Betsy Bates

STANFORD, CALIF. — Think of tuft fractures, which commonly occur when a child's finger is crushed in a car door, like toe fractures, advised Dr. Bernard W. Dannenberg at a recent pediatric update sponsored by Stanford University.

"You can get an x-ray, but we're not going to do anything … about them," said Dr. Dannenberg, director of pediatric emergency medicine at the Stanford (Calif.) University.

Dr. Dannenberg tells patients with tuft fractures or toe fractures the same thing. "If it still hurts in a week or 2, it's probably fractured. If it doesn't hurt, it was contused."

He nonetheless advises physicians to examine car door injuries closely, because an injury at the base of the nail bed needs to be surgically repaired, often under sedation, to prevent scarring or a deformity when the new nail grows out.

Such an injury should be loosely dressed, and an emergency medicine specialist or hand surgeon should see the patient within 12 hours or so, he said.

"Look very closely when you see them. [An avulsed nail base] just doesn't look like much," he said. "I've seen cases where the [physician] says, don't worry, the nail will fall off."

Fingertip amputations should be cleaned and debrided. If fingertip bones are exposed, they should be covered by closing the wound, if possible. In some cases, the bones may need to be rongeured down to permit wound closure over them. The tissue generally will not regenerate; however, Dr. Dannenberg said that the cosmetic and functional outcome often is excellent. "The skin heals wonderfully, and for the most part, you can't even see any difference."

Complete fingertip amputations can be reattached, although they are likely to necrose. "It probably will fall off, but it gives it some protection," he said.

In cases in which the skin cannot be closed around the injury, it can heal by secondary intention, so long as bone is not exposed, he said.

Subungual hematomas can be very painful, and a simple procedure can provide relief, explained Dr. Dannenberg. "All you have to do is take an 18-gauge needle and use it as a drill … [until] you see a drop of blood."

Both patients and parents should be distracted, since the procedure looks worse than it actually is, he said. Meanwhile, making tiny holes into two or three areas of the hematoma can provide "tremendous pain relief."

Dr. Dannenberg generally uses long-acting lidocaine to perform any necessary repairs of the finger after a car door crush injury. This provides 4–8 hours of pain relief until parents can fill a prescription for an analgesic such as Lortab, liquid hydrocodone, and acetaminophen.

This patient has an avulsed nail and lacerated nail bed with soft tissue loss.

In this photo, the patient's nail bed has been repaired and the nail reinserted. Photos courtesy Dr. Bernard W. Dannenberg

STANFORD, CALIF. — Think of tuft fractures, which commonly occur when a child's finger is crushed in a car door, like toe fractures, advised Dr. Bernard W. Dannenberg at a recent pediatric update sponsored by Stanford University.

"You can get an x-ray, but we're not going to do anything … about them," said Dr. Dannenberg, director of pediatric emergency medicine at the Stanford (Calif.) University.

Dr. Dannenberg tells patients with tuft fractures or toe fractures the same thing. "If it still hurts in a week or 2, it's probably fractured. If it doesn't hurt, it was contused."

He nonetheless advises physicians to examine car door injuries closely, because an injury at the base of the nail bed needs to be surgically repaired, often under sedation, to prevent scarring or a deformity when the new nail grows out.

Such an injury should be loosely dressed, and an emergency medicine specialist or hand surgeon should see the patient within 12 hours or so, he said.

"Look very closely when you see them. [An avulsed nail base] just doesn't look like much," he said. "I've seen cases where the [physician] says, don't worry, the nail will fall off."

Fingertip amputations should be cleaned and debrided. If fingertip bones are exposed, they should be covered by closing the wound, if possible. In some cases, the bones may need to be rongeured down to permit wound closure over them. The tissue generally will not regenerate; however, Dr. Dannenberg said that the cosmetic and functional outcome often is excellent. "The skin heals wonderfully, and for the most part, you can't even see any difference."

Complete fingertip amputations can be reattached, although they are likely to necrose. "It probably will fall off, but it gives it some protection," he said.

In cases in which the skin cannot be closed around the injury, it can heal by secondary intention, so long as bone is not exposed, he said.

Subungual hematomas can be very painful, and a simple procedure can provide relief, explained Dr. Dannenberg. "All you have to do is take an 18-gauge needle and use it as a drill … [until] you see a drop of blood."

Both patients and parents should be distracted, since the procedure looks worse than it actually is, he said. Meanwhile, making tiny holes into two or three areas of the hematoma can provide "tremendous pain relief."

Dr. Dannenberg generally uses long-acting lidocaine to perform any necessary repairs of the finger after a car door crush injury. This provides 4–8 hours of pain relief until parents can fill a prescription for an analgesic such as Lortab, liquid hydrocodone, and acetaminophen.

This patient has an avulsed nail and lacerated nail bed with soft tissue loss.

In this photo, the patient's nail bed has been repaired and the nail reinserted. Photos courtesy Dr. Bernard W. Dannenberg

STANFORD, CALIF. — Think of tuft fractures, which commonly occur when a child's finger is crushed in a car door, like toe fractures, advised Dr. Bernard W. Dannenberg at a recent pediatric update sponsored by Stanford University.

"You can get an x-ray, but we're not going to do anything … about them," said Dr. Dannenberg, director of pediatric emergency medicine at the Stanford (Calif.) University.

Dr. Dannenberg tells patients with tuft fractures or toe fractures the same thing. "If it still hurts in a week or 2, it's probably fractured. If it doesn't hurt, it was contused."

He nonetheless advises physicians to examine car door injuries closely, because an injury at the base of the nail bed needs to be surgically repaired, often under sedation, to prevent scarring or a deformity when the new nail grows out.

Such an injury should be loosely dressed, and an emergency medicine specialist or hand surgeon should see the patient within 12 hours or so, he said.

"Look very closely when you see them. [An avulsed nail base] just doesn't look like much," he said. "I've seen cases where the [physician] says, don't worry, the nail will fall off."

Fingertip amputations should be cleaned and debrided. If fingertip bones are exposed, they should be covered by closing the wound, if possible. In some cases, the bones may need to be rongeured down to permit wound closure over them. The tissue generally will not regenerate; however, Dr. Dannenberg said that the cosmetic and functional outcome often is excellent. "The skin heals wonderfully, and for the most part, you can't even see any difference."

Complete fingertip amputations can be reattached, although they are likely to necrose. "It probably will fall off, but it gives it some protection," he said.

In cases in which the skin cannot be closed around the injury, it can heal by secondary intention, so long as bone is not exposed, he said.

Subungual hematomas can be very painful, and a simple procedure can provide relief, explained Dr. Dannenberg. "All you have to do is take an 18-gauge needle and use it as a drill … [until] you see a drop of blood."

Both patients and parents should be distracted, since the procedure looks worse than it actually is, he said. Meanwhile, making tiny holes into two or three areas of the hematoma can provide "tremendous pain relief."

Dr. Dannenberg generally uses long-acting lidocaine to perform any necessary repairs of the finger after a car door crush injury. This provides 4–8 hours of pain relief until parents can fill a prescription for an analgesic such as Lortab, liquid hydrocodone, and acetaminophen.

This patient has an avulsed nail and lacerated nail bed with soft tissue loss.

In this photo, the patient's nail bed has been repaired and the nail reinserted. Photos courtesy Dr. Bernard W. Dannenberg

SAN DIEGO — Routine use of an enema during the first stage of labor significantly prolonged the time to delivery in a randomized trial conducted at the Carolinas Medical Center in Charlotte, N.C.

Although routine enemas have been abandoned in many hospitals, anecdotal beliefs persist that the procedure enhances uterine stimulation, makes for a “cleaner delivery,” and reduces neonatal wound infections, Dr. Noellee T. Clarke said.

Labor and delivery nurses in some regions hold to the notion that enemas for this purpose are best administered “high and hot and a hell of a lot,” she noted following the oral presentation of her study.

To see if enemas do reduce labor time, Dr. Clarke and coinvestigator Dr. Todd R. Jenkins conducted a trial that randomized 152 women in uncomplicated early labor at their institution either to undergo an enema or to have no enema on admission. At baseline, women in the two groups were similar in terms of parity, age, and other relevant variables.

Enemas were performed using a standard protocol (1 L water plus two packets of castile soap at a mean cervical dilatation of 3.6 cm). Mean time to delivery was 505 minutes in 75 women who received enemas, vs. 393 minutes in 77 women who did not receive an enema, for a highly statistically significant difference of 112 minutes.

Intrapartum infection rates were 12.3% among patients receiving enemas and 2.7% for those receiving no enema; however, this difference lost its significance when investigators controlled for differences in duration of membrane rupture.

No differences were seen between groups in epidural use, delivery mode, or presence of meconium, she said at the annual meeting of the American College of Obstetricians and Gynecologists.

Women who underwent a routine enema had less fecal soiling at delivery, observed in 8 of 75 (11%) in the enema group vs. 23 of 77 (30%) in the group that received no enema.

Dr. Clarke said the study results were accepted by some, but not all, labor and delivery nurses on her service. “I was unpopular a little bit,” she said in response to a question following her presentation.

SAN DIEGO — Routine use of an enema during the first stage of labor significantly prolonged the time to delivery in a randomized trial conducted at the Carolinas Medical Center in Charlotte, N.C.

Although routine enemas have been abandoned in many hospitals, anecdotal beliefs persist that the procedure enhances uterine stimulation, makes for a “cleaner delivery,” and reduces neonatal wound infections, Dr. Noellee T. Clarke said.

Labor and delivery nurses in some regions hold to the notion that enemas for this purpose are best administered “high and hot and a hell of a lot,” she noted following the oral presentation of her study.

To see if enemas do reduce labor time, Dr. Clarke and coinvestigator Dr. Todd R. Jenkins conducted a trial that randomized 152 women in uncomplicated early labor at their institution either to undergo an enema or to have no enema on admission. At baseline, women in the two groups were similar in terms of parity, age, and other relevant variables.

Enemas were performed using a standard protocol (1 L water plus two packets of castile soap at a mean cervical dilatation of 3.6 cm). Mean time to delivery was 505 minutes in 75 women who received enemas, vs. 393 minutes in 77 women who did not receive an enema, for a highly statistically significant difference of 112 minutes.

Intrapartum infection rates were 12.3% among patients receiving enemas and 2.7% for those receiving no enema; however, this difference lost its significance when investigators controlled for differences in duration of membrane rupture.

No differences were seen between groups in epidural use, delivery mode, or presence of meconium, she said at the annual meeting of the American College of Obstetricians and Gynecologists.

Women who underwent a routine enema had less fecal soiling at delivery, observed in 8 of 75 (11%) in the enema group vs. 23 of 77 (30%) in the group that received no enema.

Dr. Clarke said the study results were accepted by some, but not all, labor and delivery nurses on her service. “I was unpopular a little bit,” she said in response to a question following her presentation.

SAN DIEGO — Routine use of an enema during the first stage of labor significantly prolonged the time to delivery in a randomized trial conducted at the Carolinas Medical Center in Charlotte, N.C.

Although routine enemas have been abandoned in many hospitals, anecdotal beliefs persist that the procedure enhances uterine stimulation, makes for a “cleaner delivery,” and reduces neonatal wound infections, Dr. Noellee T. Clarke said.

Labor and delivery nurses in some regions hold to the notion that enemas for this purpose are best administered “high and hot and a hell of a lot,” she noted following the oral presentation of her study.

To see if enemas do reduce labor time, Dr. Clarke and coinvestigator Dr. Todd R. Jenkins conducted a trial that randomized 152 women in uncomplicated early labor at their institution either to undergo an enema or to have no enema on admission. At baseline, women in the two groups were similar in terms of parity, age, and other relevant variables.

Enemas were performed using a standard protocol (1 L water plus two packets of castile soap at a mean cervical dilatation of 3.6 cm). Mean time to delivery was 505 minutes in 75 women who received enemas, vs. 393 minutes in 77 women who did not receive an enema, for a highly statistically significant difference of 112 minutes.

Intrapartum infection rates were 12.3% among patients receiving enemas and 2.7% for those receiving no enema; however, this difference lost its significance when investigators controlled for differences in duration of membrane rupture.

No differences were seen between groups in epidural use, delivery mode, or presence of meconium, she said at the annual meeting of the American College of Obstetricians and Gynecologists.

Women who underwent a routine enema had less fecal soiling at delivery, observed in 8 of 75 (11%) in the enema group vs. 23 of 77 (30%) in the group that received no enema.

Dr. Clarke said the study results were accepted by some, but not all, labor and delivery nurses on her service. “I was unpopular a little bit,” she said in response to a question following her presentation.

STANFORD, CALIF. — Functional gastrointestinal disorders and gastroesophageal reflux disease represented the diagnoses in nearly half of 100 consecutive children with chronic abdominal pain who were referred to the pediatric gastroenterology division at Stanford University's Lucile Packard Children's Hospital.

Functional disorders—which include irritable bowel syndrome, functional dyspepsia, abdominal migraine, aerophagia, and idiopathic functional pain—were present in 24 children, division chief Dr. Kenneth L. Cox reported at a pediatric update sponsored by Stanford University.

An identical number were found to have gastroesophageal reflux disease (GERD), followed by constipation in 20 children, peptic ulcer disease in 9, malabsorption in 8, inflammatory bowel disease in 4, and pancreatitis in 4. Fewer than 2% of cases included ovarian cysts, superior mesenteric artery syndrome, gallstones, chronic appendicitis, or hydronephrosis.

What it all means is that functional abdominal pain is an important diagnosis regardless of whether the treating physician is a pediatrician or family physician, or a pediatric gastroenterologist like himself, said Dr. Cox. “The most important point is, it's real. It's physiological. It's not their imagination; they're not making it up.”

Pressure, air passage, and distention all cause real pain in children with functional disorders. The trick is to convince patients, and importantly, their parents, that stress causes this real pain.

A diagnostic evaluation should include a thorough history with a special psychosocial focus; a pain log kept by the patient or family; a physical examination including a rectal examination (to look for signs of constipation or abuse); and basic laboratory studies, including a CBC with white blood cell differential, erythrocyte sedimentation rate, urinalysis (to rule out a chronic urinary tract infection), and a stool Hemoccult.

Dr. Cox often orders a kidney, ureter, bladder x-ray to check for retained stool and to prove to parents that no organic problems underlie their child's pain.

If functional pain proves to be the diagnosis, treatment includes reassurance, stress management; a diet high in fiber and fluids; limits on dietary sorbitol, fructose, and caffeine; and drugs necessary to treat both the symptoms and the stress underlying those symptoms. These may include bulking agents; pain medications; anticholinergics (for bowel spasm); antidepressants (especially tricyclic antidepressants, which can modify pain perception); and serotonin agonists and antagonists.

Regarding the other most common diagnosis in his practice, Dr. Cox noted that GERD symptoms in children do not mimic those in adults, with epigastric pain a far more common presenting complaint in children aged 3–9 years than in adults. Heartburn is rarely seen in younger children, and is less common in 10- to 17-year-olds than in adults. But regurgitation and vomiting are common symptoms in the pediatric population.

The two most useful tests for children with suspected GERD include a 24-hour esophageal pH study and upper endoscopy, he said. Dr. Cox reserves other evaluations—including a technetium-99m gastric emptying study, upper gastrointestinal series, and esophageal motility study—for cases in which he has a particular diagnostic question in mind due to the child's history or physical examination.

Organic Origins of Abdominal Pain

A number of signs and symptoms increase the possibility of an organic cause of chronic abdominal pain in children. These include:

▸ Age less than 4 years.

▸ Localized pain, especially in the right lower quadrant.

▸ Pain that awakens the child at night.

▸ Pain during play.

▸ Associated symptoms such as blood in the stool, weight loss, nausea and vomiting.

▸ Negative psychosocial history in terms of adjustment at home and at school.

Source: Dr. Cox

STANFORD, CALIF. — Functional gastrointestinal disorders and gastroesophageal reflux disease represented the diagnoses in nearly half of 100 consecutive children with chronic abdominal pain who were referred to the pediatric gastroenterology division at Stanford University's Lucile Packard Children's Hospital.

Functional disorders—which include irritable bowel syndrome, functional dyspepsia, abdominal migraine, aerophagia, and idiopathic functional pain—were present in 24 children, division chief Dr. Kenneth L. Cox reported at a pediatric update sponsored by Stanford University.

An identical number were found to have gastroesophageal reflux disease (GERD), followed by constipation in 20 children, peptic ulcer disease in 9, malabsorption in 8, inflammatory bowel disease in 4, and pancreatitis in 4. Fewer than 2% of cases included ovarian cysts, superior mesenteric artery syndrome, gallstones, chronic appendicitis, or hydronephrosis.

What it all means is that functional abdominal pain is an important diagnosis regardless of whether the treating physician is a pediatrician or family physician, or a pediatric gastroenterologist like himself, said Dr. Cox. “The most important point is, it's real. It's physiological. It's not their imagination; they're not making it up.”

Pressure, air passage, and distention all cause real pain in children with functional disorders. The trick is to convince patients, and importantly, their parents, that stress causes this real pain.

A diagnostic evaluation should include a thorough history with a special psychosocial focus; a pain log kept by the patient or family; a physical examination including a rectal examination (to look for signs of constipation or abuse); and basic laboratory studies, including a CBC with white blood cell differential, erythrocyte sedimentation rate, urinalysis (to rule out a chronic urinary tract infection), and a stool Hemoccult.

Dr. Cox often orders a kidney, ureter, bladder x-ray to check for retained stool and to prove to parents that no organic problems underlie their child's pain.

If functional pain proves to be the diagnosis, treatment includes reassurance, stress management; a diet high in fiber and fluids; limits on dietary sorbitol, fructose, and caffeine; and drugs necessary to treat both the symptoms and the stress underlying those symptoms. These may include bulking agents; pain medications; anticholinergics (for bowel spasm); antidepressants (especially tricyclic antidepressants, which can modify pain perception); and serotonin agonists and antagonists.

Regarding the other most common diagnosis in his practice, Dr. Cox noted that GERD symptoms in children do not mimic those in adults, with epigastric pain a far more common presenting complaint in children aged 3–9 years than in adults. Heartburn is rarely seen in younger children, and is less common in 10- to 17-year-olds than in adults. But regurgitation and vomiting are common symptoms in the pediatric population.

The two most useful tests for children with suspected GERD include a 24-hour esophageal pH study and upper endoscopy, he said. Dr. Cox reserves other evaluations—including a technetium-99m gastric emptying study, upper gastrointestinal series, and esophageal motility study—for cases in which he has a particular diagnostic question in mind due to the child's history or physical examination.

Organic Origins of Abdominal Pain

A number of signs and symptoms increase the possibility of an organic cause of chronic abdominal pain in children. These include:

▸ Age less than 4 years.

▸ Localized pain, especially in the right lower quadrant.

▸ Pain that awakens the child at night.

▸ Pain during play.

▸ Associated symptoms such as blood in the stool, weight loss, nausea and vomiting.

▸ Negative psychosocial history in terms of adjustment at home and at school.

Source: Dr. Cox

STANFORD, CALIF. — Functional gastrointestinal disorders and gastroesophageal reflux disease represented the diagnoses in nearly half of 100 consecutive children with chronic abdominal pain who were referred to the pediatric gastroenterology division at Stanford University's Lucile Packard Children's Hospital.

Functional disorders—which include irritable bowel syndrome, functional dyspepsia, abdominal migraine, aerophagia, and idiopathic functional pain—were present in 24 children, division chief Dr. Kenneth L. Cox reported at a pediatric update sponsored by Stanford University.

An identical number were found to have gastroesophageal reflux disease (GERD), followed by constipation in 20 children, peptic ulcer disease in 9, malabsorption in 8, inflammatory bowel disease in 4, and pancreatitis in 4. Fewer than 2% of cases included ovarian cysts, superior mesenteric artery syndrome, gallstones, chronic appendicitis, or hydronephrosis.

What it all means is that functional abdominal pain is an important diagnosis regardless of whether the treating physician is a pediatrician or family physician, or a pediatric gastroenterologist like himself, said Dr. Cox. “The most important point is, it's real. It's physiological. It's not their imagination; they're not making it up.”

Pressure, air passage, and distention all cause real pain in children with functional disorders. The trick is to convince patients, and importantly, their parents, that stress causes this real pain.

A diagnostic evaluation should include a thorough history with a special psychosocial focus; a pain log kept by the patient or family; a physical examination including a rectal examination (to look for signs of constipation or abuse); and basic laboratory studies, including a CBC with white blood cell differential, erythrocyte sedimentation rate, urinalysis (to rule out a chronic urinary tract infection), and a stool Hemoccult.

Dr. Cox often orders a kidney, ureter, bladder x-ray to check for retained stool and to prove to parents that no organic problems underlie their child's pain.

If functional pain proves to be the diagnosis, treatment includes reassurance, stress management; a diet high in fiber and fluids; limits on dietary sorbitol, fructose, and caffeine; and drugs necessary to treat both the symptoms and the stress underlying those symptoms. These may include bulking agents; pain medications; anticholinergics (for bowel spasm); antidepressants (especially tricyclic antidepressants, which can modify pain perception); and serotonin agonists and antagonists.

Regarding the other most common diagnosis in his practice, Dr. Cox noted that GERD symptoms in children do not mimic those in adults, with epigastric pain a far more common presenting complaint in children aged 3–9 years than in adults. Heartburn is rarely seen in younger children, and is less common in 10- to 17-year-olds than in adults. But regurgitation and vomiting are common symptoms in the pediatric population.

The two most useful tests for children with suspected GERD include a 24-hour esophageal pH study and upper endoscopy, he said. Dr. Cox reserves other evaluations—including a technetium-99m gastric emptying study, upper gastrointestinal series, and esophageal motility study—for cases in which he has a particular diagnostic question in mind due to the child's history or physical examination.

Organic Origins of Abdominal Pain

A number of signs and symptoms increase the possibility of an organic cause of chronic abdominal pain in children. These include:

▸ Age less than 4 years.

▸ Localized pain, especially in the right lower quadrant.

▸ Pain that awakens the child at night.

▸ Pain during play.

▸ Associated symptoms such as blood in the stool, weight loss, nausea and vomiting.

▸ Negative psychosocial history in terms of adjustment at home and at school.

Source: Dr. Cox

LAS VEGAS — Duplex-guided balloon angioplasty provides excellent visualization and spares patients exposure to radiation and potential nephrotoxicity from contrast agents, said Dr. Enrico Ascher at the spring meeting of the American College of Surgeons.

Patients with diabetes and those with preexisting renal disease are particularly well served by the duplex approach, said Dr. Ascher, director of the vascular surgery division at Maimonides Medical Center in Brooklyn, N.Y., and professor of surgery at Mt. Sinai Medical Center in New York. However, all patients benefit from the myriad advantages of duplex-guided procedures, including multiplanar imaging and five- to sixfold magnification; the ability to view the entire vessel wall rather than just the lumen; and more precise measurement for, selection of, and placement of stents.

Furthermore, duplex techniques allow two ways of immediately assessing the adequacy of the procedure: visualization of the anatomy and hemodynamic confirmation, he said.

“I'm not here to say x-ray is bad or dye is so bad,” Dr. Ascher said. But contrast-induced renal failure occurs in up to 30% of patients with diabetes. Up to 40% of patients with preexisting renal disease have worsening renal failure after balloon angioplasty with dyes, he said.

Protection of physicians and team members also is a consideration when seeking alternatives to x-ray-guided techniques, because radiation injury is cumulative, permanent, somatic, genetic, and gonadal in onset. “When you're ready to retire, you won't be able to see,” he said.

Dr. Ascher reported the results of 470 duplex-guided balloon angioplasty procedures that he performed in a 3-year period, most—360—involving the femoropopliteal segments of the infrainguinal arteries. The rest of the cases involved infrapopliteal arterial occlusion, failing arteriovenous access fistulas and bypass grafts, infrainguinal arterial bypasses, and other indications.

Among the femoropopliteal segment cases, half of patients had diabetes, 37% had chronic renal insufficiency, and 80% had hypertension. Severe claudication was present in 63%; 65% had stenosis, and 35% had occlusion. Most patients met criteria for TransAtlantic Inter-Society Consensus (TASC) class C or D (68% and 10%, respectively), but some were class A and B (5% and 17%, respectively).

Dr. Ascher demonstrated the procedure, which involves duplex-guided ipsilateral arterial puncture and precise visualization of the tip of the wire during the entire procedure, which minimizes bleeding risk. When the wire was not easily manipulable because of multiple branches or during subintimal angioplasty, he was able to confirm, using duplex ultrasound, that it was still inside the true lumen. Stents were placed in any case where residual stenosis was greater than 40%, he said.

Technical success was achieved in 95% of cases, including 229 of 230 patients with stenosis and 104 of 122 with occlusive disease. Clinical improvement was seen in 95% of cases. One patient died of a myocardial infarction.

Among 268 patients followed for up to 6 months after angioplasty of lower extremity arteries, 10 thrombosed early (within 30 days).

All of these had TASC lesions rated as class C (6 of 185 such patients) or class D (4 of 26 such patients). A multivariant analysis found that the strongest predictor of early (30-day) and midterm (6-month) arterial thrombosis was popliteal artery volume flow of less than 100 mL/min.

Dr. Ascher also described results of 80 duplex-guided balloon angioplasties of the infrapopliteal segment that he performed.

These procedures were usually completed in less than 1 hour. Technical success was achieved in 77 of 80 cases, including 67 of 70 patients with stenosis and 9 of 10 with occlusion.

In another 49 cases, the duplex technique was used to perform infrainguinal bypass for failing grafts. There were 48 technical successes in this group, with 1 perforation by a cutting balloon repaired later by patch angioplasty, and 1 case that could not be completed due to extreme tortuosity. At 6 months, primary patency was achieved in 34 of 49 cases (69%), and all patients' limbs had been salvaged.

B-mode image shows a 6-mm balloon that is fully inflated across the superficial femoral artery origin (arrow). Images courtesy Dr. Enrico Ascher

Arrows show a balloon's blades across the severe focal stenosis in the femoral to plantar artery vein bypass graft.

The procedure involves duplex-guided ipsilateral arterial puncture and visualization of the wire tip the whole time. DR. ASCHER

LAS VEGAS — Duplex-guided balloon angioplasty provides excellent visualization and spares patients exposure to radiation and potential nephrotoxicity from contrast agents, said Dr. Enrico Ascher at the spring meeting of the American College of Surgeons.

Patients with diabetes and those with preexisting renal disease are particularly well served by the duplex approach, said Dr. Ascher, director of the vascular surgery division at Maimonides Medical Center in Brooklyn, N.Y., and professor of surgery at Mt. Sinai Medical Center in New York. However, all patients benefit from the myriad advantages of duplex-guided procedures, including multiplanar imaging and five- to sixfold magnification; the ability to view the entire vessel wall rather than just the lumen; and more precise measurement for, selection of, and placement of stents.

Furthermore, duplex techniques allow two ways of immediately assessing the adequacy of the procedure: visualization of the anatomy and hemodynamic confirmation, he said.

“I'm not here to say x-ray is bad or dye is so bad,” Dr. Ascher said. But contrast-induced renal failure occurs in up to 30% of patients with diabetes. Up to 40% of patients with preexisting renal disease have worsening renal failure after balloon angioplasty with dyes, he said.

Protection of physicians and team members also is a consideration when seeking alternatives to x-ray-guided techniques, because radiation injury is cumulative, permanent, somatic, genetic, and gonadal in onset. “When you're ready to retire, you won't be able to see,” he said.

Dr. Ascher reported the results of 470 duplex-guided balloon angioplasty procedures that he performed in a 3-year period, most—360—involving the femoropopliteal segments of the infrainguinal arteries. The rest of the cases involved infrapopliteal arterial occlusion, failing arteriovenous access fistulas and bypass grafts, infrainguinal arterial bypasses, and other indications.

Among the femoropopliteal segment cases, half of patients had diabetes, 37% had chronic renal insufficiency, and 80% had hypertension. Severe claudication was present in 63%; 65% had stenosis, and 35% had occlusion. Most patients met criteria for TransAtlantic Inter-Society Consensus (TASC) class C or D (68% and 10%, respectively), but some were class A and B (5% and 17%, respectively).

Dr. Ascher demonstrated the procedure, which involves duplex-guided ipsilateral arterial puncture and precise visualization of the tip of the wire during the entire procedure, which minimizes bleeding risk. When the wire was not easily manipulable because of multiple branches or during subintimal angioplasty, he was able to confirm, using duplex ultrasound, that it was still inside the true lumen. Stents were placed in any case where residual stenosis was greater than 40%, he said.

Technical success was achieved in 95% of cases, including 229 of 230 patients with stenosis and 104 of 122 with occlusive disease. Clinical improvement was seen in 95% of cases. One patient died of a myocardial infarction.

Among 268 patients followed for up to 6 months after angioplasty of lower extremity arteries, 10 thrombosed early (within 30 days).

All of these had TASC lesions rated as class C (6 of 185 such patients) or class D (4 of 26 such patients). A multivariant analysis found that the strongest predictor of early (30-day) and midterm (6-month) arterial thrombosis was popliteal artery volume flow of less than 100 mL/min.

Dr. Ascher also described results of 80 duplex-guided balloon angioplasties of the infrapopliteal segment that he performed.

These procedures were usually completed in less than 1 hour. Technical success was achieved in 77 of 80 cases, including 67 of 70 patients with stenosis and 9 of 10 with occlusion.

In another 49 cases, the duplex technique was used to perform infrainguinal bypass for failing grafts. There were 48 technical successes in this group, with 1 perforation by a cutting balloon repaired later by patch angioplasty, and 1 case that could not be completed due to extreme tortuosity. At 6 months, primary patency was achieved in 34 of 49 cases (69%), and all patients' limbs had been salvaged.

B-mode image shows a 6-mm balloon that is fully inflated across the superficial femoral artery origin (arrow). Images courtesy Dr. Enrico Ascher

Arrows show a balloon's blades across the severe focal stenosis in the femoral to plantar artery vein bypass graft.

The procedure involves duplex-guided ipsilateral arterial puncture and visualization of the wire tip the whole time. DR. ASCHER

LAS VEGAS — Duplex-guided balloon angioplasty provides excellent visualization and spares patients exposure to radiation and potential nephrotoxicity from contrast agents, said Dr. Enrico Ascher at the spring meeting of the American College of Surgeons.

Patients with diabetes and those with preexisting renal disease are particularly well served by the duplex approach, said Dr. Ascher, director of the vascular surgery division at Maimonides Medical Center in Brooklyn, N.Y., and professor of surgery at Mt. Sinai Medical Center in New York. However, all patients benefit from the myriad advantages of duplex-guided procedures, including multiplanar imaging and five- to sixfold magnification; the ability to view the entire vessel wall rather than just the lumen; and more precise measurement for, selection of, and placement of stents.

Furthermore, duplex techniques allow two ways of immediately assessing the adequacy of the procedure: visualization of the anatomy and hemodynamic confirmation, he said.

“I'm not here to say x-ray is bad or dye is so bad,” Dr. Ascher said. But contrast-induced renal failure occurs in up to 30% of patients with diabetes. Up to 40% of patients with preexisting renal disease have worsening renal failure after balloon angioplasty with dyes, he said.

Protection of physicians and team members also is a consideration when seeking alternatives to x-ray-guided techniques, because radiation injury is cumulative, permanent, somatic, genetic, and gonadal in onset. “When you're ready to retire, you won't be able to see,” he said.

Dr. Ascher reported the results of 470 duplex-guided balloon angioplasty procedures that he performed in a 3-year period, most—360—involving the femoropopliteal segments of the infrainguinal arteries. The rest of the cases involved infrapopliteal arterial occlusion, failing arteriovenous access fistulas and bypass grafts, infrainguinal arterial bypasses, and other indications.

Among the femoropopliteal segment cases, half of patients had diabetes, 37% had chronic renal insufficiency, and 80% had hypertension. Severe claudication was present in 63%; 65% had stenosis, and 35% had occlusion. Most patients met criteria for TransAtlantic Inter-Society Consensus (TASC) class C or D (68% and 10%, respectively), but some were class A and B (5% and 17%, respectively).

Dr. Ascher demonstrated the procedure, which involves duplex-guided ipsilateral arterial puncture and precise visualization of the tip of the wire during the entire procedure, which minimizes bleeding risk. When the wire was not easily manipulable because of multiple branches or during subintimal angioplasty, he was able to confirm, using duplex ultrasound, that it was still inside the true lumen. Stents were placed in any case where residual stenosis was greater than 40%, he said.

Technical success was achieved in 95% of cases, including 229 of 230 patients with stenosis and 104 of 122 with occlusive disease. Clinical improvement was seen in 95% of cases. One patient died of a myocardial infarction.

Among 268 patients followed for up to 6 months after angioplasty of lower extremity arteries, 10 thrombosed early (within 30 days).

All of these had TASC lesions rated as class C (6 of 185 such patients) or class D (4 of 26 such patients). A multivariant analysis found that the strongest predictor of early (30-day) and midterm (6-month) arterial thrombosis was popliteal artery volume flow of less than 100 mL/min.

Dr. Ascher also described results of 80 duplex-guided balloon angioplasties of the infrapopliteal segment that he performed.

These procedures were usually completed in less than 1 hour. Technical success was achieved in 77 of 80 cases, including 67 of 70 patients with stenosis and 9 of 10 with occlusion.

In another 49 cases, the duplex technique was used to perform infrainguinal bypass for failing grafts. There were 48 technical successes in this group, with 1 perforation by a cutting balloon repaired later by patch angioplasty, and 1 case that could not be completed due to extreme tortuosity. At 6 months, primary patency was achieved in 34 of 49 cases (69%), and all patients' limbs had been salvaged.

B-mode image shows a 6-mm balloon that is fully inflated across the superficial femoral artery origin (arrow). Images courtesy Dr. Enrico Ascher

Arrows show a balloon's blades across the severe focal stenosis in the femoral to plantar artery vein bypass graft.

The procedure involves duplex-guided ipsilateral arterial puncture and visualization of the wire tip the whole time. DR. ASCHER

LAS VEGAS — Gastrointestinal stromal tumors, long an enigma, are revealing their secrets and their vulnerabilities in the face of revolutionary discoveries about their origins, speakers said at a multidisciplinary general session of the spring meeting of the American College of Surgeons.

Complete resection remains the initial treatment of choice for these often fatal tumors, but advances in their characterization and therapy are providing a more optimistic outlook for patients whose survival was once measured in months rather than years.

“These tumors were miscategorized for 20 years,” said Dr. Stanley W. Ashley, vice chairman of surgery at Brigham and Women's Hospital and professor of surgery at Harvard Medical School, Boston.

In the late 1990s, Japanese researchers discovered that approximately 75%–80% of gastrointestinal stromal tumors (GISTs) have mutations in the c-kit gene.

This advance meant that tumors previously classified as leiomyomas, leiomyosarcomas, and leiomyoblastomas could be correctly recognized as GISTs. Further study revealed that 5%–10% of GISTs have a closely related mutation in the PDGFRA gene, while approximately 12%–15% are unrelated to these mutations and therefore characterized as “wild type” or “wild card” GISTs.

GISTs are now recognized as the most common sarcomas of the gastrointestinal tract and account for an official 0.2% of GI malignancies, “but that's changing” as the incidence increases, Dr. Ashley said.

Autopsy studies suggest that small GISTs exist in much of the population, with triggering genetic mechanisms likely responsible for turning these benign, incidental lesions into the “bad actors” they can become.

An important therapeutic turning point was the approval in 2002 of imatinib (Gleevec) for unresectable and/or metastatic GISTs, which drove median survival rates for these patients from “at best, 19 months” to about 58 months, said Dr. Martin McCarter, associate professor of surgery at the University of Colorado, Denver.

Adding nuance to basic understanding, Dr. Christopher Corless, chief of surgical pathology at Oregon Health and Science University, Portland, and others have begun to further characterize mutations according to exons within the c-kit and PDGFRA genes.

“We've come to think of GIST not as a single, unique entity, [but] rather as a family of tumors broken down by type of kit mutation or type of receptor alpha mutation,” Dr. Corless said at the meeting.

Exon 11 mutations, for example, occur in GISTs seen throughout the GI tract and are quite sensitive to Gleevec, as are “wild type” tumors. Exon 9 mutations, however, occur only in tumors arising from the duodenum, jejunum, ileum, and right colon—”never in the stomach,” he said. They respond to Gleevec in standard doses in only about 35%–40% of cases, which suggests to some the need to increase the dosage given to patients with this mutation.

And exon 18 mutations in the PDGFRA gene, seen in tumors arising in the stomach and omentum, appear to be 100% resistant to Gleevec—at least in vivo—which makes these patients potential candidates for sunitinib, which has been approved for salvage therapy and is marketed as Sutent.

Dr. McCarter recommends that advanced tumors be biopsied, then treated with one of the tyrosine kinase inhibitors for 3–6 months. Surgery should be performed while the tumor is still responding. Selective resection may be considered if focal resistance to the drug is detected.

For patients with suspected GISTs small enough to be resected, biopsy should be skipped, suggested Dr. Ashley. The best tool for preoperative planning is the CT scan, although endoscopic ultrasound-guided fine-needle aspiration has been used in the upper GI tract.

Once macroscopic disease has been resected (with negative microscopic margins, if possible), size (greater or less than 2 cm for intestinal tumors, and greater than or less than 5 cm for stomach tumors) and mitotic count determine prognosis and risk of recurrence.

Although tyrosine kinase inhibitors are approved only for advanced disease, neoadjuvant therapy is recommended by some.

“If it's less than 5 cm, proceed with surgery,” opined Dr. Ashley, who added that although Gleevec has greatly improved survival for some patients, it is “no match for the response you get with surgery.”

Dr. McCarter advised prudence in discussing prognosis with patients who have unresectable or metastatic GISTs, despite the advances made in understanding these lesions.

“It's important to point out that cure is still unlikely for those with metastatic GIST,” he said. Significant differences in progression-free survival still mean that most patients can expect a “lifetime of chemotherapy.”

Almost all patients with unresectable disease develop new mutations during the course of their treatment, he said.

CT is the best preoperative planning tool for gastrointestinal stromal tumors, the most common sarcomas of the GI tract. Courtesy Dr. Martin McCarter

LAS VEGAS — Gastrointestinal stromal tumors, long an enigma, are revealing their secrets and their vulnerabilities in the face of revolutionary discoveries about their origins, speakers said at a multidisciplinary general session of the spring meeting of the American College of Surgeons.

Complete resection remains the initial treatment of choice for these often fatal tumors, but advances in their characterization and therapy are providing a more optimistic outlook for patients whose survival was once measured in months rather than years.

“These tumors were miscategorized for 20 years,” said Dr. Stanley W. Ashley, vice chairman of surgery at Brigham and Women's Hospital and professor of surgery at Harvard Medical School, Boston.

In the late 1990s, Japanese researchers discovered that approximately 75%–80% of gastrointestinal stromal tumors (GISTs) have mutations in the c-kit gene.

This advance meant that tumors previously classified as leiomyomas, leiomyosarcomas, and leiomyoblastomas could be correctly recognized as GISTs. Further study revealed that 5%–10% of GISTs have a closely related mutation in the PDGFRA gene, while approximately 12%–15% are unrelated to these mutations and therefore characterized as “wild type” or “wild card” GISTs.

GISTs are now recognized as the most common sarcomas of the gastrointestinal tract and account for an official 0.2% of GI malignancies, “but that's changing” as the incidence increases, Dr. Ashley said.

Autopsy studies suggest that small GISTs exist in much of the population, with triggering genetic mechanisms likely responsible for turning these benign, incidental lesions into the “bad actors” they can become.

An important therapeutic turning point was the approval in 2002 of imatinib (Gleevec) for unresectable and/or metastatic GISTs, which drove median survival rates for these patients from “at best, 19 months” to about 58 months, said Dr. Martin McCarter, associate professor of surgery at the University of Colorado, Denver.

Adding nuance to basic understanding, Dr. Christopher Corless, chief of surgical pathology at Oregon Health and Science University, Portland, and others have begun to further characterize mutations according to exons within the c-kit and PDGFRA genes.

“We've come to think of GIST not as a single, unique entity, [but] rather as a family of tumors broken down by type of kit mutation or type of receptor alpha mutation,” Dr. Corless said at the meeting.

Exon 11 mutations, for example, occur in GISTs seen throughout the GI tract and are quite sensitive to Gleevec, as are “wild type” tumors. Exon 9 mutations, however, occur only in tumors arising from the duodenum, jejunum, ileum, and right colon—”never in the stomach,” he said. They respond to Gleevec in standard doses in only about 35%–40% of cases, which suggests to some the need to increase the dosage given to patients with this mutation.

And exon 18 mutations in the PDGFRA gene, seen in tumors arising in the stomach and omentum, appear to be 100% resistant to Gleevec—at least in vivo—which makes these patients potential candidates for sunitinib, which has been approved for salvage therapy and is marketed as Sutent.

Dr. McCarter recommends that advanced tumors be biopsied, then treated with one of the tyrosine kinase inhibitors for 3–6 months. Surgery should be performed while the tumor is still responding. Selective resection may be considered if focal resistance to the drug is detected.

For patients with suspected GISTs small enough to be resected, biopsy should be skipped, suggested Dr. Ashley. The best tool for preoperative planning is the CT scan, although endoscopic ultrasound-guided fine-needle aspiration has been used in the upper GI tract.

Once macroscopic disease has been resected (with negative microscopic margins, if possible), size (greater or less than 2 cm for intestinal tumors, and greater than or less than 5 cm for stomach tumors) and mitotic count determine prognosis and risk of recurrence.

Although tyrosine kinase inhibitors are approved only for advanced disease, neoadjuvant therapy is recommended by some.

“If it's less than 5 cm, proceed with surgery,” opined Dr. Ashley, who added that although Gleevec has greatly improved survival for some patients, it is “no match for the response you get with surgery.”

Dr. McCarter advised prudence in discussing prognosis with patients who have unresectable or metastatic GISTs, despite the advances made in understanding these lesions.

“It's important to point out that cure is still unlikely for those with metastatic GIST,” he said. Significant differences in progression-free survival still mean that most patients can expect a “lifetime of chemotherapy.”

Almost all patients with unresectable disease develop new mutations during the course of their treatment, he said.

CT is the best preoperative planning tool for gastrointestinal stromal tumors, the most common sarcomas of the GI tract. Courtesy Dr. Martin McCarter

LAS VEGAS — Gastrointestinal stromal tumors, long an enigma, are revealing their secrets and their vulnerabilities in the face of revolutionary discoveries about their origins, speakers said at a multidisciplinary general session of the spring meeting of the American College of Surgeons.

Complete resection remains the initial treatment of choice for these often fatal tumors, but advances in their characterization and therapy are providing a more optimistic outlook for patients whose survival was once measured in months rather than years.

“These tumors were miscategorized for 20 years,” said Dr. Stanley W. Ashley, vice chairman of surgery at Brigham and Women's Hospital and professor of surgery at Harvard Medical School, Boston.

In the late 1990s, Japanese researchers discovered that approximately 75%–80% of gastrointestinal stromal tumors (GISTs) have mutations in the c-kit gene.

This advance meant that tumors previously classified as leiomyomas, leiomyosarcomas, and leiomyoblastomas could be correctly recognized as GISTs. Further study revealed that 5%–10% of GISTs have a closely related mutation in the PDGFRA gene, while approximately 12%–15% are unrelated to these mutations and therefore characterized as “wild type” or “wild card” GISTs.

GISTs are now recognized as the most common sarcomas of the gastrointestinal tract and account for an official 0.2% of GI malignancies, “but that's changing” as the incidence increases, Dr. Ashley said.

Autopsy studies suggest that small GISTs exist in much of the population, with triggering genetic mechanisms likely responsible for turning these benign, incidental lesions into the “bad actors” they can become.

An important therapeutic turning point was the approval in 2002 of imatinib (Gleevec) for unresectable and/or metastatic GISTs, which drove median survival rates for these patients from “at best, 19 months” to about 58 months, said Dr. Martin McCarter, associate professor of surgery at the University of Colorado, Denver.

Adding nuance to basic understanding, Dr. Christopher Corless, chief of surgical pathology at Oregon Health and Science University, Portland, and others have begun to further characterize mutations according to exons within the c-kit and PDGFRA genes.

“We've come to think of GIST not as a single, unique entity, [but] rather as a family of tumors broken down by type of kit mutation or type of receptor alpha mutation,” Dr. Corless said at the meeting.

Exon 11 mutations, for example, occur in GISTs seen throughout the GI tract and are quite sensitive to Gleevec, as are “wild type” tumors. Exon 9 mutations, however, occur only in tumors arising from the duodenum, jejunum, ileum, and right colon—”never in the stomach,” he said. They respond to Gleevec in standard doses in only about 35%–40% of cases, which suggests to some the need to increase the dosage given to patients with this mutation.

And exon 18 mutations in the PDGFRA gene, seen in tumors arising in the stomach and omentum, appear to be 100% resistant to Gleevec—at least in vivo—which makes these patients potential candidates for sunitinib, which has been approved for salvage therapy and is marketed as Sutent.

Dr. McCarter recommends that advanced tumors be biopsied, then treated with one of the tyrosine kinase inhibitors for 3–6 months. Surgery should be performed while the tumor is still responding. Selective resection may be considered if focal resistance to the drug is detected.

For patients with suspected GISTs small enough to be resected, biopsy should be skipped, suggested Dr. Ashley. The best tool for preoperative planning is the CT scan, although endoscopic ultrasound-guided fine-needle aspiration has been used in the upper GI tract.

Once macroscopic disease has been resected (with negative microscopic margins, if possible), size (greater or less than 2 cm for intestinal tumors, and greater than or less than 5 cm for stomach tumors) and mitotic count determine prognosis and risk of recurrence.

Although tyrosine kinase inhibitors are approved only for advanced disease, neoadjuvant therapy is recommended by some.

“If it's less than 5 cm, proceed with surgery,” opined Dr. Ashley, who added that although Gleevec has greatly improved survival for some patients, it is “no match for the response you get with surgery.”

Dr. McCarter advised prudence in discussing prognosis with patients who have unresectable or metastatic GISTs, despite the advances made in understanding these lesions.

“It's important to point out that cure is still unlikely for those with metastatic GIST,” he said. Significant differences in progression-free survival still mean that most patients can expect a “lifetime of chemotherapy.”

Almost all patients with unresectable disease develop new mutations during the course of their treatment, he said.

CT is the best preoperative planning tool for gastrointestinal stromal tumors, the most common sarcomas of the GI tract. Courtesy Dr. Martin McCarter

SAN DIEGO – Almost a quarter of 505 women with hyperemesis gravidarum reported voluntarily terminating at least one pregnancy solely because of the severity of the condition, an international survey found.

More than 12% of women said they had terminated more than one pregnancy secondary to hyperemesis gravidarum (HG), and 30% said they feared future pregnancies because of the extreme nausea and vomiting they suffered previously in pregnancy.

Rates of termination among the 344 American women (27%) were roughly equal to rates of the group as a whole, which had about a 25% termination rate. “It was quite startling,” Dr. Borzouyeh Poursharif said of the finding concerning pregnancy termination.

Dr. Poursharif, a research fellow at the University of Southern California, Los Angeles, along with coinvestigators from USC and the National Institute of Child Health and Human Development's perinatology research branch in Detroit, analyzed registry data and results of an online survey conducted by the Hyperemesis Education and Research Foundation. They reported their results in a series of three posters at the annual meeting of the American College of Obstetricians and Gynecologists.

Among women who had terminated at least one pregnancy because of the condition, 60% perceived a “negative health provider attitude,” vs. 28% of those who did not voluntarily terminate a pregnancy, suggesting that physicians may benefit from more education about the severity of the condition and potentially effective treatments and psychosocial support measures, said Dr. Poursharif.

Compared with those who did not terminate pregnancies, women who terminated were less likely to report family or career dysfunction, decreased physical activity, or eating problems, reflecting “the burden of HG on women's lives,” the authors concluded.

Among 819 women from 31 countries who registered with the foundation, nearly half reported losing 10%-20% of their prepregnancy weight; only 16% reported losing 5% or less of their prepregnancy weight.

Generally, HG is defined as severe nausea, vomiting and associated symptoms, and a loss of greater than 5% of body weight.

More than a quarter of the women had lost at least 15% of their prepregnancy weight, a cutoff associated with severe complications both during and after pregnancy, Dr. Poursharif said in an interview at the meeting.

One in five women in the registry reported that their symptoms continued until term or beyond.

The 214 women with the greatest weight loss (more than 15%) faced a fivefold elevated risk of renal failure and retinal hemorrhage and fourfold elevated risk of liver dysfunction. Other complications significantly elevated in this group included the diagnosis of gall bladder disease in pregnancy, hematemesis, and neurologic changes.

They were more likely to have received inpatient treatment, intravenous fluids, total parenteral nutrition, and prescriptions for the medication ondansetron (Zofran). This group also experienced significantly more complications, which lasted more than 1 month beyond pregnancy, including nausea, digestive problems, gallbladder disease, insomnia, muscle pain, and food aversions.

Dr. Poursharif emphasized that neither the database nor the online survey results are considered to be representative of all women with HG. “We think that these were people who were so sick, they were desperate enough to search online, [where they] found this site and answered the surveys,” he said.

However, he noted that the findings do portray a surprisingly severe portrait of women suffering extreme cases of HG and highlight the need for more research into the true prevalence of the condition in its more extreme forms.

The database revealed that more than 20 treatment options were used by 765 women in 1,193 pregnancies.

Intravenous hydration, antihistamines, bed rest, and alternative therapies (acupuncture, herbal medicines, homeopathy, antinausea wristbands, and chiropractic) were used most frequently over a 20-year period, with the use of ondansetron dramatically increasing since 1990.

SAN DIEGO – Almost a quarter of 505 women with hyperemesis gravidarum reported voluntarily terminating at least one pregnancy solely because of the severity of the condition, an international survey found.

More than 12% of women said they had terminated more than one pregnancy secondary to hyperemesis gravidarum (HG), and 30% said they feared future pregnancies because of the extreme nausea and vomiting they suffered previously in pregnancy.

Rates of termination among the 344 American women (27%) were roughly equal to rates of the group as a whole, which had about a 25% termination rate. “It was quite startling,” Dr. Borzouyeh Poursharif said of the finding concerning pregnancy termination.

Dr. Poursharif, a research fellow at the University of Southern California, Los Angeles, along with coinvestigators from USC and the National Institute of Child Health and Human Development's perinatology research branch in Detroit, analyzed registry data and results of an online survey conducted by the Hyperemesis Education and Research Foundation. They reported their results in a series of three posters at the annual meeting of the American College of Obstetricians and Gynecologists.

Among women who had terminated at least one pregnancy because of the condition, 60% perceived a “negative health provider attitude,” vs. 28% of those who did not voluntarily terminate a pregnancy, suggesting that physicians may benefit from more education about the severity of the condition and potentially effective treatments and psychosocial support measures, said Dr. Poursharif.

Compared with those who did not terminate pregnancies, women who terminated were less likely to report family or career dysfunction, decreased physical activity, or eating problems, reflecting “the burden of HG on women's lives,” the authors concluded.

Among 819 women from 31 countries who registered with the foundation, nearly half reported losing 10%-20% of their prepregnancy weight; only 16% reported losing 5% or less of their prepregnancy weight.

Generally, HG is defined as severe nausea, vomiting and associated symptoms, and a loss of greater than 5% of body weight.

More than a quarter of the women had lost at least 15% of their prepregnancy weight, a cutoff associated with severe complications both during and after pregnancy, Dr. Poursharif said in an interview at the meeting.

One in five women in the registry reported that their symptoms continued until term or beyond.

The 214 women with the greatest weight loss (more than 15%) faced a fivefold elevated risk of renal failure and retinal hemorrhage and fourfold elevated risk of liver dysfunction. Other complications significantly elevated in this group included the diagnosis of gall bladder disease in pregnancy, hematemesis, and neurologic changes.

They were more likely to have received inpatient treatment, intravenous fluids, total parenteral nutrition, and prescriptions for the medication ondansetron (Zofran). This group also experienced significantly more complications, which lasted more than 1 month beyond pregnancy, including nausea, digestive problems, gallbladder disease, insomnia, muscle pain, and food aversions.

Dr. Poursharif emphasized that neither the database nor the online survey results are considered to be representative of all women with HG. “We think that these were people who were so sick, they were desperate enough to search online, [where they] found this site and answered the surveys,” he said.

However, he noted that the findings do portray a surprisingly severe portrait of women suffering extreme cases of HG and highlight the need for more research into the true prevalence of the condition in its more extreme forms.

The database revealed that more than 20 treatment options were used by 765 women in 1,193 pregnancies.

Intravenous hydration, antihistamines, bed rest, and alternative therapies (acupuncture, herbal medicines, homeopathy, antinausea wristbands, and chiropractic) were used most frequently over a 20-year period, with the use of ondansetron dramatically increasing since 1990.

SAN DIEGO – Almost a quarter of 505 women with hyperemesis gravidarum reported voluntarily terminating at least one pregnancy solely because of the severity of the condition, an international survey found.

More than 12% of women said they had terminated more than one pregnancy secondary to hyperemesis gravidarum (HG), and 30% said they feared future pregnancies because of the extreme nausea and vomiting they suffered previously in pregnancy.

Rates of termination among the 344 American women (27%) were roughly equal to rates of the group as a whole, which had about a 25% termination rate. “It was quite startling,” Dr. Borzouyeh Poursharif said of the finding concerning pregnancy termination.

Dr. Poursharif, a research fellow at the University of Southern California, Los Angeles, along with coinvestigators from USC and the National Institute of Child Health and Human Development's perinatology research branch in Detroit, analyzed registry data and results of an online survey conducted by the Hyperemesis Education and Research Foundation. They reported their results in a series of three posters at the annual meeting of the American College of Obstetricians and Gynecologists.

Among women who had terminated at least one pregnancy because of the condition, 60% perceived a “negative health provider attitude,” vs. 28% of those who did not voluntarily terminate a pregnancy, suggesting that physicians may benefit from more education about the severity of the condition and potentially effective treatments and psychosocial support measures, said Dr. Poursharif.

Compared with those who did not terminate pregnancies, women who terminated were less likely to report family or career dysfunction, decreased physical activity, or eating problems, reflecting “the burden of HG on women's lives,” the authors concluded.

Among 819 women from 31 countries who registered with the foundation, nearly half reported losing 10%-20% of their prepregnancy weight; only 16% reported losing 5% or less of their prepregnancy weight.

Generally, HG is defined as severe nausea, vomiting and associated symptoms, and a loss of greater than 5% of body weight.

More than a quarter of the women had lost at least 15% of their prepregnancy weight, a cutoff associated with severe complications both during and after pregnancy, Dr. Poursharif said in an interview at the meeting.

One in five women in the registry reported that their symptoms continued until term or beyond.

The 214 women with the greatest weight loss (more than 15%) faced a fivefold elevated risk of renal failure and retinal hemorrhage and fourfold elevated risk of liver dysfunction. Other complications significantly elevated in this group included the diagnosis of gall bladder disease in pregnancy, hematemesis, and neurologic changes.

They were more likely to have received inpatient treatment, intravenous fluids, total parenteral nutrition, and prescriptions for the medication ondansetron (Zofran). This group also experienced significantly more complications, which lasted more than 1 month beyond pregnancy, including nausea, digestive problems, gallbladder disease, insomnia, muscle pain, and food aversions.

Dr. Poursharif emphasized that neither the database nor the online survey results are considered to be representative of all women with HG. “We think that these were people who were so sick, they were desperate enough to search online, [where they] found this site and answered the surveys,” he said.

However, he noted that the findings do portray a surprisingly severe portrait of women suffering extreme cases of HG and highlight the need for more research into the true prevalence of the condition in its more extreme forms.

The database revealed that more than 20 treatment options were used by 765 women in 1,193 pregnancies.

Intravenous hydration, antihistamines, bed rest, and alternative therapies (acupuncture, herbal medicines, homeopathy, antinausea wristbands, and chiropractic) were used most frequently over a 20-year period, with the use of ondansetron dramatically increasing since 1990.

LAS VEGAS — Gastrointestinal stromal tumors, long an enigma, are revealing their secrets and their vulnerabilities in the face of revoluntionary discoveries about their origins, speakers said at a multidisciplinary general session of the spring meeting of the American College of Surgeons.

Complete resection remains the initial treatment of choice for these often fatal tumors, but advances in their characterization and therapy are providing a more optimistic outlook for patients whose survival was once measured in months rather than years.

“These tumors were miscategorized for 20 years,” said Dr. Stanley W. Ashley, vice-chairman of surgery at Brigham and Women's Hospital and professor of surgery at Harvard Medical School, Boston.

In the late 1990s, Japanese researchers discovered that about 75%–80% of gastrointestinal stromal tumors (GISTs) have mutations in the c-kit gene. This advance meant that tumors previously classified as leiomyomas, leiomyosarcomas, and leiomyoblastomas could be correctly recognized as GISTs. Further study revealed that 5%–10% of GISTs have a closely related mutation in the PDGFRA gene, and about 12%–15% are unrelated to these mutations and therefore characterized as “wild type” or “wild card” GISTs.

GISTs are now recognized as the most common sarcomas of the gastrointestinal tract and account for an official 0.2% of GI malignancies, “but that's changing” as the incidence increases, said Dr. Ashley.

Data from autopsy studies suggest that small GISTs exist in much of the population, with triggering genetic mechanisms likely responsible for turning these benign, incidental lesions into the “bad actors” they can become.

An important therapeutic turning point was the approval in 2002 of imatinib (Gleevec) for unresectable and/or metastatic GISTs, which drove median survival rates for these patients from “at best, 19 months” to about 58 months, said Dr. Martin McCarter, associate professor of surgery at the University of Colorado, Denver.

Adding nuance to basic understanding, Dr. Christopher Corless, chief of surgical pathology at Oregon Health and Science University, Portland, and others have begun to further characterize mutations according to exons within the c-kit and PDGFRA genes.

“We've come to think of GIST not as a single, unique entity, rather as a family of tumors broken down by type of kit mutation or type of receptor alpha mutation,” said Dr. Corless at the meeting.

Dr. McCarter recommends that advanced tumors be biopsied, then treated with one of the tyrosine kinase inhibitors for 3–6 months. Surgery should be performed while the tumor is still responding. Selective resection may be considered if focal resistance to the drug is detected.

For patients with suspected GISTs small enough to be resected, biopsy should be skipped, suggested Dr. Ashley. The best tool for preoperative planning is the CT scan, although endoscopic ultrasound-guided fine needle aspiration has been used in the upper GI tract.

Once macroscopic disease has been resected (with negative microscopic margins, if possible), size (greater or less than 2 cm for intestinal tumors, and greater than or less than 5 cm for stomach tumors) and mitotic count determine prognosis and risk of recurrence.

Although tyrosine kinase inhibitors are approved only for advanced disease, neoadjuvant therapy is recommended by some. “If it's less than 5 cm, proceed with surgery,” opined Dr. Ashley, adding that although Gleevec has greatly improved survival for some patients, it is “no match for the response you get with surgery.”

Dr. McCarter advised prudence in discussing prognosis with patients who have unresectable or metastatic GISTs, despite the advances made in understanding these lesions. “It's important to point out that cure is still unlikely for those with metastatic GIST,” he said.

Almost all patients with unresectable disease develop new mutations during the course of their treatment, said Dr. McCarter.

A bulky abdominal metastatic gastrointestinal stromal tumor is shown here on a computed tomography scan. Courtesy Dr. Martin McCarter

LAS VEGAS — Gastrointestinal stromal tumors, long an enigma, are revealing their secrets and their vulnerabilities in the face of revoluntionary discoveries about their origins, speakers said at a multidisciplinary general session of the spring meeting of the American College of Surgeons.

Complete resection remains the initial treatment of choice for these often fatal tumors, but advances in their characterization and therapy are providing a more optimistic outlook for patients whose survival was once measured in months rather than years.

“These tumors were miscategorized for 20 years,” said Dr. Stanley W. Ashley, vice-chairman of surgery at Brigham and Women's Hospital and professor of surgery at Harvard Medical School, Boston.

In the late 1990s, Japanese researchers discovered that about 75%–80% of gastrointestinal stromal tumors (GISTs) have mutations in the c-kit gene. This advance meant that tumors previously classified as leiomyomas, leiomyosarcomas, and leiomyoblastomas could be correctly recognized as GISTs. Further study revealed that 5%–10% of GISTs have a closely related mutation in the PDGFRA gene, and about 12%–15% are unrelated to these mutations and therefore characterized as “wild type” or “wild card” GISTs.

GISTs are now recognized as the most common sarcomas of the gastrointestinal tract and account for an official 0.2% of GI malignancies, “but that's changing” as the incidence increases, said Dr. Ashley.

Data from autopsy studies suggest that small GISTs exist in much of the population, with triggering genetic mechanisms likely responsible for turning these benign, incidental lesions into the “bad actors” they can become.

An important therapeutic turning point was the approval in 2002 of imatinib (Gleevec) for unresectable and/or metastatic GISTs, which drove median survival rates for these patients from “at best, 19 months” to about 58 months, said Dr. Martin McCarter, associate professor of surgery at the University of Colorado, Denver.

Adding nuance to basic understanding, Dr. Christopher Corless, chief of surgical pathology at Oregon Health and Science University, Portland, and others have begun to further characterize mutations according to exons within the c-kit and PDGFRA genes.

“We've come to think of GIST not as a single, unique entity, rather as a family of tumors broken down by type of kit mutation or type of receptor alpha mutation,” said Dr. Corless at the meeting.

Dr. McCarter recommends that advanced tumors be biopsied, then treated with one of the tyrosine kinase inhibitors for 3–6 months. Surgery should be performed while the tumor is still responding. Selective resection may be considered if focal resistance to the drug is detected.

For patients with suspected GISTs small enough to be resected, biopsy should be skipped, suggested Dr. Ashley. The best tool for preoperative planning is the CT scan, although endoscopic ultrasound-guided fine needle aspiration has been used in the upper GI tract.

Once macroscopic disease has been resected (with negative microscopic margins, if possible), size (greater or less than 2 cm for intestinal tumors, and greater than or less than 5 cm for stomach tumors) and mitotic count determine prognosis and risk of recurrence.

Although tyrosine kinase inhibitors are approved only for advanced disease, neoadjuvant therapy is recommended by some. “If it's less than 5 cm, proceed with surgery,” opined Dr. Ashley, adding that although Gleevec has greatly improved survival for some patients, it is “no match for the response you get with surgery.”

Dr. McCarter advised prudence in discussing prognosis with patients who have unresectable or metastatic GISTs, despite the advances made in understanding these lesions. “It's important to point out that cure is still unlikely for those with metastatic GIST,” he said.

Almost all patients with unresectable disease develop new mutations during the course of their treatment, said Dr. McCarter.

A bulky abdominal metastatic gastrointestinal stromal tumor is shown here on a computed tomography scan. Courtesy Dr. Martin McCarter

LAS VEGAS — Gastrointestinal stromal tumors, long an enigma, are revealing their secrets and their vulnerabilities in the face of revoluntionary discoveries about their origins, speakers said at a multidisciplinary general session of the spring meeting of the American College of Surgeons.

Complete resection remains the initial treatment of choice for these often fatal tumors, but advances in their characterization and therapy are providing a more optimistic outlook for patients whose survival was once measured in months rather than years.

“These tumors were miscategorized for 20 years,” said Dr. Stanley W. Ashley, vice-chairman of surgery at Brigham and Women's Hospital and professor of surgery at Harvard Medical School, Boston.

In the late 1990s, Japanese researchers discovered that about 75%–80% of gastrointestinal stromal tumors (GISTs) have mutations in the c-kit gene. This advance meant that tumors previously classified as leiomyomas, leiomyosarcomas, and leiomyoblastomas could be correctly recognized as GISTs. Further study revealed that 5%–10% of GISTs have a closely related mutation in the PDGFRA gene, and about 12%–15% are unrelated to these mutations and therefore characterized as “wild type” or “wild card” GISTs.

GISTs are now recognized as the most common sarcomas of the gastrointestinal tract and account for an official 0.2% of GI malignancies, “but that's changing” as the incidence increases, said Dr. Ashley.

Data from autopsy studies suggest that small GISTs exist in much of the population, with triggering genetic mechanisms likely responsible for turning these benign, incidental lesions into the “bad actors” they can become.

An important therapeutic turning point was the approval in 2002 of imatinib (Gleevec) for unresectable and/or metastatic GISTs, which drove median survival rates for these patients from “at best, 19 months” to about 58 months, said Dr. Martin McCarter, associate professor of surgery at the University of Colorado, Denver.

Adding nuance to basic understanding, Dr. Christopher Corless, chief of surgical pathology at Oregon Health and Science University, Portland, and others have begun to further characterize mutations according to exons within the c-kit and PDGFRA genes.

“We've come to think of GIST not as a single, unique entity, rather as a family of tumors broken down by type of kit mutation or type of receptor alpha mutation,” said Dr. Corless at the meeting.

Dr. McCarter recommends that advanced tumors be biopsied, then treated with one of the tyrosine kinase inhibitors for 3–6 months. Surgery should be performed while the tumor is still responding. Selective resection may be considered if focal resistance to the drug is detected.

For patients with suspected GISTs small enough to be resected, biopsy should be skipped, suggested Dr. Ashley. The best tool for preoperative planning is the CT scan, although endoscopic ultrasound-guided fine needle aspiration has been used in the upper GI tract.

Once macroscopic disease has been resected (with negative microscopic margins, if possible), size (greater or less than 2 cm for intestinal tumors, and greater than or less than 5 cm for stomach tumors) and mitotic count determine prognosis and risk of recurrence.

Although tyrosine kinase inhibitors are approved only for advanced disease, neoadjuvant therapy is recommended by some. “If it's less than 5 cm, proceed with surgery,” opined Dr. Ashley, adding that although Gleevec has greatly improved survival for some patients, it is “no match for the response you get with surgery.”

Dr. McCarter advised prudence in discussing prognosis with patients who have unresectable or metastatic GISTs, despite the advances made in understanding these lesions. “It's important to point out that cure is still unlikely for those with metastatic GIST,” he said.

Almost all patients with unresectable disease develop new mutations during the course of their treatment, said Dr. McCarter.

A bulky abdominal metastatic gastrointestinal stromal tumor is shown here on a computed tomography scan. Courtesy Dr. Martin McCarter

STANFORD, CALIF. — A preliminary analysis of a randomized, double-blind, placebo-controlled study of donepezil suggests that the Alzheimer's drug may slightly improve some neuropsychologic functions in children with autism, Dr. Antonio Hardan said at a pediatric update sponsored by Stanford University.

At the halfway point in a 20-week trial, improvements were seen in scores on some, but not all, neurocognitive tests in 10 autistic children aged 7–17 years receiving the drug, compared with 10 receiving placebo.

Specifically, children somewhat improved their performance on tests aimed at measuring spatial executive functioning (the Design Fluency Test), selective attention (the Color-Word Interference Test), and the California Verbal Learning Test. No improvement was seen on the Expressive One-Word Vocabulary Test, which measures language skills.

“We didn't see magic improvement or large improvements,” emphasized Dr. Hardan, director of the Autism and Developmental Disabilities Clinic at Lucile Packard Children's Hospital of Stanford (Calif.) University.

The trial is small and incomplete, and the results should be interpreted with caution, he said. “But what is nice about this is it opens up a whole group of medications to study.”

The use of donepezil (Aricept) in autism was first studied by Dr. Hardan at the University of Pittsburgh in an open-label study of eight children, half of whom demonstrated improvement on the Aberrant Behavior Checklist and Clinical Global Impression Scale. Improvements were suggested in irritability and hyperactivity, but not in inappropriate speech, lethargy, or stereotypies, he reported (J. Child Adolesc. Psychopharmacol. 2002;12:237–41).

Another novel study of an existing drug in autism is ongoing at Indiana University, Indianapolis, where a broad-spectrum antibiotic once used to treat tuberculosis led to apparent improvement in social withdrawal in a pilot study. A randomized, double-blind study is currently underway, pitting D-cycloserine, a partial agonist of the N-methyl-D-Aspartate (NMDA) glutamate receptor subtype, against placebo, Dr. Hardan said.

Although these are small studies, it is encouraging to see research into existing drugs to determine whether they might be effective in treating children with autism spectrum disorders, he said.

It took 15 years for risperidone (Risper-dal) to be approved for treatment of autism- related irritability, noted Dr. Hardan, who published an early case study suggesting the drug's efficacy in 1996. “That's why [parents] jump at any opportunity [to use a treatment] that could be potentially hazardous for their child.” He stressed that research must be driven by theories that make scientific sense, followed by proof-of-concept studies to see whether evidence exists that an agent may be helpful.

He pointed to “the [high] price of shortcuts,” citing as an example secretin, which was hailed as a possible treatment based on one uncontrolled observational study that hinted it may have improved behavior in three children undergoing gastrointestinal procedures.

No verification was made to determine whether the children actually met diagnostic criteria for autism, he noted. “Based on this, secretin was unfortunately the most studied medication in autism.”

Fifteen randomized, double-blind studies eventually produced uniformly negative results. “You can't find anything consistent like that in medicine,” he said.

Is Autism Prevalence Rising, or Is the Diagnosis Expanding?

An apparent increase in the prevalence of autism and autistic spectrum disorders may be largely explained by differences in diagnosis, rather than true differences in the number of children with these conditions, Dr. Hardan suggested.

“Is there an increase in incidence versus an increase in recognition?” asked Dr. Hardan. Several observations point to the latter, he said.

Much of the increase in prevalence is among children with mild symptoms: children with high-functioning autism, those with Asperger's syndrome, and children with pervasive developmental disorder, not otherwise specified.

“Fifteen or 20 years ago when somebody was verbal, it was very unlikely people were going to consider this an autism spectrum disorder,” he said.

On the other end of the spectrum, children with moderate to severe mental retardation were given that diagnosis decades ago, whereas today many children receive the autism diagnosis instead.

Traditionally, autism spectrum disorders were exclusively made in school-age children.

“Now people in their 20s and 30s who are struggling in daily living activities come to us and ask: 'Do I have an autism spectrum disorder?' Sometimes, some people do,” said Dr. Hardan, but a diagnosis in adulthood would have been unthinkable years ago.

Another important contributor to the apparently increasingly prevalence of autism is simple misdiagnosis, he maintained. Children with ADHD very often have social deficits, difficulties in developing peer relationships, and what Dr. Hardan described as “poor coherence between visual and verbal behaviors.”

But what may resemble autism or an autistic spectrum disorder, often is not, he said.

Children frequently referred to the clinic at Stanford who are misdiagnosed as autistic include those with severe anxiety symptoms, early onset personality disorders, and reactive attachment disorders.

Children in the latter category, often adopted from overseas, have many features that could lead a clinician to mistakenly diagnose autism, including severe social deficits and stereotypical behaviors, he said.

Methodological factors may also have contributed to apparent increases in autism prevalence, as depicted in a recent article, “The autism epidemic: fact or artifact?” (J. Am. Acad. Child Adolesc. Psychiatry 2007;46:721–30).

STANFORD, CALIF. — A preliminary analysis of a randomized, double-blind, placebo-controlled study of donepezil suggests that the Alzheimer's drug may slightly improve some neuropsychologic functions in children with autism, Dr. Antonio Hardan said at a pediatric update sponsored by Stanford University.

At the halfway point in a 20-week trial, improvements were seen in scores on some, but not all, neurocognitive tests in 10 autistic children aged 7–17 years receiving the drug, compared with 10 receiving placebo.

Specifically, children somewhat improved their performance on tests aimed at measuring spatial executive functioning (the Design Fluency Test), selective attention (the Color-Word Interference Test), and the California Verbal Learning Test. No improvement was seen on the Expressive One-Word Vocabulary Test, which measures language skills.

“We didn't see magic improvement or large improvements,” emphasized Dr. Hardan, director of the Autism and Developmental Disabilities Clinic at Lucile Packard Children's Hospital of Stanford (Calif.) University.

The trial is small and incomplete, and the results should be interpreted with caution, he said. “But what is nice about this is it opens up a whole group of medications to study.”

The use of donepezil (Aricept) in autism was first studied by Dr. Hardan at the University of Pittsburgh in an open-label study of eight children, half of whom demonstrated improvement on the Aberrant Behavior Checklist and Clinical Global Impression Scale. Improvements were suggested in irritability and hyperactivity, but not in inappropriate speech, lethargy, or stereotypies, he reported (J. Child Adolesc. Psychopharmacol. 2002;12:237–41).

Another novel study of an existing drug in autism is ongoing at Indiana University, Indianapolis, where a broad-spectrum antibiotic once used to treat tuberculosis led to apparent improvement in social withdrawal in a pilot study. A randomized, double-blind study is currently underway, pitting D-cycloserine, a partial agonist of the N-methyl-D-Aspartate (NMDA) glutamate receptor subtype, against placebo, Dr. Hardan said.

Although these are small studies, it is encouraging to see research into existing drugs to determine whether they might be effective in treating children with autism spectrum disorders, he said.

It took 15 years for risperidone (Risper-dal) to be approved for treatment of autism- related irritability, noted Dr. Hardan, who published an early case study suggesting the drug's efficacy in 1996. “That's why [parents] jump at any opportunity [to use a treatment] that could be potentially hazardous for their child.” He stressed that research must be driven by theories that make scientific sense, followed by proof-of-concept studies to see whether evidence exists that an agent may be helpful.

He pointed to “the [high] price of shortcuts,” citing as an example secretin, which was hailed as a possible treatment based on one uncontrolled observational study that hinted it may have improved behavior in three children undergoing gastrointestinal procedures.

No verification was made to determine whether the children actually met diagnostic criteria for autism, he noted. “Based on this, secretin was unfortunately the most studied medication in autism.”

Fifteen randomized, double-blind studies eventually produced uniformly negative results. “You can't find anything consistent like that in medicine,” he said.

Is Autism Prevalence Rising, or Is the Diagnosis Expanding?

An apparent increase in the prevalence of autism and autistic spectrum disorders may be largely explained by differences in diagnosis, rather than true differences in the number of children with these conditions, Dr. Hardan suggested.

“Is there an increase in incidence versus an increase in recognition?” asked Dr. Hardan. Several observations point to the latter, he said.

Much of the increase in prevalence is among children with mild symptoms: children with high-functioning autism, those with Asperger's syndrome, and children with pervasive developmental disorder, not otherwise specified.

“Fifteen or 20 years ago when somebody was verbal, it was very unlikely people were going to consider this an autism spectrum disorder,” he said.

On the other end of the spectrum, children with moderate to severe mental retardation were given that diagnosis decades ago, whereas today many children receive the autism diagnosis instead.

Traditionally, autism spectrum disorders were exclusively made in school-age children.

“Now people in their 20s and 30s who are struggling in daily living activities come to us and ask: 'Do I have an autism spectrum disorder?' Sometimes, some people do,” said Dr. Hardan, but a diagnosis in adulthood would have been unthinkable years ago.

Another important contributor to the apparently increasingly prevalence of autism is simple misdiagnosis, he maintained. Children with ADHD very often have social deficits, difficulties in developing peer relationships, and what Dr. Hardan described as “poor coherence between visual and verbal behaviors.”

But what may resemble autism or an autistic spectrum disorder, often is not, he said.

Children frequently referred to the clinic at Stanford who are misdiagnosed as autistic include those with severe anxiety symptoms, early onset personality disorders, and reactive attachment disorders.

Children in the latter category, often adopted from overseas, have many features that could lead a clinician to mistakenly diagnose autism, including severe social deficits and stereotypical behaviors, he said.

Methodological factors may also have contributed to apparent increases in autism prevalence, as depicted in a recent article, “The autism epidemic: fact or artifact?” (J. Am. Acad. Child Adolesc. Psychiatry 2007;46:721–30).

STANFORD, CALIF. — A preliminary analysis of a randomized, double-blind, placebo-controlled study of donepezil suggests that the Alzheimer's drug may slightly improve some neuropsychologic functions in children with autism, Dr. Antonio Hardan said at a pediatric update sponsored by Stanford University.

At the halfway point in a 20-week trial, improvements were seen in scores on some, but not all, neurocognitive tests in 10 autistic children aged 7–17 years receiving the drug, compared with 10 receiving placebo.

Specifically, children somewhat improved their performance on tests aimed at measuring spatial executive functioning (the Design Fluency Test), selective attention (the Color-Word Interference Test), and the California Verbal Learning Test. No improvement was seen on the Expressive One-Word Vocabulary Test, which measures language skills.

“We didn't see magic improvement or large improvements,” emphasized Dr. Hardan, director of the Autism and Developmental Disabilities Clinic at Lucile Packard Children's Hospital of Stanford (Calif.) University.

The trial is small and incomplete, and the results should be interpreted with caution, he said. “But what is nice about this is it opens up a whole group of medications to study.”

The use of donepezil (Aricept) in autism was first studied by Dr. Hardan at the University of Pittsburgh in an open-label study of eight children, half of whom demonstrated improvement on the Aberrant Behavior Checklist and Clinical Global Impression Scale. Improvements were suggested in irritability and hyperactivity, but not in inappropriate speech, lethargy, or stereotypies, he reported (J. Child Adolesc. Psychopharmacol. 2002;12:237–41).

Another novel study of an existing drug in autism is ongoing at Indiana University, Indianapolis, where a broad-spectrum antibiotic once used to treat tuberculosis led to apparent improvement in social withdrawal in a pilot study. A randomized, double-blind study is currently underway, pitting D-cycloserine, a partial agonist of the N-methyl-D-Aspartate (NMDA) glutamate receptor subtype, against placebo, Dr. Hardan said.

Although these are small studies, it is encouraging to see research into existing drugs to determine whether they might be effective in treating children with autism spectrum disorders, he said.

It took 15 years for risperidone (Risper-dal) to be approved for treatment of autism- related irritability, noted Dr. Hardan, who published an early case study suggesting the drug's efficacy in 1996. “That's why [parents] jump at any opportunity [to use a treatment] that could be potentially hazardous for their child.” He stressed that research must be driven by theories that make scientific sense, followed by proof-of-concept studies to see whether evidence exists that an agent may be helpful.

He pointed to “the [high] price of shortcuts,” citing as an example secretin, which was hailed as a possible treatment based on one uncontrolled observational study that hinted it may have improved behavior in three children undergoing gastrointestinal procedures.

No verification was made to determine whether the children actually met diagnostic criteria for autism, he noted. “Based on this, secretin was unfortunately the most studied medication in autism.”

Fifteen randomized, double-blind studies eventually produced uniformly negative results. “You can't find anything consistent like that in medicine,” he said.

Is Autism Prevalence Rising, or Is the Diagnosis Expanding?

An apparent increase in the prevalence of autism and autistic spectrum disorders may be largely explained by differences in diagnosis, rather than true differences in the number of children with these conditions, Dr. Hardan suggested.

“Is there an increase in incidence versus an increase in recognition?” asked Dr. Hardan. Several observations point to the latter, he said.

Much of the increase in prevalence is among children with mild symptoms: children with high-functioning autism, those with Asperger's syndrome, and children with pervasive developmental disorder, not otherwise specified.

“Fifteen or 20 years ago when somebody was verbal, it was very unlikely people were going to consider this an autism spectrum disorder,” he said.

On the other end of the spectrum, children with moderate to severe mental retardation were given that diagnosis decades ago, whereas today many children receive the autism diagnosis instead.

Traditionally, autism spectrum disorders were exclusively made in school-age children.

“Now people in their 20s and 30s who are struggling in daily living activities come to us and ask: 'Do I have an autism spectrum disorder?' Sometimes, some people do,” said Dr. Hardan, but a diagnosis in adulthood would have been unthinkable years ago.

Another important contributor to the apparently increasingly prevalence of autism is simple misdiagnosis, he maintained. Children with ADHD very often have social deficits, difficulties in developing peer relationships, and what Dr. Hardan described as “poor coherence between visual and verbal behaviors.”

But what may resemble autism or an autistic spectrum disorder, often is not, he said.

Children frequently referred to the clinic at Stanford who are misdiagnosed as autistic include those with severe anxiety symptoms, early onset personality disorders, and reactive attachment disorders.

Children in the latter category, often adopted from overseas, have many features that could lead a clinician to mistakenly diagnose autism, including severe social deficits and stereotypical behaviors, he said.

Methodological factors may also have contributed to apparent increases in autism prevalence, as depicted in a recent article, “The autism epidemic: fact or artifact?” (J. Am. Acad. Child Adolesc. Psychiatry 2007;46:721–30).

The quietest children are often the ones who make office hours run smoothly. They're in and out during well-child visits, letting Mom or Dad field the questions. When the clock is ticking and the exam rooms are full, physicians rarely try to draw them into a chat. So it's easy to miss those with selective mutism.

Dr. Barbara J. Howard, of the department of pediatrics at Johns Hopkins University, Baltimore, says that selective mutism is treatable and that without treatment, it can lead to significant social and educational impairment. It is part of the spectrum of anxiety disorders and, unchecked, it has the potential to evolve into other potentially debilitating social anxiety and mood disorders.

The disorder affects about 0.1% of children overall and 1% of children seen in mental health centers, and is as common as cystic fibrosis, according to the American Academy of Pediatrics. Yet it is often dismissed as shyness or immaturity.

Part of the problem is that selective mutism begins to manifest just after the very normal phase of separation anxiety. “Who hasn't dealt with the 3-year-old who hides her face in Mom's clothes? We are not surprised to see this behavior in children younger than 4 years of age,” added Dr. Howard, codirector of the university's Center for Promotion of Child Development Through Primary Care. “Complicating the picture is the fact that the parents may not readily share with you the fact that 4-year-old Alex never speaks in public, even though he blabs up a storm at home.”

Anxiety disorders, particularly social anxiety, tend to be familial. Parents may empathize with—even unwittingly reinforce—a child's reluctance to interact socially outside of his immediate family by stepping in too soon or making excuses for him. Although selective mutism is thought to be to the result of a biologically determined temperament and a predisposition to anxiety, it can be promoted by parental reactions.

“Unless you ask directly about his verbalization patterns, you may never know,” Dr. Howard said. She advised that the 4-year-old visit is a good time to consider the possibility of selective mutism and other anxiety problems because that's about the time the development of social relationships becomes one of a child's main goals.

Start out by specifically engaging in a conversation with the child, she said. “One of my favorite icebreakers is to ask a child to draw a picture of a boy and a girl and then suggest, 'Tell me a make-believe story about this boy.' The average 4-year-old will launch into a story, allowing you to obtain a drawing sample, a language sample, an example of some projective material, and a sense of the child's social interactions.”

If a parent jumps in while the child remains silent, ask very directly if the child is used to speaking with people outside the family, and if so, with whom and under what circumstances. If the child speaks normally with the family and close relatives, but never with peers or adults in social situations, consider selective mutism in the differential diagnosis. Then one should ask the family for details on the child's previous attempts at peer communication, for example, does the child stutter in public and therefore keep quiet?

One should also consider what role the parents are playing in this problem. “Occasionally, I see what seems to be selective mutism in a highly pressured child who will not perform by fulfilling parents' requests to recite the state capitals or the Gettysburg Address. These children usually talk just fine when their parents are not asking them to speak. Removing pressure won't get a child with selective mutism to talk in public.”

Rule out—or diagnose as a comorbid condition—separation anxiety disorder (as opposed to normal developmental separation anxiety) and the inhibited form of reactive attachment disorder.

Selective mutism is more likely if the child consistently fails to speak in a variety of social settings; if this silence is interfering with normal functioning; if the symptoms have lasted for at least 1 month (but not the first month of school); and if it is not related to having a primary language other than English.

Some children with selective mutism can be helped within the primary care practice using the same approach as for anxiety. One of the keystones is to make unfamiliar situations as familiar as possible, another is to work with parents on ways to assess and hide their own anxiety about their child's condition.

The quietest children are often the ones who make office hours run smoothly. They're in and out during well-child visits, letting Mom or Dad field the questions. When the clock is ticking and the exam rooms are full, physicians rarely try to draw them into a chat. So it's easy to miss those with selective mutism.

Dr. Barbara J. Howard, of the department of pediatrics at Johns Hopkins University, Baltimore, says that selective mutism is treatable and that without treatment, it can lead to significant social and educational impairment. It is part of the spectrum of anxiety disorders and, unchecked, it has the potential to evolve into other potentially debilitating social anxiety and mood disorders.

The disorder affects about 0.1% of children overall and 1% of children seen in mental health centers, and is as common as cystic fibrosis, according to the American Academy of Pediatrics. Yet it is often dismissed as shyness or immaturity.

Part of the problem is that selective mutism begins to manifest just after the very normal phase of separation anxiety. “Who hasn't dealt with the 3-year-old who hides her face in Mom's clothes? We are not surprised to see this behavior in children younger than 4 years of age,” added Dr. Howard, codirector of the university's Center for Promotion of Child Development Through Primary Care. “Complicating the picture is the fact that the parents may not readily share with you the fact that 4-year-old Alex never speaks in public, even though he blabs up a storm at home.”

Anxiety disorders, particularly social anxiety, tend to be familial. Parents may empathize with—even unwittingly reinforce—a child's reluctance to interact socially outside of his immediate family by stepping in too soon or making excuses for him. Although selective mutism is thought to be to the result of a biologically determined temperament and a predisposition to anxiety, it can be promoted by parental reactions.

“Unless you ask directly about his verbalization patterns, you may never know,” Dr. Howard said. She advised that the 4-year-old visit is a good time to consider the possibility of selective mutism and other anxiety problems because that's about the time the development of social relationships becomes one of a child's main goals.

Start out by specifically engaging in a conversation with the child, she said. “One of my favorite icebreakers is to ask a child to draw a picture of a boy and a girl and then suggest, 'Tell me a make-believe story about this boy.' The average 4-year-old will launch into a story, allowing you to obtain a drawing sample, a language sample, an example of some projective material, and a sense of the child's social interactions.”

If a parent jumps in while the child remains silent, ask very directly if the child is used to speaking with people outside the family, and if so, with whom and under what circumstances. If the child speaks normally with the family and close relatives, but never with peers or adults in social situations, consider selective mutism in the differential diagnosis. Then one should ask the family for details on the child's previous attempts at peer communication, for example, does the child stutter in public and therefore keep quiet?

One should also consider what role the parents are playing in this problem. “Occasionally, I see what seems to be selective mutism in a highly pressured child who will not perform by fulfilling parents' requests to recite the state capitals or the Gettysburg Address. These children usually talk just fine when their parents are not asking them to speak. Removing pressure won't get a child with selective mutism to talk in public.”

Rule out—or diagnose as a comorbid condition—separation anxiety disorder (as opposed to normal developmental separation anxiety) and the inhibited form of reactive attachment disorder.

Selective mutism is more likely if the child consistently fails to speak in a variety of social settings; if this silence is interfering with normal functioning; if the symptoms have lasted for at least 1 month (but not the first month of school); and if it is not related to having a primary language other than English.

Some children with selective mutism can be helped within the primary care practice using the same approach as for anxiety. One of the keystones is to make unfamiliar situations as familiar as possible, another is to work with parents on ways to assess and hide their own anxiety about their child's condition.

The quietest children are often the ones who make office hours run smoothly. They're in and out during well-child visits, letting Mom or Dad field the questions. When the clock is ticking and the exam rooms are full, physicians rarely try to draw them into a chat. So it's easy to miss those with selective mutism.

Dr. Barbara J. Howard, of the department of pediatrics at Johns Hopkins University, Baltimore, says that selective mutism is treatable and that without treatment, it can lead to significant social and educational impairment. It is part of the spectrum of anxiety disorders and, unchecked, it has the potential to evolve into other potentially debilitating social anxiety and mood disorders.

The disorder affects about 0.1% of children overall and 1% of children seen in mental health centers, and is as common as cystic fibrosis, according to the American Academy of Pediatrics. Yet it is often dismissed as shyness or immaturity.

Part of the problem is that selective mutism begins to manifest just after the very normal phase of separation anxiety. “Who hasn't dealt with the 3-year-old who hides her face in Mom's clothes? We are not surprised to see this behavior in children younger than 4 years of age,” added Dr. Howard, codirector of the university's Center for Promotion of Child Development Through Primary Care. “Complicating the picture is the fact that the parents may not readily share with you the fact that 4-year-old Alex never speaks in public, even though he blabs up a storm at home.”

Anxiety disorders, particularly social anxiety, tend to be familial. Parents may empathize with—even unwittingly reinforce—a child's reluctance to interact socially outside of his immediate family by stepping in too soon or making excuses for him. Although selective mutism is thought to be to the result of a biologically determined temperament and a predisposition to anxiety, it can be promoted by parental reactions.

“Unless you ask directly about his verbalization patterns, you may never know,” Dr. Howard said. She advised that the 4-year-old visit is a good time to consider the possibility of selective mutism and other anxiety problems because that's about the time the development of social relationships becomes one of a child's main goals.

Start out by specifically engaging in a conversation with the child, she said. “One of my favorite icebreakers is to ask a child to draw a picture of a boy and a girl and then suggest, 'Tell me a make-believe story about this boy.' The average 4-year-old will launch into a story, allowing you to obtain a drawing sample, a language sample, an example of some projective material, and a sense of the child's social interactions.”

If a parent jumps in while the child remains silent, ask very directly if the child is used to speaking with people outside the family, and if so, with whom and under what circumstances. If the child speaks normally with the family and close relatives, but never with peers or adults in social situations, consider selective mutism in the differential diagnosis. Then one should ask the family for details on the child's previous attempts at peer communication, for example, does the child stutter in public and therefore keep quiet?

One should also consider what role the parents are playing in this problem. “Occasionally, I see what seems to be selective mutism in a highly pressured child who will not perform by fulfilling parents' requests to recite the state capitals or the Gettysburg Address. These children usually talk just fine when their parents are not asking them to speak. Removing pressure won't get a child with selective mutism to talk in public.”

Rule out—or diagnose as a comorbid condition—separation anxiety disorder (as opposed to normal developmental separation anxiety) and the inhibited form of reactive attachment disorder.

Selective mutism is more likely if the child consistently fails to speak in a variety of social settings; if this silence is interfering with normal functioning; if the symptoms have lasted for at least 1 month (but not the first month of school); and if it is not related to having a primary language other than English.

Some children with selective mutism can be helped within the primary care practice using the same approach as for anxiety. One of the keystones is to make unfamiliar situations as familiar as possible, another is to work with parents on ways to assess and hide their own anxiety about their child's condition.

SAN DIEGO – A formal, two-question screening tool identified significantly more pregnant women in abusive relationships than did questions formulated by physicians to conform to guidelines of the American College of Obstetricians and Gynecologists, a study has found.

The two questions from the Women's Abuse Screening Tool (short form) are:

▸ In general, how would you describe your relationship? (A lot of tension, some tension, or no tension?)

▸ Do you and your partner work out arguments with a lot of difficulty, some difficulty, or no difficulty?

Dr. Tiffany A. Moore Simas and associates at the University of Massachusetts, Worcester, screened 136 prenatal patients with both the formal questions and informal physician prompts. (Guidelines from ACOG recommend asking about violence and trauma during prenatal visits; however, no formal questions are specified.)

Results were presented in poster form at the ACOG's annual meeting. Six patients (4.4%) who were experiencing intimate partner violence in their current relationships were identified by both screening methods. An additional 10 patients (7.4%) were detected only by the two questions from the Women's Abuse Screening Tool.

Six patients refused to participate in domestic violence screening. Of the total 16 patients in violent relationships, 5 separated from their partners during pregnancy.

Dr. Moore Simas and colleagues concluded that the two-question screen is “valid, reliable, easy, and unobtrusive.”

The other six questions in the long form of the Women's Abuse Screening Tool that may be used to make a more comprehensive assessment (answers for each are Occasionally, Sometimes, Never) are:

▸ Do arguments ever result in your feeling down or bad about yourself?

▸ Do arguments ever result in hitting, kicking, or pushing?

▸ Do you ever feel frightened by what your partner says or does?

▸ Has your partner ever abused you physically?

▸ Has your partner ever abused you emotionally?

▸ Has your partner ever abused you sexually?

SAN DIEGO – A formal, two-question screening tool identified significantly more pregnant women in abusive relationships than did questions formulated by physicians to conform to guidelines of the American College of Obstetricians and Gynecologists, a study has found.

The two questions from the Women's Abuse Screening Tool (short form) are:

▸ In general, how would you describe your relationship? (A lot of tension, some tension, or no tension?)

▸ Do you and your partner work out arguments with a lot of difficulty, some difficulty, or no difficulty?

Dr. Tiffany A. Moore Simas and associates at the University of Massachusetts, Worcester, screened 136 prenatal patients with both the formal questions and informal physician prompts. (Guidelines from ACOG recommend asking about violence and trauma during prenatal visits; however, no formal questions are specified.)

Results were presented in poster form at the ACOG's annual meeting. Six patients (4.4%) who were experiencing intimate partner violence in their current relationships were identified by both screening methods. An additional 10 patients (7.4%) were detected only by the two questions from the Women's Abuse Screening Tool.

Six patients refused to participate in domestic violence screening. Of the total 16 patients in violent relationships, 5 separated from their partners during pregnancy.

Dr. Moore Simas and colleagues concluded that the two-question screen is “valid, reliable, easy, and unobtrusive.”

The other six questions in the long form of the Women's Abuse Screening Tool that may be used to make a more comprehensive assessment (answers for each are Occasionally, Sometimes, Never) are:

▸ Do arguments ever result in your feeling down or bad about yourself?

▸ Do arguments ever result in hitting, kicking, or pushing?

▸ Do you ever feel frightened by what your partner says or does?

▸ Has your partner ever abused you physically?

▸ Has your partner ever abused you emotionally?

▸ Has your partner ever abused you sexually?

SAN DIEGO – A formal, two-question screening tool identified significantly more pregnant women in abusive relationships than did questions formulated by physicians to conform to guidelines of the American College of Obstetricians and Gynecologists, a study has found.

The two questions from the Women's Abuse Screening Tool (short form) are:

▸ In general, how would you describe your relationship? (A lot of tension, some tension, or no tension?)

▸ Do you and your partner work out arguments with a lot of difficulty, some difficulty, or no difficulty?

Dr. Tiffany A. Moore Simas and associates at the University of Massachusetts, Worcester, screened 136 prenatal patients with both the formal questions and informal physician prompts. (Guidelines from ACOG recommend asking about violence and trauma during prenatal visits; however, no formal questions are specified.)

Results were presented in poster form at the ACOG's annual meeting. Six patients (4.4%) who were experiencing intimate partner violence in their current relationships were identified by both screening methods. An additional 10 patients (7.4%) were detected only by the two questions from the Women's Abuse Screening Tool.

Six patients refused to participate in domestic violence screening. Of the total 16 patients in violent relationships, 5 separated from their partners during pregnancy.

Dr. Moore Simas and colleagues concluded that the two-question screen is “valid, reliable, easy, and unobtrusive.”

The other six questions in the long form of the Women's Abuse Screening Tool that may be used to make a more comprehensive assessment (answers for each are Occasionally, Sometimes, Never) are:

▸ Do arguments ever result in your feeling down or bad about yourself?

▸ Do arguments ever result in hitting, kicking, or pushing?

▸ Do you ever feel frightened by what your partner says or does?

▸ Has your partner ever abused you physically?

▸ Has your partner ever abused you emotionally?

▸ Has your partner ever abused you sexually?