Patrice Wendling

CHICAGO — Perfusion computed tomography is a useful modality in the detection of regional brain perfusion deficits in patients with severe internal carotid artery stenosis, Dr. Agnieszka Trojanowska during a poster presentation at the annual meeting of the Radiological Society of North America.

CT perfusion imaging revealed that internal carotid artery stenosis in most cases was associated with brain perfusion deficits ipsilaterally to the stenotic site, and that hypoperfusion tended to improve considerably after stent placement, said Dr. Trojanowska, who also has a PhD.

In the study, 74 patients with symptomatic internal carotid artery stenosis of more than 70% were evaluated with CT perfusion imaging, on average, 70 hours before carotid stent placement and then 3 days and 6 months after stent placement. The protocol included a non-contrast enhanced transaxial CT of the brain with a 5-mm slice and 5-mm slope and dynamic CT perfusion imaging during administration of 50 mL of contrast medium at 4 mL/s with a 5-second delay.

Before stent placement with embolic protection devices, 84% of patients had perfusion deficits ipsilaterally to the stenotic site. Three days after stent placement, 30% of patients had perfusion deficits, and at 6 months, the deficits had diminished to 6%, said Dr. Trojanowska of the Medical University of Lublin (Poland).

A marked elongation of the mean transit time (6.2–6.8 seconds) was noted at the stenotic site, together with decreased values of cerebral blood flow (40–46 mL/100 g per min) and slightly increased cerebral blood volume (3.2 mL/100 g).

CHICAGO — Perfusion computed tomography is a useful modality in the detection of regional brain perfusion deficits in patients with severe internal carotid artery stenosis, Dr. Agnieszka Trojanowska during a poster presentation at the annual meeting of the Radiological Society of North America.

CT perfusion imaging revealed that internal carotid artery stenosis in most cases was associated with brain perfusion deficits ipsilaterally to the stenotic site, and that hypoperfusion tended to improve considerably after stent placement, said Dr. Trojanowska, who also has a PhD.

In the study, 74 patients with symptomatic internal carotid artery stenosis of more than 70% were evaluated with CT perfusion imaging, on average, 70 hours before carotid stent placement and then 3 days and 6 months after stent placement. The protocol included a non-contrast enhanced transaxial CT of the brain with a 5-mm slice and 5-mm slope and dynamic CT perfusion imaging during administration of 50 mL of contrast medium at 4 mL/s with a 5-second delay.

Before stent placement with embolic protection devices, 84% of patients had perfusion deficits ipsilaterally to the stenotic site. Three days after stent placement, 30% of patients had perfusion deficits, and at 6 months, the deficits had diminished to 6%, said Dr. Trojanowska of the Medical University of Lublin (Poland).

A marked elongation of the mean transit time (6.2–6.8 seconds) was noted at the stenotic site, together with decreased values of cerebral blood flow (40–46 mL/100 g per min) and slightly increased cerebral blood volume (3.2 mL/100 g).

CHICAGO — Perfusion computed tomography is a useful modality in the detection of regional brain perfusion deficits in patients with severe internal carotid artery stenosis, Dr. Agnieszka Trojanowska during a poster presentation at the annual meeting of the Radiological Society of North America.

CT perfusion imaging revealed that internal carotid artery stenosis in most cases was associated with brain perfusion deficits ipsilaterally to the stenotic site, and that hypoperfusion tended to improve considerably after stent placement, said Dr. Trojanowska, who also has a PhD.

In the study, 74 patients with symptomatic internal carotid artery stenosis of more than 70% were evaluated with CT perfusion imaging, on average, 70 hours before carotid stent placement and then 3 days and 6 months after stent placement. The protocol included a non-contrast enhanced transaxial CT of the brain with a 5-mm slice and 5-mm slope and dynamic CT perfusion imaging during administration of 50 mL of contrast medium at 4 mL/s with a 5-second delay.

Before stent placement with embolic protection devices, 84% of patients had perfusion deficits ipsilaterally to the stenotic site. Three days after stent placement, 30% of patients had perfusion deficits, and at 6 months, the deficits had diminished to 6%, said Dr. Trojanowska of the Medical University of Lublin (Poland).

A marked elongation of the mean transit time (6.2–6.8 seconds) was noted at the stenotic site, together with decreased values of cerebral blood flow (40–46 mL/100 g per min) and slightly increased cerebral blood volume (3.2 mL/100 g).

QUEBEC CITY – Computerized assessment of mild cognitive impairment is an area of great promise and potential problems, Jason Brandt, Ph.D., said at a conference sponsored by the American Association for Geriatric Psychiatry.

A slew of new computerized tests are on the market; they're very professionally produced, glitzy, and fun to do, Dr. Brandt said. They're cost effective and provide rapid results. They can also be administered repeatedly, which makes them useful in monitoring cognitive progression and treatment effect.

But the tests need to meet established standards of reliability, validity, and lack of bias, said Dr. Brandt, professor and director of the division of medical psychology, Johns Hopkins Hospital, Baltimore. Tests also need to be adaptive to the needs of patients such as those with sensory or motor deficits.

In addition, it has to be established, and not assumed, that tests administered, scored, and interpreted by computer are comparable with traditional “pencil and paper” tests.

“Just because we call them by the same name or assert them to be measuring the same construct, doesn't mean that's true,” he said. So far, none of the computerized tests have met these conditions to his satisfaction, he said in an interview.

Some of the tests currently available are:

▸ Computer Administered Neuropsychological Screen for Mild Cognitive Impairment or CANS-MCI (Screen, Inc., Seattle) takes about 30 minutes on a personal computer with a mouse or touch screen and measures visual spatial skills, mental control, language fluency, and both immediate and delayed memory.

A recent National Institute on Aging-funded study in 310 elderly patients concluded that the test shows promise as a reliable and valid screening tool in determining if more intensive testing is warranted (J. Neuropsychiatry Clin. Neurosci. 2005;17:98–105).

▸ Mindstreams (NeuroTrax Corp., New Brunswick, N.J.) is a cognitive battery that significantly discriminated between 30 patients with mild cognitive impairment and 39 healthy elders (J. Mol. Neurosci. 2004;24:33–44). Measures of memory, executive function, visual spatial skills, and verbal fluency discriminated best. Discrimination was at least comparable with that of traditional neuropsychological tests in these domains.

▸ CNS Vital Signs (CNS Vital Signs, Chapel Hill, N.C.), which is just beginning to be explored by clinicians at Johns Hopkins, includes seven tests that can be administered in about 40 minutes or more. CNS Vital Signs provides an elaborate printout with a variety of scores, but the question is whether patients will use it, he said.

If mild cognitive impairment is suspected, Dr. Brandt recommended that primary care physicians refer their patients to a board-certified clinical neuropsychologist who specializes in disorders of the elderly.

The choice of assessment techniques for any given patient should be left up to the neuropsychologist.

QUEBEC CITY – Computerized assessment of mild cognitive impairment is an area of great promise and potential problems, Jason Brandt, Ph.D., said at a conference sponsored by the American Association for Geriatric Psychiatry.

A slew of new computerized tests are on the market; they're very professionally produced, glitzy, and fun to do, Dr. Brandt said. They're cost effective and provide rapid results. They can also be administered repeatedly, which makes them useful in monitoring cognitive progression and treatment effect.

But the tests need to meet established standards of reliability, validity, and lack of bias, said Dr. Brandt, professor and director of the division of medical psychology, Johns Hopkins Hospital, Baltimore. Tests also need to be adaptive to the needs of patients such as those with sensory or motor deficits.

In addition, it has to be established, and not assumed, that tests administered, scored, and interpreted by computer are comparable with traditional “pencil and paper” tests.

“Just because we call them by the same name or assert them to be measuring the same construct, doesn't mean that's true,” he said. So far, none of the computerized tests have met these conditions to his satisfaction, he said in an interview.

Some of the tests currently available are:

▸ Computer Administered Neuropsychological Screen for Mild Cognitive Impairment or CANS-MCI (Screen, Inc., Seattle) takes about 30 minutes on a personal computer with a mouse or touch screen and measures visual spatial skills, mental control, language fluency, and both immediate and delayed memory.

A recent National Institute on Aging-funded study in 310 elderly patients concluded that the test shows promise as a reliable and valid screening tool in determining if more intensive testing is warranted (J. Neuropsychiatry Clin. Neurosci. 2005;17:98–105).

▸ Mindstreams (NeuroTrax Corp., New Brunswick, N.J.) is a cognitive battery that significantly discriminated between 30 patients with mild cognitive impairment and 39 healthy elders (J. Mol. Neurosci. 2004;24:33–44). Measures of memory, executive function, visual spatial skills, and verbal fluency discriminated best. Discrimination was at least comparable with that of traditional neuropsychological tests in these domains.

▸ CNS Vital Signs (CNS Vital Signs, Chapel Hill, N.C.), which is just beginning to be explored by clinicians at Johns Hopkins, includes seven tests that can be administered in about 40 minutes or more. CNS Vital Signs provides an elaborate printout with a variety of scores, but the question is whether patients will use it, he said.

If mild cognitive impairment is suspected, Dr. Brandt recommended that primary care physicians refer their patients to a board-certified clinical neuropsychologist who specializes in disorders of the elderly.

The choice of assessment techniques for any given patient should be left up to the neuropsychologist.

QUEBEC CITY – Computerized assessment of mild cognitive impairment is an area of great promise and potential problems, Jason Brandt, Ph.D., said at a conference sponsored by the American Association for Geriatric Psychiatry.

A slew of new computerized tests are on the market; they're very professionally produced, glitzy, and fun to do, Dr. Brandt said. They're cost effective and provide rapid results. They can also be administered repeatedly, which makes them useful in monitoring cognitive progression and treatment effect.

But the tests need to meet established standards of reliability, validity, and lack of bias, said Dr. Brandt, professor and director of the division of medical psychology, Johns Hopkins Hospital, Baltimore. Tests also need to be adaptive to the needs of patients such as those with sensory or motor deficits.

In addition, it has to be established, and not assumed, that tests administered, scored, and interpreted by computer are comparable with traditional “pencil and paper” tests.

“Just because we call them by the same name or assert them to be measuring the same construct, doesn't mean that's true,” he said. So far, none of the computerized tests have met these conditions to his satisfaction, he said in an interview.

Some of the tests currently available are:

▸ Computer Administered Neuropsychological Screen for Mild Cognitive Impairment or CANS-MCI (Screen, Inc., Seattle) takes about 30 minutes on a personal computer with a mouse or touch screen and measures visual spatial skills, mental control, language fluency, and both immediate and delayed memory.

A recent National Institute on Aging-funded study in 310 elderly patients concluded that the test shows promise as a reliable and valid screening tool in determining if more intensive testing is warranted (J. Neuropsychiatry Clin. Neurosci. 2005;17:98–105).

▸ Mindstreams (NeuroTrax Corp., New Brunswick, N.J.) is a cognitive battery that significantly discriminated between 30 patients with mild cognitive impairment and 39 healthy elders (J. Mol. Neurosci. 2004;24:33–44). Measures of memory, executive function, visual spatial skills, and verbal fluency discriminated best. Discrimination was at least comparable with that of traditional neuropsychological tests in these domains.

▸ CNS Vital Signs (CNS Vital Signs, Chapel Hill, N.C.), which is just beginning to be explored by clinicians at Johns Hopkins, includes seven tests that can be administered in about 40 minutes or more. CNS Vital Signs provides an elaborate printout with a variety of scores, but the question is whether patients will use it, he said.

If mild cognitive impairment is suspected, Dr. Brandt recommended that primary care physicians refer their patients to a board-certified clinical neuropsychologist who specializes in disorders of the elderly.

The choice of assessment techniques for any given patient should be left up to the neuropsychologist.

QUEBEC CITY — Increasing dietary fiber intake might be warranted in patients with diabetes, hypertension, and obesity, Dr. Dana King said at the North American Primary Care Research Group annual meeting.

Dr. King presented a study in which adults with low fiber intake and at least two of the three conditions were twice as likely to have elevated C-reactive protein (CRP) levels, compared with adults with no risk conditions, even after controlling for confounding factors. In addition, the influence of fiber on CRP values was greater as the number of conditions increased, said Dr. King, professor at the Medical University of South Carolina, Charleston.

There is some evidence to suggest that dietary fiber reduces cholesterol and influences inflammation. But CRP increases the risk of cardiovascular disease independently from cholesterol, he said.

Both the American Diabetes Association and the American Heart Association suggest adults consume 25–30 g of fiber per day. However, neither group has specific recommendations for higher intake among high-risk patients, Dr. King said.

The cross-sectional study included 7,891 participants in the 1999–2002 National Health and Nutrition Examination Survey at least 20 years of age who had valid high-sensitivity CRP measurements and dietary information. The participants were asked to recall fiber consumption in the previous 24 hours. Fiber supplements were not counted toward total intake.

Individuals with two or more conditions—diabetes, hypertension, or obesity—who consumed 20 g per day or more of fiber had significantly lower median CRP (3.1 mg/L) than people who consumed 8.8 g/day or less (4.5 mg/L).

CRP was four times higher in people with these conditions who consumed less than 8.8 g/day of fiber than people without these conditions (1.4 mg/L).

Even after controlling for age, race, gender, and tobacco use, adults with two or more conditions had double the risk of having elevated CRP (odds ratio 2.3), compared with adults with no risk conditions (OR 1.5). Only 2%–3% of patients in the study had rheumatoid arthritis, which can raise CRP levels.

Only dietary fiber showed a consistent association with CRP. There was no consistent association between CRP and other dietary components such as fat, polyunsaturated fat, protein, carbohydrates, or fish-oil consumption, he said.

It's unclear what biological mechanisms might be at work, but fiber itself might not be the source of the observed benefits.

“We could very well be looking at a surrogate,” Dr. King said. “Fiber may not be changing CRP. There have been a couple of studies, including our own, that have looked at other things that travel along with fiber, other nutrients, such as magnesium.

“There is a high correlation between magnesium intake and fiber intake, and there is a high predictive value of high magnesium intake and lower blood pressure and lower cardiovascular disease. So they may be traveling together. We are still in the process of sorting these things out.”

QUEBEC CITY — Increasing dietary fiber intake might be warranted in patients with diabetes, hypertension, and obesity, Dr. Dana King said at the North American Primary Care Research Group annual meeting.

Dr. King presented a study in which adults with low fiber intake and at least two of the three conditions were twice as likely to have elevated C-reactive protein (CRP) levels, compared with adults with no risk conditions, even after controlling for confounding factors. In addition, the influence of fiber on CRP values was greater as the number of conditions increased, said Dr. King, professor at the Medical University of South Carolina, Charleston.

There is some evidence to suggest that dietary fiber reduces cholesterol and influences inflammation. But CRP increases the risk of cardiovascular disease independently from cholesterol, he said.

Both the American Diabetes Association and the American Heart Association suggest adults consume 25–30 g of fiber per day. However, neither group has specific recommendations for higher intake among high-risk patients, Dr. King said.

The cross-sectional study included 7,891 participants in the 1999–2002 National Health and Nutrition Examination Survey at least 20 years of age who had valid high-sensitivity CRP measurements and dietary information. The participants were asked to recall fiber consumption in the previous 24 hours. Fiber supplements were not counted toward total intake.

Individuals with two or more conditions—diabetes, hypertension, or obesity—who consumed 20 g per day or more of fiber had significantly lower median CRP (3.1 mg/L) than people who consumed 8.8 g/day or less (4.5 mg/L).

CRP was four times higher in people with these conditions who consumed less than 8.8 g/day of fiber than people without these conditions (1.4 mg/L).

Even after controlling for age, race, gender, and tobacco use, adults with two or more conditions had double the risk of having elevated CRP (odds ratio 2.3), compared with adults with no risk conditions (OR 1.5). Only 2%–3% of patients in the study had rheumatoid arthritis, which can raise CRP levels.

Only dietary fiber showed a consistent association with CRP. There was no consistent association between CRP and other dietary components such as fat, polyunsaturated fat, protein, carbohydrates, or fish-oil consumption, he said.

It's unclear what biological mechanisms might be at work, but fiber itself might not be the source of the observed benefits.

“We could very well be looking at a surrogate,” Dr. King said. “Fiber may not be changing CRP. There have been a couple of studies, including our own, that have looked at other things that travel along with fiber, other nutrients, such as magnesium.

“There is a high correlation between magnesium intake and fiber intake, and there is a high predictive value of high magnesium intake and lower blood pressure and lower cardiovascular disease. So they may be traveling together. We are still in the process of sorting these things out.”

QUEBEC CITY — Increasing dietary fiber intake might be warranted in patients with diabetes, hypertension, and obesity, Dr. Dana King said at the North American Primary Care Research Group annual meeting.

Dr. King presented a study in which adults with low fiber intake and at least two of the three conditions were twice as likely to have elevated C-reactive protein (CRP) levels, compared with adults with no risk conditions, even after controlling for confounding factors. In addition, the influence of fiber on CRP values was greater as the number of conditions increased, said Dr. King, professor at the Medical University of South Carolina, Charleston.

There is some evidence to suggest that dietary fiber reduces cholesterol and influences inflammation. But CRP increases the risk of cardiovascular disease independently from cholesterol, he said.

Both the American Diabetes Association and the American Heart Association suggest adults consume 25–30 g of fiber per day. However, neither group has specific recommendations for higher intake among high-risk patients, Dr. King said.

The cross-sectional study included 7,891 participants in the 1999–2002 National Health and Nutrition Examination Survey at least 20 years of age who had valid high-sensitivity CRP measurements and dietary information. The participants were asked to recall fiber consumption in the previous 24 hours. Fiber supplements were not counted toward total intake.

Individuals with two or more conditions—diabetes, hypertension, or obesity—who consumed 20 g per day or more of fiber had significantly lower median CRP (3.1 mg/L) than people who consumed 8.8 g/day or less (4.5 mg/L).

CRP was four times higher in people with these conditions who consumed less than 8.8 g/day of fiber than people without these conditions (1.4 mg/L).

Even after controlling for age, race, gender, and tobacco use, adults with two or more conditions had double the risk of having elevated CRP (odds ratio 2.3), compared with adults with no risk conditions (OR 1.5). Only 2%–3% of patients in the study had rheumatoid arthritis, which can raise CRP levels.

Only dietary fiber showed a consistent association with CRP. There was no consistent association between CRP and other dietary components such as fat, polyunsaturated fat, protein, carbohydrates, or fish-oil consumption, he said.

It's unclear what biological mechanisms might be at work, but fiber itself might not be the source of the observed benefits.

“We could very well be looking at a surrogate,” Dr. King said. “Fiber may not be changing CRP. There have been a couple of studies, including our own, that have looked at other things that travel along with fiber, other nutrients, such as magnesium.

“There is a high correlation between magnesium intake and fiber intake, and there is a high predictive value of high magnesium intake and lower blood pressure and lower cardiovascular disease. So they may be traveling together. We are still in the process of sorting these things out.”

CHICAGO — Data indicate that most pregnancies in women who undergo the Essure hysteroscopic sterilization procedure could be avoided, Dr. John F. Kerin said at the annual meeting of the AAGL (formerly the American Association of Gynecologic Laparoscopists).

There have been no pregnancies with the Essure device (Conceptus, San Carlos, Calif.) in multicenter phase II or pivotal trials after 4 years of follow-up. But in postmarketing use, there have been 37 reported pregnancies following an estimated 29,736 procedures from 1997 to December 2004, said Dr. Kerin, a consultant and principal clinical investigator for Conceptus. As of October 2005, 52 pregnancies had been reported in 40,568 procedures worldwide.

Data analysis through 2004 suggests pregnancies are occurring after the device is put into general practice because of noncompliance with protocol by the physician or patient (21 cases, 57%); the patient was probably pregnant before the procedure (6 cases, 16%); or the hysterosalpingograms were misread (6 cases, 16%). Four cases (11%) were due to other etiologies: expulsion of the device with an earlier noncommercially available design, and a device expulsion. Two are still being investigated.

“The important thing is there were no confirmed Essure device-related failures resulting in pregnancy amongst tens of thousands of women so far who have had this procedure worldwide,” Dr. Kerin said. “I think most pregnancies are avoidable, and we need to up-skill and use our care before the procedure, during the procedure, and in the follow-up.”

Among the 21 noncompliance cases, 17 patients didn't return for follow-up at 3 months. These failures were related to errors that could have been identified at the postplacement exam, such as failure of long-term bilateral placement (12), unilateral device expulsion (6), and perforation (3). Three other cases of failure to place one of the devices were not followed up and alternative contraception was not provided.

“Why a doctor would fail to provide alternative contraception following an incomplete sterilization is beyond me,” said Dr. Kerin, professor of reproductive medicine at Flinders University, Adelaide, Australia. He advised physicians to ensure that their patients are using reliable birth control before and after device placement, and to perform the procedure prior to ovulation to avoid the risk of luteal phase pregnancy.

“Beware of the patient who is not on reliable contraception who may be using condoms only or the 'safe method' and you choose to do that procedure after ovulation,” he said. “The patient may already have an embryo in that fallopian tube just ready to pop into the uterus when you are doing the procedure and [that would] therefore sabotage the outcome.”

Physicians should also always follow the instructions for correct Essure device placement and hysterosalpingogram protocols, educate their patients on the necessity of follow-up, and review the complete radiology report and all films themselves.

Even during this introduction of a new technique, the failure rate with Essure is comparable with the established laparoscopic methods of sterilization, with the distinct advantage of avoiding incisional surgery and general anesthesia, he said.

CHICAGO — Data indicate that most pregnancies in women who undergo the Essure hysteroscopic sterilization procedure could be avoided, Dr. John F. Kerin said at the annual meeting of the AAGL (formerly the American Association of Gynecologic Laparoscopists).

There have been no pregnancies with the Essure device (Conceptus, San Carlos, Calif.) in multicenter phase II or pivotal trials after 4 years of follow-up. But in postmarketing use, there have been 37 reported pregnancies following an estimated 29,736 procedures from 1997 to December 2004, said Dr. Kerin, a consultant and principal clinical investigator for Conceptus. As of October 2005, 52 pregnancies had been reported in 40,568 procedures worldwide.

Data analysis through 2004 suggests pregnancies are occurring after the device is put into general practice because of noncompliance with protocol by the physician or patient (21 cases, 57%); the patient was probably pregnant before the procedure (6 cases, 16%); or the hysterosalpingograms were misread (6 cases, 16%). Four cases (11%) were due to other etiologies: expulsion of the device with an earlier noncommercially available design, and a device expulsion. Two are still being investigated.

“The important thing is there were no confirmed Essure device-related failures resulting in pregnancy amongst tens of thousands of women so far who have had this procedure worldwide,” Dr. Kerin said. “I think most pregnancies are avoidable, and we need to up-skill and use our care before the procedure, during the procedure, and in the follow-up.”

Among the 21 noncompliance cases, 17 patients didn't return for follow-up at 3 months. These failures were related to errors that could have been identified at the postplacement exam, such as failure of long-term bilateral placement (12), unilateral device expulsion (6), and perforation (3). Three other cases of failure to place one of the devices were not followed up and alternative contraception was not provided.

“Why a doctor would fail to provide alternative contraception following an incomplete sterilization is beyond me,” said Dr. Kerin, professor of reproductive medicine at Flinders University, Adelaide, Australia. He advised physicians to ensure that their patients are using reliable birth control before and after device placement, and to perform the procedure prior to ovulation to avoid the risk of luteal phase pregnancy.

“Beware of the patient who is not on reliable contraception who may be using condoms only or the 'safe method' and you choose to do that procedure after ovulation,” he said. “The patient may already have an embryo in that fallopian tube just ready to pop into the uterus when you are doing the procedure and [that would] therefore sabotage the outcome.”

Physicians should also always follow the instructions for correct Essure device placement and hysterosalpingogram protocols, educate their patients on the necessity of follow-up, and review the complete radiology report and all films themselves.

Even during this introduction of a new technique, the failure rate with Essure is comparable with the established laparoscopic methods of sterilization, with the distinct advantage of avoiding incisional surgery and general anesthesia, he said.

CHICAGO — Data indicate that most pregnancies in women who undergo the Essure hysteroscopic sterilization procedure could be avoided, Dr. John F. Kerin said at the annual meeting of the AAGL (formerly the American Association of Gynecologic Laparoscopists).

There have been no pregnancies with the Essure device (Conceptus, San Carlos, Calif.) in multicenter phase II or pivotal trials after 4 years of follow-up. But in postmarketing use, there have been 37 reported pregnancies following an estimated 29,736 procedures from 1997 to December 2004, said Dr. Kerin, a consultant and principal clinical investigator for Conceptus. As of October 2005, 52 pregnancies had been reported in 40,568 procedures worldwide.

Data analysis through 2004 suggests pregnancies are occurring after the device is put into general practice because of noncompliance with protocol by the physician or patient (21 cases, 57%); the patient was probably pregnant before the procedure (6 cases, 16%); or the hysterosalpingograms were misread (6 cases, 16%). Four cases (11%) were due to other etiologies: expulsion of the device with an earlier noncommercially available design, and a device expulsion. Two are still being investigated.

“The important thing is there were no confirmed Essure device-related failures resulting in pregnancy amongst tens of thousands of women so far who have had this procedure worldwide,” Dr. Kerin said. “I think most pregnancies are avoidable, and we need to up-skill and use our care before the procedure, during the procedure, and in the follow-up.”

Among the 21 noncompliance cases, 17 patients didn't return for follow-up at 3 months. These failures were related to errors that could have been identified at the postplacement exam, such as failure of long-term bilateral placement (12), unilateral device expulsion (6), and perforation (3). Three other cases of failure to place one of the devices were not followed up and alternative contraception was not provided.

“Why a doctor would fail to provide alternative contraception following an incomplete sterilization is beyond me,” said Dr. Kerin, professor of reproductive medicine at Flinders University, Adelaide, Australia. He advised physicians to ensure that their patients are using reliable birth control before and after device placement, and to perform the procedure prior to ovulation to avoid the risk of luteal phase pregnancy.

“Beware of the patient who is not on reliable contraception who may be using condoms only or the 'safe method' and you choose to do that procedure after ovulation,” he said. “The patient may already have an embryo in that fallopian tube just ready to pop into the uterus when you are doing the procedure and [that would] therefore sabotage the outcome.”

Physicians should also always follow the instructions for correct Essure device placement and hysterosalpingogram protocols, educate their patients on the necessity of follow-up, and review the complete radiology report and all films themselves.

Even during this introduction of a new technique, the failure rate with Essure is comparable with the established laparoscopic methods of sterilization, with the distinct advantage of avoiding incisional surgery and general anesthesia, he said.

CHICAGO — Global endometrial ablation can be performed easily and safely in the office as long as physicians are adequately prepared and strictly adhere to protocols, Dr. Ted Anderson said at the annual meeting of the AAGL (formerly the American Association of Gynecologic Laparoscopists).

Dr. Anderson and his associates developed a protocol incorporating guidelines for office-based procedures from the American College of Surgeons, American Society of Anesthesiologists (ASA), personal or published accounts, and professional liability insurance providers.

Some of its primary considerations are:

▸ Strict adherence to the indications and contraindications for each technique.

▸ Thorough diagnostic evaluation. Imaging and sampling should be done in advance to avoid surprises and to determine the thickness of the myometrium, a frequently overlooked aspect.

“Doing these procedures in the office is not the place for an atypical patient or an atypical uterus,” he said. “You want a straightforward procedure, don't take risks, and keep in mind that doing this procedure in your office is not just simply changing the place that you're doing it. It's a mentality that you're changing as well. You need to be absolutely comfortable before you move to the office.”

▸ Careful patient selection. Consider American Society of Anesthesiologists class I or II patients only. Avoid patients with comorbid conditions such as asthma, anxiety, obesity, or heart disease which might decompensate in the office.

▸ Consider psychosocial issues. Look for clues during the biopsy for how well the patient might tolerate an in-office procedure. Make sure she has realistic expectations of the procedure and its outcomes.

▸ Anesthesia considerations. Start with full sedation in the operating room (OR) and slowly lessen the anesthesia over time as you become confident in your technique. Operate at this reduced level of anesthesia in the OR before moving the procedure to your office.

“Ultimately, how you may modify the exact nature of the anesthesia will be dictated by your comfort level and the technology you use,” said Dr. Anderson of Vanderbilt University Medical Center, Nashville.

▸ Ergonomic considerations. Reduce the instrumentation in the OR to exactly what you will have available in your office. Ultimately, you want to be performing the procedure in the operating room exactly the way you plan to do it in the office.

▸ Use oral NSAIDs and intravenous ketorolac (Toradol) 30 mg up to an hour before the procedure, and paracervical blocks in all patients.

▸ Patient monitoring. If you're going to use conscious sedation, have someone present with advanced cardiac life support certification or someone who is a certified registered nurse anesthetist. Resuscitation and stabilization equipment should be readily available in the event that the patient decompensates and needs to be stabilized or moved to another facility.

▸ Physician preparation. Have absolute comfort with the technology and technique, and your ability to perform that technique. Written protocols should be in place that detail how and what you are going to do. Regulatory agencies and professional liability carriers will demand them.

The protocol, “Office-based Endometrial Ablation: paradigm for the future,” is available free of charge from CME Outfitters of Rockville, Md., 240–243–1300, www.cmeoutfitters.com

CHICAGO — Global endometrial ablation can be performed easily and safely in the office as long as physicians are adequately prepared and strictly adhere to protocols, Dr. Ted Anderson said at the annual meeting of the AAGL (formerly the American Association of Gynecologic Laparoscopists).

Dr. Anderson and his associates developed a protocol incorporating guidelines for office-based procedures from the American College of Surgeons, American Society of Anesthesiologists (ASA), personal or published accounts, and professional liability insurance providers.

Some of its primary considerations are:

▸ Strict adherence to the indications and contraindications for each technique.

▸ Thorough diagnostic evaluation. Imaging and sampling should be done in advance to avoid surprises and to determine the thickness of the myometrium, a frequently overlooked aspect.

“Doing these procedures in the office is not the place for an atypical patient or an atypical uterus,” he said. “You want a straightforward procedure, don't take risks, and keep in mind that doing this procedure in your office is not just simply changing the place that you're doing it. It's a mentality that you're changing as well. You need to be absolutely comfortable before you move to the office.”

▸ Careful patient selection. Consider American Society of Anesthesiologists class I or II patients only. Avoid patients with comorbid conditions such as asthma, anxiety, obesity, or heart disease which might decompensate in the office.

▸ Consider psychosocial issues. Look for clues during the biopsy for how well the patient might tolerate an in-office procedure. Make sure she has realistic expectations of the procedure and its outcomes.

▸ Anesthesia considerations. Start with full sedation in the operating room (OR) and slowly lessen the anesthesia over time as you become confident in your technique. Operate at this reduced level of anesthesia in the OR before moving the procedure to your office.

“Ultimately, how you may modify the exact nature of the anesthesia will be dictated by your comfort level and the technology you use,” said Dr. Anderson of Vanderbilt University Medical Center, Nashville.

▸ Ergonomic considerations. Reduce the instrumentation in the OR to exactly what you will have available in your office. Ultimately, you want to be performing the procedure in the operating room exactly the way you plan to do it in the office.

▸ Use oral NSAIDs and intravenous ketorolac (Toradol) 30 mg up to an hour before the procedure, and paracervical blocks in all patients.

▸ Patient monitoring. If you're going to use conscious sedation, have someone present with advanced cardiac life support certification or someone who is a certified registered nurse anesthetist. Resuscitation and stabilization equipment should be readily available in the event that the patient decompensates and needs to be stabilized or moved to another facility.

▸ Physician preparation. Have absolute comfort with the technology and technique, and your ability to perform that technique. Written protocols should be in place that detail how and what you are going to do. Regulatory agencies and professional liability carriers will demand them.

The protocol, “Office-based Endometrial Ablation: paradigm for the future,” is available free of charge from CME Outfitters of Rockville, Md., 240–243–1300, www.cmeoutfitters.com

CHICAGO — Global endometrial ablation can be performed easily and safely in the office as long as physicians are adequately prepared and strictly adhere to protocols, Dr. Ted Anderson said at the annual meeting of the AAGL (formerly the American Association of Gynecologic Laparoscopists).

Dr. Anderson and his associates developed a protocol incorporating guidelines for office-based procedures from the American College of Surgeons, American Society of Anesthesiologists (ASA), personal or published accounts, and professional liability insurance providers.

Some of its primary considerations are:

▸ Strict adherence to the indications and contraindications for each technique.

▸ Thorough diagnostic evaluation. Imaging and sampling should be done in advance to avoid surprises and to determine the thickness of the myometrium, a frequently overlooked aspect.

“Doing these procedures in the office is not the place for an atypical patient or an atypical uterus,” he said. “You want a straightforward procedure, don't take risks, and keep in mind that doing this procedure in your office is not just simply changing the place that you're doing it. It's a mentality that you're changing as well. You need to be absolutely comfortable before you move to the office.”

▸ Careful patient selection. Consider American Society of Anesthesiologists class I or II patients only. Avoid patients with comorbid conditions such as asthma, anxiety, obesity, or heart disease which might decompensate in the office.

▸ Consider psychosocial issues. Look for clues during the biopsy for how well the patient might tolerate an in-office procedure. Make sure she has realistic expectations of the procedure and its outcomes.

▸ Anesthesia considerations. Start with full sedation in the operating room (OR) and slowly lessen the anesthesia over time as you become confident in your technique. Operate at this reduced level of anesthesia in the OR before moving the procedure to your office.

“Ultimately, how you may modify the exact nature of the anesthesia will be dictated by your comfort level and the technology you use,” said Dr. Anderson of Vanderbilt University Medical Center, Nashville.

▸ Ergonomic considerations. Reduce the instrumentation in the OR to exactly what you will have available in your office. Ultimately, you want to be performing the procedure in the operating room exactly the way you plan to do it in the office.

▸ Use oral NSAIDs and intravenous ketorolac (Toradol) 30 mg up to an hour before the procedure, and paracervical blocks in all patients.

▸ Patient monitoring. If you're going to use conscious sedation, have someone present with advanced cardiac life support certification or someone who is a certified registered nurse anesthetist. Resuscitation and stabilization equipment should be readily available in the event that the patient decompensates and needs to be stabilized or moved to another facility.

▸ Physician preparation. Have absolute comfort with the technology and technique, and your ability to perform that technique. Written protocols should be in place that detail how and what you are going to do. Regulatory agencies and professional liability carriers will demand them.

The protocol, “Office-based Endometrial Ablation: paradigm for the future,” is available free of charge from CME Outfitters of Rockville, Md., 240–243–1300, www.cmeoutfitters.com

CHICAGO — Preevacuation hysteroscopy is useful for identifying localized and systemic defects during morphogenesis in patients with unexplained recurring pregnancy loss, said Dr. Artin Ternamian.

“we're convinced that preevacuation hysteroscopy can help us understand and maybe explain a lot of the miscarriages that we take for granted,” he said at the annual meeting of the AAGL (formerly the American Association of Gynecologic Laparoscopists).

Sonography, tissue analysis, and biochemical studies are generally used to evaluate recurrent pregnancy loss, which occurs in 1% of reproductive-age women. But once the evacuation or D&C has been performed, couple counseling becomes more difficult, if not impossible, and the willingness to investigate further wanes, he said.

Preevacuation hysteroscopy allows physicians to examine the fetoplacental environment and provides excellent visualization of the surface anatomy before the tissue is eviscerated or contaminated, said Dr. Ternamian, director of gynecologic endoscopy, St. Joseph's Health Centre, University of Toronto.

In particular, one can examine the ventral bony clefts, which can be difficult to do with ultrasound and which reveals subtle skin surface changes, such as human papillomavirus skin lesions or raised corneal lesions that can be targeted for biopsy. The procedure can demonstrate most fetal extremity deformities and the exact topography of the limbs, identifying cystic hydromas and sacral coccygeal keratomas.

The accurate surface observation of hysteroscopy can identify congenital ear abnormalities such as clefts and congenital hairy nevi that are notoriously missed on ultrasound, he said. Preevacuation hysteroscopy can also confirm or rule out amniotic bands, Meckel-Gruber syndrome, Klippel-Trénaunay-Weber syndrome, and first-trimester varicella.

In a prospective, preliminary feasibility study, preevacuation hysteroscopy was performed using a continuous-flow resectoscope with a 12-degree lens in 12 consecutive patients with confirmed spontaneous pregnancy loss. Gestational ages ranged from 9 weeks to 19 weeks.

In this procedure, the cervix is dilated and a small amniotic membrane window created at a location away from the placenta and fetus, using a monopolar 5-by-8-mm cutting loop set at 100 W pure cut power. The often stained amniotic fluid is exchanged for 1.5% glycine while the hysteroscope is navigated through the amniotic window into the fetal compartment.

Abnormalities were detected in all but one patient. None of the abnormalities observed on hysteroscopy were identified on previous ultrasound scans or subsequent surgical pathology reports.

“The objective of a pathology report is to make sure that what you've retrieved is indeed fetal tissue and you've evacuated the uterus; [it] isn't intended to detect abnormalities,” Dr. Ternamian said in an interview. “If, by chance, they see some gross histologic abnormalities that will be reported, but that's 1 in 10,000.”

Hysteroscopy adds no more than 20 minutes to an evacuation or D&C, and the majority of patients offered the additional testing consent. Patients are advised not to decide at the first interview when the fetal death is discovered, and particular care is taken if the patient is pregnant for the first time.

“From the patient's point of view it's a horrendous area,” he said. “To use hysteroscopy is the next logical step to help these patients, and, hopefully, we can take it to the next level, where, if you have a miscarriage, it becomes standard of care.”

CHICAGO — Preevacuation hysteroscopy is useful for identifying localized and systemic defects during morphogenesis in patients with unexplained recurring pregnancy loss, said Dr. Artin Ternamian.

“we're convinced that preevacuation hysteroscopy can help us understand and maybe explain a lot of the miscarriages that we take for granted,” he said at the annual meeting of the AAGL (formerly the American Association of Gynecologic Laparoscopists).

Sonography, tissue analysis, and biochemical studies are generally used to evaluate recurrent pregnancy loss, which occurs in 1% of reproductive-age women. But once the evacuation or D&C has been performed, couple counseling becomes more difficult, if not impossible, and the willingness to investigate further wanes, he said.

Preevacuation hysteroscopy allows physicians to examine the fetoplacental environment and provides excellent visualization of the surface anatomy before the tissue is eviscerated or contaminated, said Dr. Ternamian, director of gynecologic endoscopy, St. Joseph's Health Centre, University of Toronto.

In particular, one can examine the ventral bony clefts, which can be difficult to do with ultrasound and which reveals subtle skin surface changes, such as human papillomavirus skin lesions or raised corneal lesions that can be targeted for biopsy. The procedure can demonstrate most fetal extremity deformities and the exact topography of the limbs, identifying cystic hydromas and sacral coccygeal keratomas.

The accurate surface observation of hysteroscopy can identify congenital ear abnormalities such as clefts and congenital hairy nevi that are notoriously missed on ultrasound, he said. Preevacuation hysteroscopy can also confirm or rule out amniotic bands, Meckel-Gruber syndrome, Klippel-Trénaunay-Weber syndrome, and first-trimester varicella.

In a prospective, preliminary feasibility study, preevacuation hysteroscopy was performed using a continuous-flow resectoscope with a 12-degree lens in 12 consecutive patients with confirmed spontaneous pregnancy loss. Gestational ages ranged from 9 weeks to 19 weeks.

In this procedure, the cervix is dilated and a small amniotic membrane window created at a location away from the placenta and fetus, using a monopolar 5-by-8-mm cutting loop set at 100 W pure cut power. The often stained amniotic fluid is exchanged for 1.5% glycine while the hysteroscope is navigated through the amniotic window into the fetal compartment.

Abnormalities were detected in all but one patient. None of the abnormalities observed on hysteroscopy were identified on previous ultrasound scans or subsequent surgical pathology reports.

“The objective of a pathology report is to make sure that what you've retrieved is indeed fetal tissue and you've evacuated the uterus; [it] isn't intended to detect abnormalities,” Dr. Ternamian said in an interview. “If, by chance, they see some gross histologic abnormalities that will be reported, but that's 1 in 10,000.”

Hysteroscopy adds no more than 20 minutes to an evacuation or D&C, and the majority of patients offered the additional testing consent. Patients are advised not to decide at the first interview when the fetal death is discovered, and particular care is taken if the patient is pregnant for the first time.

“From the patient's point of view it's a horrendous area,” he said. “To use hysteroscopy is the next logical step to help these patients, and, hopefully, we can take it to the next level, where, if you have a miscarriage, it becomes standard of care.”

CHICAGO — Preevacuation hysteroscopy is useful for identifying localized and systemic defects during morphogenesis in patients with unexplained recurring pregnancy loss, said Dr. Artin Ternamian.

“we're convinced that preevacuation hysteroscopy can help us understand and maybe explain a lot of the miscarriages that we take for granted,” he said at the annual meeting of the AAGL (formerly the American Association of Gynecologic Laparoscopists).

Sonography, tissue analysis, and biochemical studies are generally used to evaluate recurrent pregnancy loss, which occurs in 1% of reproductive-age women. But once the evacuation or D&C has been performed, couple counseling becomes more difficult, if not impossible, and the willingness to investigate further wanes, he said.

Preevacuation hysteroscopy allows physicians to examine the fetoplacental environment and provides excellent visualization of the surface anatomy before the tissue is eviscerated or contaminated, said Dr. Ternamian, director of gynecologic endoscopy, St. Joseph's Health Centre, University of Toronto.

In particular, one can examine the ventral bony clefts, which can be difficult to do with ultrasound and which reveals subtle skin surface changes, such as human papillomavirus skin lesions or raised corneal lesions that can be targeted for biopsy. The procedure can demonstrate most fetal extremity deformities and the exact topography of the limbs, identifying cystic hydromas and sacral coccygeal keratomas.

The accurate surface observation of hysteroscopy can identify congenital ear abnormalities such as clefts and congenital hairy nevi that are notoriously missed on ultrasound, he said. Preevacuation hysteroscopy can also confirm or rule out amniotic bands, Meckel-Gruber syndrome, Klippel-Trénaunay-Weber syndrome, and first-trimester varicella.

In a prospective, preliminary feasibility study, preevacuation hysteroscopy was performed using a continuous-flow resectoscope with a 12-degree lens in 12 consecutive patients with confirmed spontaneous pregnancy loss. Gestational ages ranged from 9 weeks to 19 weeks.

In this procedure, the cervix is dilated and a small amniotic membrane window created at a location away from the placenta and fetus, using a monopolar 5-by-8-mm cutting loop set at 100 W pure cut power. The often stained amniotic fluid is exchanged for 1.5% glycine while the hysteroscope is navigated through the amniotic window into the fetal compartment.

Abnormalities were detected in all but one patient. None of the abnormalities observed on hysteroscopy were identified on previous ultrasound scans or subsequent surgical pathology reports.

“The objective of a pathology report is to make sure that what you've retrieved is indeed fetal tissue and you've evacuated the uterus; [it] isn't intended to detect abnormalities,” Dr. Ternamian said in an interview. “If, by chance, they see some gross histologic abnormalities that will be reported, but that's 1 in 10,000.”

Hysteroscopy adds no more than 20 minutes to an evacuation or D&C, and the majority of patients offered the additional testing consent. Patients are advised not to decide at the first interview when the fetal death is discovered, and particular care is taken if the patient is pregnant for the first time.

“From the patient's point of view it's a horrendous area,” he said. “To use hysteroscopy is the next logical step to help these patients, and, hopefully, we can take it to the next level, where, if you have a miscarriage, it becomes standard of care.”

QUEBEC CITY — Paternal depression is relatively common and can negatively affect child behavior, Shreya Davé reported at the annual meeting of the North American Primary Care Research Group.

She presented a cross-sectional study in which questionnaires were sent to 2,352 biological fathers with children aged 4–6 years from 13 general practices in greater London and Hertfordshire, England.

Questionnaires included a diagnostic depression measure and standardized inventories on child behavior, parenting, couple relationship, alcohol use, and demographics.

Mothers were sent a similar but smaller packet. Their responses were used to assess child behavior and were thought to be a more objective way to assess the relationship of paternal depression and child behavior, said Ms. Davé, a research fellow in the department of primary care and population sciences at University College London.

The prevalence of paternal depression was 8% in the study, with 29 of the 365 fathers who responded scoring positively for depressive symptoms. Of the 365 responders, 12 (3%) fathers had major depressive symptoms and 17 (5%) had mild or moderate depressive symptoms.

Fathers with major depression were almost 20 times more likely to have a child with peer problem signs and 13 times more likely to have a child with a low prosocial behavior assessment score, after controlling for maternal depression, couple relationship quality, paternal age, and number of children.

Study limitations were its cross-sectional design, low response rate, and wide confidence intervals resulting from the small number of participants, she said. But findings clearly point to the need for further studies.

“Family practice is an ideal location for assessment and prevention,” she said.

QUEBEC CITY — Paternal depression is relatively common and can negatively affect child behavior, Shreya Davé reported at the annual meeting of the North American Primary Care Research Group.

She presented a cross-sectional study in which questionnaires were sent to 2,352 biological fathers with children aged 4–6 years from 13 general practices in greater London and Hertfordshire, England.

Questionnaires included a diagnostic depression measure and standardized inventories on child behavior, parenting, couple relationship, alcohol use, and demographics.

Mothers were sent a similar but smaller packet. Their responses were used to assess child behavior and were thought to be a more objective way to assess the relationship of paternal depression and child behavior, said Ms. Davé, a research fellow in the department of primary care and population sciences at University College London.

The prevalence of paternal depression was 8% in the study, with 29 of the 365 fathers who responded scoring positively for depressive symptoms. Of the 365 responders, 12 (3%) fathers had major depressive symptoms and 17 (5%) had mild or moderate depressive symptoms.

Fathers with major depression were almost 20 times more likely to have a child with peer problem signs and 13 times more likely to have a child with a low prosocial behavior assessment score, after controlling for maternal depression, couple relationship quality, paternal age, and number of children.

Study limitations were its cross-sectional design, low response rate, and wide confidence intervals resulting from the small number of participants, she said. But findings clearly point to the need for further studies.

“Family practice is an ideal location for assessment and prevention,” she said.

QUEBEC CITY — Paternal depression is relatively common and can negatively affect child behavior, Shreya Davé reported at the annual meeting of the North American Primary Care Research Group.

She presented a cross-sectional study in which questionnaires were sent to 2,352 biological fathers with children aged 4–6 years from 13 general practices in greater London and Hertfordshire, England.

Questionnaires included a diagnostic depression measure and standardized inventories on child behavior, parenting, couple relationship, alcohol use, and demographics.

Mothers were sent a similar but smaller packet. Their responses were used to assess child behavior and were thought to be a more objective way to assess the relationship of paternal depression and child behavior, said Ms. Davé, a research fellow in the department of primary care and population sciences at University College London.

The prevalence of paternal depression was 8% in the study, with 29 of the 365 fathers who responded scoring positively for depressive symptoms. Of the 365 responders, 12 (3%) fathers had major depressive symptoms and 17 (5%) had mild or moderate depressive symptoms.

Fathers with major depression were almost 20 times more likely to have a child with peer problem signs and 13 times more likely to have a child with a low prosocial behavior assessment score, after controlling for maternal depression, couple relationship quality, paternal age, and number of children.

Study limitations were its cross-sectional design, low response rate, and wide confidence intervals resulting from the small number of participants, she said. But findings clearly point to the need for further studies.

“Family practice is an ideal location for assessment and prevention,” she said.

QUEBEC CITY — Brief depression screening during well-child visits can detect parents at risk and requires little extra time, Dr. Ardis L. Olson reported at the annual meeting of the North American Primary Care Research Group.

The U.S. Preventive Services Task Force recommends that all adults have brief depression screening, and pediatricians and family physicians may be the health professionals seen most by parents. Detecting parental mental health issues is an important way to lessen the impact of such issues on children.

In these cases, the role of the child's physician is not to diagnose depression, but to identify parents at risk for depression, encourage them to seek help, and refer them to available resources, said Dr. Olson of the departments of pediatrics and community and family medicine at Dartmouth Medical School, Lebanon, N.H.

As part of Dartmouth's parental well-being project, Dr. Olson and colleagues prepared practitioners to screen parents for depression with a two-question screener given during well-child visits over 6 months in six community pediatric practices in New Hampshire and Vermont.

Screening results were discussed with the parents, and a centralized telephone referral service was provided for those who screened positive.

The two questions were, “Over the past 2 weeks, have you felt down, depressed, or hopeless?” and “Over the past 2 weeks, have you felt little interest or pleasure in doing things?” If they answered yes to either question, they were then asked to identify if it had been for several days, more than half the days, or nearly every day.

Providers and staff also completed follow-up surveys during three 1-week periods.

The two-question screeners were collected during 7,990 of 16,716 well-child visits (48%). After removing screeners with incomplete data, a total of 6,446 were analyzed.

One in seven parents revealed mood or anhedonia symptoms (881 of 5,772 mothers and 88 of 674 fathers).

Of the parents screened, 1 in 20 was at risk for major depression (285 mothers and 34 fathers).

The screening also generated discussion with mothers with fewer symptoms, she said. One in five of these mothers (31 of 152) admitted possible depression and were willing to take action to treat it.

The discussion with parents about their screening results took less than 3 minutes in 90% of cases and more than 10 minutes in 1.4%.

Nurse practitioners were more likely than were physicians (46% vs. 37%, respectively) to refer screen-positive parents to their primary care or mental health providers.

Although physicians and nurse practitioners referred 21% of screen-positive parents to the support line, only 20 parents called the 800 number in the first 12 weeks of the study. Overall, 5% of referred parents received some telephone counselor assistance.

The findings demonstrate that community practices can implement routine, brief parental depression screening when administrative and leadership support is in place, Dr. Olson said. The staff of the six practices that participated in the study stressed that reduced staffing affected their ability to routinely screen.

QUEBEC CITY — Brief depression screening during well-child visits can detect parents at risk and requires little extra time, Dr. Ardis L. Olson reported at the annual meeting of the North American Primary Care Research Group.

The U.S. Preventive Services Task Force recommends that all adults have brief depression screening, and pediatricians and family physicians may be the health professionals seen most by parents. Detecting parental mental health issues is an important way to lessen the impact of such issues on children.

In these cases, the role of the child's physician is not to diagnose depression, but to identify parents at risk for depression, encourage them to seek help, and refer them to available resources, said Dr. Olson of the departments of pediatrics and community and family medicine at Dartmouth Medical School, Lebanon, N.H.

As part of Dartmouth's parental well-being project, Dr. Olson and colleagues prepared practitioners to screen parents for depression with a two-question screener given during well-child visits over 6 months in six community pediatric practices in New Hampshire and Vermont.

Screening results were discussed with the parents, and a centralized telephone referral service was provided for those who screened positive.

The two questions were, “Over the past 2 weeks, have you felt down, depressed, or hopeless?” and “Over the past 2 weeks, have you felt little interest or pleasure in doing things?” If they answered yes to either question, they were then asked to identify if it had been for several days, more than half the days, or nearly every day.

Providers and staff also completed follow-up surveys during three 1-week periods.

The two-question screeners were collected during 7,990 of 16,716 well-child visits (48%). After removing screeners with incomplete data, a total of 6,446 were analyzed.

One in seven parents revealed mood or anhedonia symptoms (881 of 5,772 mothers and 88 of 674 fathers).

Of the parents screened, 1 in 20 was at risk for major depression (285 mothers and 34 fathers).

The screening also generated discussion with mothers with fewer symptoms, she said. One in five of these mothers (31 of 152) admitted possible depression and were willing to take action to treat it.

The discussion with parents about their screening results took less than 3 minutes in 90% of cases and more than 10 minutes in 1.4%.

Nurse practitioners were more likely than were physicians (46% vs. 37%, respectively) to refer screen-positive parents to their primary care or mental health providers.

Although physicians and nurse practitioners referred 21% of screen-positive parents to the support line, only 20 parents called the 800 number in the first 12 weeks of the study. Overall, 5% of referred parents received some telephone counselor assistance.

The findings demonstrate that community practices can implement routine, brief parental depression screening when administrative and leadership support is in place, Dr. Olson said. The staff of the six practices that participated in the study stressed that reduced staffing affected their ability to routinely screen.

QUEBEC CITY — Brief depression screening during well-child visits can detect parents at risk and requires little extra time, Dr. Ardis L. Olson reported at the annual meeting of the North American Primary Care Research Group.

The U.S. Preventive Services Task Force recommends that all adults have brief depression screening, and pediatricians and family physicians may be the health professionals seen most by parents. Detecting parental mental health issues is an important way to lessen the impact of such issues on children.

In these cases, the role of the child's physician is not to diagnose depression, but to identify parents at risk for depression, encourage them to seek help, and refer them to available resources, said Dr. Olson of the departments of pediatrics and community and family medicine at Dartmouth Medical School, Lebanon, N.H.

As part of Dartmouth's parental well-being project, Dr. Olson and colleagues prepared practitioners to screen parents for depression with a two-question screener given during well-child visits over 6 months in six community pediatric practices in New Hampshire and Vermont.

Screening results were discussed with the parents, and a centralized telephone referral service was provided for those who screened positive.

The two questions were, “Over the past 2 weeks, have you felt down, depressed, or hopeless?” and “Over the past 2 weeks, have you felt little interest or pleasure in doing things?” If they answered yes to either question, they were then asked to identify if it had been for several days, more than half the days, or nearly every day.

Providers and staff also completed follow-up surveys during three 1-week periods.

The two-question screeners were collected during 7,990 of 16,716 well-child visits (48%). After removing screeners with incomplete data, a total of 6,446 were analyzed.

One in seven parents revealed mood or anhedonia symptoms (881 of 5,772 mothers and 88 of 674 fathers).

Of the parents screened, 1 in 20 was at risk for major depression (285 mothers and 34 fathers).

The screening also generated discussion with mothers with fewer symptoms, she said. One in five of these mothers (31 of 152) admitted possible depression and were willing to take action to treat it.

The discussion with parents about their screening results took less than 3 minutes in 90% of cases and more than 10 minutes in 1.4%.

Nurse practitioners were more likely than were physicians (46% vs. 37%, respectively) to refer screen-positive parents to their primary care or mental health providers.

Although physicians and nurse practitioners referred 21% of screen-positive parents to the support line, only 20 parents called the 800 number in the first 12 weeks of the study. Overall, 5% of referred parents received some telephone counselor assistance.

The findings demonstrate that community practices can implement routine, brief parental depression screening when administrative and leadership support is in place, Dr. Olson said. The staff of the six practices that participated in the study stressed that reduced staffing affected their ability to routinely screen.

CHICAGO — Breast tomosynthesis was equivalent or superior to conventional diagnostic mammography in 9 of 10 women in a preliminary study of 98 women.

“In a screening capacity, we estimate about a 40% decrease in screening mammography, which would be a huge benefit to women and public health to save the patient the anxiety, cost, and time of going for diagnostic evaluation,” lead author Dr. Steven P. Poplack said at the annual meeting of the Radiological Society of North America. Nationally, about 12% of all screening mammograms are recalled for additional evaluation.

The investigational three-dimensional technique uses conventional x-ray tubes and digital imaging plates. But a series of low-dose exposures are made every few degrees while the x-ray tube is rotated over the patient in a 30-degree arc, creating a series of digital images.

The individual digital images are then reconstructed into a series of thin, high-resolution slices that can be displayed individually or in a dynamic cine mode, said Dr. Poplack, who serves as a scientific advisory board member for Hologic Inc., which sponsored the study.

He presented data from a study in which 98 women with abnormal digital screening mammograms were sequentially recruited and underwent tomosynthesis of the affected breasts.

Tomosynthesis images were evaluated prospectively and compared with the initial screening mammography exams showing 112 findings in the women.

Tomosynthesis detected five invasive carcinomas in 4 of the 98 women, including one lesion that was not apparent on digital mammography.

As a diagnostic imaging technique, tomosynthesis was equivalent (60/112) or superior (39/112) to diagnostic mammography in 86 of 98 (88%) women. Half (49) of the women would not have been recalled if tomosynthesis had been used on the first screening.

The advantage of tomosynthesis is its ability to reduce or eliminate the tissue overlap and structure noise seen in single-slice two-dimensional mammography, said Dr. Poplack of Dartmouth Medical School, Hanover, N.H.

“It's my own belief that not only are we going to get benefit in specificity, but we're also going to get a benefit in sensitivity and decrease our false-negative rate,” he said.

Another benefit of tomosynthesis is that it builds on a huge base of knowledge already established in mammography, so the images will not be foreign to radiologists. It requires the same amount of compression as film or digital mammography, so the discomfort is no less for the patient, however.

Dr. Poplack cautioned that the results are preliminary, and that the study was too small to identify characteristics of women in whom tomosynthesis might offer the greatest benefit.

CHICAGO — Breast tomosynthesis was equivalent or superior to conventional diagnostic mammography in 9 of 10 women in a preliminary study of 98 women.

“In a screening capacity, we estimate about a 40% decrease in screening mammography, which would be a huge benefit to women and public health to save the patient the anxiety, cost, and time of going for diagnostic evaluation,” lead author Dr. Steven P. Poplack said at the annual meeting of the Radiological Society of North America. Nationally, about 12% of all screening mammograms are recalled for additional evaluation.

The investigational three-dimensional technique uses conventional x-ray tubes and digital imaging plates. But a series of low-dose exposures are made every few degrees while the x-ray tube is rotated over the patient in a 30-degree arc, creating a series of digital images.

The individual digital images are then reconstructed into a series of thin, high-resolution slices that can be displayed individually or in a dynamic cine mode, said Dr. Poplack, who serves as a scientific advisory board member for Hologic Inc., which sponsored the study.

He presented data from a study in which 98 women with abnormal digital screening mammograms were sequentially recruited and underwent tomosynthesis of the affected breasts.

Tomosynthesis images were evaluated prospectively and compared with the initial screening mammography exams showing 112 findings in the women.

Tomosynthesis detected five invasive carcinomas in 4 of the 98 women, including one lesion that was not apparent on digital mammography.

As a diagnostic imaging technique, tomosynthesis was equivalent (60/112) or superior (39/112) to diagnostic mammography in 86 of 98 (88%) women. Half (49) of the women would not have been recalled if tomosynthesis had been used on the first screening.

The advantage of tomosynthesis is its ability to reduce or eliminate the tissue overlap and structure noise seen in single-slice two-dimensional mammography, said Dr. Poplack of Dartmouth Medical School, Hanover, N.H.

“It's my own belief that not only are we going to get benefit in specificity, but we're also going to get a benefit in sensitivity and decrease our false-negative rate,” he said.

Another benefit of tomosynthesis is that it builds on a huge base of knowledge already established in mammography, so the images will not be foreign to radiologists. It requires the same amount of compression as film or digital mammography, so the discomfort is no less for the patient, however.

Dr. Poplack cautioned that the results are preliminary, and that the study was too small to identify characteristics of women in whom tomosynthesis might offer the greatest benefit.

CHICAGO — Breast tomosynthesis was equivalent or superior to conventional diagnostic mammography in 9 of 10 women in a preliminary study of 98 women.

“In a screening capacity, we estimate about a 40% decrease in screening mammography, which would be a huge benefit to women and public health to save the patient the anxiety, cost, and time of going for diagnostic evaluation,” lead author Dr. Steven P. Poplack said at the annual meeting of the Radiological Society of North America. Nationally, about 12% of all screening mammograms are recalled for additional evaluation.

The investigational three-dimensional technique uses conventional x-ray tubes and digital imaging plates. But a series of low-dose exposures are made every few degrees while the x-ray tube is rotated over the patient in a 30-degree arc, creating a series of digital images.

The individual digital images are then reconstructed into a series of thin, high-resolution slices that can be displayed individually or in a dynamic cine mode, said Dr. Poplack, who serves as a scientific advisory board member for Hologic Inc., which sponsored the study.

He presented data from a study in which 98 women with abnormal digital screening mammograms were sequentially recruited and underwent tomosynthesis of the affected breasts.

Tomosynthesis images were evaluated prospectively and compared with the initial screening mammography exams showing 112 findings in the women.

Tomosynthesis detected five invasive carcinomas in 4 of the 98 women, including one lesion that was not apparent on digital mammography.

As a diagnostic imaging technique, tomosynthesis was equivalent (60/112) or superior (39/112) to diagnostic mammography in 86 of 98 (88%) women. Half (49) of the women would not have been recalled if tomosynthesis had been used on the first screening.

The advantage of tomosynthesis is its ability to reduce or eliminate the tissue overlap and structure noise seen in single-slice two-dimensional mammography, said Dr. Poplack of Dartmouth Medical School, Hanover, N.H.

“It's my own belief that not only are we going to get benefit in specificity, but we're also going to get a benefit in sensitivity and decrease our false-negative rate,” he said.

Another benefit of tomosynthesis is that it builds on a huge base of knowledge already established in mammography, so the images will not be foreign to radiologists. It requires the same amount of compression as film or digital mammography, so the discomfort is no less for the patient, however.

Dr. Poplack cautioned that the results are preliminary, and that the study was too small to identify characteristics of women in whom tomosynthesis might offer the greatest benefit.

CHICAGO — Routine concurrent breast and thyroid sonographic examinations are useful in detecting small thyroid cancers, Dr. Jeong Seon Park said at the annual meeting of the Radiological Society of North America.

The two tests were combined in a prospective study conducted between January 2003 and March 2004 of 5,549 women.

The findings were so convincing that thyroid testing is now routine practice when a breast ultrasound is ordered at the Korean Cancer Center in Koyang, where the study was conducted.

Breast ultrasounds are added to mammography for women with dense breasts, and detect additional cancers in about 1 in 1,000 cases, she said.

All participants, aged 13–83 years, underwent breast and thyroid screening sonography (4,864 women) or sonography for diagnosis or follow-up of breast cancer (685 women).

Ultrasound-guided fine needle aspiration was performed when a thyroid lesion was suspicious for malignancy based on hypoechogenicity, irregular shape, or poorly defined margins.

A total of 42 (0.75%) cases of thyroid cancer were detected and confirmed pathologically. All were papillary carcinomas.

The incidence of thyroid cancer was significantly higher in women with breast cancer, reported Dr. Park and colleagues.

There were 13 (1.9%) thyroid cancers among the patients with breast cancer, compared with 29 (0.6%) thyroid cancers among patients with negative or benign breast disease.

The mean diameter of the thyroid masses was 9.9 mm in the breast cancer group and 8.6 mm in the noncancer group.

A total of 28 (66%) thyroid cancers were less than 1 cm in diameter. There were no metastases.

In the breast cancer group, 6 of the 13 cases were detected as having concurrent breast and thyroid cancers; the remaining 7 thyroid cancers were diagnosed after 6–14 months of follow-up.

“Sonographic screening to detect thyroid cancer in women is effective, but the survival benefit of early detection needs to be studied further,” she said.

Patients were offered the thyroid test free of charge during the study but are now charged and willing to pay for the additional test, she said.

CHICAGO — Routine concurrent breast and thyroid sonographic examinations are useful in detecting small thyroid cancers, Dr. Jeong Seon Park said at the annual meeting of the Radiological Society of North America.

The two tests were combined in a prospective study conducted between January 2003 and March 2004 of 5,549 women.

The findings were so convincing that thyroid testing is now routine practice when a breast ultrasound is ordered at the Korean Cancer Center in Koyang, where the study was conducted.

Breast ultrasounds are added to mammography for women with dense breasts, and detect additional cancers in about 1 in 1,000 cases, she said.

All participants, aged 13–83 years, underwent breast and thyroid screening sonography (4,864 women) or sonography for diagnosis or follow-up of breast cancer (685 women).

Ultrasound-guided fine needle aspiration was performed when a thyroid lesion was suspicious for malignancy based on hypoechogenicity, irregular shape, or poorly defined margins.

A total of 42 (0.75%) cases of thyroid cancer were detected and confirmed pathologically. All were papillary carcinomas.

The incidence of thyroid cancer was significantly higher in women with breast cancer, reported Dr. Park and colleagues.

There were 13 (1.9%) thyroid cancers among the patients with breast cancer, compared with 29 (0.6%) thyroid cancers among patients with negative or benign breast disease.

The mean diameter of the thyroid masses was 9.9 mm in the breast cancer group and 8.6 mm in the noncancer group.

A total of 28 (66%) thyroid cancers were less than 1 cm in diameter. There were no metastases.

In the breast cancer group, 6 of the 13 cases were detected as having concurrent breast and thyroid cancers; the remaining 7 thyroid cancers were diagnosed after 6–14 months of follow-up.

“Sonographic screening to detect thyroid cancer in women is effective, but the survival benefit of early detection needs to be studied further,” she said.

Patients were offered the thyroid test free of charge during the study but are now charged and willing to pay for the additional test, she said.

CHICAGO — Routine concurrent breast and thyroid sonographic examinations are useful in detecting small thyroid cancers, Dr. Jeong Seon Park said at the annual meeting of the Radiological Society of North America.

The two tests were combined in a prospective study conducted between January 2003 and March 2004 of 5,549 women.

The findings were so convincing that thyroid testing is now routine practice when a breast ultrasound is ordered at the Korean Cancer Center in Koyang, where the study was conducted.

Breast ultrasounds are added to mammography for women with dense breasts, and detect additional cancers in about 1 in 1,000 cases, she said.

All participants, aged 13–83 years, underwent breast and thyroid screening sonography (4,864 women) or sonography for diagnosis or follow-up of breast cancer (685 women).

Ultrasound-guided fine needle aspiration was performed when a thyroid lesion was suspicious for malignancy based on hypoechogenicity, irregular shape, or poorly defined margins.

A total of 42 (0.75%) cases of thyroid cancer were detected and confirmed pathologically. All were papillary carcinomas.

The incidence of thyroid cancer was significantly higher in women with breast cancer, reported Dr. Park and colleagues.

There were 13 (1.9%) thyroid cancers among the patients with breast cancer, compared with 29 (0.6%) thyroid cancers among patients with negative or benign breast disease.

The mean diameter of the thyroid masses was 9.9 mm in the breast cancer group and 8.6 mm in the noncancer group.

A total of 28 (66%) thyroid cancers were less than 1 cm in diameter. There were no metastases.

In the breast cancer group, 6 of the 13 cases were detected as having concurrent breast and thyroid cancers; the remaining 7 thyroid cancers were diagnosed after 6–14 months of follow-up.

“Sonographic screening to detect thyroid cancer in women is effective, but the survival benefit of early detection needs to be studied further,” she said.

Patients were offered the thyroid test free of charge during the study but are now charged and willing to pay for the additional test, she said.