Robert Finn

SAN FRANCISCO — Physicians play an important role in identifying women at high risk for ovarian cancer because when such a woman is identified, much can be done to prevent the cancer, Karen H. Lu, M.D., said at the annual meeting of the American College of Obstetricians and Gynecologists.

The lifetime risk of ovarian cancer in the general population is about 1.7%, and most cases are found in a late stage. But among women who have certain mutations in the BRCA1 or BRCA2 genes, the lifetime risk rises to 40%–50%. These genes also are responsible for hereditary forms of breast cancer.

Only about 10% of ovarian cancers can be attributed to these mutations, with the remaining 90% regarded as “sporadic.” While one marker of ovarian cancer—the antigen CA-125—has been found, screening the public at large has not been recommended, since the poor specificity of the CA-125 test, combined with the cancer's low prevalence, would result in a high rate of false positives.

But for women at high risk, screening, chemoprevention, and preventive surgery may make more sense, said Dr. Lu of the University of Texas M.D. Anderson Cancer Center, Houston. The trick is to determine which women are at high risk.

The strongest indication of risk is a family history of breast or ovarian cancer. Your index of suspicion should rise whenever a woman mentions several relatives who have died young from these cancers, Dr. Lu recommended.

Ethnic heritage can be another indicator. Among Ashkenazi Jewish women with ovarian cancer, 40%–50% have BRCA1 or BRCA2 mutations. The general population of Ashkenazi Jewish women has a 2%–3% chance of carrying one of the mutations, compared with 1 in 500 for the full U.S. population.

When a woman reports a strong family history of cancer, genetic testing is worthwhile, Dr. Lu said. If possible, the testing should start with a family member with a confirmed case of ovarian cancer. The test is a simple blood draw with no fasting required. But the testing, which involves full sequencing of both BRCA1 and BRCA2, costs about $3,000. Many insurance carriers are willing to pick up the tab.

If a mutation is identified in the patient with cancer, other family members need not have the full sequencing done. Instead, they need a simpler test that would confirm or refute the presence of that specific mutation. This test costs about $350. If the mutation is not present, a physician can be confident that the woman's risk of ovarian cancer is 1.7%, no higher than the general population.

Women at high risk may benefit from CA-125 screening, although a definitive recommendation won't be available until the large Risk of Ovarian Cancer Algorithm (ROCA) study is completed. It is known that absolute CA-125 levels are not as important as whether a woman's level remains constant or increases. In the ROCA study, blood levels of CA-125 are being measured every 3 months. An increasing CA-125 level appears to carry a high risk of ovarian cancer.

Dr. Lu recommended women at high risk consider chemoprevention. Oral contraceptives are known to reduce the risk of ovarian cancer by about 50%. There's a detectable effect after 1 year of use, and the protection increases for each additional year of use.

The definitive preventive technique is risk-reducing salpingo-oophorectomy (RRSO). Dr. Lu recommended that women past childbearing who are known mutation carriers and over age 35 years should undergo the surgery. “As a secondary benefit, removing their ovaries reduces their breast-cancer risk by 50%.”

When performing an RRSO, it's important to enlist the aid of the pathologist. About 8%–17% of patients will have occult, microscopic cancers at the time of prophylactic surgery, a relatively high rate. Unless serial sectioning (every 2 mm) is specifically requested, the pathologist is likely to take only a single “representative” sample of the ovary and the fallopian tube.

SAN FRANCISCO — Physicians play an important role in identifying women at high risk for ovarian cancer because when such a woman is identified, much can be done to prevent the cancer, Karen H. Lu, M.D., said at the annual meeting of the American College of Obstetricians and Gynecologists.

The lifetime risk of ovarian cancer in the general population is about 1.7%, and most cases are found in a late stage. But among women who have certain mutations in the BRCA1 or BRCA2 genes, the lifetime risk rises to 40%–50%. These genes also are responsible for hereditary forms of breast cancer.

Only about 10% of ovarian cancers can be attributed to these mutations, with the remaining 90% regarded as “sporadic.” While one marker of ovarian cancer—the antigen CA-125—has been found, screening the public at large has not been recommended, since the poor specificity of the CA-125 test, combined with the cancer's low prevalence, would result in a high rate of false positives.

But for women at high risk, screening, chemoprevention, and preventive surgery may make more sense, said Dr. Lu of the University of Texas M.D. Anderson Cancer Center, Houston. The trick is to determine which women are at high risk.

The strongest indication of risk is a family history of breast or ovarian cancer. Your index of suspicion should rise whenever a woman mentions several relatives who have died young from these cancers, Dr. Lu recommended.

Ethnic heritage can be another indicator. Among Ashkenazi Jewish women with ovarian cancer, 40%–50% have BRCA1 or BRCA2 mutations. The general population of Ashkenazi Jewish women has a 2%–3% chance of carrying one of the mutations, compared with 1 in 500 for the full U.S. population.

When a woman reports a strong family history of cancer, genetic testing is worthwhile, Dr. Lu said. If possible, the testing should start with a family member with a confirmed case of ovarian cancer. The test is a simple blood draw with no fasting required. But the testing, which involves full sequencing of both BRCA1 and BRCA2, costs about $3,000. Many insurance carriers are willing to pick up the tab.

If a mutation is identified in the patient with cancer, other family members need not have the full sequencing done. Instead, they need a simpler test that would confirm or refute the presence of that specific mutation. This test costs about $350. If the mutation is not present, a physician can be confident that the woman's risk of ovarian cancer is 1.7%, no higher than the general population.

Women at high risk may benefit from CA-125 screening, although a definitive recommendation won't be available until the large Risk of Ovarian Cancer Algorithm (ROCA) study is completed. It is known that absolute CA-125 levels are not as important as whether a woman's level remains constant or increases. In the ROCA study, blood levels of CA-125 are being measured every 3 months. An increasing CA-125 level appears to carry a high risk of ovarian cancer.

Dr. Lu recommended women at high risk consider chemoprevention. Oral contraceptives are known to reduce the risk of ovarian cancer by about 50%. There's a detectable effect after 1 year of use, and the protection increases for each additional year of use.

The definitive preventive technique is risk-reducing salpingo-oophorectomy (RRSO). Dr. Lu recommended that women past childbearing who are known mutation carriers and over age 35 years should undergo the surgery. “As a secondary benefit, removing their ovaries reduces their breast-cancer risk by 50%.”

When performing an RRSO, it's important to enlist the aid of the pathologist. About 8%–17% of patients will have occult, microscopic cancers at the time of prophylactic surgery, a relatively high rate. Unless serial sectioning (every 2 mm) is specifically requested, the pathologist is likely to take only a single “representative” sample of the ovary and the fallopian tube.

SAN FRANCISCO — Physicians play an important role in identifying women at high risk for ovarian cancer because when such a woman is identified, much can be done to prevent the cancer, Karen H. Lu, M.D., said at the annual meeting of the American College of Obstetricians and Gynecologists.

The lifetime risk of ovarian cancer in the general population is about 1.7%, and most cases are found in a late stage. But among women who have certain mutations in the BRCA1 or BRCA2 genes, the lifetime risk rises to 40%–50%. These genes also are responsible for hereditary forms of breast cancer.

Only about 10% of ovarian cancers can be attributed to these mutations, with the remaining 90% regarded as “sporadic.” While one marker of ovarian cancer—the antigen CA-125—has been found, screening the public at large has not been recommended, since the poor specificity of the CA-125 test, combined with the cancer's low prevalence, would result in a high rate of false positives.

But for women at high risk, screening, chemoprevention, and preventive surgery may make more sense, said Dr. Lu of the University of Texas M.D. Anderson Cancer Center, Houston. The trick is to determine which women are at high risk.

The strongest indication of risk is a family history of breast or ovarian cancer. Your index of suspicion should rise whenever a woman mentions several relatives who have died young from these cancers, Dr. Lu recommended.

Ethnic heritage can be another indicator. Among Ashkenazi Jewish women with ovarian cancer, 40%–50% have BRCA1 or BRCA2 mutations. The general population of Ashkenazi Jewish women has a 2%–3% chance of carrying one of the mutations, compared with 1 in 500 for the full U.S. population.

When a woman reports a strong family history of cancer, genetic testing is worthwhile, Dr. Lu said. If possible, the testing should start with a family member with a confirmed case of ovarian cancer. The test is a simple blood draw with no fasting required. But the testing, which involves full sequencing of both BRCA1 and BRCA2, costs about $3,000. Many insurance carriers are willing to pick up the tab.

If a mutation is identified in the patient with cancer, other family members need not have the full sequencing done. Instead, they need a simpler test that would confirm or refute the presence of that specific mutation. This test costs about $350. If the mutation is not present, a physician can be confident that the woman's risk of ovarian cancer is 1.7%, no higher than the general population.

Women at high risk may benefit from CA-125 screening, although a definitive recommendation won't be available until the large Risk of Ovarian Cancer Algorithm (ROCA) study is completed. It is known that absolute CA-125 levels are not as important as whether a woman's level remains constant or increases. In the ROCA study, blood levels of CA-125 are being measured every 3 months. An increasing CA-125 level appears to carry a high risk of ovarian cancer.

Dr. Lu recommended women at high risk consider chemoprevention. Oral contraceptives are known to reduce the risk of ovarian cancer by about 50%. There's a detectable effect after 1 year of use, and the protection increases for each additional year of use.

The definitive preventive technique is risk-reducing salpingo-oophorectomy (RRSO). Dr. Lu recommended that women past childbearing who are known mutation carriers and over age 35 years should undergo the surgery. “As a secondary benefit, removing their ovaries reduces their breast-cancer risk by 50%.”

When performing an RRSO, it's important to enlist the aid of the pathologist. About 8%–17% of patients will have occult, microscopic cancers at the time of prophylactic surgery, a relatively high rate. Unless serial sectioning (every 2 mm) is specifically requested, the pathologist is likely to take only a single “representative” sample of the ovary and the fallopian tube.

SAN FRANCISCO — Anticonvulsants are known to cause birth defects when taken during pregnancy, but physicians should weigh the benefits and risks before discontinuing anticonvulsant therapy, Jennifer R. Niebyl, M.D., said at the annual meeting of the American College of Obstetricians and Gynecologists.

The risks are not all that large, said Dr. Niebyl of the University of Iowa, Iowa City. Only 5%–10% of women taking anticonvulsants during pregnancy develop fetal hydantoin syndrome.

Women taking a single anticonvulsant medication have about 2.5 times the risk of having this embryopathy as do epileptic women not taking anticonvulsants. Those taking at least two anticonvulsants have a significantly higher risk: 3.7 times as high as epileptics not taking anticonvulsants. This suggests it is the drug, not the epilepsy itself, that causes the syndrome.

Children with fetal hydantoin syndrome typically show multiple symptoms, including disorders of growth and of mental development, dysmorphic craniofacial features, and hypoplasia of the nails and distal phalanges.

Dr. Niebyl said it's becoming clear that it's desirable to wean women planning a pregnancy from their anticonvulsant medications if possible. This is more likely to be successful in women whose epilepsy is idiopathic, rather than caused by a head injury.

Other factors that bode well for getting women off anticonvulsants include a lack of neurologic abnormalities, a normal EEG, onset of epilepsy in childhood, seizures controlled by a single drug, and being seizure free for at least 2 years.

About 75% of these women will remain seizure free after discontinuing medication. But since 25% will have a seizure—and it's impossible to predict who will fall into that group—these women should be instructed not to drive during the time they're off the drug.

“If you don't see the patient until they're already pregnant, the benefits of continuing therapy usually outweigh the risks,” Dr. Niebyl said.

Anticonvulsants can interfere with folate metabolism, so Dr. Niebyl recommended being especially vigilant about folic acid supplementation. And some of these drugs—particularly phenytoin, primidone (Mysoline), and phenobarbital—inhibit the transfer of vitamin K across the placenta. This results in a decrease in fetal clotting factors and an increase in the risk of fetal hemorrhage. For this reason, many physicians will put patients on vitamin K supplementation (20 mg/day) for the final month or two of pregnancy, although there's no definitive evidence that this has a beneficial effect.

Some of the newer anticonvulsant medications, such as lamotrigine (Lamictal), may confer a smaller risk of birth defects than the older drugs, Dr. Niebyl said, but once again definitive evidence is lacking.

Dr. Niebyl said she had no financial conflicts of interest relevant to her presentation.

SAN FRANCISCO — Anticonvulsants are known to cause birth defects when taken during pregnancy, but physicians should weigh the benefits and risks before discontinuing anticonvulsant therapy, Jennifer R. Niebyl, M.D., said at the annual meeting of the American College of Obstetricians and Gynecologists.

The risks are not all that large, said Dr. Niebyl of the University of Iowa, Iowa City. Only 5%–10% of women taking anticonvulsants during pregnancy develop fetal hydantoin syndrome.

Women taking a single anticonvulsant medication have about 2.5 times the risk of having this embryopathy as do epileptic women not taking anticonvulsants. Those taking at least two anticonvulsants have a significantly higher risk: 3.7 times as high as epileptics not taking anticonvulsants. This suggests it is the drug, not the epilepsy itself, that causes the syndrome.

Children with fetal hydantoin syndrome typically show multiple symptoms, including disorders of growth and of mental development, dysmorphic craniofacial features, and hypoplasia of the nails and distal phalanges.

Dr. Niebyl said it's becoming clear that it's desirable to wean women planning a pregnancy from their anticonvulsant medications if possible. This is more likely to be successful in women whose epilepsy is idiopathic, rather than caused by a head injury.

Other factors that bode well for getting women off anticonvulsants include a lack of neurologic abnormalities, a normal EEG, onset of epilepsy in childhood, seizures controlled by a single drug, and being seizure free for at least 2 years.

About 75% of these women will remain seizure free after discontinuing medication. But since 25% will have a seizure—and it's impossible to predict who will fall into that group—these women should be instructed not to drive during the time they're off the drug.

“If you don't see the patient until they're already pregnant, the benefits of continuing therapy usually outweigh the risks,” Dr. Niebyl said.

Anticonvulsants can interfere with folate metabolism, so Dr. Niebyl recommended being especially vigilant about folic acid supplementation. And some of these drugs—particularly phenytoin, primidone (Mysoline), and phenobarbital—inhibit the transfer of vitamin K across the placenta. This results in a decrease in fetal clotting factors and an increase in the risk of fetal hemorrhage. For this reason, many physicians will put patients on vitamin K supplementation (20 mg/day) for the final month or two of pregnancy, although there's no definitive evidence that this has a beneficial effect.

Some of the newer anticonvulsant medications, such as lamotrigine (Lamictal), may confer a smaller risk of birth defects than the older drugs, Dr. Niebyl said, but once again definitive evidence is lacking.

Dr. Niebyl said she had no financial conflicts of interest relevant to her presentation.

SAN FRANCISCO — Anticonvulsants are known to cause birth defects when taken during pregnancy, but physicians should weigh the benefits and risks before discontinuing anticonvulsant therapy, Jennifer R. Niebyl, M.D., said at the annual meeting of the American College of Obstetricians and Gynecologists.

The risks are not all that large, said Dr. Niebyl of the University of Iowa, Iowa City. Only 5%–10% of women taking anticonvulsants during pregnancy develop fetal hydantoin syndrome.

Women taking a single anticonvulsant medication have about 2.5 times the risk of having this embryopathy as do epileptic women not taking anticonvulsants. Those taking at least two anticonvulsants have a significantly higher risk: 3.7 times as high as epileptics not taking anticonvulsants. This suggests it is the drug, not the epilepsy itself, that causes the syndrome.

Children with fetal hydantoin syndrome typically show multiple symptoms, including disorders of growth and of mental development, dysmorphic craniofacial features, and hypoplasia of the nails and distal phalanges.

Dr. Niebyl said it's becoming clear that it's desirable to wean women planning a pregnancy from their anticonvulsant medications if possible. This is more likely to be successful in women whose epilepsy is idiopathic, rather than caused by a head injury.

Other factors that bode well for getting women off anticonvulsants include a lack of neurologic abnormalities, a normal EEG, onset of epilepsy in childhood, seizures controlled by a single drug, and being seizure free for at least 2 years.

About 75% of these women will remain seizure free after discontinuing medication. But since 25% will have a seizure—and it's impossible to predict who will fall into that group—these women should be instructed not to drive during the time they're off the drug.

“If you don't see the patient until they're already pregnant, the benefits of continuing therapy usually outweigh the risks,” Dr. Niebyl said.

Anticonvulsants can interfere with folate metabolism, so Dr. Niebyl recommended being especially vigilant about folic acid supplementation. And some of these drugs—particularly phenytoin, primidone (Mysoline), and phenobarbital—inhibit the transfer of vitamin K across the placenta. This results in a decrease in fetal clotting factors and an increase in the risk of fetal hemorrhage. For this reason, many physicians will put patients on vitamin K supplementation (20 mg/day) for the final month or two of pregnancy, although there's no definitive evidence that this has a beneficial effect.

Some of the newer anticonvulsant medications, such as lamotrigine (Lamictal), may confer a smaller risk of birth defects than the older drugs, Dr. Niebyl said, but once again definitive evidence is lacking.

Dr. Niebyl said she had no financial conflicts of interest relevant to her presentation.

SAN FRANCISCO — A careful history and physical exam, without the need for lab tests or radiography, can help identify any red flags in patients presenting with low back pain, David Borenstein, M.D., said at the annual meeting of the American College of Physicians.

The history can distinguish mechanical from systemic disorders, and the physical exam can distinguish neurologic from nonneurologic conditions, said Dr. Borenstein of George Washington University, Washington.

“Laboratory tests are notably inconsequential,” he said. “When you're taking your history and you don't think they have one of these systemic illnesses, you really don't have to do laboratory tests on these individuals.”

Laboratory tests can be useful in distinguishing inflammatory from noninflammatory disorders, and radiologic tests can confirm a diagnosis derived from other means. But testing can just as easily confuse the issue.

It's critical to quickly identify the 5% or so of patients with cauda equina compression, often associated with an expanding aneurism or a herniated disc because they require emergency surgery. Typically these patients will have urinary retention, incontinence, or saddle anesthesia. In those cases, Dr. Borenstein recommended getting an MRI on an emergent basis. Results of one recent study showed that patients with cauda equina compression do much better if they get surgery within 48 hours of the start of acute symptoms. Patients whose surgery was delayed often experienced severe and persistent motor deficits, persistent sciatica, and sexual dysfunction (Spine 2000;25:348–51).

In a history of a patient with low back pain, five areas of questioning can identify many red flags. If the answers to these constitutional symptom questions are all negative, “you can treat an individual with back pain conservatively without doing an x-ray, without doing lab tests, in fact by telling them they're going to get better—and being right most of the time,” Dr. Borenstein said.

▸ Weight loss and/or fever can signal either vertebral osteomyelitis or a vertebral neoplasm. Radiography—either a plain x-ray, a CT scan, an MRI, or a bone scan—can be helpful here.

▸ Pain at night or with recumbency can signal either a bone tumor or a spinal-cord tumor. “If they tell you pain is worse at night, and they have any neurologic sign, that's a patient for whom I'd get an MRI,” he said.

▸ Morning stiffness that lasts for hours can signal spondyloarthropathy or ankylosing spondylitis. Making this diagnosis is now more critical because effective therapies have recently become available. An x-ray taken with Ferguson's view of the sacroiliac joints is helpful in this diagnosis.

▸ A patient who has acute, localized bone pain, equivalent in intensity to a bone fracture “is one of the few times where our laboratory tests can be helpful,” Dr. Borenstein said. He suggested getting an erythrocyte sedimentation rate, a CBC, and a chemistry profile. These tests can help differentiate the acute fracture of osteoporosis from a tumor, Paget's disease, or sickle cell disease.

▸ Finally, if the patient has viscerogenic pain, the physician should determine whether the pain is colicky, tearing, or episodic. Colicky pain suggests a kidney or gall bladder problem; tearing pain suggests a vascular problem such as an aneurism; and pain that's episodic, coinciding with meals or with the menstrual cycle, suggests pancreatitis, peptic ulcer, or endometriosis.

Only about 10%–15% of patients presenting with lower back pain will have one of those red flags, Dr. Borenstein said. Most whose pain has a mechanical origin will get better within 4–8 weeks with conservative therapy that may consist of NSAIDs plus a muscle relaxant.

In fact, telling patients that they'll soon feel better itself has a therapeutic value. It's also good for them to be up and around as they are able, performing the normal activities of daily living. Studies have shown that patients who get 2 weeks of bed rest do no better than those performing normal activities. Patients should be counseled, however, not to go back to a vigorous exercise routine until the episode abates.

SAN FRANCISCO — A careful history and physical exam, without the need for lab tests or radiography, can help identify any red flags in patients presenting with low back pain, David Borenstein, M.D., said at the annual meeting of the American College of Physicians.

The history can distinguish mechanical from systemic disorders, and the physical exam can distinguish neurologic from nonneurologic conditions, said Dr. Borenstein of George Washington University, Washington.

“Laboratory tests are notably inconsequential,” he said. “When you're taking your history and you don't think they have one of these systemic illnesses, you really don't have to do laboratory tests on these individuals.”

Laboratory tests can be useful in distinguishing inflammatory from noninflammatory disorders, and radiologic tests can confirm a diagnosis derived from other means. But testing can just as easily confuse the issue.

It's critical to quickly identify the 5% or so of patients with cauda equina compression, often associated with an expanding aneurism or a herniated disc because they require emergency surgery. Typically these patients will have urinary retention, incontinence, or saddle anesthesia. In those cases, Dr. Borenstein recommended getting an MRI on an emergent basis. Results of one recent study showed that patients with cauda equina compression do much better if they get surgery within 48 hours of the start of acute symptoms. Patients whose surgery was delayed often experienced severe and persistent motor deficits, persistent sciatica, and sexual dysfunction (Spine 2000;25:348–51).

In a history of a patient with low back pain, five areas of questioning can identify many red flags. If the answers to these constitutional symptom questions are all negative, “you can treat an individual with back pain conservatively without doing an x-ray, without doing lab tests, in fact by telling them they're going to get better—and being right most of the time,” Dr. Borenstein said.

▸ Weight loss and/or fever can signal either vertebral osteomyelitis or a vertebral neoplasm. Radiography—either a plain x-ray, a CT scan, an MRI, or a bone scan—can be helpful here.

▸ Pain at night or with recumbency can signal either a bone tumor or a spinal-cord tumor. “If they tell you pain is worse at night, and they have any neurologic sign, that's a patient for whom I'd get an MRI,” he said.

▸ Morning stiffness that lasts for hours can signal spondyloarthropathy or ankylosing spondylitis. Making this diagnosis is now more critical because effective therapies have recently become available. An x-ray taken with Ferguson's view of the sacroiliac joints is helpful in this diagnosis.

▸ A patient who has acute, localized bone pain, equivalent in intensity to a bone fracture “is one of the few times where our laboratory tests can be helpful,” Dr. Borenstein said. He suggested getting an erythrocyte sedimentation rate, a CBC, and a chemistry profile. These tests can help differentiate the acute fracture of osteoporosis from a tumor, Paget's disease, or sickle cell disease.

▸ Finally, if the patient has viscerogenic pain, the physician should determine whether the pain is colicky, tearing, or episodic. Colicky pain suggests a kidney or gall bladder problem; tearing pain suggests a vascular problem such as an aneurism; and pain that's episodic, coinciding with meals or with the menstrual cycle, suggests pancreatitis, peptic ulcer, or endometriosis.

Only about 10%–15% of patients presenting with lower back pain will have one of those red flags, Dr. Borenstein said. Most whose pain has a mechanical origin will get better within 4–8 weeks with conservative therapy that may consist of NSAIDs plus a muscle relaxant.

In fact, telling patients that they'll soon feel better itself has a therapeutic value. It's also good for them to be up and around as they are able, performing the normal activities of daily living. Studies have shown that patients who get 2 weeks of bed rest do no better than those performing normal activities. Patients should be counseled, however, not to go back to a vigorous exercise routine until the episode abates.

SAN FRANCISCO — A careful history and physical exam, without the need for lab tests or radiography, can help identify any red flags in patients presenting with low back pain, David Borenstein, M.D., said at the annual meeting of the American College of Physicians.

The history can distinguish mechanical from systemic disorders, and the physical exam can distinguish neurologic from nonneurologic conditions, said Dr. Borenstein of George Washington University, Washington.

“Laboratory tests are notably inconsequential,” he said. “When you're taking your history and you don't think they have one of these systemic illnesses, you really don't have to do laboratory tests on these individuals.”

Laboratory tests can be useful in distinguishing inflammatory from noninflammatory disorders, and radiologic tests can confirm a diagnosis derived from other means. But testing can just as easily confuse the issue.

It's critical to quickly identify the 5% or so of patients with cauda equina compression, often associated with an expanding aneurism or a herniated disc because they require emergency surgery. Typically these patients will have urinary retention, incontinence, or saddle anesthesia. In those cases, Dr. Borenstein recommended getting an MRI on an emergent basis. Results of one recent study showed that patients with cauda equina compression do much better if they get surgery within 48 hours of the start of acute symptoms. Patients whose surgery was delayed often experienced severe and persistent motor deficits, persistent sciatica, and sexual dysfunction (Spine 2000;25:348–51).

In a history of a patient with low back pain, five areas of questioning can identify many red flags. If the answers to these constitutional symptom questions are all negative, “you can treat an individual with back pain conservatively without doing an x-ray, without doing lab tests, in fact by telling them they're going to get better—and being right most of the time,” Dr. Borenstein said.

▸ Weight loss and/or fever can signal either vertebral osteomyelitis or a vertebral neoplasm. Radiography—either a plain x-ray, a CT scan, an MRI, or a bone scan—can be helpful here.

▸ Pain at night or with recumbency can signal either a bone tumor or a spinal-cord tumor. “If they tell you pain is worse at night, and they have any neurologic sign, that's a patient for whom I'd get an MRI,” he said.

▸ Morning stiffness that lasts for hours can signal spondyloarthropathy or ankylosing spondylitis. Making this diagnosis is now more critical because effective therapies have recently become available. An x-ray taken with Ferguson's view of the sacroiliac joints is helpful in this diagnosis.

▸ A patient who has acute, localized bone pain, equivalent in intensity to a bone fracture “is one of the few times where our laboratory tests can be helpful,” Dr. Borenstein said. He suggested getting an erythrocyte sedimentation rate, a CBC, and a chemistry profile. These tests can help differentiate the acute fracture of osteoporosis from a tumor, Paget's disease, or sickle cell disease.

▸ Finally, if the patient has viscerogenic pain, the physician should determine whether the pain is colicky, tearing, or episodic. Colicky pain suggests a kidney or gall bladder problem; tearing pain suggests a vascular problem such as an aneurism; and pain that's episodic, coinciding with meals or with the menstrual cycle, suggests pancreatitis, peptic ulcer, or endometriosis.

Only about 10%–15% of patients presenting with lower back pain will have one of those red flags, Dr. Borenstein said. Most whose pain has a mechanical origin will get better within 4–8 weeks with conservative therapy that may consist of NSAIDs plus a muscle relaxant.

In fact, telling patients that they'll soon feel better itself has a therapeutic value. It's also good for them to be up and around as they are able, performing the normal activities of daily living. Studies have shown that patients who get 2 weeks of bed rest do no better than those performing normal activities. Patients should be counseled, however, not to go back to a vigorous exercise routine until the episode abates.

PORTLAND, ORE. — Recurrent infections with methicillin-resistant Staphylococcus aureus are common in children, and the effectiveness of the available treatments is “modest at best,” Sarah S. Long, M.D., said at a conference sponsored by the North Pacific Pediatric Society.

Still, one must try something because repeated episodes of furunculosis are so common in children. S. aureus colonizes the nasal passages, and when a child picks her nose, the infection can spread to anything the child touches. Especially vulnerable are areas with microabrasions, such as the diaper area and any place the child has eczema, said Dr. Long of Drexel University, Philadelphia.

About 70% of the cases of S. aureus infection in her hospital are community acquired and methicillin resistant. Because of that, “you now have to consider the bacteriology of every case,” she said.

Gone are the days when one could use amoxicillin/clavulanate because of its activity against staph and strep. Now once a furuncle is drained, “everybody deserves to have a culture” with susceptibility testing. Dr. Long said.

No one strategy against recurrent methicillin-resistant S. aureus (MRSA) has more than modest effectiveness. Nevertheless, she described the available strategies and how she might apply them.

▸ A repeat course of antibiotics is certainly indicated, but only after susceptibility testing to ensure that the antibiotic will be effective. Dr. Long said she might try a third course of antibiotics if the infection recurred.

▸ Rifampin by itself gives unimpressive results, but it can reduce MRSA colonization. At about the third recurrence, Dr. Long would add oral rifampin, 10 mg/kg per day, toward the end of a course of antibiotics.

▸ Alternatively, the third recurrence may be the time to use mupirocin applied in the nasal passages twice a day for 2 weeks.

▸ By the fourth recurrence, Dr. Long will combine rifampin, mupirocin, and a course of antibiotics.

Additionally, there are several hygiene measures that physicians may wish to recommend to the parents.

▸ Shower the child using chlorhexidine (Hibiclens) once a day for 2 weeks, and then once every 3 days. This reduces the chance that S. aureus will colonize various sites on the skin. But one note of caution: Chlorhexidine can cause dry skin, and parents should keep an eye out for this.

▸ It's important to take aggressive care of diaper rashes, which can easily be complicated by MRSA infections.

▸ Have the parent empty and clean the bathroom thoroughly. Soap, toothpaste, toothbrushes, and cosmetics all are frequently contaminated by S. aureus. “Do a blitz on the bathroom,” Dr. Long advised.

▸ Ensure that all family members use separate towels and washcloths because these are common vectors for the spread of staph infections. This precaution is critical for older children involved in sports, such as wrestling, where abrasions are commonplace.

PORTLAND, ORE. — Recurrent infections with methicillin-resistant Staphylococcus aureus are common in children, and the effectiveness of the available treatments is “modest at best,” Sarah S. Long, M.D., said at a conference sponsored by the North Pacific Pediatric Society.

Still, one must try something because repeated episodes of furunculosis are so common in children. S. aureus colonizes the nasal passages, and when a child picks her nose, the infection can spread to anything the child touches. Especially vulnerable are areas with microabrasions, such as the diaper area and any place the child has eczema, said Dr. Long of Drexel University, Philadelphia.

About 70% of the cases of S. aureus infection in her hospital are community acquired and methicillin resistant. Because of that, “you now have to consider the bacteriology of every case,” she said.

Gone are the days when one could use amoxicillin/clavulanate because of its activity against staph and strep. Now once a furuncle is drained, “everybody deserves to have a culture” with susceptibility testing. Dr. Long said.

No one strategy against recurrent methicillin-resistant S. aureus (MRSA) has more than modest effectiveness. Nevertheless, she described the available strategies and how she might apply them.

▸ A repeat course of antibiotics is certainly indicated, but only after susceptibility testing to ensure that the antibiotic will be effective. Dr. Long said she might try a third course of antibiotics if the infection recurred.

▸ Rifampin by itself gives unimpressive results, but it can reduce MRSA colonization. At about the third recurrence, Dr. Long would add oral rifampin, 10 mg/kg per day, toward the end of a course of antibiotics.

▸ Alternatively, the third recurrence may be the time to use mupirocin applied in the nasal passages twice a day for 2 weeks.

▸ By the fourth recurrence, Dr. Long will combine rifampin, mupirocin, and a course of antibiotics.

Additionally, there are several hygiene measures that physicians may wish to recommend to the parents.

▸ Shower the child using chlorhexidine (Hibiclens) once a day for 2 weeks, and then once every 3 days. This reduces the chance that S. aureus will colonize various sites on the skin. But one note of caution: Chlorhexidine can cause dry skin, and parents should keep an eye out for this.

▸ It's important to take aggressive care of diaper rashes, which can easily be complicated by MRSA infections.

▸ Have the parent empty and clean the bathroom thoroughly. Soap, toothpaste, toothbrushes, and cosmetics all are frequently contaminated by S. aureus. “Do a blitz on the bathroom,” Dr. Long advised.

▸ Ensure that all family members use separate towels and washcloths because these are common vectors for the spread of staph infections. This precaution is critical for older children involved in sports, such as wrestling, where abrasions are commonplace.

PORTLAND, ORE. — Recurrent infections with methicillin-resistant Staphylococcus aureus are common in children, and the effectiveness of the available treatments is “modest at best,” Sarah S. Long, M.D., said at a conference sponsored by the North Pacific Pediatric Society.

Still, one must try something because repeated episodes of furunculosis are so common in children. S. aureus colonizes the nasal passages, and when a child picks her nose, the infection can spread to anything the child touches. Especially vulnerable are areas with microabrasions, such as the diaper area and any place the child has eczema, said Dr. Long of Drexel University, Philadelphia.

About 70% of the cases of S. aureus infection in her hospital are community acquired and methicillin resistant. Because of that, “you now have to consider the bacteriology of every case,” she said.

Gone are the days when one could use amoxicillin/clavulanate because of its activity against staph and strep. Now once a furuncle is drained, “everybody deserves to have a culture” with susceptibility testing. Dr. Long said.

No one strategy against recurrent methicillin-resistant S. aureus (MRSA) has more than modest effectiveness. Nevertheless, she described the available strategies and how she might apply them.

▸ A repeat course of antibiotics is certainly indicated, but only after susceptibility testing to ensure that the antibiotic will be effective. Dr. Long said she might try a third course of antibiotics if the infection recurred.

▸ Rifampin by itself gives unimpressive results, but it can reduce MRSA colonization. At about the third recurrence, Dr. Long would add oral rifampin, 10 mg/kg per day, toward the end of a course of antibiotics.

▸ Alternatively, the third recurrence may be the time to use mupirocin applied in the nasal passages twice a day for 2 weeks.

▸ By the fourth recurrence, Dr. Long will combine rifampin, mupirocin, and a course of antibiotics.

Additionally, there are several hygiene measures that physicians may wish to recommend to the parents.

▸ Shower the child using chlorhexidine (Hibiclens) once a day for 2 weeks, and then once every 3 days. This reduces the chance that S. aureus will colonize various sites on the skin. But one note of caution: Chlorhexidine can cause dry skin, and parents should keep an eye out for this.

▸ It's important to take aggressive care of diaper rashes, which can easily be complicated by MRSA infections.

▸ Have the parent empty and clean the bathroom thoroughly. Soap, toothpaste, toothbrushes, and cosmetics all are frequently contaminated by S. aureus. “Do a blitz on the bathroom,” Dr. Long advised.

▸ Ensure that all family members use separate towels and washcloths because these are common vectors for the spread of staph infections. This precaution is critical for older children involved in sports, such as wrestling, where abrasions are commonplace.

SAN FRANCISCO — It may be appropriate to wean some patients from the daily use of proton pump inhibitors, but acid rebound can make this more difficult, David A. Peura, M.D., reported at the annual meeting of the American College of Physicians.

In his review of the evidence, Dr. Peura, professor of internal medicine at the University of Virginia, Charlottesville, drew a distinction between patients with gastroesophageal reflux disease (GERD) and those with the less serious nonerosive reflux disease (NERD).

Patients with NERD appear to have a much easier time discontinuing proton pump inhibitors (PPIs) or using them intermittently. In one study, 677 people with NERD who were asymptomatic after 2–4 weeks of PPI treatment were instructed to take a 2-week course of 20 mg of omeprazole, 10 mg of omeprazole, or 150 mg of ranitidine (a histamine2 receptor blocker) whenever symptoms developed (BMJ 1999;318:502–7).

During the year, 40% of patients had no relapses, and 90% of them required three or fewer courses of therapy to maintain satisfaction. This study influenced the dosing recommendation for over-the-counter omeprazole, Dr. Peura said.

On the other hand, weaning patients with GERD from daily PPI therapy may be difficult. An as-yet-unpublished systematic review from the Cochrane Collaboration concluded that about 80% of patients with GERD would experience a relapse of symptoms or esophagitis within 6–12 months if switched to a placebo.

“You can decrease that by giving an individual a half-dose treatment,” Dr. Peura said. “I personally never give half-dose PPIs because they're cost equivalent. The only reason you ever reduce the dose is if you worry about cost or safety. There's no safety issue with these doses, and they're flat priced.”

When PPIs are stopped abruptly in patients who have been treated long term with PPIs, there's often an acid rebound. According to one study, this effect appears to be restricted to patients who are negative for Helicobacter pylori infection (Gastroenterology 2004;126:980–8).

Dr. Peura said that tapering works better than abrupt withdrawal. “If I have somebody who's been on a drug for a while, I won't just stop it. I'll treat them every other day for a while, then every third day, trying to get them off the drug.” Tapering can be especially difficult in patients who have been taking twice-daily doses of a PPI, he said, making it important to use only the lowest effective dose.

Dr. Peura acknowledged serving on the speakers' bureaus of TAP Pharmaceutical Products Inc., AstraZeneca PLC, and Wyeth Pharmaceuticals, all of which make medications for gastric reflux.

SAN FRANCISCO — It may be appropriate to wean some patients from the daily use of proton pump inhibitors, but acid rebound can make this more difficult, David A. Peura, M.D., reported at the annual meeting of the American College of Physicians.

In his review of the evidence, Dr. Peura, professor of internal medicine at the University of Virginia, Charlottesville, drew a distinction between patients with gastroesophageal reflux disease (GERD) and those with the less serious nonerosive reflux disease (NERD).

Patients with NERD appear to have a much easier time discontinuing proton pump inhibitors (PPIs) or using them intermittently. In one study, 677 people with NERD who were asymptomatic after 2–4 weeks of PPI treatment were instructed to take a 2-week course of 20 mg of omeprazole, 10 mg of omeprazole, or 150 mg of ranitidine (a histamine2 receptor blocker) whenever symptoms developed (BMJ 1999;318:502–7).

During the year, 40% of patients had no relapses, and 90% of them required three or fewer courses of therapy to maintain satisfaction. This study influenced the dosing recommendation for over-the-counter omeprazole, Dr. Peura said.

On the other hand, weaning patients with GERD from daily PPI therapy may be difficult. An as-yet-unpublished systematic review from the Cochrane Collaboration concluded that about 80% of patients with GERD would experience a relapse of symptoms or esophagitis within 6–12 months if switched to a placebo.

“You can decrease that by giving an individual a half-dose treatment,” Dr. Peura said. “I personally never give half-dose PPIs because they're cost equivalent. The only reason you ever reduce the dose is if you worry about cost or safety. There's no safety issue with these doses, and they're flat priced.”

When PPIs are stopped abruptly in patients who have been treated long term with PPIs, there's often an acid rebound. According to one study, this effect appears to be restricted to patients who are negative for Helicobacter pylori infection (Gastroenterology 2004;126:980–8).

Dr. Peura said that tapering works better than abrupt withdrawal. “If I have somebody who's been on a drug for a while, I won't just stop it. I'll treat them every other day for a while, then every third day, trying to get them off the drug.” Tapering can be especially difficult in patients who have been taking twice-daily doses of a PPI, he said, making it important to use only the lowest effective dose.

Dr. Peura acknowledged serving on the speakers' bureaus of TAP Pharmaceutical Products Inc., AstraZeneca PLC, and Wyeth Pharmaceuticals, all of which make medications for gastric reflux.

SAN FRANCISCO — It may be appropriate to wean some patients from the daily use of proton pump inhibitors, but acid rebound can make this more difficult, David A. Peura, M.D., reported at the annual meeting of the American College of Physicians.

In his review of the evidence, Dr. Peura, professor of internal medicine at the University of Virginia, Charlottesville, drew a distinction between patients with gastroesophageal reflux disease (GERD) and those with the less serious nonerosive reflux disease (NERD).

Patients with NERD appear to have a much easier time discontinuing proton pump inhibitors (PPIs) or using them intermittently. In one study, 677 people with NERD who were asymptomatic after 2–4 weeks of PPI treatment were instructed to take a 2-week course of 20 mg of omeprazole, 10 mg of omeprazole, or 150 mg of ranitidine (a histamine2 receptor blocker) whenever symptoms developed (BMJ 1999;318:502–7).

During the year, 40% of patients had no relapses, and 90% of them required three or fewer courses of therapy to maintain satisfaction. This study influenced the dosing recommendation for over-the-counter omeprazole, Dr. Peura said.

On the other hand, weaning patients with GERD from daily PPI therapy may be difficult. An as-yet-unpublished systematic review from the Cochrane Collaboration concluded that about 80% of patients with GERD would experience a relapse of symptoms or esophagitis within 6–12 months if switched to a placebo.

“You can decrease that by giving an individual a half-dose treatment,” Dr. Peura said. “I personally never give half-dose PPIs because they're cost equivalent. The only reason you ever reduce the dose is if you worry about cost or safety. There's no safety issue with these doses, and they're flat priced.”

When PPIs are stopped abruptly in patients who have been treated long term with PPIs, there's often an acid rebound. According to one study, this effect appears to be restricted to patients who are negative for Helicobacter pylori infection (Gastroenterology 2004;126:980–8).

Dr. Peura said that tapering works better than abrupt withdrawal. “If I have somebody who's been on a drug for a while, I won't just stop it. I'll treat them every other day for a while, then every third day, trying to get them off the drug.” Tapering can be especially difficult in patients who have been taking twice-daily doses of a PPI, he said, making it important to use only the lowest effective dose.

Dr. Peura acknowledged serving on the speakers' bureaus of TAP Pharmaceutical Products Inc., AstraZeneca PLC, and Wyeth Pharmaceuticals, all of which make medications for gastric reflux.

PORTLAND, ORE. — It's easy to misinterpret the results of serology tests for Epstein-Barr virus, so these results should not substitute for clinical judgment in suspected cases of Epstein-Barr mononucleosis in children, Sarah S. Long, M.D., said at a conference sponsored by the North Pacific Pediatric Society.

“You do laboratory tests to confirm your clinical suspicion, not to go fishing,” said Dr. Long of Drexel University, Philadelphia.

“If you apply [these tests] to populations that are at low pretest probability of having the disease, most of your results will be false positives.”

And in the specific case of Epstein-Barr virus (EBV), some of the serology results will remain positive for the rest of the patient's life, long after the clinical syndrome has resolved.

Although some patients believe that they have a chronic EBV infection, often it's because they test positive for these antibodies, and the physician can provide reassurance that the antibodies are an indication of a resolved, not a chronic, infection.

Serology is not always necessary when clinical signs and symptoms are strongly suggestive of EBV mononucleosis, Dr. Long said.

“If you have a 16-year-old with exudative pharyngitis, you get a CBC and you've got 30% atypical lymphocytosis, don't go any further,” she said. “He's got EBV mononucleosis and you're home free and can predict the rest of it. You don't need a heterophile [antibody test], you don't ever want to follow up if that test ever becomes negative, and you don't need specific serology.”

On the other hand, one shouldn't turn a blind eye to the hemoglobin, neutrophil, and platelet counts. Patients with thrombocytopenia or neutropenia in addition to lymphocytosis may have leukemia.

Of the four serology tests, the Epstein-Barr nuclear antigen (EBNA) test can be the most misleading. The virus expresses nuclear antigen only when it becomes latent, and after that, the patient will be EBNA positive for the rest of his or her life.

Therefore, a positive EBNA means that the patient does not currently have EBV mononucleosis.

The way to remember this, Dr. Long suggested, is to think of the acronym EBNA as standing for “Epstein-Barr not applicable.”

In a patient with acute EBV mononucleosis, the heterophile antibody test will be positive, as will tests for IgM viral capsid antigen (VCA) and IgG VCA. EBNA will be negative.

When the mononucleosis is on its way toward resolution, the heterophile antibody and the IgM VCA may be positive or negative. IgG VCA will be positive (and will remain so for life), but EBNA still will be negative.

Finally, once the mononucleosis has resolved, heterophile antibody and IgM VCA will both be negative, while IgG VCA and EBNA will both be positive.

PORTLAND, ORE. — It's easy to misinterpret the results of serology tests for Epstein-Barr virus, so these results should not substitute for clinical judgment in suspected cases of Epstein-Barr mononucleosis in children, Sarah S. Long, M.D., said at a conference sponsored by the North Pacific Pediatric Society.

“You do laboratory tests to confirm your clinical suspicion, not to go fishing,” said Dr. Long of Drexel University, Philadelphia.

“If you apply [these tests] to populations that are at low pretest probability of having the disease, most of your results will be false positives.”

And in the specific case of Epstein-Barr virus (EBV), some of the serology results will remain positive for the rest of the patient's life, long after the clinical syndrome has resolved.

Although some patients believe that they have a chronic EBV infection, often it's because they test positive for these antibodies, and the physician can provide reassurance that the antibodies are an indication of a resolved, not a chronic, infection.

Serology is not always necessary when clinical signs and symptoms are strongly suggestive of EBV mononucleosis, Dr. Long said.

“If you have a 16-year-old with exudative pharyngitis, you get a CBC and you've got 30% atypical lymphocytosis, don't go any further,” she said. “He's got EBV mononucleosis and you're home free and can predict the rest of it. You don't need a heterophile [antibody test], you don't ever want to follow up if that test ever becomes negative, and you don't need specific serology.”

On the other hand, one shouldn't turn a blind eye to the hemoglobin, neutrophil, and platelet counts. Patients with thrombocytopenia or neutropenia in addition to lymphocytosis may have leukemia.

Of the four serology tests, the Epstein-Barr nuclear antigen (EBNA) test can be the most misleading. The virus expresses nuclear antigen only when it becomes latent, and after that, the patient will be EBNA positive for the rest of his or her life.

Therefore, a positive EBNA means that the patient does not currently have EBV mononucleosis.

The way to remember this, Dr. Long suggested, is to think of the acronym EBNA as standing for “Epstein-Barr not applicable.”

In a patient with acute EBV mononucleosis, the heterophile antibody test will be positive, as will tests for IgM viral capsid antigen (VCA) and IgG VCA. EBNA will be negative.

When the mononucleosis is on its way toward resolution, the heterophile antibody and the IgM VCA may be positive or negative. IgG VCA will be positive (and will remain so for life), but EBNA still will be negative.

Finally, once the mononucleosis has resolved, heterophile antibody and IgM VCA will both be negative, while IgG VCA and EBNA will both be positive.

PORTLAND, ORE. — It's easy to misinterpret the results of serology tests for Epstein-Barr virus, so these results should not substitute for clinical judgment in suspected cases of Epstein-Barr mononucleosis in children, Sarah S. Long, M.D., said at a conference sponsored by the North Pacific Pediatric Society.

“You do laboratory tests to confirm your clinical suspicion, not to go fishing,” said Dr. Long of Drexel University, Philadelphia.

“If you apply [these tests] to populations that are at low pretest probability of having the disease, most of your results will be false positives.”

And in the specific case of Epstein-Barr virus (EBV), some of the serology results will remain positive for the rest of the patient's life, long after the clinical syndrome has resolved.

Although some patients believe that they have a chronic EBV infection, often it's because they test positive for these antibodies, and the physician can provide reassurance that the antibodies are an indication of a resolved, not a chronic, infection.

Serology is not always necessary when clinical signs and symptoms are strongly suggestive of EBV mononucleosis, Dr. Long said.

“If you have a 16-year-old with exudative pharyngitis, you get a CBC and you've got 30% atypical lymphocytosis, don't go any further,” she said. “He's got EBV mononucleosis and you're home free and can predict the rest of it. You don't need a heterophile [antibody test], you don't ever want to follow up if that test ever becomes negative, and you don't need specific serology.”

On the other hand, one shouldn't turn a blind eye to the hemoglobin, neutrophil, and platelet counts. Patients with thrombocytopenia or neutropenia in addition to lymphocytosis may have leukemia.

Of the four serology tests, the Epstein-Barr nuclear antigen (EBNA) test can be the most misleading. The virus expresses nuclear antigen only when it becomes latent, and after that, the patient will be EBNA positive for the rest of his or her life.

Therefore, a positive EBNA means that the patient does not currently have EBV mononucleosis.

The way to remember this, Dr. Long suggested, is to think of the acronym EBNA as standing for “Epstein-Barr not applicable.”

In a patient with acute EBV mononucleosis, the heterophile antibody test will be positive, as will tests for IgM viral capsid antigen (VCA) and IgG VCA. EBNA will be negative.

When the mononucleosis is on its way toward resolution, the heterophile antibody and the IgM VCA may be positive or negative. IgG VCA will be positive (and will remain so for life), but EBNA still will be negative.

Finally, once the mononucleosis has resolved, heterophile antibody and IgM VCA will both be negative, while IgG VCA and EBNA will both be positive.

SANTA FE, N.M. — A study of children's autonomic responses to reward and negative mood induction suggests that when conduct disorder and depression are comorbid, depression is the primary disorder.

In a poster presentation at the annual meeting of the Society for Psychophysiological Research, Hilary K. Mead, a graduate student working in the Child and Adolescent Adjustment Project at the University of Washington (Seattle), noted that previous studies have suggested that comorbidity rates for the two conditions may be as high as 82%, but that it's unclear whether conduct disorder (CD) arises from depression or whether depression arises from CD.

The National Institutes of Health funded experiment involved 116 children, aged 8–12 years. Eighteen had conduct disorder and/or oppositional defiant disorder, 15 had depression and/or dysthymia, 37 had comorbid depression and conduct disorder, and 46 had no psychiatric condition.

All children had their electrodermal responses (EDR), their respiratory sinus arrhythmia (RSA), and their cardiac pre-ejection period (PEP) measured during three successive experimental conditions: a 5-minute baseline, a monetary incentive task, and negative mood induction via an emotionally evocative film clip.

If CD were the primary disorder, groups with CD alone and with comorbid CD and depression would be expected to have a similar pattern of autonomic responses. If depression were primary, groups with depression alone and comorbid CD and depression would show similar autonomic responses. If neither condition were primary, all three groups of children with psychiatric disorders would be expected to be similar.

As it turned out, children with CD had a pattern of autonomic responses that differed significantly from the other groups. The EDR of children with CD did not change across trials of the reward incentive task, while all other groups showed decreases in EDR. During negative mood induction, children with CD had decreasing PEP and increasing RSA, while the other groups showed no change from baseline.

The investigators concluded that depression is the primary disorder in children with comorbid internalizing and externalizing psychopathologic symptoms.

SANTA FE, N.M. — A study of children's autonomic responses to reward and negative mood induction suggests that when conduct disorder and depression are comorbid, depression is the primary disorder.

In a poster presentation at the annual meeting of the Society for Psychophysiological Research, Hilary K. Mead, a graduate student working in the Child and Adolescent Adjustment Project at the University of Washington (Seattle), noted that previous studies have suggested that comorbidity rates for the two conditions may be as high as 82%, but that it's unclear whether conduct disorder (CD) arises from depression or whether depression arises from CD.

The National Institutes of Health funded experiment involved 116 children, aged 8–12 years. Eighteen had conduct disorder and/or oppositional defiant disorder, 15 had depression and/or dysthymia, 37 had comorbid depression and conduct disorder, and 46 had no psychiatric condition.

All children had their electrodermal responses (EDR), their respiratory sinus arrhythmia (RSA), and their cardiac pre-ejection period (PEP) measured during three successive experimental conditions: a 5-minute baseline, a monetary incentive task, and negative mood induction via an emotionally evocative film clip.

If CD were the primary disorder, groups with CD alone and with comorbid CD and depression would be expected to have a similar pattern of autonomic responses. If depression were primary, groups with depression alone and comorbid CD and depression would show similar autonomic responses. If neither condition were primary, all three groups of children with psychiatric disorders would be expected to be similar.

As it turned out, children with CD had a pattern of autonomic responses that differed significantly from the other groups. The EDR of children with CD did not change across trials of the reward incentive task, while all other groups showed decreases in EDR. During negative mood induction, children with CD had decreasing PEP and increasing RSA, while the other groups showed no change from baseline.

The investigators concluded that depression is the primary disorder in children with comorbid internalizing and externalizing psychopathologic symptoms.

SANTA FE, N.M. — A study of children's autonomic responses to reward and negative mood induction suggests that when conduct disorder and depression are comorbid, depression is the primary disorder.

In a poster presentation at the annual meeting of the Society for Psychophysiological Research, Hilary K. Mead, a graduate student working in the Child and Adolescent Adjustment Project at the University of Washington (Seattle), noted that previous studies have suggested that comorbidity rates for the two conditions may be as high as 82%, but that it's unclear whether conduct disorder (CD) arises from depression or whether depression arises from CD.

The National Institutes of Health funded experiment involved 116 children, aged 8–12 years. Eighteen had conduct disorder and/or oppositional defiant disorder, 15 had depression and/or dysthymia, 37 had comorbid depression and conduct disorder, and 46 had no psychiatric condition.

All children had their electrodermal responses (EDR), their respiratory sinus arrhythmia (RSA), and their cardiac pre-ejection period (PEP) measured during three successive experimental conditions: a 5-minute baseline, a monetary incentive task, and negative mood induction via an emotionally evocative film clip.

If CD were the primary disorder, groups with CD alone and with comorbid CD and depression would be expected to have a similar pattern of autonomic responses. If depression were primary, groups with depression alone and comorbid CD and depression would show similar autonomic responses. If neither condition were primary, all three groups of children with psychiatric disorders would be expected to be similar.

As it turned out, children with CD had a pattern of autonomic responses that differed significantly from the other groups. The EDR of children with CD did not change across trials of the reward incentive task, while all other groups showed decreases in EDR. During negative mood induction, children with CD had decreasing PEP and increasing RSA, while the other groups showed no change from baseline.

The investigators concluded that depression is the primary disorder in children with comorbid internalizing and externalizing psychopathologic symptoms.

SPOKANE, WASH. — The top three reasons to consider treatment of a neonatal hemangioma are the same as the top three determinants of value in real estate: location, location, and location, explained Howard B. Pride, M.D.

While most neonatal hemangiomas will involute and resolve spontaneously, some require treatment, Dr. Pride said at the annual Pacific Northwest Dermatological Conference:

▸ Hemangiomas in the “beard” area of the face can grow to compromise the airway.

In one study, children with extensive hemangiomas in the beard area had a 63% chance of airway involvement, and 40% needed tracheotomy (J. Pediatr. 1997;131:643–6). In a separate study of “parotid” hemangiomas (a term often used synonymously with “beard-area hemangiomas”), 59% ulcerated, 26% had airway involvement, 7% required tracheotomy, and 70% required systemic treatment (Plast. Reconstr. Surg. 2004;113:53–60).

▸ Hemangiomas near the eye, while not life threatening, can be vision threatening, said Dr. Pride of Geisinger Medical Center, Danville, Pa.

If the hemangioma grows large enough to block vision during a critical period of neural development, the child's cortical vision centers may never develop normally.

Even if the hemangioma goes on to resolve spontaneously, that child will suffer permanent vision damage.

▸ Hemangiomas on the nasal tip can have bad cosmetic outcomes after they resolve.

“Sometimes, fairly banal hemangiomas [on the nose] will leave very significant cosmetic problems,” Dr. Pride said at the conference, which was sponsored by the Washington State Dermatology Association.

▸ Lip hemangiomas can also have bad cosmetic outcomes, although the chances of this happening are somewhat less than when the nose is involved. The skin on the lip has a degree of laxity, and therefore there's a smaller risk of scarring.

▸ Hemangiomas on the hand or fingers can have functional as well as cosmetic consequences.

▸ Hemangiomas in the diaper area, even fairly small ones, “have an unbelievable propensity for ulceration and are really bad,” Dr. Pride said.

▸ Whether to treat pedunculated hemangiomas is a subject of debate.

While some plastic surgeons prefer to fix residual cosmetic defects after the hemangioma resolves, others recommend early surgical excision. Hemangiomas that grow like a mushroom, with a large mass on a narrow stalk, are especially good candidates for early intervention, Dr. Pride said.

When dealing with any pedunculated hemangioma, “get the surgeons involved early and then let them walk through the nuances of whether it should be done early or late,” he said.

▸ Diffuse neonatal hemangiomatosis is a serious condition, since it's often accompanied by visceral hemangiomas in the liver, lung, brain, or GI tract.

The presence of five or more cutaneous hemangiomas should trigger an ultrasound examination of the infant, hemoccult stools, and possibly a chest x-ray if lung involvement or congestive heart failure is suspected.

Untreated, this condition has a 75% mortality rate.

▸ PHACES syndrome is another serious hemangioma-related condition requiring treatment.

It's named from an acronym of its main features: posterior fossa malformations; hemangiomas of the cervicofacial area; arterial anomalies, especially in the CNS; cardiac anomalies, sometimes including coarctation of the aorta; eye abnormalities; and sternal or abdominal clefting.

This 5-week-old child has a large hemangioma around the eye. The lesion was treated with prednisone for 4 months and responded well to the therapy. Courtesy Dr. Howard B. Pride

SPOKANE, WASH. — The top three reasons to consider treatment of a neonatal hemangioma are the same as the top three determinants of value in real estate: location, location, and location, explained Howard B. Pride, M.D.

While most neonatal hemangiomas will involute and resolve spontaneously, some require treatment, Dr. Pride said at the annual Pacific Northwest Dermatological Conference:

▸ Hemangiomas in the “beard” area of the face can grow to compromise the airway.

In one study, children with extensive hemangiomas in the beard area had a 63% chance of airway involvement, and 40% needed tracheotomy (J. Pediatr. 1997;131:643–6). In a separate study of “parotid” hemangiomas (a term often used synonymously with “beard-area hemangiomas”), 59% ulcerated, 26% had airway involvement, 7% required tracheotomy, and 70% required systemic treatment (Plast. Reconstr. Surg. 2004;113:53–60).

▸ Hemangiomas near the eye, while not life threatening, can be vision threatening, said Dr. Pride of Geisinger Medical Center, Danville, Pa.

If the hemangioma grows large enough to block vision during a critical period of neural development, the child's cortical vision centers may never develop normally.

Even if the hemangioma goes on to resolve spontaneously, that child will suffer permanent vision damage.

▸ Hemangiomas on the nasal tip can have bad cosmetic outcomes after they resolve.

“Sometimes, fairly banal hemangiomas [on the nose] will leave very significant cosmetic problems,” Dr. Pride said at the conference, which was sponsored by the Washington State Dermatology Association.

▸ Lip hemangiomas can also have bad cosmetic outcomes, although the chances of this happening are somewhat less than when the nose is involved. The skin on the lip has a degree of laxity, and therefore there's a smaller risk of scarring.

▸ Hemangiomas on the hand or fingers can have functional as well as cosmetic consequences.

▸ Hemangiomas in the diaper area, even fairly small ones, “have an unbelievable propensity for ulceration and are really bad,” Dr. Pride said.

▸ Whether to treat pedunculated hemangiomas is a subject of debate.

While some plastic surgeons prefer to fix residual cosmetic defects after the hemangioma resolves, others recommend early surgical excision. Hemangiomas that grow like a mushroom, with a large mass on a narrow stalk, are especially good candidates for early intervention, Dr. Pride said.

When dealing with any pedunculated hemangioma, “get the surgeons involved early and then let them walk through the nuances of whether it should be done early or late,” he said.

▸ Diffuse neonatal hemangiomatosis is a serious condition, since it's often accompanied by visceral hemangiomas in the liver, lung, brain, or GI tract.

The presence of five or more cutaneous hemangiomas should trigger an ultrasound examination of the infant, hemoccult stools, and possibly a chest x-ray if lung involvement or congestive heart failure is suspected.

Untreated, this condition has a 75% mortality rate.

▸ PHACES syndrome is another serious hemangioma-related condition requiring treatment.

It's named from an acronym of its main features: posterior fossa malformations; hemangiomas of the cervicofacial area; arterial anomalies, especially in the CNS; cardiac anomalies, sometimes including coarctation of the aorta; eye abnormalities; and sternal or abdominal clefting.

This 5-week-old child has a large hemangioma around the eye. The lesion was treated with prednisone for 4 months and responded well to the therapy. Courtesy Dr. Howard B. Pride

SPOKANE, WASH. — The top three reasons to consider treatment of a neonatal hemangioma are the same as the top three determinants of value in real estate: location, location, and location, explained Howard B. Pride, M.D.

While most neonatal hemangiomas will involute and resolve spontaneously, some require treatment, Dr. Pride said at the annual Pacific Northwest Dermatological Conference:

▸ Hemangiomas in the “beard” area of the face can grow to compromise the airway.

In one study, children with extensive hemangiomas in the beard area had a 63% chance of airway involvement, and 40% needed tracheotomy (J. Pediatr. 1997;131:643–6). In a separate study of “parotid” hemangiomas (a term often used synonymously with “beard-area hemangiomas”), 59% ulcerated, 26% had airway involvement, 7% required tracheotomy, and 70% required systemic treatment (Plast. Reconstr. Surg. 2004;113:53–60).

▸ Hemangiomas near the eye, while not life threatening, can be vision threatening, said Dr. Pride of Geisinger Medical Center, Danville, Pa.

If the hemangioma grows large enough to block vision during a critical period of neural development, the child's cortical vision centers may never develop normally.

Even if the hemangioma goes on to resolve spontaneously, that child will suffer permanent vision damage.

▸ Hemangiomas on the nasal tip can have bad cosmetic outcomes after they resolve.

“Sometimes, fairly banal hemangiomas [on the nose] will leave very significant cosmetic problems,” Dr. Pride said at the conference, which was sponsored by the Washington State Dermatology Association.

▸ Lip hemangiomas can also have bad cosmetic outcomes, although the chances of this happening are somewhat less than when the nose is involved. The skin on the lip has a degree of laxity, and therefore there's a smaller risk of scarring.

▸ Hemangiomas on the hand or fingers can have functional as well as cosmetic consequences.

▸ Hemangiomas in the diaper area, even fairly small ones, “have an unbelievable propensity for ulceration and are really bad,” Dr. Pride said.

▸ Whether to treat pedunculated hemangiomas is a subject of debate.

While some plastic surgeons prefer to fix residual cosmetic defects after the hemangioma resolves, others recommend early surgical excision. Hemangiomas that grow like a mushroom, with a large mass on a narrow stalk, are especially good candidates for early intervention, Dr. Pride said.

When dealing with any pedunculated hemangioma, “get the surgeons involved early and then let them walk through the nuances of whether it should be done early or late,” he said.

▸ Diffuse neonatal hemangiomatosis is a serious condition, since it's often accompanied by visceral hemangiomas in the liver, lung, brain, or GI tract.

The presence of five or more cutaneous hemangiomas should trigger an ultrasound examination of the infant, hemoccult stools, and possibly a chest x-ray if lung involvement or congestive heart failure is suspected.

Untreated, this condition has a 75% mortality rate.

▸ PHACES syndrome is another serious hemangioma-related condition requiring treatment.

It's named from an acronym of its main features: posterior fossa malformations; hemangiomas of the cervicofacial area; arterial anomalies, especially in the CNS; cardiac anomalies, sometimes including coarctation of the aorta; eye abnormalities; and sternal or abdominal clefting.

This 5-week-old child has a large hemangioma around the eye. The lesion was treated with prednisone for 4 months and responded well to the therapy. Courtesy Dr. Howard B. Pride

SAN FRANCISCO — The American College of Physicians and the American College of Physicians Foundation have begun a major 3-year initiative to improve diabetes care in the United States.

The initiative, announced at a press briefing during the annual meeting of the ACP, is aimed not only at physicians, but also at the entire diabetes management team, including subspecialists, physician assistants, diabetes educators, nurses, office staff, and the patients themselves.

Of the 18.2 million Americans with diabetes, 5.2 million are undiagnosed, according to information distributed at the briefing.

Novo Nordisk, the Denmark-based pharmaceutical company that first commercialized insulin, has funded the initiative with an unrestricted educational grant of $9.27 million.

“We believe this intensive 3-year project, combining an emphasis on highest standards of care, measurable goals for practice in office settings, and research, can dramatically improve diabetes care,” Charles K. Francis, M.D., president of the ACP said in a statement.

Some of the educational programs and materials will be available to the medical profession in general, while others will be limited to ACP members.

Vincenza Snow, M.D., the ACP's director of clinical programs, said that the project has three goals: to increase physician awareness of high-quality diabetes care and the gap between current practice and acceptable standards, to provide proven educational interventions for improving care to the entire diabetes team, and to recognize physicians and physician practices that make demonstrable improvements in the care of patients with diabetes.

“Knowledge is necessary but not sufficient for change,” Dr. Snow said, noting that all internists have extensive training in diabetes care.

“It's not necessarily that our members don't know what to do. We need to empower them to do that in their real-life practices. What has been shown is that multifaceted and multi-intervention educational programs are what works. You have to hit people over the head many, many times in many different ways to make sure that new things are implemented and that they don't disappear once the intervention goes away.”

The initiative was inaugurated at the ACP annual meeting with a diabetes track consisting of 16 workshops and courses. This track will be a feature of future annual meetings, and clinical skills modules will be offered at local chapter meetings.

Other parts of the program will be introduced at a rapid pace, Dr. Snow said. For example, enhanced diabetes information will become part of the ACP's Web-based point-of-care decision support tool, Physicians' Information and Education Resource (PIER); the medical knowledge self-assessment program (MKSAP); and the college's Web site (www.acponline.org

Versions of MKSAP will be developed for nonphysician members of the diabetes management team.

And ACP will develop a self-management tool kit to help patients become working partners with their health care providers in diabetes care. These materials, available in both English and Spanish, will include versions intended for patients whose literacy is at the third- or fourth-grade level.

Additionally, ACP will develop a Web portal collecting all of its diabetes information in one place, offering clinical decision support, CME credit, and the latest research in diabetes care.

“Beating diabetes is our passion, not just our business,” said Alan C. Moses, M.D., vice president of medical affairs for Novo Nordisk. “We try to distinguish ourselves from other companies by acting in accordance with our triple-bottom-line principle, [which] emphasizes a commitment not only to the economic success of the business, but just as importantly, to environmental soundness and social responsibility.”

The initiative will include a research component that will assess measurable outcomes as the project progresses.

“I hope that 3 years from now we'll be here again talking about the positive results of the project and the real changes that have occurred in diabetes care,” Dr. Francis said.

SAN FRANCISCO — The American College of Physicians and the American College of Physicians Foundation have begun a major 3-year initiative to improve diabetes care in the United States.

The initiative, announced at a press briefing during the annual meeting of the ACP, is aimed not only at physicians, but also at the entire diabetes management team, including subspecialists, physician assistants, diabetes educators, nurses, office staff, and the patients themselves.

Of the 18.2 million Americans with diabetes, 5.2 million are undiagnosed, according to information distributed at the briefing.

Novo Nordisk, the Denmark-based pharmaceutical company that first commercialized insulin, has funded the initiative with an unrestricted educational grant of $9.27 million.

“We believe this intensive 3-year project, combining an emphasis on highest standards of care, measurable goals for practice in office settings, and research, can dramatically improve diabetes care,” Charles K. Francis, M.D., president of the ACP said in a statement.

Some of the educational programs and materials will be available to the medical profession in general, while others will be limited to ACP members.

Vincenza Snow, M.D., the ACP's director of clinical programs, said that the project has three goals: to increase physician awareness of high-quality diabetes care and the gap between current practice and acceptable standards, to provide proven educational interventions for improving care to the entire diabetes team, and to recognize physicians and physician practices that make demonstrable improvements in the care of patients with diabetes.

“Knowledge is necessary but not sufficient for change,” Dr. Snow said, noting that all internists have extensive training in diabetes care.

“It's not necessarily that our members don't know what to do. We need to empower them to do that in their real-life practices. What has been shown is that multifaceted and multi-intervention educational programs are what works. You have to hit people over the head many, many times in many different ways to make sure that new things are implemented and that they don't disappear once the intervention goes away.”

The initiative was inaugurated at the ACP annual meeting with a diabetes track consisting of 16 workshops and courses. This track will be a feature of future annual meetings, and clinical skills modules will be offered at local chapter meetings.

Other parts of the program will be introduced at a rapid pace, Dr. Snow said. For example, enhanced diabetes information will become part of the ACP's Web-based point-of-care decision support tool, Physicians' Information and Education Resource (PIER); the medical knowledge self-assessment program (MKSAP); and the college's Web site (www.acponline.org

Versions of MKSAP will be developed for nonphysician members of the diabetes management team.

And ACP will develop a self-management tool kit to help patients become working partners with their health care providers in diabetes care. These materials, available in both English and Spanish, will include versions intended for patients whose literacy is at the third- or fourth-grade level.

Additionally, ACP will develop a Web portal collecting all of its diabetes information in one place, offering clinical decision support, CME credit, and the latest research in diabetes care.

“Beating diabetes is our passion, not just our business,” said Alan C. Moses, M.D., vice president of medical affairs for Novo Nordisk. “We try to distinguish ourselves from other companies by acting in accordance with our triple-bottom-line principle, [which] emphasizes a commitment not only to the economic success of the business, but just as importantly, to environmental soundness and social responsibility.”

The initiative will include a research component that will assess measurable outcomes as the project progresses.

“I hope that 3 years from now we'll be here again talking about the positive results of the project and the real changes that have occurred in diabetes care,” Dr. Francis said.

SAN FRANCISCO — The American College of Physicians and the American College of Physicians Foundation have begun a major 3-year initiative to improve diabetes care in the United States.

The initiative, announced at a press briefing during the annual meeting of the ACP, is aimed not only at physicians, but also at the entire diabetes management team, including subspecialists, physician assistants, diabetes educators, nurses, office staff, and the patients themselves.

Of the 18.2 million Americans with diabetes, 5.2 million are undiagnosed, according to information distributed at the briefing.

Novo Nordisk, the Denmark-based pharmaceutical company that first commercialized insulin, has funded the initiative with an unrestricted educational grant of $9.27 million.

“We believe this intensive 3-year project, combining an emphasis on highest standards of care, measurable goals for practice in office settings, and research, can dramatically improve diabetes care,” Charles K. Francis, M.D., president of the ACP said in a statement.

Some of the educational programs and materials will be available to the medical profession in general, while others will be limited to ACP members.

Vincenza Snow, M.D., the ACP's director of clinical programs, said that the project has three goals: to increase physician awareness of high-quality diabetes care and the gap between current practice and acceptable standards, to provide proven educational interventions for improving care to the entire diabetes team, and to recognize physicians and physician practices that make demonstrable improvements in the care of patients with diabetes.

“Knowledge is necessary but not sufficient for change,” Dr. Snow said, noting that all internists have extensive training in diabetes care.

“It's not necessarily that our members don't know what to do. We need to empower them to do that in their real-life practices. What has been shown is that multifaceted and multi-intervention educational programs are what works. You have to hit people over the head many, many times in many different ways to make sure that new things are implemented and that they don't disappear once the intervention goes away.”

The initiative was inaugurated at the ACP annual meeting with a diabetes track consisting of 16 workshops and courses. This track will be a feature of future annual meetings, and clinical skills modules will be offered at local chapter meetings.

Other parts of the program will be introduced at a rapid pace, Dr. Snow said. For example, enhanced diabetes information will become part of the ACP's Web-based point-of-care decision support tool, Physicians' Information and Education Resource (PIER); the medical knowledge self-assessment program (MKSAP); and the college's Web site (www.acponline.org

Versions of MKSAP will be developed for nonphysician members of the diabetes management team.

And ACP will develop a self-management tool kit to help patients become working partners with their health care providers in diabetes care. These materials, available in both English and Spanish, will include versions intended for patients whose literacy is at the third- or fourth-grade level.

Additionally, ACP will develop a Web portal collecting all of its diabetes information in one place, offering clinical decision support, CME credit, and the latest research in diabetes care.

“Beating diabetes is our passion, not just our business,” said Alan C. Moses, M.D., vice president of medical affairs for Novo Nordisk. “We try to distinguish ourselves from other companies by acting in accordance with our triple-bottom-line principle, [which] emphasizes a commitment not only to the economic success of the business, but just as importantly, to environmental soundness and social responsibility.”

The initiative will include a research component that will assess measurable outcomes as the project progresses.

“I hope that 3 years from now we'll be here again talking about the positive results of the project and the real changes that have occurred in diabetes care,” Dr. Francis said.

PORTLAND, ORE. — It's easy to misinterpret the results of serology tests for Epstein-Barr virus, so these results should not substitute for clinical judgment in suspected cases of Epstein-Barr mononucleosis in children, Sarah S. Long, M.D., said at a conference sponsored by the North Pacific Pediatric Society.

“You do laboratory tests to confirm your clinical suspicion, not to go fishing,” said Dr. Long of Drexel University, Philadelphia. “If you apply [these tests] to populations that are at low pretest probability of having the disease, most of your results will be false positives.”

And in the specific case of Epstein-Barr virus (EBV), some of the serology results will remain positive for the rest of the patient's life, long after the clinical syndrome has resolved.

Although some patients believe that they have a chronic EBV infection, often it's because they test positive for these antibodies, and the physician can provide reassurance that the antibodies are an indication of a resolved, not a chronic, infection.

Serology is not always necessary when clinical signs and symptoms are strongly suggestive of EBV mononucleosis, Dr. Long said.

“If you have a 16-year-old with exudative pharyngitis, you get a CBC and you've got 30% atypical lymphocytosis, don't go any further,” she said.

“He's got EBV mononucleosis and you're home free and can predict the rest of it. You don't need a heterophile [antibody test], you don't ever want to follow up if that test ever becomes negative, and you don't need specific serology.”

On the other hand, one shouldn't turn a blind eye to the hemoglobin, neutrophil, and platelet counts. Patients with thrombocytopenia or neutropenia in addition to lymphocytosis may have leukemia.

Of the four serology tests, the Epstein-Barr nuclear antigen (EBNA) test can be the most misleading.

The virus expresses nuclear antigen only when it becomes latent, and following that, the patient will be EBNA positive for the rest of his or her life, Dr. Long said.

Therefore, a positive EBNA means that the patient does not currently have EBV mononucleosis.

The way to remember this, Dr. Long suggested, is to think of the acronym EBNA as standing for “Epstein-Barr not applicable.”

In a patient with acute EBV mononucleosis, the heterophile antibody test will be positive, as will tests for IgM viral capsid antigen (VCA) and IgG VCA. EBNA will be negative. When the mononucleosis is on its way toward resolution, the heterophile antibody and the IgM VCA may be positive or negative. IgG VCA will be positive (and will remain so for life), but EBNA still will be negative.

Finally, once the mononucleosis has resolved, heterophile antibody and IgM VCA will both be negative, while IgG VCA and EBNA will both be positive.

PORTLAND, ORE. — It's easy to misinterpret the results of serology tests for Epstein-Barr virus, so these results should not substitute for clinical judgment in suspected cases of Epstein-Barr mononucleosis in children, Sarah S. Long, M.D., said at a conference sponsored by the North Pacific Pediatric Society.

“You do laboratory tests to confirm your clinical suspicion, not to go fishing,” said Dr. Long of Drexel University, Philadelphia. “If you apply [these tests] to populations that are at low pretest probability of having the disease, most of your results will be false positives.”

And in the specific case of Epstein-Barr virus (EBV), some of the serology results will remain positive for the rest of the patient's life, long after the clinical syndrome has resolved.

Although some patients believe that they have a chronic EBV infection, often it's because they test positive for these antibodies, and the physician can provide reassurance that the antibodies are an indication of a resolved, not a chronic, infection.

Serology is not always necessary when clinical signs and symptoms are strongly suggestive of EBV mononucleosis, Dr. Long said.

“If you have a 16-year-old with exudative pharyngitis, you get a CBC and you've got 30% atypical lymphocytosis, don't go any further,” she said.

“He's got EBV mononucleosis and you're home free and can predict the rest of it. You don't need a heterophile [antibody test], you don't ever want to follow up if that test ever becomes negative, and you don't need specific serology.”

On the other hand, one shouldn't turn a blind eye to the hemoglobin, neutrophil, and platelet counts. Patients with thrombocytopenia or neutropenia in addition to lymphocytosis may have leukemia.

Of the four serology tests, the Epstein-Barr nuclear antigen (EBNA) test can be the most misleading.

The virus expresses nuclear antigen only when it becomes latent, and following that, the patient will be EBNA positive for the rest of his or her life, Dr. Long said.

Therefore, a positive EBNA means that the patient does not currently have EBV mononucleosis.

The way to remember this, Dr. Long suggested, is to think of the acronym EBNA as standing for “Epstein-Barr not applicable.”

In a patient with acute EBV mononucleosis, the heterophile antibody test will be positive, as will tests for IgM viral capsid antigen (VCA) and IgG VCA. EBNA will be negative. When the mononucleosis is on its way toward resolution, the heterophile antibody and the IgM VCA may be positive or negative. IgG VCA will be positive (and will remain so for life), but EBNA still will be negative.

Finally, once the mononucleosis has resolved, heterophile antibody and IgM VCA will both be negative, while IgG VCA and EBNA will both be positive.

PORTLAND, ORE. — It's easy to misinterpret the results of serology tests for Epstein-Barr virus, so these results should not substitute for clinical judgment in suspected cases of Epstein-Barr mononucleosis in children, Sarah S. Long, M.D., said at a conference sponsored by the North Pacific Pediatric Society.

“You do laboratory tests to confirm your clinical suspicion, not to go fishing,” said Dr. Long of Drexel University, Philadelphia. “If you apply [these tests] to populations that are at low pretest probability of having the disease, most of your results will be false positives.”

And in the specific case of Epstein-Barr virus (EBV), some of the serology results will remain positive for the rest of the patient's life, long after the clinical syndrome has resolved.

Although some patients believe that they have a chronic EBV infection, often it's because they test positive for these antibodies, and the physician can provide reassurance that the antibodies are an indication of a resolved, not a chronic, infection.

Serology is not always necessary when clinical signs and symptoms are strongly suggestive of EBV mononucleosis, Dr. Long said.

“If you have a 16-year-old with exudative pharyngitis, you get a CBC and you've got 30% atypical lymphocytosis, don't go any further,” she said.

“He's got EBV mononucleosis and you're home free and can predict the rest of it. You don't need a heterophile [antibody test], you don't ever want to follow up if that test ever becomes negative, and you don't need specific serology.”

On the other hand, one shouldn't turn a blind eye to the hemoglobin, neutrophil, and platelet counts. Patients with thrombocytopenia or neutropenia in addition to lymphocytosis may have leukemia.

Of the four serology tests, the Epstein-Barr nuclear antigen (EBNA) test can be the most misleading.

The virus expresses nuclear antigen only when it becomes latent, and following that, the patient will be EBNA positive for the rest of his or her life, Dr. Long said.

Therefore, a positive EBNA means that the patient does not currently have EBV mononucleosis.

The way to remember this, Dr. Long suggested, is to think of the acronym EBNA as standing for “Epstein-Barr not applicable.”

In a patient with acute EBV mononucleosis, the heterophile antibody test will be positive, as will tests for IgM viral capsid antigen (VCA) and IgG VCA. EBNA will be negative. When the mononucleosis is on its way toward resolution, the heterophile antibody and the IgM VCA may be positive or negative. IgG VCA will be positive (and will remain so for life), but EBNA still will be negative.

Finally, once the mononucleosis has resolved, heterophile antibody and IgM VCA will both be negative, while IgG VCA and EBNA will both be positive.