Robert Finn

SAN FRANCISCO — Chest pain represents one of the most common presenting symptoms in emergency departments, and it also represents a diagnostic challenge: Is it a pulmonary embolism? Is it an aortic dissection? Is it coronary artery disease? Or is it nothing?

Now, new CT technology promises to revolutionize this diagnosis, giving the ability to rule out all three conditions with a single 15-second scan.

In theory, this scan can replace stress testing for coronary artery disease, echocardiography or CT for aortic dissection, and CT pulmonary angiography or a ventilation-perfusion scan for pulmonary embolism, Matthew J. Budoff, M.D., said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

Although no diagnostic or prognostic studies on the triple rule out have yet been published, there's some indication that the single scan will have 90% accuracy or better for each of the three conditions, said Dr. Budoff of Harbor-UCLA Medical Center in Torrance, Calif.

The technology involves a 64-slice CT scan from the apex to the base of the lungs. Patients will have to hold their breath for 20–30 seconds as contrast is injected and the images are acquired. Acquisition of the slices will be gated to the heart's rhythm, allowing for stable, high-resolution images of the heart and lungs. The slice thickness will be 0.625 mm.

Software and a sophisticated workstation will allow the clinician to construct three-dimensional images of the heart, lungs, or aorta, and to manipulate three-dimensional and two-dimensional images in a variety of ways.

In addition to aortic dissection, pulmonary embolism, and coronary artery disease, the technique will allow clear views of the pericardium, permitting the diagnosis of calcified or thickened pericardium and sometimes pericarditis.

In addition, “you might pick up pneumonia, and you might pick up pulmonary adhesions or even pericardial adhesions,” Dr. Budoff said. “There are a lot of things you could possibly see. And it could be done during the chest pain episode, which is a great advantage over some of the other modalities where you'd want to wait until their chest pain is quiescent.”

Dr. Budoff described the case of an elderly woman who complained of chest pain and shortness of breath. Because of her age, he was reluctant to order a stress test. The CT angiography showed that her coronary arteries were normal and that her ejection fraction was acceptably high. When he examined the lung images closely, however, he discovered several pulmonary emboli.

“We admitted her to the hospital, put her on heparin, and it all cleared up,” he said.

Despite its promise, the triple rule out does have some limitations. For one thing, it subjects patients to a relatively high dose of radiation—in the neighborhood of 24–30 millisieverts, equivalent to 240–300 chest x-rays.

Because it's a gated study, more contrast must be used and the injection time is longer than for a standard CT. Some patients may have trouble holding their breath for 20–30 seconds.

Then there's the issue of who is going to read these images when a patient presents at 3 a.m. The radiologist staffing the emergency department may not be facile with cardiac CT angiography. Although the images could be transferred over data lines, the cardiologist is not likely to have a workstation with the proper software at home. In all likelihood, someone will have to come to the hospital to read the study.

Still, Dr. Budoff expects the triple rule out to become a routine test in the emergency department, a prospect he greets with mixed emotions.

“We really need to see how this is going to pan out, and work out the reading issues before we start applying this to everybody who comes in with a twinge in their chest or shortness of breath,” he said. “I'm a little leery … to say just because we can do it we should.”

Views of aortic dissection: Left, it is shown as a long, thin dissection flap in the descending aorta; right, the true lumen (larger area) and false lumen are shown endoscopically. Photos courtesy Dr. Matthew J. Budoff

SAN FRANCISCO — Chest pain represents one of the most common presenting symptoms in emergency departments, and it also represents a diagnostic challenge: Is it a pulmonary embolism? Is it an aortic dissection? Is it coronary artery disease? Or is it nothing?

Now, new CT technology promises to revolutionize this diagnosis, giving the ability to rule out all three conditions with a single 15-second scan.

In theory, this scan can replace stress testing for coronary artery disease, echocardiography or CT for aortic dissection, and CT pulmonary angiography or a ventilation-perfusion scan for pulmonary embolism, Matthew J. Budoff, M.D., said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

Although no diagnostic or prognostic studies on the triple rule out have yet been published, there's some indication that the single scan will have 90% accuracy or better for each of the three conditions, said Dr. Budoff of Harbor-UCLA Medical Center in Torrance, Calif.

The technology involves a 64-slice CT scan from the apex to the base of the lungs. Patients will have to hold their breath for 20–30 seconds as contrast is injected and the images are acquired. Acquisition of the slices will be gated to the heart's rhythm, allowing for stable, high-resolution images of the heart and lungs. The slice thickness will be 0.625 mm.

Software and a sophisticated workstation will allow the clinician to construct three-dimensional images of the heart, lungs, or aorta, and to manipulate three-dimensional and two-dimensional images in a variety of ways.

In addition to aortic dissection, pulmonary embolism, and coronary artery disease, the technique will allow clear views of the pericardium, permitting the diagnosis of calcified or thickened pericardium and sometimes pericarditis.

In addition, “you might pick up pneumonia, and you might pick up pulmonary adhesions or even pericardial adhesions,” Dr. Budoff said. “There are a lot of things you could possibly see. And it could be done during the chest pain episode, which is a great advantage over some of the other modalities where you'd want to wait until their chest pain is quiescent.”

Dr. Budoff described the case of an elderly woman who complained of chest pain and shortness of breath. Because of her age, he was reluctant to order a stress test. The CT angiography showed that her coronary arteries were normal and that her ejection fraction was acceptably high. When he examined the lung images closely, however, he discovered several pulmonary emboli.

“We admitted her to the hospital, put her on heparin, and it all cleared up,” he said.

Despite its promise, the triple rule out does have some limitations. For one thing, it subjects patients to a relatively high dose of radiation—in the neighborhood of 24–30 millisieverts, equivalent to 240–300 chest x-rays.

Because it's a gated study, more contrast must be used and the injection time is longer than for a standard CT. Some patients may have trouble holding their breath for 20–30 seconds.

Then there's the issue of who is going to read these images when a patient presents at 3 a.m. The radiologist staffing the emergency department may not be facile with cardiac CT angiography. Although the images could be transferred over data lines, the cardiologist is not likely to have a workstation with the proper software at home. In all likelihood, someone will have to come to the hospital to read the study.

Still, Dr. Budoff expects the triple rule out to become a routine test in the emergency department, a prospect he greets with mixed emotions.

“We really need to see how this is going to pan out, and work out the reading issues before we start applying this to everybody who comes in with a twinge in their chest or shortness of breath,” he said. “I'm a little leery … to say just because we can do it we should.”

Views of aortic dissection: Left, it is shown as a long, thin dissection flap in the descending aorta; right, the true lumen (larger area) and false lumen are shown endoscopically. Photos courtesy Dr. Matthew J. Budoff

SAN FRANCISCO — Chest pain represents one of the most common presenting symptoms in emergency departments, and it also represents a diagnostic challenge: Is it a pulmonary embolism? Is it an aortic dissection? Is it coronary artery disease? Or is it nothing?

Now, new CT technology promises to revolutionize this diagnosis, giving the ability to rule out all three conditions with a single 15-second scan.

In theory, this scan can replace stress testing for coronary artery disease, echocardiography or CT for aortic dissection, and CT pulmonary angiography or a ventilation-perfusion scan for pulmonary embolism, Matthew J. Budoff, M.D., said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

Although no diagnostic or prognostic studies on the triple rule out have yet been published, there's some indication that the single scan will have 90% accuracy or better for each of the three conditions, said Dr. Budoff of Harbor-UCLA Medical Center in Torrance, Calif.

The technology involves a 64-slice CT scan from the apex to the base of the lungs. Patients will have to hold their breath for 20–30 seconds as contrast is injected and the images are acquired. Acquisition of the slices will be gated to the heart's rhythm, allowing for stable, high-resolution images of the heart and lungs. The slice thickness will be 0.625 mm.

Software and a sophisticated workstation will allow the clinician to construct three-dimensional images of the heart, lungs, or aorta, and to manipulate three-dimensional and two-dimensional images in a variety of ways.

In addition to aortic dissection, pulmonary embolism, and coronary artery disease, the technique will allow clear views of the pericardium, permitting the diagnosis of calcified or thickened pericardium and sometimes pericarditis.

In addition, “you might pick up pneumonia, and you might pick up pulmonary adhesions or even pericardial adhesions,” Dr. Budoff said. “There are a lot of things you could possibly see. And it could be done during the chest pain episode, which is a great advantage over some of the other modalities where you'd want to wait until their chest pain is quiescent.”

Dr. Budoff described the case of an elderly woman who complained of chest pain and shortness of breath. Because of her age, he was reluctant to order a stress test. The CT angiography showed that her coronary arteries were normal and that her ejection fraction was acceptably high. When he examined the lung images closely, however, he discovered several pulmonary emboli.

“We admitted her to the hospital, put her on heparin, and it all cleared up,” he said.

Despite its promise, the triple rule out does have some limitations. For one thing, it subjects patients to a relatively high dose of radiation—in the neighborhood of 24–30 millisieverts, equivalent to 240–300 chest x-rays.

Because it's a gated study, more contrast must be used and the injection time is longer than for a standard CT. Some patients may have trouble holding their breath for 20–30 seconds.

Then there's the issue of who is going to read these images when a patient presents at 3 a.m. The radiologist staffing the emergency department may not be facile with cardiac CT angiography. Although the images could be transferred over data lines, the cardiologist is not likely to have a workstation with the proper software at home. In all likelihood, someone will have to come to the hospital to read the study.

Still, Dr. Budoff expects the triple rule out to become a routine test in the emergency department, a prospect he greets with mixed emotions.

“We really need to see how this is going to pan out, and work out the reading issues before we start applying this to everybody who comes in with a twinge in their chest or shortness of breath,” he said. “I'm a little leery … to say just because we can do it we should.”

Views of aortic dissection: Left, it is shown as a long, thin dissection flap in the descending aorta; right, the true lumen (larger area) and false lumen are shown endoscopically. Photos courtesy Dr. Matthew J. Budoff

A small outbreak of poliovirus infection has been reported among unvaccinated children in rural Minnesota. All cases to date have been linked to the live attentuated virus used in the oral polio vaccine, according to the Minnesota Department of Health and the Centers for Disease Control and Prevention.

Because oral poliovirus vaccine (OPV) is known to cause paralysis in about 1 in every 13 million doses, its use was discontinued in Canada in 1997 and in the United States in 2000. An injected inactivated polio vaccine (IPV) is used instead in accordance with recommendations by the CDC's Advisory Committee on Immunization Practices and the American Academy of Pediatrics Committee on Infectious Diseases. But other countries around the world continue to use OPV. Health workers presume that a person vaccinated with OPV in another country was the original source of the outbreak, according to the CDC report.

The five children reported to have poliovirus infection are members of a remote Amish community in central Minnesota. The Amish often decline to vaccinate their children. None of the children exhibited the flaccid paralysis that accompanies poliovirus infection in 1 of every 200 cases. The first four cases are described by the CDC (MMWR 2005;54:1053–5), and the fifth case was reported at press time.

The polio outbreak was discovered by chance on Sept. 29, 2005, during testing of a stool sample from a 7-month-old infant with severe combined immunodeficiency disease. Subsequent testing of other community members uncovered infections from the same viral strain in three unvaccinated siblings from an unrelated family and a fifth unvaccinated child from a third family. All three families are members of the same small Amish community, which includes about 200 members in 24 families.

Partial sequencing of the viral capsid identified it as a type 1 poliovirus derived from one of the three strains in the Sabin OPV. The viral sequence differed from the original vaccine strain by 2.3%. This vaccine is known to mutate at a rate of about 1% per year, suggesting it's been circulating for 2–3 years.

Although the source of the infection likely was someone who received OPV abroad, none of the infected children or their family members had a recent history of international travel or contact with foreigners, and the community has little association with outsiders.

Public health officials have been going door to door in the affected community offering vaccinations. IPV offers protection against the OPV-derived vaccine strain of polio. As of Oct. 14, 2005, fewer than 20 children in the affected community have been vaccinated against polio since this outbreak of disease.

A small outbreak of poliovirus infection has been reported among unvaccinated children in rural Minnesota. All cases to date have been linked to the live attentuated virus used in the oral polio vaccine, according to the Minnesota Department of Health and the Centers for Disease Control and Prevention.

Because oral poliovirus vaccine (OPV) is known to cause paralysis in about 1 in every 13 million doses, its use was discontinued in Canada in 1997 and in the United States in 2000. An injected inactivated polio vaccine (IPV) is used instead in accordance with recommendations by the CDC's Advisory Committee on Immunization Practices and the American Academy of Pediatrics Committee on Infectious Diseases. But other countries around the world continue to use OPV. Health workers presume that a person vaccinated with OPV in another country was the original source of the outbreak, according to the CDC report.

The five children reported to have poliovirus infection are members of a remote Amish community in central Minnesota. The Amish often decline to vaccinate their children. None of the children exhibited the flaccid paralysis that accompanies poliovirus infection in 1 of every 200 cases. The first four cases are described by the CDC (MMWR 2005;54:1053–5), and the fifth case was reported at press time.

The polio outbreak was discovered by chance on Sept. 29, 2005, during testing of a stool sample from a 7-month-old infant with severe combined immunodeficiency disease. Subsequent testing of other community members uncovered infections from the same viral strain in three unvaccinated siblings from an unrelated family and a fifth unvaccinated child from a third family. All three families are members of the same small Amish community, which includes about 200 members in 24 families.

Partial sequencing of the viral capsid identified it as a type 1 poliovirus derived from one of the three strains in the Sabin OPV. The viral sequence differed from the original vaccine strain by 2.3%. This vaccine is known to mutate at a rate of about 1% per year, suggesting it's been circulating for 2–3 years.

Although the source of the infection likely was someone who received OPV abroad, none of the infected children or their family members had a recent history of international travel or contact with foreigners, and the community has little association with outsiders.

Public health officials have been going door to door in the affected community offering vaccinations. IPV offers protection against the OPV-derived vaccine strain of polio. As of Oct. 14, 2005, fewer than 20 children in the affected community have been vaccinated against polio since this outbreak of disease.

A small outbreak of poliovirus infection has been reported among unvaccinated children in rural Minnesota. All cases to date have been linked to the live attentuated virus used in the oral polio vaccine, according to the Minnesota Department of Health and the Centers for Disease Control and Prevention.

Because oral poliovirus vaccine (OPV) is known to cause paralysis in about 1 in every 13 million doses, its use was discontinued in Canada in 1997 and in the United States in 2000. An injected inactivated polio vaccine (IPV) is used instead in accordance with recommendations by the CDC's Advisory Committee on Immunization Practices and the American Academy of Pediatrics Committee on Infectious Diseases. But other countries around the world continue to use OPV. Health workers presume that a person vaccinated with OPV in another country was the original source of the outbreak, according to the CDC report.

The five children reported to have poliovirus infection are members of a remote Amish community in central Minnesota. The Amish often decline to vaccinate their children. None of the children exhibited the flaccid paralysis that accompanies poliovirus infection in 1 of every 200 cases. The first four cases are described by the CDC (MMWR 2005;54:1053–5), and the fifth case was reported at press time.

The polio outbreak was discovered by chance on Sept. 29, 2005, during testing of a stool sample from a 7-month-old infant with severe combined immunodeficiency disease. Subsequent testing of other community members uncovered infections from the same viral strain in three unvaccinated siblings from an unrelated family and a fifth unvaccinated child from a third family. All three families are members of the same small Amish community, which includes about 200 members in 24 families.

Partial sequencing of the viral capsid identified it as a type 1 poliovirus derived from one of the three strains in the Sabin OPV. The viral sequence differed from the original vaccine strain by 2.3%. This vaccine is known to mutate at a rate of about 1% per year, suggesting it's been circulating for 2–3 years.

Although the source of the infection likely was someone who received OPV abroad, none of the infected children or their family members had a recent history of international travel or contact with foreigners, and the community has little association with outsiders.

Public health officials have been going door to door in the affected community offering vaccinations. IPV offers protection against the OPV-derived vaccine strain of polio. As of Oct. 14, 2005, fewer than 20 children in the affected community have been vaccinated against polio since this outbreak of disease.

BLAINE, WASH. — Pediatricians and family physicians need to be alert for the signs of global developmental delay in young children.

And when these signs are found they must be carefully followed up, Forrest C. Bennett, M.D., said at a conference sponsored by the North Pacific Pediatric Society.

Global developmental delay (GDD) refers to a constellation of delays in several areas, including motor, language, and cognitive skills, as well as in socioemotional development. Many of these children also have diffuse hypotonia as well.

“You can't find GDD in the DSM, but it is a term that most developmentalists, neurologists, and geneticists use,” said Dr. Bennett of the University of Washington (Seattle). “When you have low-tone kids and they present with development that's something like half their chronologic age in the first 3 years of life, that's a concerning presenting constellation.”

By the time these children reach school age, the most common ultimate diagnosis will be mental retardation. A smaller number of children will be diagnosed with autism spectrum disorders or pervasive developmental disorder. An even smaller number of children are able to close the gap, emerging with specific learning disorders. The least common outcome is a child who overcomes the delay entirely, returning to the normal developmental track.

“Parents ask, 'Doctor, have you ever seen a child like this turn out just fine?' And I try to look at them honestly and say, 'It's possible [but] I don't see it a lot,'” Dr. Bennett said.

Pediatricians have typically screened for GDD at well-child visits by using parental questionnaires such as the PDQ (Prescreening Development Questionnaire) and ASQ (Ages & Stages Questionnaire), but some child-development professionals say that screening isn't enough. They advocate a more in-depth process called developmental surveillance.

“[Developmental surveillance] means asking the right questions at the right times, knowing that some milestones are more important than others,” Dr. Bennett said. “It's really important to be sitting by 9 months, to have a pincer grasp by 12 months, to understand body parts at 18 months, … to put two words together at 2 years of age. In a busy office, some milestones are just more important and a little more relevant than others.”

In addition, “You don't think developmentally just at the well-child visit. You see the family in the parking lot at the grocery store [and] you can whip a few developmental questions in there.”

Developmental surveillance is not always practical, Dr. Bennett said. He admitted that he often forgets the milestones, even though he's raised three children of his own. And, in busy urban settings, it's not likely that physicians can count on running into their patients at the grocery store or anywhere else.

As a reminder to ask developmental questions, Dr. Bennett has placed a laminated poster on the wall of the exam room with developmental milestones based on the Denver II, an instrument intended to be used by professionals.

He also recommended having the parents complete the PDQ II, which consists of 10–12 age-appropriate questions and takes 4–5 minutes, or the ASQ, a 35-item questionnaire that takes 10–15 minutes. These can be mailed to the parents in advance of a well-child visit or handed to them in the waiting room. Many similar instruments exist, but most physicians use “home-grown” checklists, Dr. Bennett said.

This screening is just a first step if any red flags present themselves. “Screening does not make you a psychologist,” Dr. Bennett said. “It should be just like when we find an abdominal mass unexpectedly. That triggers a whole bunch more questions, a much more careful physical exam, you probably order some laboratory [tests], and then perhaps you refer to subspecialists.”

Assess the child's growth, health, vision, hearing, and medications in terms of their impact on development and behavior. Search for contributing factors to the problem by characterizing its nature, its timing, and whether it seems to be static or progressive.

Dr. Bennett finds that asking parents, “When did you first worry,” yields some good information. “Unless they bring in the baby book, a lot of parents don't remember exactly when the child sat, crawled, pulled up, stood alone,” he said. “But most parents in my experience are pretty good at remembering when they first got the sick feeling in their gut that something wasn't quite right about this kid.”

For example, they may have noticed that in utero, the child didn't move as much as their other children; or in the nursery they may have had to wake the child to feed; or at 8 weeks of age, they couldn't get a responsive smile.

In most cases, the child's developmental delay will be static, but the physician should pay particularly close attention if it appears to be progressive. Children with GDD reach their milestones slowly, but they should not be losing any milestones. If they do, think about a missed phenylketonuria diagnosis or similar disorders.

During the physical exam, look closely for dysmorphic features. Most normal individuals will have three or four dysmorphologies, but children who have five or more may have a brain disorder.

Make sure also that the developmental delay isn't caused by a chronic organ-system problem, such as occult renal disease, and consider genetic causes as well.

Dr. Bennett recommended all children with developmental delay get a high-resolution banded karyotype, a DNA test for fragile X syndrome, and a urine metabolic screen.

An MRI may be indicated in some children, although these often come back with a nondescript finding such as “cerebral dysgenesis,” he said.

And an EEG, while not routine, should be considered for any child in whom there is a high index of suspicion for atypical seizures.

BLAINE, WASH. — Pediatricians and family physicians need to be alert for the signs of global developmental delay in young children.

And when these signs are found they must be carefully followed up, Forrest C. Bennett, M.D., said at a conference sponsored by the North Pacific Pediatric Society.

Global developmental delay (GDD) refers to a constellation of delays in several areas, including motor, language, and cognitive skills, as well as in socioemotional development. Many of these children also have diffuse hypotonia as well.

“You can't find GDD in the DSM, but it is a term that most developmentalists, neurologists, and geneticists use,” said Dr. Bennett of the University of Washington (Seattle). “When you have low-tone kids and they present with development that's something like half their chronologic age in the first 3 years of life, that's a concerning presenting constellation.”

By the time these children reach school age, the most common ultimate diagnosis will be mental retardation. A smaller number of children will be diagnosed with autism spectrum disorders or pervasive developmental disorder. An even smaller number of children are able to close the gap, emerging with specific learning disorders. The least common outcome is a child who overcomes the delay entirely, returning to the normal developmental track.

“Parents ask, 'Doctor, have you ever seen a child like this turn out just fine?' And I try to look at them honestly and say, 'It's possible [but] I don't see it a lot,'” Dr. Bennett said.

Pediatricians have typically screened for GDD at well-child visits by using parental questionnaires such as the PDQ (Prescreening Development Questionnaire) and ASQ (Ages & Stages Questionnaire), but some child-development professionals say that screening isn't enough. They advocate a more in-depth process called developmental surveillance.

“[Developmental surveillance] means asking the right questions at the right times, knowing that some milestones are more important than others,” Dr. Bennett said. “It's really important to be sitting by 9 months, to have a pincer grasp by 12 months, to understand body parts at 18 months, … to put two words together at 2 years of age. In a busy office, some milestones are just more important and a little more relevant than others.”

In addition, “You don't think developmentally just at the well-child visit. You see the family in the parking lot at the grocery store [and] you can whip a few developmental questions in there.”

Developmental surveillance is not always practical, Dr. Bennett said. He admitted that he often forgets the milestones, even though he's raised three children of his own. And, in busy urban settings, it's not likely that physicians can count on running into their patients at the grocery store or anywhere else.

As a reminder to ask developmental questions, Dr. Bennett has placed a laminated poster on the wall of the exam room with developmental milestones based on the Denver II, an instrument intended to be used by professionals.

He also recommended having the parents complete the PDQ II, which consists of 10–12 age-appropriate questions and takes 4–5 minutes, or the ASQ, a 35-item questionnaire that takes 10–15 minutes. These can be mailed to the parents in advance of a well-child visit or handed to them in the waiting room. Many similar instruments exist, but most physicians use “home-grown” checklists, Dr. Bennett said.

This screening is just a first step if any red flags present themselves. “Screening does not make you a psychologist,” Dr. Bennett said. “It should be just like when we find an abdominal mass unexpectedly. That triggers a whole bunch more questions, a much more careful physical exam, you probably order some laboratory [tests], and then perhaps you refer to subspecialists.”

Assess the child's growth, health, vision, hearing, and medications in terms of their impact on development and behavior. Search for contributing factors to the problem by characterizing its nature, its timing, and whether it seems to be static or progressive.

Dr. Bennett finds that asking parents, “When did you first worry,” yields some good information. “Unless they bring in the baby book, a lot of parents don't remember exactly when the child sat, crawled, pulled up, stood alone,” he said. “But most parents in my experience are pretty good at remembering when they first got the sick feeling in their gut that something wasn't quite right about this kid.”

For example, they may have noticed that in utero, the child didn't move as much as their other children; or in the nursery they may have had to wake the child to feed; or at 8 weeks of age, they couldn't get a responsive smile.

In most cases, the child's developmental delay will be static, but the physician should pay particularly close attention if it appears to be progressive. Children with GDD reach their milestones slowly, but they should not be losing any milestones. If they do, think about a missed phenylketonuria diagnosis or similar disorders.

During the physical exam, look closely for dysmorphic features. Most normal individuals will have three or four dysmorphologies, but children who have five or more may have a brain disorder.

Make sure also that the developmental delay isn't caused by a chronic organ-system problem, such as occult renal disease, and consider genetic causes as well.

Dr. Bennett recommended all children with developmental delay get a high-resolution banded karyotype, a DNA test for fragile X syndrome, and a urine metabolic screen.

An MRI may be indicated in some children, although these often come back with a nondescript finding such as “cerebral dysgenesis,” he said.

And an EEG, while not routine, should be considered for any child in whom there is a high index of suspicion for atypical seizures.

BLAINE, WASH. — Pediatricians and family physicians need to be alert for the signs of global developmental delay in young children.

And when these signs are found they must be carefully followed up, Forrest C. Bennett, M.D., said at a conference sponsored by the North Pacific Pediatric Society.

Global developmental delay (GDD) refers to a constellation of delays in several areas, including motor, language, and cognitive skills, as well as in socioemotional development. Many of these children also have diffuse hypotonia as well.

“You can't find GDD in the DSM, but it is a term that most developmentalists, neurologists, and geneticists use,” said Dr. Bennett of the University of Washington (Seattle). “When you have low-tone kids and they present with development that's something like half their chronologic age in the first 3 years of life, that's a concerning presenting constellation.”

By the time these children reach school age, the most common ultimate diagnosis will be mental retardation. A smaller number of children will be diagnosed with autism spectrum disorders or pervasive developmental disorder. An even smaller number of children are able to close the gap, emerging with specific learning disorders. The least common outcome is a child who overcomes the delay entirely, returning to the normal developmental track.

“Parents ask, 'Doctor, have you ever seen a child like this turn out just fine?' And I try to look at them honestly and say, 'It's possible [but] I don't see it a lot,'” Dr. Bennett said.

Pediatricians have typically screened for GDD at well-child visits by using parental questionnaires such as the PDQ (Prescreening Development Questionnaire) and ASQ (Ages & Stages Questionnaire), but some child-development professionals say that screening isn't enough. They advocate a more in-depth process called developmental surveillance.

“[Developmental surveillance] means asking the right questions at the right times, knowing that some milestones are more important than others,” Dr. Bennett said. “It's really important to be sitting by 9 months, to have a pincer grasp by 12 months, to understand body parts at 18 months, … to put two words together at 2 years of age. In a busy office, some milestones are just more important and a little more relevant than others.”

In addition, “You don't think developmentally just at the well-child visit. You see the family in the parking lot at the grocery store [and] you can whip a few developmental questions in there.”

Developmental surveillance is not always practical, Dr. Bennett said. He admitted that he often forgets the milestones, even though he's raised three children of his own. And, in busy urban settings, it's not likely that physicians can count on running into their patients at the grocery store or anywhere else.

As a reminder to ask developmental questions, Dr. Bennett has placed a laminated poster on the wall of the exam room with developmental milestones based on the Denver II, an instrument intended to be used by professionals.

He also recommended having the parents complete the PDQ II, which consists of 10–12 age-appropriate questions and takes 4–5 minutes, or the ASQ, a 35-item questionnaire that takes 10–15 minutes. These can be mailed to the parents in advance of a well-child visit or handed to them in the waiting room. Many similar instruments exist, but most physicians use “home-grown” checklists, Dr. Bennett said.

This screening is just a first step if any red flags present themselves. “Screening does not make you a psychologist,” Dr. Bennett said. “It should be just like when we find an abdominal mass unexpectedly. That triggers a whole bunch more questions, a much more careful physical exam, you probably order some laboratory [tests], and then perhaps you refer to subspecialists.”

Assess the child's growth, health, vision, hearing, and medications in terms of their impact on development and behavior. Search for contributing factors to the problem by characterizing its nature, its timing, and whether it seems to be static or progressive.

Dr. Bennett finds that asking parents, “When did you first worry,” yields some good information. “Unless they bring in the baby book, a lot of parents don't remember exactly when the child sat, crawled, pulled up, stood alone,” he said. “But most parents in my experience are pretty good at remembering when they first got the sick feeling in their gut that something wasn't quite right about this kid.”

For example, they may have noticed that in utero, the child didn't move as much as their other children; or in the nursery they may have had to wake the child to feed; or at 8 weeks of age, they couldn't get a responsive smile.

In most cases, the child's developmental delay will be static, but the physician should pay particularly close attention if it appears to be progressive. Children with GDD reach their milestones slowly, but they should not be losing any milestones. If they do, think about a missed phenylketonuria diagnosis or similar disorders.

During the physical exam, look closely for dysmorphic features. Most normal individuals will have three or four dysmorphologies, but children who have five or more may have a brain disorder.

Make sure also that the developmental delay isn't caused by a chronic organ-system problem, such as occult renal disease, and consider genetic causes as well.

Dr. Bennett recommended all children with developmental delay get a high-resolution banded karyotype, a DNA test for fragile X syndrome, and a urine metabolic screen.

An MRI may be indicated in some children, although these often come back with a nondescript finding such as “cerebral dysgenesis,” he said.

And an EEG, while not routine, should be considered for any child in whom there is a high index of suspicion for atypical seizures.

The number of young adults, aged 20–44 years, receiving prescriptions for adult attention-deficit hyperactivity disorder has more than doubled in just 4 years, according to an analysis by Medco Health Solutions Inc.

And the increase in prescriptions for adult ADHD is likely to continue, predicted Lon Castle, M.D., director of medical policy and programs for Medco.

The analysis, based on a random sample of 2.4 million patients from the company's 60 million member database, showed that just over 1% of all adults were on ADHD medications in 2004, compared with 0.5% in 2000.

Medco is in the business of managing prescription drug benefit programs for public and private employers, health plans, labor unions, and government agencies.

The ADHD analysis, part of the company's annual Drug Trend Analysis, was highlighted on Sept. 15, 2005, at Medco's Best Practices Workshop in Chicago.

Dr. Castle pointed to recent epidemiologic studies indicating that about 4.4% of the adult population have ADHD, but only about 20% of these people have been properly diagnosed.

Increased awareness of adult ADHD among the medical community and the general population is likely to result in further increases in prescription rates.

In addition to the overall increase in adult ADHD prescriptions, the study uncovered several other interesting facts. For example, the use of ADHD medication increased 44% faster among women aged 20–44 years than it did among men in the same age group.

Furthermore, the most recent data show that in 2004, women aged 20–64 years used ADHD medications just as frequently as did men in the same age group. This is noteworthy, because in the pediatric population about twice as many boys as girls use ADHD medication.

“[This finding is] consistent with the science, in that more women relative to men present in adulthood,” said Lenard Adler, M.D., director of the adult ADHD program at New York University, in an interview.

“Women tend to have more inattentive symptoms in general, and therefore, they have more trouble with daydreaming and distraction and organization and planning, rather than being more frankly hyperactive and disruptive [as are boys],” Dr. Alder said.

In 2004, nearly 78% of all adult ADHD prescriptions were for brand-name medications, a 30% increase since 2000 in the use of brands.

“Usually, we're talking about people switching to generic drugs,” Dr. Castle said in an interview. “We see the switch in this category to brand name drugs, which are going to be more expensive.”

He attributed this unusual pattern to the fact that adults are more likely to take the newer, extended-release ADHD medications, which have not yet gone off patent.

This is likely to change later this year and early in 2006, when Concerta (extended-release methylphenidate HCl) and Adderall XR (an extended-release mixture of several amphetamines) are both scheduled to lose their patent protection.

Dr. Adler cautioned that the increase in adult ADHD prescribing is positive, but still insufficient, because such a large percentage of adults with the disorder remain undiagnosed and untreated.

“The consequences of not getting it treated are really significant,” he said. “We know that adults with ADHD are more likely to be unemployed or underemployed. We know they're more likely to be divorced or separated. They're more likely to smoke. If untreated, they're more likely to use substances. They're more likely to have motor vehicle accidents.” And he referred to a recent study showing that the annual lost household income from ADHD is about $77 billion.

Some skeptics contend that adult ADHD is not a real disorder, but Dr. Castle said the evidence suggests otherwise. “The medical community and our health agencies in the government are also recognizing that this is real and that we're just seeing the tip of the iceberg. We're kind of sounding a warning.

“Rather than burying their heads in the sand, it might be better for the managed care companies to really take a critical look at this and do some planning.”

The number of young adults, aged 20–44 years, receiving prescriptions for adult attention-deficit hyperactivity disorder has more than doubled in just 4 years, according to an analysis by Medco Health Solutions Inc.

And the increase in prescriptions for adult ADHD is likely to continue, predicted Lon Castle, M.D., director of medical policy and programs for Medco.

The analysis, based on a random sample of 2.4 million patients from the company's 60 million member database, showed that just over 1% of all adults were on ADHD medications in 2004, compared with 0.5% in 2000.

Medco is in the business of managing prescription drug benefit programs for public and private employers, health plans, labor unions, and government agencies.

The ADHD analysis, part of the company's annual Drug Trend Analysis, was highlighted on Sept. 15, 2005, at Medco's Best Practices Workshop in Chicago.

Dr. Castle pointed to recent epidemiologic studies indicating that about 4.4% of the adult population have ADHD, but only about 20% of these people have been properly diagnosed.

Increased awareness of adult ADHD among the medical community and the general population is likely to result in further increases in prescription rates.

In addition to the overall increase in adult ADHD prescriptions, the study uncovered several other interesting facts. For example, the use of ADHD medication increased 44% faster among women aged 20–44 years than it did among men in the same age group.

Furthermore, the most recent data show that in 2004, women aged 20–64 years used ADHD medications just as frequently as did men in the same age group. This is noteworthy, because in the pediatric population about twice as many boys as girls use ADHD medication.

“[This finding is] consistent with the science, in that more women relative to men present in adulthood,” said Lenard Adler, M.D., director of the adult ADHD program at New York University, in an interview.

“Women tend to have more inattentive symptoms in general, and therefore, they have more trouble with daydreaming and distraction and organization and planning, rather than being more frankly hyperactive and disruptive [as are boys],” Dr. Alder said.

In 2004, nearly 78% of all adult ADHD prescriptions were for brand-name medications, a 30% increase since 2000 in the use of brands.

“Usually, we're talking about people switching to generic drugs,” Dr. Castle said in an interview. “We see the switch in this category to brand name drugs, which are going to be more expensive.”

He attributed this unusual pattern to the fact that adults are more likely to take the newer, extended-release ADHD medications, which have not yet gone off patent.

This is likely to change later this year and early in 2006, when Concerta (extended-release methylphenidate HCl) and Adderall XR (an extended-release mixture of several amphetamines) are both scheduled to lose their patent protection.

Dr. Adler cautioned that the increase in adult ADHD prescribing is positive, but still insufficient, because such a large percentage of adults with the disorder remain undiagnosed and untreated.

“The consequences of not getting it treated are really significant,” he said. “We know that adults with ADHD are more likely to be unemployed or underemployed. We know they're more likely to be divorced or separated. They're more likely to smoke. If untreated, they're more likely to use substances. They're more likely to have motor vehicle accidents.” And he referred to a recent study showing that the annual lost household income from ADHD is about $77 billion.

Some skeptics contend that adult ADHD is not a real disorder, but Dr. Castle said the evidence suggests otherwise. “The medical community and our health agencies in the government are also recognizing that this is real and that we're just seeing the tip of the iceberg. We're kind of sounding a warning.

“Rather than burying their heads in the sand, it might be better for the managed care companies to really take a critical look at this and do some planning.”

The number of young adults, aged 20–44 years, receiving prescriptions for adult attention-deficit hyperactivity disorder has more than doubled in just 4 years, according to an analysis by Medco Health Solutions Inc.

And the increase in prescriptions for adult ADHD is likely to continue, predicted Lon Castle, M.D., director of medical policy and programs for Medco.

The analysis, based on a random sample of 2.4 million patients from the company's 60 million member database, showed that just over 1% of all adults were on ADHD medications in 2004, compared with 0.5% in 2000.

Medco is in the business of managing prescription drug benefit programs for public and private employers, health plans, labor unions, and government agencies.

The ADHD analysis, part of the company's annual Drug Trend Analysis, was highlighted on Sept. 15, 2005, at Medco's Best Practices Workshop in Chicago.

Dr. Castle pointed to recent epidemiologic studies indicating that about 4.4% of the adult population have ADHD, but only about 20% of these people have been properly diagnosed.

Increased awareness of adult ADHD among the medical community and the general population is likely to result in further increases in prescription rates.

In addition to the overall increase in adult ADHD prescriptions, the study uncovered several other interesting facts. For example, the use of ADHD medication increased 44% faster among women aged 20–44 years than it did among men in the same age group.

Furthermore, the most recent data show that in 2004, women aged 20–64 years used ADHD medications just as frequently as did men in the same age group. This is noteworthy, because in the pediatric population about twice as many boys as girls use ADHD medication.

“[This finding is] consistent with the science, in that more women relative to men present in adulthood,” said Lenard Adler, M.D., director of the adult ADHD program at New York University, in an interview.

“Women tend to have more inattentive symptoms in general, and therefore, they have more trouble with daydreaming and distraction and organization and planning, rather than being more frankly hyperactive and disruptive [as are boys],” Dr. Alder said.

In 2004, nearly 78% of all adult ADHD prescriptions were for brand-name medications, a 30% increase since 2000 in the use of brands.

“Usually, we're talking about people switching to generic drugs,” Dr. Castle said in an interview. “We see the switch in this category to brand name drugs, which are going to be more expensive.”

He attributed this unusual pattern to the fact that adults are more likely to take the newer, extended-release ADHD medications, which have not yet gone off patent.

This is likely to change later this year and early in 2006, when Concerta (extended-release methylphenidate HCl) and Adderall XR (an extended-release mixture of several amphetamines) are both scheduled to lose their patent protection.

Dr. Adler cautioned that the increase in adult ADHD prescribing is positive, but still insufficient, because such a large percentage of adults with the disorder remain undiagnosed and untreated.

“The consequences of not getting it treated are really significant,” he said. “We know that adults with ADHD are more likely to be unemployed or underemployed. We know they're more likely to be divorced or separated. They're more likely to smoke. If untreated, they're more likely to use substances. They're more likely to have motor vehicle accidents.” And he referred to a recent study showing that the annual lost household income from ADHD is about $77 billion.

Some skeptics contend that adult ADHD is not a real disorder, but Dr. Castle said the evidence suggests otherwise. “The medical community and our health agencies in the government are also recognizing that this is real and that we're just seeing the tip of the iceberg. We're kind of sounding a warning.

“Rather than burying their heads in the sand, it might be better for the managed care companies to really take a critical look at this and do some planning.”

BLAINE, WASH. — Skin disorders such as dermatitis can be vexing to parents and children alike, often out of proportion to their seriousness, Marvin J. Scotvold, M.D., said at a conference sponsored by the North Pacific Pediatric Society.

In other instances, “I've had pediatric patients and adult patients with severe internal medical problems, but they're really concerned about that spot on their skin, which is pretty benign,” said Dr. Scotvold of the University of Washington in Seattle.

He offered a number of pearls for diagnosing and treating dermatitis:

▸ Acute dermatitis is wet, and chronic dermatitis is dry. In both cases, the skin will be red, it will itch or burn, and it's often infected. In acute dermatitis, the primary pathology in acute dermatitis is in the epidermis, and you'll see vesicles, bullae, edema, oozing, and weeping. In chronic dermatitis, the primary pathology is located in deeper skin layers. The skin will be lichenified, scaled, excoriated, and thickened, and may have accentuated skin markings.

▸ Healing from acute or chronic dermatitis usually takes a minimum of 2–8 weeks, depending on the severity and how long it has been present. Most physicians and patients fail in treating dermatitis by treating only until the skin heals. Despite being healed, that skin remains quite sensitive, and it takes very little to irritate it again. The skin takes a minimum of 6–24 months to lose that irritation, to toughen up, and to become resistant, and it should be protected for at least that long.

▸ Treat the redness, treat the burning and itching, eliminate the infection, remove the wetness, prevent the dryness, and keep the skin covered when treating dermatitis.

▸ None of that will help much unless the patient avoids continued irritation. As dermatitis is healing, the physician should give patients a list of don'ts, including: don't expose the skin, don't scratch, don't use hot water, don't use soap with harsh chemicals, and avoid dirt, grime, salt, friction, rubbing, and chafing near the affected area.

▸ Intermittent compresses work well for acute dermatitis. Use a porous material, such as a worn-out cotton T-shirt. Apply it to the skin, and leave it open to the air. That produces evaporation, which dries the wetness, cuts down on edema, and also cools, relieving the itchiness.

▸ Apply topical corticosteroids very sparingly but very frequently, four to six times a day. Since the epidermis maintains a certain reservoir of drug, it is not necessary to set the alarm clock for midnight and 4 a.m. “I find that if I tell patients to put it on six times a day, they'll probably get it on three or four,” Dr. Scotvold said. “If I tell them to put it on four times a day, they're going to get it on two or maybe three. If I tell them to put it on morning and night, they may get it on in the morning.”

▸ Tell patients to keep the topical corticosteroid in the refrigerator and apply it cold. When you put something cold on the skin it's more soothing.

▸ Continue topical corticosteroids until the redness is gone, not just the itchiness.

▸ Often, patients don't use their medication long enough, then return to the office saying it doesn't work, because every time they quit using it the dermatitis comes back. Dr. Scotvold's reply? “Well I guess my razor doesn't work, because every time I stop using it my whiskers return.”

▸ The greasier an emollient, the better it is at softening and keeping the skin moisturized. A similar principle applies when choosing what form of a topical corticosteroid to use. A lotion of 0.1% triamcinolone is at the lower end of the potency scale. A cream of 0.1% triamcinolone is a level of potency higher than the lotion, and in an ointment it is still more potent.

▸ Tell patients to treat their skin like they treat the dishes. You put dirty dishes into hot soapy water; you don't put clean dishes in the dishwasher. The same thing goes for people. Have you been rolling in the mud or yanking out transmissions? Probably not. People who wear clothing generally need soap regularly only on the scalp, in the armpits, and in the groin.

BLAINE, WASH. — Skin disorders such as dermatitis can be vexing to parents and children alike, often out of proportion to their seriousness, Marvin J. Scotvold, M.D., said at a conference sponsored by the North Pacific Pediatric Society.

In other instances, “I've had pediatric patients and adult patients with severe internal medical problems, but they're really concerned about that spot on their skin, which is pretty benign,” said Dr. Scotvold of the University of Washington in Seattle.

He offered a number of pearls for diagnosing and treating dermatitis:

▸ Acute dermatitis is wet, and chronic dermatitis is dry. In both cases, the skin will be red, it will itch or burn, and it's often infected. In acute dermatitis, the primary pathology in acute dermatitis is in the epidermis, and you'll see vesicles, bullae, edema, oozing, and weeping. In chronic dermatitis, the primary pathology is located in deeper skin layers. The skin will be lichenified, scaled, excoriated, and thickened, and may have accentuated skin markings.

▸ Healing from acute or chronic dermatitis usually takes a minimum of 2–8 weeks, depending on the severity and how long it has been present. Most physicians and patients fail in treating dermatitis by treating only until the skin heals. Despite being healed, that skin remains quite sensitive, and it takes very little to irritate it again. The skin takes a minimum of 6–24 months to lose that irritation, to toughen up, and to become resistant, and it should be protected for at least that long.

▸ Treat the redness, treat the burning and itching, eliminate the infection, remove the wetness, prevent the dryness, and keep the skin covered when treating dermatitis.

▸ None of that will help much unless the patient avoids continued irritation. As dermatitis is healing, the physician should give patients a list of don'ts, including: don't expose the skin, don't scratch, don't use hot water, don't use soap with harsh chemicals, and avoid dirt, grime, salt, friction, rubbing, and chafing near the affected area.

▸ Intermittent compresses work well for acute dermatitis. Use a porous material, such as a worn-out cotton T-shirt. Apply it to the skin, and leave it open to the air. That produces evaporation, which dries the wetness, cuts down on edema, and also cools, relieving the itchiness.

▸ Apply topical corticosteroids very sparingly but very frequently, four to six times a day. Since the epidermis maintains a certain reservoir of drug, it is not necessary to set the alarm clock for midnight and 4 a.m. “I find that if I tell patients to put it on six times a day, they'll probably get it on three or four,” Dr. Scotvold said. “If I tell them to put it on four times a day, they're going to get it on two or maybe three. If I tell them to put it on morning and night, they may get it on in the morning.”

▸ Tell patients to keep the topical corticosteroid in the refrigerator and apply it cold. When you put something cold on the skin it's more soothing.

▸ Continue topical corticosteroids until the redness is gone, not just the itchiness.

▸ Often, patients don't use their medication long enough, then return to the office saying it doesn't work, because every time they quit using it the dermatitis comes back. Dr. Scotvold's reply? “Well I guess my razor doesn't work, because every time I stop using it my whiskers return.”

▸ The greasier an emollient, the better it is at softening and keeping the skin moisturized. A similar principle applies when choosing what form of a topical corticosteroid to use. A lotion of 0.1% triamcinolone is at the lower end of the potency scale. A cream of 0.1% triamcinolone is a level of potency higher than the lotion, and in an ointment it is still more potent.

▸ Tell patients to treat their skin like they treat the dishes. You put dirty dishes into hot soapy water; you don't put clean dishes in the dishwasher. The same thing goes for people. Have you been rolling in the mud or yanking out transmissions? Probably not. People who wear clothing generally need soap regularly only on the scalp, in the armpits, and in the groin.

BLAINE, WASH. — Skin disorders such as dermatitis can be vexing to parents and children alike, often out of proportion to their seriousness, Marvin J. Scotvold, M.D., said at a conference sponsored by the North Pacific Pediatric Society.

In other instances, “I've had pediatric patients and adult patients with severe internal medical problems, but they're really concerned about that spot on their skin, which is pretty benign,” said Dr. Scotvold of the University of Washington in Seattle.

He offered a number of pearls for diagnosing and treating dermatitis:

▸ Acute dermatitis is wet, and chronic dermatitis is dry. In both cases, the skin will be red, it will itch or burn, and it's often infected. In acute dermatitis, the primary pathology in acute dermatitis is in the epidermis, and you'll see vesicles, bullae, edema, oozing, and weeping. In chronic dermatitis, the primary pathology is located in deeper skin layers. The skin will be lichenified, scaled, excoriated, and thickened, and may have accentuated skin markings.

▸ Healing from acute or chronic dermatitis usually takes a minimum of 2–8 weeks, depending on the severity and how long it has been present. Most physicians and patients fail in treating dermatitis by treating only until the skin heals. Despite being healed, that skin remains quite sensitive, and it takes very little to irritate it again. The skin takes a minimum of 6–24 months to lose that irritation, to toughen up, and to become resistant, and it should be protected for at least that long.

▸ Treat the redness, treat the burning and itching, eliminate the infection, remove the wetness, prevent the dryness, and keep the skin covered when treating dermatitis.

▸ None of that will help much unless the patient avoids continued irritation. As dermatitis is healing, the physician should give patients a list of don'ts, including: don't expose the skin, don't scratch, don't use hot water, don't use soap with harsh chemicals, and avoid dirt, grime, salt, friction, rubbing, and chafing near the affected area.

▸ Intermittent compresses work well for acute dermatitis. Use a porous material, such as a worn-out cotton T-shirt. Apply it to the skin, and leave it open to the air. That produces evaporation, which dries the wetness, cuts down on edema, and also cools, relieving the itchiness.

▸ Apply topical corticosteroids very sparingly but very frequently, four to six times a day. Since the epidermis maintains a certain reservoir of drug, it is not necessary to set the alarm clock for midnight and 4 a.m. “I find that if I tell patients to put it on six times a day, they'll probably get it on three or four,” Dr. Scotvold said. “If I tell them to put it on four times a day, they're going to get it on two or maybe three. If I tell them to put it on morning and night, they may get it on in the morning.”

▸ Tell patients to keep the topical corticosteroid in the refrigerator and apply it cold. When you put something cold on the skin it's more soothing.

▸ Continue topical corticosteroids until the redness is gone, not just the itchiness.

▸ Often, patients don't use their medication long enough, then return to the office saying it doesn't work, because every time they quit using it the dermatitis comes back. Dr. Scotvold's reply? “Well I guess my razor doesn't work, because every time I stop using it my whiskers return.”

▸ The greasier an emollient, the better it is at softening and keeping the skin moisturized. A similar principle applies when choosing what form of a topical corticosteroid to use. A lotion of 0.1% triamcinolone is at the lower end of the potency scale. A cream of 0.1% triamcinolone is a level of potency higher than the lotion, and in an ointment it is still more potent.

▸ Tell patients to treat their skin like they treat the dishes. You put dirty dishes into hot soapy water; you don't put clean dishes in the dishwasher. The same thing goes for people. Have you been rolling in the mud or yanking out transmissions? Probably not. People who wear clothing generally need soap regularly only on the scalp, in the armpits, and in the groin.

SAN FRANCISCO — Chest pain represents one of the most common presenting symptoms in an emergent situation, and it also represents a diagnostic challenge: Is it a pulmonary embolism? Is it an aortic dissection? Is it coronary artery disease? Or is it nothing?

Now, new CT technology promises to revolutionize this diagnosis, giving the ability to rule out all three conditions with a single 15-second scan.

In theory, this scan can replace stress testing for coronary artery disease, echocardiography or CT for aortic dissection, and CT pulmonary angiography or a ventilation-perfusion scan for pulmonary embolism, Matthew J. Budoff, M.D., said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

Although no diagnostic or prognostic studies on the triple rule out have yet been published, there's some indication that the single scan will have 90% accuracy or better for each of the three conditions, said Dr. Budoff of Harbor-UCLA Medical Center in Torrance, Calif.

The technology involves a 64-slice CT scan from the apex to the base of the lungs. Patients will have to hold their breath for 20–30 seconds as contrast is injected and the images are acquired. Acquisition of the slices will be gated to the heart's rhythm, allowing for stable, high-resolution images of the heart and lungs. The slice thickness will be 0.625 mm.

Software and a sophisticated workstation will allow the clinician to construct three-dimensional images of the heart, lungs, or aorta, and to manipulate three-dimensional and two-dimensional images in a variety of ways.

In addition to aortic dissection, pulmonary embolism, and coronary artery disease, the technique will allow clear views of the pericardium, permitting the diagnosis of calcified or thickened pericardium and sometimes pericarditis.

In addition, “you might pick up pneumonia, and you might pick up pulmonary adhesions or even pericardial adhesions,” Dr. Budoff said. “There are a lot of things you could possibly see. And it could be done during the chest pain episode, which is a great advantage over some of the other modalities where you'd want to wait until their chest pain is quiescent.”

Dr. Budoff described the case of an elderly woman who complained of chest pain and shortness of breath. Because of her age, he was reluctant to order a stress test. The CT angiography showed that her coronary arteries were normal and that her ejection fraction was acceptably high. When he examined the lung images closely, however, he discovered several pulmonary emboli.

“We admitted her to the hospital, put her on heparin, and it all cleared up,” he said.

Despite its promise, the triple rule out does have some limitations. For one thing, it subjects patients to a relatively high dose of radiation—in the neighborhood of 24–30 millisieverts, equivalent to 240–300 chest x-rays.

Because it's a gated study, more contrast must be used and the injection time is longer than for a standard CT. Some patients may have trouble holding their breath for 20–30 seconds.

Then there's the issue of who is going to read these images when a patient presents at 3 a.m. The radiologist staffing the emergency department may not be facile with cardiac CT angiography. Although the images could be transferred over data lines, the cardiologist is not likely to have an appropriate workstation at home. In all likelihood, someone will have to come to the hospital to read the study.

Still, Dr. Budoff expects the triple rule out to become a routine test in the emergency department, a prospect he greets with mixed emotions.

“We really need to see how this is going to pan out, and work out the reading issues before we start applying this to everybody who comes in with a twinge in their chest or shortness of breath,” he said. “I'm a little leery … to say just because we can do it we should.”

On left: An aortic dissection appears as a long, thin dissection flap in the descending aorta. In center: An endoscopic view of the aortic dissection shows the true lumen (larger area) and false lumen. On right: A high-grade stenosis is shown in the mid-left anterior descending artery. Photos courtesy Dr. Matthew J. Budoff

SAN FRANCISCO — Chest pain represents one of the most common presenting symptoms in an emergent situation, and it also represents a diagnostic challenge: Is it a pulmonary embolism? Is it an aortic dissection? Is it coronary artery disease? Or is it nothing?

Now, new CT technology promises to revolutionize this diagnosis, giving the ability to rule out all three conditions with a single 15-second scan.

In theory, this scan can replace stress testing for coronary artery disease, echocardiography or CT for aortic dissection, and CT pulmonary angiography or a ventilation-perfusion scan for pulmonary embolism, Matthew J. Budoff, M.D., said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

Although no diagnostic or prognostic studies on the triple rule out have yet been published, there's some indication that the single scan will have 90% accuracy or better for each of the three conditions, said Dr. Budoff of Harbor-UCLA Medical Center in Torrance, Calif.

The technology involves a 64-slice CT scan from the apex to the base of the lungs. Patients will have to hold their breath for 20–30 seconds as contrast is injected and the images are acquired. Acquisition of the slices will be gated to the heart's rhythm, allowing for stable, high-resolution images of the heart and lungs. The slice thickness will be 0.625 mm.

Software and a sophisticated workstation will allow the clinician to construct three-dimensional images of the heart, lungs, or aorta, and to manipulate three-dimensional and two-dimensional images in a variety of ways.

In addition to aortic dissection, pulmonary embolism, and coronary artery disease, the technique will allow clear views of the pericardium, permitting the diagnosis of calcified or thickened pericardium and sometimes pericarditis.

In addition, “you might pick up pneumonia, and you might pick up pulmonary adhesions or even pericardial adhesions,” Dr. Budoff said. “There are a lot of things you could possibly see. And it could be done during the chest pain episode, which is a great advantage over some of the other modalities where you'd want to wait until their chest pain is quiescent.”

Dr. Budoff described the case of an elderly woman who complained of chest pain and shortness of breath. Because of her age, he was reluctant to order a stress test. The CT angiography showed that her coronary arteries were normal and that her ejection fraction was acceptably high. When he examined the lung images closely, however, he discovered several pulmonary emboli.

“We admitted her to the hospital, put her on heparin, and it all cleared up,” he said.

Despite its promise, the triple rule out does have some limitations. For one thing, it subjects patients to a relatively high dose of radiation—in the neighborhood of 24–30 millisieverts, equivalent to 240–300 chest x-rays.

Because it's a gated study, more contrast must be used and the injection time is longer than for a standard CT. Some patients may have trouble holding their breath for 20–30 seconds.

Then there's the issue of who is going to read these images when a patient presents at 3 a.m. The radiologist staffing the emergency department may not be facile with cardiac CT angiography. Although the images could be transferred over data lines, the cardiologist is not likely to have an appropriate workstation at home. In all likelihood, someone will have to come to the hospital to read the study.

Still, Dr. Budoff expects the triple rule out to become a routine test in the emergency department, a prospect he greets with mixed emotions.

“We really need to see how this is going to pan out, and work out the reading issues before we start applying this to everybody who comes in with a twinge in their chest or shortness of breath,” he said. “I'm a little leery … to say just because we can do it we should.”

On left: An aortic dissection appears as a long, thin dissection flap in the descending aorta. In center: An endoscopic view of the aortic dissection shows the true lumen (larger area) and false lumen. On right: A high-grade stenosis is shown in the mid-left anterior descending artery. Photos courtesy Dr. Matthew J. Budoff

SAN FRANCISCO — Chest pain represents one of the most common presenting symptoms in an emergent situation, and it also represents a diagnostic challenge: Is it a pulmonary embolism? Is it an aortic dissection? Is it coronary artery disease? Or is it nothing?

Now, new CT technology promises to revolutionize this diagnosis, giving the ability to rule out all three conditions with a single 15-second scan.

In theory, this scan can replace stress testing for coronary artery disease, echocardiography or CT for aortic dissection, and CT pulmonary angiography or a ventilation-perfusion scan for pulmonary embolism, Matthew J. Budoff, M.D., said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

Although no diagnostic or prognostic studies on the triple rule out have yet been published, there's some indication that the single scan will have 90% accuracy or better for each of the three conditions, said Dr. Budoff of Harbor-UCLA Medical Center in Torrance, Calif.

The technology involves a 64-slice CT scan from the apex to the base of the lungs. Patients will have to hold their breath for 20–30 seconds as contrast is injected and the images are acquired. Acquisition of the slices will be gated to the heart's rhythm, allowing for stable, high-resolution images of the heart and lungs. The slice thickness will be 0.625 mm.

Software and a sophisticated workstation will allow the clinician to construct three-dimensional images of the heart, lungs, or aorta, and to manipulate three-dimensional and two-dimensional images in a variety of ways.

In addition to aortic dissection, pulmonary embolism, and coronary artery disease, the technique will allow clear views of the pericardium, permitting the diagnosis of calcified or thickened pericardium and sometimes pericarditis.

In addition, “you might pick up pneumonia, and you might pick up pulmonary adhesions or even pericardial adhesions,” Dr. Budoff said. “There are a lot of things you could possibly see. And it could be done during the chest pain episode, which is a great advantage over some of the other modalities where you'd want to wait until their chest pain is quiescent.”

Dr. Budoff described the case of an elderly woman who complained of chest pain and shortness of breath. Because of her age, he was reluctant to order a stress test. The CT angiography showed that her coronary arteries were normal and that her ejection fraction was acceptably high. When he examined the lung images closely, however, he discovered several pulmonary emboli.

“We admitted her to the hospital, put her on heparin, and it all cleared up,” he said.

Despite its promise, the triple rule out does have some limitations. For one thing, it subjects patients to a relatively high dose of radiation—in the neighborhood of 24–30 millisieverts, equivalent to 240–300 chest x-rays.

Because it's a gated study, more contrast must be used and the injection time is longer than for a standard CT. Some patients may have trouble holding their breath for 20–30 seconds.

Then there's the issue of who is going to read these images when a patient presents at 3 a.m. The radiologist staffing the emergency department may not be facile with cardiac CT angiography. Although the images could be transferred over data lines, the cardiologist is not likely to have an appropriate workstation at home. In all likelihood, someone will have to come to the hospital to read the study.

Still, Dr. Budoff expects the triple rule out to become a routine test in the emergency department, a prospect he greets with mixed emotions.

“We really need to see how this is going to pan out, and work out the reading issues before we start applying this to everybody who comes in with a twinge in their chest or shortness of breath,” he said. “I'm a little leery … to say just because we can do it we should.”

On left: An aortic dissection appears as a long, thin dissection flap in the descending aorta. In center: An endoscopic view of the aortic dissection shows the true lumen (larger area) and false lumen. On right: A high-grade stenosis is shown in the mid-left anterior descending artery. Photos courtesy Dr. Matthew J. Budoff

A large, head-to-head comparison of digital and film mammography found no overall difference in diagnostic accuracy, but digital mammography appears to have better diagnostic accuracy in some subgroups of women.

Digital mammography was significantly more accurate among women aged under 50 years, women with heterogeneously dense or extremely dense breasts, and premenopausal or perimenopausal women, according to the study by Etta D. Pisano, M.D., of the University of North Carolina at Chapel Hill, and colleagues.

The study involved a total of 49,528 women recruited over a 2-year period at 33 sites in North America. The final analysis included data from 42,760 women for whom the investigators had all relevant information (N. Engl. J. Med. 2005;353:[Epub ahead of print] doi 10.1056/NEJMoa052911, www.nejm.org

All women underwent both digital and film mammography, and these were independently interpreted by two readers. Readers rated the mammograms on a seven-point malignancy scale and used the classification of the Breast Imaging Reporting and Data System (BIRADS).

Biopsy or aspiration of the suspicious lesion was performed if either reader recommended it. These patients received follow-up mammograms an average of 455 days following their initial screening. A total of 335 cancers were detected among the women enrolled in the study.

Investigators used five digital mammography systems from four manufacturers. No statistically significant differences were found among the different mammography systems.

The investigators noted that the cancers detected by digital mammography but missed by film mammography included many invasive and high-grade in situ cases, precisely the lesions that must be detected to save lives.

The study found no advantage in the diagnostic accuracy of digital mammography for women aged 50 years and older, women with fatty breasts or scattered fibroglandular densities, and postmenopausal women.

But digital mammography has other advantages, the investigators noted. These include easier access to images and to computer-assisted diagnosis; improved means of image transmission, storage, and retrieval; and the use of a lower average dose of radiation without compromising diagnostic accuracy.

Conversely, the cost of digital mammography systems, which the investigators place at 1.5–4 times higher than film systems, provides a barrier to the universal use of this modality.

A large, head-to-head comparison of digital and film mammography found no overall difference in diagnostic accuracy, but digital mammography appears to have better diagnostic accuracy in some subgroups of women.

Digital mammography was significantly more accurate among women aged under 50 years, women with heterogeneously dense or extremely dense breasts, and premenopausal or perimenopausal women, according to the study by Etta D. Pisano, M.D., of the University of North Carolina at Chapel Hill, and colleagues.

The study involved a total of 49,528 women recruited over a 2-year period at 33 sites in North America. The final analysis included data from 42,760 women for whom the investigators had all relevant information (N. Engl. J. Med. 2005;353:[Epub ahead of print] doi 10.1056/NEJMoa052911, www.nejm.org

All women underwent both digital and film mammography, and these were independently interpreted by two readers. Readers rated the mammograms on a seven-point malignancy scale and used the classification of the Breast Imaging Reporting and Data System (BIRADS).

Biopsy or aspiration of the suspicious lesion was performed if either reader recommended it. These patients received follow-up mammograms an average of 455 days following their initial screening. A total of 335 cancers were detected among the women enrolled in the study.

Investigators used five digital mammography systems from four manufacturers. No statistically significant differences were found among the different mammography systems.

The investigators noted that the cancers detected by digital mammography but missed by film mammography included many invasive and high-grade in situ cases, precisely the lesions that must be detected to save lives.

The study found no advantage in the diagnostic accuracy of digital mammography for women aged 50 years and older, women with fatty breasts or scattered fibroglandular densities, and postmenopausal women.

But digital mammography has other advantages, the investigators noted. These include easier access to images and to computer-assisted diagnosis; improved means of image transmission, storage, and retrieval; and the use of a lower average dose of radiation without compromising diagnostic accuracy.

Conversely, the cost of digital mammography systems, which the investigators place at 1.5–4 times higher than film systems, provides a barrier to the universal use of this modality.

A large, head-to-head comparison of digital and film mammography found no overall difference in diagnostic accuracy, but digital mammography appears to have better diagnostic accuracy in some subgroups of women.

Digital mammography was significantly more accurate among women aged under 50 years, women with heterogeneously dense or extremely dense breasts, and premenopausal or perimenopausal women, according to the study by Etta D. Pisano, M.D., of the University of North Carolina at Chapel Hill, and colleagues.

The study involved a total of 49,528 women recruited over a 2-year period at 33 sites in North America. The final analysis included data from 42,760 women for whom the investigators had all relevant information (N. Engl. J. Med. 2005;353:[Epub ahead of print] doi 10.1056/NEJMoa052911, www.nejm.org

All women underwent both digital and film mammography, and these were independently interpreted by two readers. Readers rated the mammograms on a seven-point malignancy scale and used the classification of the Breast Imaging Reporting and Data System (BIRADS).

Biopsy or aspiration of the suspicious lesion was performed if either reader recommended it. These patients received follow-up mammograms an average of 455 days following their initial screening. A total of 335 cancers were detected among the women enrolled in the study.

Investigators used five digital mammography systems from four manufacturers. No statistically significant differences were found among the different mammography systems.

The investigators noted that the cancers detected by digital mammography but missed by film mammography included many invasive and high-grade in situ cases, precisely the lesions that must be detected to save lives.

The study found no advantage in the diagnostic accuracy of digital mammography for women aged 50 years and older, women with fatty breasts or scattered fibroglandular densities, and postmenopausal women.

But digital mammography has other advantages, the investigators noted. These include easier access to images and to computer-assisted diagnosis; improved means of image transmission, storage, and retrieval; and the use of a lower average dose of radiation without compromising diagnostic accuracy.

Conversely, the cost of digital mammography systems, which the investigators place at 1.5–4 times higher than film systems, provides a barrier to the universal use of this modality.

BLAINE, WASH. — Several tests are available to help in the diagnosis of gastroesophageal reflux in infants and children, Dennis L. Christie, M.D., said at a conference sponsored by the North Pacific Pediatric Society.

These include extended barium swallows, scintiscan, ultrasound, extended pH monitoring, and endoscopy, said Dr. Christie of the University of Washington, Seattle.

▸ A barium contrast study, which may be accompanied by an upper GI study or a small bowel study, can be used to exclude anatomic abnormalities. This test can detect pyloric stenosis and other upper GI abnormalities, malrotation, hiatal hernia, vascular ring, and stricture.

Swallowing studies can be useful in evaluating nasopharyngeal reflux, aspiration, and esophageal peristalsis. But if you want a swallowing study, you'll have to be explicit, since radiologists no longer do this routinely.

▸ The technetium-99 scintiscan is not especially sensitive, but it can be useful in evaluating nonacid reflux, gastric emptying, and aspiration.

▸ Ultrasound is not used very commonly, but it can be useful in detecting pyloric stenosis.

▸ Extended pH monitoring is the preferred method for diagnosing gastroesophageal reflux. Typically, the pH probe is inserted intranasally and positioned just above the gastroesophageal sphincter. To determine the proximal extent of the reflux, some probes include two measuring devices, separated by 15–20 cm, allowing one to be positioned distally in the esophagus and the other proximally. Software converts the raw data to useful measures, including the percentage of the total time in which the pH is less than 4.0 (more than 5%–10% is abnormal), the total number of episodes, and the total number of episodes longer than 5 minutes.

Children with respiratory disease, for example, will not have esophagitis on biopsy but they do show frequent episodes of reflux—up to 100 episodes in 24 hours—that are very short lived. Children with tracheoesophageal fistula may have fewer episodes, but their episodes last much longer.

▸ Endoscopy is indicated to identify esophagitis and to establish a GER diagnosis in a patient with other negative studies but persistent symptoms. The esophagitis can be graded to plan adequate management, and endoscopy can also evaluate and exclude other upper GI pathology.

On biopsy, esophagitis is judged on the number of eosinophils and neutrophils present, the papillary height, and the basal cell thickness. The presence of any inflammatory cells indicates esophagitis, as does a papillary height greater than 53% and a basal cell thickness of greater than 25%.

Endoscopy also is useful fordiagnosing Barrett's esophagus, a precancerous condition that is rare, but not unheard of, in children, Dr. Christie said.

He described the case of a 5-year-old child with recurrent wheezing and frequent colds. The child had been diagnosed with reflux at 6 months of age, and with asthma more recently. He was brought to the emergency department after a bout of coffee-ground emesis.

A chest x-ray was normal, but given the child's history Dr. Christie suspected reflux. Dual-probe extended pH monitoring showed abnormal acid levels in the distal esophagus 8.9% of the time, with 396 episodes. The proximal esophagus showed abnormal acid levels 4.6% of the time with 66 episodes.

On endoscopy, the child was seen to have a wide-open gastroesophageal junction, severe mucosal erosion, and inflammation. Dr. Christie said that in such a child corrective surgery would likely be needed sooner or later.

BLAINE, WASH. — Several tests are available to help in the diagnosis of gastroesophageal reflux in infants and children, Dennis L. Christie, M.D., said at a conference sponsored by the North Pacific Pediatric Society.

These include extended barium swallows, scintiscan, ultrasound, extended pH monitoring, and endoscopy, said Dr. Christie of the University of Washington, Seattle.

▸ A barium contrast study, which may be accompanied by an upper GI study or a small bowel study, can be used to exclude anatomic abnormalities. This test can detect pyloric stenosis and other upper GI abnormalities, malrotation, hiatal hernia, vascular ring, and stricture.

Swallowing studies can be useful in evaluating nasopharyngeal reflux, aspiration, and esophageal peristalsis. But if you want a swallowing study, you'll have to be explicit, since radiologists no longer do this routinely.

▸ The technetium-99 scintiscan is not especially sensitive, but it can be useful in evaluating nonacid reflux, gastric emptying, and aspiration.

▸ Ultrasound is not used very commonly, but it can be useful in detecting pyloric stenosis.

▸ Extended pH monitoring is the preferred method for diagnosing gastroesophageal reflux. Typically, the pH probe is inserted intranasally and positioned just above the gastroesophageal sphincter. To determine the proximal extent of the reflux, some probes include two measuring devices, separated by 15–20 cm, allowing one to be positioned distally in the esophagus and the other proximally. Software converts the raw data to useful measures, including the percentage of the total time in which the pH is less than 4.0 (more than 5%–10% is abnormal), the total number of episodes, and the total number of episodes longer than 5 minutes.

Children with respiratory disease, for example, will not have esophagitis on biopsy but they do show frequent episodes of reflux—up to 100 episodes in 24 hours—that are very short lived. Children with tracheoesophageal fistula may have fewer episodes, but their episodes last much longer.

▸ Endoscopy is indicated to identify esophagitis and to establish a GER diagnosis in a patient with other negative studies but persistent symptoms. The esophagitis can be graded to plan adequate management, and endoscopy can also evaluate and exclude other upper GI pathology.

On biopsy, esophagitis is judged on the number of eosinophils and neutrophils present, the papillary height, and the basal cell thickness. The presence of any inflammatory cells indicates esophagitis, as does a papillary height greater than 53% and a basal cell thickness of greater than 25%.

Endoscopy also is useful fordiagnosing Barrett's esophagus, a precancerous condition that is rare, but not unheard of, in children, Dr. Christie said.

He described the case of a 5-year-old child with recurrent wheezing and frequent colds. The child had been diagnosed with reflux at 6 months of age, and with asthma more recently. He was brought to the emergency department after a bout of coffee-ground emesis.

A chest x-ray was normal, but given the child's history Dr. Christie suspected reflux. Dual-probe extended pH monitoring showed abnormal acid levels in the distal esophagus 8.9% of the time, with 396 episodes. The proximal esophagus showed abnormal acid levels 4.6% of the time with 66 episodes.

On endoscopy, the child was seen to have a wide-open gastroesophageal junction, severe mucosal erosion, and inflammation. Dr. Christie said that in such a child corrective surgery would likely be needed sooner or later.

BLAINE, WASH. — Several tests are available to help in the diagnosis of gastroesophageal reflux in infants and children, Dennis L. Christie, M.D., said at a conference sponsored by the North Pacific Pediatric Society.

These include extended barium swallows, scintiscan, ultrasound, extended pH monitoring, and endoscopy, said Dr. Christie of the University of Washington, Seattle.

▸ A barium contrast study, which may be accompanied by an upper GI study or a small bowel study, can be used to exclude anatomic abnormalities. This test can detect pyloric stenosis and other upper GI abnormalities, malrotation, hiatal hernia, vascular ring, and stricture.

Swallowing studies can be useful in evaluating nasopharyngeal reflux, aspiration, and esophageal peristalsis. But if you want a swallowing study, you'll have to be explicit, since radiologists no longer do this routinely.

▸ The technetium-99 scintiscan is not especially sensitive, but it can be useful in evaluating nonacid reflux, gastric emptying, and aspiration.

▸ Ultrasound is not used very commonly, but it can be useful in detecting pyloric stenosis.

▸ Extended pH monitoring is the preferred method for diagnosing gastroesophageal reflux. Typically, the pH probe is inserted intranasally and positioned just above the gastroesophageal sphincter. To determine the proximal extent of the reflux, some probes include two measuring devices, separated by 15–20 cm, allowing one to be positioned distally in the esophagus and the other proximally. Software converts the raw data to useful measures, including the percentage of the total time in which the pH is less than 4.0 (more than 5%–10% is abnormal), the total number of episodes, and the total number of episodes longer than 5 minutes.

Children with respiratory disease, for example, will not have esophagitis on biopsy but they do show frequent episodes of reflux—up to 100 episodes in 24 hours—that are very short lived. Children with tracheoesophageal fistula may have fewer episodes, but their episodes last much longer.

▸ Endoscopy is indicated to identify esophagitis and to establish a GER diagnosis in a patient with other negative studies but persistent symptoms. The esophagitis can be graded to plan adequate management, and endoscopy can also evaluate and exclude other upper GI pathology.

On biopsy, esophagitis is judged on the number of eosinophils and neutrophils present, the papillary height, and the basal cell thickness. The presence of any inflammatory cells indicates esophagitis, as does a papillary height greater than 53% and a basal cell thickness of greater than 25%.

Endoscopy also is useful fordiagnosing Barrett's esophagus, a precancerous condition that is rare, but not unheard of, in children, Dr. Christie said.

He described the case of a 5-year-old child with recurrent wheezing and frequent colds. The child had been diagnosed with reflux at 6 months of age, and with asthma more recently. He was brought to the emergency department after a bout of coffee-ground emesis.

A chest x-ray was normal, but given the child's history Dr. Christie suspected reflux. Dual-probe extended pH monitoring showed abnormal acid levels in the distal esophagus 8.9% of the time, with 396 episodes. The proximal esophagus showed abnormal acid levels 4.6% of the time with 66 episodes.

On endoscopy, the child was seen to have a wide-open gastroesophageal junction, severe mucosal erosion, and inflammation. Dr. Christie said that in such a child corrective surgery would likely be needed sooner or later.

BLAINE, WASH. — Topical calcineurin inhibitors remain an excellent second-line treatment for atopic dermatitis in children, despite a public health advisory by the Food and Drug Administration earlier this year and the promise of a black-box warning in the near future, Robert Sidbury, M.D., said at a conference sponsored by the North Pacific Pediatric Society.

Dr. Sidbury, of the University of Washington, Seattle, addressed the questions of when and how to use the topical calcineurin inhibitor (TCI) tacrolimus (Protopic) and pimecrolimus (Elidel) for atopic dermatitis in light of the FDA warning.

TCIs should be used only for short-term or intermittent long-term treatment, he said. They should not be used continually, on large body-surface areas, or on children younger than 2 years of age except in unusual circumstances.

“If I felt that an infant was using so much topical steroid that I was worried, I would use [a TCI] in a heartbeat, and with the cleanest conscience that I know how to have,” Dr. Sidbury said.

TCIs seem to work best on skin folds and on the head and neck. These happen to be the areas where the use of topical steroids is most problematic, since thinning of the skin is a well-known side effect of these agents. Additionally, topical steroids carry the risk of glaucoma and cataracts when used near the eyes.

TCIs are least effective on palms and soles; on thick, lichenified areas; and on hyperkeratotic areas such as those seen in psoriasis.

These agents tend to sting quite a bit when used on open, excoriated areas, and Dr. Sidbury suggested pretreating those areas with topical steroids before introducing a TCI.

TCIs should be applied twice daily to affected areas to induce remission and then as needed for flares. To avoid continual use, they can be alternated with topical steroids, thus decreasing the potential for side effects from both agents. And TCIs should be part of a total skin-care regimen, including bathing, moisturizing, avoiding irritants and allergens, and using antibiotics and antihistamines when appropriate.

There are some differences between tacrolimus and pimecrolimus. Tacrolimus is said to be better for moderate to severe atopic dermatitis, whereas pimecrolimus is said to be better for mild to moderate disease.

Tacrolimus comes in two strengths, 0.03% and 0.1% in an ointment base. The lower dose is approved for children aged 2–15 years, and the higher dose is approved for adults and children older than 15 years. Pimecrolimus comes in a single, 1% cream formulation that's approved for use in children older than 2 years.

A review of three randomized head-to-head studies indicated that tacrolimus is more effective on thicker, more refractory areas and has a faster onset of action. Pimecrolimus, on the other hand, stings less (J. Am. Acad. Dermatol. 2005;52:810–22).

BLAINE, WASH. — Topical calcineurin inhibitors remain an excellent second-line treatment for atopic dermatitis in children, despite a public health advisory by the Food and Drug Administration earlier this year and the promise of a black-box warning in the near future, Robert Sidbury, M.D., said at a conference sponsored by the North Pacific Pediatric Society.

Dr. Sidbury, of the University of Washington, Seattle, addressed the questions of when and how to use the topical calcineurin inhibitor (TCI) tacrolimus (Protopic) and pimecrolimus (Elidel) for atopic dermatitis in light of the FDA warning.

TCIs should be used only for short-term or intermittent long-term treatment, he said. They should not be used continually, on large body-surface areas, or on children younger than 2 years of age except in unusual circumstances.

“If I felt that an infant was using so much topical steroid that I was worried, I would use [a TCI] in a heartbeat, and with the cleanest conscience that I know how to have,” Dr. Sidbury said.

TCIs seem to work best on skin folds and on the head and neck. These happen to be the areas where the use of topical steroids is most problematic, since thinning of the skin is a well-known side effect of these agents. Additionally, topical steroids carry the risk of glaucoma and cataracts when used near the eyes.

TCIs are least effective on palms and soles; on thick, lichenified areas; and on hyperkeratotic areas such as those seen in psoriasis.

These agents tend to sting quite a bit when used on open, excoriated areas, and Dr. Sidbury suggested pretreating those areas with topical steroids before introducing a TCI.

TCIs should be applied twice daily to affected areas to induce remission and then as needed for flares. To avoid continual use, they can be alternated with topical steroids, thus decreasing the potential for side effects from both agents. And TCIs should be part of a total skin-care regimen, including bathing, moisturizing, avoiding irritants and allergens, and using antibiotics and antihistamines when appropriate.

There are some differences between tacrolimus and pimecrolimus. Tacrolimus is said to be better for moderate to severe atopic dermatitis, whereas pimecrolimus is said to be better for mild to moderate disease.

Tacrolimus comes in two strengths, 0.03% and 0.1% in an ointment base. The lower dose is approved for children aged 2–15 years, and the higher dose is approved for adults and children older than 15 years. Pimecrolimus comes in a single, 1% cream formulation that's approved for use in children older than 2 years.

A review of three randomized head-to-head studies indicated that tacrolimus is more effective on thicker, more refractory areas and has a faster onset of action. Pimecrolimus, on the other hand, stings less (J. Am. Acad. Dermatol. 2005;52:810–22).

BLAINE, WASH. — Topical calcineurin inhibitors remain an excellent second-line treatment for atopic dermatitis in children, despite a public health advisory by the Food and Drug Administration earlier this year and the promise of a black-box warning in the near future, Robert Sidbury, M.D., said at a conference sponsored by the North Pacific Pediatric Society.

Dr. Sidbury, of the University of Washington, Seattle, addressed the questions of when and how to use the topical calcineurin inhibitor (TCI) tacrolimus (Protopic) and pimecrolimus (Elidel) for atopic dermatitis in light of the FDA warning.

TCIs should be used only for short-term or intermittent long-term treatment, he said. They should not be used continually, on large body-surface areas, or on children younger than 2 years of age except in unusual circumstances.

“If I felt that an infant was using so much topical steroid that I was worried, I would use [a TCI] in a heartbeat, and with the cleanest conscience that I know how to have,” Dr. Sidbury said.

TCIs seem to work best on skin folds and on the head and neck. These happen to be the areas where the use of topical steroids is most problematic, since thinning of the skin is a well-known side effect of these agents. Additionally, topical steroids carry the risk of glaucoma and cataracts when used near the eyes.

TCIs are least effective on palms and soles; on thick, lichenified areas; and on hyperkeratotic areas such as those seen in psoriasis.

These agents tend to sting quite a bit when used on open, excoriated areas, and Dr. Sidbury suggested pretreating those areas with topical steroids before introducing a TCI.

TCIs should be applied twice daily to affected areas to induce remission and then as needed for flares. To avoid continual use, they can be alternated with topical steroids, thus decreasing the potential for side effects from both agents. And TCIs should be part of a total skin-care regimen, including bathing, moisturizing, avoiding irritants and allergens, and using antibiotics and antihistamines when appropriate.

There are some differences between tacrolimus and pimecrolimus. Tacrolimus is said to be better for moderate to severe atopic dermatitis, whereas pimecrolimus is said to be better for mild to moderate disease.

Tacrolimus comes in two strengths, 0.03% and 0.1% in an ointment base. The lower dose is approved for children aged 2–15 years, and the higher dose is approved for adults and children older than 15 years. Pimecrolimus comes in a single, 1% cream formulation that's approved for use in children older than 2 years.

A review of three randomized head-to-head studies indicated that tacrolimus is more effective on thicker, more refractory areas and has a faster onset of action. Pimecrolimus, on the other hand, stings less (J. Am. Acad. Dermatol. 2005;52:810–22).

SAN FRANCISCO — With CT angiography, “patients literally go home with a Band-Aid and a bottle of water” after just 20 minutes, Matthew J. Budoff, M.D., said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

With high sensitivity and specificity and images that rival the resolution obtainable with traditional coronary angiography from the catheterization lab, CT angiography will allow many more patients to avoid an invasive procedure, said Dr. Budoff of Harbor-UCLA Medical Center, Torrance, Calif.

After an injection of 80–100 mL of nonionic iodinated contrast solution, up to 4,000 two-dimensional images can be obtained within 20–30 seconds as the patient holds his or her breath. The entire procedure takes 20 minutes, and interpretation takes another 10 minutes, according to Dr. Budoff.

Sophisticated workstations assemble the stack of 2D images into a three-dimensional reconstruction. Interpretations are made on the basis of the 3D reconstruction with reference to the 2D images.

Dr. Budoff started working with CT angiography in the mid-1990s. In those days it took 3 weeks of full-time computation to assemble a single 3D reconstruction. This same function takes just 30 seconds today.

And these workstations allow the cardiologist to rotate the heart image in three dimensions, to zoom in to interesting features, and to easily reference the original 2D data from any point of interest, he said at the conference.

The initial studies of four-slice CT angiography revealed the limitations of this early technique. Only 30% of patients had all three major arteries available for analysis, and in detecting stenosis the sensitivity was just 58% with 76% specificity.

Nowadays, as 16-slice and even 64-slice CT angiography become available, the sensitivity and specificity have improved considerably. Studies have calculated sensitivities as high as 97% and specificities as high as 94%.

Most important, the negative predictive value is 98%–100%.

“The benefit of CT angio is that when the coronaries look normal, the coronaries are normal,” Dr. Budoff said at the meeting.

The temporal resolution of the CT images is about 175 milliseconds, so reducing the heart rate to below 60 beats per minute is important for accuracy and interpretability.

Most centers use 100 mg metoprolol 1 hour prior to the study and/or a 5-mg intravenous metoprolol push every 5 minutes until the patient achieves a slow heart rate.

A regular rhythm is also important. If there's a regular rhythm, with multiple detectors obtaining images at specific parts of the heart cycle, the modality reaches an effective frame speed of 15 images per second.

This is slower than the cath lab, but fast enough that the images are free of motion artifact.

CT angiography may be the best technique for imaging the results of bypass grafting as the anastomoses are clearly visible.

Other clinical indications for CT angiography are: in cases of equivocal results following stress testing; to evaluate patency post angioplasty, post stent, and post bypass surgery; in cases of congenital abnormalities and anomalous coronaries; before and after atrial fibrillation ablation; and before placing a biventricular pacer.

CT angiography is not without its disadvantages, however. It's not very good for visualizing vessels with diameters less than 1.5 mm.

It is subject to artifacts from extensive calcification, stents, or extensive clips after bypass grafting.

And it subjects patients to a relatively high dose of radiation—about 9.3–11.3 mSv, compared with 2.1–2.3 mSv for the cath lab and 0.1 mSv for a chest x-ray, Dr. Budoff said.

CT angiography reveals high-grade stenosis (dark area) in the mid-left anterior descending artery. Courtesy Dr. Matthew J. Budoff

SAN FRANCISCO — With CT angiography, “patients literally go home with a Band-Aid and a bottle of water” after just 20 minutes, Matthew J. Budoff, M.D., said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

With high sensitivity and specificity and images that rival the resolution obtainable with traditional coronary angiography from the catheterization lab, CT angiography will allow many more patients to avoid an invasive procedure, said Dr. Budoff of Harbor-UCLA Medical Center, Torrance, Calif.

After an injection of 80–100 mL of nonionic iodinated contrast solution, up to 4,000 two-dimensional images can be obtained within 20–30 seconds as the patient holds his or her breath. The entire procedure takes 20 minutes, and interpretation takes another 10 minutes, according to Dr. Budoff.

Sophisticated workstations assemble the stack of 2D images into a three-dimensional reconstruction. Interpretations are made on the basis of the 3D reconstruction with reference to the 2D images.

Dr. Budoff started working with CT angiography in the mid-1990s. In those days it took 3 weeks of full-time computation to assemble a single 3D reconstruction. This same function takes just 30 seconds today.

And these workstations allow the cardiologist to rotate the heart image in three dimensions, to zoom in to interesting features, and to easily reference the original 2D data from any point of interest, he said at the conference.

The initial studies of four-slice CT angiography revealed the limitations of this early technique. Only 30% of patients had all three major arteries available for analysis, and in detecting stenosis the sensitivity was just 58% with 76% specificity.

Nowadays, as 16-slice and even 64-slice CT angiography become available, the sensitivity and specificity have improved considerably. Studies have calculated sensitivities as high as 97% and specificities as high as 94%.

Most important, the negative predictive value is 98%–100%.

“The benefit of CT angio is that when the coronaries look normal, the coronaries are normal,” Dr. Budoff said at the meeting.

The temporal resolution of the CT images is about 175 milliseconds, so reducing the heart rate to below 60 beats per minute is important for accuracy and interpretability.

Most centers use 100 mg metoprolol 1 hour prior to the study and/or a 5-mg intravenous metoprolol push every 5 minutes until the patient achieves a slow heart rate.

A regular rhythm is also important. If there's a regular rhythm, with multiple detectors obtaining images at specific parts of the heart cycle, the modality reaches an effective frame speed of 15 images per second.

This is slower than the cath lab, but fast enough that the images are free of motion artifact.

CT angiography may be the best technique for imaging the results of bypass grafting as the anastomoses are clearly visible.

Other clinical indications for CT angiography are: in cases of equivocal results following stress testing; to evaluate patency post angioplasty, post stent, and post bypass surgery; in cases of congenital abnormalities and anomalous coronaries; before and after atrial fibrillation ablation; and before placing a biventricular pacer.

CT angiography is not without its disadvantages, however. It's not very good for visualizing vessels with diameters less than 1.5 mm.

It is subject to artifacts from extensive calcification, stents, or extensive clips after bypass grafting.

And it subjects patients to a relatively high dose of radiation—about 9.3–11.3 mSv, compared with 2.1–2.3 mSv for the cath lab and 0.1 mSv for a chest x-ray, Dr. Budoff said.

CT angiography reveals high-grade stenosis (dark area) in the mid-left anterior descending artery. Courtesy Dr. Matthew J. Budoff

SAN FRANCISCO — With CT angiography, “patients literally go home with a Band-Aid and a bottle of water” after just 20 minutes, Matthew J. Budoff, M.D., said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

With high sensitivity and specificity and images that rival the resolution obtainable with traditional coronary angiography from the catheterization lab, CT angiography will allow many more patients to avoid an invasive procedure, said Dr. Budoff of Harbor-UCLA Medical Center, Torrance, Calif.

After an injection of 80–100 mL of nonionic iodinated contrast solution, up to 4,000 two-dimensional images can be obtained within 20–30 seconds as the patient holds his or her breath. The entire procedure takes 20 minutes, and interpretation takes another 10 minutes, according to Dr. Budoff.

Sophisticated workstations assemble the stack of 2D images into a three-dimensional reconstruction. Interpretations are made on the basis of the 3D reconstruction with reference to the 2D images.

Dr. Budoff started working with CT angiography in the mid-1990s. In those days it took 3 weeks of full-time computation to assemble a single 3D reconstruction. This same function takes just 30 seconds today.

And these workstations allow the cardiologist to rotate the heart image in three dimensions, to zoom in to interesting features, and to easily reference the original 2D data from any point of interest, he said at the conference.

The initial studies of four-slice CT angiography revealed the limitations of this early technique. Only 30% of patients had all three major arteries available for analysis, and in detecting stenosis the sensitivity was just 58% with 76% specificity.

Nowadays, as 16-slice and even 64-slice CT angiography become available, the sensitivity and specificity have improved considerably. Studies have calculated sensitivities as high as 97% and specificities as high as 94%.

Most important, the negative predictive value is 98%–100%.

“The benefit of CT angio is that when the coronaries look normal, the coronaries are normal,” Dr. Budoff said at the meeting.

The temporal resolution of the CT images is about 175 milliseconds, so reducing the heart rate to below 60 beats per minute is important for accuracy and interpretability.

Most centers use 100 mg metoprolol 1 hour prior to the study and/or a 5-mg intravenous metoprolol push every 5 minutes until the patient achieves a slow heart rate.

A regular rhythm is also important. If there's a regular rhythm, with multiple detectors obtaining images at specific parts of the heart cycle, the modality reaches an effective frame speed of 15 images per second.

This is slower than the cath lab, but fast enough that the images are free of motion artifact.

CT angiography may be the best technique for imaging the results of bypass grafting as the anastomoses are clearly visible.

Other clinical indications for CT angiography are: in cases of equivocal results following stress testing; to evaluate patency post angioplasty, post stent, and post bypass surgery; in cases of congenital abnormalities and anomalous coronaries; before and after atrial fibrillation ablation; and before placing a biventricular pacer.

CT angiography is not without its disadvantages, however. It's not very good for visualizing vessels with diameters less than 1.5 mm.

It is subject to artifacts from extensive calcification, stents, or extensive clips after bypass grafting.

And it subjects patients to a relatively high dose of radiation—about 9.3–11.3 mSv, compared with 2.1–2.3 mSv for the cath lab and 0.1 mSv for a chest x-ray, Dr. Budoff said.

CT angiography reveals high-grade stenosis (dark area) in the mid-left anterior descending artery. Courtesy Dr. Matthew J. Budoff