Doug Brunk

SAN DIEGO – About 11% of ninth graders reported acts of deliberate self-harm in the form of cutting or burning themselves one to three times in the previous year, while an additional 4% reported performing such behavior more than four times in the previous year, results from a large German study show.

In addition, girls were more likely than boys to perform acts of deliberate self-harm, Dr. Romuald Brunner reported during a poster session at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

The study also found that young people who performed acts of deliberate self-harm scored significantly higher on the Youth Self Report subscales of somatic complaints; anxiety and depressive symptoms; and delinquent behavior, compared with their counterparts who did not report committing self-harm.

“The adolescents who practice deliberate self-harm only a few times a year have emotional and behavior problems,” Dr. Brunner said in an interview. “It suggests that we can rule out [self-harm] as a phenomenon of fashion. It's really linked to emotional problems.”

In what he said is the largest study of its kind, he and his associates performed a cross-sectional survey of 5,759 ninth graders in the Rhein-Neckar area in Germany between October 2005 and January 2006. Their mean age was 15 years, and half were female.

To assess the frequency of self-harm, the researchers administered parts of the German version of the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL). Occasional deliberate self-harm was defined as performing self-mutilative acts by cutting or burning themselves one to three times in the previous year. The repetitive deliberate form was defined as performing such behavior four or more times in the previous year.

The Youth Self Report was used to assess respondents' emotional and behavioral disturbances.

Of the 5,759 students, 630 (10.9%) reported occasional forms of deliberate self-harm in the previous year, while an additional 229 (4.0%) reported repetitive forms of deliberate self-harm.

Compared with boys, girls were 1.60 times more likely to report occasional forms of deliberate self-harm and 2.64 times more likely to report repetitive forms of deliberate self-harm.

The major forms of emotional problems linked to deliberate self-harm on the Youth Self Report were somatoform problems; anxiety and depressive symptoms; and delinquent behavior. The ninth graders who performed self-injurious behavior “demonstrate externalizing problems and internalizing problems,” said Dr. Brunner, of the center for psychosocial medicine in the department of child and adolescent psychiatry at the University of Heidelberg, Mannheim, Germany. “It's an interesting finding.”

He and his associates also observed a significant correlation between cigarette smoking and the risk of deliberate self-harm in girls but not in boys.

“There's no link between smoking in male adolescents and self-injurious behavior,” he said.

“Smoking in girls has another meaning. Perhaps it's linked to a higher grade of impulsive behavior. Girls with a more impulsive style are more prone to smoke,” he added.

Dr. Brunner also reported that most of the adolescents who reported taking drugs did not practice self-harming behavior.

“They regulate their emotion in other [ways], but they don't use this form,” he said. “This was a very surprising finding.”

'We can rule out [self-harm] as a phenomenon of fashion. It's really linked to emotional problems.' DR. BRUNNER

SAN DIEGO – About 11% of ninth graders reported acts of deliberate self-harm in the form of cutting or burning themselves one to three times in the previous year, while an additional 4% reported performing such behavior more than four times in the previous year, results from a large German study show.

In addition, girls were more likely than boys to perform acts of deliberate self-harm, Dr. Romuald Brunner reported during a poster session at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

The study also found that young people who performed acts of deliberate self-harm scored significantly higher on the Youth Self Report subscales of somatic complaints; anxiety and depressive symptoms; and delinquent behavior, compared with their counterparts who did not report committing self-harm.

“The adolescents who practice deliberate self-harm only a few times a year have emotional and behavior problems,” Dr. Brunner said in an interview. “It suggests that we can rule out [self-harm] as a phenomenon of fashion. It's really linked to emotional problems.”

In what he said is the largest study of its kind, he and his associates performed a cross-sectional survey of 5,759 ninth graders in the Rhein-Neckar area in Germany between October 2005 and January 2006. Their mean age was 15 years, and half were female.

To assess the frequency of self-harm, the researchers administered parts of the German version of the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL). Occasional deliberate self-harm was defined as performing self-mutilative acts by cutting or burning themselves one to three times in the previous year. The repetitive deliberate form was defined as performing such behavior four or more times in the previous year.

The Youth Self Report was used to assess respondents' emotional and behavioral disturbances.

Of the 5,759 students, 630 (10.9%) reported occasional forms of deliberate self-harm in the previous year, while an additional 229 (4.0%) reported repetitive forms of deliberate self-harm.

Compared with boys, girls were 1.60 times more likely to report occasional forms of deliberate self-harm and 2.64 times more likely to report repetitive forms of deliberate self-harm.

The major forms of emotional problems linked to deliberate self-harm on the Youth Self Report were somatoform problems; anxiety and depressive symptoms; and delinquent behavior. The ninth graders who performed self-injurious behavior “demonstrate externalizing problems and internalizing problems,” said Dr. Brunner, of the center for psychosocial medicine in the department of child and adolescent psychiatry at the University of Heidelberg, Mannheim, Germany. “It's an interesting finding.”

He and his associates also observed a significant correlation between cigarette smoking and the risk of deliberate self-harm in girls but not in boys.

“There's no link between smoking in male adolescents and self-injurious behavior,” he said.

“Smoking in girls has another meaning. Perhaps it's linked to a higher grade of impulsive behavior. Girls with a more impulsive style are more prone to smoke,” he added.

Dr. Brunner also reported that most of the adolescents who reported taking drugs did not practice self-harming behavior.

“They regulate their emotion in other [ways], but they don't use this form,” he said. “This was a very surprising finding.”

'We can rule out [self-harm] as a phenomenon of fashion. It's really linked to emotional problems.' DR. BRUNNER

SAN DIEGO – About 11% of ninth graders reported acts of deliberate self-harm in the form of cutting or burning themselves one to three times in the previous year, while an additional 4% reported performing such behavior more than four times in the previous year, results from a large German study show.

In addition, girls were more likely than boys to perform acts of deliberate self-harm, Dr. Romuald Brunner reported during a poster session at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

The study also found that young people who performed acts of deliberate self-harm scored significantly higher on the Youth Self Report subscales of somatic complaints; anxiety and depressive symptoms; and delinquent behavior, compared with their counterparts who did not report committing self-harm.

“The adolescents who practice deliberate self-harm only a few times a year have emotional and behavior problems,” Dr. Brunner said in an interview. “It suggests that we can rule out [self-harm] as a phenomenon of fashion. It's really linked to emotional problems.”

In what he said is the largest study of its kind, he and his associates performed a cross-sectional survey of 5,759 ninth graders in the Rhein-Neckar area in Germany between October 2005 and January 2006. Their mean age was 15 years, and half were female.

To assess the frequency of self-harm, the researchers administered parts of the German version of the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL). Occasional deliberate self-harm was defined as performing self-mutilative acts by cutting or burning themselves one to three times in the previous year. The repetitive deliberate form was defined as performing such behavior four or more times in the previous year.

The Youth Self Report was used to assess respondents' emotional and behavioral disturbances.

Of the 5,759 students, 630 (10.9%) reported occasional forms of deliberate self-harm in the previous year, while an additional 229 (4.0%) reported repetitive forms of deliberate self-harm.

Compared with boys, girls were 1.60 times more likely to report occasional forms of deliberate self-harm and 2.64 times more likely to report repetitive forms of deliberate self-harm.

The major forms of emotional problems linked to deliberate self-harm on the Youth Self Report were somatoform problems; anxiety and depressive symptoms; and delinquent behavior. The ninth graders who performed self-injurious behavior “demonstrate externalizing problems and internalizing problems,” said Dr. Brunner, of the center for psychosocial medicine in the department of child and adolescent psychiatry at the University of Heidelberg, Mannheim, Germany. “It's an interesting finding.”

He and his associates also observed a significant correlation between cigarette smoking and the risk of deliberate self-harm in girls but not in boys.

“There's no link between smoking in male adolescents and self-injurious behavior,” he said.

“Smoking in girls has another meaning. Perhaps it's linked to a higher grade of impulsive behavior. Girls with a more impulsive style are more prone to smoke,” he added.

Dr. Brunner also reported that most of the adolescents who reported taking drugs did not practice self-harming behavior.

“They regulate their emotion in other [ways], but they don't use this form,” he said. “This was a very surprising finding.”

'We can rule out [self-harm] as a phenomenon of fashion. It's really linked to emotional problems.' DR. BRUNNER

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 stem from our understanding of familial colorectal cancer,” said Dr. Canto, director of clinical research in the division of gastroenterology and hepatology at 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,” Dr. Canto 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 in the medical literature 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 the use of such screening tests will make it possible to detect early curable noninvasive pancreatic neoplasia in high-risk individuals before it progresses to invasive cancer.

Patients eligible for enrollment in the study 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 have at least one family member who had pancreatic cancer.

“We'll try to improve patient and physician access to screening, and it will potentially be a base for our ongoing translational studies [as well as] future and prevention and intervention trials,” Dr. Canto said of the trial.

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

Each year in the United States, 31,860 people are diagnosed with pancreatic cancer and 31,270 die from the disease.

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 stem from our understanding of familial colorectal cancer,” said Dr. Canto, director of clinical research in the division of gastroenterology and hepatology at 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,” Dr. Canto 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 in the medical literature 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 the use of such screening tests will make it possible to detect early curable noninvasive pancreatic neoplasia in high-risk individuals before it progresses to invasive cancer.

Patients eligible for enrollment in the study 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 have at least one family member who had pancreatic cancer.

“We'll try to improve patient and physician access to screening, and it will potentially be a base for our ongoing translational studies [as well as] future and prevention and intervention trials,” Dr. Canto said of the trial.

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

Each year in the United States, 31,860 people are diagnosed with pancreatic cancer and 31,270 die from the disease.

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 stem from our understanding of familial colorectal cancer,” said Dr. Canto, director of clinical research in the division of gastroenterology and hepatology at 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,” Dr. Canto 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 in the medical literature 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 the use of such screening tests will make it possible to detect early curable noninvasive pancreatic neoplasia in high-risk individuals before it progresses to invasive cancer.

Patients eligible for enrollment in the study 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 have at least one family member who had pancreatic cancer.

“We'll try to improve patient and physician access to screening, and it will potentially be a base for our ongoing translational studies [as well as] future and prevention and intervention trials,” Dr. Canto said of the trial.

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

Each year in the United States, 31,860 people are diagnosed with pancreatic cancer and 31,270 die from the disease.

SAN DIEGO — Colonoscopy remains the standard for imaging the colon, but the future may rest in nonoptical techniques such as virtual colonography and colonic visualization devices such as the PillCam, Dr. P. Jay Pasricha said at a meeting jointly sponsored by the AGA Institute and the Japanese Society of Gastroenterology.

“For a long time, colonoscopy was considered a done deal in terms of technology,” said Dr. Pasricha, chief of the division of gastroenterology and hepatology at the University of Texas, Galveston. “But it's interesting to see in the last 3-4 years that there has been a virtual revolution in the way we're thinking about colonoscopy.”

One force that has led to innovations is patients themselves, who are increasingly concerned about safety and “hassle” factors such as inconveniences related to sedation.

“They also want standardization of quality,” Dr. Pasricha said. “They don't want to go to one endoscopist and have one outcome and go to another endoscopist and have another outcome. They think of this as a standardized test; they don't view colonoscopy as a variable. It should be done the same way with the same results every time. The patients expect that.”

Another force driving new technologies is physicians who are concerned about the limitations of colonoscopy. The “miss rate” of conventional colonoscopy for adenomas greater than 1 cm is 12%-17%, Dr. Pasricha said. Reasons why adenomas are missed include anatomical factors, such as lesions hiding behind folds, and variability in examiner skills. Detection rates can vary 4- to 10-fold among clinicians in the same practice, he noted.

“Some of it is skill, some of it is the interpretation, and some of it is just how long you take,” he said. “The pressure of time has become very important in today's practice. Longer withdrawal times improve detection rates.”

He added that colonoscopy as it is currently practiced—as opposed to the large national trials, such as the National Polyp Study—“may not consistently protect against colorectal cancer or prevent mortality. However, this is the implicit promise that we have offered to our patients. Are we really delivering on that promise? We need to be sure.”

Last year, a joint task force of the American College of Gastroenterology and the American Society for Gastrointestinal Endoscopy recommended that the withdrawal time for examining the mucosa should be at least 6 minutes. As a measure of efficacy, clinicians should be able to document that 25% of male patients and 15% of female patients older than age 50 years had one or more adenomas.

Even if you follow the best-practice guidelines, clinicians “still have this problem of excessive demand [for colonoscopies] and the pressure to do more,” Dr. Pasricha said.

“You are going to have to spend more time per colonoscopy if you adhere to these guidelines. You're going to get less well paid for the time you spend if current trends in reimbursement continue; there are going to be increases in liability and probably increases in patient dissatisfaction as our performance, in terms of missed rates, gets publicity. That's going to lead to increasing oversight by regulatory agencies,” Dr. Pasricha said.

The good news, he noted, is that almost all of these problems are amenable to technologic solutions. One solution is to use nonoptical techniques such as virtual colonography and improved biomarkers.

Virtual colonography is a high-resolution CT scan with a software program that allows you to recreate or simulate the colon. “Some researchers have suggested that the sensitivity is not as good, but there are a lot of new developments in this area that are probably going to make this a reality,” he said. “It's going to be along the lines of computer-aided diagnosis, which is really going to shorten the time frame for interpretation of images.”

“Prepless” CT colonography, which eliminates the need to cleanse the colon, is another promising approach. “Once that becomes a reality, probably in the next 2-3 years, you will see a lot of patients embrace this,” he said.

Combining CT colonography with colonoscopy also shows promise. One study suggests that if you stratify patients into low-risk and high-risk categories, with the former undergoing colonoscopy directly while the latter undergo CT colonography as the initial test, you can detect 89% of advanced neoplasia, with far fewer colonoscopies being performed, compared with a rate of 94% when universal colonoscopy was performed (Gastroenterology 2006;131:1011-9).

Other promising alternatives to colonoscopy include non-physician-based colonic visualization devices such as the Aer-O-Scope and the PillCam. The Aer-O-Scope, an investigational device made by G.I. View Ltd., is a disposable, self-propelling visualization device that travels from the rectum to the cecum. It has two balloons: The distal balloon contains an optical scanning component, whereas the proximal balloon seals off the rectum.

Proof of concept was achieved in 12 human cases (Gastroenterology 2006;130:672-7). The device reached the cecum in 10 patients in an average of 14 minutes. Only two patients required sedation, and no major mucosal damage was observed.

In two patients, the device stopped at the hepatic flexure, “so it's not perfect,” Dr. Pasricha said. The device “still requires insertion of a blunt instrument into the rectum. Some patients would object to that.”

The PillCam, a device made by Given Imaging Ltd., is a variation of the capsule endoscopy devices currently on the market. Its dual cameras cover twice as much area as most of the small bowel capsules do.

A pilot study of 91 patients found that the sensitivity of the PillCam was 56%-76%, and the specificity was 69%-100% (Endoscopy 2006;38:963-70). “We have a way to go with this technology,” Dr. Pasricha said. “But given its simplicity and the rate of innovation, this may well be the so-called magic bullet in the future.”

The PillCam is not currently approved for use in the United States.

Other solutions include products that decrease the duration without compromising the quality of care. These include NeoGuide Systems Inc.'s Navigator Endoscopy System, the ShapeLock endoscopic guide (USGI Medical), and the SoftScope (SoftScope Medical Technologies Inc.).

Devices that address the problem of missed polyps include the Third-Eye Retroscope (Avantis Medical Systems Inc.), cap-assisted colonoscopy, wide-angle colonoscopy, and bioendoscopic techniques such as chromoendoscopy.

“Clearly, at this point colonoscopy is still the gold standard, but I think this emerging technology is going to catch up in about 3-5 years,” Dr. Pasricha said.

'Colonoscopy is still the gold standard, but … this emerging technology [will] catch up in about 3-5 years.' DR. PASRICHA

SAN DIEGO — Colonoscopy remains the standard for imaging the colon, but the future may rest in nonoptical techniques such as virtual colonography and colonic visualization devices such as the PillCam, Dr. P. Jay Pasricha said at a meeting jointly sponsored by the AGA Institute and the Japanese Society of Gastroenterology.

“For a long time, colonoscopy was considered a done deal in terms of technology,” said Dr. Pasricha, chief of the division of gastroenterology and hepatology at the University of Texas, Galveston. “But it's interesting to see in the last 3-4 years that there has been a virtual revolution in the way we're thinking about colonoscopy.”

One force that has led to innovations is patients themselves, who are increasingly concerned about safety and “hassle” factors such as inconveniences related to sedation.

“They also want standardization of quality,” Dr. Pasricha said. “They don't want to go to one endoscopist and have one outcome and go to another endoscopist and have another outcome. They think of this as a standardized test; they don't view colonoscopy as a variable. It should be done the same way with the same results every time. The patients expect that.”

Another force driving new technologies is physicians who are concerned about the limitations of colonoscopy. The “miss rate” of conventional colonoscopy for adenomas greater than 1 cm is 12%-17%, Dr. Pasricha said. Reasons why adenomas are missed include anatomical factors, such as lesions hiding behind folds, and variability in examiner skills. Detection rates can vary 4- to 10-fold among clinicians in the same practice, he noted.

“Some of it is skill, some of it is the interpretation, and some of it is just how long you take,” he said. “The pressure of time has become very important in today's practice. Longer withdrawal times improve detection rates.”

He added that colonoscopy as it is currently practiced—as opposed to the large national trials, such as the National Polyp Study—“may not consistently protect against colorectal cancer or prevent mortality. However, this is the implicit promise that we have offered to our patients. Are we really delivering on that promise? We need to be sure.”

Last year, a joint task force of the American College of Gastroenterology and the American Society for Gastrointestinal Endoscopy recommended that the withdrawal time for examining the mucosa should be at least 6 minutes. As a measure of efficacy, clinicians should be able to document that 25% of male patients and 15% of female patients older than age 50 years had one or more adenomas.

Even if you follow the best-practice guidelines, clinicians “still have this problem of excessive demand [for colonoscopies] and the pressure to do more,” Dr. Pasricha said.

“You are going to have to spend more time per colonoscopy if you adhere to these guidelines. You're going to get less well paid for the time you spend if current trends in reimbursement continue; there are going to be increases in liability and probably increases in patient dissatisfaction as our performance, in terms of missed rates, gets publicity. That's going to lead to increasing oversight by regulatory agencies,” Dr. Pasricha said.

The good news, he noted, is that almost all of these problems are amenable to technologic solutions. One solution is to use nonoptical techniques such as virtual colonography and improved biomarkers.

Virtual colonography is a high-resolution CT scan with a software program that allows you to recreate or simulate the colon. “Some researchers have suggested that the sensitivity is not as good, but there are a lot of new developments in this area that are probably going to make this a reality,” he said. “It's going to be along the lines of computer-aided diagnosis, which is really going to shorten the time frame for interpretation of images.”

“Prepless” CT colonography, which eliminates the need to cleanse the colon, is another promising approach. “Once that becomes a reality, probably in the next 2-3 years, you will see a lot of patients embrace this,” he said.

Combining CT colonography with colonoscopy also shows promise. One study suggests that if you stratify patients into low-risk and high-risk categories, with the former undergoing colonoscopy directly while the latter undergo CT colonography as the initial test, you can detect 89% of advanced neoplasia, with far fewer colonoscopies being performed, compared with a rate of 94% when universal colonoscopy was performed (Gastroenterology 2006;131:1011-9).

Other promising alternatives to colonoscopy include non-physician-based colonic visualization devices such as the Aer-O-Scope and the PillCam. The Aer-O-Scope, an investigational device made by G.I. View Ltd., is a disposable, self-propelling visualization device that travels from the rectum to the cecum. It has two balloons: The distal balloon contains an optical scanning component, whereas the proximal balloon seals off the rectum.

Proof of concept was achieved in 12 human cases (Gastroenterology 2006;130:672-7). The device reached the cecum in 10 patients in an average of 14 minutes. Only two patients required sedation, and no major mucosal damage was observed.

In two patients, the device stopped at the hepatic flexure, “so it's not perfect,” Dr. Pasricha said. The device “still requires insertion of a blunt instrument into the rectum. Some patients would object to that.”

The PillCam, a device made by Given Imaging Ltd., is a variation of the capsule endoscopy devices currently on the market. Its dual cameras cover twice as much area as most of the small bowel capsules do.

A pilot study of 91 patients found that the sensitivity of the PillCam was 56%-76%, and the specificity was 69%-100% (Endoscopy 2006;38:963-70). “We have a way to go with this technology,” Dr. Pasricha said. “But given its simplicity and the rate of innovation, this may well be the so-called magic bullet in the future.”

The PillCam is not currently approved for use in the United States.

Other solutions include products that decrease the duration without compromising the quality of care. These include NeoGuide Systems Inc.'s Navigator Endoscopy System, the ShapeLock endoscopic guide (USGI Medical), and the SoftScope (SoftScope Medical Technologies Inc.).

Devices that address the problem of missed polyps include the Third-Eye Retroscope (Avantis Medical Systems Inc.), cap-assisted colonoscopy, wide-angle colonoscopy, and bioendoscopic techniques such as chromoendoscopy.

“Clearly, at this point colonoscopy is still the gold standard, but I think this emerging technology is going to catch up in about 3-5 years,” Dr. Pasricha said.

'Colonoscopy is still the gold standard, but … this emerging technology [will] catch up in about 3-5 years.' DR. PASRICHA

SAN DIEGO — Colonoscopy remains the standard for imaging the colon, but the future may rest in nonoptical techniques such as virtual colonography and colonic visualization devices such as the PillCam, Dr. P. Jay Pasricha said at a meeting jointly sponsored by the AGA Institute and the Japanese Society of Gastroenterology.

“For a long time, colonoscopy was considered a done deal in terms of technology,” said Dr. Pasricha, chief of the division of gastroenterology and hepatology at the University of Texas, Galveston. “But it's interesting to see in the last 3-4 years that there has been a virtual revolution in the way we're thinking about colonoscopy.”

One force that has led to innovations is patients themselves, who are increasingly concerned about safety and “hassle” factors such as inconveniences related to sedation.

“They also want standardization of quality,” Dr. Pasricha said. “They don't want to go to one endoscopist and have one outcome and go to another endoscopist and have another outcome. They think of this as a standardized test; they don't view colonoscopy as a variable. It should be done the same way with the same results every time. The patients expect that.”

Another force driving new technologies is physicians who are concerned about the limitations of colonoscopy. The “miss rate” of conventional colonoscopy for adenomas greater than 1 cm is 12%-17%, Dr. Pasricha said. Reasons why adenomas are missed include anatomical factors, such as lesions hiding behind folds, and variability in examiner skills. Detection rates can vary 4- to 10-fold among clinicians in the same practice, he noted.

“Some of it is skill, some of it is the interpretation, and some of it is just how long you take,” he said. “The pressure of time has become very important in today's practice. Longer withdrawal times improve detection rates.”

He added that colonoscopy as it is currently practiced—as opposed to the large national trials, such as the National Polyp Study—“may not consistently protect against colorectal cancer or prevent mortality. However, this is the implicit promise that we have offered to our patients. Are we really delivering on that promise? We need to be sure.”

Last year, a joint task force of the American College of Gastroenterology and the American Society for Gastrointestinal Endoscopy recommended that the withdrawal time for examining the mucosa should be at least 6 minutes. As a measure of efficacy, clinicians should be able to document that 25% of male patients and 15% of female patients older than age 50 years had one or more adenomas.

Even if you follow the best-practice guidelines, clinicians “still have this problem of excessive demand [for colonoscopies] and the pressure to do more,” Dr. Pasricha said.

“You are going to have to spend more time per colonoscopy if you adhere to these guidelines. You're going to get less well paid for the time you spend if current trends in reimbursement continue; there are going to be increases in liability and probably increases in patient dissatisfaction as our performance, in terms of missed rates, gets publicity. That's going to lead to increasing oversight by regulatory agencies,” Dr. Pasricha said.

The good news, he noted, is that almost all of these problems are amenable to technologic solutions. One solution is to use nonoptical techniques such as virtual colonography and improved biomarkers.

Virtual colonography is a high-resolution CT scan with a software program that allows you to recreate or simulate the colon. “Some researchers have suggested that the sensitivity is not as good, but there are a lot of new developments in this area that are probably going to make this a reality,” he said. “It's going to be along the lines of computer-aided diagnosis, which is really going to shorten the time frame for interpretation of images.”

“Prepless” CT colonography, which eliminates the need to cleanse the colon, is another promising approach. “Once that becomes a reality, probably in the next 2-3 years, you will see a lot of patients embrace this,” he said.

Combining CT colonography with colonoscopy also shows promise. One study suggests that if you stratify patients into low-risk and high-risk categories, with the former undergoing colonoscopy directly while the latter undergo CT colonography as the initial test, you can detect 89% of advanced neoplasia, with far fewer colonoscopies being performed, compared with a rate of 94% when universal colonoscopy was performed (Gastroenterology 2006;131:1011-9).

Other promising alternatives to colonoscopy include non-physician-based colonic visualization devices such as the Aer-O-Scope and the PillCam. The Aer-O-Scope, an investigational device made by G.I. View Ltd., is a disposable, self-propelling visualization device that travels from the rectum to the cecum. It has two balloons: The distal balloon contains an optical scanning component, whereas the proximal balloon seals off the rectum.

Proof of concept was achieved in 12 human cases (Gastroenterology 2006;130:672-7). The device reached the cecum in 10 patients in an average of 14 minutes. Only two patients required sedation, and no major mucosal damage was observed.

In two patients, the device stopped at the hepatic flexure, “so it's not perfect,” Dr. Pasricha said. The device “still requires insertion of a blunt instrument into the rectum. Some patients would object to that.”

The PillCam, a device made by Given Imaging Ltd., is a variation of the capsule endoscopy devices currently on the market. Its dual cameras cover twice as much area as most of the small bowel capsules do.

A pilot study of 91 patients found that the sensitivity of the PillCam was 56%-76%, and the specificity was 69%-100% (Endoscopy 2006;38:963-70). “We have a way to go with this technology,” Dr. Pasricha said. “But given its simplicity and the rate of innovation, this may well be the so-called magic bullet in the future.”

The PillCam is not currently approved for use in the United States.

Other solutions include products that decrease the duration without compromising the quality of care. These include NeoGuide Systems Inc.'s Navigator Endoscopy System, the ShapeLock endoscopic guide (USGI Medical), and the SoftScope (SoftScope Medical Technologies Inc.).

Devices that address the problem of missed polyps include the Third-Eye Retroscope (Avantis Medical Systems Inc.), cap-assisted colonoscopy, wide-angle colonoscopy, and bioendoscopic techniques such as chromoendoscopy.

“Clearly, at this point colonoscopy is still the gold standard, but I think this emerging technology is going to catch up in about 3-5 years,” Dr. Pasricha said.

'Colonoscopy is still the gold standard, but … this emerging technology [will] catch up in about 3-5 years.' DR. PASRICHA

CORONADO, CALIF. — As a two-time all-star Major League Baseball player, Mark Loretta knows a thing or two about how to handle pressure.

But nothing could prepare the second baseman for the curve ball diagnosis of melanoma he received in the summer of 2004 during a routine skin screening program sponsored by Major League Baseball and the American Academy of Dermatology.

There, a dermatologist noticed a mole on the center of his chest.

"It's something I felt had there for a long time, but the doctor said, 'This looks a bit precarious. It looks like a bad actor. We probably don't need to take it off today, but after the season's over why don't you have it looked at?'" Mr. Loretta said at an update on melanoma sponsored by the Scripps Clinic.

In October of that year he had the lesion biopsied and it came back positive for stage I melanoma. A month later the lesion was removed in a wide excision operation performed by Dr. Hubert T. Greenway Jr., director of cutaneous oncology at the Ida M. and Cecil H. Green Cancer Center at Scripps Clinic, La Jolla, Calif.

The lesion "was the size of a large piece of sushi," said Mr. Loretta, who signed with the Houston Astros in January after playing for the Boston Red Sox last year. "I didn't expect such a large piece to be taken out."

His current follow-up regimen involves clinical exams every 3 months.

He went on to note that two aspects of his diagnosis and treatment proved difficult from a patient standpoint. One was the anxiety of "not knowing what you're dealing with," he said, explaining that you can get on the Internet "and get bits of information [about melanoma] here and there, and all of a sudden your head starts spinning. You start reading about sentinel node biopsy, about chemotherapy and radiation."

Mr. Loretta, who grew up in Southern California and had an uncle who died from melanoma, also said that he underestimated what the wide excision procedure was going to entail.

That "was probably based on where the tumor was, in the center of my chest, which doesn't have a lot of meaty tissue," he said. "I also underestimated the time it would take for me to recover."

During public speaking engagements to raise awareness of skin cancer, Mr. Loretta said that he imparts a simple message: "Get in and get checked. "A skin exam, he noted, is "not very invasive."

CORONADO, CALIF. — As a two-time all-star Major League Baseball player, Mark Loretta knows a thing or two about how to handle pressure.

But nothing could prepare the second baseman for the curve ball diagnosis of melanoma he received in the summer of 2004 during a routine skin screening program sponsored by Major League Baseball and the American Academy of Dermatology.

There, a dermatologist noticed a mole on the center of his chest.

"It's something I felt had there for a long time, but the doctor said, 'This looks a bit precarious. It looks like a bad actor. We probably don't need to take it off today, but after the season's over why don't you have it looked at?'" Mr. Loretta said at an update on melanoma sponsored by the Scripps Clinic.

In October of that year he had the lesion biopsied and it came back positive for stage I melanoma. A month later the lesion was removed in a wide excision operation performed by Dr. Hubert T. Greenway Jr., director of cutaneous oncology at the Ida M. and Cecil H. Green Cancer Center at Scripps Clinic, La Jolla, Calif.

The lesion "was the size of a large piece of sushi," said Mr. Loretta, who signed with the Houston Astros in January after playing for the Boston Red Sox last year. "I didn't expect such a large piece to be taken out."

His current follow-up regimen involves clinical exams every 3 months.

He went on to note that two aspects of his diagnosis and treatment proved difficult from a patient standpoint. One was the anxiety of "not knowing what you're dealing with," he said, explaining that you can get on the Internet "and get bits of information [about melanoma] here and there, and all of a sudden your head starts spinning. You start reading about sentinel node biopsy, about chemotherapy and radiation."

Mr. Loretta, who grew up in Southern California and had an uncle who died from melanoma, also said that he underestimated what the wide excision procedure was going to entail.

That "was probably based on where the tumor was, in the center of my chest, which doesn't have a lot of meaty tissue," he said. "I also underestimated the time it would take for me to recover."

During public speaking engagements to raise awareness of skin cancer, Mr. Loretta said that he imparts a simple message: "Get in and get checked. "A skin exam, he noted, is "not very invasive."

CORONADO, CALIF. — As a two-time all-star Major League Baseball player, Mark Loretta knows a thing or two about how to handle pressure.

But nothing could prepare the second baseman for the curve ball diagnosis of melanoma he received in the summer of 2004 during a routine skin screening program sponsored by Major League Baseball and the American Academy of Dermatology.

There, a dermatologist noticed a mole on the center of his chest.

"It's something I felt had there for a long time, but the doctor said, 'This looks a bit precarious. It looks like a bad actor. We probably don't need to take it off today, but after the season's over why don't you have it looked at?'" Mr. Loretta said at an update on melanoma sponsored by the Scripps Clinic.

In October of that year he had the lesion biopsied and it came back positive for stage I melanoma. A month later the lesion was removed in a wide excision operation performed by Dr. Hubert T. Greenway Jr., director of cutaneous oncology at the Ida M. and Cecil H. Green Cancer Center at Scripps Clinic, La Jolla, Calif.

The lesion "was the size of a large piece of sushi," said Mr. Loretta, who signed with the Houston Astros in January after playing for the Boston Red Sox last year. "I didn't expect such a large piece to be taken out."

His current follow-up regimen involves clinical exams every 3 months.

He went on to note that two aspects of his diagnosis and treatment proved difficult from a patient standpoint. One was the anxiety of "not knowing what you're dealing with," he said, explaining that you can get on the Internet "and get bits of information [about melanoma] here and there, and all of a sudden your head starts spinning. You start reading about sentinel node biopsy, about chemotherapy and radiation."

Mr. Loretta, who grew up in Southern California and had an uncle who died from melanoma, also said that he underestimated what the wide excision procedure was going to entail.

That "was probably based on where the tumor was, in the center of my chest, which doesn't have a lot of meaty tissue," he said. "I also underestimated the time it would take for me to recover."

During public speaking engagements to raise awareness of skin cancer, Mr. Loretta said that he imparts a simple message: "Get in and get checked. "A skin exam, he noted, is "not very invasive."

CORONADO, CALIF. — Radiation therapy is underused as a treatment for malignant melanoma, Dr. Ray Lin said at a melanoma update sponsored by the Scripps Clinic.

"The reasons are traced back to in vitro studies which showed that melanomas are more radioresistant," explained Dr. Lin of the department of radiation oncology at the clinic in La Jolla, Calif.

Most studies actually show that malignant melanoma responds to high doses of radiation per fraction, but this approach raises concern about late effects of radiation toxicity.

"The more fractionated the treatments are, the lower the risk for late toxicity," he said. "For instance, delivering higher doses of radiation in fewer fractions for a tumor near the spinal cord could lead to late spinal cord injury. For skin cancers, late tissue injury usually involves the soft tissues, bones, and normal structures underneath the skin irradiated."

One recent study demonstrated that melanoma patients treated with conventional fractionation had similar rates of local control, compared with those who were treated with hypofractionation (Int. J. Radiat. Oncol. Biol. Phys. 2006;66:1051–5).

Results from this and other studies "really take out the concern for late toxicity," Dr. Lin said. "Approximately 17% of patients with locoregional disease and 51% of patients with metastatic disease will benefit from radiation therapy."

Current studies show a wide range of response to radiation therapy, sometimes with similar sensitivities to other epithelial cancers. Most melanomas "are easily seen and have a high chance of cure with surgical excision alone," he said. "Locally advanced melanomas have a propensity for local and distant recurrences with surgery alone, and local control is associated with longer survival."

One use of radiation therapy in melanoma includes treating lentigo maligna, particularly for large cancers on the face, which could be difficult to remove surgically. Radiation therapy is delivered for 3 weeks, and it takes 18–24 months before most of the pigmentation resolves. Recurrences can be easily salvaged with surgery.

Radiation therapy may also be indicated after biopsy of primary melanoma for high-risk patients, including those with close or positive margins, rapid or multiple recurrences, extensive perineural invasion, and large primary tumors.

For patients with stage I-III melanoma, surgery alone without radiation therapy "is usually fine, because these patients have a higher risk of distant relapse," Dr. Lin said. "However, for these patients it's important to assess local failure risk, including margin status, head and neck site, thickness of 4 cm or greater, and history of recurrence or desmoplasia."

One trial of radiation therapy in 174 patients with head and neck melanoma found that the 5-year local regional control was 88%. The patients ranged in age from 16 to 89 years and they received a total of 30 Gy of hypofractionated radiotherapy delivered in five fractions over 2.5 weeks (Int. J. Radiat. Oncol. Biol. Phys. 1994;30:795–8).

The 5-year survival rate correlated with lymph node status. Only 23% of patients who had more than three involved lymph nodes survived, while 39% of those who had one to three involved lymph nodes survived.

The 5-year survival rate also correlated with the thickness of the tumor. The rate of survival in patients with a tumor up to 1.5 mm thick was 100%, but it dropped to 72% for those with tumors 1.5–4 mm thick and 30% for those with tumors greater than 4 mm thick.

"Unfortunately, most patients with high-risk features have poor survival," Dr. Lin commented. "There is some controversy on whether there is a clear survival advantage with radiation therapy, but [it] should be considered for certain high-risk features," he suggested. These include melanoma patients with recurrent disease, large nodal size (3 cm or greater), multiple lymph node involvement, and extracapsular extension.

Radiation therapy also is offered to stage IV melanoma patients who have brain, bone, or skin metastases. It is used on brain metastases to prevent further growth, shrink tumors, and control neurologic defects, and on bone metastases to control pain and prevent pathologic fracture. "After several treatments, patients usually experience significant pain relief," he said.

Complete response in patients with primary malignant melanoma ranges from 14% to 57%.

Sequelae from skin irradiation "depend on size, dose, and fractionation scheme," Dr. Lin said. "Usually there's some pruritus, hair loss, and desquamation. Late reactions may include telangiectasia, hyperpigmentation, hypopigmentation, and local hair loss."

This patient with lentigo maligna is about to begin radiation therapy.

Three weeks after therapy, the treated area is back to normal coloration. Photos courtesy Dr. Ray Lin

CORONADO, CALIF. — Radiation therapy is underused as a treatment for malignant melanoma, Dr. Ray Lin said at a melanoma update sponsored by the Scripps Clinic.

"The reasons are traced back to in vitro studies which showed that melanomas are more radioresistant," explained Dr. Lin of the department of radiation oncology at the clinic in La Jolla, Calif.

Most studies actually show that malignant melanoma responds to high doses of radiation per fraction, but this approach raises concern about late effects of radiation toxicity.

"The more fractionated the treatments are, the lower the risk for late toxicity," he said. "For instance, delivering higher doses of radiation in fewer fractions for a tumor near the spinal cord could lead to late spinal cord injury. For skin cancers, late tissue injury usually involves the soft tissues, bones, and normal structures underneath the skin irradiated."

One recent study demonstrated that melanoma patients treated with conventional fractionation had similar rates of local control, compared with those who were treated with hypofractionation (Int. J. Radiat. Oncol. Biol. Phys. 2006;66:1051–5).

Results from this and other studies "really take out the concern for late toxicity," Dr. Lin said. "Approximately 17% of patients with locoregional disease and 51% of patients with metastatic disease will benefit from radiation therapy."

Current studies show a wide range of response to radiation therapy, sometimes with similar sensitivities to other epithelial cancers. Most melanomas "are easily seen and have a high chance of cure with surgical excision alone," he said. "Locally advanced melanomas have a propensity for local and distant recurrences with surgery alone, and local control is associated with longer survival."

One use of radiation therapy in melanoma includes treating lentigo maligna, particularly for large cancers on the face, which could be difficult to remove surgically. Radiation therapy is delivered for 3 weeks, and it takes 18–24 months before most of the pigmentation resolves. Recurrences can be easily salvaged with surgery.

Radiation therapy may also be indicated after biopsy of primary melanoma for high-risk patients, including those with close or positive margins, rapid or multiple recurrences, extensive perineural invasion, and large primary tumors.

For patients with stage I-III melanoma, surgery alone without radiation therapy "is usually fine, because these patients have a higher risk of distant relapse," Dr. Lin said. "However, for these patients it's important to assess local failure risk, including margin status, head and neck site, thickness of 4 cm or greater, and history of recurrence or desmoplasia."

One trial of radiation therapy in 174 patients with head and neck melanoma found that the 5-year local regional control was 88%. The patients ranged in age from 16 to 89 years and they received a total of 30 Gy of hypofractionated radiotherapy delivered in five fractions over 2.5 weeks (Int. J. Radiat. Oncol. Biol. Phys. 1994;30:795–8).

The 5-year survival rate correlated with lymph node status. Only 23% of patients who had more than three involved lymph nodes survived, while 39% of those who had one to three involved lymph nodes survived.

The 5-year survival rate also correlated with the thickness of the tumor. The rate of survival in patients with a tumor up to 1.5 mm thick was 100%, but it dropped to 72% for those with tumors 1.5–4 mm thick and 30% for those with tumors greater than 4 mm thick.

"Unfortunately, most patients with high-risk features have poor survival," Dr. Lin commented. "There is some controversy on whether there is a clear survival advantage with radiation therapy, but [it] should be considered for certain high-risk features," he suggested. These include melanoma patients with recurrent disease, large nodal size (3 cm or greater), multiple lymph node involvement, and extracapsular extension.

Radiation therapy also is offered to stage IV melanoma patients who have brain, bone, or skin metastases. It is used on brain metastases to prevent further growth, shrink tumors, and control neurologic defects, and on bone metastases to control pain and prevent pathologic fracture. "After several treatments, patients usually experience significant pain relief," he said.

Complete response in patients with primary malignant melanoma ranges from 14% to 57%.

Sequelae from skin irradiation "depend on size, dose, and fractionation scheme," Dr. Lin said. "Usually there's some pruritus, hair loss, and desquamation. Late reactions may include telangiectasia, hyperpigmentation, hypopigmentation, and local hair loss."

This patient with lentigo maligna is about to begin radiation therapy.

Three weeks after therapy, the treated area is back to normal coloration. Photos courtesy Dr. Ray Lin

CORONADO, CALIF. — Radiation therapy is underused as a treatment for malignant melanoma, Dr. Ray Lin said at a melanoma update sponsored by the Scripps Clinic.

"The reasons are traced back to in vitro studies which showed that melanomas are more radioresistant," explained Dr. Lin of the department of radiation oncology at the clinic in La Jolla, Calif.

Most studies actually show that malignant melanoma responds to high doses of radiation per fraction, but this approach raises concern about late effects of radiation toxicity.

"The more fractionated the treatments are, the lower the risk for late toxicity," he said. "For instance, delivering higher doses of radiation in fewer fractions for a tumor near the spinal cord could lead to late spinal cord injury. For skin cancers, late tissue injury usually involves the soft tissues, bones, and normal structures underneath the skin irradiated."

One recent study demonstrated that melanoma patients treated with conventional fractionation had similar rates of local control, compared with those who were treated with hypofractionation (Int. J. Radiat. Oncol. Biol. Phys. 2006;66:1051–5).

Results from this and other studies "really take out the concern for late toxicity," Dr. Lin said. "Approximately 17% of patients with locoregional disease and 51% of patients with metastatic disease will benefit from radiation therapy."

Current studies show a wide range of response to radiation therapy, sometimes with similar sensitivities to other epithelial cancers. Most melanomas "are easily seen and have a high chance of cure with surgical excision alone," he said. "Locally advanced melanomas have a propensity for local and distant recurrences with surgery alone, and local control is associated with longer survival."

One use of radiation therapy in melanoma includes treating lentigo maligna, particularly for large cancers on the face, which could be difficult to remove surgically. Radiation therapy is delivered for 3 weeks, and it takes 18–24 months before most of the pigmentation resolves. Recurrences can be easily salvaged with surgery.

Radiation therapy may also be indicated after biopsy of primary melanoma for high-risk patients, including those with close or positive margins, rapid or multiple recurrences, extensive perineural invasion, and large primary tumors.

For patients with stage I-III melanoma, surgery alone without radiation therapy "is usually fine, because these patients have a higher risk of distant relapse," Dr. Lin said. "However, for these patients it's important to assess local failure risk, including margin status, head and neck site, thickness of 4 cm or greater, and history of recurrence or desmoplasia."

One trial of radiation therapy in 174 patients with head and neck melanoma found that the 5-year local regional control was 88%. The patients ranged in age from 16 to 89 years and they received a total of 30 Gy of hypofractionated radiotherapy delivered in five fractions over 2.5 weeks (Int. J. Radiat. Oncol. Biol. Phys. 1994;30:795–8).

The 5-year survival rate correlated with lymph node status. Only 23% of patients who had more than three involved lymph nodes survived, while 39% of those who had one to three involved lymph nodes survived.

The 5-year survival rate also correlated with the thickness of the tumor. The rate of survival in patients with a tumor up to 1.5 mm thick was 100%, but it dropped to 72% for those with tumors 1.5–4 mm thick and 30% for those with tumors greater than 4 mm thick.

"Unfortunately, most patients with high-risk features have poor survival," Dr. Lin commented. "There is some controversy on whether there is a clear survival advantage with radiation therapy, but [it] should be considered for certain high-risk features," he suggested. These include melanoma patients with recurrent disease, large nodal size (3 cm or greater), multiple lymph node involvement, and extracapsular extension.

Radiation therapy also is offered to stage IV melanoma patients who have brain, bone, or skin metastases. It is used on brain metastases to prevent further growth, shrink tumors, and control neurologic defects, and on bone metastases to control pain and prevent pathologic fracture. "After several treatments, patients usually experience significant pain relief," he said.

Complete response in patients with primary malignant melanoma ranges from 14% to 57%.

Sequelae from skin irradiation "depend on size, dose, and fractionation scheme," Dr. Lin said. "Usually there's some pruritus, hair loss, and desquamation. Late reactions may include telangiectasia, hyperpigmentation, hypopigmentation, and local hair loss."

This patient with lentigo maligna is about to begin radiation therapy.

Three weeks after therapy, the treated area is back to normal coloration. Photos courtesy Dr. Ray Lin

The risk of coronary heart disease among women with type 2 diabetes appears to be elevated for those who consume high levels of heme iron and red meat, according to a large, long-term analysis from the ongoing Nurses' Health Study.

“Whether the increased iron intake is causally related to increased risk in CHD remains to be proven,” Dr. Lu Qi, of the department of nutrition at the Harvard School of Public Health, Boston, and colleagues wrote. “These findings suggest that patients with type 2 diabetes may consider reducing their consumption of heme iron and red meat for the prevention of CHD.”

The study included 6,161 women from the Nurses' Health Study who self-reported a physician diagnosis of type 2 diabetes between 1980 and 2000. The researchers excluded women with a history of CHD, stroke, or cancer as reported on follow-up questionnaires the women filled out prior to or during 1980 (Diabetes Care 2007;30:101–6).

At baseline, the women were divided into quintiles based on their median intakes of heme iron and red meat. The investigators then analyzed three of those five quintiles. In quintile 1, the median intakes were 1.70 mg/day and 0.55 servings per day, respectively. In quintile 3, the median intakes were 2.23 mg/day and 1.22 servings per day, respectively. In quintile 5, the median intakes were 2.83 mg/day and 2.39 servings per day, respectively.

During the follow-up period, which included 54,455 person years, the researchers documented 550 cases of CHD among the 6,161 women. These included 259 nonfatal myocardial infarctions, 153 CHD deaths, and 138 bypass operations or angioplasties.

After the researchers adjusted for age and body mass index, they found that women who consumed high levels of heme iron and red meat faced a significantly increased risk of fatal CHD, coronary revascularization, and total CHD, compared with those who consumed lower levels. The risk of total CHD was 50% greater among women who consumed the highest levels of heme iron compared with those who consumed the lowest levels.

The associations remained consistent when adjusted for physical activity and other covariates.

Subanalysis revealed that postmenopausal women were at greater risk of CHD compared with premenopausal women, possibly because of the loss of iron during menstruation.

The researchers acknowledged limitations of the study, including its self-reported nature and “the possibilities of residual confounding because of imperfect measures of diet and lifestyle factors.”

The study was funded by the National Institutes of Health.

The risk of coronary heart disease among women with type 2 diabetes appears to be elevated for those who consume high levels of heme iron and red meat, according to a large, long-term analysis from the ongoing Nurses' Health Study.

“Whether the increased iron intake is causally related to increased risk in CHD remains to be proven,” Dr. Lu Qi, of the department of nutrition at the Harvard School of Public Health, Boston, and colleagues wrote. “These findings suggest that patients with type 2 diabetes may consider reducing their consumption of heme iron and red meat for the prevention of CHD.”

The study included 6,161 women from the Nurses' Health Study who self-reported a physician diagnosis of type 2 diabetes between 1980 and 2000. The researchers excluded women with a history of CHD, stroke, or cancer as reported on follow-up questionnaires the women filled out prior to or during 1980 (Diabetes Care 2007;30:101–6).

At baseline, the women were divided into quintiles based on their median intakes of heme iron and red meat. The investigators then analyzed three of those five quintiles. In quintile 1, the median intakes were 1.70 mg/day and 0.55 servings per day, respectively. In quintile 3, the median intakes were 2.23 mg/day and 1.22 servings per day, respectively. In quintile 5, the median intakes were 2.83 mg/day and 2.39 servings per day, respectively.

During the follow-up period, which included 54,455 person years, the researchers documented 550 cases of CHD among the 6,161 women. These included 259 nonfatal myocardial infarctions, 153 CHD deaths, and 138 bypass operations or angioplasties.

After the researchers adjusted for age and body mass index, they found that women who consumed high levels of heme iron and red meat faced a significantly increased risk of fatal CHD, coronary revascularization, and total CHD, compared with those who consumed lower levels. The risk of total CHD was 50% greater among women who consumed the highest levels of heme iron compared with those who consumed the lowest levels.

The associations remained consistent when adjusted for physical activity and other covariates.

Subanalysis revealed that postmenopausal women were at greater risk of CHD compared with premenopausal women, possibly because of the loss of iron during menstruation.

The researchers acknowledged limitations of the study, including its self-reported nature and “the possibilities of residual confounding because of imperfect measures of diet and lifestyle factors.”

The study was funded by the National Institutes of Health.

The risk of coronary heart disease among women with type 2 diabetes appears to be elevated for those who consume high levels of heme iron and red meat, according to a large, long-term analysis from the ongoing Nurses' Health Study.

“Whether the increased iron intake is causally related to increased risk in CHD remains to be proven,” Dr. Lu Qi, of the department of nutrition at the Harvard School of Public Health, Boston, and colleagues wrote. “These findings suggest that patients with type 2 diabetes may consider reducing their consumption of heme iron and red meat for the prevention of CHD.”

The study included 6,161 women from the Nurses' Health Study who self-reported a physician diagnosis of type 2 diabetes between 1980 and 2000. The researchers excluded women with a history of CHD, stroke, or cancer as reported on follow-up questionnaires the women filled out prior to or during 1980 (Diabetes Care 2007;30:101–6).

At baseline, the women were divided into quintiles based on their median intakes of heme iron and red meat. The investigators then analyzed three of those five quintiles. In quintile 1, the median intakes were 1.70 mg/day and 0.55 servings per day, respectively. In quintile 3, the median intakes were 2.23 mg/day and 1.22 servings per day, respectively. In quintile 5, the median intakes were 2.83 mg/day and 2.39 servings per day, respectively.

During the follow-up period, which included 54,455 person years, the researchers documented 550 cases of CHD among the 6,161 women. These included 259 nonfatal myocardial infarctions, 153 CHD deaths, and 138 bypass operations or angioplasties.

After the researchers adjusted for age and body mass index, they found that women who consumed high levels of heme iron and red meat faced a significantly increased risk of fatal CHD, coronary revascularization, and total CHD, compared with those who consumed lower levels. The risk of total CHD was 50% greater among women who consumed the highest levels of heme iron compared with those who consumed the lowest levels.

The associations remained consistent when adjusted for physical activity and other covariates.

Subanalysis revealed that postmenopausal women were at greater risk of CHD compared with premenopausal women, possibly because of the loss of iron during menstruation.

The researchers acknowledged limitations of the study, including its self-reported nature and “the possibilities of residual confounding because of imperfect measures of diet and lifestyle factors.”

The study was funded by the National Institutes of Health.

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 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?”

While 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 during her seizures her world seems very unreal, he said. “She feels like she's walking in a dreamlike state. Her art represents this experience.”

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 artist 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, a program supported by an educational grant from Abbott Laboratories, Cyberonics, and GlaxoSmithKline Pharmaceuticals.

Dr. Schachter has collected over 1,200 works such as 'Transcending' (above). 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 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?”

While 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 during her seizures her world seems very unreal, he said. “She feels like she's walking in a dreamlike state. Her art represents this experience.”

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 artist 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, a program supported by an educational grant from Abbott Laboratories, Cyberonics, and GlaxoSmithKline Pharmaceuticals.

Dr. Schachter has collected over 1,200 works such as 'Transcending' (above). 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 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?”

While 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 during her seizures her world seems very unreal, he said. “She feels like she's walking in a dreamlike state. Her art represents this experience.”

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 artist 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, a program supported by an educational grant from Abbott Laboratories, Cyberonics, and GlaxoSmithKline Pharmaceuticals.

Dr. Schachter has collected over 1,200 works such as 'Transcending' (above). Jennifer Hall

LAS VEGAS — Although renal cortical scintigraphy remains the accepted standard for diagnosing pyelonephritis—with a sensitivity of 92% and a specificity of 100%—it's far from perfect, Dr. Melvin O. Senac Jr., said at a meeting sponsored by the American Academy of Pediatrics' California Chapters 1, 2, 3, and 4 and the AAP.

First, it's difficult to tell scars from pyelonephritis on renal cortical scintigraphy using dimercaptosuccinic acid (DMSA).

It's also expensive, around $700 per scan.

Finally, because renal damage is already done, the scan may not change the approach to managing these patients.

“The jury's still out on DMSA [scans],” said Dr. Senac, medical director and chief of radiology at Children's Hospital San Diego. “I wouldn't recommend it routinely.”

He went on to note that ultrasounds in children with clinical evidence of pyelonephritis are usually normal, and vesicoureteral reflux occurs 35%–40% of the time.

One episode of pyelonephritis produces a 10% chance of renal scarring, while four episodes result in a 58% chance of renal scarring.

In a study of 111 children with clinical findings of pyelonephritis, DMSA scans detected positive renal changes indicative of pyelonephritis in 67% of patients. The rest (33%) were normal (J. Pediatr. 1994;124:17–20). In addition, 64% of the patients had scarring at 1-year follow-up, and 39% had vesicoureteral reflux.

In light of the findings, the researchers recommended that all children with clinical signs of pyelonephritis undergo DMSA scans. However, Dr. Senac said that current medical evidence does not warrant such a practice.

“If I had data to support it, maybe I could recommend following this protocol, but as of 2006, I just can't,” Dr. Senac commented.

An “overlooked” way to diagnose pyelonephritis is by CT scan. “It's just as good as a DMSA renal scan,” he said. “I'm not advocating that, but it's easy when we have a child with right abdominal pain.”

He acknowledged that many questions exist about the best way to diagnose pyelonephritis and other urinary tract infections in infants.

“Is ultrasound necessary in the imaging workup? That really needs to be addressed once and for all,” said Dr. Senac, also of the department of radiology at the University of California, San Diego.

“Even more important, is there evidence-based value of prophylaxis in reducing reinfections and preventing renal scarring?” he asked. “That is a critical question. It needs to be a well-designed study with placebo control to see if prophylaxis is truly helping. We think it does, but there is not good evidence-based medicine on that.”

LAS VEGAS — Although renal cortical scintigraphy remains the accepted standard for diagnosing pyelonephritis—with a sensitivity of 92% and a specificity of 100%—it's far from perfect, Dr. Melvin O. Senac Jr., said at a meeting sponsored by the American Academy of Pediatrics' California Chapters 1, 2, 3, and 4 and the AAP.

First, it's difficult to tell scars from pyelonephritis on renal cortical scintigraphy using dimercaptosuccinic acid (DMSA).

It's also expensive, around $700 per scan.

Finally, because renal damage is already done, the scan may not change the approach to managing these patients.

“The jury's still out on DMSA [scans],” said Dr. Senac, medical director and chief of radiology at Children's Hospital San Diego. “I wouldn't recommend it routinely.”

He went on to note that ultrasounds in children with clinical evidence of pyelonephritis are usually normal, and vesicoureteral reflux occurs 35%–40% of the time.

One episode of pyelonephritis produces a 10% chance of renal scarring, while four episodes result in a 58% chance of renal scarring.

In a study of 111 children with clinical findings of pyelonephritis, DMSA scans detected positive renal changes indicative of pyelonephritis in 67% of patients. The rest (33%) were normal (J. Pediatr. 1994;124:17–20). In addition, 64% of the patients had scarring at 1-year follow-up, and 39% had vesicoureteral reflux.

In light of the findings, the researchers recommended that all children with clinical signs of pyelonephritis undergo DMSA scans. However, Dr. Senac said that current medical evidence does not warrant such a practice.

“If I had data to support it, maybe I could recommend following this protocol, but as of 2006, I just can't,” Dr. Senac commented.

An “overlooked” way to diagnose pyelonephritis is by CT scan. “It's just as good as a DMSA renal scan,” he said. “I'm not advocating that, but it's easy when we have a child with right abdominal pain.”

He acknowledged that many questions exist about the best way to diagnose pyelonephritis and other urinary tract infections in infants.

“Is ultrasound necessary in the imaging workup? That really needs to be addressed once and for all,” said Dr. Senac, also of the department of radiology at the University of California, San Diego.

“Even more important, is there evidence-based value of prophylaxis in reducing reinfections and preventing renal scarring?” he asked. “That is a critical question. It needs to be a well-designed study with placebo control to see if prophylaxis is truly helping. We think it does, but there is not good evidence-based medicine on that.”

LAS VEGAS — Although renal cortical scintigraphy remains the accepted standard for diagnosing pyelonephritis—with a sensitivity of 92% and a specificity of 100%—it's far from perfect, Dr. Melvin O. Senac Jr., said at a meeting sponsored by the American Academy of Pediatrics' California Chapters 1, 2, 3, and 4 and the AAP.

First, it's difficult to tell scars from pyelonephritis on renal cortical scintigraphy using dimercaptosuccinic acid (DMSA).

It's also expensive, around $700 per scan.

Finally, because renal damage is already done, the scan may not change the approach to managing these patients.

“The jury's still out on DMSA [scans],” said Dr. Senac, medical director and chief of radiology at Children's Hospital San Diego. “I wouldn't recommend it routinely.”

He went on to note that ultrasounds in children with clinical evidence of pyelonephritis are usually normal, and vesicoureteral reflux occurs 35%–40% of the time.

One episode of pyelonephritis produces a 10% chance of renal scarring, while four episodes result in a 58% chance of renal scarring.

In a study of 111 children with clinical findings of pyelonephritis, DMSA scans detected positive renal changes indicative of pyelonephritis in 67% of patients. The rest (33%) were normal (J. Pediatr. 1994;124:17–20). In addition, 64% of the patients had scarring at 1-year follow-up, and 39% had vesicoureteral reflux.

In light of the findings, the researchers recommended that all children with clinical signs of pyelonephritis undergo DMSA scans. However, Dr. Senac said that current medical evidence does not warrant such a practice.

“If I had data to support it, maybe I could recommend following this protocol, but as of 2006, I just can't,” Dr. Senac commented.

An “overlooked” way to diagnose pyelonephritis is by CT scan. “It's just as good as a DMSA renal scan,” he said. “I'm not advocating that, but it's easy when we have a child with right abdominal pain.”

He acknowledged that many questions exist about the best way to diagnose pyelonephritis and other urinary tract infections in infants.

“Is ultrasound necessary in the imaging workup? That really needs to be addressed once and for all,” said Dr. Senac, also of the department of radiology at the University of California, San Diego.

“Even more important, is there evidence-based value of prophylaxis in reducing reinfections and preventing renal scarring?” he asked. “That is a critical question. It needs to be a well-designed study with placebo control to see if prophylaxis is truly helping. We think it does, but there is not good evidence-based medicine on that.”

LAS VEGAS — If a child presents to your office with fever, chills, muscle pain, joint swelling/pain, and a skin rash and has a pet rat, consider rat bite fever, Dr. Jay M. Lieberman advised at a meeting that was sponsored by the American Academy of Pediatrics' California Chapters 1, 2, 3, and 4 and the AAP.

In the summer of 2002, one of his colleagues at Miller Children's Hospital in Long Beach, Calif., consulted on a 6-year-old boy who was admitted with a 3-day history of fever as high as 103 and petechial and pustular lesions on his feet.

He had initially complained of left ankle pain and refusal to walk and then had diffuse pain of the left knee, elbow, and wrist.

The boy's lab tests were normal except for a relatively low blood platelet count (146,000/mcL of blood). Liver function tests also were normal. The family was from Pennsylvania and had been living in southern California for 2 months. The patient had a pet rat that the family had acquired several weeks before the onset of his symptoms.

“This boy liked to kiss his rat,” said Dr. Lieberman, chief of pediatric infectious diseases at the hospital.

The history of the pet rat prompted Dr. Lieberman's colleague to review the medical literature on rat bite fever, and it became apparent that the boy had a classic presentation of the disease. Rat bite fever is caused by Streptobacillus moniliformis, a bacterium that is found in the normal oral flora of rats and can be excreted in rat urine.

Humans can become infected with S. moniliformis after a bite or scratch from the infected rat, from handling it, or by ingesting food or water contaminated with rat excrement.

The incubation period ranges from 2 to 10 days and patients present with a flu-like illness, including an abrupt onset of fever, chills, headache, and myalgia. A rash may develop 2–4 days after the onset of fever.

The rash “is usually maculopapular, predominantly involves the palms and soles, and may evolve into petechia, purpura, and vesicles,” said Dr. Lieberman, who also is a professor of pediatrics at the University of California, Irvine.

Penicillin G is the treatment of choice, and the boy improved rapidly once on the regimen. Untreated, the infection may have a relapsing course for 3 weeks or more with a case fatality rate as high as 10%.

Dr. Lieberman said the case underscores the importance of asking about pets in every febrile patient and considering the possibility of rat bite fever in acutely ill patients with rat exposure.

According to the textbooks, “children inhabiting crowded urban dwellings or rural areas infested with wild rats” are at risk. Half or more of wild rats carry the organism in their nasopharynx, Dr. Lieberman explained.

According to the Centers for Disease Control and Prevention, two people died from rat bite fever in 2003 (MMWR 2005;53:1198–202). One of the victims, a previously healthy 19-year-old woman in Washington, was pronounced dead on arrival at a hospital emergency department after being ill for 3 days. She had lived in an apartment with nine pet rats, and S. moniliformis was identified from the liver and kidney on autopsy.

In a California case, a 6-year-old boy was admitted with a 3-day history of fever as high as 103° F and petechial and pustular lesions on his feet; the eventual diagnosis was rat bite fever. Courtesy Dr. Felice C. Adler-Shohet

LAS VEGAS — If a child presents to your office with fever, chills, muscle pain, joint swelling/pain, and a skin rash and has a pet rat, consider rat bite fever, Dr. Jay M. Lieberman advised at a meeting that was sponsored by the American Academy of Pediatrics' California Chapters 1, 2, 3, and 4 and the AAP.

In the summer of 2002, one of his colleagues at Miller Children's Hospital in Long Beach, Calif., consulted on a 6-year-old boy who was admitted with a 3-day history of fever as high as 103 and petechial and pustular lesions on his feet.

He had initially complained of left ankle pain and refusal to walk and then had diffuse pain of the left knee, elbow, and wrist.

The boy's lab tests were normal except for a relatively low blood platelet count (146,000/mcL of blood). Liver function tests also were normal. The family was from Pennsylvania and had been living in southern California for 2 months. The patient had a pet rat that the family had acquired several weeks before the onset of his symptoms.

“This boy liked to kiss his rat,” said Dr. Lieberman, chief of pediatric infectious diseases at the hospital.

The history of the pet rat prompted Dr. Lieberman's colleague to review the medical literature on rat bite fever, and it became apparent that the boy had a classic presentation of the disease. Rat bite fever is caused by Streptobacillus moniliformis, a bacterium that is found in the normal oral flora of rats and can be excreted in rat urine.

Humans can become infected with S. moniliformis after a bite or scratch from the infected rat, from handling it, or by ingesting food or water contaminated with rat excrement.

The incubation period ranges from 2 to 10 days and patients present with a flu-like illness, including an abrupt onset of fever, chills, headache, and myalgia. A rash may develop 2–4 days after the onset of fever.

The rash “is usually maculopapular, predominantly involves the palms and soles, and may evolve into petechia, purpura, and vesicles,” said Dr. Lieberman, who also is a professor of pediatrics at the University of California, Irvine.

Penicillin G is the treatment of choice, and the boy improved rapidly once on the regimen. Untreated, the infection may have a relapsing course for 3 weeks or more with a case fatality rate as high as 10%.

Dr. Lieberman said the case underscores the importance of asking about pets in every febrile patient and considering the possibility of rat bite fever in acutely ill patients with rat exposure.

According to the textbooks, “children inhabiting crowded urban dwellings or rural areas infested with wild rats” are at risk. Half or more of wild rats carry the organism in their nasopharynx, Dr. Lieberman explained.

According to the Centers for Disease Control and Prevention, two people died from rat bite fever in 2003 (MMWR 2005;53:1198–202). One of the victims, a previously healthy 19-year-old woman in Washington, was pronounced dead on arrival at a hospital emergency department after being ill for 3 days. She had lived in an apartment with nine pet rats, and S. moniliformis was identified from the liver and kidney on autopsy.

In a California case, a 6-year-old boy was admitted with a 3-day history of fever as high as 103° F and petechial and pustular lesions on his feet; the eventual diagnosis was rat bite fever. Courtesy Dr. Felice C. Adler-Shohet

LAS VEGAS — If a child presents to your office with fever, chills, muscle pain, joint swelling/pain, and a skin rash and has a pet rat, consider rat bite fever, Dr. Jay M. Lieberman advised at a meeting that was sponsored by the American Academy of Pediatrics' California Chapters 1, 2, 3, and 4 and the AAP.

In the summer of 2002, one of his colleagues at Miller Children's Hospital in Long Beach, Calif., consulted on a 6-year-old boy who was admitted with a 3-day history of fever as high as 103 and petechial and pustular lesions on his feet.

He had initially complained of left ankle pain and refusal to walk and then had diffuse pain of the left knee, elbow, and wrist.

The boy's lab tests were normal except for a relatively low blood platelet count (146,000/mcL of blood). Liver function tests also were normal. The family was from Pennsylvania and had been living in southern California for 2 months. The patient had a pet rat that the family had acquired several weeks before the onset of his symptoms.

“This boy liked to kiss his rat,” said Dr. Lieberman, chief of pediatric infectious diseases at the hospital.

The history of the pet rat prompted Dr. Lieberman's colleague to review the medical literature on rat bite fever, and it became apparent that the boy had a classic presentation of the disease. Rat bite fever is caused by Streptobacillus moniliformis, a bacterium that is found in the normal oral flora of rats and can be excreted in rat urine.

Humans can become infected with S. moniliformis after a bite or scratch from the infected rat, from handling it, or by ingesting food or water contaminated with rat excrement.

The incubation period ranges from 2 to 10 days and patients present with a flu-like illness, including an abrupt onset of fever, chills, headache, and myalgia. A rash may develop 2–4 days after the onset of fever.

The rash “is usually maculopapular, predominantly involves the palms and soles, and may evolve into petechia, purpura, and vesicles,” said Dr. Lieberman, who also is a professor of pediatrics at the University of California, Irvine.

Penicillin G is the treatment of choice, and the boy improved rapidly once on the regimen. Untreated, the infection may have a relapsing course for 3 weeks or more with a case fatality rate as high as 10%.

Dr. Lieberman said the case underscores the importance of asking about pets in every febrile patient and considering the possibility of rat bite fever in acutely ill patients with rat exposure.

According to the textbooks, “children inhabiting crowded urban dwellings or rural areas infested with wild rats” are at risk. Half or more of wild rats carry the organism in their nasopharynx, Dr. Lieberman explained.

According to the Centers for Disease Control and Prevention, two people died from rat bite fever in 2003 (MMWR 2005;53:1198–202). One of the victims, a previously healthy 19-year-old woman in Washington, was pronounced dead on arrival at a hospital emergency department after being ill for 3 days. She had lived in an apartment with nine pet rats, and S. moniliformis was identified from the liver and kidney on autopsy.

In a California case, a 6-year-old boy was admitted with a 3-day history of fever as high as 103° F and petechial and pustular lesions on his feet; the eventual diagnosis was rat bite fever. Courtesy Dr. Felice C. Adler-Shohet

The risk of coronary heart disease among women with type 2 diabetes appears to be elevated for those who consume high levels of heme iron and red meat, according to a large, long-term analysis from the ongoing Nurses' Health Study.

“Whether the increased iron intake is causally related to increased risk in CHD remains to be proven,” Dr. Lu Qi, of the department of nutrition at the Harvard School of Public Health, Boston, and colleagues wrote. “These findings suggest that patients with type 2 diabetes may consider reducing their consumption of heme iron and red meat for the prevention of CHD.”

The study included 6,161 women from the Nurses' Health Study who self-reported a physician diagnosis of type 2 diabetes between 1980 and 2000. The researchers excluded women with a history of CHD, stroke, or cancer as reported on follow-up questionnaires the women filled out prior to or during 1980 (Diabetes Care 2007;30:101–6).

At baseline, the women were divided into quintiles based on their median intakes of heme iron and red meat. The investigators then analyzed three of those five quintiles. In quintile 1, the median intakes were 1.70 mg/day and 0.55 servings per day, respectively. In quintile 3, the median intakes were 2.23 mg/day and 1.22 servings per day, respectively. In quintile 5, the median intakes were 2.83 mg/day and 2.39 servings per day, respectively.

During the follow-up period, which included 54,455 person years, the researchers documented 550 cases of CHD among the 6,161 women. These included 259 nonfatal myocardial infarctions, 153 CHD deaths, and 138 bypass operations or angioplasties.

After the researchers adjusted for age and body mass index, they found that women who consumed high levels of heme iron and red meat faced a significantly increased risk of fatal CHD, coronary revascularization, and total CHD, compared with those who consumed lower levels. The risk of total CHD was 50% greater among women who consumed the highest levels of heme iron compared with those who consumed the lowest levels.

The associations remained consistent when the researchers adjusted for level of physical activity, aspirin use, duration of diabetes, and other covariates.

Subanalysis revealed that postmenopausal women were at greater risk of CHD, compared with premenopausal women. “Premenopausal women may lose a significant amount of iron during menstruation, which may dilute the relationship between iron intake and CHD risk,” the researchers hypothesized.

They acknowledged limitations of the study, including its self-reported nature and “the possibilities of residual confounding because of imperfect measures of diet and lifestyle factors.”

The study was funded by the National Institutes of Health.

The risk of coronary heart disease among women with type 2 diabetes appears to be elevated for those who consume high levels of heme iron and red meat, according to a large, long-term analysis from the ongoing Nurses' Health Study.

“Whether the increased iron intake is causally related to increased risk in CHD remains to be proven,” Dr. Lu Qi, of the department of nutrition at the Harvard School of Public Health, Boston, and colleagues wrote. “These findings suggest that patients with type 2 diabetes may consider reducing their consumption of heme iron and red meat for the prevention of CHD.”

The study included 6,161 women from the Nurses' Health Study who self-reported a physician diagnosis of type 2 diabetes between 1980 and 2000. The researchers excluded women with a history of CHD, stroke, or cancer as reported on follow-up questionnaires the women filled out prior to or during 1980 (Diabetes Care 2007;30:101–6).

At baseline, the women were divided into quintiles based on their median intakes of heme iron and red meat. The investigators then analyzed three of those five quintiles. In quintile 1, the median intakes were 1.70 mg/day and 0.55 servings per day, respectively. In quintile 3, the median intakes were 2.23 mg/day and 1.22 servings per day, respectively. In quintile 5, the median intakes were 2.83 mg/day and 2.39 servings per day, respectively.

During the follow-up period, which included 54,455 person years, the researchers documented 550 cases of CHD among the 6,161 women. These included 259 nonfatal myocardial infarctions, 153 CHD deaths, and 138 bypass operations or angioplasties.

After the researchers adjusted for age and body mass index, they found that women who consumed high levels of heme iron and red meat faced a significantly increased risk of fatal CHD, coronary revascularization, and total CHD, compared with those who consumed lower levels. The risk of total CHD was 50% greater among women who consumed the highest levels of heme iron compared with those who consumed the lowest levels.

The associations remained consistent when the researchers adjusted for level of physical activity, aspirin use, duration of diabetes, and other covariates.

Subanalysis revealed that postmenopausal women were at greater risk of CHD, compared with premenopausal women. “Premenopausal women may lose a significant amount of iron during menstruation, which may dilute the relationship between iron intake and CHD risk,” the researchers hypothesized.

They acknowledged limitations of the study, including its self-reported nature and “the possibilities of residual confounding because of imperfect measures of diet and lifestyle factors.”

The study was funded by the National Institutes of Health.

The risk of coronary heart disease among women with type 2 diabetes appears to be elevated for those who consume high levels of heme iron and red meat, according to a large, long-term analysis from the ongoing Nurses' Health Study.

“Whether the increased iron intake is causally related to increased risk in CHD remains to be proven,” Dr. Lu Qi, of the department of nutrition at the Harvard School of Public Health, Boston, and colleagues wrote. “These findings suggest that patients with type 2 diabetes may consider reducing their consumption of heme iron and red meat for the prevention of CHD.”

The study included 6,161 women from the Nurses' Health Study who self-reported a physician diagnosis of type 2 diabetes between 1980 and 2000. The researchers excluded women with a history of CHD, stroke, or cancer as reported on follow-up questionnaires the women filled out prior to or during 1980 (Diabetes Care 2007;30:101–6).

At baseline, the women were divided into quintiles based on their median intakes of heme iron and red meat. The investigators then analyzed three of those five quintiles. In quintile 1, the median intakes were 1.70 mg/day and 0.55 servings per day, respectively. In quintile 3, the median intakes were 2.23 mg/day and 1.22 servings per day, respectively. In quintile 5, the median intakes were 2.83 mg/day and 2.39 servings per day, respectively.

During the follow-up period, which included 54,455 person years, the researchers documented 550 cases of CHD among the 6,161 women. These included 259 nonfatal myocardial infarctions, 153 CHD deaths, and 138 bypass operations or angioplasties.

After the researchers adjusted for age and body mass index, they found that women who consumed high levels of heme iron and red meat faced a significantly increased risk of fatal CHD, coronary revascularization, and total CHD, compared with those who consumed lower levels. The risk of total CHD was 50% greater among women who consumed the highest levels of heme iron compared with those who consumed the lowest levels.

The associations remained consistent when the researchers adjusted for level of physical activity, aspirin use, duration of diabetes, and other covariates.

Subanalysis revealed that postmenopausal women were at greater risk of CHD, compared with premenopausal women. “Premenopausal women may lose a significant amount of iron during menstruation, which may dilute the relationship between iron intake and CHD risk,” the researchers hypothesized.

They acknowledged limitations of the study, including its self-reported nature and “the possibilities of residual confounding because of imperfect measures of diet and lifestyle factors.”

The study was funded by the National Institutes of Health.