Jeff Evans

BALTIMORE – Growing evidence suggests that a small minority of children with autistic spectrum disorder can recover from the condition to near-normal levels with only mild residual deficits, Deborah Fein, Ph.D., said at a meeting on developmental disabilities sponsored by Johns Hopkins University.

“We have no idea yet [whether recovery] is due to maturation of kids who have a certain type of autism or treatment effects. There are very few people who are looking at this, but there are a few groups that are starting to look at it now,” said Dr. Fein, professor of psychology at the University of Connecticut, Storrs.

Early studies in the late 1960s and early 1970s included a small minority of children who moved off the spectrum, but in most cases the investigators did not point this out, which seems to imply that those children were misdiagnosed. More recent studies have found that early diagnoses are stable in most children with autistic spectrum disorder (ASD), but there is a subgroup that moves off the autistic spectrum. These children have been regarded as misdiagnosed by some, but evidence from other studies suggests that these children had unstable autism and “probably were not misdiagnosed,” she said.

In one study, recovery from autism was reported in 9 of 19 children who received 40 hours per week of applied behavior analysis therapy (ABA). These children successfully completed normal first grade in a public school and had normal or above average IQ scores. They gained an average of 30 IQ points more than their counterparts in a control group of 40 children who received 10 hours per week of ABA; only 1 child in the control group recovered. Of the 10 other children in the intense ABA therapy group, 8 remained in the mildly impaired range, and 2 were profoundly retarded (J. Consult. Clin. Psychol. 1987;55:3–9)

In two attempts to replicate this study, there was substantial improvement in ABA-treated autistic children in areas such as cognition and academics but not in adaptive skills and behavior. Yet ABA therapists in the two studies did not report recovery among any of the children.

One recent study did replicate the results of the positive study with ABA therapy. After 4 years of treatment with ABA, 11 of 23 children with autism were in regular classes and scored normally on tests of IQ, language, adaptive functioning, and personality (Am. J. Ment. Retard. 2005;110:417–38). Although 3 of the 11 children needed classroom aides for attention problems and 1 would probably still meet criteria for ASD, the other 7 would probably meet criteria for an optimal outcome.

“This is a very exciting study,” Dr. Fein said.

In general, studies have found that communicative language by 5 years of age and a good response to early intervention within 3 months are positive signs for a good prognosis. Higher IQs appear to be associated with better social, communicative, and adaptive behaviors as the child ages.

In Dr. Fein's clinical impression, the children near 4–6 years of age who make limited progress despite good intervention will be those with mental retardation “across the board,” dense language disorder, or an intense need for repetitive behavior despite the appearance of normal cognitive potential at certain times. The presence of seizures also may indicate a poor prognosis.

Children with ASD have been shown to leave the spectrum but then reveal or develop another condition, such as ADHD. In a report, Dr. Fein described 11 children with ASD who developed clear-cut cases of ADHD by about 6 or 7 years of age. Eight of these children received intensive applied behavior analysis therapy while the other three participated in integrated or special education preschool. The children retained some mild residual features of autism, such as social awkwardness (but more impulsive and immature than aloof), perseverative interests, and occasional mild motor stereotypies (J. Autism Dev. Disord. 2005;35:525–34).

In those cases, the children may have had comorbid ASD and ADHD, leaving ADHD when autism resolved. These children also could have had a severe subtype of ADHD that presents as autism in the early years, but this may not be the case because the children looked “pretty indistinguishable from kids who stay autistic,” she noted. Or it could be that attention impairment is a feature of ASD that remains when social, behavioral, and communication impairments subside.

In a separate ongoing study conducted by Dr. Fein and her colleagues, a group of 77 children who screened positive on the Modified Checklist for Autism in Toddlers at 2 years of age were later seen at 4 years of age, regardless of whether they were autistic or not.

Of the 61 children who had autism at 2 years of age, 46 also had it at 4 years of age. The remaining 15 children moved off the autistic spectrum. A total of 16 children were not autistic at either age but still screened positive because they had some problems, such as global developmental and language delays. No children who were nonautistic at 2 years of age became autistic at 4 years of age.

At 2 years of age, the 15 children in that study who left the spectrum were indistinguishable on measures of communication, socialization, symptom severity, and cognitive ability from children who remained autistic. But at 4 years of age, the “recovered” children reached almost normal levels on these measures, she said.

The only major difference between these groups at 2 years of age was in motor skills, in which recovered children had significantly higher scores that reached near-normal levels at 4 years of age.

In another study that will appear in the Journal of Autism and Developmental Disorders, Dr. Fein and her associates reported on 14 children aged 5–9 years with prior ASD diagnoses. These children had IQ scores in the normal range, were placed in age-appropriate mainstream classes, and were considered to be generally functioning at the level of their normally developing peers.

They had normal performance on many measures, including different aspects of linguistic ability, expressive vocabulary, and sentence memory, and had adaptive skills in communication and socialization.

But these children still had impairments in knowing the difference between mental state verbs (know, guess, estimate) and in reasoning about animate objects (not including people). They failed to produce good narratives, judged by such factors as being less likely to discuss major events and characters' motivations. They also were not good at understanding “second order theory of mind” situations, such as knowing “what does Johnny know that Suzie knows about what Rick thinks,” Dr. Fein said.

But follow-up visits with these children at 9–12 years of age indicated that the children were “closing the gap” between themselves and normal children because their only remaining deficit was with mental state verbs.

Misdiagnosis of children who leave the spectrum appears unlikely, so the reasons why a small minority of autistic children can recover may lie in the possibility that they have a form of autism that can be alleviated with maturation or that their recovery was mediated by successful treatment or some interaction between treatment and their characteristics, she said.

These possibilities leave two big questions that remain to be answered, Dr. Fein said: Are the children for whom recovery is possible the ones with minimal structural brain abnormalities? When recovered children do a task normally, are they using the same brain systems as children who were never autistic?

BALTIMORE – Growing evidence suggests that a small minority of children with autistic spectrum disorder can recover from the condition to near-normal levels with only mild residual deficits, Deborah Fein, Ph.D., said at a meeting on developmental disabilities sponsored by Johns Hopkins University.

“We have no idea yet [whether recovery] is due to maturation of kids who have a certain type of autism or treatment effects. There are very few people who are looking at this, but there are a few groups that are starting to look at it now,” said Dr. Fein, professor of psychology at the University of Connecticut, Storrs.

Early studies in the late 1960s and early 1970s included a small minority of children who moved off the spectrum, but in most cases the investigators did not point this out, which seems to imply that those children were misdiagnosed. More recent studies have found that early diagnoses are stable in most children with autistic spectrum disorder (ASD), but there is a subgroup that moves off the autistic spectrum. These children have been regarded as misdiagnosed by some, but evidence from other studies suggests that these children had unstable autism and “probably were not misdiagnosed,” she said.

In one study, recovery from autism was reported in 9 of 19 children who received 40 hours per week of applied behavior analysis therapy (ABA). These children successfully completed normal first grade in a public school and had normal or above average IQ scores. They gained an average of 30 IQ points more than their counterparts in a control group of 40 children who received 10 hours per week of ABA; only 1 child in the control group recovered. Of the 10 other children in the intense ABA therapy group, 8 remained in the mildly impaired range, and 2 were profoundly retarded (J. Consult. Clin. Psychol. 1987;55:3–9)

In two attempts to replicate this study, there was substantial improvement in ABA-treated autistic children in areas such as cognition and academics but not in adaptive skills and behavior. Yet ABA therapists in the two studies did not report recovery among any of the children.

One recent study did replicate the results of the positive study with ABA therapy. After 4 years of treatment with ABA, 11 of 23 children with autism were in regular classes and scored normally on tests of IQ, language, adaptive functioning, and personality (Am. J. Ment. Retard. 2005;110:417–38). Although 3 of the 11 children needed classroom aides for attention problems and 1 would probably still meet criteria for ASD, the other 7 would probably meet criteria for an optimal outcome.

“This is a very exciting study,” Dr. Fein said.

In general, studies have found that communicative language by 5 years of age and a good response to early intervention within 3 months are positive signs for a good prognosis. Higher IQs appear to be associated with better social, communicative, and adaptive behaviors as the child ages.

In Dr. Fein's clinical impression, the children near 4–6 years of age who make limited progress despite good intervention will be those with mental retardation “across the board,” dense language disorder, or an intense need for repetitive behavior despite the appearance of normal cognitive potential at certain times. The presence of seizures also may indicate a poor prognosis.

Children with ASD have been shown to leave the spectrum but then reveal or develop another condition, such as ADHD. In a report, Dr. Fein described 11 children with ASD who developed clear-cut cases of ADHD by about 6 or 7 years of age. Eight of these children received intensive applied behavior analysis therapy while the other three participated in integrated or special education preschool. The children retained some mild residual features of autism, such as social awkwardness (but more impulsive and immature than aloof), perseverative interests, and occasional mild motor stereotypies (J. Autism Dev. Disord. 2005;35:525–34).

In those cases, the children may have had comorbid ASD and ADHD, leaving ADHD when autism resolved. These children also could have had a severe subtype of ADHD that presents as autism in the early years, but this may not be the case because the children looked “pretty indistinguishable from kids who stay autistic,” she noted. Or it could be that attention impairment is a feature of ASD that remains when social, behavioral, and communication impairments subside.

In a separate ongoing study conducted by Dr. Fein and her colleagues, a group of 77 children who screened positive on the Modified Checklist for Autism in Toddlers at 2 years of age were later seen at 4 years of age, regardless of whether they were autistic or not.

Of the 61 children who had autism at 2 years of age, 46 also had it at 4 years of age. The remaining 15 children moved off the autistic spectrum. A total of 16 children were not autistic at either age but still screened positive because they had some problems, such as global developmental and language delays. No children who were nonautistic at 2 years of age became autistic at 4 years of age.

At 2 years of age, the 15 children in that study who left the spectrum were indistinguishable on measures of communication, socialization, symptom severity, and cognitive ability from children who remained autistic. But at 4 years of age, the “recovered” children reached almost normal levels on these measures, she said.

The only major difference between these groups at 2 years of age was in motor skills, in which recovered children had significantly higher scores that reached near-normal levels at 4 years of age.

In another study that will appear in the Journal of Autism and Developmental Disorders, Dr. Fein and her associates reported on 14 children aged 5–9 years with prior ASD diagnoses. These children had IQ scores in the normal range, were placed in age-appropriate mainstream classes, and were considered to be generally functioning at the level of their normally developing peers.

They had normal performance on many measures, including different aspects of linguistic ability, expressive vocabulary, and sentence memory, and had adaptive skills in communication and socialization.

But these children still had impairments in knowing the difference between mental state verbs (know, guess, estimate) and in reasoning about animate objects (not including people). They failed to produce good narratives, judged by such factors as being less likely to discuss major events and characters' motivations. They also were not good at understanding “second order theory of mind” situations, such as knowing “what does Johnny know that Suzie knows about what Rick thinks,” Dr. Fein said.

But follow-up visits with these children at 9–12 years of age indicated that the children were “closing the gap” between themselves and normal children because their only remaining deficit was with mental state verbs.

Misdiagnosis of children who leave the spectrum appears unlikely, so the reasons why a small minority of autistic children can recover may lie in the possibility that they have a form of autism that can be alleviated with maturation or that their recovery was mediated by successful treatment or some interaction between treatment and their characteristics, she said.

These possibilities leave two big questions that remain to be answered, Dr. Fein said: Are the children for whom recovery is possible the ones with minimal structural brain abnormalities? When recovered children do a task normally, are they using the same brain systems as children who were never autistic?

BALTIMORE – Growing evidence suggests that a small minority of children with autistic spectrum disorder can recover from the condition to near-normal levels with only mild residual deficits, Deborah Fein, Ph.D., said at a meeting on developmental disabilities sponsored by Johns Hopkins University.

“We have no idea yet [whether recovery] is due to maturation of kids who have a certain type of autism or treatment effects. There are very few people who are looking at this, but there are a few groups that are starting to look at it now,” said Dr. Fein, professor of psychology at the University of Connecticut, Storrs.

Early studies in the late 1960s and early 1970s included a small minority of children who moved off the spectrum, but in most cases the investigators did not point this out, which seems to imply that those children were misdiagnosed. More recent studies have found that early diagnoses are stable in most children with autistic spectrum disorder (ASD), but there is a subgroup that moves off the autistic spectrum. These children have been regarded as misdiagnosed by some, but evidence from other studies suggests that these children had unstable autism and “probably were not misdiagnosed,” she said.

In one study, recovery from autism was reported in 9 of 19 children who received 40 hours per week of applied behavior analysis therapy (ABA). These children successfully completed normal first grade in a public school and had normal or above average IQ scores. They gained an average of 30 IQ points more than their counterparts in a control group of 40 children who received 10 hours per week of ABA; only 1 child in the control group recovered. Of the 10 other children in the intense ABA therapy group, 8 remained in the mildly impaired range, and 2 were profoundly retarded (J. Consult. Clin. Psychol. 1987;55:3–9)

In two attempts to replicate this study, there was substantial improvement in ABA-treated autistic children in areas such as cognition and academics but not in adaptive skills and behavior. Yet ABA therapists in the two studies did not report recovery among any of the children.

One recent study did replicate the results of the positive study with ABA therapy. After 4 years of treatment with ABA, 11 of 23 children with autism were in regular classes and scored normally on tests of IQ, language, adaptive functioning, and personality (Am. J. Ment. Retard. 2005;110:417–38). Although 3 of the 11 children needed classroom aides for attention problems and 1 would probably still meet criteria for ASD, the other 7 would probably meet criteria for an optimal outcome.

“This is a very exciting study,” Dr. Fein said.

In general, studies have found that communicative language by 5 years of age and a good response to early intervention within 3 months are positive signs for a good prognosis. Higher IQs appear to be associated with better social, communicative, and adaptive behaviors as the child ages.

In Dr. Fein's clinical impression, the children near 4–6 years of age who make limited progress despite good intervention will be those with mental retardation “across the board,” dense language disorder, or an intense need for repetitive behavior despite the appearance of normal cognitive potential at certain times. The presence of seizures also may indicate a poor prognosis.

Children with ASD have been shown to leave the spectrum but then reveal or develop another condition, such as ADHD. In a report, Dr. Fein described 11 children with ASD who developed clear-cut cases of ADHD by about 6 or 7 years of age. Eight of these children received intensive applied behavior analysis therapy while the other three participated in integrated or special education preschool. The children retained some mild residual features of autism, such as social awkwardness (but more impulsive and immature than aloof), perseverative interests, and occasional mild motor stereotypies (J. Autism Dev. Disord. 2005;35:525–34).

In those cases, the children may have had comorbid ASD and ADHD, leaving ADHD when autism resolved. These children also could have had a severe subtype of ADHD that presents as autism in the early years, but this may not be the case because the children looked “pretty indistinguishable from kids who stay autistic,” she noted. Or it could be that attention impairment is a feature of ASD that remains when social, behavioral, and communication impairments subside.

In a separate ongoing study conducted by Dr. Fein and her colleagues, a group of 77 children who screened positive on the Modified Checklist for Autism in Toddlers at 2 years of age were later seen at 4 years of age, regardless of whether they were autistic or not.

Of the 61 children who had autism at 2 years of age, 46 also had it at 4 years of age. The remaining 15 children moved off the autistic spectrum. A total of 16 children were not autistic at either age but still screened positive because they had some problems, such as global developmental and language delays. No children who were nonautistic at 2 years of age became autistic at 4 years of age.

At 2 years of age, the 15 children in that study who left the spectrum were indistinguishable on measures of communication, socialization, symptom severity, and cognitive ability from children who remained autistic. But at 4 years of age, the “recovered” children reached almost normal levels on these measures, she said.

The only major difference between these groups at 2 years of age was in motor skills, in which recovered children had significantly higher scores that reached near-normal levels at 4 years of age.

In another study that will appear in the Journal of Autism and Developmental Disorders, Dr. Fein and her associates reported on 14 children aged 5–9 years with prior ASD diagnoses. These children had IQ scores in the normal range, were placed in age-appropriate mainstream classes, and were considered to be generally functioning at the level of their normally developing peers.

They had normal performance on many measures, including different aspects of linguistic ability, expressive vocabulary, and sentence memory, and had adaptive skills in communication and socialization.

But these children still had impairments in knowing the difference between mental state verbs (know, guess, estimate) and in reasoning about animate objects (not including people). They failed to produce good narratives, judged by such factors as being less likely to discuss major events and characters' motivations. They also were not good at understanding “second order theory of mind” situations, such as knowing “what does Johnny know that Suzie knows about what Rick thinks,” Dr. Fein said.

But follow-up visits with these children at 9–12 years of age indicated that the children were “closing the gap” between themselves and normal children because their only remaining deficit was with mental state verbs.

Misdiagnosis of children who leave the spectrum appears unlikely, so the reasons why a small minority of autistic children can recover may lie in the possibility that they have a form of autism that can be alleviated with maturation or that their recovery was mediated by successful treatment or some interaction between treatment and their characteristics, she said.

These possibilities leave two big questions that remain to be answered, Dr. Fein said: Are the children for whom recovery is possible the ones with minimal structural brain abnormalities? When recovered children do a task normally, are they using the same brain systems as children who were never autistic?

BALTIMORE — Childhood regression may be related to epileptic encephalopathy only among children with language regression alone, rather than among those with autistic regression, Dr. John F. Mantovani said at a meeting on developmental disabilities sponsored by Johns Hopkins University.

But study data do not rule out the possibility of a continuum of regressive disorders in which epileptic encephalopathies underlie the process in some children who do not fit the general pattern, said Dr. Mantovani, medical director of the St. John's Mercy Child Development Center, St. Louis.

The evidence for an association between epileptic encephalopathy and autistic regression seems plausible based on the known prevalences with which regression, seizures, and epileptiform EEG activity occur in both children with autistic spectrum disorders (ASD) and those with Landau-Kleffner syndrome (LKS) and other regressive conditions in childhood.

LKS usually occurs at 3–8 years of age in previously normal children; these children may have isolated language regression and variable behavioral abnormalities occurring with severely epileptiform EEGs and/or clinical seizures.

About 20%–40% of children with autism have experienced autistic regression. The prevalence of seizure history in children with ASD increases with age, so they have occurred in 20%–30% by 30 years of age.

Epileptiform activity on EEGs—which is highly associated with, but not specific for, epilepsy—also occurs in about 15% of children with ASD who do not have seizures during brief testing, and in up to 60% of these children during prolonged, overnight testing. It is also known that LKS is caused by epileptic encephalopathy even without the presence of clinical seizures, Dr. Mantovani said.

But reports have shown that children with autistic regression before 2–3 years of age are significantly less likely to have epileptic encephalopathy than are children who develop language regression alone at 2–3 years of age or older, which is similar to the pattern described for children with LKS. Clinical seizures and epileptiform EEGs occur more than twice as often in children with language regression alone, compared with those with the broader profile of autistic regression, said Dr. Mantovani, of the neurology and pediatrics departments at Washington University, St. Louis.

There is a lack of temporal correlation between seizures and ASD. People with ASD, especially the nonsyndromic or idiopathic type, tend to have few seizures at early ages but then start to have them at older ages. Yet autistic regression mostly occurs before 2 years of age. There also is a lack of EEG and clinical specificity to associate epileptic encephalography with autistic regression, because most children with autistic regression on overnight EEG testing do not have epileptiform activity and there is no clinical difference between children with autistic regression and those with nonregressive ASD. Dr. Mantovani said it is reasonable to get an overnight EEG for children who develop isolated language regression at ages older than 2 years, or global regression at ages older than 3 years.

An EEG obtained in an overnight sleep study shows the characteristic pattern of high voltage, frontally dominant constant spike and wave activity consistent with epileptic encephalopathy. Courtesy Dr. John F. Mantovani

BALTIMORE — Childhood regression may be related to epileptic encephalopathy only among children with language regression alone, rather than among those with autistic regression, Dr. John F. Mantovani said at a meeting on developmental disabilities sponsored by Johns Hopkins University.

But study data do not rule out the possibility of a continuum of regressive disorders in which epileptic encephalopathies underlie the process in some children who do not fit the general pattern, said Dr. Mantovani, medical director of the St. John's Mercy Child Development Center, St. Louis.

The evidence for an association between epileptic encephalopathy and autistic regression seems plausible based on the known prevalences with which regression, seizures, and epileptiform EEG activity occur in both children with autistic spectrum disorders (ASD) and those with Landau-Kleffner syndrome (LKS) and other regressive conditions in childhood.

LKS usually occurs at 3–8 years of age in previously normal children; these children may have isolated language regression and variable behavioral abnormalities occurring with severely epileptiform EEGs and/or clinical seizures.

About 20%–40% of children with autism have experienced autistic regression. The prevalence of seizure history in children with ASD increases with age, so they have occurred in 20%–30% by 30 years of age.

Epileptiform activity on EEGs—which is highly associated with, but not specific for, epilepsy—also occurs in about 15% of children with ASD who do not have seizures during brief testing, and in up to 60% of these children during prolonged, overnight testing. It is also known that LKS is caused by epileptic encephalopathy even without the presence of clinical seizures, Dr. Mantovani said.

But reports have shown that children with autistic regression before 2–3 years of age are significantly less likely to have epileptic encephalopathy than are children who develop language regression alone at 2–3 years of age or older, which is similar to the pattern described for children with LKS. Clinical seizures and epileptiform EEGs occur more than twice as often in children with language regression alone, compared with those with the broader profile of autistic regression, said Dr. Mantovani, of the neurology and pediatrics departments at Washington University, St. Louis.

There is a lack of temporal correlation between seizures and ASD. People with ASD, especially the nonsyndromic or idiopathic type, tend to have few seizures at early ages but then start to have them at older ages. Yet autistic regression mostly occurs before 2 years of age. There also is a lack of EEG and clinical specificity to associate epileptic encephalography with autistic regression, because most children with autistic regression on overnight EEG testing do not have epileptiform activity and there is no clinical difference between children with autistic regression and those with nonregressive ASD. Dr. Mantovani said it is reasonable to get an overnight EEG for children who develop isolated language regression at ages older than 2 years, or global regression at ages older than 3 years.

An EEG obtained in an overnight sleep study shows the characteristic pattern of high voltage, frontally dominant constant spike and wave activity consistent with epileptic encephalopathy. Courtesy Dr. John F. Mantovani

BALTIMORE — Childhood regression may be related to epileptic encephalopathy only among children with language regression alone, rather than among those with autistic regression, Dr. John F. Mantovani said at a meeting on developmental disabilities sponsored by Johns Hopkins University.

But study data do not rule out the possibility of a continuum of regressive disorders in which epileptic encephalopathies underlie the process in some children who do not fit the general pattern, said Dr. Mantovani, medical director of the St. John's Mercy Child Development Center, St. Louis.

The evidence for an association between epileptic encephalopathy and autistic regression seems plausible based on the known prevalences with which regression, seizures, and epileptiform EEG activity occur in both children with autistic spectrum disorders (ASD) and those with Landau-Kleffner syndrome (LKS) and other regressive conditions in childhood.

LKS usually occurs at 3–8 years of age in previously normal children; these children may have isolated language regression and variable behavioral abnormalities occurring with severely epileptiform EEGs and/or clinical seizures.

About 20%–40% of children with autism have experienced autistic regression. The prevalence of seizure history in children with ASD increases with age, so they have occurred in 20%–30% by 30 years of age.

Epileptiform activity on EEGs—which is highly associated with, but not specific for, epilepsy—also occurs in about 15% of children with ASD who do not have seizures during brief testing, and in up to 60% of these children during prolonged, overnight testing. It is also known that LKS is caused by epileptic encephalopathy even without the presence of clinical seizures, Dr. Mantovani said.

But reports have shown that children with autistic regression before 2–3 years of age are significantly less likely to have epileptic encephalopathy than are children who develop language regression alone at 2–3 years of age or older, which is similar to the pattern described for children with LKS. Clinical seizures and epileptiform EEGs occur more than twice as often in children with language regression alone, compared with those with the broader profile of autistic regression, said Dr. Mantovani, of the neurology and pediatrics departments at Washington University, St. Louis.

There is a lack of temporal correlation between seizures and ASD. People with ASD, especially the nonsyndromic or idiopathic type, tend to have few seizures at early ages but then start to have them at older ages. Yet autistic regression mostly occurs before 2 years of age. There also is a lack of EEG and clinical specificity to associate epileptic encephalography with autistic regression, because most children with autistic regression on overnight EEG testing do not have epileptiform activity and there is no clinical difference between children with autistic regression and those with nonregressive ASD. Dr. Mantovani said it is reasonable to get an overnight EEG for children who develop isolated language regression at ages older than 2 years, or global regression at ages older than 3 years.

An EEG obtained in an overnight sleep study shows the characteristic pattern of high voltage, frontally dominant constant spike and wave activity consistent with epileptic encephalopathy. Courtesy Dr. John F. Mantovani

LOUISVILLE, KY. — “Super-super obese” patients obtain nearly the same benefits from laparoscopic Roux-en-Y gastric bypass as do less obese patients without incurring unwarranted risks, Dr. Jon C. Gould reported at the annual meeting of the Central Surgical Association.

Surgeons have taken several different approaches in treating super-super obesity (a body mass index greater than 60 kg/m

Still others consider super-super obese patients to be nonoperable, said Dr. Gould of the bariatric program at the University of Wisconsin, Madison.

Laparoscopic bariatric surgery, which is considered to be more technically challenging as the degree of obesity increases, may pose a higher risk of death and postoperative morbidity—especially in super-super obese patients. These patients have thicker abdominal walls, greater amounts of intraabdominal and visceral fat, and larger livers that can contribute to longer operative times in which the margin of safety declines, Dr. Gould said.

To study the results of laparoscopic surgery in these patients, he and his colleagues reviewed prospectively collected data on procedures performed on 28 patients with a BMI (kg/m

The super-super obese patients in the study were required to lose a specific amount of weight on a high-protein, low-calorie diet before undergoing the operation. The required amount of weight loss, determined at the discretion of the surgeon, was “somewhat subjectively” based on where a patient carried his or her weight, but the amount typically was 30–40 pounds, he said.

The surgical technique involved a circular stapled gastrojejunostomy with an antecolic, antegastric placement of a 150-cm Roux limb. A 50-cm biliopancreatic limb was used.

Few early complications developed in patients in either group. The group of less obese patients incurred one death, two staple-line leaks, four bleeding episodes, and six wound infections. One staple-line leak and one wound infection occurred among the 28 super-super obese patients.

Stenosis developed among significantly more of the super-super obese patients (29%) than among those with a lower BMI (9%). This difference persisted even after the investigators had switched from using a 21-mm stapler in the first 142 patients to a 25-mm stapler in the following 142 patients. Dr. Gould was unsure whether stenosis resulted from surgeons routinely oversewing the gastrojejunostomy in the super-super obese patients, from increased tension on the anastomosis, or from intraabdominal pressure.

But all of the patients with stenosis responded well to endoscopic dilatation without any long-term comorbidity, he said.

Patients with lower BMI lost a significantly higher percentage of their excess weight at 1 and 2 years (69% and 75%, respectively) than did higher-BMI patients (57% and 61%). But the super-super obese patients lost significantly more weight overall (about 150 vs. 120 pounds). Most of the super-super obese patients (92%) failed to achieve a BMI less than 35, compared with 17% of the less obese patients.

Resolution of preoperative medical conditions post surgery was similar among super-super obese and less obese patients: type 2 diabetes (100% vs. 80%, respectively), gastroesophageal reflux disease (80% vs. 96%), and hyperlipidemia (80% vs. 91%). But hypertension resolved in significantly more of the less obese than in the super-super obese patients (89% vs. 63%). The super-super obese patients also reported a quality of life similar to that reported by the less obese patients after the operation.

“It's not clear to me why [super-super obese] patients respond somewhat differently to some of these procedures than our less obese patients do,” Dr. Gould said.

“I think we do need to take a step back to assess and think about how we're going to define success in these patients,” he added. “To what lengths should we go to achieve a specific postoperative BMI, what morbidity should we accept to achieve that BMI, or should our end point—our definition of success—be more related to quality of life and health?”

In the last 18 months of the study, all patients went on the preoperative high-protein, low-calorie diet for 2 weeks regardless of their BMI; this diet was extended by an additional 2–4 weeks for the super-super obese patients, Dr. Gould said.

Preoperative acute weight loss could help reduce the size of the liver and create excessive stretch in abdominal skin that could increase the laparoscopic operating space with insufflation, he suggested.

LOUISVILLE, KY. — “Super-super obese” patients obtain nearly the same benefits from laparoscopic Roux-en-Y gastric bypass as do less obese patients without incurring unwarranted risks, Dr. Jon C. Gould reported at the annual meeting of the Central Surgical Association.

Surgeons have taken several different approaches in treating super-super obesity (a body mass index greater than 60 kg/m

Still others consider super-super obese patients to be nonoperable, said Dr. Gould of the bariatric program at the University of Wisconsin, Madison.

Laparoscopic bariatric surgery, which is considered to be more technically challenging as the degree of obesity increases, may pose a higher risk of death and postoperative morbidity—especially in super-super obese patients. These patients have thicker abdominal walls, greater amounts of intraabdominal and visceral fat, and larger livers that can contribute to longer operative times in which the margin of safety declines, Dr. Gould said.

To study the results of laparoscopic surgery in these patients, he and his colleagues reviewed prospectively collected data on procedures performed on 28 patients with a BMI (kg/m

The super-super obese patients in the study were required to lose a specific amount of weight on a high-protein, low-calorie diet before undergoing the operation. The required amount of weight loss, determined at the discretion of the surgeon, was “somewhat subjectively” based on where a patient carried his or her weight, but the amount typically was 30–40 pounds, he said.

The surgical technique involved a circular stapled gastrojejunostomy with an antecolic, antegastric placement of a 150-cm Roux limb. A 50-cm biliopancreatic limb was used.

Few early complications developed in patients in either group. The group of less obese patients incurred one death, two staple-line leaks, four bleeding episodes, and six wound infections. One staple-line leak and one wound infection occurred among the 28 super-super obese patients.

Stenosis developed among significantly more of the super-super obese patients (29%) than among those with a lower BMI (9%). This difference persisted even after the investigators had switched from using a 21-mm stapler in the first 142 patients to a 25-mm stapler in the following 142 patients. Dr. Gould was unsure whether stenosis resulted from surgeons routinely oversewing the gastrojejunostomy in the super-super obese patients, from increased tension on the anastomosis, or from intraabdominal pressure.

But all of the patients with stenosis responded well to endoscopic dilatation without any long-term comorbidity, he said.

Patients with lower BMI lost a significantly higher percentage of their excess weight at 1 and 2 years (69% and 75%, respectively) than did higher-BMI patients (57% and 61%). But the super-super obese patients lost significantly more weight overall (about 150 vs. 120 pounds). Most of the super-super obese patients (92%) failed to achieve a BMI less than 35, compared with 17% of the less obese patients.

Resolution of preoperative medical conditions post surgery was similar among super-super obese and less obese patients: type 2 diabetes (100% vs. 80%, respectively), gastroesophageal reflux disease (80% vs. 96%), and hyperlipidemia (80% vs. 91%). But hypertension resolved in significantly more of the less obese than in the super-super obese patients (89% vs. 63%). The super-super obese patients also reported a quality of life similar to that reported by the less obese patients after the operation.

“It's not clear to me why [super-super obese] patients respond somewhat differently to some of these procedures than our less obese patients do,” Dr. Gould said.

“I think we do need to take a step back to assess and think about how we're going to define success in these patients,” he added. “To what lengths should we go to achieve a specific postoperative BMI, what morbidity should we accept to achieve that BMI, or should our end point—our definition of success—be more related to quality of life and health?”

In the last 18 months of the study, all patients went on the preoperative high-protein, low-calorie diet for 2 weeks regardless of their BMI; this diet was extended by an additional 2–4 weeks for the super-super obese patients, Dr. Gould said.

Preoperative acute weight loss could help reduce the size of the liver and create excessive stretch in abdominal skin that could increase the laparoscopic operating space with insufflation, he suggested.

LOUISVILLE, KY. — “Super-super obese” patients obtain nearly the same benefits from laparoscopic Roux-en-Y gastric bypass as do less obese patients without incurring unwarranted risks, Dr. Jon C. Gould reported at the annual meeting of the Central Surgical Association.

Surgeons have taken several different approaches in treating super-super obesity (a body mass index greater than 60 kg/m

Still others consider super-super obese patients to be nonoperable, said Dr. Gould of the bariatric program at the University of Wisconsin, Madison.

Laparoscopic bariatric surgery, which is considered to be more technically challenging as the degree of obesity increases, may pose a higher risk of death and postoperative morbidity—especially in super-super obese patients. These patients have thicker abdominal walls, greater amounts of intraabdominal and visceral fat, and larger livers that can contribute to longer operative times in which the margin of safety declines, Dr. Gould said.

To study the results of laparoscopic surgery in these patients, he and his colleagues reviewed prospectively collected data on procedures performed on 28 patients with a BMI (kg/m

The super-super obese patients in the study were required to lose a specific amount of weight on a high-protein, low-calorie diet before undergoing the operation. The required amount of weight loss, determined at the discretion of the surgeon, was “somewhat subjectively” based on where a patient carried his or her weight, but the amount typically was 30–40 pounds, he said.

The surgical technique involved a circular stapled gastrojejunostomy with an antecolic, antegastric placement of a 150-cm Roux limb. A 50-cm biliopancreatic limb was used.

Few early complications developed in patients in either group. The group of less obese patients incurred one death, two staple-line leaks, four bleeding episodes, and six wound infections. One staple-line leak and one wound infection occurred among the 28 super-super obese patients.

Stenosis developed among significantly more of the super-super obese patients (29%) than among those with a lower BMI (9%). This difference persisted even after the investigators had switched from using a 21-mm stapler in the first 142 patients to a 25-mm stapler in the following 142 patients. Dr. Gould was unsure whether stenosis resulted from surgeons routinely oversewing the gastrojejunostomy in the super-super obese patients, from increased tension on the anastomosis, or from intraabdominal pressure.

But all of the patients with stenosis responded well to endoscopic dilatation without any long-term comorbidity, he said.

Patients with lower BMI lost a significantly higher percentage of their excess weight at 1 and 2 years (69% and 75%, respectively) than did higher-BMI patients (57% and 61%). But the super-super obese patients lost significantly more weight overall (about 150 vs. 120 pounds). Most of the super-super obese patients (92%) failed to achieve a BMI less than 35, compared with 17% of the less obese patients.

Resolution of preoperative medical conditions post surgery was similar among super-super obese and less obese patients: type 2 diabetes (100% vs. 80%, respectively), gastroesophageal reflux disease (80% vs. 96%), and hyperlipidemia (80% vs. 91%). But hypertension resolved in significantly more of the less obese than in the super-super obese patients (89% vs. 63%). The super-super obese patients also reported a quality of life similar to that reported by the less obese patients after the operation.

“It's not clear to me why [super-super obese] patients respond somewhat differently to some of these procedures than our less obese patients do,” Dr. Gould said.

“I think we do need to take a step back to assess and think about how we're going to define success in these patients,” he added. “To what lengths should we go to achieve a specific postoperative BMI, what morbidity should we accept to achieve that BMI, or should our end point—our definition of success—be more related to quality of life and health?”

In the last 18 months of the study, all patients went on the preoperative high-protein, low-calorie diet for 2 weeks regardless of their BMI; this diet was extended by an additional 2–4 weeks for the super-super obese patients, Dr. Gould said.

Preoperative acute weight loss could help reduce the size of the liver and create excessive stretch in abdominal skin that could increase the laparoscopic operating space with insufflation, he suggested.

LOUISVILLE, KY. — Extension of the Roux limb in Roux-en-Y gastric bypass procedures for “super obese” patients may provide good long-term weight loss and resolution of comorbidities with an acceptable rate of complications, Mr. Wayne K. Nelson reported at the annual meeting of the Central Surgical Association.

Surgeons at the Mayo Clinic, Rochester, Minn., developed and refined the very, very long-limb Roux-en-Y gastric bypass (RYGBP) to meet the needs of their large referral practice in bariatric surgery, which accepts patients who are more overweight and have worse comorbidities than are typically seen.

The more commonly performed RYGBP operations for super obese patients—the distal gastric bypass and the biliopancreatic diversion with or without duodenal switch—both leave a relatively short Roux limb, a relatively long biliopancreatic limb, and a short (100-cm) common channel where food and digestive enzymes mix.

The proximal anatomy of the very, very long-limb RYGBP is similar to that of the distal RYGBP, but the Roux limb is much longer (typically 400–500 cm).

The extra length leaves a longer transit and greater ability to absorb water, minerals, and vitamins, said Mr. Nelson, who is a student at the Mayo Medical School in Rochester.

The common channel is the same 100-cm length, whereas the length of the biliopancreatic limb is typically shorter—around 50–70 cm—than in other RYGBP procedures.

“Remember, this isn't a typical Roux-en-Y gastric bypass,” he said.

Of 1,435 bariatric procedures performed at the Mayo Clinic during 1985–2003, 257 were performed with the very, very long-limb RYGBP. These 257 consecutive patients were 45 years old on average, and had an average body mass index (kg/m

More than 90% of the operations were open.

When the investigators began their study, they sent a detailed survey to patients to gather data in addition to what had been captured at normal follow-up visits; 73% of the patients responded to the survey.

After an average of 45 months of follow-up, the patients' BMI had dropped to a mean value of 37, and 82% had lost more than 50% of their excess body weight, an amount commonly considered as a marker of success in bariatric surgery.

The patients who did not lose greater than 50% of their excess body weight still lost a great deal of weight, Mr. Nelson said, but many of them needed to lose hundreds of pounds to reach their ideal body weight. On average, patients lost 66% of their excess body weight.

Medical comorbidities resolved without the need for further treatment in a large number of the patients after the operation, including type 2 diabetes in 95% of patients, hypertension in 65%, sleep apnea in 48%, and asthma in 30%.

In the survey, 90% of patients reported that they were satisfied with the results of the operation, and 93% said that they would recommend the procedure.

Procedural complications included two deaths, four staple-line leaks (one of which required reoperation), two intraabdominal abscesses, five wound dehiscences, 22 wound infections, and two pulmonary emboli.

About 82% of the patients reported some food intolerance, and 70% had occasional loose or watery stools. The more serious complication of malnutrition resulting from protein or caloric deficiency developed in 4%; this was resolved with a proximal relocation of the jejunoileostomy to lengthen the common channel to 200–300 cm. Other problems included oxalate nephrolithiasis in 16% of the patients, and gross steatorrhea in 5%.

“Because of the potential metabolic sequelae, [the very, very long-limb RYGBP] should not be offered” to patients who are medically naive, noncompliant, or unreliable regarding follow-up, or who have extremely abnormal preoperative amounts of urinary oxalate, Mr. Nelson said.

EMILY BRANNAN, ILLUSTRATION

LOUISVILLE, KY. — Extension of the Roux limb in Roux-en-Y gastric bypass procedures for “super obese” patients may provide good long-term weight loss and resolution of comorbidities with an acceptable rate of complications, Mr. Wayne K. Nelson reported at the annual meeting of the Central Surgical Association.

Surgeons at the Mayo Clinic, Rochester, Minn., developed and refined the very, very long-limb Roux-en-Y gastric bypass (RYGBP) to meet the needs of their large referral practice in bariatric surgery, which accepts patients who are more overweight and have worse comorbidities than are typically seen.

The more commonly performed RYGBP operations for super obese patients—the distal gastric bypass and the biliopancreatic diversion with or without duodenal switch—both leave a relatively short Roux limb, a relatively long biliopancreatic limb, and a short (100-cm) common channel where food and digestive enzymes mix.

The proximal anatomy of the very, very long-limb RYGBP is similar to that of the distal RYGBP, but the Roux limb is much longer (typically 400–500 cm).

The extra length leaves a longer transit and greater ability to absorb water, minerals, and vitamins, said Mr. Nelson, who is a student at the Mayo Medical School in Rochester.

The common channel is the same 100-cm length, whereas the length of the biliopancreatic limb is typically shorter—around 50–70 cm—than in other RYGBP procedures.

“Remember, this isn't a typical Roux-en-Y gastric bypass,” he said.

Of 1,435 bariatric procedures performed at the Mayo Clinic during 1985–2003, 257 were performed with the very, very long-limb RYGBP. These 257 consecutive patients were 45 years old on average, and had an average body mass index (kg/m

More than 90% of the operations were open.

When the investigators began their study, they sent a detailed survey to patients to gather data in addition to what had been captured at normal follow-up visits; 73% of the patients responded to the survey.

After an average of 45 months of follow-up, the patients' BMI had dropped to a mean value of 37, and 82% had lost more than 50% of their excess body weight, an amount commonly considered as a marker of success in bariatric surgery.

The patients who did not lose greater than 50% of their excess body weight still lost a great deal of weight, Mr. Nelson said, but many of them needed to lose hundreds of pounds to reach their ideal body weight. On average, patients lost 66% of their excess body weight.

Medical comorbidities resolved without the need for further treatment in a large number of the patients after the operation, including type 2 diabetes in 95% of patients, hypertension in 65%, sleep apnea in 48%, and asthma in 30%.

In the survey, 90% of patients reported that they were satisfied with the results of the operation, and 93% said that they would recommend the procedure.

Procedural complications included two deaths, four staple-line leaks (one of which required reoperation), two intraabdominal abscesses, five wound dehiscences, 22 wound infections, and two pulmonary emboli.

About 82% of the patients reported some food intolerance, and 70% had occasional loose or watery stools. The more serious complication of malnutrition resulting from protein or caloric deficiency developed in 4%; this was resolved with a proximal relocation of the jejunoileostomy to lengthen the common channel to 200–300 cm. Other problems included oxalate nephrolithiasis in 16% of the patients, and gross steatorrhea in 5%.

“Because of the potential metabolic sequelae, [the very, very long-limb RYGBP] should not be offered” to patients who are medically naive, noncompliant, or unreliable regarding follow-up, or who have extremely abnormal preoperative amounts of urinary oxalate, Mr. Nelson said.

EMILY BRANNAN, ILLUSTRATION

LOUISVILLE, KY. — Extension of the Roux limb in Roux-en-Y gastric bypass procedures for “super obese” patients may provide good long-term weight loss and resolution of comorbidities with an acceptable rate of complications, Mr. Wayne K. Nelson reported at the annual meeting of the Central Surgical Association.

Surgeons at the Mayo Clinic, Rochester, Minn., developed and refined the very, very long-limb Roux-en-Y gastric bypass (RYGBP) to meet the needs of their large referral practice in bariatric surgery, which accepts patients who are more overweight and have worse comorbidities than are typically seen.

The more commonly performed RYGBP operations for super obese patients—the distal gastric bypass and the biliopancreatic diversion with or without duodenal switch—both leave a relatively short Roux limb, a relatively long biliopancreatic limb, and a short (100-cm) common channel where food and digestive enzymes mix.

The proximal anatomy of the very, very long-limb RYGBP is similar to that of the distal RYGBP, but the Roux limb is much longer (typically 400–500 cm).

The extra length leaves a longer transit and greater ability to absorb water, minerals, and vitamins, said Mr. Nelson, who is a student at the Mayo Medical School in Rochester.

The common channel is the same 100-cm length, whereas the length of the biliopancreatic limb is typically shorter—around 50–70 cm—than in other RYGBP procedures.

“Remember, this isn't a typical Roux-en-Y gastric bypass,” he said.

Of 1,435 bariatric procedures performed at the Mayo Clinic during 1985–2003, 257 were performed with the very, very long-limb RYGBP. These 257 consecutive patients were 45 years old on average, and had an average body mass index (kg/m

More than 90% of the operations were open.

When the investigators began their study, they sent a detailed survey to patients to gather data in addition to what had been captured at normal follow-up visits; 73% of the patients responded to the survey.

After an average of 45 months of follow-up, the patients' BMI had dropped to a mean value of 37, and 82% had lost more than 50% of their excess body weight, an amount commonly considered as a marker of success in bariatric surgery.

The patients who did not lose greater than 50% of their excess body weight still lost a great deal of weight, Mr. Nelson said, but many of them needed to lose hundreds of pounds to reach their ideal body weight. On average, patients lost 66% of their excess body weight.

Medical comorbidities resolved without the need for further treatment in a large number of the patients after the operation, including type 2 diabetes in 95% of patients, hypertension in 65%, sleep apnea in 48%, and asthma in 30%.

In the survey, 90% of patients reported that they were satisfied with the results of the operation, and 93% said that they would recommend the procedure.

Procedural complications included two deaths, four staple-line leaks (one of which required reoperation), two intraabdominal abscesses, five wound dehiscences, 22 wound infections, and two pulmonary emboli.

About 82% of the patients reported some food intolerance, and 70% had occasional loose or watery stools. The more serious complication of malnutrition resulting from protein or caloric deficiency developed in 4%; this was resolved with a proximal relocation of the jejunoileostomy to lengthen the common channel to 200–300 cm. Other problems included oxalate nephrolithiasis in 16% of the patients, and gross steatorrhea in 5%.

“Because of the potential metabolic sequelae, [the very, very long-limb RYGBP] should not be offered” to patients who are medically naive, noncompliant, or unreliable regarding follow-up, or who have extremely abnormal preoperative amounts of urinary oxalate, Mr. Nelson said.

EMILY BRANNAN, ILLUSTRATION

LOUISVILLE, KY. — Treatment of enterocutaneous fistulas continues to rely primarily on surgery, augmented in some cases by octreotide or vacuum-assisted closure, according to a review of 106 patients.

The management of enterocutaneous fistulas continues to be a problem because of 5%–15% mortality, a spontaneous healing rate of less than 30%, and an overall healing rate hovering around 80%–90%, Dr. John M. Draus said at the annual meeting of the Central Surgical Association.

He and his colleagues in the surgery department at the University of Louisville, Ky., reviewed cases of gastrointestinal-cutaneous fistulas that occurred from 1997 to 2005 at two large teaching hospitals. The investigators excluded patients with inflammatory bowel disease and those with esophageal, pancreatic, or anorectal fistulas.

Among the 106 patients, fistulas most often resulted from a previous operation (81) and originated from the small bowel (67), colon (26), stomach (8), or duodenum (5). These operations were performed to treat cancer, adhesions, small bowel obstruction, gynecologic problems, or ventral hernias. Other fistula etiologies included trauma (15), hernia mesh erosion (6), diverticulitis (2), and radiation (2).

The group of patients comprised 31 with high-output fistulas (leaking more than 200 mL/day), 44 with low-output fistulas (less than 200 mL/day), and 31 whose fistula output was managed with a single gauze dressing. The analysis showed that the rate of healing or need for operation did not differ among patients with low- or high-output fistulas.

In general, the initial treatment plan for each of the patients consisted of the correction of fluid and electrolyte imbalances, nutritional support through total parenteral or enteral feeding, wound care, diagnostic imaging, early recognition of sepsis, drainage of abscesses, and an operation when necessary.

Among 13 patients who received treatment with vacuum-assisted closure (VAC), all had improved wound care and overall healing, but only 1 patient had complete healing that was attributed to VAC. The other 12 required an operation. No septic complications occurred with the use of VAC and fistula output did not increase, Dr. Draus noted.

VAC should be used in the subset of patients whose wounds are free of active infection, have no exposed bowel, and have a healthy layer of surrounding soft tissue, he advised.

The application of fibrin glue resulted in only one completely healed fistula among eight patients, all of whom had small bowel fistulas with high output. The glue transiently healed one patient's fistula for 11 days.

Of 24 patients who received treatment with octreotide, 8 responded with at least a 50% decrease in fistula output within 3 days; 4 of these 8 patients healed without an operation.

“Octreotide responders appear more likely to heal their fistula without operation” than those who receive other nonoperative modalities, Dr. Draus said. He recommended that most patients with an enterocutaneous fistula be given at least a 3-day trial of octreotide. If there isn't a dramatic decrease in fistula output by the end of 3 days, there is probably not much benefit in continuing octreotide, he suggested. Most patients in the study began receiving 100 mcg of octreotide three times per day, but the dose was increased to 500 mcg three times per day in one patient.

Audience member Dr. Bruce A. Harms of the University of Wisconsin, Madison, found this recommendation to be “a little bit of a stretch” in light of the fact that there is no hard efficacy data to back up Dr. Draus' advice. Octreotide should fall into the category of an ancillary treatment, said Dr. Harms.

Of 77 patients who had a planned operation, 69 (90%) healed. The average time from fistula formation to operation was 12 weeks. Some audience members said that 12 weeks was too short of an interval to wait to repair the fistulas, but Dr. Draus noted that the operation occurred after 3–6 months in about half of the patients.

“It is frustrating that in 2006 we still have made so little progress in treating fistulas with nothing but an operation,” said audience member Dr. Merril Dayton of the State University of New York at Buffalo.

Fistulas healed in 82% of patients regardless of which treatment was used. Seven of the patients in the study died as a result of continued sepsis or persistent cancer.

LOUISVILLE, KY. — Treatment of enterocutaneous fistulas continues to rely primarily on surgery, augmented in some cases by octreotide or vacuum-assisted closure, according to a review of 106 patients.

The management of enterocutaneous fistulas continues to be a problem because of 5%–15% mortality, a spontaneous healing rate of less than 30%, and an overall healing rate hovering around 80%–90%, Dr. John M. Draus said at the annual meeting of the Central Surgical Association.

He and his colleagues in the surgery department at the University of Louisville, Ky., reviewed cases of gastrointestinal-cutaneous fistulas that occurred from 1997 to 2005 at two large teaching hospitals. The investigators excluded patients with inflammatory bowel disease and those with esophageal, pancreatic, or anorectal fistulas.

Among the 106 patients, fistulas most often resulted from a previous operation (81) and originated from the small bowel (67), colon (26), stomach (8), or duodenum (5). These operations were performed to treat cancer, adhesions, small bowel obstruction, gynecologic problems, or ventral hernias. Other fistula etiologies included trauma (15), hernia mesh erosion (6), diverticulitis (2), and radiation (2).

The group of patients comprised 31 with high-output fistulas (leaking more than 200 mL/day), 44 with low-output fistulas (less than 200 mL/day), and 31 whose fistula output was managed with a single gauze dressing. The analysis showed that the rate of healing or need for operation did not differ among patients with low- or high-output fistulas.

In general, the initial treatment plan for each of the patients consisted of the correction of fluid and electrolyte imbalances, nutritional support through total parenteral or enteral feeding, wound care, diagnostic imaging, early recognition of sepsis, drainage of abscesses, and an operation when necessary.

Among 13 patients who received treatment with vacuum-assisted closure (VAC), all had improved wound care and overall healing, but only 1 patient had complete healing that was attributed to VAC. The other 12 required an operation. No septic complications occurred with the use of VAC and fistula output did not increase, Dr. Draus noted.

VAC should be used in the subset of patients whose wounds are free of active infection, have no exposed bowel, and have a healthy layer of surrounding soft tissue, he advised.

The application of fibrin glue resulted in only one completely healed fistula among eight patients, all of whom had small bowel fistulas with high output. The glue transiently healed one patient's fistula for 11 days.

Of 24 patients who received treatment with octreotide, 8 responded with at least a 50% decrease in fistula output within 3 days; 4 of these 8 patients healed without an operation.

“Octreotide responders appear more likely to heal their fistula without operation” than those who receive other nonoperative modalities, Dr. Draus said. He recommended that most patients with an enterocutaneous fistula be given at least a 3-day trial of octreotide. If there isn't a dramatic decrease in fistula output by the end of 3 days, there is probably not much benefit in continuing octreotide, he suggested. Most patients in the study began receiving 100 mcg of octreotide three times per day, but the dose was increased to 500 mcg three times per day in one patient.

Audience member Dr. Bruce A. Harms of the University of Wisconsin, Madison, found this recommendation to be “a little bit of a stretch” in light of the fact that there is no hard efficacy data to back up Dr. Draus' advice. Octreotide should fall into the category of an ancillary treatment, said Dr. Harms.

Of 77 patients who had a planned operation, 69 (90%) healed. The average time from fistula formation to operation was 12 weeks. Some audience members said that 12 weeks was too short of an interval to wait to repair the fistulas, but Dr. Draus noted that the operation occurred after 3–6 months in about half of the patients.

“It is frustrating that in 2006 we still have made so little progress in treating fistulas with nothing but an operation,” said audience member Dr. Merril Dayton of the State University of New York at Buffalo.

Fistulas healed in 82% of patients regardless of which treatment was used. Seven of the patients in the study died as a result of continued sepsis or persistent cancer.

LOUISVILLE, KY. — Treatment of enterocutaneous fistulas continues to rely primarily on surgery, augmented in some cases by octreotide or vacuum-assisted closure, according to a review of 106 patients.

The management of enterocutaneous fistulas continues to be a problem because of 5%–15% mortality, a spontaneous healing rate of less than 30%, and an overall healing rate hovering around 80%–90%, Dr. John M. Draus said at the annual meeting of the Central Surgical Association.

He and his colleagues in the surgery department at the University of Louisville, Ky., reviewed cases of gastrointestinal-cutaneous fistulas that occurred from 1997 to 2005 at two large teaching hospitals. The investigators excluded patients with inflammatory bowel disease and those with esophageal, pancreatic, or anorectal fistulas.

Among the 106 patients, fistulas most often resulted from a previous operation (81) and originated from the small bowel (67), colon (26), stomach (8), or duodenum (5). These operations were performed to treat cancer, adhesions, small bowel obstruction, gynecologic problems, or ventral hernias. Other fistula etiologies included trauma (15), hernia mesh erosion (6), diverticulitis (2), and radiation (2).

The group of patients comprised 31 with high-output fistulas (leaking more than 200 mL/day), 44 with low-output fistulas (less than 200 mL/day), and 31 whose fistula output was managed with a single gauze dressing. The analysis showed that the rate of healing or need for operation did not differ among patients with low- or high-output fistulas.

In general, the initial treatment plan for each of the patients consisted of the correction of fluid and electrolyte imbalances, nutritional support through total parenteral or enteral feeding, wound care, diagnostic imaging, early recognition of sepsis, drainage of abscesses, and an operation when necessary.

Among 13 patients who received treatment with vacuum-assisted closure (VAC), all had improved wound care and overall healing, but only 1 patient had complete healing that was attributed to VAC. The other 12 required an operation. No septic complications occurred with the use of VAC and fistula output did not increase, Dr. Draus noted.

VAC should be used in the subset of patients whose wounds are free of active infection, have no exposed bowel, and have a healthy layer of surrounding soft tissue, he advised.

The application of fibrin glue resulted in only one completely healed fistula among eight patients, all of whom had small bowel fistulas with high output. The glue transiently healed one patient's fistula for 11 days.

Of 24 patients who received treatment with octreotide, 8 responded with at least a 50% decrease in fistula output within 3 days; 4 of these 8 patients healed without an operation.

“Octreotide responders appear more likely to heal their fistula without operation” than those who receive other nonoperative modalities, Dr. Draus said. He recommended that most patients with an enterocutaneous fistula be given at least a 3-day trial of octreotide. If there isn't a dramatic decrease in fistula output by the end of 3 days, there is probably not much benefit in continuing octreotide, he suggested. Most patients in the study began receiving 100 mcg of octreotide three times per day, but the dose was increased to 500 mcg three times per day in one patient.

Audience member Dr. Bruce A. Harms of the University of Wisconsin, Madison, found this recommendation to be “a little bit of a stretch” in light of the fact that there is no hard efficacy data to back up Dr. Draus' advice. Octreotide should fall into the category of an ancillary treatment, said Dr. Harms.

Of 77 patients who had a planned operation, 69 (90%) healed. The average time from fistula formation to operation was 12 weeks. Some audience members said that 12 weeks was too short of an interval to wait to repair the fistulas, but Dr. Draus noted that the operation occurred after 3–6 months in about half of the patients.

“It is frustrating that in 2006 we still have made so little progress in treating fistulas with nothing but an operation,” said audience member Dr. Merril Dayton of the State University of New York at Buffalo.

Fistulas healed in 82% of patients regardless of which treatment was used. Seven of the patients in the study died as a result of continued sepsis or persistent cancer.

BALTIMORE — Growing evidence suggests that a small minority of children with autistic spectrum disorder can recover from the condition to near-normal levels with only mild residual deficits, Deborah Fein, Ph.D., said at a meeting on developmental disabilities sponsored by Johns Hopkins University.

“We have no idea yet [whether recovery] is due to maturation of kids who have a certain type of autism or treatment effects. There are very few people who are looking at this, but there are a few groups that are starting to look at it now,” said Dr. Fein, professor of psychology at the University of Connecticut, Storrs.

Early studies in the late 1960s and early 1970s included a small minority of children who moved off the spectrum, but in most cases the investigators did not point this out, which seems to imply that those children were misdiagnosed. More recent studies have found that early diagnoses are stable in most children with autistic spectrum disorder (ASD), but there is a subgroup that moves off the autistic spectrum. These children have been regarded as misdiagnosed by some, but evidence from other studies suggests that these children had unstable autism and “probably were not misdiagnosed,” she said.

In one study, recovery from autism was reported in 9 of 19 children who received 40 hours per week of applied behavior analysis therapy (ABA). These children successfully completed normal first grade in a public school and had normal or above average IQ scores. They gained an average of 30 IQ points more than their counterparts in a control group of 40 children who received 10 hours per week of ABA; only 1 child in the control group recovered. Of the 10 other children in the intense ABA therapy group, 8 remained in the mildly impaired range, and 2 were profoundly retarded (J. Consult. Clin. Psychol. 1987;55:3–9).

In two attempts to replicate this study, there was substantial improvement in ABA-treated autistic children in areas such as cognition and academics but not in adaptive skills and behavior. Yet ABA therapists in the two studies did not report recovery among any of the children.

One recent study did replicate the results of the positive study with ABA therapy. After 4 years of treatment with ABA, 11 of 23 children with autism were in regular classes and scored normally on tests of IQ, language, adaptive functioning, and personality (Am. J. Ment. Retard. 2005;110:417–38). Although 3 of the 11 children needed classroom aides for attention problems and 1 would probably still meet criteria for ASD, the other 7 would probably meet criteria for an optimal outcome.

“This is a very exciting study,” Dr. Fein said.

In general, studies have found that communicative language by 5 years of age and a good response to early intervention within 3 months are positive signs for a good prognosis. Higher IQs appear to be associated with better social, communicative, and adaptive behaviors as the child ages.

In Dr. Fein's clinical impression, the children near 4–6 years of age who make limited progress despite good intervention will be those with mental retardation “across the board,” dense language disorder, or an intense need for repetitive behavior despite the appearance of normal cognitive potential at certain times. The presence of seizures also may indicate a poor prognosis.

Children with ASD have been shown to leave the spectrum but then reveal or develop another condition, such as ADHD. In a report, Dr. Fein described 11 children with ASD who developed clear-cut cases of ADHD by about 6 or 7 years of age. Eight of these children received intensive applied behavior analysis therapy while the other three participated in integrated or special education preschool. The children retained some mild residual features of autism, such as social awkwardness (but more impulsive and immature than aloof), perseverative interests, and occasional mild motor stereotypies (J. Autism Dev. Disord. 2005;35:525–34).

In those cases, the children may have had comorbid ASD and ADHD, leaving ADHD when autism resolved. These children also could have had a severe subtype of ADHD that presents as autism in the early years, but this may not be the case because the children looked “pretty indistinguishable from kids who stay autistic,” she noted. Or it could be that attention impairment is a feature of ASD that remains when social, behavioral, and communication impairments subside.

In a separate ongoing study conducted by Dr. Fein and her colleagues, a group of 77 children who screened positive on the Modified Checklist for Autism in Toddlers at 2 years of age were later seen at 4 years of age, regardless of whether they were autistic or not. Of the 61 children who had autism at 2 years of age, 46 also had it at 4 years of age. The remaining 15 children moved off the autistic spectrum. A total of 16 children were not autistic at either age but still screened positive because they had some problems, such as global developmental and language delays. No children who were nonautistic at 2 years of age became autistic at 4 years of age.

At 2 years of age, the 15 children in that study who left the spectrum were indistinguishable on measures of communication, socialization, symptom severity, and cognitive ability from children who remained autistic. But at 4 years of age, the “recovered” children reached almost normal levels on these measures, she said.

The only major difference between these groups at 2 years of age was in motor skills, in which recovered children had significantly higher scores that reached near-normal levels at 4 years of age.

In another study that will appear in the Journal of Autism and Developmental Disorders, Dr. Fein and her associates reported on 14 children aged 5–9 years with prior ASD diagnoses. These children had IQ scores in the normal range, were placed in age-appropriate mainstream classes, and were considered to be generally functioning at the level of their normally developing peers. They had normal performance on many measures, including different aspects of linguistic ability, expressive vocabulary, and sentence memory, and had adaptive skills in communication and socialization.

But these children still had impairments in knowing the difference between mental state verbs (know, guess, estimate) and in reasoning about animate objects (not including people). They failed to produce good narratives, judged by such factors as being less likely to discuss major events and characters' motivations. They also were not good at understanding “second order theory of mind” situations, such as knowing “what does Johnny know that Suzie knows about what Rick thinks,” Dr. Fein said.

But follow-up visits with these children at 9–12 years of age indicated that the children were “closing the gap” between themselves and normal children because their only remaining deficit was with mental state verbs.

Misdiagnosis of children who leave the spectrum appears unlikely, so the reasons why a small minority of autistic children can recover may lie in the possibility that they have a form of autism that can be alleviated with maturation or that their recovery was mediated by successful treatment or some interaction between treatment and their characteristics, she said.

These possibilities leave two big questions that remain to be answered, Dr. Fein said: Are the children for whom recovery is possible the ones with minimal structural brain abnormalities? When recovered children do a task normally, are they using the same brain systems as children who were never autistic?

BALTIMORE — Growing evidence suggests that a small minority of children with autistic spectrum disorder can recover from the condition to near-normal levels with only mild residual deficits, Deborah Fein, Ph.D., said at a meeting on developmental disabilities sponsored by Johns Hopkins University.

“We have no idea yet [whether recovery] is due to maturation of kids who have a certain type of autism or treatment effects. There are very few people who are looking at this, but there are a few groups that are starting to look at it now,” said Dr. Fein, professor of psychology at the University of Connecticut, Storrs.

Early studies in the late 1960s and early 1970s included a small minority of children who moved off the spectrum, but in most cases the investigators did not point this out, which seems to imply that those children were misdiagnosed. More recent studies have found that early diagnoses are stable in most children with autistic spectrum disorder (ASD), but there is a subgroup that moves off the autistic spectrum. These children have been regarded as misdiagnosed by some, but evidence from other studies suggests that these children had unstable autism and “probably were not misdiagnosed,” she said.

In one study, recovery from autism was reported in 9 of 19 children who received 40 hours per week of applied behavior analysis therapy (ABA). These children successfully completed normal first grade in a public school and had normal or above average IQ scores. They gained an average of 30 IQ points more than their counterparts in a control group of 40 children who received 10 hours per week of ABA; only 1 child in the control group recovered. Of the 10 other children in the intense ABA therapy group, 8 remained in the mildly impaired range, and 2 were profoundly retarded (J. Consult. Clin. Psychol. 1987;55:3–9).

In two attempts to replicate this study, there was substantial improvement in ABA-treated autistic children in areas such as cognition and academics but not in adaptive skills and behavior. Yet ABA therapists in the two studies did not report recovery among any of the children.

One recent study did replicate the results of the positive study with ABA therapy. After 4 years of treatment with ABA, 11 of 23 children with autism were in regular classes and scored normally on tests of IQ, language, adaptive functioning, and personality (Am. J. Ment. Retard. 2005;110:417–38). Although 3 of the 11 children needed classroom aides for attention problems and 1 would probably still meet criteria for ASD, the other 7 would probably meet criteria for an optimal outcome.

“This is a very exciting study,” Dr. Fein said.

In general, studies have found that communicative language by 5 years of age and a good response to early intervention within 3 months are positive signs for a good prognosis. Higher IQs appear to be associated with better social, communicative, and adaptive behaviors as the child ages.

In Dr. Fein's clinical impression, the children near 4–6 years of age who make limited progress despite good intervention will be those with mental retardation “across the board,” dense language disorder, or an intense need for repetitive behavior despite the appearance of normal cognitive potential at certain times. The presence of seizures also may indicate a poor prognosis.

Children with ASD have been shown to leave the spectrum but then reveal or develop another condition, such as ADHD. In a report, Dr. Fein described 11 children with ASD who developed clear-cut cases of ADHD by about 6 or 7 years of age. Eight of these children received intensive applied behavior analysis therapy while the other three participated in integrated or special education preschool. The children retained some mild residual features of autism, such as social awkwardness (but more impulsive and immature than aloof), perseverative interests, and occasional mild motor stereotypies (J. Autism Dev. Disord. 2005;35:525–34).

In those cases, the children may have had comorbid ASD and ADHD, leaving ADHD when autism resolved. These children also could have had a severe subtype of ADHD that presents as autism in the early years, but this may not be the case because the children looked “pretty indistinguishable from kids who stay autistic,” she noted. Or it could be that attention impairment is a feature of ASD that remains when social, behavioral, and communication impairments subside.

In a separate ongoing study conducted by Dr. Fein and her colleagues, a group of 77 children who screened positive on the Modified Checklist for Autism in Toddlers at 2 years of age were later seen at 4 years of age, regardless of whether they were autistic or not. Of the 61 children who had autism at 2 years of age, 46 also had it at 4 years of age. The remaining 15 children moved off the autistic spectrum. A total of 16 children were not autistic at either age but still screened positive because they had some problems, such as global developmental and language delays. No children who were nonautistic at 2 years of age became autistic at 4 years of age.

At 2 years of age, the 15 children in that study who left the spectrum were indistinguishable on measures of communication, socialization, symptom severity, and cognitive ability from children who remained autistic. But at 4 years of age, the “recovered” children reached almost normal levels on these measures, she said.

The only major difference between these groups at 2 years of age was in motor skills, in which recovered children had significantly higher scores that reached near-normal levels at 4 years of age.

In another study that will appear in the Journal of Autism and Developmental Disorders, Dr. Fein and her associates reported on 14 children aged 5–9 years with prior ASD diagnoses. These children had IQ scores in the normal range, were placed in age-appropriate mainstream classes, and were considered to be generally functioning at the level of their normally developing peers. They had normal performance on many measures, including different aspects of linguistic ability, expressive vocabulary, and sentence memory, and had adaptive skills in communication and socialization.

But these children still had impairments in knowing the difference between mental state verbs (know, guess, estimate) and in reasoning about animate objects (not including people). They failed to produce good narratives, judged by such factors as being less likely to discuss major events and characters' motivations. They also were not good at understanding “second order theory of mind” situations, such as knowing “what does Johnny know that Suzie knows about what Rick thinks,” Dr. Fein said.

But follow-up visits with these children at 9–12 years of age indicated that the children were “closing the gap” between themselves and normal children because their only remaining deficit was with mental state verbs.

Misdiagnosis of children who leave the spectrum appears unlikely, so the reasons why a small minority of autistic children can recover may lie in the possibility that they have a form of autism that can be alleviated with maturation or that their recovery was mediated by successful treatment or some interaction between treatment and their characteristics, she said.

These possibilities leave two big questions that remain to be answered, Dr. Fein said: Are the children for whom recovery is possible the ones with minimal structural brain abnormalities? When recovered children do a task normally, are they using the same brain systems as children who were never autistic?

BALTIMORE — Growing evidence suggests that a small minority of children with autistic spectrum disorder can recover from the condition to near-normal levels with only mild residual deficits, Deborah Fein, Ph.D., said at a meeting on developmental disabilities sponsored by Johns Hopkins University.

“We have no idea yet [whether recovery] is due to maturation of kids who have a certain type of autism or treatment effects. There are very few people who are looking at this, but there are a few groups that are starting to look at it now,” said Dr. Fein, professor of psychology at the University of Connecticut, Storrs.

Early studies in the late 1960s and early 1970s included a small minority of children who moved off the spectrum, but in most cases the investigators did not point this out, which seems to imply that those children were misdiagnosed. More recent studies have found that early diagnoses are stable in most children with autistic spectrum disorder (ASD), but there is a subgroup that moves off the autistic spectrum. These children have been regarded as misdiagnosed by some, but evidence from other studies suggests that these children had unstable autism and “probably were not misdiagnosed,” she said.

In one study, recovery from autism was reported in 9 of 19 children who received 40 hours per week of applied behavior analysis therapy (ABA). These children successfully completed normal first grade in a public school and had normal or above average IQ scores. They gained an average of 30 IQ points more than their counterparts in a control group of 40 children who received 10 hours per week of ABA; only 1 child in the control group recovered. Of the 10 other children in the intense ABA therapy group, 8 remained in the mildly impaired range, and 2 were profoundly retarded (J. Consult. Clin. Psychol. 1987;55:3–9).

In two attempts to replicate this study, there was substantial improvement in ABA-treated autistic children in areas such as cognition and academics but not in adaptive skills and behavior. Yet ABA therapists in the two studies did not report recovery among any of the children.

One recent study did replicate the results of the positive study with ABA therapy. After 4 years of treatment with ABA, 11 of 23 children with autism were in regular classes and scored normally on tests of IQ, language, adaptive functioning, and personality (Am. J. Ment. Retard. 2005;110:417–38). Although 3 of the 11 children needed classroom aides for attention problems and 1 would probably still meet criteria for ASD, the other 7 would probably meet criteria for an optimal outcome.

“This is a very exciting study,” Dr. Fein said.

In general, studies have found that communicative language by 5 years of age and a good response to early intervention within 3 months are positive signs for a good prognosis. Higher IQs appear to be associated with better social, communicative, and adaptive behaviors as the child ages.

In Dr. Fein's clinical impression, the children near 4–6 years of age who make limited progress despite good intervention will be those with mental retardation “across the board,” dense language disorder, or an intense need for repetitive behavior despite the appearance of normal cognitive potential at certain times. The presence of seizures also may indicate a poor prognosis.

Children with ASD have been shown to leave the spectrum but then reveal or develop another condition, such as ADHD. In a report, Dr. Fein described 11 children with ASD who developed clear-cut cases of ADHD by about 6 or 7 years of age. Eight of these children received intensive applied behavior analysis therapy while the other three participated in integrated or special education preschool. The children retained some mild residual features of autism, such as social awkwardness (but more impulsive and immature than aloof), perseverative interests, and occasional mild motor stereotypies (J. Autism Dev. Disord. 2005;35:525–34).

In those cases, the children may have had comorbid ASD and ADHD, leaving ADHD when autism resolved. These children also could have had a severe subtype of ADHD that presents as autism in the early years, but this may not be the case because the children looked “pretty indistinguishable from kids who stay autistic,” she noted. Or it could be that attention impairment is a feature of ASD that remains when social, behavioral, and communication impairments subside.

In a separate ongoing study conducted by Dr. Fein and her colleagues, a group of 77 children who screened positive on the Modified Checklist for Autism in Toddlers at 2 years of age were later seen at 4 years of age, regardless of whether they were autistic or not. Of the 61 children who had autism at 2 years of age, 46 also had it at 4 years of age. The remaining 15 children moved off the autistic spectrum. A total of 16 children were not autistic at either age but still screened positive because they had some problems, such as global developmental and language delays. No children who were nonautistic at 2 years of age became autistic at 4 years of age.

At 2 years of age, the 15 children in that study who left the spectrum were indistinguishable on measures of communication, socialization, symptom severity, and cognitive ability from children who remained autistic. But at 4 years of age, the “recovered” children reached almost normal levels on these measures, she said.

The only major difference between these groups at 2 years of age was in motor skills, in which recovered children had significantly higher scores that reached near-normal levels at 4 years of age.

In another study that will appear in the Journal of Autism and Developmental Disorders, Dr. Fein and her associates reported on 14 children aged 5–9 years with prior ASD diagnoses. These children had IQ scores in the normal range, were placed in age-appropriate mainstream classes, and were considered to be generally functioning at the level of their normally developing peers. They had normal performance on many measures, including different aspects of linguistic ability, expressive vocabulary, and sentence memory, and had adaptive skills in communication and socialization.

But these children still had impairments in knowing the difference between mental state verbs (know, guess, estimate) and in reasoning about animate objects (not including people). They failed to produce good narratives, judged by such factors as being less likely to discuss major events and characters' motivations. They also were not good at understanding “second order theory of mind” situations, such as knowing “what does Johnny know that Suzie knows about what Rick thinks,” Dr. Fein said.

But follow-up visits with these children at 9–12 years of age indicated that the children were “closing the gap” between themselves and normal children because their only remaining deficit was with mental state verbs.

Misdiagnosis of children who leave the spectrum appears unlikely, so the reasons why a small minority of autistic children can recover may lie in the possibility that they have a form of autism that can be alleviated with maturation or that their recovery was mediated by successful treatment or some interaction between treatment and their characteristics, she said.

These possibilities leave two big questions that remain to be answered, Dr. Fein said: Are the children for whom recovery is possible the ones with minimal structural brain abnormalities? When recovered children do a task normally, are they using the same brain systems as children who were never autistic?

BETHESDA, MD. — A test that measures six serum peptides appears to have high sensitivity and specificity in detecting hepatocellular carcinoma, Radoslav Goldman, Ph.D., reported at the annual meeting of the American Society of Preventive Oncology.

Dr. Goldman's research group at Georgetown University, Washington, analyzed serum samples from 78 patients with hepatocellular carcinoma (HCC) and 72 control patients. These patients were part of a larger case-control study of HCC that included 1,000 age- and gender-matched patients from Egypt.

The researchers compared the mass spectrometry profiles of serum from HCC and control patients. Six peptides were selected for further analysis from a set of nearly 300, said Dr. Goldman of the department of oncology at the university.

Three of the peptides occurred at significantly higher concentrations in serum from HCC patients, whereas the other three occurred at significantly higher levels in controls.

Each peptide on its own independently predicted HCC with a sensitivity and specificity comparable to the serum level of α-fetoprotein, which has been reported to detect HCC with 39%–64% sensitivity and 76%–91% specificity; α-fetoprotein testing is routinely used to detect the presence of HCC. The sensitivity and specificity of the peptides climbed to 100% and 91%, respectively, when the results for all six peptides were combined, Dr. Goldman said.

Of 45 HCC patients for whom the cancer stage was known, 11 had stage I or II and 34 had stage III or IV. “There is a nice trend for increase in the biomarkers with increasing stage of disease,” Dr. Goldman said. He is currently analyzing whether the six-peptide test can detect early-stage HCC.

The peptide test might be used in combination with a liver biopsy or imaging methods that are currently used to diagnose HCC, he suggested.

Chronic hepatitis C virus (HCV) infection accounts for about 90% of the attributable risk for HCC in Egypt. In the United States, about 50% of HCC cases have a chronic HCV etiology, according to Dr. Goldman.

Significantly more patients with HCC were positive for HCV RNA (80%) or antibodies against HCV (88%) than were control patients (22% and 33%, respectively).

Many patients in both groups had detectable antibodies against hepatitis B virus (HBV), but only a small percentage of these patients had chronic HBV infections.

The difference in the prevalence of chronic infections “is the major difference between HCV and HBV viral hepatitis,” he said. “Another important point is that for HCV, there isn't a vaccine, and there isn't one on the horizon.”

BETHESDA, MD. — A test that measures six serum peptides appears to have high sensitivity and specificity in detecting hepatocellular carcinoma, Radoslav Goldman, Ph.D., reported at the annual meeting of the American Society of Preventive Oncology.

Dr. Goldman's research group at Georgetown University, Washington, analyzed serum samples from 78 patients with hepatocellular carcinoma (HCC) and 72 control patients. These patients were part of a larger case-control study of HCC that included 1,000 age- and gender-matched patients from Egypt.

The researchers compared the mass spectrometry profiles of serum from HCC and control patients. Six peptides were selected for further analysis from a set of nearly 300, said Dr. Goldman of the department of oncology at the university.

Three of the peptides occurred at significantly higher concentrations in serum from HCC patients, whereas the other three occurred at significantly higher levels in controls.

Each peptide on its own independently predicted HCC with a sensitivity and specificity comparable to the serum level of α-fetoprotein, which has been reported to detect HCC with 39%–64% sensitivity and 76%–91% specificity; α-fetoprotein testing is routinely used to detect the presence of HCC. The sensitivity and specificity of the peptides climbed to 100% and 91%, respectively, when the results for all six peptides were combined, Dr. Goldman said.

Of 45 HCC patients for whom the cancer stage was known, 11 had stage I or II and 34 had stage III or IV. “There is a nice trend for increase in the biomarkers with increasing stage of disease,” Dr. Goldman said. He is currently analyzing whether the six-peptide test can detect early-stage HCC.

The peptide test might be used in combination with a liver biopsy or imaging methods that are currently used to diagnose HCC, he suggested.

Chronic hepatitis C virus (HCV) infection accounts for about 90% of the attributable risk for HCC in Egypt. In the United States, about 50% of HCC cases have a chronic HCV etiology, according to Dr. Goldman.

Significantly more patients with HCC were positive for HCV RNA (80%) or antibodies against HCV (88%) than were control patients (22% and 33%, respectively).

Many patients in both groups had detectable antibodies against hepatitis B virus (HBV), but only a small percentage of these patients had chronic HBV infections.

The difference in the prevalence of chronic infections “is the major difference between HCV and HBV viral hepatitis,” he said. “Another important point is that for HCV, there isn't a vaccine, and there isn't one on the horizon.”

BETHESDA, MD. — A test that measures six serum peptides appears to have high sensitivity and specificity in detecting hepatocellular carcinoma, Radoslav Goldman, Ph.D., reported at the annual meeting of the American Society of Preventive Oncology.

Dr. Goldman's research group at Georgetown University, Washington, analyzed serum samples from 78 patients with hepatocellular carcinoma (HCC) and 72 control patients. These patients were part of a larger case-control study of HCC that included 1,000 age- and gender-matched patients from Egypt.

The researchers compared the mass spectrometry profiles of serum from HCC and control patients. Six peptides were selected for further analysis from a set of nearly 300, said Dr. Goldman of the department of oncology at the university.

Three of the peptides occurred at significantly higher concentrations in serum from HCC patients, whereas the other three occurred at significantly higher levels in controls.

Each peptide on its own independently predicted HCC with a sensitivity and specificity comparable to the serum level of α-fetoprotein, which has been reported to detect HCC with 39%–64% sensitivity and 76%–91% specificity; α-fetoprotein testing is routinely used to detect the presence of HCC. The sensitivity and specificity of the peptides climbed to 100% and 91%, respectively, when the results for all six peptides were combined, Dr. Goldman said.

Of 45 HCC patients for whom the cancer stage was known, 11 had stage I or II and 34 had stage III or IV. “There is a nice trend for increase in the biomarkers with increasing stage of disease,” Dr. Goldman said. He is currently analyzing whether the six-peptide test can detect early-stage HCC.

The peptide test might be used in combination with a liver biopsy or imaging methods that are currently used to diagnose HCC, he suggested.

Chronic hepatitis C virus (HCV) infection accounts for about 90% of the attributable risk for HCC in Egypt. In the United States, about 50% of HCC cases have a chronic HCV etiology, according to Dr. Goldman.

Significantly more patients with HCC were positive for HCV RNA (80%) or antibodies against HCV (88%) than were control patients (22% and 33%, respectively).

Many patients in both groups had detectable antibodies against hepatitis B virus (HBV), but only a small percentage of these patients had chronic HBV infections.

The difference in the prevalence of chronic infections “is the major difference between HCV and HBV viral hepatitis,” he said. “Another important point is that for HCV, there isn't a vaccine, and there isn't one on the horizon.”

LOUISVILLE, KY. — The high rate of serious burns among adults older than 65 years suggests a need for greater patient education and prevention programs for this age group, Dr. Palmer Q. Bessey reported at the annual meeting of the Central Surgical Association.

Physicians and parents know that children are at risk for burns, several members of the audience said. But older adults appear to be equally vulnerable to burn injuries requiring hospitalization.

Dr. Bessey gathered discharge diagnoses reported by all hospitals in California, Florida, New Jersey, and New York for patients with ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification) diagnostic codes for burns during 2000–2004. The number of burns requiring hospitalization by state were as follows: 24,925 (California), 18,872 (New York), 12,445 (Florida), and 5,742 (New Jersey).

Except for the very young, the hospitalization rate for burns increased with age. This situation is different from other forms of trauma, in which the peak rate of hospitalization is in the late teens and early 20s, said Dr. Bessey, professor of surgery at Weill Cornell Medical College, New York.

Serious burns occurred in children aged 0–4 years at an incidence of more than 350 per million people. Adults aged 85 years or older also had an incidence of serious burns of more than 350 per million, while those aged 75–84 years had an incidence of just under 250 per million.

Burns comprise no more than 4% of emergency department visits. But the case fatality rate rivals that of motor vehicle crashes and consumes large amounts of health care resources, because burn patients require the longest hospital length of stay of all injuries reported in the National Trauma Data Bank, Dr. Bessey noted.

In the subset of patients for whom data on the type and extent of burn injury were available, more than half of the discharge diagnoses were for scalding burns and one-third were for flame burns, he reported.

Most burns occupied a small fraction of total body surface area: About 75% of burns occupied 0%–9% of total body surface area, while 15% of burns cover 10%–19% of total body surface area and 10% cover 20% or greater total body surface area.

Scalding burns occurred in significantly more children under age 15 than adults aged 65 or older (63% vs. 38%). But flame or inhalation burns were nearly three times as likely to occur in older adults as in children. Older adults also had more than twice the risk of receiving large burns, compared with children.

Older adults could be at high risk for burns because of their failure to respond to a fire or burn hazard. They may be less able to move out of the way quickly if water suddenly becomes very hot in the shower or if hot water is spilled, Dr. Bessey said.

Prevention programs could target potential hazards such as old hot-water heaters, which may be present in the homes of older adults who have lived in one place for a long time, he said.

Although burn prevention has usually been the domain of pediatricians, an education campaign among physicians such as internists or geriatricians would be worthwhile, Dr. Bessey said.

Prevention efforts and educational programs directed toward physicians and the public are needed, in order to reduce serious burn injuries in elderly persons. Craig Reinaker

LOUISVILLE, KY. — The high rate of serious burns among adults older than 65 years suggests a need for greater patient education and prevention programs for this age group, Dr. Palmer Q. Bessey reported at the annual meeting of the Central Surgical Association.

Physicians and parents know that children are at risk for burns, several members of the audience said. But older adults appear to be equally vulnerable to burn injuries requiring hospitalization.

Dr. Bessey gathered discharge diagnoses reported by all hospitals in California, Florida, New Jersey, and New York for patients with ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification) diagnostic codes for burns during 2000–2004. The number of burns requiring hospitalization by state were as follows: 24,925 (California), 18,872 (New York), 12,445 (Florida), and 5,742 (New Jersey).

Except for the very young, the hospitalization rate for burns increased with age. This situation is different from other forms of trauma, in which the peak rate of hospitalization is in the late teens and early 20s, said Dr. Bessey, professor of surgery at Weill Cornell Medical College, New York.

Serious burns occurred in children aged 0–4 years at an incidence of more than 350 per million people. Adults aged 85 years or older also had an incidence of serious burns of more than 350 per million, while those aged 75–84 years had an incidence of just under 250 per million.

Burns comprise no more than 4% of emergency department visits. But the case fatality rate rivals that of motor vehicle crashes and consumes large amounts of health care resources, because burn patients require the longest hospital length of stay of all injuries reported in the National Trauma Data Bank, Dr. Bessey noted.

In the subset of patients for whom data on the type and extent of burn injury were available, more than half of the discharge diagnoses were for scalding burns and one-third were for flame burns, he reported.

Most burns occupied a small fraction of total body surface area: About 75% of burns occupied 0%–9% of total body surface area, while 15% of burns cover 10%–19% of total body surface area and 10% cover 20% or greater total body surface area.

Scalding burns occurred in significantly more children under age 15 than adults aged 65 or older (63% vs. 38%). But flame or inhalation burns were nearly three times as likely to occur in older adults as in children. Older adults also had more than twice the risk of receiving large burns, compared with children.

Older adults could be at high risk for burns because of their failure to respond to a fire or burn hazard. They may be less able to move out of the way quickly if water suddenly becomes very hot in the shower or if hot water is spilled, Dr. Bessey said.

Prevention programs could target potential hazards such as old hot-water heaters, which may be present in the homes of older adults who have lived in one place for a long time, he said.

Although burn prevention has usually been the domain of pediatricians, an education campaign among physicians such as internists or geriatricians would be worthwhile, Dr. Bessey said.

Prevention efforts and educational programs directed toward physicians and the public are needed, in order to reduce serious burn injuries in elderly persons. Craig Reinaker

LOUISVILLE, KY. — The high rate of serious burns among adults older than 65 years suggests a need for greater patient education and prevention programs for this age group, Dr. Palmer Q. Bessey reported at the annual meeting of the Central Surgical Association.

Physicians and parents know that children are at risk for burns, several members of the audience said. But older adults appear to be equally vulnerable to burn injuries requiring hospitalization.

Dr. Bessey gathered discharge diagnoses reported by all hospitals in California, Florida, New Jersey, and New York for patients with ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification) diagnostic codes for burns during 2000–2004. The number of burns requiring hospitalization by state were as follows: 24,925 (California), 18,872 (New York), 12,445 (Florida), and 5,742 (New Jersey).

Except for the very young, the hospitalization rate for burns increased with age. This situation is different from other forms of trauma, in which the peak rate of hospitalization is in the late teens and early 20s, said Dr. Bessey, professor of surgery at Weill Cornell Medical College, New York.

Serious burns occurred in children aged 0–4 years at an incidence of more than 350 per million people. Adults aged 85 years or older also had an incidence of serious burns of more than 350 per million, while those aged 75–84 years had an incidence of just under 250 per million.

Burns comprise no more than 4% of emergency department visits. But the case fatality rate rivals that of motor vehicle crashes and consumes large amounts of health care resources, because burn patients require the longest hospital length of stay of all injuries reported in the National Trauma Data Bank, Dr. Bessey noted.

In the subset of patients for whom data on the type and extent of burn injury were available, more than half of the discharge diagnoses were for scalding burns and one-third were for flame burns, he reported.

Most burns occupied a small fraction of total body surface area: About 75% of burns occupied 0%–9% of total body surface area, while 15% of burns cover 10%–19% of total body surface area and 10% cover 20% or greater total body surface area.

Scalding burns occurred in significantly more children under age 15 than adults aged 65 or older (63% vs. 38%). But flame or inhalation burns were nearly three times as likely to occur in older adults as in children. Older adults also had more than twice the risk of receiving large burns, compared with children.

Older adults could be at high risk for burns because of their failure to respond to a fire or burn hazard. They may be less able to move out of the way quickly if water suddenly becomes very hot in the shower or if hot water is spilled, Dr. Bessey said.

Prevention programs could target potential hazards such as old hot-water heaters, which may be present in the homes of older adults who have lived in one place for a long time, he said.

Although burn prevention has usually been the domain of pediatricians, an education campaign among physicians such as internists or geriatricians would be worthwhile, Dr. Bessey said.

Prevention efforts and educational programs directed toward physicians and the public are needed, in order to reduce serious burn injuries in elderly persons. Craig Reinaker

Simultaneous kidney-pancreas transplant patients may be at risk for long-term kidney dysfunction if they continue to meet criteria for metabolic syndrome 1 year after the procedure, according to a prospective study.

The risk of long-term kidney dysfunction was especially high if patients had both metabolic syndrome and pancreas graft failure 1 year after transplantation. Poor selection of the pancreas graft or technical failures during surgery may contribute to pancreas graft loss and incomplete correction of metabolic syndrome in patients, according to surgeons who were interviewed.

In the study, Dr. Jeffrey Rogers, then at the Medical University of South Carolina, Charleston, and his colleagues used data from 241 insulin-dependent (mostly type 1) diabetic patients who were participating in a randomized, double-blind trial that tested different dosing regimens of daclizumab after simultaneous kidney-pancreas transplantation (Transplant. Proc. 2005;37:3549–51).

The incidence of metabolic syndrome in the patients decreased from 59% pretransplantation to 19% 1 year after the procedure.

But all of the patients could have potentially been free from metabolic syndrome had they received adequate pancreas grafts, Dr. David Sutherland said in an interview.

Two scenarios could explain why these patients developed metabolic syndrome, suggested Dr. Sutherland, director of the Diabetes Institute for Immunology and Transplantation at the University of Minnesota, Minneapolis. Some patients may have had a severe form of metabolic syndrome in which their insulin resistance or need for insulin was so high that even a normal pancreas could not have reduced their blood glucose level. Other patients may have had a form of metabolic syndrome that could have been reversed by receipt of a normal, healthy pancreas. Imperfect testing of deceased donors may be the reason these patients continued to have metabolic syndrome after transplant, he said.

Brain-dead donors on life support often have hyperglycemia because they receive drugs that raise blood glucose levels, such as steroids, Dr. Sutherland said. At the University of Minnesota, donors are given insulin so that hyperglycemia doesn't damage the beta islet cells of the pancreas. Donors who require hundreds of units of insulin to decrease their blood glucose level have extreme insulin resistance but may actually have a good pancreas, he said.

One can be more certain that donors who require 4 or 5 units of insulin to reduce their blood glucose level have a bad pancreas because the organ was not able to produce that amount of insulin itself.

Yet “most people think the opposite,” Dr. Sutherland said. “If it takes 4 to 5 units for blood glucose to come down, they think, 'Oh, good, we'll use the pancreas.' Actually, that's the one I wouldn't use.”

One can be “absolutely sure” that a pancreas is healthy when a donor does not need any insulin and has a normal blood glucose level despite the stress of brain death, he said.

Data on the donors were not provided in the current study.

Many of the donors were likely hyperglycemic when the organs were procured, and probably little attention was paid to how much insulin it would take to correct hyperglycemia in those donors, Dr. Sutherland surmised.

None of the patients with metabolic syndrome who developed pancreas graft failure at 1 year had a prior documented episode of kidney or pancreas rejection. Pancreas graft failure in these patients did not develop secondary to rejection of the organ.

“To me, that means that they got bum pancreases to begin with,” Dr. Sutherland said.

In the study, the presence of metabolic syndrome in patients after 1 year was significantly associated with several changes 3 years after transplant, including decreased glomerular filtration rate, increased HbA_1c levels, a lower rate of pancreas graft survival, and a higher rate of acute pancreas graft rejection.

When rejection is diagnosed in one graft in simultaneous kidney-pancreas recipients, most of the time rejection is present in the other grafts as well, Dr. Rogers said in an interview. But in the current study, metabolic syndrome patients with and without pancreas graft failure at 1 year had similar rates of kidney rejection, which suggests that kidney rejection did not play a role in the difference in kidney function.

Pancreas grafts probably failed early in patients with metabolic syndrome because of thrombosis or other technical problems, said Dr. Rogers, who is now in the surgery department at Wake Forest University, Winston-Salem, N.C.

Dr. Rogers suggested using low-dose anticoagulation postoperatively, and being cautious about using pancreases that are fatty, are from older donors, or are from donors who died of a stroke.

Simultaneous kidney-pancreas transplant patients may be at risk for long-term kidney dysfunction if they continue to meet criteria for metabolic syndrome 1 year after the procedure, according to a prospective study.

The risk of long-term kidney dysfunction was especially high if patients had both metabolic syndrome and pancreas graft failure 1 year after transplantation. Poor selection of the pancreas graft or technical failures during surgery may contribute to pancreas graft loss and incomplete correction of metabolic syndrome in patients, according to surgeons who were interviewed.

In the study, Dr. Jeffrey Rogers, then at the Medical University of South Carolina, Charleston, and his colleagues used data from 241 insulin-dependent (mostly type 1) diabetic patients who were participating in a randomized, double-blind trial that tested different dosing regimens of daclizumab after simultaneous kidney-pancreas transplantation (Transplant. Proc. 2005;37:3549–51).

The incidence of metabolic syndrome in the patients decreased from 59% pretransplantation to 19% 1 year after the procedure.

But all of the patients could have potentially been free from metabolic syndrome had they received adequate pancreas grafts, Dr. David Sutherland said in an interview.

Two scenarios could explain why these patients developed metabolic syndrome, suggested Dr. Sutherland, director of the Diabetes Institute for Immunology and Transplantation at the University of Minnesota, Minneapolis. Some patients may have had a severe form of metabolic syndrome in which their insulin resistance or need for insulin was so high that even a normal pancreas could not have reduced their blood glucose level. Other patients may have had a form of metabolic syndrome that could have been reversed by receipt of a normal, healthy pancreas. Imperfect testing of deceased donors may be the reason these patients continued to have metabolic syndrome after transplant, he said.

Brain-dead donors on life support often have hyperglycemia because they receive drugs that raise blood glucose levels, such as steroids, Dr. Sutherland said. At the University of Minnesota, donors are given insulin so that hyperglycemia doesn't damage the beta islet cells of the pancreas. Donors who require hundreds of units of insulin to decrease their blood glucose level have extreme insulin resistance but may actually have a good pancreas, he said.

One can be more certain that donors who require 4 or 5 units of insulin to reduce their blood glucose level have a bad pancreas because the organ was not able to produce that amount of insulin itself.

Yet “most people think the opposite,” Dr. Sutherland said. “If it takes 4 to 5 units for blood glucose to come down, they think, 'Oh, good, we'll use the pancreas.' Actually, that's the one I wouldn't use.”

One can be “absolutely sure” that a pancreas is healthy when a donor does not need any insulin and has a normal blood glucose level despite the stress of brain death, he said.

Data on the donors were not provided in the current study.

Many of the donors were likely hyperglycemic when the organs were procured, and probably little attention was paid to how much insulin it would take to correct hyperglycemia in those donors, Dr. Sutherland surmised.

None of the patients with metabolic syndrome who developed pancreas graft failure at 1 year had a prior documented episode of kidney or pancreas rejection. Pancreas graft failure in these patients did not develop secondary to rejection of the organ.

“To me, that means that they got bum pancreases to begin with,” Dr. Sutherland said.

In the study, the presence of metabolic syndrome in patients after 1 year was significantly associated with several changes 3 years after transplant, including decreased glomerular filtration rate, increased HbA_1c levels, a lower rate of pancreas graft survival, and a higher rate of acute pancreas graft rejection.

When rejection is diagnosed in one graft in simultaneous kidney-pancreas recipients, most of the time rejection is present in the other grafts as well, Dr. Rogers said in an interview. But in the current study, metabolic syndrome patients with and without pancreas graft failure at 1 year had similar rates of kidney rejection, which suggests that kidney rejection did not play a role in the difference in kidney function.

Pancreas grafts probably failed early in patients with metabolic syndrome because of thrombosis or other technical problems, said Dr. Rogers, who is now in the surgery department at Wake Forest University, Winston-Salem, N.C.

Dr. Rogers suggested using low-dose anticoagulation postoperatively, and being cautious about using pancreases that are fatty, are from older donors, or are from donors who died of a stroke.

Simultaneous kidney-pancreas transplant patients may be at risk for long-term kidney dysfunction if they continue to meet criteria for metabolic syndrome 1 year after the procedure, according to a prospective study.

The risk of long-term kidney dysfunction was especially high if patients had both metabolic syndrome and pancreas graft failure 1 year after transplantation. Poor selection of the pancreas graft or technical failures during surgery may contribute to pancreas graft loss and incomplete correction of metabolic syndrome in patients, according to surgeons who were interviewed.

In the study, Dr. Jeffrey Rogers, then at the Medical University of South Carolina, Charleston, and his colleagues used data from 241 insulin-dependent (mostly type 1) diabetic patients who were participating in a randomized, double-blind trial that tested different dosing regimens of daclizumab after simultaneous kidney-pancreas transplantation (Transplant. Proc. 2005;37:3549–51).

The incidence of metabolic syndrome in the patients decreased from 59% pretransplantation to 19% 1 year after the procedure.

But all of the patients could have potentially been free from metabolic syndrome had they received adequate pancreas grafts, Dr. David Sutherland said in an interview.

Two scenarios could explain why these patients developed metabolic syndrome, suggested Dr. Sutherland, director of the Diabetes Institute for Immunology and Transplantation at the University of Minnesota, Minneapolis. Some patients may have had a severe form of metabolic syndrome in which their insulin resistance or need for insulin was so high that even a normal pancreas could not have reduced their blood glucose level. Other patients may have had a form of metabolic syndrome that could have been reversed by receipt of a normal, healthy pancreas. Imperfect testing of deceased donors may be the reason these patients continued to have metabolic syndrome after transplant, he said.

Brain-dead donors on life support often have hyperglycemia because they receive drugs that raise blood glucose levels, such as steroids, Dr. Sutherland said. At the University of Minnesota, donors are given insulin so that hyperglycemia doesn't damage the beta islet cells of the pancreas. Donors who require hundreds of units of insulin to decrease their blood glucose level have extreme insulin resistance but may actually have a good pancreas, he said.

One can be more certain that donors who require 4 or 5 units of insulin to reduce their blood glucose level have a bad pancreas because the organ was not able to produce that amount of insulin itself.

Yet “most people think the opposite,” Dr. Sutherland said. “If it takes 4 to 5 units for blood glucose to come down, they think, 'Oh, good, we'll use the pancreas.' Actually, that's the one I wouldn't use.”

One can be “absolutely sure” that a pancreas is healthy when a donor does not need any insulin and has a normal blood glucose level despite the stress of brain death, he said.

Data on the donors were not provided in the current study.

Many of the donors were likely hyperglycemic when the organs were procured, and probably little attention was paid to how much insulin it would take to correct hyperglycemia in those donors, Dr. Sutherland surmised.

None of the patients with metabolic syndrome who developed pancreas graft failure at 1 year had a prior documented episode of kidney or pancreas rejection. Pancreas graft failure in these patients did not develop secondary to rejection of the organ.

“To me, that means that they got bum pancreases to begin with,” Dr. Sutherland said.

In the study, the presence of metabolic syndrome in patients after 1 year was significantly associated with several changes 3 years after transplant, including decreased glomerular filtration rate, increased HbA_1c levels, a lower rate of pancreas graft survival, and a higher rate of acute pancreas graft rejection.

When rejection is diagnosed in one graft in simultaneous kidney-pancreas recipients, most of the time rejection is present in the other grafts as well, Dr. Rogers said in an interview. But in the current study, metabolic syndrome patients with and without pancreas graft failure at 1 year had similar rates of kidney rejection, which suggests that kidney rejection did not play a role in the difference in kidney function.

Pancreas grafts probably failed early in patients with metabolic syndrome because of thrombosis or other technical problems, said Dr. Rogers, who is now in the surgery department at Wake Forest University, Winston-Salem, N.C.

Dr. Rogers suggested using low-dose anticoagulation postoperatively, and being cautious about using pancreases that are fatty, are from older donors, or are from donors who died of a stroke.

Accepting living kidney donors with mild hypertension or proteinuria would increase the transplantation rate by only 3%, according to a review of cases from four transplant centers.

But increasing live donor awareness and overcoming immunologic barriers may more successfully mitigate the effects of donor organ shortage in patients who need kidney transplants, Dr. Martin Karpinski of the University of Manitoba, Winnipeg, and his associates wrote (Am. J. Kidney Dis. 2006;47:317–23).

Yet even a 3% increase indicates that the glass is “half full” rather than “half empty,” because transplants increase longevity and improve quality of life, Dr. Arthur J. Matas of the University of Minnesota, Minneapolis, wrote in an editorial (Am. J. Kidney Dis. 2006;47:353–5).

In the study of 352 wait-listed patients with end-stage renal disease, 31 potential living kidney donors were turned down because of hypertension or proteinuria. The researchers identified 12 (3%) donors with acceptable levels of hypertension (untreated blood pressure between 140/90 mm Hg and 150/100 mm Hg or treated with a single antihypertensive medication to less than 140/90 mm Hg) or proteinuria (protein 0.15–0.30 g/day).

Only 124 (35%) of the 352 patients on the wait list had at least 1 potential living donor evaluated. Overall, 180 potential donors for these 124 patients were evaluated and excluded. Positive crossmatch and blood group type incompatibility accounted for 55% of the donor exclusions.

Efforts to make greater use of living donors need not be mutually exclusive, because each of the potential ways of addressing the problem has its own set of issues, Dr. Matas wrote.

“There is no reason why transplant centers could not simultaneously work to increase living donor rates, overcome immunologic barriers, and accept living donors with mild hypertension,” he said.

The long-term effects of these types of kidney transplants are not yet known, nor is it clear whether recipients fare better by continuing with dialysis until a deceased donor kidney is available, Dr. Matas and Dr. Karpinski and his colleagues noted.

A study of 24 white living kidney donors with essential hypertension found no adverse effects of the donation on blood pressure after a mean of 282 days of follow-up (Transplantation 2004;78:276–82). Longer follow-up will be necessary to accept such living donors, Dr. Matas wrote.

Any centers that want to take on these challenges must have systems in place for adequate evaluation, counseling, education, and long-term follow-up of prospective living donors and recipients, he added.

Accepting living kidney donors with mild hypertension or proteinuria would increase the transplantation rate by only 3%, according to a review of cases from four transplant centers.

But increasing live donor awareness and overcoming immunologic barriers may more successfully mitigate the effects of donor organ shortage in patients who need kidney transplants, Dr. Martin Karpinski of the University of Manitoba, Winnipeg, and his associates wrote (Am. J. Kidney Dis. 2006;47:317–23).

Yet even a 3% increase indicates that the glass is “half full” rather than “half empty,” because transplants increase longevity and improve quality of life, Dr. Arthur J. Matas of the University of Minnesota, Minneapolis, wrote in an editorial (Am. J. Kidney Dis. 2006;47:353–5).

In the study of 352 wait-listed patients with end-stage renal disease, 31 potential living kidney donors were turned down because of hypertension or proteinuria. The researchers identified 12 (3%) donors with acceptable levels of hypertension (untreated blood pressure between 140/90 mm Hg and 150/100 mm Hg or treated with a single antihypertensive medication to less than 140/90 mm Hg) or proteinuria (protein 0.15–0.30 g/day).

Only 124 (35%) of the 352 patients on the wait list had at least 1 potential living donor evaluated. Overall, 180 potential donors for these 124 patients were evaluated and excluded. Positive crossmatch and blood group type incompatibility accounted for 55% of the donor exclusions.

Efforts to make greater use of living donors need not be mutually exclusive, because each of the potential ways of addressing the problem has its own set of issues, Dr. Matas wrote.

“There is no reason why transplant centers could not simultaneously work to increase living donor rates, overcome immunologic barriers, and accept living donors with mild hypertension,” he said.

The long-term effects of these types of kidney transplants are not yet known, nor is it clear whether recipients fare better by continuing with dialysis until a deceased donor kidney is available, Dr. Matas and Dr. Karpinski and his colleagues noted.

A study of 24 white living kidney donors with essential hypertension found no adverse effects of the donation on blood pressure after a mean of 282 days of follow-up (Transplantation 2004;78:276–82). Longer follow-up will be necessary to accept such living donors, Dr. Matas wrote.

Any centers that want to take on these challenges must have systems in place for adequate evaluation, counseling, education, and long-term follow-up of prospective living donors and recipients, he added.

Accepting living kidney donors with mild hypertension or proteinuria would increase the transplantation rate by only 3%, according to a review of cases from four transplant centers.

But increasing live donor awareness and overcoming immunologic barriers may more successfully mitigate the effects of donor organ shortage in patients who need kidney transplants, Dr. Martin Karpinski of the University of Manitoba, Winnipeg, and his associates wrote (Am. J. Kidney Dis. 2006;47:317–23).

Yet even a 3% increase indicates that the glass is “half full” rather than “half empty,” because transplants increase longevity and improve quality of life, Dr. Arthur J. Matas of the University of Minnesota, Minneapolis, wrote in an editorial (Am. J. Kidney Dis. 2006;47:353–5).

In the study of 352 wait-listed patients with end-stage renal disease, 31 potential living kidney donors were turned down because of hypertension or proteinuria. The researchers identified 12 (3%) donors with acceptable levels of hypertension (untreated blood pressure between 140/90 mm Hg and 150/100 mm Hg or treated with a single antihypertensive medication to less than 140/90 mm Hg) or proteinuria (protein 0.15–0.30 g/day).

Only 124 (35%) of the 352 patients on the wait list had at least 1 potential living donor evaluated. Overall, 180 potential donors for these 124 patients were evaluated and excluded. Positive crossmatch and blood group type incompatibility accounted for 55% of the donor exclusions.

Efforts to make greater use of living donors need not be mutually exclusive, because each of the potential ways of addressing the problem has its own set of issues, Dr. Matas wrote.

“There is no reason why transplant centers could not simultaneously work to increase living donor rates, overcome immunologic barriers, and accept living donors with mild hypertension,” he said.

The long-term effects of these types of kidney transplants are not yet known, nor is it clear whether recipients fare better by continuing with dialysis until a deceased donor kidney is available, Dr. Matas and Dr. Karpinski and his colleagues noted.

A study of 24 white living kidney donors with essential hypertension found no adverse effects of the donation on blood pressure after a mean of 282 days of follow-up (Transplantation 2004;78:276–82). Longer follow-up will be necessary to accept such living donors, Dr. Matas wrote.

Any centers that want to take on these challenges must have systems in place for adequate evaluation, counseling, education, and long-term follow-up of prospective living donors and recipients, he added.