Doug Brunk

Be alert to the possibility of Rocky Mountain spotted fever in endemic areas when any of four common symptoms present, especially in spring or summer, results of a new study suggest.

Common symptoms are fever, rash, nausea and/or vomiting, and headache.

Moreover, a medical outpatient visit early in the course of illness is significantly associated with delay in therapy.

Those are key findings from a review of 92 children with laboratory-confirmed Rocky Mountain spotted fever who were treated at six medical centers in the South Central United States between Jan. 1, 1990, and Dec. 31, 2002.

Diagnosis of the condition “should be considered in children in the first few days of their illness who have any single compatible finding especially during the spring and summer,” wrote the researchers, who were led by Dr. Steven C. Buckingham of the department of pediatrics at the University of Tennessee, Memphis. “Children generally improve markedly after starting antirickettsial therapy—as demonstrated by, on average, defervescence within 2 days and hospital discharge within 5 days. Those outcomes are certainly worth achieving.”

He and his associates with the Tick-Borne Infections in Children Study Group reviewed the demographic, clinical, and laboratory data from the medical charts of 92 children with the illness (J. Pediatr. 2007;150:180–4). Their mean age was 6 years and most (92%) were white.

The researchers reported that children presented to the respective medical centers after a median of 6 days of symptoms. The four most common symptoms were fever (98%), rash, (97%), nausea and/or vomiting (73%), and headache (61%); 49% of children reported antecedent tick bites.

Blood platelet counts were below 150,000/mm

Most (86%) sought medical care before hospital admission yet only four patients received antirickettsial therapy during that time. Delays in treatment “occurred not because patients … failed to seek medical attention, but because their treating clinicians failed to consider [the diagnosis],” the researchers wrote. “Such diagnostic misadventures are understandable given the nonspecificity of the usual presenting clinical and laboratory features.”

Three children died and 13 had neurologic deficits on discharge, including speech and/or swallowing dysfunction (6 patients), global encephalopathy (4), ataxia or other gait disturbances (4), and cortical blindness (1). Follow-up data were available for only five: One had weakness that resolved by 10 days after discharge; the other four had persistent abnormalities reported from 2 months to 4 years after discharge, the researchers said.

Antirickettsial therapy included doxycycline alone, chloramphenicol alone, tetracycline alone, doxycycline plus chloramphenicol, and tetracycline plus chloramphenicol.

Since 1994, doxycycline alone has been the sole treatment used.

The study was limited by the fact that only medical records were analyzed and that serologic testing for the disease is an imperfect science.

Be alert to the possibility of Rocky Mountain spotted fever in endemic areas when any of four common symptoms present, especially in spring or summer, results of a new study suggest.

Common symptoms are fever, rash, nausea and/or vomiting, and headache.

Moreover, a medical outpatient visit early in the course of illness is significantly associated with delay in therapy.

Those are key findings from a review of 92 children with laboratory-confirmed Rocky Mountain spotted fever who were treated at six medical centers in the South Central United States between Jan. 1, 1990, and Dec. 31, 2002.

Diagnosis of the condition “should be considered in children in the first few days of their illness who have any single compatible finding especially during the spring and summer,” wrote the researchers, who were led by Dr. Steven C. Buckingham of the department of pediatrics at the University of Tennessee, Memphis. “Children generally improve markedly after starting antirickettsial therapy—as demonstrated by, on average, defervescence within 2 days and hospital discharge within 5 days. Those outcomes are certainly worth achieving.”

He and his associates with the Tick-Borne Infections in Children Study Group reviewed the demographic, clinical, and laboratory data from the medical charts of 92 children with the illness (J. Pediatr. 2007;150:180–4). Their mean age was 6 years and most (92%) were white.

The researchers reported that children presented to the respective medical centers after a median of 6 days of symptoms. The four most common symptoms were fever (98%), rash, (97%), nausea and/or vomiting (73%), and headache (61%); 49% of children reported antecedent tick bites.

Blood platelet counts were below 150,000/mm

Most (86%) sought medical care before hospital admission yet only four patients received antirickettsial therapy during that time. Delays in treatment “occurred not because patients … failed to seek medical attention, but because their treating clinicians failed to consider [the diagnosis],” the researchers wrote. “Such diagnostic misadventures are understandable given the nonspecificity of the usual presenting clinical and laboratory features.”

Three children died and 13 had neurologic deficits on discharge, including speech and/or swallowing dysfunction (6 patients), global encephalopathy (4), ataxia or other gait disturbances (4), and cortical blindness (1). Follow-up data were available for only five: One had weakness that resolved by 10 days after discharge; the other four had persistent abnormalities reported from 2 months to 4 years after discharge, the researchers said.

Antirickettsial therapy included doxycycline alone, chloramphenicol alone, tetracycline alone, doxycycline plus chloramphenicol, and tetracycline plus chloramphenicol.

Since 1994, doxycycline alone has been the sole treatment used.

The study was limited by the fact that only medical records were analyzed and that serologic testing for the disease is an imperfect science.

Be alert to the possibility of Rocky Mountain spotted fever in endemic areas when any of four common symptoms present, especially in spring or summer, results of a new study suggest.

Common symptoms are fever, rash, nausea and/or vomiting, and headache.

Moreover, a medical outpatient visit early in the course of illness is significantly associated with delay in therapy.

Those are key findings from a review of 92 children with laboratory-confirmed Rocky Mountain spotted fever who were treated at six medical centers in the South Central United States between Jan. 1, 1990, and Dec. 31, 2002.

Diagnosis of the condition “should be considered in children in the first few days of their illness who have any single compatible finding especially during the spring and summer,” wrote the researchers, who were led by Dr. Steven C. Buckingham of the department of pediatrics at the University of Tennessee, Memphis. “Children generally improve markedly after starting antirickettsial therapy—as demonstrated by, on average, defervescence within 2 days and hospital discharge within 5 days. Those outcomes are certainly worth achieving.”

He and his associates with the Tick-Borne Infections in Children Study Group reviewed the demographic, clinical, and laboratory data from the medical charts of 92 children with the illness (J. Pediatr. 2007;150:180–4). Their mean age was 6 years and most (92%) were white.

The researchers reported that children presented to the respective medical centers after a median of 6 days of symptoms. The four most common symptoms were fever (98%), rash, (97%), nausea and/or vomiting (73%), and headache (61%); 49% of children reported antecedent tick bites.

Blood platelet counts were below 150,000/mm

Most (86%) sought medical care before hospital admission yet only four patients received antirickettsial therapy during that time. Delays in treatment “occurred not because patients … failed to seek medical attention, but because their treating clinicians failed to consider [the diagnosis],” the researchers wrote. “Such diagnostic misadventures are understandable given the nonspecificity of the usual presenting clinical and laboratory features.”

Three children died and 13 had neurologic deficits on discharge, including speech and/or swallowing dysfunction (6 patients), global encephalopathy (4), ataxia or other gait disturbances (4), and cortical blindness (1). Follow-up data were available for only five: One had weakness that resolved by 10 days after discharge; the other four had persistent abnormalities reported from 2 months to 4 years after discharge, the researchers said.

Antirickettsial therapy included doxycycline alone, chloramphenicol alone, tetracycline alone, doxycycline plus chloramphenicol, and tetracycline plus chloramphenicol.

Since 1994, doxycycline alone has been the sole treatment used.

The study was limited by the fact that only medical records were analyzed and that serologic testing for the disease is an imperfect science.

CARMEL, CALIF. — Cognitively impaired older adults who participate in exercise rehabilitation programs have similar strength and endurance outcomes as their cognitively intact peers, results from a large meta-analysis showed.

The finding suggests that cognitively impaired older adults should not be excluded from rehabilitation programs, Kyle E. Johnson reported at the Western regional meeting of the American Federation for Medical Research.

“It's a fallacy that cognitively impaired older adults are unable to follow instructions and that they will not benefit from physical therapy,” said Mr. Johnson, who is a second-year medical student at the University of Colorado, Denver.

He and his associate, Patricia C. Heyn, Ph.D., of the university's division of geriatric medicine, searched electronic and printed databases for randomized, controlled trials that included physical rehabilitation outcomes of cognitively impaired older adults (defined as those with a Mini-Mental State Examination score of less than 24) and cognitively intact older adults (defined as those with an MMSE score of 24 or higher).

Of the more than 500 articles reviewed, 41 met inclusion criteria. Of these, 21 trials involved 1,411 older adults with cognitive impairment and 20 trials involved 1,565 older adults who were cognitively intact. The mean age of the patients was 81 years.

The mean MMSE score among the cognitively impaired older adults was 16, compared with a mean MMSE score of 28 among those who were cognitively intact.

When the researchers combined the strength and endurance outcomes from the two groups, they observed an effect size of 0.51 for the cognitively impaired elderly and an effect size of 0.49 for the cognitively intact elderly. No statistically significant differences were seen in the strength and endurance outcomes between the two groups.

“Every study showed a positive result” from physical exercise, Mr. Johnson said. “We need more research to directly compare these two groups and to consider the need for different exercise guidelines for varying degrees of cognitive impairment.”

CARMEL, CALIF. — Cognitively impaired older adults who participate in exercise rehabilitation programs have similar strength and endurance outcomes as their cognitively intact peers, results from a large meta-analysis showed.

The finding suggests that cognitively impaired older adults should not be excluded from rehabilitation programs, Kyle E. Johnson reported at the Western regional meeting of the American Federation for Medical Research.

“It's a fallacy that cognitively impaired older adults are unable to follow instructions and that they will not benefit from physical therapy,” said Mr. Johnson, who is a second-year medical student at the University of Colorado, Denver.

He and his associate, Patricia C. Heyn, Ph.D., of the university's division of geriatric medicine, searched electronic and printed databases for randomized, controlled trials that included physical rehabilitation outcomes of cognitively impaired older adults (defined as those with a Mini-Mental State Examination score of less than 24) and cognitively intact older adults (defined as those with an MMSE score of 24 or higher).

Of the more than 500 articles reviewed, 41 met inclusion criteria. Of these, 21 trials involved 1,411 older adults with cognitive impairment and 20 trials involved 1,565 older adults who were cognitively intact. The mean age of the patients was 81 years.

The mean MMSE score among the cognitively impaired older adults was 16, compared with a mean MMSE score of 28 among those who were cognitively intact.

When the researchers combined the strength and endurance outcomes from the two groups, they observed an effect size of 0.51 for the cognitively impaired elderly and an effect size of 0.49 for the cognitively intact elderly. No statistically significant differences were seen in the strength and endurance outcomes between the two groups.

“Every study showed a positive result” from physical exercise, Mr. Johnson said. “We need more research to directly compare these two groups and to consider the need for different exercise guidelines for varying degrees of cognitive impairment.”

CARMEL, CALIF. — Cognitively impaired older adults who participate in exercise rehabilitation programs have similar strength and endurance outcomes as their cognitively intact peers, results from a large meta-analysis showed.

The finding suggests that cognitively impaired older adults should not be excluded from rehabilitation programs, Kyle E. Johnson reported at the Western regional meeting of the American Federation for Medical Research.

“It's a fallacy that cognitively impaired older adults are unable to follow instructions and that they will not benefit from physical therapy,” said Mr. Johnson, who is a second-year medical student at the University of Colorado, Denver.

He and his associate, Patricia C. Heyn, Ph.D., of the university's division of geriatric medicine, searched electronic and printed databases for randomized, controlled trials that included physical rehabilitation outcomes of cognitively impaired older adults (defined as those with a Mini-Mental State Examination score of less than 24) and cognitively intact older adults (defined as those with an MMSE score of 24 or higher).

Of the more than 500 articles reviewed, 41 met inclusion criteria. Of these, 21 trials involved 1,411 older adults with cognitive impairment and 20 trials involved 1,565 older adults who were cognitively intact. The mean age of the patients was 81 years.

The mean MMSE score among the cognitively impaired older adults was 16, compared with a mean MMSE score of 28 among those who were cognitively intact.

When the researchers combined the strength and endurance outcomes from the two groups, they observed an effect size of 0.51 for the cognitively impaired elderly and an effect size of 0.49 for the cognitively intact elderly. No statistically significant differences were seen in the strength and endurance outcomes between the two groups.

“Every study showed a positive result” from physical exercise, Mr. Johnson said. “We need more research to directly compare these two groups and to consider the need for different exercise guidelines for varying degrees of cognitive impairment.”

LAS VEGAS — Not long ago, physicians were taught to believe that chronic back pain does not occur in children.

“But that just isn't true,” Dr. David L. Skaggs said at meeting sponsored by the American Academy of Pediatrics' California Chapters 1, 2, 3, and 4 and the AAP.

“We did a study of kids between the ages of 11 and 14, and found that 37% of them had back pain at any given time,” said Dr. Skaggs, associate director of the Children's Orthopedic Center at Children's Hospital Los Angeles. “So when a child comes in with back pain, it can be difficult to decide what's pathologic and what's not.”

If a child presents with diffuse back pain that is triggered by physical activity, that comes and goes over time with periods of no pain, and that does not get worse at night, this is probably nothing to worry about. “Ask the child where it hurts,” Dr. Skaggs advised. If they demonstrate region of interest distribution of pain across the back, “that's when you say, 'Welcome to adulthood.' That's chronic low back pain.”

Worry when a child presents with point tenderness back pain, or what he calls the “positive finger test” on physical exam. The culprit could be spondylolysis, diskitis, or a tumor. “If the child points at one place and says, 'It hurts there,' that's when you should be concerned,” he said. “Ask, 'Does it ever hurt at night, worse enough to wake you up? Is the pain getting worse?' If they say yes, you should order a MRI of the cervicothoracic lumbar spine.”

He also recommends asking if the child has ever had a lumbar puncture, because sometimes a little skin gets into the spinal canal and can cause an epidermoid cyst.

Heavy backpacks also can be associated with back pain. Dr. Skaggs and his associates studied the risk of back pain in adolescents who carry backpacks. “We found that the heavier the backpack, the more likely you are to have some back pain,” he said. “It's a linear relationship.”

While some experts advocate physical therapy for kids with generalized back pain, “I don't think that's in the kid's best interest, because most kids don't keep up physical therapy,” Dr. Skaggs said. “I think it's better to get them involved with something like yoga and Pilates, and go to the gym to get personal strength training. If you get them involved with something fun, it's going to strengthen their back and they're likely to keep it up.”

Exercise that involves core strengthening with an emphasis on back extensor training is best. Dr. Skaggs also discussed the following spinal problems that can occur in children:

▸ Congenital muscular torticollis. In this condition, the child's head tilts laterally with the ear toward one shoulder while the chin is rotated toward the opposite shoulder. The cause is thought to be fibrosis or compartment syndrome of the sternocleidomastoid muscle.

“Oftentimes, when the kids are born they may not have this position, but within a few weeks, it develops. … That's because it takes a while for the sternocleidomastoid muscle to fibrose or develop compartment sydrome after the trauma of birth,” he said.

If picked up early and physical therapy is begun in a timely fashion, the condition remits more than 95% of the time within the first year of life. However, most case series report about a 5% association with developmental dysplasia of the hip, “so I recommend getting a screening ultrasound in an infant who has congenital muscular torticollis. There are not enough studies to make recommendations, but I think it makes common sense,” he said.

▸ Plagiocephaly. This is secondary to congenital muscular torticollis most of the time. The best treatment for this is to treat the torticollis. “Encourage the child to sleep with the head tilted in the opposite position of normal, and eventually the plagiocephaly will resolve spontaneously,” he said.

If the plagiocephaly doesn't resolve in 6–8 months, referral to a neurosurgeon or an expert in bracing is warranted. “I'm generally not the biggest fan of bracing for most things in orthopedics, but [using a brace for] this really seems to work,” said Dr. Skaggs, who is also a professor of orthopedics at the University of Southern California, Los Angeles.

▸ Late-onset torticollis. In this condition, which is most commonly due to C1-C2 rotatory subluxation, the sternocleidomastoid muscle is tight on the opposite side to where the ear is toward the chin. It's in spasm from being stretched to accommodate the head position. “Most of the time, it resolves spontaneously in a few days,” he said. “If it doesn't resolve in a week, that means an instant referral to a specialist in pediatric spine disorders.”

A CT scan of C1-C2 with the head turned to the right and left makes the diagnosis in most cases. If detected within 1 week, treatment involves placement of a soft cervical collar. If detected within 1 month, treatment involves traction for reduction followed by placement of a cervical collar. Detection after 1 month of onset usually requires surgical fusion.

Kids don't keep up physical therapy. 'It's better to get them involved with something like yoga and Pilates.' DR. SKAGGS

The 60-Second Exam for Back Pain

Here are tips to quickly assess children for back pain:

▸ Have the child jump up and down on one foot, then jump up and down on the other.

▸ Have the child walk on his or her heels with the toes pointed upward. That covers L4 for ankle dorsiflexion. With these first two tests, almost all of the strength and balance of the lower extremities have been covered.

▸ Test the reflexes, including the umbilicus. If you lightly stroke the umbilicus on either side, the belly button should move to one side or the other. If it doesn't move, that's normal. “But if it's asymmetrical, there's a great chance there's syrinx.”

▸ Test for ankle clonus. Push up on the ball of the foot and forcibly dorsiflex the ankle. “If it beats once or twice that's normal,” he said. “Three or four beats of clonus and I'd consider a neurological work-up and/or an MRI.”

▸ Assess hamstring tightness. A popliteal angle up to 30–40 degrees is normal.

▸ Check the feet. “If you have claw toes or a cavus foot, that's a sign that something neurological is going on in the spine,” he said.

LAS VEGAS — Not long ago, physicians were taught to believe that chronic back pain does not occur in children.

“But that just isn't true,” Dr. David L. Skaggs said at meeting sponsored by the American Academy of Pediatrics' California Chapters 1, 2, 3, and 4 and the AAP.

“We did a study of kids between the ages of 11 and 14, and found that 37% of them had back pain at any given time,” said Dr. Skaggs, associate director of the Children's Orthopedic Center at Children's Hospital Los Angeles. “So when a child comes in with back pain, it can be difficult to decide what's pathologic and what's not.”

If a child presents with diffuse back pain that is triggered by physical activity, that comes and goes over time with periods of no pain, and that does not get worse at night, this is probably nothing to worry about. “Ask the child where it hurts,” Dr. Skaggs advised. If they demonstrate region of interest distribution of pain across the back, “that's when you say, 'Welcome to adulthood.' That's chronic low back pain.”

Worry when a child presents with point tenderness back pain, or what he calls the “positive finger test” on physical exam. The culprit could be spondylolysis, diskitis, or a tumor. “If the child points at one place and says, 'It hurts there,' that's when you should be concerned,” he said. “Ask, 'Does it ever hurt at night, worse enough to wake you up? Is the pain getting worse?' If they say yes, you should order a MRI of the cervicothoracic lumbar spine.”

He also recommends asking if the child has ever had a lumbar puncture, because sometimes a little skin gets into the spinal canal and can cause an epidermoid cyst.

Heavy backpacks also can be associated with back pain. Dr. Skaggs and his associates studied the risk of back pain in adolescents who carry backpacks. “We found that the heavier the backpack, the more likely you are to have some back pain,” he said. “It's a linear relationship.”

While some experts advocate physical therapy for kids with generalized back pain, “I don't think that's in the kid's best interest, because most kids don't keep up physical therapy,” Dr. Skaggs said. “I think it's better to get them involved with something like yoga and Pilates, and go to the gym to get personal strength training. If you get them involved with something fun, it's going to strengthen their back and they're likely to keep it up.”

Exercise that involves core strengthening with an emphasis on back extensor training is best. Dr. Skaggs also discussed the following spinal problems that can occur in children:

▸ Congenital muscular torticollis. In this condition, the child's head tilts laterally with the ear toward one shoulder while the chin is rotated toward the opposite shoulder. The cause is thought to be fibrosis or compartment syndrome of the sternocleidomastoid muscle.

“Oftentimes, when the kids are born they may not have this position, but within a few weeks, it develops. … That's because it takes a while for the sternocleidomastoid muscle to fibrose or develop compartment sydrome after the trauma of birth,” he said.

If picked up early and physical therapy is begun in a timely fashion, the condition remits more than 95% of the time within the first year of life. However, most case series report about a 5% association with developmental dysplasia of the hip, “so I recommend getting a screening ultrasound in an infant who has congenital muscular torticollis. There are not enough studies to make recommendations, but I think it makes common sense,” he said.

▸ Plagiocephaly. This is secondary to congenital muscular torticollis most of the time. The best treatment for this is to treat the torticollis. “Encourage the child to sleep with the head tilted in the opposite position of normal, and eventually the plagiocephaly will resolve spontaneously,” he said.

If the plagiocephaly doesn't resolve in 6–8 months, referral to a neurosurgeon or an expert in bracing is warranted. “I'm generally not the biggest fan of bracing for most things in orthopedics, but [using a brace for] this really seems to work,” said Dr. Skaggs, who is also a professor of orthopedics at the University of Southern California, Los Angeles.

▸ Late-onset torticollis. In this condition, which is most commonly due to C1-C2 rotatory subluxation, the sternocleidomastoid muscle is tight on the opposite side to where the ear is toward the chin. It's in spasm from being stretched to accommodate the head position. “Most of the time, it resolves spontaneously in a few days,” he said. “If it doesn't resolve in a week, that means an instant referral to a specialist in pediatric spine disorders.”

A CT scan of C1-C2 with the head turned to the right and left makes the diagnosis in most cases. If detected within 1 week, treatment involves placement of a soft cervical collar. If detected within 1 month, treatment involves traction for reduction followed by placement of a cervical collar. Detection after 1 month of onset usually requires surgical fusion.

Kids don't keep up physical therapy. 'It's better to get them involved with something like yoga and Pilates.' DR. SKAGGS

The 60-Second Exam for Back Pain

Here are tips to quickly assess children for back pain:

▸ Have the child jump up and down on one foot, then jump up and down on the other.

▸ Have the child walk on his or her heels with the toes pointed upward. That covers L4 for ankle dorsiflexion. With these first two tests, almost all of the strength and balance of the lower extremities have been covered.

▸ Test the reflexes, including the umbilicus. If you lightly stroke the umbilicus on either side, the belly button should move to one side or the other. If it doesn't move, that's normal. “But if it's asymmetrical, there's a great chance there's syrinx.”

▸ Test for ankle clonus. Push up on the ball of the foot and forcibly dorsiflex the ankle. “If it beats once or twice that's normal,” he said. “Three or four beats of clonus and I'd consider a neurological work-up and/or an MRI.”

▸ Assess hamstring tightness. A popliteal angle up to 30–40 degrees is normal.

▸ Check the feet. “If you have claw toes or a cavus foot, that's a sign that something neurological is going on in the spine,” he said.

LAS VEGAS — Not long ago, physicians were taught to believe that chronic back pain does not occur in children.

“But that just isn't true,” Dr. David L. Skaggs said at meeting sponsored by the American Academy of Pediatrics' California Chapters 1, 2, 3, and 4 and the AAP.

“We did a study of kids between the ages of 11 and 14, and found that 37% of them had back pain at any given time,” said Dr. Skaggs, associate director of the Children's Orthopedic Center at Children's Hospital Los Angeles. “So when a child comes in with back pain, it can be difficult to decide what's pathologic and what's not.”

If a child presents with diffuse back pain that is triggered by physical activity, that comes and goes over time with periods of no pain, and that does not get worse at night, this is probably nothing to worry about. “Ask the child where it hurts,” Dr. Skaggs advised. If they demonstrate region of interest distribution of pain across the back, “that's when you say, 'Welcome to adulthood.' That's chronic low back pain.”

Worry when a child presents with point tenderness back pain, or what he calls the “positive finger test” on physical exam. The culprit could be spondylolysis, diskitis, or a tumor. “If the child points at one place and says, 'It hurts there,' that's when you should be concerned,” he said. “Ask, 'Does it ever hurt at night, worse enough to wake you up? Is the pain getting worse?' If they say yes, you should order a MRI of the cervicothoracic lumbar spine.”

He also recommends asking if the child has ever had a lumbar puncture, because sometimes a little skin gets into the spinal canal and can cause an epidermoid cyst.

Heavy backpacks also can be associated with back pain. Dr. Skaggs and his associates studied the risk of back pain in adolescents who carry backpacks. “We found that the heavier the backpack, the more likely you are to have some back pain,” he said. “It's a linear relationship.”

While some experts advocate physical therapy for kids with generalized back pain, “I don't think that's in the kid's best interest, because most kids don't keep up physical therapy,” Dr. Skaggs said. “I think it's better to get them involved with something like yoga and Pilates, and go to the gym to get personal strength training. If you get them involved with something fun, it's going to strengthen their back and they're likely to keep it up.”

Exercise that involves core strengthening with an emphasis on back extensor training is best. Dr. Skaggs also discussed the following spinal problems that can occur in children:

▸ Congenital muscular torticollis. In this condition, the child's head tilts laterally with the ear toward one shoulder while the chin is rotated toward the opposite shoulder. The cause is thought to be fibrosis or compartment syndrome of the sternocleidomastoid muscle.

“Oftentimes, when the kids are born they may not have this position, but within a few weeks, it develops. … That's because it takes a while for the sternocleidomastoid muscle to fibrose or develop compartment sydrome after the trauma of birth,” he said.

If picked up early and physical therapy is begun in a timely fashion, the condition remits more than 95% of the time within the first year of life. However, most case series report about a 5% association with developmental dysplasia of the hip, “so I recommend getting a screening ultrasound in an infant who has congenital muscular torticollis. There are not enough studies to make recommendations, but I think it makes common sense,” he said.

▸ Plagiocephaly. This is secondary to congenital muscular torticollis most of the time. The best treatment for this is to treat the torticollis. “Encourage the child to sleep with the head tilted in the opposite position of normal, and eventually the plagiocephaly will resolve spontaneously,” he said.

If the plagiocephaly doesn't resolve in 6–8 months, referral to a neurosurgeon or an expert in bracing is warranted. “I'm generally not the biggest fan of bracing for most things in orthopedics, but [using a brace for] this really seems to work,” said Dr. Skaggs, who is also a professor of orthopedics at the University of Southern California, Los Angeles.

▸ Late-onset torticollis. In this condition, which is most commonly due to C1-C2 rotatory subluxation, the sternocleidomastoid muscle is tight on the opposite side to where the ear is toward the chin. It's in spasm from being stretched to accommodate the head position. “Most of the time, it resolves spontaneously in a few days,” he said. “If it doesn't resolve in a week, that means an instant referral to a specialist in pediatric spine disorders.”

A CT scan of C1-C2 with the head turned to the right and left makes the diagnosis in most cases. If detected within 1 week, treatment involves placement of a soft cervical collar. If detected within 1 month, treatment involves traction for reduction followed by placement of a cervical collar. Detection after 1 month of onset usually requires surgical fusion.

Kids don't keep up physical therapy. 'It's better to get them involved with something like yoga and Pilates.' DR. SKAGGS

The 60-Second Exam for Back Pain

Here are tips to quickly assess children for back pain:

▸ Have the child jump up and down on one foot, then jump up and down on the other.

▸ Have the child walk on his or her heels with the toes pointed upward. That covers L4 for ankle dorsiflexion. With these first two tests, almost all of the strength and balance of the lower extremities have been covered.

▸ Test the reflexes, including the umbilicus. If you lightly stroke the umbilicus on either side, the belly button should move to one side or the other. If it doesn't move, that's normal. “But if it's asymmetrical, there's a great chance there's syrinx.”

▸ Test for ankle clonus. Push up on the ball of the foot and forcibly dorsiflex the ankle. “If it beats once or twice that's normal,” he said. “Three or four beats of clonus and I'd consider a neurological work-up and/or an MRI.”

▸ Assess hamstring tightness. A popliteal angle up to 30–40 degrees is normal.

▸ Check the feet. “If you have claw toes or a cavus foot, that's a sign that something neurological is going on in the spine,” he said.

SAN DIEGO — There is a lack of strong evidence to support the current screening and surveillance guidelines for Barrett's esophagus and associated neoplasia, Dr. Marcia Irene Canto said at a meeting jointly sponsored by the AGA Institute and the Japanese Society of Gastroenterology.

“Sedated esophagogastroduodenoscopy [EGD] screening may be more cost effective than surveillance only if Barrett's patients with dysplasia who are diagnosed by screening are followed,” said Dr. Canto, director of clinical research in the division of gastroenterology and hepatology at Johns Hopkins University, Baltimore.

“The biopsy protocol detects cancer, but current guidelines regarding increased surveillance intervals in Barrett's patients without dysplasia would lead to missed high-grade dysplasia and cancer. We need better endoscopic techniques and better risk stratification,” she said.

Current practices for screening and surveillance of Barrett's esophagus are not based on randomized, controlled trials (level I evidence) or even well-designed cohort or case-control trials (level II), she explained. They are based on decision analyses, case series, case reports, or flawed clinical trials (level III); opinions of expert authorities based on clinical evidence, descriptive studies, or reports of expert committees (level IV); and insufficient evidence to form an opinion (level V).

“The rationale for screening and surveillance is to improve survival, but [increasingly], we are trying to prevent cancer in Barrett's patients. It's a different approach, by detecting high-grade dysplasia and intervening with ablation endoscopic mucosal resection or esophagectomy in this precancerous phase.”

Data on 783 patients from five prospective studies and one patient registry suggest that the risk of cancer in Barrett's esophagus is related to the grade of dysplasia. The risk for patients with no dysplasia stands at 2%, and the risk for those with low-grade and high-grade dysplasia is 7% and 22%, respectively.

Dr. Canto noted that there are no randomized, controlled trials on the evidence for surveillance in Barrett's esophagus, only three retrospective case series and one ongoing prospective study. But data from those studies indicate that the 2-year survival rate seems better for patients who undergo surveillance, compared with those who do not (86% vs. 46%, respectively).

And it is probably cost effective to target patients with dysplastic Barrett's, she said.

The evidence against surveillance is largely based on the fact that most Barrett's patients die from causes other than cancer. “When you look prospectively, the risk of cancer in Barrett's is low: about 0.5%–1.2% per year, so EGD, the standard way of doing surveillance, is very costly.”

Moreover, “there is such inconsistency in techniques for surveillance. Many practicing gastroenterologists do not follow any particular biopsy or surveillance technique.”

Since clinicians at Johns Hopkins began endoscopic surveillance in 1994, the prevalence of occult cancer in 39 Barrett's patients with high-grade dysplasia has decreased from 43% to 21%. None of the 15 patients who had some type of biopsy protocol or imaging technique implemented in their surveillance had occult cancer, whereas 8 of the 24 who did not follow a biopsy protocol had occult cancer. “This is even with modern endoscopy techniques, so there is some benefit to trying to do that,” Dr. Canto said.

For a Barrett's patient with no dysplasia, the American Gastroenterological Association (AGA) recommends a second EGD 1 year later, and then surveillance every 5 years (Gastroenterology 2005;128:1468–70).

The American College of Gastroenterology (ACG) guidelines are similar, but recommend surveillance every 3 years (Am. J. Gastroenterol. 2002;97:1888–95).

“Guidelines written by the GI societies are based on current data and decision analyses in terms of what the best surveillance interval is. There will never be the equivalent of the National Polyp Study for colon cancer surveillance,” Dr. Canto said.

For a Barrett's patient with low-grade dysplasia, the AGA recommends an EGD every 6 months for 1 year, then increasing the surveillance interval to every 1–2 years. The ACG guidelines are similar, but recommend surveillance every year.

For a Barrett's patient with high-grade dysplasia, the American Society for Gastrointestinal Endoscopy recommends confirming the diagnosis with two experienced pathologists, then offering the patient surgery or endoscopic therapy (Gastrointest. Endosc. 2006;63:570–80). The patient should undergo surveillance every 3 months for at least 2 years.

The ACG guidelines are similar but recommend endoscopic mucosal resection for more severe disease.

Preliminary results from a prospective multicenter study of 618 patients show that the prevalent cancer risk within 1 year of diagnosing the index lesion was 6.7% (Clin. Gastro. Hepatol. 2006;4:566–72). When the researchers followed the patients, the risk of cancer in patients with no dysplasia was 0.5% a year, and in those with low-grade dysplasia, it was similar, at 0.6% a year.

So far, regression of low-grade dysplasia has occurred in 66% of the patients. Dr. Canto pointed out that 53% of the incident high-grade dysplasias or cancers developed after two EGDs with no dysplasia.

“What if you have the patient back at year 5 according to the AGA guidelines, but the patient developed a Barrett's cancer or high-grade dysplasia in year 2? We don't have the evidence for increasing the surveillance intervals. In fact, preliminary evidence suggests Barrett's high-grade dysplasia or cancer might be missed if you followed the AGA guidelines.”

Screening for Barrett's esophagus and associated neoplasia presents another quagmire. ACG guidelines state that patients with chronic GERD symptoms are most likely to have Barrett's esophagus and should undergo upper endoscopy, but an AGA technical review concluded there is no direct evidence that has validated screening for esophageal cancer in the United States. This is in part because 40% of Barrett's patients with cancer have no GERD symptoms and fewer than 4% have Barrett's diagnosed before the cancer is diagnosed.

Endoscopic tools for screening include a standard videoendoscope (sedated or unsedated), an unsedated thin videoendoscope, an office-based thin battery-powered endoscope, and wireless capsule endoscopy.

Patients with low-grade dysplasia, shown here, need an EGD every 6 months for a year. Courtesy Dr. Marcia Irene Canto

SAN DIEGO — There is a lack of strong evidence to support the current screening and surveillance guidelines for Barrett's esophagus and associated neoplasia, Dr. Marcia Irene Canto said at a meeting jointly sponsored by the AGA Institute and the Japanese Society of Gastroenterology.

“Sedated esophagogastroduodenoscopy [EGD] screening may be more cost effective than surveillance only if Barrett's patients with dysplasia who are diagnosed by screening are followed,” said Dr. Canto, director of clinical research in the division of gastroenterology and hepatology at Johns Hopkins University, Baltimore.

“The biopsy protocol detects cancer, but current guidelines regarding increased surveillance intervals in Barrett's patients without dysplasia would lead to missed high-grade dysplasia and cancer. We need better endoscopic techniques and better risk stratification,” she said.

Current practices for screening and surveillance of Barrett's esophagus are not based on randomized, controlled trials (level I evidence) or even well-designed cohort or case-control trials (level II), she explained. They are based on decision analyses, case series, case reports, or flawed clinical trials (level III); opinions of expert authorities based on clinical evidence, descriptive studies, or reports of expert committees (level IV); and insufficient evidence to form an opinion (level V).

“The rationale for screening and surveillance is to improve survival, but [increasingly], we are trying to prevent cancer in Barrett's patients. It's a different approach, by detecting high-grade dysplasia and intervening with ablation endoscopic mucosal resection or esophagectomy in this precancerous phase.”

Data on 783 patients from five prospective studies and one patient registry suggest that the risk of cancer in Barrett's esophagus is related to the grade of dysplasia. The risk for patients with no dysplasia stands at 2%, and the risk for those with low-grade and high-grade dysplasia is 7% and 22%, respectively.

Dr. Canto noted that there are no randomized, controlled trials on the evidence for surveillance in Barrett's esophagus, only three retrospective case series and one ongoing prospective study. But data from those studies indicate that the 2-year survival rate seems better for patients who undergo surveillance, compared with those who do not (86% vs. 46%, respectively).

And it is probably cost effective to target patients with dysplastic Barrett's, she said.

The evidence against surveillance is largely based on the fact that most Barrett's patients die from causes other than cancer. “When you look prospectively, the risk of cancer in Barrett's is low: about 0.5%–1.2% per year, so EGD, the standard way of doing surveillance, is very costly.”

Moreover, “there is such inconsistency in techniques for surveillance. Many practicing gastroenterologists do not follow any particular biopsy or surveillance technique.”

Since clinicians at Johns Hopkins began endoscopic surveillance in 1994, the prevalence of occult cancer in 39 Barrett's patients with high-grade dysplasia has decreased from 43% to 21%. None of the 15 patients who had some type of biopsy protocol or imaging technique implemented in their surveillance had occult cancer, whereas 8 of the 24 who did not follow a biopsy protocol had occult cancer. “This is even with modern endoscopy techniques, so there is some benefit to trying to do that,” Dr. Canto said.

For a Barrett's patient with no dysplasia, the American Gastroenterological Association (AGA) recommends a second EGD 1 year later, and then surveillance every 5 years (Gastroenterology 2005;128:1468–70).

The American College of Gastroenterology (ACG) guidelines are similar, but recommend surveillance every 3 years (Am. J. Gastroenterol. 2002;97:1888–95).

“Guidelines written by the GI societies are based on current data and decision analyses in terms of what the best surveillance interval is. There will never be the equivalent of the National Polyp Study for colon cancer surveillance,” Dr. Canto said.

For a Barrett's patient with low-grade dysplasia, the AGA recommends an EGD every 6 months for 1 year, then increasing the surveillance interval to every 1–2 years. The ACG guidelines are similar, but recommend surveillance every year.

For a Barrett's patient with high-grade dysplasia, the American Society for Gastrointestinal Endoscopy recommends confirming the diagnosis with two experienced pathologists, then offering the patient surgery or endoscopic therapy (Gastrointest. Endosc. 2006;63:570–80). The patient should undergo surveillance every 3 months for at least 2 years.

The ACG guidelines are similar but recommend endoscopic mucosal resection for more severe disease.

Preliminary results from a prospective multicenter study of 618 patients show that the prevalent cancer risk within 1 year of diagnosing the index lesion was 6.7% (Clin. Gastro. Hepatol. 2006;4:566–72). When the researchers followed the patients, the risk of cancer in patients with no dysplasia was 0.5% a year, and in those with low-grade dysplasia, it was similar, at 0.6% a year.

So far, regression of low-grade dysplasia has occurred in 66% of the patients. Dr. Canto pointed out that 53% of the incident high-grade dysplasias or cancers developed after two EGDs with no dysplasia.

“What if you have the patient back at year 5 according to the AGA guidelines, but the patient developed a Barrett's cancer or high-grade dysplasia in year 2? We don't have the evidence for increasing the surveillance intervals. In fact, preliminary evidence suggests Barrett's high-grade dysplasia or cancer might be missed if you followed the AGA guidelines.”

Screening for Barrett's esophagus and associated neoplasia presents another quagmire. ACG guidelines state that patients with chronic GERD symptoms are most likely to have Barrett's esophagus and should undergo upper endoscopy, but an AGA technical review concluded there is no direct evidence that has validated screening for esophageal cancer in the United States. This is in part because 40% of Barrett's patients with cancer have no GERD symptoms and fewer than 4% have Barrett's diagnosed before the cancer is diagnosed.

Endoscopic tools for screening include a standard videoendoscope (sedated or unsedated), an unsedated thin videoendoscope, an office-based thin battery-powered endoscope, and wireless capsule endoscopy.

Patients with low-grade dysplasia, shown here, need an EGD every 6 months for a year. Courtesy Dr. Marcia Irene Canto

SAN DIEGO — There is a lack of strong evidence to support the current screening and surveillance guidelines for Barrett's esophagus and associated neoplasia, Dr. Marcia Irene Canto said at a meeting jointly sponsored by the AGA Institute and the Japanese Society of Gastroenterology.

“Sedated esophagogastroduodenoscopy [EGD] screening may be more cost effective than surveillance only if Barrett's patients with dysplasia who are diagnosed by screening are followed,” said Dr. Canto, director of clinical research in the division of gastroenterology and hepatology at Johns Hopkins University, Baltimore.

“The biopsy protocol detects cancer, but current guidelines regarding increased surveillance intervals in Barrett's patients without dysplasia would lead to missed high-grade dysplasia and cancer. We need better endoscopic techniques and better risk stratification,” she said.

Current practices for screening and surveillance of Barrett's esophagus are not based on randomized, controlled trials (level I evidence) or even well-designed cohort or case-control trials (level II), she explained. They are based on decision analyses, case series, case reports, or flawed clinical trials (level III); opinions of expert authorities based on clinical evidence, descriptive studies, or reports of expert committees (level IV); and insufficient evidence to form an opinion (level V).

“The rationale for screening and surveillance is to improve survival, but [increasingly], we are trying to prevent cancer in Barrett's patients. It's a different approach, by detecting high-grade dysplasia and intervening with ablation endoscopic mucosal resection or esophagectomy in this precancerous phase.”

Data on 783 patients from five prospective studies and one patient registry suggest that the risk of cancer in Barrett's esophagus is related to the grade of dysplasia. The risk for patients with no dysplasia stands at 2%, and the risk for those with low-grade and high-grade dysplasia is 7% and 22%, respectively.

Dr. Canto noted that there are no randomized, controlled trials on the evidence for surveillance in Barrett's esophagus, only three retrospective case series and one ongoing prospective study. But data from those studies indicate that the 2-year survival rate seems better for patients who undergo surveillance, compared with those who do not (86% vs. 46%, respectively).

And it is probably cost effective to target patients with dysplastic Barrett's, she said.

The evidence against surveillance is largely based on the fact that most Barrett's patients die from causes other than cancer. “When you look prospectively, the risk of cancer in Barrett's is low: about 0.5%–1.2% per year, so EGD, the standard way of doing surveillance, is very costly.”

Moreover, “there is such inconsistency in techniques for surveillance. Many practicing gastroenterologists do not follow any particular biopsy or surveillance technique.”

Since clinicians at Johns Hopkins began endoscopic surveillance in 1994, the prevalence of occult cancer in 39 Barrett's patients with high-grade dysplasia has decreased from 43% to 21%. None of the 15 patients who had some type of biopsy protocol or imaging technique implemented in their surveillance had occult cancer, whereas 8 of the 24 who did not follow a biopsy protocol had occult cancer. “This is even with modern endoscopy techniques, so there is some benefit to trying to do that,” Dr. Canto said.

For a Barrett's patient with no dysplasia, the American Gastroenterological Association (AGA) recommends a second EGD 1 year later, and then surveillance every 5 years (Gastroenterology 2005;128:1468–70).

The American College of Gastroenterology (ACG) guidelines are similar, but recommend surveillance every 3 years (Am. J. Gastroenterol. 2002;97:1888–95).

“Guidelines written by the GI societies are based on current data and decision analyses in terms of what the best surveillance interval is. There will never be the equivalent of the National Polyp Study for colon cancer surveillance,” Dr. Canto said.

For a Barrett's patient with low-grade dysplasia, the AGA recommends an EGD every 6 months for 1 year, then increasing the surveillance interval to every 1–2 years. The ACG guidelines are similar, but recommend surveillance every year.

For a Barrett's patient with high-grade dysplasia, the American Society for Gastrointestinal Endoscopy recommends confirming the diagnosis with two experienced pathologists, then offering the patient surgery or endoscopic therapy (Gastrointest. Endosc. 2006;63:570–80). The patient should undergo surveillance every 3 months for at least 2 years.

The ACG guidelines are similar but recommend endoscopic mucosal resection for more severe disease.

Preliminary results from a prospective multicenter study of 618 patients show that the prevalent cancer risk within 1 year of diagnosing the index lesion was 6.7% (Clin. Gastro. Hepatol. 2006;4:566–72). When the researchers followed the patients, the risk of cancer in patients with no dysplasia was 0.5% a year, and in those with low-grade dysplasia, it was similar, at 0.6% a year.

So far, regression of low-grade dysplasia has occurred in 66% of the patients. Dr. Canto pointed out that 53% of the incident high-grade dysplasias or cancers developed after two EGDs with no dysplasia.

“What if you have the patient back at year 5 according to the AGA guidelines, but the patient developed a Barrett's cancer or high-grade dysplasia in year 2? We don't have the evidence for increasing the surveillance intervals. In fact, preliminary evidence suggests Barrett's high-grade dysplasia or cancer might be missed if you followed the AGA guidelines.”

Screening for Barrett's esophagus and associated neoplasia presents another quagmire. ACG guidelines state that patients with chronic GERD symptoms are most likely to have Barrett's esophagus and should undergo upper endoscopy, but an AGA technical review concluded there is no direct evidence that has validated screening for esophageal cancer in the United States. This is in part because 40% of Barrett's patients with cancer have no GERD symptoms and fewer than 4% have Barrett's diagnosed before the cancer is diagnosed.

Endoscopic tools for screening include a standard videoendoscope (sedated or unsedated), an unsedated thin videoendoscope, an office-based thin battery-powered endoscope, and wireless capsule endoscopy.

Patients with low-grade dysplasia, shown here, need an EGD every 6 months for a year. Courtesy Dr. Marcia Irene Canto

SAN DIEGO — Screening for pancreatic cancer in people with a family history of the disease is not a perfect science, Dr. Marcia Irene Canto said at a meeting jointly sponsored by the AGA Institute and the Japanese Society of Gastroenterology.

“Much of our understanding of the genetics on the development of sporadic colorectal cancer stems from our understanding of familial colorectal cancer,” said Dr. Canto, director of clinical research in the division of gastroenterology and hepatology at the Johns Hopkins University, Baltimore.

“Maybe we're 10 years behind in fully understanding the genetics of pancreatic cancer, but hopefully we'll get there.” Since pancreatic cancer in relatives tends to develop in the 60s, Dr. Canto recommends that family members be screened starting at age 40 years, or 10 years younger than the youngest relative with the disease.

“Clearly, known family history is a risk factor,” she said. “Screening can detect asymptomatic treatable neoplasms, as well as pancreatic neoplasms and extrapancreatic neoplasms.”

In patients with Peutz-Jeghers syndrome, pancreatic cancer tends to present in the fourth decade of life. “Therefore, we propose that perhaps you would [screen these patients] at an earlier age, maybe at age 30,” she said. “We don't know for sure.”

In addition, smoking increases the risk and lowers age of onset by 10 years in people with a family history of the disease. “The first thing you can do for your patients besides taking a family history is tell them to stop smoking,” she said.

Intraductal papillary mucinous neoplasm, multifocal pancreatic intraepithelial neoplasia, and lobulocentric chronic pancreatitis are part of the phenotype of familial pancreatic cancer. The best screening tests remain unknown, but various studies have suggested a role for endoscopic ultrasound (EUS), computed tomography (CT), magnetic resonance imaging (MRI), combined EUS/fine-needle aspiration, and endoscopic retrograde cholangiopancreatography.

In an effort to determine the optimal screening methods, Dr. Canto and her associates are currently recruiting patients for The Lustgarten Foundation for Pancreatic Cancer Research-National Cancer Institute Specialized Programs of Research Excellence Cancer of the Pancreas Screening Study (CAPS 3).

The researchers plan to screen high-risk individuals for early pancreatic neoplasia using EUS, CT, and MRI/magnetic resonance cholangiopancreatography (MRCP), and test a panel of candidate biomarkers.

They hypothesize that screening tests can detect early curable noninvasive pancreatic neoplasia in high-risk individuals before it progresses to invasive cancer.

Patients eligible for enrollment in the investigation include:

▸ Adults with at least two first-degree relatives (parent, sibling, child) with pancreatic cancer. If the family has three or more relatives with the disease, then the individual must have at least one first-degree relative affected; if the family has two relatives with pancreatic cancer, then the individual must have two first-degree relatives affected.

▸ Adults with Peutz-Jeghers syndrome.

▸ Adults who are carriers of the BRCA2 or familial atypical multiple mole melanoma (FAMMM) p16(CDKN2A) gene and there is at least one family member who had pancreatic cancer.

For additional questions about patient enrollment, contact caps3@jhmi.edu

SAN DIEGO — Screening for pancreatic cancer in people with a family history of the disease is not a perfect science, Dr. Marcia Irene Canto said at a meeting jointly sponsored by the AGA Institute and the Japanese Society of Gastroenterology.

“Much of our understanding of the genetics on the development of sporadic colorectal cancer stems from our understanding of familial colorectal cancer,” said Dr. Canto, director of clinical research in the division of gastroenterology and hepatology at the Johns Hopkins University, Baltimore.

“Maybe we're 10 years behind in fully understanding the genetics of pancreatic cancer, but hopefully we'll get there.” Since pancreatic cancer in relatives tends to develop in the 60s, Dr. Canto recommends that family members be screened starting at age 40 years, or 10 years younger than the youngest relative with the disease.

“Clearly, known family history is a risk factor,” she said. “Screening can detect asymptomatic treatable neoplasms, as well as pancreatic neoplasms and extrapancreatic neoplasms.”

In patients with Peutz-Jeghers syndrome, pancreatic cancer tends to present in the fourth decade of life. “Therefore, we propose that perhaps you would [screen these patients] at an earlier age, maybe at age 30,” she said. “We don't know for sure.”

In addition, smoking increases the risk and lowers age of onset by 10 years in people with a family history of the disease. “The first thing you can do for your patients besides taking a family history is tell them to stop smoking,” she said.

Intraductal papillary mucinous neoplasm, multifocal pancreatic intraepithelial neoplasia, and lobulocentric chronic pancreatitis are part of the phenotype of familial pancreatic cancer. The best screening tests remain unknown, but various studies have suggested a role for endoscopic ultrasound (EUS), computed tomography (CT), magnetic resonance imaging (MRI), combined EUS/fine-needle aspiration, and endoscopic retrograde cholangiopancreatography.

In an effort to determine the optimal screening methods, Dr. Canto and her associates are currently recruiting patients for The Lustgarten Foundation for Pancreatic Cancer Research-National Cancer Institute Specialized Programs of Research Excellence Cancer of the Pancreas Screening Study (CAPS 3).

The researchers plan to screen high-risk individuals for early pancreatic neoplasia using EUS, CT, and MRI/magnetic resonance cholangiopancreatography (MRCP), and test a panel of candidate biomarkers.

They hypothesize that screening tests can detect early curable noninvasive pancreatic neoplasia in high-risk individuals before it progresses to invasive cancer.

Patients eligible for enrollment in the investigation include:

▸ Adults with at least two first-degree relatives (parent, sibling, child) with pancreatic cancer. If the family has three or more relatives with the disease, then the individual must have at least one first-degree relative affected; if the family has two relatives with pancreatic cancer, then the individual must have two first-degree relatives affected.

▸ Adults with Peutz-Jeghers syndrome.

▸ Adults who are carriers of the BRCA2 or familial atypical multiple mole melanoma (FAMMM) p16(CDKN2A) gene and there is at least one family member who had pancreatic cancer.

For additional questions about patient enrollment, contact caps3@jhmi.edu

SAN DIEGO — Screening for pancreatic cancer in people with a family history of the disease is not a perfect science, Dr. Marcia Irene Canto said at a meeting jointly sponsored by the AGA Institute and the Japanese Society of Gastroenterology.

“Much of our understanding of the genetics on the development of sporadic colorectal cancer stems from our understanding of familial colorectal cancer,” said Dr. Canto, director of clinical research in the division of gastroenterology and hepatology at the Johns Hopkins University, Baltimore.

“Maybe we're 10 years behind in fully understanding the genetics of pancreatic cancer, but hopefully we'll get there.” Since pancreatic cancer in relatives tends to develop in the 60s, Dr. Canto recommends that family members be screened starting at age 40 years, or 10 years younger than the youngest relative with the disease.

“Clearly, known family history is a risk factor,” she said. “Screening can detect asymptomatic treatable neoplasms, as well as pancreatic neoplasms and extrapancreatic neoplasms.”

In patients with Peutz-Jeghers syndrome, pancreatic cancer tends to present in the fourth decade of life. “Therefore, we propose that perhaps you would [screen these patients] at an earlier age, maybe at age 30,” she said. “We don't know for sure.”

In addition, smoking increases the risk and lowers age of onset by 10 years in people with a family history of the disease. “The first thing you can do for your patients besides taking a family history is tell them to stop smoking,” she said.

Intraductal papillary mucinous neoplasm, multifocal pancreatic intraepithelial neoplasia, and lobulocentric chronic pancreatitis are part of the phenotype of familial pancreatic cancer. The best screening tests remain unknown, but various studies have suggested a role for endoscopic ultrasound (EUS), computed tomography (CT), magnetic resonance imaging (MRI), combined EUS/fine-needle aspiration, and endoscopic retrograde cholangiopancreatography.

In an effort to determine the optimal screening methods, Dr. Canto and her associates are currently recruiting patients for The Lustgarten Foundation for Pancreatic Cancer Research-National Cancer Institute Specialized Programs of Research Excellence Cancer of the Pancreas Screening Study (CAPS 3).

The researchers plan to screen high-risk individuals for early pancreatic neoplasia using EUS, CT, and MRI/magnetic resonance cholangiopancreatography (MRCP), and test a panel of candidate biomarkers.

They hypothesize that screening tests can detect early curable noninvasive pancreatic neoplasia in high-risk individuals before it progresses to invasive cancer.

Patients eligible for enrollment in the investigation include:

▸ Adults with at least two first-degree relatives (parent, sibling, child) with pancreatic cancer. If the family has three or more relatives with the disease, then the individual must have at least one first-degree relative affected; if the family has two relatives with pancreatic cancer, then the individual must have two first-degree relatives affected.

▸ Adults with Peutz-Jeghers syndrome.

▸ Adults who are carriers of the BRCA2 or familial atypical multiple mole melanoma (FAMMM) p16(CDKN2A) gene and there is at least one family member who had pancreatic cancer.

For additional questions about patient enrollment, contact caps3@jhmi.edu

SAN DIEGO — Between 1990 and 2001, the number of children and adolescents diagnosed with depression increased 2.4-fold, and the use of serotonin reuptake inhibitors increased from 21% to 40%, Linda M. Robison reported during a poster session at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

In a study led by her associate, David A. Sclar, B.Pharm, of the Washington State University College of Pharmacy in Pullman, Wash, U.S. National Ambulatory Medical Care Survey data were used to determine the population-adjusted rates of office-based physician visits that resulted in a diagnosis of depression in patients aged 5–18 years between 1990 and 2001.

Over the 12-year time period, the population-adjusted rate of depression increased 2.4-fold, from 12.9 per 1,000 patients to 31.1 per 1,000 patients.

At the same time, the number of patients who were prescribed an antidepressant increased from 44% in 1990–1993 to 59% in 1998–2001. The use of SSRIs increased from 21% in 1990–1993 to 40% in 1998–2001, while the use of tricyclic antidepressants fell from 21% to 3%.

The study was supported by the National Alliance for Research on Schizophrenia and Depression.

SAN DIEGO — Between 1990 and 2001, the number of children and adolescents diagnosed with depression increased 2.4-fold, and the use of serotonin reuptake inhibitors increased from 21% to 40%, Linda M. Robison reported during a poster session at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

In a study led by her associate, David A. Sclar, B.Pharm, of the Washington State University College of Pharmacy in Pullman, Wash, U.S. National Ambulatory Medical Care Survey data were used to determine the population-adjusted rates of office-based physician visits that resulted in a diagnosis of depression in patients aged 5–18 years between 1990 and 2001.

Over the 12-year time period, the population-adjusted rate of depression increased 2.4-fold, from 12.9 per 1,000 patients to 31.1 per 1,000 patients.

At the same time, the number of patients who were prescribed an antidepressant increased from 44% in 1990–1993 to 59% in 1998–2001. The use of SSRIs increased from 21% in 1990–1993 to 40% in 1998–2001, while the use of tricyclic antidepressants fell from 21% to 3%.

The study was supported by the National Alliance for Research on Schizophrenia and Depression.

SAN DIEGO — Between 1990 and 2001, the number of children and adolescents diagnosed with depression increased 2.4-fold, and the use of serotonin reuptake inhibitors increased from 21% to 40%, Linda M. Robison reported during a poster session at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

In a study led by her associate, David A. Sclar, B.Pharm, of the Washington State University College of Pharmacy in Pullman, Wash, U.S. National Ambulatory Medical Care Survey data were used to determine the population-adjusted rates of office-based physician visits that resulted in a diagnosis of depression in patients aged 5–18 years between 1990 and 2001.

Over the 12-year time period, the population-adjusted rate of depression increased 2.4-fold, from 12.9 per 1,000 patients to 31.1 per 1,000 patients.

At the same time, the number of patients who were prescribed an antidepressant increased from 44% in 1990–1993 to 59% in 1998–2001. The use of SSRIs increased from 21% in 1990–1993 to 40% in 1998–2001, while the use of tricyclic antidepressants fell from 21% to 3%.

The study was supported by the National Alliance for Research on Schizophrenia and Depression.

CARMEL, CALIF. — Many clinicians underprescribe warfarin in elderly patients with atrial fibrillation because of the perceived risks of anticoagulation therapy, results from a study of Department of Veterans Affairs patients showed.

“Knowing how our practices measure up to current guidelines will increase awareness,” said Dr. Rose Do, who presented the findings with Dr. Reza Habibzadeh at the Western regional meeting of the American Federation for Medical Research.

Current guidelines from the American College of Cardiology, the American Heart Association, and the European Society of Cardiology recommend anticoagulation with a vitamin K antagonist for patients with more than one moderate risk factor for stroke or for patients with a history of cerebrovascular accident (J. Am. Coll. Cardiol. 2001;38:1266i-lxx). Risk factors for stroke include being aged 75 years or older and having hypertension, impaired left ventricular systolic function (an ejection fraction of 35% or less or a fractional shortening of less than 25%), diabetes, prior thromboembolism, or rheumatic mitral stenosis.

Dr. Habibzadeh pointed out that despite evidence in favor of anticoagulation, warfarin is consistently underprescribed for patients with atrial fibrillation (AF). One study of long-term care patients found that only 53% of ideal candidates were receiving warfarin (Arch. Intern. Med. 2001;161:2458–63).

Another study found that among AF patients discharged from the hospital, only 50% received a prescription for warfarin (Chest 2006;130: 1296–9).

One poll found that the risk of falls is the most commonly cited reason for not using anticoagulation in AF patients (J. Am. Med. Dir. Assoc. 2006;7:23–8). However, Dr. Habibzadeh noted that few studies in the medical literature have assessed the use of anticoagulation in elderly AF patients who are at risk for falls (Arch. Intern. Med. 1999;159:677–85). One of the main studies concluded that the risk-to-benefit ratio favored anticoagulation.

Dr. Do and Dr. Habibzadeh sought to determine warfarin prescribing patterns in 66 patients with AF who were part of the Southern Arizona VA Medical Center Home-Based Primary Care Program. AF diagnoses were confirmed by reviews of electrocardiograms, echocardiography reports, and Holter monitor reports. If patients were not anticoagulated, the reasons for deferring this therapy were explored through extensive chart review.

The researchers found that 59.1% of patients had a prior cerebrovascular accident or more than one risk factor for stroke and therefore met criteria for warfarin therapy. However, among patients with a history of cerebrovascular accident, only 19.7% received warfarin.

Among patients with one risk factor for stroke, 3% received clopidogrel, 13.6% received aspirin, and 9.1% received warfarin.

Among patients with two risk factors for stroke, 24.2% received warfarin. The percentages of patients with three and four risk factors for stroke who received warfarin were 7.6% and 1.5%, respectively.

Dr. Do and Dr. Habibzadeh, who are both third-year residents in the department of internal medicine at the University of Arizona, Tucson, pointed out that 9.1% of patients with more than one risk factor received no anticoagulation at all.

Reasons cited for not using warfarin included risk of falls (31.8%, even though only 21.2% of these patients had a documented history of falls), “other” (18.2%), patient refusal (7.6%), adherence issues (6.1%), alcohol dependence (3%), and life expectancy (1.5%).

Dr. Do noted certain limitations of the study, including that it was retrospective, was not randomized, that it relied heavily on documentation, and that it involved a mostly male population.

Even so, the study serves as “more background for future cardiovascular research,” she said.

Despite its limitations, the study serves as 'more background for future cardiovascular research.' DR. DO

CARMEL, CALIF. — Many clinicians underprescribe warfarin in elderly patients with atrial fibrillation because of the perceived risks of anticoagulation therapy, results from a study of Department of Veterans Affairs patients showed.

“Knowing how our practices measure up to current guidelines will increase awareness,” said Dr. Rose Do, who presented the findings with Dr. Reza Habibzadeh at the Western regional meeting of the American Federation for Medical Research.

Current guidelines from the American College of Cardiology, the American Heart Association, and the European Society of Cardiology recommend anticoagulation with a vitamin K antagonist for patients with more than one moderate risk factor for stroke or for patients with a history of cerebrovascular accident (J. Am. Coll. Cardiol. 2001;38:1266i-lxx). Risk factors for stroke include being aged 75 years or older and having hypertension, impaired left ventricular systolic function (an ejection fraction of 35% or less or a fractional shortening of less than 25%), diabetes, prior thromboembolism, or rheumatic mitral stenosis.

Dr. Habibzadeh pointed out that despite evidence in favor of anticoagulation, warfarin is consistently underprescribed for patients with atrial fibrillation (AF). One study of long-term care patients found that only 53% of ideal candidates were receiving warfarin (Arch. Intern. Med. 2001;161:2458–63).

Another study found that among AF patients discharged from the hospital, only 50% received a prescription for warfarin (Chest 2006;130: 1296–9).

One poll found that the risk of falls is the most commonly cited reason for not using anticoagulation in AF patients (J. Am. Med. Dir. Assoc. 2006;7:23–8). However, Dr. Habibzadeh noted that few studies in the medical literature have assessed the use of anticoagulation in elderly AF patients who are at risk for falls (Arch. Intern. Med. 1999;159:677–85). One of the main studies concluded that the risk-to-benefit ratio favored anticoagulation.

Dr. Do and Dr. Habibzadeh sought to determine warfarin prescribing patterns in 66 patients with AF who were part of the Southern Arizona VA Medical Center Home-Based Primary Care Program. AF diagnoses were confirmed by reviews of electrocardiograms, echocardiography reports, and Holter monitor reports. If patients were not anticoagulated, the reasons for deferring this therapy were explored through extensive chart review.

The researchers found that 59.1% of patients had a prior cerebrovascular accident or more than one risk factor for stroke and therefore met criteria for warfarin therapy. However, among patients with a history of cerebrovascular accident, only 19.7% received warfarin.

Among patients with one risk factor for stroke, 3% received clopidogrel, 13.6% received aspirin, and 9.1% received warfarin.

Among patients with two risk factors for stroke, 24.2% received warfarin. The percentages of patients with three and four risk factors for stroke who received warfarin were 7.6% and 1.5%, respectively.

Dr. Do and Dr. Habibzadeh, who are both third-year residents in the department of internal medicine at the University of Arizona, Tucson, pointed out that 9.1% of patients with more than one risk factor received no anticoagulation at all.

Reasons cited for not using warfarin included risk of falls (31.8%, even though only 21.2% of these patients had a documented history of falls), “other” (18.2%), patient refusal (7.6%), adherence issues (6.1%), alcohol dependence (3%), and life expectancy (1.5%).

Dr. Do noted certain limitations of the study, including that it was retrospective, was not randomized, that it relied heavily on documentation, and that it involved a mostly male population.

Even so, the study serves as “more background for future cardiovascular research,” she said.

Despite its limitations, the study serves as 'more background for future cardiovascular research.' DR. DO

CARMEL, CALIF. — Many clinicians underprescribe warfarin in elderly patients with atrial fibrillation because of the perceived risks of anticoagulation therapy, results from a study of Department of Veterans Affairs patients showed.

“Knowing how our practices measure up to current guidelines will increase awareness,” said Dr. Rose Do, who presented the findings with Dr. Reza Habibzadeh at the Western regional meeting of the American Federation for Medical Research.

Current guidelines from the American College of Cardiology, the American Heart Association, and the European Society of Cardiology recommend anticoagulation with a vitamin K antagonist for patients with more than one moderate risk factor for stroke or for patients with a history of cerebrovascular accident (J. Am. Coll. Cardiol. 2001;38:1266i-lxx). Risk factors for stroke include being aged 75 years or older and having hypertension, impaired left ventricular systolic function (an ejection fraction of 35% or less or a fractional shortening of less than 25%), diabetes, prior thromboembolism, or rheumatic mitral stenosis.

Dr. Habibzadeh pointed out that despite evidence in favor of anticoagulation, warfarin is consistently underprescribed for patients with atrial fibrillation (AF). One study of long-term care patients found that only 53% of ideal candidates were receiving warfarin (Arch. Intern. Med. 2001;161:2458–63).

Another study found that among AF patients discharged from the hospital, only 50% received a prescription for warfarin (Chest 2006;130: 1296–9).

One poll found that the risk of falls is the most commonly cited reason for not using anticoagulation in AF patients (J. Am. Med. Dir. Assoc. 2006;7:23–8). However, Dr. Habibzadeh noted that few studies in the medical literature have assessed the use of anticoagulation in elderly AF patients who are at risk for falls (Arch. Intern. Med. 1999;159:677–85). One of the main studies concluded that the risk-to-benefit ratio favored anticoagulation.

Dr. Do and Dr. Habibzadeh sought to determine warfarin prescribing patterns in 66 patients with AF who were part of the Southern Arizona VA Medical Center Home-Based Primary Care Program. AF diagnoses were confirmed by reviews of electrocardiograms, echocardiography reports, and Holter monitor reports. If patients were not anticoagulated, the reasons for deferring this therapy were explored through extensive chart review.

The researchers found that 59.1% of patients had a prior cerebrovascular accident or more than one risk factor for stroke and therefore met criteria for warfarin therapy. However, among patients with a history of cerebrovascular accident, only 19.7% received warfarin.

Among patients with one risk factor for stroke, 3% received clopidogrel, 13.6% received aspirin, and 9.1% received warfarin.

Among patients with two risk factors for stroke, 24.2% received warfarin. The percentages of patients with three and four risk factors for stroke who received warfarin were 7.6% and 1.5%, respectively.

Dr. Do and Dr. Habibzadeh, who are both third-year residents in the department of internal medicine at the University of Arizona, Tucson, pointed out that 9.1% of patients with more than one risk factor received no anticoagulation at all.

Reasons cited for not using warfarin included risk of falls (31.8%, even though only 21.2% of these patients had a documented history of falls), “other” (18.2%), patient refusal (7.6%), adherence issues (6.1%), alcohol dependence (3%), and life expectancy (1.5%).

Dr. Do noted certain limitations of the study, including that it was retrospective, was not randomized, that it relied heavily on documentation, and that it involved a mostly male population.

Even so, the study serves as “more background for future cardiovascular research,” she said.

Despite its limitations, the study serves as 'more background for future cardiovascular research.' DR. DO

SAN DIEGO – Artwork created by persons with epilepsy can help others gain insight to the experiences of patients with the condition, Dr. Steven C. Schachter said at the annual meetings of the American Epilepsy Society and the Canadian League Against Epilepsy.

Dr. Schachter has collected more than 1,200 paintings, photographs, and other works of art by 52 artists with epilepsy from around the world. “I often show the art when I'm seeing other patients to help them verbalize feelings,” he said.

Many of the works in his collection appear in “Vision: Artists Living With Epilepsy” (Elsevier Science and Technology, 2003), a book that was edited by Dr. Schachter. All royalties from sales of the book support the Epilepsy Foundation.

Studying the art of people with epilepsy serves to recognize their contributions to society, but it also raises certain research questions, said Dr. Schachter, professor of neurology at Harvard Medical School, Boston, and director of neurotechnology at the Center for Integration of Medicine and Innovative Technology, Boston. “For example, are people with epilepsy particularly likely to engage in artistic activities?” he asked. “Is there a link between epilepsy and creativity? If so, what are the epilepsy-specific variables that are involved?”

Although he did not offer answers to those questions during his presentation, he did discuss four general themes that emerge in the artwork in his collection:

▸ Seizures and the postictal state. Many works represent the artists' conscious experiences during their seizures. “One artist says there are many times during her seizures that her world seems very unreal,” he said. “She feels like she's walking in a dreamlike state. Her art represents this experience.”

He added that for many epilepsy patients, “the postictal state is their only clue that they've had a seizure. It can be a period of time with very intense emotional symptoms.”

One of the artists told Dr. Schachter that, after having a seizure she “has an overwhelming sense that everything she knows to be present in her world is actually distant in time and space. With that comes a powerful sense of anguish, pain, and loneliness.”

▸ Psychiatric comorbidities. Themes that reflect anxiety and depression also are common in the artwork, and the prevalence of these conditions may be higher in people with epilepsy than in the general population. The fear of the next seizure and the fear of dying “are all common anxieties people with epilepsy have,” he said.

One of his patients likened the beginning of a seizure to being “in front of an oncoming train with no way to escape.” Psychosis also occurs in patients with epilepsy, perhaps as a function of severity.

▸ Psychosocial aspects of epilepsy. These include themes of isolation from society, stigma, and reminders of living with epilepsy. “For some patients, the place where they feel the safest is their home or bedroom, which is a common theme in the art,” Dr. Schachter said.

▸ Non-epilepsy related. There are many artists with epilepsy “whose art has no ostensible connection to their epilepsy at all,” he said. Such works serve to destigmatize epilepsy, “to emphasize that people with epilepsy … can be creative and contribute to society. It's art for art's sake.”

The presentation was part of the AES Annual Course, which is supported by an educational grant from Abbott Laboratories, Cyberonics, and GlaxoSmithKline Pharmaceuticals.

Dr. Steven C. Schachter's collection of more than 1,200 works of art by people with epilepsy includes “Springtime.” KLAAS VERBOOM/PHOTOGRAPHED BY ANDRE NUPER

“Transcending” reflects the postictal state many patients experience. Jennifer Hall

SAN DIEGO – Artwork created by persons with epilepsy can help others gain insight to the experiences of patients with the condition, Dr. Steven C. Schachter said at the annual meetings of the American Epilepsy Society and the Canadian League Against Epilepsy.

Dr. Schachter has collected more than 1,200 paintings, photographs, and other works of art by 52 artists with epilepsy from around the world. “I often show the art when I'm seeing other patients to help them verbalize feelings,” he said.

Many of the works in his collection appear in “Vision: Artists Living With Epilepsy” (Elsevier Science and Technology, 2003), a book that was edited by Dr. Schachter. All royalties from sales of the book support the Epilepsy Foundation.

Studying the art of people with epilepsy serves to recognize their contributions to society, but it also raises certain research questions, said Dr. Schachter, professor of neurology at Harvard Medical School, Boston, and director of neurotechnology at the Center for Integration of Medicine and Innovative Technology, Boston. “For example, are people with epilepsy particularly likely to engage in artistic activities?” he asked. “Is there a link between epilepsy and creativity? If so, what are the epilepsy-specific variables that are involved?”

Although he did not offer answers to those questions during his presentation, he did discuss four general themes that emerge in the artwork in his collection:

▸ Seizures and the postictal state. Many works represent the artists' conscious experiences during their seizures. “One artist says there are many times during her seizures that her world seems very unreal,” he said. “She feels like she's walking in a dreamlike state. Her art represents this experience.”

He added that for many epilepsy patients, “the postictal state is their only clue that they've had a seizure. It can be a period of time with very intense emotional symptoms.”

One of the artists told Dr. Schachter that, after having a seizure she “has an overwhelming sense that everything she knows to be present in her world is actually distant in time and space. With that comes a powerful sense of anguish, pain, and loneliness.”

▸ Psychiatric comorbidities. Themes that reflect anxiety and depression also are common in the artwork, and the prevalence of these conditions may be higher in people with epilepsy than in the general population. The fear of the next seizure and the fear of dying “are all common anxieties people with epilepsy have,” he said.

One of his patients likened the beginning of a seizure to being “in front of an oncoming train with no way to escape.” Psychosis also occurs in patients with epilepsy, perhaps as a function of severity.

▸ Psychosocial aspects of epilepsy. These include themes of isolation from society, stigma, and reminders of living with epilepsy. “For some patients, the place where they feel the safest is their home or bedroom, which is a common theme in the art,” Dr. Schachter said.

▸ Non-epilepsy related. There are many artists with epilepsy “whose art has no ostensible connection to their epilepsy at all,” he said. Such works serve to destigmatize epilepsy, “to emphasize that people with epilepsy … can be creative and contribute to society. It's art for art's sake.”

The presentation was part of the AES Annual Course, which is supported by an educational grant from Abbott Laboratories, Cyberonics, and GlaxoSmithKline Pharmaceuticals.

Dr. Steven C. Schachter's collection of more than 1,200 works of art by people with epilepsy includes “Springtime.” KLAAS VERBOOM/PHOTOGRAPHED BY ANDRE NUPER

“Transcending” reflects the postictal state many patients experience. Jennifer Hall

SAN DIEGO – Artwork created by persons with epilepsy can help others gain insight to the experiences of patients with the condition, Dr. Steven C. Schachter said at the annual meetings of the American Epilepsy Society and the Canadian League Against Epilepsy.

Dr. Schachter has collected more than 1,200 paintings, photographs, and other works of art by 52 artists with epilepsy from around the world. “I often show the art when I'm seeing other patients to help them verbalize feelings,” he said.

Many of the works in his collection appear in “Vision: Artists Living With Epilepsy” (Elsevier Science and Technology, 2003), a book that was edited by Dr. Schachter. All royalties from sales of the book support the Epilepsy Foundation.

Studying the art of people with epilepsy serves to recognize their contributions to society, but it also raises certain research questions, said Dr. Schachter, professor of neurology at Harvard Medical School, Boston, and director of neurotechnology at the Center for Integration of Medicine and Innovative Technology, Boston. “For example, are people with epilepsy particularly likely to engage in artistic activities?” he asked. “Is there a link between epilepsy and creativity? If so, what are the epilepsy-specific variables that are involved?”

Although he did not offer answers to those questions during his presentation, he did discuss four general themes that emerge in the artwork in his collection:

▸ Seizures and the postictal state. Many works represent the artists' conscious experiences during their seizures. “One artist says there are many times during her seizures that her world seems very unreal,” he said. “She feels like she's walking in a dreamlike state. Her art represents this experience.”

He added that for many epilepsy patients, “the postictal state is their only clue that they've had a seizure. It can be a period of time with very intense emotional symptoms.”

One of the artists told Dr. Schachter that, after having a seizure she “has an overwhelming sense that everything she knows to be present in her world is actually distant in time and space. With that comes a powerful sense of anguish, pain, and loneliness.”

▸ Psychiatric comorbidities. Themes that reflect anxiety and depression also are common in the artwork, and the prevalence of these conditions may be higher in people with epilepsy than in the general population. The fear of the next seizure and the fear of dying “are all common anxieties people with epilepsy have,” he said.

One of his patients likened the beginning of a seizure to being “in front of an oncoming train with no way to escape.” Psychosis also occurs in patients with epilepsy, perhaps as a function of severity.

▸ Psychosocial aspects of epilepsy. These include themes of isolation from society, stigma, and reminders of living with epilepsy. “For some patients, the place where they feel the safest is their home or bedroom, which is a common theme in the art,” Dr. Schachter said.

▸ Non-epilepsy related. There are many artists with epilepsy “whose art has no ostensible connection to their epilepsy at all,” he said. Such works serve to destigmatize epilepsy, “to emphasize that people with epilepsy … can be creative and contribute to society. It's art for art's sake.”

The presentation was part of the AES Annual Course, which is supported by an educational grant from Abbott Laboratories, Cyberonics, and GlaxoSmithKline Pharmaceuticals.

Dr. Steven C. Schachter's collection of more than 1,200 works of art by people with epilepsy includes “Springtime.” KLAAS VERBOOM/PHOTOGRAPHED BY ANDRE NUPER

“Transcending” reflects the postictal state many patients experience. Jennifer Hall

SAN DIEGO – A presurgical history of depression appears to predict the persistence of auras after an anterotemporal lobectomy in which patients became free of disabling seizures, Dr. Andres M. Kanner reported during a poster session at the annual meetings of the American Epilepsy Society and the Canadian League Against Epilepsy.

While the cause of the association remains unclear, one hypothesis is that the aura “may be an expression of epileptogenic activity in the insula, because sometimes the insula can be a culprit in the generation of the aura in patients with temporal lobe epilepsy,” said Dr. Kanner, associate director of epilepsy and clinical neurophysiology at Rush University Medical Center, Chicago. “It opens up a lot of questions that I don't have answers for.”

He and his associates studied 58 men and 39 women (mean age of 31 years) who underwent an anterotemporal lobectomy at the Rush Epilepsy Center. Of the 97 patients, 60 had mesial temporal sclerosis, 18 had lesional temporal lobe epilepsy, and 19 had idiopathic temporal lobe epilepsy.

All patients had undergone presurgical psychiatric evaluation and had a mean postsurgical follow-up time of 7 years.

Dr. Kanner reported that of the 97 patients, 37 (38%) were free of any disabling seizures and auras since having their surgery, while 43 patients (44%) were free of disabling seizures but had auras. Nearly half of the patients (47) had a lifetime history of depression.

Logistic regression analysis revealed the absence of a lifetime history of depression as the only variable that predicted a seizure-free outcome without auras.

“There is a bidirectional relationship between depression and epilepsy that has been pretty well recognized,” Dr. Kanner said. “If you have a history of epilepsy you are more likely to be at risk for depression, and if you have a history of depression you have a four- to seven-times greater risk of developing epilepsy.”

SAN DIEGO – A presurgical history of depression appears to predict the persistence of auras after an anterotemporal lobectomy in which patients became free of disabling seizures, Dr. Andres M. Kanner reported during a poster session at the annual meetings of the American Epilepsy Society and the Canadian League Against Epilepsy.

While the cause of the association remains unclear, one hypothesis is that the aura “may be an expression of epileptogenic activity in the insula, because sometimes the insula can be a culprit in the generation of the aura in patients with temporal lobe epilepsy,” said Dr. Kanner, associate director of epilepsy and clinical neurophysiology at Rush University Medical Center, Chicago. “It opens up a lot of questions that I don't have answers for.”

He and his associates studied 58 men and 39 women (mean age of 31 years) who underwent an anterotemporal lobectomy at the Rush Epilepsy Center. Of the 97 patients, 60 had mesial temporal sclerosis, 18 had lesional temporal lobe epilepsy, and 19 had idiopathic temporal lobe epilepsy.

All patients had undergone presurgical psychiatric evaluation and had a mean postsurgical follow-up time of 7 years.

Dr. Kanner reported that of the 97 patients, 37 (38%) were free of any disabling seizures and auras since having their surgery, while 43 patients (44%) were free of disabling seizures but had auras. Nearly half of the patients (47) had a lifetime history of depression.

Logistic regression analysis revealed the absence of a lifetime history of depression as the only variable that predicted a seizure-free outcome without auras.

“There is a bidirectional relationship between depression and epilepsy that has been pretty well recognized,” Dr. Kanner said. “If you have a history of epilepsy you are more likely to be at risk for depression, and if you have a history of depression you have a four- to seven-times greater risk of developing epilepsy.”

SAN DIEGO – A presurgical history of depression appears to predict the persistence of auras after an anterotemporal lobectomy in which patients became free of disabling seizures, Dr. Andres M. Kanner reported during a poster session at the annual meetings of the American Epilepsy Society and the Canadian League Against Epilepsy.

While the cause of the association remains unclear, one hypothesis is that the aura “may be an expression of epileptogenic activity in the insula, because sometimes the insula can be a culprit in the generation of the aura in patients with temporal lobe epilepsy,” said Dr. Kanner, associate director of epilepsy and clinical neurophysiology at Rush University Medical Center, Chicago. “It opens up a lot of questions that I don't have answers for.”

He and his associates studied 58 men and 39 women (mean age of 31 years) who underwent an anterotemporal lobectomy at the Rush Epilepsy Center. Of the 97 patients, 60 had mesial temporal sclerosis, 18 had lesional temporal lobe epilepsy, and 19 had idiopathic temporal lobe epilepsy.

All patients had undergone presurgical psychiatric evaluation and had a mean postsurgical follow-up time of 7 years.

Dr. Kanner reported that of the 97 patients, 37 (38%) were free of any disabling seizures and auras since having their surgery, while 43 patients (44%) were free of disabling seizures but had auras. Nearly half of the patients (47) had a lifetime history of depression.

Logistic regression analysis revealed the absence of a lifetime history of depression as the only variable that predicted a seizure-free outcome without auras.

“There is a bidirectional relationship between depression and epilepsy that has been pretty well recognized,” Dr. Kanner said. “If you have a history of epilepsy you are more likely to be at risk for depression, and if you have a history of depression you have a four- to seven-times greater risk of developing epilepsy.”

SAN DIEGO – Studies have suggested that the social environment can be a rocky place for children with epilepsy, Joan K. Austin, D.N.S., said at the annual meetings of the American Epilepsy Society and the Canadian League Against Epilepsy.

According to a survey that she and her associates conducted of 19,441 teens in the general population, 75% of the respondents thought that teens with epilepsy were more likely to be bullied or picked on, compared with their peers (Epilepsy Behav. 2002;3:368–75). More than half of the respondents (52%) had never heard of epilepsy; 46% were not sure if it was contagious; and 40% were not sure if people with epilepsy were dangerous. Only 31% reported that they would date someone with epilepsy, and 19% thought it was a form of mental illness.

“This survey shows lack of familiarity with epilepsy,” said Dr. Austin, a distinguished professor of nursing at Indiana University, Indianapolis. “It also reflects some of the dimensions of risk and safety concerns … about the contagiousness or the dangerousness. It also has hints of social avoidance.”

In a Canadian survey of 41 healthy children and 108 teens with chronic conditions, most respondents held several misconceptions about epilepsy, compared with other chronic conditions, including the notion that epilepsy causes a mental handicap, leads to self-injury and death, and that epilepsy causes injury to others during a seizure (J. Child. Neurol. 2006;21:214–22). “Other perceptions about epilepsy were that persons with epilepsy were less honest, less popular, less fun, and less adept at sports, compared with normal teens,” said Dr. Austin, also a past president of the American Epilepsy Society.

A survey of 512 teachers in all regions of the United States revealed that while their attitudes toward epilepsy were generally positive, less than 5% had ever had frequent contact with a child with epilepsy and 70% reported inadequate knowledge about the condition (Epilepsy Behav. 2006;8:397–405).

Another study led by one of Dr. Austin's colleagues showed that when teachers knew a child had epilepsy, they underestimated the child's academic achievement on objective achievement tests (Epilepsia 2005;46[suppl 8]:A1.185). “These results suggest that teachers' ratings of children's achievement might be negatively influenced by the label of epilepsy,” she said.

Ms. Austin went on to note that children's perceptions of the stigma are associated with mental health problems. Parents' perception of stigma is associated with depressed mood and behavior problems at home and at school. In addition, child stigma perceptions have been associated with poor self-concept and depressive symptoms, while adolescent stigma perceptions have been associated with anxiety and also depression.

One way to address the roots of internalized stigma in the clinical setting is to focus on the child's fears and worries about having epilepsy.

Based on research Ms. Austin and her associates have conducted in children with epilepsy “we found them to have imagined causes of seizures, unfounded worries about getting hurt, worries about not knowing when another seizure would occur and how to make plans, concerns that they would continue to get sicker and sicker, worries about death, and worries about becoming mentally ill.”

Many of their anxieties “were based on inaccurate or incomplete information,” she said. “These could be addressed in a clinical setting.” Another helpful strategy is to address the child's need for information and support. Ms. Austin said children like to know about the causes of seizures, techniques for handling future seizures, how to prevent injury, and how to handle restrictions on their activity.

The presentation was part of a program supported by an educational grant from Abbott Laboratories, Cyberonics Inc., and GlaxoSmithKline.

SAN DIEGO – Studies have suggested that the social environment can be a rocky place for children with epilepsy, Joan K. Austin, D.N.S., said at the annual meetings of the American Epilepsy Society and the Canadian League Against Epilepsy.

According to a survey that she and her associates conducted of 19,441 teens in the general population, 75% of the respondents thought that teens with epilepsy were more likely to be bullied or picked on, compared with their peers (Epilepsy Behav. 2002;3:368–75). More than half of the respondents (52%) had never heard of epilepsy; 46% were not sure if it was contagious; and 40% were not sure if people with epilepsy were dangerous. Only 31% reported that they would date someone with epilepsy, and 19% thought it was a form of mental illness.

“This survey shows lack of familiarity with epilepsy,” said Dr. Austin, a distinguished professor of nursing at Indiana University, Indianapolis. “It also reflects some of the dimensions of risk and safety concerns … about the contagiousness or the dangerousness. It also has hints of social avoidance.”

In a Canadian survey of 41 healthy children and 108 teens with chronic conditions, most respondents held several misconceptions about epilepsy, compared with other chronic conditions, including the notion that epilepsy causes a mental handicap, leads to self-injury and death, and that epilepsy causes injury to others during a seizure (J. Child. Neurol. 2006;21:214–22). “Other perceptions about epilepsy were that persons with epilepsy were less honest, less popular, less fun, and less adept at sports, compared with normal teens,” said Dr. Austin, also a past president of the American Epilepsy Society.

A survey of 512 teachers in all regions of the United States revealed that while their attitudes toward epilepsy were generally positive, less than 5% had ever had frequent contact with a child with epilepsy and 70% reported inadequate knowledge about the condition (Epilepsy Behav. 2006;8:397–405).

Another study led by one of Dr. Austin's colleagues showed that when teachers knew a child had epilepsy, they underestimated the child's academic achievement on objective achievement tests (Epilepsia 2005;46[suppl 8]:A1.185). “These results suggest that teachers' ratings of children's achievement might be negatively influenced by the label of epilepsy,” she said.

Ms. Austin went on to note that children's perceptions of the stigma are associated with mental health problems. Parents' perception of stigma is associated with depressed mood and behavior problems at home and at school. In addition, child stigma perceptions have been associated with poor self-concept and depressive symptoms, while adolescent stigma perceptions have been associated with anxiety and also depression.

One way to address the roots of internalized stigma in the clinical setting is to focus on the child's fears and worries about having epilepsy.

Based on research Ms. Austin and her associates have conducted in children with epilepsy “we found them to have imagined causes of seizures, unfounded worries about getting hurt, worries about not knowing when another seizure would occur and how to make plans, concerns that they would continue to get sicker and sicker, worries about death, and worries about becoming mentally ill.”

Many of their anxieties “were based on inaccurate or incomplete information,” she said. “These could be addressed in a clinical setting.” Another helpful strategy is to address the child's need for information and support. Ms. Austin said children like to know about the causes of seizures, techniques for handling future seizures, how to prevent injury, and how to handle restrictions on their activity.

The presentation was part of a program supported by an educational grant from Abbott Laboratories, Cyberonics Inc., and GlaxoSmithKline.

SAN DIEGO – Studies have suggested that the social environment can be a rocky place for children with epilepsy, Joan K. Austin, D.N.S., said at the annual meetings of the American Epilepsy Society and the Canadian League Against Epilepsy.

According to a survey that she and her associates conducted of 19,441 teens in the general population, 75% of the respondents thought that teens with epilepsy were more likely to be bullied or picked on, compared with their peers (Epilepsy Behav. 2002;3:368–75). More than half of the respondents (52%) had never heard of epilepsy; 46% were not sure if it was contagious; and 40% were not sure if people with epilepsy were dangerous. Only 31% reported that they would date someone with epilepsy, and 19% thought it was a form of mental illness.

“This survey shows lack of familiarity with epilepsy,” said Dr. Austin, a distinguished professor of nursing at Indiana University, Indianapolis. “It also reflects some of the dimensions of risk and safety concerns … about the contagiousness or the dangerousness. It also has hints of social avoidance.”

In a Canadian survey of 41 healthy children and 108 teens with chronic conditions, most respondents held several misconceptions about epilepsy, compared with other chronic conditions, including the notion that epilepsy causes a mental handicap, leads to self-injury and death, and that epilepsy causes injury to others during a seizure (J. Child. Neurol. 2006;21:214–22). “Other perceptions about epilepsy were that persons with epilepsy were less honest, less popular, less fun, and less adept at sports, compared with normal teens,” said Dr. Austin, also a past president of the American Epilepsy Society.

A survey of 512 teachers in all regions of the United States revealed that while their attitudes toward epilepsy were generally positive, less than 5% had ever had frequent contact with a child with epilepsy and 70% reported inadequate knowledge about the condition (Epilepsy Behav. 2006;8:397–405).

Another study led by one of Dr. Austin's colleagues showed that when teachers knew a child had epilepsy, they underestimated the child's academic achievement on objective achievement tests (Epilepsia 2005;46[suppl 8]:A1.185). “These results suggest that teachers' ratings of children's achievement might be negatively influenced by the label of epilepsy,” she said.

Ms. Austin went on to note that children's perceptions of the stigma are associated with mental health problems. Parents' perception of stigma is associated with depressed mood and behavior problems at home and at school. In addition, child stigma perceptions have been associated with poor self-concept and depressive symptoms, while adolescent stigma perceptions have been associated with anxiety and also depression.

One way to address the roots of internalized stigma in the clinical setting is to focus on the child's fears and worries about having epilepsy.

Based on research Ms. Austin and her associates have conducted in children with epilepsy “we found them to have imagined causes of seizures, unfounded worries about getting hurt, worries about not knowing when another seizure would occur and how to make plans, concerns that they would continue to get sicker and sicker, worries about death, and worries about becoming mentally ill.”

Many of their anxieties “were based on inaccurate or incomplete information,” she said. “These could be addressed in a clinical setting.” Another helpful strategy is to address the child's need for information and support. Ms. Austin said children like to know about the causes of seizures, techniques for handling future seizures, how to prevent injury, and how to handle restrictions on their activity.

The presentation was part of a program supported by an educational grant from Abbott Laboratories, Cyberonics Inc., and GlaxoSmithKline.