Betsy Bates

LOS ANGELES — High-risk findings on myocardial perfusion studies require an immediate telephone call from a nuclear cardiologist to the referring physician, even when the temptation is to perform more tests to clarify the extent of cardiac viability, said Robert C. Hendel, M.D., at a meeting sponsored by the American College of Cardiology.

Dr. Hendel presented the case of a 31-year-old man, 6' 4” tall, 244 pounds, who presented with exertional chest pain. He had a history of radiation therapy for Hodgkin's disease.

During cardiac function tests, the patient was only able to proceed 4.5 minutes on the Bruce protocol before he experienced chest pain with ST-segment changes lasting about 15 minutes.

The patient's nuclear single-photon emission computed tomography (SPECT) images showed significant ischemia and large regions of decreased perfusion. Yet, in the interaction session attended by nuclear cardiologists, just over half of audience members voted that they would respond by immediately calling the referring physician.

Other attendees split their votes among other options, including repeating the SPECT using pharmacologic stress, performing additional imaging to assess viability, or reporting the likelihood of single-vessel disease.

Clearly, those in attendance were influenced by the patient's young age and the fact that more studies might provide more precise information.

However, the study's findings, combined with the patient's response to the cardiac function test, should be enough to warrant an immediate consultation with the referring physician, said Dr. Hendel at the meeting, which was cosponsored by the American Society of Nuclear Cardiology and Cedars-Sinai Medical Center.

“This is a very high-risk study,” he said. “Our responsibility is to pick up the phone and communicate that kind of information.”

In the case he presented, consultation with the referring cardiologist led to a referral to coronary angiography. The patient was found to have extensive coronary artery disease, including high-grade narrows (greater than 95%) in the proximal left anterior descending coronary artery involving the bifurcation of a large first diagonal branch.

“This high-risk anatomy was unsuitable for percutaneous coronary intervention, and he was referred for bypass surgery,” said Dr. Hendel following the meeting.

One week after his SPECT study, the patient underwent five-vessel bypass graft surgery. “He is doing well now, without symptoms.”

Dr. Hendel, a former president of the American Society of Nuclear Cardiology who practices with Midwest Heart Specialists in Fox River Grove, Ill., said nuclear cardiologists should lower their threshold for immediately conveying ominous test results to referring physicians.

LOS ANGELES — High-risk findings on myocardial perfusion studies require an immediate telephone call from a nuclear cardiologist to the referring physician, even when the temptation is to perform more tests to clarify the extent of cardiac viability, said Robert C. Hendel, M.D., at a meeting sponsored by the American College of Cardiology.

Dr. Hendel presented the case of a 31-year-old man, 6' 4” tall, 244 pounds, who presented with exertional chest pain. He had a history of radiation therapy for Hodgkin's disease.

During cardiac function tests, the patient was only able to proceed 4.5 minutes on the Bruce protocol before he experienced chest pain with ST-segment changes lasting about 15 minutes.

The patient's nuclear single-photon emission computed tomography (SPECT) images showed significant ischemia and large regions of decreased perfusion. Yet, in the interaction session attended by nuclear cardiologists, just over half of audience members voted that they would respond by immediately calling the referring physician.

Other attendees split their votes among other options, including repeating the SPECT using pharmacologic stress, performing additional imaging to assess viability, or reporting the likelihood of single-vessel disease.

Clearly, those in attendance were influenced by the patient's young age and the fact that more studies might provide more precise information.

However, the study's findings, combined with the patient's response to the cardiac function test, should be enough to warrant an immediate consultation with the referring physician, said Dr. Hendel at the meeting, which was cosponsored by the American Society of Nuclear Cardiology and Cedars-Sinai Medical Center.

“This is a very high-risk study,” he said. “Our responsibility is to pick up the phone and communicate that kind of information.”

In the case he presented, consultation with the referring cardiologist led to a referral to coronary angiography. The patient was found to have extensive coronary artery disease, including high-grade narrows (greater than 95%) in the proximal left anterior descending coronary artery involving the bifurcation of a large first diagonal branch.

“This high-risk anatomy was unsuitable for percutaneous coronary intervention, and he was referred for bypass surgery,” said Dr. Hendel following the meeting.

One week after his SPECT study, the patient underwent five-vessel bypass graft surgery. “He is doing well now, without symptoms.”

Dr. Hendel, a former president of the American Society of Nuclear Cardiology who practices with Midwest Heart Specialists in Fox River Grove, Ill., said nuclear cardiologists should lower their threshold for immediately conveying ominous test results to referring physicians.

LOS ANGELES — High-risk findings on myocardial perfusion studies require an immediate telephone call from a nuclear cardiologist to the referring physician, even when the temptation is to perform more tests to clarify the extent of cardiac viability, said Robert C. Hendel, M.D., at a meeting sponsored by the American College of Cardiology.

Dr. Hendel presented the case of a 31-year-old man, 6' 4” tall, 244 pounds, who presented with exertional chest pain. He had a history of radiation therapy for Hodgkin's disease.

During cardiac function tests, the patient was only able to proceed 4.5 minutes on the Bruce protocol before he experienced chest pain with ST-segment changes lasting about 15 minutes.

The patient's nuclear single-photon emission computed tomography (SPECT) images showed significant ischemia and large regions of decreased perfusion. Yet, in the interaction session attended by nuclear cardiologists, just over half of audience members voted that they would respond by immediately calling the referring physician.

Other attendees split their votes among other options, including repeating the SPECT using pharmacologic stress, performing additional imaging to assess viability, or reporting the likelihood of single-vessel disease.

Clearly, those in attendance were influenced by the patient's young age and the fact that more studies might provide more precise information.

However, the study's findings, combined with the patient's response to the cardiac function test, should be enough to warrant an immediate consultation with the referring physician, said Dr. Hendel at the meeting, which was cosponsored by the American Society of Nuclear Cardiology and Cedars-Sinai Medical Center.

“This is a very high-risk study,” he said. “Our responsibility is to pick up the phone and communicate that kind of information.”

In the case he presented, consultation with the referring cardiologist led to a referral to coronary angiography. The patient was found to have extensive coronary artery disease, including high-grade narrows (greater than 95%) in the proximal left anterior descending coronary artery involving the bifurcation of a large first diagonal branch.

“This high-risk anatomy was unsuitable for percutaneous coronary intervention, and he was referred for bypass surgery,” said Dr. Hendel following the meeting.

One week after his SPECT study, the patient underwent five-vessel bypass graft surgery. “He is doing well now, without symptoms.”

Dr. Hendel, a former president of the American Society of Nuclear Cardiology who practices with Midwest Heart Specialists in Fox River Grove, Ill., said nuclear cardiologists should lower their threshold for immediately conveying ominous test results to referring physicians.

LOS ANGELES — Specific findings on adenosine stress myocardial perfusion imaging can be combined with other risk factors to offer precise guidance about whether a patient would obtain a significant survival advantage with early revascularization, Rory Hachamovitch, M.D., said at a meeting sponsored by the American College of Cardiology.

Dr. Hachamovitch outlined the simplest of three new prognostic adenosine scores he validated in a group of 5,873 consecutive patients who underwent adenosine stress, dual-isotope single-photon emission computed tomography (SPECT) scanning, and were followed for a mean 2.2 years.

The simple score uses a patient's age, percent of ischemic myocardium, percent of fixed myocardium, presence or absence of dyspnea, resting ECG results, resting and peak stress heart rates, and scan results following early revascularization to predict 2-year mortality from cardiac causes.

Because revascularization can be plugged into the equation or left out, the formula can offer specific guidance as to the clinical management of an individual patient, said Dr. Hachamovitch of the clinical cardiovascular medicine unit at the University of Southern California, Los Angeles.

He offered the example of an 80-year-old man with atypical angina, assessing points to account for his age, the fact that 30% of his myocardium is ischemic, and other clinical characteristics and scan findings.

His final score was plotted on the x-axis of a graph against the 2-year Kaplan Meier Survival Curve on the y-axis.

The hypothetical patient received a total of 150 points if he underwent medical therapy, for a survival score of 91%, meaning he had a 9% chance of dying of cardiac causes in the ensuing 2 years.

When revascularization was factored into the formula, the patient's score dropped to 85 points, and his 2-year survival estimate rose to 97%.

The derivation of such a formula has been dependent on years of research into risk stratification for cardiac patients based on nuclear scan findings, said Dr. Hachamovitch at the meeting, which was cosponsored by the American Society of Nuclear Cardiology and Cedars-Sinai Medical Center.

This research has determined predictors of both relative and absolute risk reduction based on nuclear perfusion study results. Following Dr. Hachamovitch's talk, his findings were published (J. Am. Coll. Cardiol. 2005;45:722–9).

The relative benefit of revascularization over medical therapy after nuclear imaging is dependent on the extent and severity of the myocardium at risk.

The absolute benefit of revascularization— number of lives saved per 100 treated—depends on left ventricular ejection fraction (LVEF) and underlying clinical risk factors.

“Hence, if you want to figure out who is in need of revascularization, look for ischemia. If you want to know how big an impact on their survival that revascularization will be, look at LVEF and clinical risk factors,” said Dr. Hachamovitch.

LOS ANGELES — Specific findings on adenosine stress myocardial perfusion imaging can be combined with other risk factors to offer precise guidance about whether a patient would obtain a significant survival advantage with early revascularization, Rory Hachamovitch, M.D., said at a meeting sponsored by the American College of Cardiology.

Dr. Hachamovitch outlined the simplest of three new prognostic adenosine scores he validated in a group of 5,873 consecutive patients who underwent adenosine stress, dual-isotope single-photon emission computed tomography (SPECT) scanning, and were followed for a mean 2.2 years.

The simple score uses a patient's age, percent of ischemic myocardium, percent of fixed myocardium, presence or absence of dyspnea, resting ECG results, resting and peak stress heart rates, and scan results following early revascularization to predict 2-year mortality from cardiac causes.

Because revascularization can be plugged into the equation or left out, the formula can offer specific guidance as to the clinical management of an individual patient, said Dr. Hachamovitch of the clinical cardiovascular medicine unit at the University of Southern California, Los Angeles.

He offered the example of an 80-year-old man with atypical angina, assessing points to account for his age, the fact that 30% of his myocardium is ischemic, and other clinical characteristics and scan findings.

His final score was plotted on the x-axis of a graph against the 2-year Kaplan Meier Survival Curve on the y-axis.

The hypothetical patient received a total of 150 points if he underwent medical therapy, for a survival score of 91%, meaning he had a 9% chance of dying of cardiac causes in the ensuing 2 years.

When revascularization was factored into the formula, the patient's score dropped to 85 points, and his 2-year survival estimate rose to 97%.

The derivation of such a formula has been dependent on years of research into risk stratification for cardiac patients based on nuclear scan findings, said Dr. Hachamovitch at the meeting, which was cosponsored by the American Society of Nuclear Cardiology and Cedars-Sinai Medical Center.

This research has determined predictors of both relative and absolute risk reduction based on nuclear perfusion study results. Following Dr. Hachamovitch's talk, his findings were published (J. Am. Coll. Cardiol. 2005;45:722–9).

The relative benefit of revascularization over medical therapy after nuclear imaging is dependent on the extent and severity of the myocardium at risk.

The absolute benefit of revascularization— number of lives saved per 100 treated—depends on left ventricular ejection fraction (LVEF) and underlying clinical risk factors.

“Hence, if you want to figure out who is in need of revascularization, look for ischemia. If you want to know how big an impact on their survival that revascularization will be, look at LVEF and clinical risk factors,” said Dr. Hachamovitch.

LOS ANGELES — Specific findings on adenosine stress myocardial perfusion imaging can be combined with other risk factors to offer precise guidance about whether a patient would obtain a significant survival advantage with early revascularization, Rory Hachamovitch, M.D., said at a meeting sponsored by the American College of Cardiology.

Dr. Hachamovitch outlined the simplest of three new prognostic adenosine scores he validated in a group of 5,873 consecutive patients who underwent adenosine stress, dual-isotope single-photon emission computed tomography (SPECT) scanning, and were followed for a mean 2.2 years.

The simple score uses a patient's age, percent of ischemic myocardium, percent of fixed myocardium, presence or absence of dyspnea, resting ECG results, resting and peak stress heart rates, and scan results following early revascularization to predict 2-year mortality from cardiac causes.

Because revascularization can be plugged into the equation or left out, the formula can offer specific guidance as to the clinical management of an individual patient, said Dr. Hachamovitch of the clinical cardiovascular medicine unit at the University of Southern California, Los Angeles.

He offered the example of an 80-year-old man with atypical angina, assessing points to account for his age, the fact that 30% of his myocardium is ischemic, and other clinical characteristics and scan findings.

His final score was plotted on the x-axis of a graph against the 2-year Kaplan Meier Survival Curve on the y-axis.

The hypothetical patient received a total of 150 points if he underwent medical therapy, for a survival score of 91%, meaning he had a 9% chance of dying of cardiac causes in the ensuing 2 years.

When revascularization was factored into the formula, the patient's score dropped to 85 points, and his 2-year survival estimate rose to 97%.

The derivation of such a formula has been dependent on years of research into risk stratification for cardiac patients based on nuclear scan findings, said Dr. Hachamovitch at the meeting, which was cosponsored by the American Society of Nuclear Cardiology and Cedars-Sinai Medical Center.

This research has determined predictors of both relative and absolute risk reduction based on nuclear perfusion study results. Following Dr. Hachamovitch's talk, his findings were published (J. Am. Coll. Cardiol. 2005;45:722–9).

The relative benefit of revascularization over medical therapy after nuclear imaging is dependent on the extent and severity of the myocardium at risk.

The absolute benefit of revascularization— number of lives saved per 100 treated—depends on left ventricular ejection fraction (LVEF) and underlying clinical risk factors.

“Hence, if you want to figure out who is in need of revascularization, look for ischemia. If you want to know how big an impact on their survival that revascularization will be, look at LVEF and clinical risk factors,” said Dr. Hachamovitch.

LOS ANGELES — Forty percent of infectious disease specialists named multidrug-resistant gram-negative bacilli as the greatest threat to ICU patients, among all drug-resistant organisms.

Those physicians practicing in the mid-Atlantic region expressed the most concern in the survey.

Of particular note, specialists say they are having to resort to polymyxins to treat MDR-GNB infections despite the risk of nephrotoxicity and neurotoxicity associated with such drugs, said Rebecca H. Sunenshine, M.D., of the Centers for Disease Control and Prevention in Atlanta.

“People are starting to worry a lot about 'gram-negatives,'” she said in an interview at the annual meeting of the Society for Healthcare Epidemiology of America.

The Infectious Diseases Society of America's Emerging Infections Network surveyed its members in September 2004 regarding the emergence of nosocomial infections involving MDR-GNB.

More than 60% of 440 members surveyed from throughout the United States, U.S. territories, and Canada said they had treated at least one MDR-GNB infection resistant to all antimicrobials tested except polymyxins in the previous 12 months. In the mid-Atlantic states, 76% reported seeing at least one such infection during the year.

Most reported were MDR Pseudomonas infections—2,581 reported by 197 infectious disease specialists. Next was MDR Acinetobacter—reported by 140 specialists who had seen 1,439 cases.

Just 60% of respondents said polymyxins were available in their hospitals, and only a quarter said they were on formulary. “These drugs are not universally available, and susceptibility testing for them is not routinely performed. Other antimicrobial agents should be developed to treat these resistant infections,” the investigators said.

LOS ANGELES — Forty percent of infectious disease specialists named multidrug-resistant gram-negative bacilli as the greatest threat to ICU patients, among all drug-resistant organisms.

Those physicians practicing in the mid-Atlantic region expressed the most concern in the survey.

Of particular note, specialists say they are having to resort to polymyxins to treat MDR-GNB infections despite the risk of nephrotoxicity and neurotoxicity associated with such drugs, said Rebecca H. Sunenshine, M.D., of the Centers for Disease Control and Prevention in Atlanta.

“People are starting to worry a lot about 'gram-negatives,'” she said in an interview at the annual meeting of the Society for Healthcare Epidemiology of America.

The Infectious Diseases Society of America's Emerging Infections Network surveyed its members in September 2004 regarding the emergence of nosocomial infections involving MDR-GNB.

More than 60% of 440 members surveyed from throughout the United States, U.S. territories, and Canada said they had treated at least one MDR-GNB infection resistant to all antimicrobials tested except polymyxins in the previous 12 months. In the mid-Atlantic states, 76% reported seeing at least one such infection during the year.

Most reported were MDR Pseudomonas infections—2,581 reported by 197 infectious disease specialists. Next was MDR Acinetobacter—reported by 140 specialists who had seen 1,439 cases.

Just 60% of respondents said polymyxins were available in their hospitals, and only a quarter said they were on formulary. “These drugs are not universally available, and susceptibility testing for them is not routinely performed. Other antimicrobial agents should be developed to treat these resistant infections,” the investigators said.

LOS ANGELES — Forty percent of infectious disease specialists named multidrug-resistant gram-negative bacilli as the greatest threat to ICU patients, among all drug-resistant organisms.

Those physicians practicing in the mid-Atlantic region expressed the most concern in the survey.

Of particular note, specialists say they are having to resort to polymyxins to treat MDR-GNB infections despite the risk of nephrotoxicity and neurotoxicity associated with such drugs, said Rebecca H. Sunenshine, M.D., of the Centers for Disease Control and Prevention in Atlanta.

“People are starting to worry a lot about 'gram-negatives,'” she said in an interview at the annual meeting of the Society for Healthcare Epidemiology of America.

The Infectious Diseases Society of America's Emerging Infections Network surveyed its members in September 2004 regarding the emergence of nosocomial infections involving MDR-GNB.

More than 60% of 440 members surveyed from throughout the United States, U.S. territories, and Canada said they had treated at least one MDR-GNB infection resistant to all antimicrobials tested except polymyxins in the previous 12 months. In the mid-Atlantic states, 76% reported seeing at least one such infection during the year.

Most reported were MDR Pseudomonas infections—2,581 reported by 197 infectious disease specialists. Next was MDR Acinetobacter—reported by 140 specialists who had seen 1,439 cases.

Just 60% of respondents said polymyxins were available in their hospitals, and only a quarter said they were on formulary. “These drugs are not universally available, and susceptibility testing for them is not routinely performed. Other antimicrobial agents should be developed to treat these resistant infections,” the investigators said.

SAN DIEGO — New Zealand school-aged children who were conceived using in vitro fertilization were taller and had more favorable lipid profiles than those conceived naturally, a case-control study concluded.

Harriet Miles, M.D., and associates at the Liggins Institute of the University of Auckland studied 50 healthy children conceived via in vitro fertilization (IVF) with fresh embryos and 60 matched controls, when the children were 7–9 years old.

Participants were singletons, born at term, she said in an oral presentation at the annual meeting of the Endocrine Society.

After controlling for midparental height, members of the IVF group were considerably taller than the naturally conceived children. “This is surprising, as 15% of the IVF group were born small for gestational age, defined as weight below the 10th percentile,” said Dr. Miles, a pediatric endocrinologist.

According to standard growth prediction models, the IVF group would be up to half a standard deviation shorter than their naturally conceived peers, yet they were more than half a standard deviation taller.

“Another interesting finding is sexual dimorphism, with difference in height being more marked in females,” she said.

There were no differences in body composition between the two groups of children, yet IVF-conceived children had significantly higher insulin-like growth factor I (IGF-1), IGF-II, and insulin-like growth factor-binding protein 3 (IGFBP-3).

Their lipid profiles were more favorable, even when researchers controlled for age, sex, height, and percentage of body fat.

For example, the mean HDL cholesterol for IVF-conceived children was 1.61 mmol/L, compared with 1.51 mmol/L in naturally conceived controls.

There was a trend toward lower triglycerides and significantly lower LDL cholesterol in IVF-conceived children.

“Differences in growth and lipid metabolism in IVF children may be due to changes in genes influencing these factors, which are known to be imprinted,” Dr. Miles said.

She hypothesized that imprinting of these genes might be influenced by alterations in methylation patterns in the first few days after conception, as in the preimplantation period. A candidate gene to test this hypothesis has been found, and a future study will examine expression of this gene in IVF- and naturally conceived children.

In an interview, Dr. Miles explained that something as simple as the culture used during IVF may have an impact on methylation and expression of imprinted genes involved in growth and metabolism. The culture used in Australia and New Zealand contains glucose, for example.

Eric Surrey, M.D., president of the Society for Assisted Reproductive Technologies and a reproductive endocrinologist from Englewood, Colo., said in an interview after the conference that he found the study results “intriguing, but preliminary.”

Most studies of children conceived by IVF have focused on developmental issues and have found an occasional “blip,” but no significant, consistent differences between them and naturally conceived children. This may be the first study to address metabolic differences, he added.

“This is a small study, and I'm not sure any conclusions can be drawn from it. But anything suggesting differences in outcomes between children born using assisted reproductive techniques and those conceived naturally is very important to follow up on,” he said.

SAN DIEGO — New Zealand school-aged children who were conceived using in vitro fertilization were taller and had more favorable lipid profiles than those conceived naturally, a case-control study concluded.

Harriet Miles, M.D., and associates at the Liggins Institute of the University of Auckland studied 50 healthy children conceived via in vitro fertilization (IVF) with fresh embryos and 60 matched controls, when the children were 7–9 years old.

Participants were singletons, born at term, she said in an oral presentation at the annual meeting of the Endocrine Society.

After controlling for midparental height, members of the IVF group were considerably taller than the naturally conceived children. “This is surprising, as 15% of the IVF group were born small for gestational age, defined as weight below the 10th percentile,” said Dr. Miles, a pediatric endocrinologist.

According to standard growth prediction models, the IVF group would be up to half a standard deviation shorter than their naturally conceived peers, yet they were more than half a standard deviation taller.

“Another interesting finding is sexual dimorphism, with difference in height being more marked in females,” she said.

There were no differences in body composition between the two groups of children, yet IVF-conceived children had significantly higher insulin-like growth factor I (IGF-1), IGF-II, and insulin-like growth factor-binding protein 3 (IGFBP-3).

Their lipid profiles were more favorable, even when researchers controlled for age, sex, height, and percentage of body fat.

For example, the mean HDL cholesterol for IVF-conceived children was 1.61 mmol/L, compared with 1.51 mmol/L in naturally conceived controls.

There was a trend toward lower triglycerides and significantly lower LDL cholesterol in IVF-conceived children.

“Differences in growth and lipid metabolism in IVF children may be due to changes in genes influencing these factors, which are known to be imprinted,” Dr. Miles said.

She hypothesized that imprinting of these genes might be influenced by alterations in methylation patterns in the first few days after conception, as in the preimplantation period. A candidate gene to test this hypothesis has been found, and a future study will examine expression of this gene in IVF- and naturally conceived children.

In an interview, Dr. Miles explained that something as simple as the culture used during IVF may have an impact on methylation and expression of imprinted genes involved in growth and metabolism. The culture used in Australia and New Zealand contains glucose, for example.

Eric Surrey, M.D., president of the Society for Assisted Reproductive Technologies and a reproductive endocrinologist from Englewood, Colo., said in an interview after the conference that he found the study results “intriguing, but preliminary.”

Most studies of children conceived by IVF have focused on developmental issues and have found an occasional “blip,” but no significant, consistent differences between them and naturally conceived children. This may be the first study to address metabolic differences, he added.

“This is a small study, and I'm not sure any conclusions can be drawn from it. But anything suggesting differences in outcomes between children born using assisted reproductive techniques and those conceived naturally is very important to follow up on,” he said.

SAN DIEGO — New Zealand school-aged children who were conceived using in vitro fertilization were taller and had more favorable lipid profiles than those conceived naturally, a case-control study concluded.

Harriet Miles, M.D., and associates at the Liggins Institute of the University of Auckland studied 50 healthy children conceived via in vitro fertilization (IVF) with fresh embryos and 60 matched controls, when the children were 7–9 years old.

Participants were singletons, born at term, she said in an oral presentation at the annual meeting of the Endocrine Society.

After controlling for midparental height, members of the IVF group were considerably taller than the naturally conceived children. “This is surprising, as 15% of the IVF group were born small for gestational age, defined as weight below the 10th percentile,” said Dr. Miles, a pediatric endocrinologist.

According to standard growth prediction models, the IVF group would be up to half a standard deviation shorter than their naturally conceived peers, yet they were more than half a standard deviation taller.

“Another interesting finding is sexual dimorphism, with difference in height being more marked in females,” she said.

There were no differences in body composition between the two groups of children, yet IVF-conceived children had significantly higher insulin-like growth factor I (IGF-1), IGF-II, and insulin-like growth factor-binding protein 3 (IGFBP-3).

Their lipid profiles were more favorable, even when researchers controlled for age, sex, height, and percentage of body fat.

For example, the mean HDL cholesterol for IVF-conceived children was 1.61 mmol/L, compared with 1.51 mmol/L in naturally conceived controls.

There was a trend toward lower triglycerides and significantly lower LDL cholesterol in IVF-conceived children.

“Differences in growth and lipid metabolism in IVF children may be due to changes in genes influencing these factors, which are known to be imprinted,” Dr. Miles said.

She hypothesized that imprinting of these genes might be influenced by alterations in methylation patterns in the first few days after conception, as in the preimplantation period. A candidate gene to test this hypothesis has been found, and a future study will examine expression of this gene in IVF- and naturally conceived children.

In an interview, Dr. Miles explained that something as simple as the culture used during IVF may have an impact on methylation and expression of imprinted genes involved in growth and metabolism. The culture used in Australia and New Zealand contains glucose, for example.

Eric Surrey, M.D., president of the Society for Assisted Reproductive Technologies and a reproductive endocrinologist from Englewood, Colo., said in an interview after the conference that he found the study results “intriguing, but preliminary.”

Most studies of children conceived by IVF have focused on developmental issues and have found an occasional “blip,” but no significant, consistent differences between them and naturally conceived children. This may be the first study to address metabolic differences, he added.

“This is a small study, and I'm not sure any conclusions can be drawn from it. But anything suggesting differences in outcomes between children born using assisted reproductive techniques and those conceived naturally is very important to follow up on,” he said.

SAN DIEGO — Infertile men undergoing intracytoplasmic sperm injection display an elevated rate of genetic variations that may predispose them to pass on traits associated with neurodegenerative diseases, according to a study presented at the annual meeting of the Endocrine Society.

“This technique overcomes tremendous genetic barriers to reproduction and allows men with genetic disorders to achieve a pregnancy. It is therefore our concern that they will transmit these diseases to offspring,” said Francesca Gordon, a research associate at Baylor College of Medicine, Houston.

Ms. Gordon, Dolores J. Lamb, Ph.D., and their associates at Baylor and Monash Medical Center, Melbourne, obtained DNA samples from 647 infertile men whose partners were undergoing in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) in Houston and Melbourne and 369 normal controls from the same cities.

Polymerase chain reaction was used to analyze the lengths of triplet repeat tracts, also known as microsatellites, for three alleles associated with neurodegenerative disease: spinocerebral ataxia type 1 (SCA1), spinocerebral ataxia type 2 (SCA2), and dystrophia myotonica.

Several triplet repeat diseases such as Kennedy syndrome and myotonic dystrophy are associated with infertility.

The researchers hypothesized that expanded (normal, but unstable) microsatellite lengths associated with other triplet repeat diseases might be more common in infertile men, potentially putting at risk their children conceived through ICSI.

Ms. Gordon explained that there is a spectrum of repeat triplet lengths for each allele, ranging from normal to expanded-normal—a pattern that might pose a “pool of instability for future generations”—to a long expanse of triplet repeat tracks, associated with the development of symptoms. The length of the repeat correlates with disease severity and the age of onset. In general, the longer the triple repeat, the more severe the illness and the earlier symptoms occur.

There was a significantly increased incidence of unstable alleles associated with dystrophia myotonica in infertile men in Houston and Melbourne, compared with study controls.

Infertile men in Houston had an elevated incidence of unstable SCA2 alleles, compared with fertile control men. Conversely, only the men in Melbourne had a significantly elevated incidence of unstable SCA1 alleles, when compared with men in the control group.

Several of the patients exhibited repeat lengths in the mild to moderate disease range, whereas none of the control men did. The incidence of these unstable alleles varies by ethnicity and region, with SCA1 being more common in the general Australian population.

The incidence of dystrophia myotonica in the general population is estimated to be 5 in 100,000 people (0.00005%).

Infertile men in Houston had evidence of increased incidence of mild disease alleles, compared with men in the general population.

The estimated incidences of SCA1 and SCA2 are 0.006% in the general population.

Infertile men from both Houston and Melbourne had a higher incidence of SCA2 disease alleles than normal control samples. SCA1 disease alleles, in contrast, were increased, compared with controls only in the Melbourne population.

These results indicate there may be an increased risk of microsatellite expansion in infertile men using ICSI to father children. These men could then transmit these expanded alleles to their children, resulting in an increased risk of microsatellite expansion of neurodegenerative disease alleles in these individuals as well.

SAN DIEGO — Infertile men undergoing intracytoplasmic sperm injection display an elevated rate of genetic variations that may predispose them to pass on traits associated with neurodegenerative diseases, according to a study presented at the annual meeting of the Endocrine Society.

“This technique overcomes tremendous genetic barriers to reproduction and allows men with genetic disorders to achieve a pregnancy. It is therefore our concern that they will transmit these diseases to offspring,” said Francesca Gordon, a research associate at Baylor College of Medicine, Houston.

Ms. Gordon, Dolores J. Lamb, Ph.D., and their associates at Baylor and Monash Medical Center, Melbourne, obtained DNA samples from 647 infertile men whose partners were undergoing in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) in Houston and Melbourne and 369 normal controls from the same cities.

Polymerase chain reaction was used to analyze the lengths of triplet repeat tracts, also known as microsatellites, for three alleles associated with neurodegenerative disease: spinocerebral ataxia type 1 (SCA1), spinocerebral ataxia type 2 (SCA2), and dystrophia myotonica.

Several triplet repeat diseases such as Kennedy syndrome and myotonic dystrophy are associated with infertility.

The researchers hypothesized that expanded (normal, but unstable) microsatellite lengths associated with other triplet repeat diseases might be more common in infertile men, potentially putting at risk their children conceived through ICSI.

Ms. Gordon explained that there is a spectrum of repeat triplet lengths for each allele, ranging from normal to expanded-normal—a pattern that might pose a “pool of instability for future generations”—to a long expanse of triplet repeat tracks, associated with the development of symptoms. The length of the repeat correlates with disease severity and the age of onset. In general, the longer the triple repeat, the more severe the illness and the earlier symptoms occur.

There was a significantly increased incidence of unstable alleles associated with dystrophia myotonica in infertile men in Houston and Melbourne, compared with study controls.

Infertile men in Houston had an elevated incidence of unstable SCA2 alleles, compared with fertile control men. Conversely, only the men in Melbourne had a significantly elevated incidence of unstable SCA1 alleles, when compared with men in the control group.

Several of the patients exhibited repeat lengths in the mild to moderate disease range, whereas none of the control men did. The incidence of these unstable alleles varies by ethnicity and region, with SCA1 being more common in the general Australian population.

The incidence of dystrophia myotonica in the general population is estimated to be 5 in 100,000 people (0.00005%).

Infertile men in Houston had evidence of increased incidence of mild disease alleles, compared with men in the general population.

The estimated incidences of SCA1 and SCA2 are 0.006% in the general population.

Infertile men from both Houston and Melbourne had a higher incidence of SCA2 disease alleles than normal control samples. SCA1 disease alleles, in contrast, were increased, compared with controls only in the Melbourne population.

These results indicate there may be an increased risk of microsatellite expansion in infertile men using ICSI to father children. These men could then transmit these expanded alleles to their children, resulting in an increased risk of microsatellite expansion of neurodegenerative disease alleles in these individuals as well.

SAN DIEGO — Infertile men undergoing intracytoplasmic sperm injection display an elevated rate of genetic variations that may predispose them to pass on traits associated with neurodegenerative diseases, according to a study presented at the annual meeting of the Endocrine Society.

“This technique overcomes tremendous genetic barriers to reproduction and allows men with genetic disorders to achieve a pregnancy. It is therefore our concern that they will transmit these diseases to offspring,” said Francesca Gordon, a research associate at Baylor College of Medicine, Houston.

Ms. Gordon, Dolores J. Lamb, Ph.D., and their associates at Baylor and Monash Medical Center, Melbourne, obtained DNA samples from 647 infertile men whose partners were undergoing in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) in Houston and Melbourne and 369 normal controls from the same cities.

Polymerase chain reaction was used to analyze the lengths of triplet repeat tracts, also known as microsatellites, for three alleles associated with neurodegenerative disease: spinocerebral ataxia type 1 (SCA1), spinocerebral ataxia type 2 (SCA2), and dystrophia myotonica.

Several triplet repeat diseases such as Kennedy syndrome and myotonic dystrophy are associated with infertility.

The researchers hypothesized that expanded (normal, but unstable) microsatellite lengths associated with other triplet repeat diseases might be more common in infertile men, potentially putting at risk their children conceived through ICSI.

Ms. Gordon explained that there is a spectrum of repeat triplet lengths for each allele, ranging from normal to expanded-normal—a pattern that might pose a “pool of instability for future generations”—to a long expanse of triplet repeat tracks, associated with the development of symptoms. The length of the repeat correlates with disease severity and the age of onset. In general, the longer the triple repeat, the more severe the illness and the earlier symptoms occur.

There was a significantly increased incidence of unstable alleles associated with dystrophia myotonica in infertile men in Houston and Melbourne, compared with study controls.

Infertile men in Houston had an elevated incidence of unstable SCA2 alleles, compared with fertile control men. Conversely, only the men in Melbourne had a significantly elevated incidence of unstable SCA1 alleles, when compared with men in the control group.

Several of the patients exhibited repeat lengths in the mild to moderate disease range, whereas none of the control men did. The incidence of these unstable alleles varies by ethnicity and region, with SCA1 being more common in the general Australian population.

The incidence of dystrophia myotonica in the general population is estimated to be 5 in 100,000 people (0.00005%).

Infertile men in Houston had evidence of increased incidence of mild disease alleles, compared with men in the general population.

The estimated incidences of SCA1 and SCA2 are 0.006% in the general population.

Infertile men from both Houston and Melbourne had a higher incidence of SCA2 disease alleles than normal control samples. SCA1 disease alleles, in contrast, were increased, compared with controls only in the Melbourne population.

These results indicate there may be an increased risk of microsatellite expansion in infertile men using ICSI to father children. These men could then transmit these expanded alleles to their children, resulting in an increased risk of microsatellite expansion of neurodegenerative disease alleles in these individuals as well.

LOS ANGELES — High-risk findings on myocardial perfusion studies require an immediate telephone call from a nuclear cardiologist to the referring physician, even when the temptation is to perform more tests to clarify the extent of cardiac viability, said Robert C. Hendel, M.D., at a meeting sponsored by the American College of Cardiology.

Dr. Hendel presented the case of a 31-year-old man, 6' 4” tall, 244 pounds, who presented with exertional chest pain. He had a history of radiation therapy for Hodgkin's disease. During cardiac function tests, the patient was only able to proceed 4.5 minutes on the Bruce protocol before he experienced chest pain with ST-segment changes lasting about 15 minutes.

The patient's nuclear single-photon emission computed tomography (SPECT) images showed significant ischemia and large regions of decreased perfusion.

Yet, in the interaction session attended by nuclear cardiologists, just over half of audience members voted that they would respond by immediately calling the referring physician. Other attendees split their votes among other options, including repeating the SPECT using pharmacologic stress, performing additional imaging to assess viability, or reporting the likelihood of single-vessel disease.

Clearly, those in attendance were influenced by the patient's young age and the fact that more studies might provide more precise information. However, the study's findings, combined with the patient's response to the cardiac function test, should be enough to warrant an immediate consultation with the referring physician, said Dr. Hendel at the meeting, cosponsored by the American Society of Nuclear Cardiology and Cedars-Sinai Medical Center.

“This is a very high-risk study,” he said. “Our responsibility is to pick up the phone and communicate that kind of information.”

In the case he presented, consultation with the referring cardiologist led to a referral to coronary angiography. The patient was found to have extensive coronary artery disease, including high-grade narrows (greater than 95%) in the proximal left anterior descending coronary artery involving the bifurcation of a large first diagonal branch. “This high-risk anatomy was unsuitable for percutaneous coronary intervention, and he was referred for bypass surgery,” said Dr. Hendel following the meeting.

One week after his SPECT study, the patient underwent five-vessel bypass graft surgery. “He is doing well now, without symptoms.”

Dr. Hendel, a former president of the American Society of Nuclear Cardiology who practices in Fox River Grove, Ill., said he was familiar with two lawsuits in the past 5 years in which both the nuclear cardiologist and internist were sued owing to a lack of timely notification of a high-risk finding.

LOS ANGELES — High-risk findings on myocardial perfusion studies require an immediate telephone call from a nuclear cardiologist to the referring physician, even when the temptation is to perform more tests to clarify the extent of cardiac viability, said Robert C. Hendel, M.D., at a meeting sponsored by the American College of Cardiology.

Dr. Hendel presented the case of a 31-year-old man, 6' 4” tall, 244 pounds, who presented with exertional chest pain. He had a history of radiation therapy for Hodgkin's disease. During cardiac function tests, the patient was only able to proceed 4.5 minutes on the Bruce protocol before he experienced chest pain with ST-segment changes lasting about 15 minutes.

The patient's nuclear single-photon emission computed tomography (SPECT) images showed significant ischemia and large regions of decreased perfusion.

Yet, in the interaction session attended by nuclear cardiologists, just over half of audience members voted that they would respond by immediately calling the referring physician. Other attendees split their votes among other options, including repeating the SPECT using pharmacologic stress, performing additional imaging to assess viability, or reporting the likelihood of single-vessel disease.

Clearly, those in attendance were influenced by the patient's young age and the fact that more studies might provide more precise information. However, the study's findings, combined with the patient's response to the cardiac function test, should be enough to warrant an immediate consultation with the referring physician, said Dr. Hendel at the meeting, cosponsored by the American Society of Nuclear Cardiology and Cedars-Sinai Medical Center.

“This is a very high-risk study,” he said. “Our responsibility is to pick up the phone and communicate that kind of information.”

In the case he presented, consultation with the referring cardiologist led to a referral to coronary angiography. The patient was found to have extensive coronary artery disease, including high-grade narrows (greater than 95%) in the proximal left anterior descending coronary artery involving the bifurcation of a large first diagonal branch. “This high-risk anatomy was unsuitable for percutaneous coronary intervention, and he was referred for bypass surgery,” said Dr. Hendel following the meeting.

One week after his SPECT study, the patient underwent five-vessel bypass graft surgery. “He is doing well now, without symptoms.”

Dr. Hendel, a former president of the American Society of Nuclear Cardiology who practices in Fox River Grove, Ill., said he was familiar with two lawsuits in the past 5 years in which both the nuclear cardiologist and internist were sued owing to a lack of timely notification of a high-risk finding.

LOS ANGELES — High-risk findings on myocardial perfusion studies require an immediate telephone call from a nuclear cardiologist to the referring physician, even when the temptation is to perform more tests to clarify the extent of cardiac viability, said Robert C. Hendel, M.D., at a meeting sponsored by the American College of Cardiology.

Dr. Hendel presented the case of a 31-year-old man, 6' 4” tall, 244 pounds, who presented with exertional chest pain. He had a history of radiation therapy for Hodgkin's disease. During cardiac function tests, the patient was only able to proceed 4.5 minutes on the Bruce protocol before he experienced chest pain with ST-segment changes lasting about 15 minutes.

The patient's nuclear single-photon emission computed tomography (SPECT) images showed significant ischemia and large regions of decreased perfusion.

Yet, in the interaction session attended by nuclear cardiologists, just over half of audience members voted that they would respond by immediately calling the referring physician. Other attendees split their votes among other options, including repeating the SPECT using pharmacologic stress, performing additional imaging to assess viability, or reporting the likelihood of single-vessel disease.

Clearly, those in attendance were influenced by the patient's young age and the fact that more studies might provide more precise information. However, the study's findings, combined with the patient's response to the cardiac function test, should be enough to warrant an immediate consultation with the referring physician, said Dr. Hendel at the meeting, cosponsored by the American Society of Nuclear Cardiology and Cedars-Sinai Medical Center.

“This is a very high-risk study,” he said. “Our responsibility is to pick up the phone and communicate that kind of information.”

In the case he presented, consultation with the referring cardiologist led to a referral to coronary angiography. The patient was found to have extensive coronary artery disease, including high-grade narrows (greater than 95%) in the proximal left anterior descending coronary artery involving the bifurcation of a large first diagonal branch. “This high-risk anatomy was unsuitable for percutaneous coronary intervention, and he was referred for bypass surgery,” said Dr. Hendel following the meeting.

One week after his SPECT study, the patient underwent five-vessel bypass graft surgery. “He is doing well now, without symptoms.”

Dr. Hendel, a former president of the American Society of Nuclear Cardiology who practices in Fox River Grove, Ill., said he was familiar with two lawsuits in the past 5 years in which both the nuclear cardiologist and internist were sued owing to a lack of timely notification of a high-risk finding.

LOS ANGELES — Clinical and imaging clues provide excellent guidance as to which patients would derive the most benefit from endoscopic pancreatic calculi removal, Robert H. Hawes, M.D., said at the 12th International Symposium on Pancreatic and Biliary Endoscopy sponsored by Cedars-Sinai Medical Center.

“The main issue when you're looking at patients with pancreatic stones or calcific chronic pancreatitis is pain relief,” said Dr. Hawes, professor of gastroenterology and hepatology at the Medical University of South Carolina in Charleston.

“We can talk about improving ductal drainage. We can talk about … improving functional deficits. We can talk about weight gain. We can talk about improving quality of life. But the fact of the matter is, the main issue is pain.”

Therefore, patients with chronic calcific pancreatitis who do not have pain should not be considered candidates for stone removal, he asserted. Nor should stone removal be attempted in an effort to improve steatorrhea, which should be treated with enzymes.

Among patients who do experience pain, those living a “plateau-type existence” with chronic pancreatitis—suffering constant pain—are least likely to achieve significant relief by having calculi removed and obstructions of the main pancreatic duct alleviated, Dr. Hawes said.

The best candidates, he said, are those with chronic relapsing calcific pancreatitis.

These are patients who are “cruising along fine” until they suffer periodic acute bouts of pancreatitis, complete with an elevation of enzymes, extreme pain, and often, nausea and vomiting.

Their chances of success with endoscopic intervention improve even more if they meet certain criteria evident on imaging studies, including:

▸ A large, dilated pancreatic duct.

▸ Three or fewer stones.

▸ Stones confined to the head and/or body of the pancreas.

▸ Stone size less than 10 mm.

▸ The absence of impacted stones.

▸ The absence of downstream strictures.

Ideal candidates can achieve dramatic results from sphincterotomy with endoscopic calculi removal, ideally in conjunction with extracorporeal shock wave lithotripsy, Dr. Hawes said.

Even without the advantage of adjunctive extracorporeal shock wave lithotripsy, increasingly considered “almost indispensable” in centers treating chronic pancreatitis, endoscopic techniques can be highly effective.

A study by Dr. Hawes and his colleagues, published in 1991, showed endoscopic therapy to be effective in 83% of patients with chronic relapsing pancreatitis, compared with just 46% of those presenting with continuous pain (Gastrointest. Endosc. 1991;37:511–7).

Not every stone must be removed to achieve substantial pain relief, Dr. Hawes emphasized. He stopped short of discouraging endoscopic therapy in patients with unrelenting pain. He noted, “It's worth a try but may not help.”

Divergent rates of success for stone removal may be related to the fact that there are two underlying explanations for pain associated with chronic calcific pancreatitis.

In pancreatic duct obstruction, pain results from parenchymal hypertension. This scenario responds well to ductal decompression.

Pain associated with pancreatic and peripancreatic neural inflammation, most often associated with long-standing chronic disease, does not.

Careful imaging can point to whether endoscopic treatment should be undertaken. In some cases, careful imaging can bring to light massive stones and strictures that could be managed only by lithotripsy or surgical Whipple resection.

“I would strongly recommend that if you see patients with chronic pancreatitis, that you switch your gears from a reflex of just getting a CT scan to talking to your radiologist and getting geared up for high-quality MRI scanning … with secretin stimulation,” he said. No other modality gives such clear or important information in treatment planning for patients with chronic pancreatitis.

Dr. Hawes disclosed that he has received grants from Olympus America Inc. and research support from Wilson-Cook Medical Inc. and Boston Scientific Corp, and is a consultant for InScope.

LOS ANGELES — Clinical and imaging clues provide excellent guidance as to which patients would derive the most benefit from endoscopic pancreatic calculi removal, Robert H. Hawes, M.D., said at the 12th International Symposium on Pancreatic and Biliary Endoscopy sponsored by Cedars-Sinai Medical Center.

“The main issue when you're looking at patients with pancreatic stones or calcific chronic pancreatitis is pain relief,” said Dr. Hawes, professor of gastroenterology and hepatology at the Medical University of South Carolina in Charleston.

“We can talk about improving ductal drainage. We can talk about … improving functional deficits. We can talk about weight gain. We can talk about improving quality of life. But the fact of the matter is, the main issue is pain.”

Therefore, patients with chronic calcific pancreatitis who do not have pain should not be considered candidates for stone removal, he asserted. Nor should stone removal be attempted in an effort to improve steatorrhea, which should be treated with enzymes.

Among patients who do experience pain, those living a “plateau-type existence” with chronic pancreatitis—suffering constant pain—are least likely to achieve significant relief by having calculi removed and obstructions of the main pancreatic duct alleviated, Dr. Hawes said.

The best candidates, he said, are those with chronic relapsing calcific pancreatitis.

These are patients who are “cruising along fine” until they suffer periodic acute bouts of pancreatitis, complete with an elevation of enzymes, extreme pain, and often, nausea and vomiting.

Their chances of success with endoscopic intervention improve even more if they meet certain criteria evident on imaging studies, including:

▸ A large, dilated pancreatic duct.

▸ Three or fewer stones.

▸ Stones confined to the head and/or body of the pancreas.

▸ Stone size less than 10 mm.

▸ The absence of impacted stones.

▸ The absence of downstream strictures.

Ideal candidates can achieve dramatic results from sphincterotomy with endoscopic calculi removal, ideally in conjunction with extracorporeal shock wave lithotripsy, Dr. Hawes said.

Even without the advantage of adjunctive extracorporeal shock wave lithotripsy, increasingly considered “almost indispensable” in centers treating chronic pancreatitis, endoscopic techniques can be highly effective.

A study by Dr. Hawes and his colleagues, published in 1991, showed endoscopic therapy to be effective in 83% of patients with chronic relapsing pancreatitis, compared with just 46% of those presenting with continuous pain (Gastrointest. Endosc. 1991;37:511–7).

Not every stone must be removed to achieve substantial pain relief, Dr. Hawes emphasized. He stopped short of discouraging endoscopic therapy in patients with unrelenting pain. He noted, “It's worth a try but may not help.”

Divergent rates of success for stone removal may be related to the fact that there are two underlying explanations for pain associated with chronic calcific pancreatitis.

In pancreatic duct obstruction, pain results from parenchymal hypertension. This scenario responds well to ductal decompression.

Pain associated with pancreatic and peripancreatic neural inflammation, most often associated with long-standing chronic disease, does not.

Careful imaging can point to whether endoscopic treatment should be undertaken. In some cases, careful imaging can bring to light massive stones and strictures that could be managed only by lithotripsy or surgical Whipple resection.

“I would strongly recommend that if you see patients with chronic pancreatitis, that you switch your gears from a reflex of just getting a CT scan to talking to your radiologist and getting geared up for high-quality MRI scanning … with secretin stimulation,” he said. No other modality gives such clear or important information in treatment planning for patients with chronic pancreatitis.

Dr. Hawes disclosed that he has received grants from Olympus America Inc. and research support from Wilson-Cook Medical Inc. and Boston Scientific Corp, and is a consultant for InScope.

LOS ANGELES — Clinical and imaging clues provide excellent guidance as to which patients would derive the most benefit from endoscopic pancreatic calculi removal, Robert H. Hawes, M.D., said at the 12th International Symposium on Pancreatic and Biliary Endoscopy sponsored by Cedars-Sinai Medical Center.

“The main issue when you're looking at patients with pancreatic stones or calcific chronic pancreatitis is pain relief,” said Dr. Hawes, professor of gastroenterology and hepatology at the Medical University of South Carolina in Charleston.

“We can talk about improving ductal drainage. We can talk about … improving functional deficits. We can talk about weight gain. We can talk about improving quality of life. But the fact of the matter is, the main issue is pain.”

Therefore, patients with chronic calcific pancreatitis who do not have pain should not be considered candidates for stone removal, he asserted. Nor should stone removal be attempted in an effort to improve steatorrhea, which should be treated with enzymes.

Among patients who do experience pain, those living a “plateau-type existence” with chronic pancreatitis—suffering constant pain—are least likely to achieve significant relief by having calculi removed and obstructions of the main pancreatic duct alleviated, Dr. Hawes said.

The best candidates, he said, are those with chronic relapsing calcific pancreatitis.

These are patients who are “cruising along fine” until they suffer periodic acute bouts of pancreatitis, complete with an elevation of enzymes, extreme pain, and often, nausea and vomiting.

Their chances of success with endoscopic intervention improve even more if they meet certain criteria evident on imaging studies, including:

▸ A large, dilated pancreatic duct.

▸ Three or fewer stones.

▸ Stones confined to the head and/or body of the pancreas.

▸ Stone size less than 10 mm.

▸ The absence of impacted stones.

▸ The absence of downstream strictures.

Ideal candidates can achieve dramatic results from sphincterotomy with endoscopic calculi removal, ideally in conjunction with extracorporeal shock wave lithotripsy, Dr. Hawes said.

Even without the advantage of adjunctive extracorporeal shock wave lithotripsy, increasingly considered “almost indispensable” in centers treating chronic pancreatitis, endoscopic techniques can be highly effective.

A study by Dr. Hawes and his colleagues, published in 1991, showed endoscopic therapy to be effective in 83% of patients with chronic relapsing pancreatitis, compared with just 46% of those presenting with continuous pain (Gastrointest. Endosc. 1991;37:511–7).

Not every stone must be removed to achieve substantial pain relief, Dr. Hawes emphasized. He stopped short of discouraging endoscopic therapy in patients with unrelenting pain. He noted, “It's worth a try but may not help.”

Divergent rates of success for stone removal may be related to the fact that there are two underlying explanations for pain associated with chronic calcific pancreatitis.

In pancreatic duct obstruction, pain results from parenchymal hypertension. This scenario responds well to ductal decompression.

Pain associated with pancreatic and peripancreatic neural inflammation, most often associated with long-standing chronic disease, does not.

Careful imaging can point to whether endoscopic treatment should be undertaken. In some cases, careful imaging can bring to light massive stones and strictures that could be managed only by lithotripsy or surgical Whipple resection.

“I would strongly recommend that if you see patients with chronic pancreatitis, that you switch your gears from a reflex of just getting a CT scan to talking to your radiologist and getting geared up for high-quality MRI scanning … with secretin stimulation,” he said. No other modality gives such clear or important information in treatment planning for patients with chronic pancreatitis.

Dr. Hawes disclosed that he has received grants from Olympus America Inc. and research support from Wilson-Cook Medical Inc. and Boston Scientific Corp, and is a consultant for InScope.

WAILEA, MAUI — Histology revealed changes consistent with allergic granulomatous vasculitis, or Churg-Strauss syndrome, an eosinophilic condition that has been reported in rare cases in patients who use inhaled fluticasone propionate and other inhaled corticosteroids.

Microscopic changes included epidermal necrosis and an extensive superficial and deep granulomatous dermal infiltrate with numerous eosinophils.

Some evidence for granulomatous vasculitis also was noted.

Occasional granulomas, radially arranged around degenerated collagen bundles and cellular debris, were also present.

Churg-Strauss syndrome is a small-vessel, systemic vasculitis that can result in eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications.

Neuropathy may or may not be present.

Persistent questioning by telephone revealed that this patient used an oral inhaler, Advair Diskus, for pulmonary disease associated with his former occupation as a coal miner in West Virginia, reported Kenneth E. Greer, M.D., professor and chair of dermatology at the University of Virginia in Charlottesville.

The active ingredients in Advair Discus are fluticasone propionate, a corticosteroid, and salmeterol, a long-acting bronchodilator.

The medication was discontinued, and the patient's lesions resolved within 2 weeks, as shown in the picture below.

The patient's prescription for prednisone also was discontinued.

Dr. Greer presented this case at the annual Hawaii dermatology seminar sponsored by the Skin Disease Education Foundation.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

Photos courtesy Dr. Kenneth E. Greer

A 62-year-old retired coal miner was hospitalized in West Virginia for a weeklong history of symmetric necrotic lesions with blisters on the dorsum and palmar aspect of both hands. Herpes zoster was diagnosed. A consultation was sought with the University of Virginia department of dermatology when his condition failed to improve with intravenous acyclovir. A biopsy was taken and the patient was treated with oral prednisone, 40 mg/day for a potential diagnosis of Sweet's syndrome. What's your diagnosis?

WAILEA, MAUI — Histology revealed changes consistent with allergic granulomatous vasculitis, or Churg-Strauss syndrome, an eosinophilic condition that has been reported in rare cases in patients who use inhaled fluticasone propionate and other inhaled corticosteroids.

Microscopic changes included epidermal necrosis and an extensive superficial and deep granulomatous dermal infiltrate with numerous eosinophils.

Some evidence for granulomatous vasculitis also was noted.

Occasional granulomas, radially arranged around degenerated collagen bundles and cellular debris, were also present.

Churg-Strauss syndrome is a small-vessel, systemic vasculitis that can result in eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications.

Neuropathy may or may not be present.

Persistent questioning by telephone revealed that this patient used an oral inhaler, Advair Diskus, for pulmonary disease associated with his former occupation as a coal miner in West Virginia, reported Kenneth E. Greer, M.D., professor and chair of dermatology at the University of Virginia in Charlottesville.

The active ingredients in Advair Discus are fluticasone propionate, a corticosteroid, and salmeterol, a long-acting bronchodilator.

The medication was discontinued, and the patient's lesions resolved within 2 weeks, as shown in the picture below.

The patient's prescription for prednisone also was discontinued.

Dr. Greer presented this case at the annual Hawaii dermatology seminar sponsored by the Skin Disease Education Foundation.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

Photos courtesy Dr. Kenneth E. Greer

A 62-year-old retired coal miner was hospitalized in West Virginia for a weeklong history of symmetric necrotic lesions with blisters on the dorsum and palmar aspect of both hands. Herpes zoster was diagnosed. A consultation was sought with the University of Virginia department of dermatology when his condition failed to improve with intravenous acyclovir. A biopsy was taken and the patient was treated with oral prednisone, 40 mg/day for a potential diagnosis of Sweet's syndrome. What's your diagnosis?

WAILEA, MAUI — Histology revealed changes consistent with allergic granulomatous vasculitis, or Churg-Strauss syndrome, an eosinophilic condition that has been reported in rare cases in patients who use inhaled fluticasone propionate and other inhaled corticosteroids.

Microscopic changes included epidermal necrosis and an extensive superficial and deep granulomatous dermal infiltrate with numerous eosinophils.

Some evidence for granulomatous vasculitis also was noted.

Occasional granulomas, radially arranged around degenerated collagen bundles and cellular debris, were also present.

Churg-Strauss syndrome is a small-vessel, systemic vasculitis that can result in eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications.

Neuropathy may or may not be present.

Persistent questioning by telephone revealed that this patient used an oral inhaler, Advair Diskus, for pulmonary disease associated with his former occupation as a coal miner in West Virginia, reported Kenneth E. Greer, M.D., professor and chair of dermatology at the University of Virginia in Charlottesville.

The active ingredients in Advair Discus are fluticasone propionate, a corticosteroid, and salmeterol, a long-acting bronchodilator.

The medication was discontinued, and the patient's lesions resolved within 2 weeks, as shown in the picture below.

The patient's prescription for prednisone also was discontinued.

Dr. Greer presented this case at the annual Hawaii dermatology seminar sponsored by the Skin Disease Education Foundation.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

Photos courtesy Dr. Kenneth E. Greer

A 62-year-old retired coal miner was hospitalized in West Virginia for a weeklong history of symmetric necrotic lesions with blisters on the dorsum and palmar aspect of both hands. Herpes zoster was diagnosed. A consultation was sought with the University of Virginia department of dermatology when his condition failed to improve with intravenous acyclovir. A biopsy was taken and the patient was treated with oral prednisone, 40 mg/day for a potential diagnosis of Sweet's syndrome. What's your diagnosis?

MAUI, HAWAII — An open-label trial of adapalene gel 0.3% offered a rare long-term look at efficacy beyond the standard duration of most clinical acne medication trials.

“Most of the trials that we do with retinoids or topical acne treatments are for 12 weeks, and you often wonder what happens to the patient after that 12 weeks,” Diane M. Thiboutot, M.D., said at an annual Hawaii dermatology seminar sponsored by the Skin Disease Education Foundation.

A 1-year, open-label, 277-patient trial sponsored by Galderma Laboratories found that lesion counts continue to improve beyond the 50%–55% reduction from baseline seen at 12 weeks.

By 52 weeks, lesion counts had declined 80% from baseline.

Dryness was reported by 2.3% of patients at 12 months, compared with 8.2% at 3 months.

Discomfort and scaling, reported by 7.6% and 2.5% of patients, respectively, at 3 months, were no longer reported by patients 12 months into adapalene therapy.

These data are “exciting,” said Dr. Thiboutot, professor of dermatology at Pennsylvania State University, Hershey.

“As time goes on, patients do become accustomed” to the medication, she said.

“Most of the adverse events, as you might imagine, occurred during the first 12 weeks of the study,” Dr. Thiboutot added.

Dr. Thiboutot received funding for the clinical trial and also serves as a consultant to Galderma Laboratories.

The Skin Disease Education Foundation and this newspaper are wholly owned subsidiaries of Elsevier.

MAUI, HAWAII — An open-label trial of adapalene gel 0.3% offered a rare long-term look at efficacy beyond the standard duration of most clinical acne medication trials.

“Most of the trials that we do with retinoids or topical acne treatments are for 12 weeks, and you often wonder what happens to the patient after that 12 weeks,” Diane M. Thiboutot, M.D., said at an annual Hawaii dermatology seminar sponsored by the Skin Disease Education Foundation.

A 1-year, open-label, 277-patient trial sponsored by Galderma Laboratories found that lesion counts continue to improve beyond the 50%–55% reduction from baseline seen at 12 weeks.

By 52 weeks, lesion counts had declined 80% from baseline.

Dryness was reported by 2.3% of patients at 12 months, compared with 8.2% at 3 months.

Discomfort and scaling, reported by 7.6% and 2.5% of patients, respectively, at 3 months, were no longer reported by patients 12 months into adapalene therapy.

These data are “exciting,” said Dr. Thiboutot, professor of dermatology at Pennsylvania State University, Hershey.

“As time goes on, patients do become accustomed” to the medication, she said.

“Most of the adverse events, as you might imagine, occurred during the first 12 weeks of the study,” Dr. Thiboutot added.

Dr. Thiboutot received funding for the clinical trial and also serves as a consultant to Galderma Laboratories.

The Skin Disease Education Foundation and this newspaper are wholly owned subsidiaries of Elsevier.

MAUI, HAWAII — An open-label trial of adapalene gel 0.3% offered a rare long-term look at efficacy beyond the standard duration of most clinical acne medication trials.

“Most of the trials that we do with retinoids or topical acne treatments are for 12 weeks, and you often wonder what happens to the patient after that 12 weeks,” Diane M. Thiboutot, M.D., said at an annual Hawaii dermatology seminar sponsored by the Skin Disease Education Foundation.

A 1-year, open-label, 277-patient trial sponsored by Galderma Laboratories found that lesion counts continue to improve beyond the 50%–55% reduction from baseline seen at 12 weeks.

By 52 weeks, lesion counts had declined 80% from baseline.

Dryness was reported by 2.3% of patients at 12 months, compared with 8.2% at 3 months.

Discomfort and scaling, reported by 7.6% and 2.5% of patients, respectively, at 3 months, were no longer reported by patients 12 months into adapalene therapy.

These data are “exciting,” said Dr. Thiboutot, professor of dermatology at Pennsylvania State University, Hershey.

“As time goes on, patients do become accustomed” to the medication, she said.

“Most of the adverse events, as you might imagine, occurred during the first 12 weeks of the study,” Dr. Thiboutot added.

Dr. Thiboutot received funding for the clinical trial and also serves as a consultant to Galderma Laboratories.

The Skin Disease Education Foundation and this newspaper are wholly owned subsidiaries of Elsevier.

PALM SPRINGS, CALIF. – Ziconotide is a welcome addition to alternatives for relieving pain via intrathecal infusion, but many questions remain about its dosing, side effects, and potential best use, pain specialists said at the annual meeting of the American Academy of Pain Medicine.

“There are a lot of nuances with this drug,” said Samuel J. Hassenbusch III, M.D., professor of neurosurgery at the University of Texas, Houston.

“It's got to be on the market maybe 5 years before we can really say what its role is,” he said.

The Food and Drug Administration approved the nonopioid, N-type calcium channel blocker in December for treating chronic, intractable pain via an implanted intrathecal pump, making it the only analgesic other than morphine approved for intrathecal use. (Baclofen, marketed as Lioresal, is approved for intrathecal use in the treatment of cerebral spasticity.)

In practice, ziconotide (Prialt) will probably be used alone or in combination with other drugs to treat intractable malignant and nonmalignant pain.

A synthetic equivalent of a peptide used by the Conus magus marine snail to numb its prey, ziconotide is said to be 1,000-fold more potent than morphine in blocking phase 2 pain responses.

A combined analysis of three controlled trials presented at the meeting found the mean Visual Analogue Scale of Pain Intensity (VASPI) scores of 402 patients with nonmalignant pain improved 23%, compared with an 8% improvement in patients receiving placebo from the initial dose to the end of titration. The difference between the groups was significant.

In 51 patients with malignant pain, VASPI scores improved by 37% with ziconotide treatment, compared with 9% for placebo.

Within the study conducted by Ronald Collins, M.D., in private practice in Hampton Cove, Ala., significant VASPI score improvement was found in patients with myelopathic pain (19% vs. 0.1%), neuropathic pain (29% vs. 9%), radiculopathic pain (44% vs. 4%), spinal pain (21% vs. 7%), and failed back surgery syndrome (22% vs. 7%).

A trend toward significance was seen for patients with bone pain, according to the study findings, which were presented in poster form.

Dizziness, nausea, headache, and confusion are commonly reported side effects of ziconotide. Serious adverse events have been reported, including neurologic problems (such as confusion and somnolence) and urinary retention. The incidence and severity of side effects are believed to be modifiable with careful dosing and titration.

Indeed, the ideal dosing of the powerful drug–specifically, the initial intrathecal dose and titration schedule–drew significant attention at the meeting.

Many early study patients received an initial dose of 0.4 mcg/hour, with upward dose adjustments at 12-hour intervals. However, a safety evaluation conducted after 48 patients had been enrolled in a phase III trial prompted investigators led by Peter S. Staats, M.D., to decrease the initial dose to 0.1 mcg/hr and schedule increases in titration at 24-hour intervals (JAMA 2004;291:63–70).

The FDA-approved package insert recommends initiation at a dose of no more than 0.1 mcg/hour (2.4 mcg/day), with dose increases at intervals of no more than 2–3 times per week.

Some specialists at the meeting cautioned that the dose in the package insert may still be too high and the titration schedule too fast.

“You really do have to go low and very slow,” said Dr. Staats, chief of the division of pain medicine at Johns Hopkins University in Baltimore.

Aggressive dosing can trigger what Dr. Staats called a “fly by” effect; that is, the precipitation of side effects before pain relief sets in.

“The package insert says to change the dose every few days; I wouldn't even go there,” said Dr. Staats, who consults for Elan Pharmaceuticals Inc., the maker of ziconotide, and receives research support from Medtronic Inc., maker of a pump used to infuse ziconotide.

An initial dose of 0.5 mcg/day with dose adjustments every other week was recommended by Elliot Krames, M.D., a private practitioner in San Francisco. Dr. Krames disclosed that he receives research support and is on an advisory/review panel for Elan.

PALM SPRINGS, CALIF. – Ziconotide is a welcome addition to alternatives for relieving pain via intrathecal infusion, but many questions remain about its dosing, side effects, and potential best use, pain specialists said at the annual meeting of the American Academy of Pain Medicine.

“There are a lot of nuances with this drug,” said Samuel J. Hassenbusch III, M.D., professor of neurosurgery at the University of Texas, Houston.

“It's got to be on the market maybe 5 years before we can really say what its role is,” he said.

The Food and Drug Administration approved the nonopioid, N-type calcium channel blocker in December for treating chronic, intractable pain via an implanted intrathecal pump, making it the only analgesic other than morphine approved for intrathecal use. (Baclofen, marketed as Lioresal, is approved for intrathecal use in the treatment of cerebral spasticity.)

In practice, ziconotide (Prialt) will probably be used alone or in combination with other drugs to treat intractable malignant and nonmalignant pain.

A synthetic equivalent of a peptide used by the Conus magus marine snail to numb its prey, ziconotide is said to be 1,000-fold more potent than morphine in blocking phase 2 pain responses.

A combined analysis of three controlled trials presented at the meeting found the mean Visual Analogue Scale of Pain Intensity (VASPI) scores of 402 patients with nonmalignant pain improved 23%, compared with an 8% improvement in patients receiving placebo from the initial dose to the end of titration. The difference between the groups was significant.

In 51 patients with malignant pain, VASPI scores improved by 37% with ziconotide treatment, compared with 9% for placebo.

Within the study conducted by Ronald Collins, M.D., in private practice in Hampton Cove, Ala., significant VASPI score improvement was found in patients with myelopathic pain (19% vs. 0.1%), neuropathic pain (29% vs. 9%), radiculopathic pain (44% vs. 4%), spinal pain (21% vs. 7%), and failed back surgery syndrome (22% vs. 7%).

A trend toward significance was seen for patients with bone pain, according to the study findings, which were presented in poster form.

Dizziness, nausea, headache, and confusion are commonly reported side effects of ziconotide. Serious adverse events have been reported, including neurologic problems (such as confusion and somnolence) and urinary retention. The incidence and severity of side effects are believed to be modifiable with careful dosing and titration.

Indeed, the ideal dosing of the powerful drug–specifically, the initial intrathecal dose and titration schedule–drew significant attention at the meeting.

Many early study patients received an initial dose of 0.4 mcg/hour, with upward dose adjustments at 12-hour intervals. However, a safety evaluation conducted after 48 patients had been enrolled in a phase III trial prompted investigators led by Peter S. Staats, M.D., to decrease the initial dose to 0.1 mcg/hr and schedule increases in titration at 24-hour intervals (JAMA 2004;291:63–70).

The FDA-approved package insert recommends initiation at a dose of no more than 0.1 mcg/hour (2.4 mcg/day), with dose increases at intervals of no more than 2–3 times per week.

Some specialists at the meeting cautioned that the dose in the package insert may still be too high and the titration schedule too fast.

“You really do have to go low and very slow,” said Dr. Staats, chief of the division of pain medicine at Johns Hopkins University in Baltimore.

Aggressive dosing can trigger what Dr. Staats called a “fly by” effect; that is, the precipitation of side effects before pain relief sets in.

“The package insert says to change the dose every few days; I wouldn't even go there,” said Dr. Staats, who consults for Elan Pharmaceuticals Inc., the maker of ziconotide, and receives research support from Medtronic Inc., maker of a pump used to infuse ziconotide.

An initial dose of 0.5 mcg/day with dose adjustments every other week was recommended by Elliot Krames, M.D., a private practitioner in San Francisco. Dr. Krames disclosed that he receives research support and is on an advisory/review panel for Elan.

PALM SPRINGS, CALIF. – Ziconotide is a welcome addition to alternatives for relieving pain via intrathecal infusion, but many questions remain about its dosing, side effects, and potential best use, pain specialists said at the annual meeting of the American Academy of Pain Medicine.

“There are a lot of nuances with this drug,” said Samuel J. Hassenbusch III, M.D., professor of neurosurgery at the University of Texas, Houston.

“It's got to be on the market maybe 5 years before we can really say what its role is,” he said.

The Food and Drug Administration approved the nonopioid, N-type calcium channel blocker in December for treating chronic, intractable pain via an implanted intrathecal pump, making it the only analgesic other than morphine approved for intrathecal use. (Baclofen, marketed as Lioresal, is approved for intrathecal use in the treatment of cerebral spasticity.)

In practice, ziconotide (Prialt) will probably be used alone or in combination with other drugs to treat intractable malignant and nonmalignant pain.

A synthetic equivalent of a peptide used by the Conus magus marine snail to numb its prey, ziconotide is said to be 1,000-fold more potent than morphine in blocking phase 2 pain responses.

A combined analysis of three controlled trials presented at the meeting found the mean Visual Analogue Scale of Pain Intensity (VASPI) scores of 402 patients with nonmalignant pain improved 23%, compared with an 8% improvement in patients receiving placebo from the initial dose to the end of titration. The difference between the groups was significant.

In 51 patients with malignant pain, VASPI scores improved by 37% with ziconotide treatment, compared with 9% for placebo.

Within the study conducted by Ronald Collins, M.D., in private practice in Hampton Cove, Ala., significant VASPI score improvement was found in patients with myelopathic pain (19% vs. 0.1%), neuropathic pain (29% vs. 9%), radiculopathic pain (44% vs. 4%), spinal pain (21% vs. 7%), and failed back surgery syndrome (22% vs. 7%).

A trend toward significance was seen for patients with bone pain, according to the study findings, which were presented in poster form.

Dizziness, nausea, headache, and confusion are commonly reported side effects of ziconotide. Serious adverse events have been reported, including neurologic problems (such as confusion and somnolence) and urinary retention. The incidence and severity of side effects are believed to be modifiable with careful dosing and titration.

Indeed, the ideal dosing of the powerful drug–specifically, the initial intrathecal dose and titration schedule–drew significant attention at the meeting.

Many early study patients received an initial dose of 0.4 mcg/hour, with upward dose adjustments at 12-hour intervals. However, a safety evaluation conducted after 48 patients had been enrolled in a phase III trial prompted investigators led by Peter S. Staats, M.D., to decrease the initial dose to 0.1 mcg/hr and schedule increases in titration at 24-hour intervals (JAMA 2004;291:63–70).

The FDA-approved package insert recommends initiation at a dose of no more than 0.1 mcg/hour (2.4 mcg/day), with dose increases at intervals of no more than 2–3 times per week.

Some specialists at the meeting cautioned that the dose in the package insert may still be too high and the titration schedule too fast.

“You really do have to go low and very slow,” said Dr. Staats, chief of the division of pain medicine at Johns Hopkins University in Baltimore.

Aggressive dosing can trigger what Dr. Staats called a “fly by” effect; that is, the precipitation of side effects before pain relief sets in.

“The package insert says to change the dose every few days; I wouldn't even go there,” said Dr. Staats, who consults for Elan Pharmaceuticals Inc., the maker of ziconotide, and receives research support from Medtronic Inc., maker of a pump used to infuse ziconotide.

An initial dose of 0.5 mcg/day with dose adjustments every other week was recommended by Elliot Krames, M.D., a private practitioner in San Francisco. Dr. Krames disclosed that he receives research support and is on an advisory/review panel for Elan.