remain on hormone therapy remains unclear. The mantra “lowest dose, shortest time” is widely accepted, “but what does that really mean?” Dr. Stuenkel asked. “I'm not sure we really know. The downside to long-term therapy is probably risk of breast cancer, which varies by type of hormone therapy, duration, and timing of exposure.”

Women who quit hormone therapy cold turkey can expect their symptoms to peak at 8–12 weeks, Dr. Stuenkel said. She recommends a tapering schedule by days or by dose.

Dr. Stuenkel had no relevant financial disclosures to make.

The presentation was part of a session sponsored by Bayer HealthCare Pharmaceuticals.

'We don't just make a plan and then put these women on autopilot forever.' DR. STUENKEL

CALGARY, ALTA. — Reassurance, relief, and reassessment are hallmark factors in providing practical management of menopausal symptoms.

“We need to remind women that menopausal symptoms are normal,” Dr. Cynthia Stuenkel said at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada. “For many women, vasomotor symptoms are self-limited. There is a small percentage of women in whom these symptoms go on for a very long period of time. But for most women these symptoms will abate within a number of years.”

Dr. Stuenkel of the division of endocrinology and metabolism at the University of California, San Diego, also emphasized the importance of reassuring women that vaginal symptoms are easy to treat. “I'm surprised that I still encounter women who don't know that there is a whole aisle at their drugstore with vaginal moisturizers and vaginal lubricants, or the fact that we can just use vaginal estrogens,” she commented.

Another key factor in the practical management of menopausal symptoms is providing “relief.” Dr. Stuenkel makes it a point to tell healthy menopausal women that short-term hormone therapy is relatively safe, noting that use of hormone therapy has switched from an emphasis on prevention of heart disease and other disorders to a focus on symptom relief if necessary.

Women opposed to hormone therapy can try alternative strategies for relief of hot flashes, such as lowering their core temperature; getting regular exercise; and avoiding hot flash triggers such as coffee, alcohol, and spicy foods. Nonprescriptive remedies such as soy foods, isoflavones, black cohosh, and vitamin E may work for some women, “though in randomized clinical trials these have not been of particular benefit,” said Dr. Stuenkel, who is a member of the Board of Trustees of the North American Menopause Society.

Clinical trials of paroxetine, fluoxetine, venlafaxine, gabapentin, and clonidine have shown some positive effect on hot flashes. However, the consensus is that for women who are able to take it, hormone therapy most effectively treats vasomotor and vaginal symptoms.

Dr. Stuenkel and other experts advocate initiating hormone therapy at lower doses than those used in the Women's Health Initiative. For example, low-dose forms of oral estrogen found to be effective for treatment of vasomotor symptoms include conjugated equine estrogens 0.3 mg, micronized 17-β-estradiol 0.5 mg, and ethinyl estradiol 2.5 mcg. Low-dose transdermal preparations found to be effective include the 17-β-estradiol patch 25 mcg, cutaneous gel 1–1.25 g, and estrogen lotion (one packet).

Compared with oral preparations of estrogen, Dr. Stuenkel said, transdermal preparations possibly lower levels of venous thromboembolic events, triglycerides, C-reactive protein, and sex hormone-binding globulin.

Another hallmark factor in the practical management of menopausal symptoms is reassessment. “We don't just make a plan and then put these women on autopilot forever,” she said. “Have the symptoms been relieved? With the low-dose therapies it may take longer, and there may not be a complete obliteration of all symptoms, but there should be an improvement.”

If you're giving hormone therapy and symptoms aren't improving at all, “there's a rare woman who may have an absorption problem, but remember to think about other possibilities, such as thyroid disease,” Dr. Stuenkel advised.

How long a woman should remain on hormone therapy remains unclear. The mantra “lowest dose, shortest time” is widely accepted, “but what does that really mean?” Dr. Stuenkel asked. “I'm not sure we really know. The downside to long-term therapy is probably risk of breast cancer, which varies by type of hormone therapy, duration, and timing of exposure.”

Women who quit hormone therapy cold turkey can expect their symptoms to peak at 8–12 weeks, Dr. Stuenkel said. She recommends a tapering schedule by days or by dose.

Dr. Stuenkel had no relevant financial disclosures to make.

The presentation was part of a session sponsored by Bayer HealthCare Pharmaceuticals.

'We don't just make a plan and then put these women on autopilot forever.' DR. STUENKEL

CALGARY, ALTA. — Reassurance, relief, and reassessment are hallmark factors in providing practical management of menopausal symptoms.

“We need to remind women that menopausal symptoms are normal,” Dr. Cynthia Stuenkel said at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada. “For many women, vasomotor symptoms are self-limited. There is a small percentage of women in whom these symptoms go on for a very long period of time. But for most women these symptoms will abate within a number of years.”

Dr. Stuenkel of the division of endocrinology and metabolism at the University of California, San Diego, also emphasized the importance of reassuring women that vaginal symptoms are easy to treat. “I'm surprised that I still encounter women who don't know that there is a whole aisle at their drugstore with vaginal moisturizers and vaginal lubricants, or the fact that we can just use vaginal estrogens,” she commented.

Another key factor in the practical management of menopausal symptoms is providing “relief.” Dr. Stuenkel makes it a point to tell healthy menopausal women that short-term hormone therapy is relatively safe, noting that use of hormone therapy has switched from an emphasis on prevention of heart disease and other disorders to a focus on symptom relief if necessary.

Women opposed to hormone therapy can try alternative strategies for relief of hot flashes, such as lowering their core temperature; getting regular exercise; and avoiding hot flash triggers such as coffee, alcohol, and spicy foods. Nonprescriptive remedies such as soy foods, isoflavones, black cohosh, and vitamin E may work for some women, “though in randomized clinical trials these have not been of particular benefit,” said Dr. Stuenkel, who is a member of the Board of Trustees of the North American Menopause Society.

Clinical trials of paroxetine, fluoxetine, venlafaxine, gabapentin, and clonidine have shown some positive effect on hot flashes. However, the consensus is that for women who are able to take it, hormone therapy most effectively treats vasomotor and vaginal symptoms.

Dr. Stuenkel and other experts advocate initiating hormone therapy at lower doses than those used in the Women's Health Initiative. For example, low-dose forms of oral estrogen found to be effective for treatment of vasomotor symptoms include conjugated equine estrogens 0.3 mg, micronized 17-β-estradiol 0.5 mg, and ethinyl estradiol 2.5 mcg. Low-dose transdermal preparations found to be effective include the 17-β-estradiol patch 25 mcg, cutaneous gel 1–1.25 g, and estrogen lotion (one packet).

Compared with oral preparations of estrogen, Dr. Stuenkel said, transdermal preparations possibly lower levels of venous thromboembolic events, triglycerides, C-reactive protein, and sex hormone-binding globulin.

Another hallmark factor in the practical management of menopausal symptoms is reassessment. “We don't just make a plan and then put these women on autopilot forever,” she said. “Have the symptoms been relieved? With the low-dose therapies it may take longer, and there may not be a complete obliteration of all symptoms, but there should be an improvement.”

If you're giving hormone therapy and symptoms aren't improving at all, “there's a rare woman who may have an absorption problem, but remember to think about other possibilities, such as thyroid disease,” Dr. Stuenkel advised.

How long a woman should remain on hormone therapy remains unclear. The mantra “lowest dose, shortest time” is widely accepted, “but what does that really mean?” Dr. Stuenkel asked. “I'm not sure we really know. The downside to long-term therapy is probably risk of breast cancer, which varies by type of hormone therapy, duration, and timing of exposure.”

Women who quit hormone therapy cold turkey can expect their symptoms to peak at 8–12 weeks, Dr. Stuenkel said. She recommends a tapering schedule by days or by dose.

Dr. Stuenkel had no relevant financial disclosures to make.

The presentation was part of a session sponsored by Bayer HealthCare Pharmaceuticals.

'We don't just make a plan and then put these women on autopilot forever.' DR. STUENKEL

CALGARY, ALTA. — Infertility is a common symptom of women who present with endometriosis. In fact, the American Society for Reproductive Medicine estimates that 30%–50% of women with endometriosis are infertile.

At the annual meeting of the Society of Obstetricians and Gynaecologists of Canada, Dr. Allison Case discussed the common causes of infertility in women with endometriosis. They include the following:

▸ Distorted pelvic anatomy. “We know from laparoscopy that major pelvic adhesions impair tubal function,” said Dr. Case, medical director of the ARTUS Fertility Center at the University of Saskatchewan, Saskatoon. “They impair the release of the oocyte and the ability to pick up or transport the oocyte.”

▸ Altered peritoneal function. Clinical studies have demonstrated that women with endometriosis have increased volume of peritoneal fluid, increased concentration of activated macrophages, and increased peritoneal concentrations of prostaglandins, interleukin-1, tumor necrosis factor, and proteases.

In addition, the peritoneal fluid captures what Dr. Case termed an “ovum capture inhibitor” that prevents normal interaction between the cumulus and the fimbria. These alterations have adverse effects on egg, sperm, embryo, or fallopian tube function.

▸ Altered hormonal and cell-mediated function. Increased IgG and lymphocytes in the endometrium “may alter endometrial receptivity and embryo implantation,” she said.

▸ Endocrine and ovulatory abnormalities. Women with endometriosis are more likely to have luteinized unruptured follicle syndrome, luteal phase dysfunction, abnormal follicular growth, and premature and/or multiple luteinizing hormone surges.

▸ Impaired implantation. “This is an area we're going to hear a lot more about,” said Dr. Case, who is also with the department of obstetrics, gynecology, and reproductive sciences at the university. “The hypothesis is that functional disorders of endometrium may predispose women to the development of endometriosis, but may also impair implantation mechanisms in affected women.”

In 2006, the ASRM Practice Committee concluded that there is no evidence that medical treatment of endometriosis improves fecundity (Fertil. Steril. 2006; 86[suppl. 4]:S156–60). Neither is there evidence that a combination of medical and surgical treatment significantly enhances fertility.

However, a Cochrane review of combined data demonstrated an increased ongoing pregnancy and live birth rate in women who underwent surgery for endometriosis-associated infertility (Cochrane Database Syst. Rev. 2002;CD001398 [doi: 10.1002/14651858.CD001398]). The odds ratio was 1.64, and the number needed to treat was 12.

Another area of study concerns the removal of endometriomas, Dr. Case said. Specifically, does an endometrioma affect the response to stimulation or chance of success with infertility treatment? Conversely, does removal of the endometrioma have a positive or negative effect on treatment?

In a case-control study of 189 women with endometriomas, 133 underwent cystectomy prior to in vitro fertilization (IVF) and 56 went directly to IVF (Fertil. Steril. 2004; 81:1194–7). The researchers found that there was no difference in IVF outcomes between the two groups.

“A significant finding was that patients who had undergone surgery required a higher FSH dose, which raises the question: When we do surgery, are we compromising ovarian reserve in these patients?” Dr. Case said. “When you remove an endometrioma from the ovary, it's very difficult to get clean planes between the endometrioma and the rest of the ovary.”

Results from this study and two others related to ovarian surgery for endometriosis “emphasize the importance of cautious technique, an experienced operator, and meticulous hemostasis,” Dr. Case said.

She recommends limiting surgical treatment to symptomatic women.

“Expectant management is unlikely to be successful,” she said. “IVF is the most effective therapy, although success may be lower than in women with other causes of infertility.”

Dr. Case stated that she had no relevant disclosures to make.

CALGARY, ALTA. — Infertility is a common symptom of women who present with endometriosis. In fact, the American Society for Reproductive Medicine estimates that 30%–50% of women with endometriosis are infertile.

At the annual meeting of the Society of Obstetricians and Gynaecologists of Canada, Dr. Allison Case discussed the common causes of infertility in women with endometriosis. They include the following:

▸ Distorted pelvic anatomy. “We know from laparoscopy that major pelvic adhesions impair tubal function,” said Dr. Case, medical director of the ARTUS Fertility Center at the University of Saskatchewan, Saskatoon. “They impair the release of the oocyte and the ability to pick up or transport the oocyte.”

▸ Altered peritoneal function. Clinical studies have demonstrated that women with endometriosis have increased volume of peritoneal fluid, increased concentration of activated macrophages, and increased peritoneal concentrations of prostaglandins, interleukin-1, tumor necrosis factor, and proteases.

In addition, the peritoneal fluid captures what Dr. Case termed an “ovum capture inhibitor” that prevents normal interaction between the cumulus and the fimbria. These alterations have adverse effects on egg, sperm, embryo, or fallopian tube function.

▸ Altered hormonal and cell-mediated function. Increased IgG and lymphocytes in the endometrium “may alter endometrial receptivity and embryo implantation,” she said.

▸ Endocrine and ovulatory abnormalities. Women with endometriosis are more likely to have luteinized unruptured follicle syndrome, luteal phase dysfunction, abnormal follicular growth, and premature and/or multiple luteinizing hormone surges.

▸ Impaired implantation. “This is an area we're going to hear a lot more about,” said Dr. Case, who is also with the department of obstetrics, gynecology, and reproductive sciences at the university. “The hypothesis is that functional disorders of endometrium may predispose women to the development of endometriosis, but may also impair implantation mechanisms in affected women.”

In 2006, the ASRM Practice Committee concluded that there is no evidence that medical treatment of endometriosis improves fecundity (Fertil. Steril. 2006; 86[suppl. 4]:S156–60). Neither is there evidence that a combination of medical and surgical treatment significantly enhances fertility.

However, a Cochrane review of combined data demonstrated an increased ongoing pregnancy and live birth rate in women who underwent surgery for endometriosis-associated infertility (Cochrane Database Syst. Rev. 2002;CD001398 [doi: 10.1002/14651858.CD001398]). The odds ratio was 1.64, and the number needed to treat was 12.

Another area of study concerns the removal of endometriomas, Dr. Case said. Specifically, does an endometrioma affect the response to stimulation or chance of success with infertility treatment? Conversely, does removal of the endometrioma have a positive or negative effect on treatment?

In a case-control study of 189 women with endometriomas, 133 underwent cystectomy prior to in vitro fertilization (IVF) and 56 went directly to IVF (Fertil. Steril. 2004; 81:1194–7). The researchers found that there was no difference in IVF outcomes between the two groups.

“A significant finding was that patients who had undergone surgery required a higher FSH dose, which raises the question: When we do surgery, are we compromising ovarian reserve in these patients?” Dr. Case said. “When you remove an endometrioma from the ovary, it's very difficult to get clean planes between the endometrioma and the rest of the ovary.”

Results from this study and two others related to ovarian surgery for endometriosis “emphasize the importance of cautious technique, an experienced operator, and meticulous hemostasis,” Dr. Case said.

She recommends limiting surgical treatment to symptomatic women.

“Expectant management is unlikely to be successful,” she said. “IVF is the most effective therapy, although success may be lower than in women with other causes of infertility.”

Dr. Case stated that she had no relevant disclosures to make.

CALGARY, ALTA. — Infertility is a common symptom of women who present with endometriosis. In fact, the American Society for Reproductive Medicine estimates that 30%–50% of women with endometriosis are infertile.

At the annual meeting of the Society of Obstetricians and Gynaecologists of Canada, Dr. Allison Case discussed the common causes of infertility in women with endometriosis. They include the following:

▸ Distorted pelvic anatomy. “We know from laparoscopy that major pelvic adhesions impair tubal function,” said Dr. Case, medical director of the ARTUS Fertility Center at the University of Saskatchewan, Saskatoon. “They impair the release of the oocyte and the ability to pick up or transport the oocyte.”

▸ Altered peritoneal function. Clinical studies have demonstrated that women with endometriosis have increased volume of peritoneal fluid, increased concentration of activated macrophages, and increased peritoneal concentrations of prostaglandins, interleukin-1, tumor necrosis factor, and proteases.

In addition, the peritoneal fluid captures what Dr. Case termed an “ovum capture inhibitor” that prevents normal interaction between the cumulus and the fimbria. These alterations have adverse effects on egg, sperm, embryo, or fallopian tube function.

▸ Altered hormonal and cell-mediated function. Increased IgG and lymphocytes in the endometrium “may alter endometrial receptivity and embryo implantation,” she said.

▸ Endocrine and ovulatory abnormalities. Women with endometriosis are more likely to have luteinized unruptured follicle syndrome, luteal phase dysfunction, abnormal follicular growth, and premature and/or multiple luteinizing hormone surges.

▸ Impaired implantation. “This is an area we're going to hear a lot more about,” said Dr. Case, who is also with the department of obstetrics, gynecology, and reproductive sciences at the university. “The hypothesis is that functional disorders of endometrium may predispose women to the development of endometriosis, but may also impair implantation mechanisms in affected women.”

In 2006, the ASRM Practice Committee concluded that there is no evidence that medical treatment of endometriosis improves fecundity (Fertil. Steril. 2006; 86[suppl. 4]:S156–60). Neither is there evidence that a combination of medical and surgical treatment significantly enhances fertility.

However, a Cochrane review of combined data demonstrated an increased ongoing pregnancy and live birth rate in women who underwent surgery for endometriosis-associated infertility (Cochrane Database Syst. Rev. 2002;CD001398 [doi: 10.1002/14651858.CD001398]). The odds ratio was 1.64, and the number needed to treat was 12.

Another area of study concerns the removal of endometriomas, Dr. Case said. Specifically, does an endometrioma affect the response to stimulation or chance of success with infertility treatment? Conversely, does removal of the endometrioma have a positive or negative effect on treatment?

In a case-control study of 189 women with endometriomas, 133 underwent cystectomy prior to in vitro fertilization (IVF) and 56 went directly to IVF (Fertil. Steril. 2004; 81:1194–7). The researchers found that there was no difference in IVF outcomes between the two groups.

“A significant finding was that patients who had undergone surgery required a higher FSH dose, which raises the question: When we do surgery, are we compromising ovarian reserve in these patients?” Dr. Case said. “When you remove an endometrioma from the ovary, it's very difficult to get clean planes between the endometrioma and the rest of the ovary.”

Results from this study and two others related to ovarian surgery for endometriosis “emphasize the importance of cautious technique, an experienced operator, and meticulous hemostasis,” Dr. Case said.

She recommends limiting surgical treatment to symptomatic women.

“Expectant management is unlikely to be successful,” she said. “IVF is the most effective therapy, although success may be lower than in women with other causes of infertility.”

Dr. Case stated that she had no relevant disclosures to make.

CALGARY, ALTA. — Obese women may not want to hear that their physical condition impacts their fertility, but it's up to clinicians to deliver that sobering news, according to a Canadian fertility center director.

“Obesity is associated with anovulation, pregnancy loss, late-pregnancy complications, and is also associated with infertility treatment failure,” Dr. Allison Case said at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada. “Patients don't want to hear that, but I think it's very important to tell them, not just for their overall health, but for the health of their pregnancy.”

A recent consensus statement from the European Society for Human Reproduction and Embryology and the American Society for Reproductive Medicine on infertility treatment related to polycystic ovary syndrome concluded that treatment of adverse lifestyles, including obesity and physical inactivity, should precede ovulation induction (Human Reprod. 2008;23:462–77).

“We all preach this to our patients but this consensus statement gives us proof to show them that this is what the recommendation is, before we do anything else,” said Dr. Case, medical director of the ARTUS Fertility Center at the University of Saskatchewan, Saskatoon.

Weight loss before infertility treatment has been shown to improve ovulation rates. Results from other studies suggest that weight loss improves fecundity rates and lowers pregnancy complications, “but more studies are needed to support that,” Dr. Case said. “What are the best diet and exercise regimens? That's still to be determined. But the basics of caloric restriction and exercise are what we should be promoting.”

If lifestyle modifications fail to resolve infertility in normogonadotropic anovulatory women, Dr. Case moves on to the use of clomiphene citrate for ovulation induction. The starting dose is 50 mg daily for 5 days starting cycle day 3–5, increasing to about 150 mg daily in subsequent cycles. The approved maximum dose is 750 mg/cycle.

“One of the most important things is to monitor response to clomiphene, which is ovulation,” she said. A decade-long study of clomiphene use found that 52% of women with PCOS will ovulate when given a 50-mg dose, compared with 22% on 10 mg, 12% on 150 mg, and 7% on 200–250 mg (Fertil. Steril. 1982;37:161–7).

“I rarely go higher than 150 mg unless the woman has a high body mass index,” said Dr. Case, who noted that 85% of anovulatory women will ovulate in response to clomiphene while 15% are clomiphene resistant.

The least expensive way to monitor for signs of ovulation is basal body temperature. “It doesn't really cost anything, but it's very tedious,” Dr. Case said. “Luteinizing hormone testing can also be used. This can get expensive, because the ovulation sticks are about $10 each.”

Other options include measuring luteal phase progesterone, “which can be labor intensive,” and serial transvaginal ultrasound monitoring for follicle growth. “We use this a lot in our clinic,” she said. “When all else fails, ask the patient if she got a spontaneous period. If yes, then she most likely ovulated.”

Side effects of clomiphene citrate may include hot flushes, headache, nausea, fatigue, multiple pregnancies (in 8%–10% of women), and ovarian cyst formation (in 8%–20% of women).

Pitfalls of clomiphene citrate therapy include lack of monitoring to determine response, prolonged treatment (more than 6–12 cycles), and the presence of other undetected infertility factors. “I recommend doing an HSG [hysterosalpingogram] at least within the first three cycles, and a semen analysis as well,” Dr. Case said.

Clomiphene is ineffective for women with hypothalamic amenorrhea and hyperprolactinemia.

Dr. Case stated that she had no relevant conflicts to disclose.

'One of the most important things is to monitor response to clomiphene, which is ovulation.' DR. CASE

CALGARY, ALTA. — Obese women may not want to hear that their physical condition impacts their fertility, but it's up to clinicians to deliver that sobering news, according to a Canadian fertility center director.

“Obesity is associated with anovulation, pregnancy loss, late-pregnancy complications, and is also associated with infertility treatment failure,” Dr. Allison Case said at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada. “Patients don't want to hear that, but I think it's very important to tell them, not just for their overall health, but for the health of their pregnancy.”

A recent consensus statement from the European Society for Human Reproduction and Embryology and the American Society for Reproductive Medicine on infertility treatment related to polycystic ovary syndrome concluded that treatment of adverse lifestyles, including obesity and physical inactivity, should precede ovulation induction (Human Reprod. 2008;23:462–77).

“We all preach this to our patients but this consensus statement gives us proof to show them that this is what the recommendation is, before we do anything else,” said Dr. Case, medical director of the ARTUS Fertility Center at the University of Saskatchewan, Saskatoon.

Weight loss before infertility treatment has been shown to improve ovulation rates. Results from other studies suggest that weight loss improves fecundity rates and lowers pregnancy complications, “but more studies are needed to support that,” Dr. Case said. “What are the best diet and exercise regimens? That's still to be determined. But the basics of caloric restriction and exercise are what we should be promoting.”

If lifestyle modifications fail to resolve infertility in normogonadotropic anovulatory women, Dr. Case moves on to the use of clomiphene citrate for ovulation induction. The starting dose is 50 mg daily for 5 days starting cycle day 3–5, increasing to about 150 mg daily in subsequent cycles. The approved maximum dose is 750 mg/cycle.

“One of the most important things is to monitor response to clomiphene, which is ovulation,” she said. A decade-long study of clomiphene use found that 52% of women with PCOS will ovulate when given a 50-mg dose, compared with 22% on 10 mg, 12% on 150 mg, and 7% on 200–250 mg (Fertil. Steril. 1982;37:161–7).

“I rarely go higher than 150 mg unless the woman has a high body mass index,” said Dr. Case, who noted that 85% of anovulatory women will ovulate in response to clomiphene while 15% are clomiphene resistant.

The least expensive way to monitor for signs of ovulation is basal body temperature. “It doesn't really cost anything, but it's very tedious,” Dr. Case said. “Luteinizing hormone testing can also be used. This can get expensive, because the ovulation sticks are about $10 each.”

Other options include measuring luteal phase progesterone, “which can be labor intensive,” and serial transvaginal ultrasound monitoring for follicle growth. “We use this a lot in our clinic,” she said. “When all else fails, ask the patient if she got a spontaneous period. If yes, then she most likely ovulated.”

Side effects of clomiphene citrate may include hot flushes, headache, nausea, fatigue, multiple pregnancies (in 8%–10% of women), and ovarian cyst formation (in 8%–20% of women).

Pitfalls of clomiphene citrate therapy include lack of monitoring to determine response, prolonged treatment (more than 6–12 cycles), and the presence of other undetected infertility factors. “I recommend doing an HSG [hysterosalpingogram] at least within the first three cycles, and a semen analysis as well,” Dr. Case said.

Clomiphene is ineffective for women with hypothalamic amenorrhea and hyperprolactinemia.

Dr. Case stated that she had no relevant conflicts to disclose.

'One of the most important things is to monitor response to clomiphene, which is ovulation.' DR. CASE

CALGARY, ALTA. — Obese women may not want to hear that their physical condition impacts their fertility, but it's up to clinicians to deliver that sobering news, according to a Canadian fertility center director.

“Obesity is associated with anovulation, pregnancy loss, late-pregnancy complications, and is also associated with infertility treatment failure,” Dr. Allison Case said at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada. “Patients don't want to hear that, but I think it's very important to tell them, not just for their overall health, but for the health of their pregnancy.”

A recent consensus statement from the European Society for Human Reproduction and Embryology and the American Society for Reproductive Medicine on infertility treatment related to polycystic ovary syndrome concluded that treatment of adverse lifestyles, including obesity and physical inactivity, should precede ovulation induction (Human Reprod. 2008;23:462–77).

“We all preach this to our patients but this consensus statement gives us proof to show them that this is what the recommendation is, before we do anything else,” said Dr. Case, medical director of the ARTUS Fertility Center at the University of Saskatchewan, Saskatoon.

Weight loss before infertility treatment has been shown to improve ovulation rates. Results from other studies suggest that weight loss improves fecundity rates and lowers pregnancy complications, “but more studies are needed to support that,” Dr. Case said. “What are the best diet and exercise regimens? That's still to be determined. But the basics of caloric restriction and exercise are what we should be promoting.”

If lifestyle modifications fail to resolve infertility in normogonadotropic anovulatory women, Dr. Case moves on to the use of clomiphene citrate for ovulation induction. The starting dose is 50 mg daily for 5 days starting cycle day 3–5, increasing to about 150 mg daily in subsequent cycles. The approved maximum dose is 750 mg/cycle.

“One of the most important things is to monitor response to clomiphene, which is ovulation,” she said. A decade-long study of clomiphene use found that 52% of women with PCOS will ovulate when given a 50-mg dose, compared with 22% on 10 mg, 12% on 150 mg, and 7% on 200–250 mg (Fertil. Steril. 1982;37:161–7).

“I rarely go higher than 150 mg unless the woman has a high body mass index,” said Dr. Case, who noted that 85% of anovulatory women will ovulate in response to clomiphene while 15% are clomiphene resistant.

The least expensive way to monitor for signs of ovulation is basal body temperature. “It doesn't really cost anything, but it's very tedious,” Dr. Case said. “Luteinizing hormone testing can also be used. This can get expensive, because the ovulation sticks are about $10 each.”

Other options include measuring luteal phase progesterone, “which can be labor intensive,” and serial transvaginal ultrasound monitoring for follicle growth. “We use this a lot in our clinic,” she said. “When all else fails, ask the patient if she got a spontaneous period. If yes, then she most likely ovulated.”

Side effects of clomiphene citrate may include hot flushes, headache, nausea, fatigue, multiple pregnancies (in 8%–10% of women), and ovarian cyst formation (in 8%–20% of women).

Pitfalls of clomiphene citrate therapy include lack of monitoring to determine response, prolonged treatment (more than 6–12 cycles), and the presence of other undetected infertility factors. “I recommend doing an HSG [hysterosalpingogram] at least within the first three cycles, and a semen analysis as well,” Dr. Case said.

Clomiphene is ineffective for women with hypothalamic amenorrhea and hyperprolactinemia.

Dr. Case stated that she had no relevant conflicts to disclose.

'One of the most important things is to monitor response to clomiphene, which is ovulation.' DR. CASE

SAN DIEGO — Significant reductions in peri-procedural embolic events were achieved after implementation of quality improvement measures for carotid angioplasty and stenting, results from a single-center study showed.

In a previous report, Dr. Maureen M. Tedesco and her associates in the division of vascular and endovascular surgery at Stanford (Calif.) University found a 70% incidence of microemboli in patients who underwent carotid angioplasty and stenting (CAS) as detected by diffusion weighted MRI, compared with no microemboli in those who received carotid endarterectomy for carotid disease (J. Vasc. Surg. 2007;46:244–50).

“Although there was a much higher incidence of microemboli after CAS, most of the emboli were asymptomatic; only two of the CAS patients who had microemboli demonstrated temporary neurologic symptoms that resolved within 24 hours,” Dr. Tedesco said at the Vascular Annual Meeting. “Of all patient demographic, anatomic, and procedure-related factors that were analyzed, only the performance of arch angiography and history of significant coronary artery disease were associated with an increased risk of microemboli formation.”

Before publication of that report, the vascular group at Stanford demonstrated that a multidisciplinary peer review process for carotid procedures at Stanford University Medical Center reduced the risk and cost of surgical endarterectomy (Arch. Surg. 2000; 135; 939–42). In an effort to study the impact of this peer review process since the advent of the CAS program at Stanford, two time periods were compared before and after quality-improvement measures were implemented, under the direction of the project's principal investigator, Dr. Jason T. Lee, director of endovascular surgery at Stanford University Medical Center.

Period 1 (November 2004 through April 2006) included a review of 27 patients undergoing CAS with pre- and postprocedure diffusion-weighted MRI. “During period 1, our standard protocol for CAS included performance under local anesthesia, routine arch angiography, use of a distal protection device, pre- and poststent deployment balloon dilatation, and completion intracranial cerebral angiograms,” Dr. Tedesco said.

Period 2 (May 2006 through February 2008) was a prospective analysis of 20 patients undergoing CAS who underwent pre- and postprocedure MRI. The quality improvement measures implemented during period 2 included early heparinization “as soon as groin access was obtained as opposed to period 1 when heparinization was instituted after sheath placement into the target common carotid artery; the preferential change to a closed cell carotid stent system [Abbott Xact stent], and elimination of routine arch angiography.”

The researchers then reviewed the hospital records of all patients and collected symptoms, comorbidities, lesion characteristics, preprocedural information, and postoperative outcomes. They used diffusion-weighted MRI to determine the incidence and location of acute, postprocedural microemboli.

The mean age of patients was 70 years and most (90%) were male. There were no differences between period 1 and period 2 patients with respect to gender, the presence of diabetes, hypertension, or hyperlipidemia. However, there was a higher percentage of smokers in period 1 and a higher incidence of obesity in period 2 patients. In addition, analysis of comorbidities revealed that there were no differences between period 1 and period 2 in terms of history of coronary artery disease, chronic obstructive pulmonary disease, peripheral vascular disease, atrial fibrillation, redo CAS procedures, or symptomatic patients.

Compared with period 1 patients, period 2 patients had significantly more calcified lesions (68% vs. 27%, respectively), longer lesions (15.9 mm vs. 8.2 mm), and ulceration of their lesions (55% vs. 27%), but there were no differences between the two groups in the type of arch. “[These data suggest] that the period 2 lesions were perhaps technically more challenging than the period 1 lesions,” Dr. Tedesco commented.

Further analysis showed no differences between the two groups in fluoroscopy time or in the number of stents used. However, period 2 patients received significantly less contrast volume than did period 1 patients (58 mL vs. 77 mL, respectively). This difference “is likely due to the elimination of the routine arch angiography,” she said.

Dr. Tedesco reported the main findings of the study, that 20 patients from period 1 (74%) and 7 patients from period 2 (35%) demonstrated acute microemboli on postprocedural MRI, a difference that was statistically significant. The mean number of microemboli was 4.1 in period 1 patients, and 1.5 in period 2 patients, a difference that was also statistically significant.

Even with these microemboli, however, only two patients in period 1 and one of the patients in period 2 experienced temporary neurologic symptoms that resolved within 24 hours. The 30-day stroke rate in both groups was 0%.

“The long-term neurologic benefits associated with reduced subclinical neurologic events remains to be determined, but there remains a significant risk of microemboli as identified by diffusion- weighed magnetic resonance imaging following carotid angioplasty and stenting,” Dr. Tedesco concluded. “Efforts to reduce these subclinical radiographic findings may have a positive impact on long-term outcomes after CAS with respect to device improvement, procedural modifications, and patient selection.”

Dr. Tedesco and Dr. Lee had no conflicts to disclose.

There was a much higher incidence of microemboli after CAS, but most were asymptomatic. DR. TEDESCO

This diffusion-weighted MRI image demonstrates the presence of microemboli. Courtesy Dr. Maureen M. Tedesco

SAN DIEGO — Significant reductions in peri-procedural embolic events were achieved after implementation of quality improvement measures for carotid angioplasty and stenting, results from a single-center study showed.

In a previous report, Dr. Maureen M. Tedesco and her associates in the division of vascular and endovascular surgery at Stanford (Calif.) University found a 70% incidence of microemboli in patients who underwent carotid angioplasty and stenting (CAS) as detected by diffusion weighted MRI, compared with no microemboli in those who received carotid endarterectomy for carotid disease (J. Vasc. Surg. 2007;46:244–50).

“Although there was a much higher incidence of microemboli after CAS, most of the emboli were asymptomatic; only two of the CAS patients who had microemboli demonstrated temporary neurologic symptoms that resolved within 24 hours,” Dr. Tedesco said at the Vascular Annual Meeting. “Of all patient demographic, anatomic, and procedure-related factors that were analyzed, only the performance of arch angiography and history of significant coronary artery disease were associated with an increased risk of microemboli formation.”

Before publication of that report, the vascular group at Stanford demonstrated that a multidisciplinary peer review process for carotid procedures at Stanford University Medical Center reduced the risk and cost of surgical endarterectomy (Arch. Surg. 2000; 135; 939–42). In an effort to study the impact of this peer review process since the advent of the CAS program at Stanford, two time periods were compared before and after quality-improvement measures were implemented, under the direction of the project's principal investigator, Dr. Jason T. Lee, director of endovascular surgery at Stanford University Medical Center.

Period 1 (November 2004 through April 2006) included a review of 27 patients undergoing CAS with pre- and postprocedure diffusion-weighted MRI. “During period 1, our standard protocol for CAS included performance under local anesthesia, routine arch angiography, use of a distal protection device, pre- and poststent deployment balloon dilatation, and completion intracranial cerebral angiograms,” Dr. Tedesco said.

Period 2 (May 2006 through February 2008) was a prospective analysis of 20 patients undergoing CAS who underwent pre- and postprocedure MRI. The quality improvement measures implemented during period 2 included early heparinization “as soon as groin access was obtained as opposed to period 1 when heparinization was instituted after sheath placement into the target common carotid artery; the preferential change to a closed cell carotid stent system [Abbott Xact stent], and elimination of routine arch angiography.”

The researchers then reviewed the hospital records of all patients and collected symptoms, comorbidities, lesion characteristics, preprocedural information, and postoperative outcomes. They used diffusion-weighted MRI to determine the incidence and location of acute, postprocedural microemboli.

The mean age of patients was 70 years and most (90%) were male. There were no differences between period 1 and period 2 patients with respect to gender, the presence of diabetes, hypertension, or hyperlipidemia. However, there was a higher percentage of smokers in period 1 and a higher incidence of obesity in period 2 patients. In addition, analysis of comorbidities revealed that there were no differences between period 1 and period 2 in terms of history of coronary artery disease, chronic obstructive pulmonary disease, peripheral vascular disease, atrial fibrillation, redo CAS procedures, or symptomatic patients.

Compared with period 1 patients, period 2 patients had significantly more calcified lesions (68% vs. 27%, respectively), longer lesions (15.9 mm vs. 8.2 mm), and ulceration of their lesions (55% vs. 27%), but there were no differences between the two groups in the type of arch. “[These data suggest] that the period 2 lesions were perhaps technically more challenging than the period 1 lesions,” Dr. Tedesco commented.

Further analysis showed no differences between the two groups in fluoroscopy time or in the number of stents used. However, period 2 patients received significantly less contrast volume than did period 1 patients (58 mL vs. 77 mL, respectively). This difference “is likely due to the elimination of the routine arch angiography,” she said.

Dr. Tedesco reported the main findings of the study, that 20 patients from period 1 (74%) and 7 patients from period 2 (35%) demonstrated acute microemboli on postprocedural MRI, a difference that was statistically significant. The mean number of microemboli was 4.1 in period 1 patients, and 1.5 in period 2 patients, a difference that was also statistically significant.

Even with these microemboli, however, only two patients in period 1 and one of the patients in period 2 experienced temporary neurologic symptoms that resolved within 24 hours. The 30-day stroke rate in both groups was 0%.

“The long-term neurologic benefits associated with reduced subclinical neurologic events remains to be determined, but there remains a significant risk of microemboli as identified by diffusion- weighed magnetic resonance imaging following carotid angioplasty and stenting,” Dr. Tedesco concluded. “Efforts to reduce these subclinical radiographic findings may have a positive impact on long-term outcomes after CAS with respect to device improvement, procedural modifications, and patient selection.”

Dr. Tedesco and Dr. Lee had no conflicts to disclose.

There was a much higher incidence of microemboli after CAS, but most were asymptomatic. DR. TEDESCO

This diffusion-weighted MRI image demonstrates the presence of microemboli. Courtesy Dr. Maureen M. Tedesco

SAN DIEGO — Significant reductions in peri-procedural embolic events were achieved after implementation of quality improvement measures for carotid angioplasty and stenting, results from a single-center study showed.

In a previous report, Dr. Maureen M. Tedesco and her associates in the division of vascular and endovascular surgery at Stanford (Calif.) University found a 70% incidence of microemboli in patients who underwent carotid angioplasty and stenting (CAS) as detected by diffusion weighted MRI, compared with no microemboli in those who received carotid endarterectomy for carotid disease (J. Vasc. Surg. 2007;46:244–50).

“Although there was a much higher incidence of microemboli after CAS, most of the emboli were asymptomatic; only two of the CAS patients who had microemboli demonstrated temporary neurologic symptoms that resolved within 24 hours,” Dr. Tedesco said at the Vascular Annual Meeting. “Of all patient demographic, anatomic, and procedure-related factors that were analyzed, only the performance of arch angiography and history of significant coronary artery disease were associated with an increased risk of microemboli formation.”

Before publication of that report, the vascular group at Stanford demonstrated that a multidisciplinary peer review process for carotid procedures at Stanford University Medical Center reduced the risk and cost of surgical endarterectomy (Arch. Surg. 2000; 135; 939–42). In an effort to study the impact of this peer review process since the advent of the CAS program at Stanford, two time periods were compared before and after quality-improvement measures were implemented, under the direction of the project's principal investigator, Dr. Jason T. Lee, director of endovascular surgery at Stanford University Medical Center.

Period 1 (November 2004 through April 2006) included a review of 27 patients undergoing CAS with pre- and postprocedure diffusion-weighted MRI. “During period 1, our standard protocol for CAS included performance under local anesthesia, routine arch angiography, use of a distal protection device, pre- and poststent deployment balloon dilatation, and completion intracranial cerebral angiograms,” Dr. Tedesco said.

Period 2 (May 2006 through February 2008) was a prospective analysis of 20 patients undergoing CAS who underwent pre- and postprocedure MRI. The quality improvement measures implemented during period 2 included early heparinization “as soon as groin access was obtained as opposed to period 1 when heparinization was instituted after sheath placement into the target common carotid artery; the preferential change to a closed cell carotid stent system [Abbott Xact stent], and elimination of routine arch angiography.”

The researchers then reviewed the hospital records of all patients and collected symptoms, comorbidities, lesion characteristics, preprocedural information, and postoperative outcomes. They used diffusion-weighted MRI to determine the incidence and location of acute, postprocedural microemboli.

The mean age of patients was 70 years and most (90%) were male. There were no differences between period 1 and period 2 patients with respect to gender, the presence of diabetes, hypertension, or hyperlipidemia. However, there was a higher percentage of smokers in period 1 and a higher incidence of obesity in period 2 patients. In addition, analysis of comorbidities revealed that there were no differences between period 1 and period 2 in terms of history of coronary artery disease, chronic obstructive pulmonary disease, peripheral vascular disease, atrial fibrillation, redo CAS procedures, or symptomatic patients.

Compared with period 1 patients, period 2 patients had significantly more calcified lesions (68% vs. 27%, respectively), longer lesions (15.9 mm vs. 8.2 mm), and ulceration of their lesions (55% vs. 27%), but there were no differences between the two groups in the type of arch. “[These data suggest] that the period 2 lesions were perhaps technically more challenging than the period 1 lesions,” Dr. Tedesco commented.

Further analysis showed no differences between the two groups in fluoroscopy time or in the number of stents used. However, period 2 patients received significantly less contrast volume than did period 1 patients (58 mL vs. 77 mL, respectively). This difference “is likely due to the elimination of the routine arch angiography,” she said.

Dr. Tedesco reported the main findings of the study, that 20 patients from period 1 (74%) and 7 patients from period 2 (35%) demonstrated acute microemboli on postprocedural MRI, a difference that was statistically significant. The mean number of microemboli was 4.1 in period 1 patients, and 1.5 in period 2 patients, a difference that was also statistically significant.

Even with these microemboli, however, only two patients in period 1 and one of the patients in period 2 experienced temporary neurologic symptoms that resolved within 24 hours. The 30-day stroke rate in both groups was 0%.

“The long-term neurologic benefits associated with reduced subclinical neurologic events remains to be determined, but there remains a significant risk of microemboli as identified by diffusion- weighed magnetic resonance imaging following carotid angioplasty and stenting,” Dr. Tedesco concluded. “Efforts to reduce these subclinical radiographic findings may have a positive impact on long-term outcomes after CAS with respect to device improvement, procedural modifications, and patient selection.”

Dr. Tedesco and Dr. Lee had no conflicts to disclose.

There was a much higher incidence of microemboli after CAS, but most were asymptomatic. DR. TEDESCO

This diffusion-weighted MRI image demonstrates the presence of microemboli. Courtesy Dr. Maureen M. Tedesco