Bruce K. Dixon

SAN DIEGO — Physicians involved in pain treatment and palliative care have been asked to get involved in grassroots efforts in support of the National Pain Care Policy Act, which has been stalled in the health subcommittee of the Committee on Energy and Commerce.

Introduced on March 1, 2005, by Congressman Michael Rogers (R-Mich.), HR 1020 is the first comprehensive pain care bill ever introduced on Capitol Hill. Its passage is a top priority of the Pain Care Coalition (PCC), which is composed of the American Pain Society, the American Academy of Pain Medicine (AAPM), and the American Association for the Study of Headache.

HR 1020, though it has the backing of more than 100 patient advocacy groups, has only 33 cosponsors in the House. Support has been unenthusiastic in part because of a general feeling that the bill tries to do too much, said PCC Washington counsel Robert J. Saner II.

“It's the very comprehensiveness of the bill that is slowing its progress. Many people have looked at the legislation and said it's too broad and should be more focused,” Mr. Saner told the annual meeting of the AAPM. “The PCC has been reluctant to pare because what's in it is necessary.”

The bill would declare adequate pain care research, education, and treatment as national public health priorities, and would establish the National Center for Pain and Palliative Care Research at the National Institutes of Health “to conduct clinical and basic science research into the biology of, the causes of, and effective treatments for pain.”

It also would establish “a national agenda for conducting and supporting pain and palliative care research and to identify, coordinate, and support research, research training, and related activities with respect to primary and secondary pain,” according to the Office of Legislative Policy and Analysis.

“All of these things are new; they're things the NIH doesn't do now and doesn't want to spend money on,” Mr. Saner explained.

The legislation would take some of the pain care emphasis off the Drug Enforcement Agency (DEA), Mr. Saner added.

“One of the problems is we've been barking up the wrong tree. Many people in the pain community go to the DEA because the DEA has been focusing on pain care; we need to develop some other trees to bark up, and principal among those are the NIH, the Agency for Healthcare Research and Quality, the Health Resources and Services Administration, and the Centers for Medicare and Medicaid Services,” he said. Various aspects of this bill address those agencies.

“We would like to have 250 cosponsors in the House of Representatives, and getting there depends a lot on you and your colleagues around the country getting engaged in grassroots activities in support of this bill,” Mr. Saner said.

His comments were echoed by Sylvia Warner, a spokesperson for Rep. Rogers, who said patients have the most to gain and should contact their representatives in support of 1020.

“The average patient goes through 13 physicians before he or she finds a doctor who will help with their pain,” Warner said in an interview, adding that an ongoing effort to get the pain care bill into the full committee might bear fruit this year.

SAN DIEGO — Physicians involved in pain treatment and palliative care have been asked to get involved in grassroots efforts in support of the National Pain Care Policy Act, which has been stalled in the health subcommittee of the Committee on Energy and Commerce.

Introduced on March 1, 2005, by Congressman Michael Rogers (R-Mich.), HR 1020 is the first comprehensive pain care bill ever introduced on Capitol Hill. Its passage is a top priority of the Pain Care Coalition (PCC), which is composed of the American Pain Society, the American Academy of Pain Medicine (AAPM), and the American Association for the Study of Headache.

HR 1020, though it has the backing of more than 100 patient advocacy groups, has only 33 cosponsors in the House. Support has been unenthusiastic in part because of a general feeling that the bill tries to do too much, said PCC Washington counsel Robert J. Saner II.

“It's the very comprehensiveness of the bill that is slowing its progress. Many people have looked at the legislation and said it's too broad and should be more focused,” Mr. Saner told the annual meeting of the AAPM. “The PCC has been reluctant to pare because what's in it is necessary.”

The bill would declare adequate pain care research, education, and treatment as national public health priorities, and would establish the National Center for Pain and Palliative Care Research at the National Institutes of Health “to conduct clinical and basic science research into the biology of, the causes of, and effective treatments for pain.”

It also would establish “a national agenda for conducting and supporting pain and palliative care research and to identify, coordinate, and support research, research training, and related activities with respect to primary and secondary pain,” according to the Office of Legislative Policy and Analysis.

“All of these things are new; they're things the NIH doesn't do now and doesn't want to spend money on,” Mr. Saner explained.

The legislation would take some of the pain care emphasis off the Drug Enforcement Agency (DEA), Mr. Saner added.

“One of the problems is we've been barking up the wrong tree. Many people in the pain community go to the DEA because the DEA has been focusing on pain care; we need to develop some other trees to bark up, and principal among those are the NIH, the Agency for Healthcare Research and Quality, the Health Resources and Services Administration, and the Centers for Medicare and Medicaid Services,” he said. Various aspects of this bill address those agencies.

“We would like to have 250 cosponsors in the House of Representatives, and getting there depends a lot on you and your colleagues around the country getting engaged in grassroots activities in support of this bill,” Mr. Saner said.

His comments were echoed by Sylvia Warner, a spokesperson for Rep. Rogers, who said patients have the most to gain and should contact their representatives in support of 1020.

“The average patient goes through 13 physicians before he or she finds a doctor who will help with their pain,” Warner said in an interview, adding that an ongoing effort to get the pain care bill into the full committee might bear fruit this year.

SAN DIEGO — Physicians involved in pain treatment and palliative care have been asked to get involved in grassroots efforts in support of the National Pain Care Policy Act, which has been stalled in the health subcommittee of the Committee on Energy and Commerce.

Introduced on March 1, 2005, by Congressman Michael Rogers (R-Mich.), HR 1020 is the first comprehensive pain care bill ever introduced on Capitol Hill. Its passage is a top priority of the Pain Care Coalition (PCC), which is composed of the American Pain Society, the American Academy of Pain Medicine (AAPM), and the American Association for the Study of Headache.

HR 1020, though it has the backing of more than 100 patient advocacy groups, has only 33 cosponsors in the House. Support has been unenthusiastic in part because of a general feeling that the bill tries to do too much, said PCC Washington counsel Robert J. Saner II.

“It's the very comprehensiveness of the bill that is slowing its progress. Many people have looked at the legislation and said it's too broad and should be more focused,” Mr. Saner told the annual meeting of the AAPM. “The PCC has been reluctant to pare because what's in it is necessary.”

The bill would declare adequate pain care research, education, and treatment as national public health priorities, and would establish the National Center for Pain and Palliative Care Research at the National Institutes of Health “to conduct clinical and basic science research into the biology of, the causes of, and effective treatments for pain.”

It also would establish “a national agenda for conducting and supporting pain and palliative care research and to identify, coordinate, and support research, research training, and related activities with respect to primary and secondary pain,” according to the Office of Legislative Policy and Analysis.

“All of these things are new; they're things the NIH doesn't do now and doesn't want to spend money on,” Mr. Saner explained.

The legislation would take some of the pain care emphasis off the Drug Enforcement Agency (DEA), Mr. Saner added.

“One of the problems is we've been barking up the wrong tree. Many people in the pain community go to the DEA because the DEA has been focusing on pain care; we need to develop some other trees to bark up, and principal among those are the NIH, the Agency for Healthcare Research and Quality, the Health Resources and Services Administration, and the Centers for Medicare and Medicaid Services,” he said. Various aspects of this bill address those agencies.

“We would like to have 250 cosponsors in the House of Representatives, and getting there depends a lot on you and your colleagues around the country getting engaged in grassroots activities in support of this bill,” Mr. Saner said.

His comments were echoed by Sylvia Warner, a spokesperson for Rep. Rogers, who said patients have the most to gain and should contact their representatives in support of 1020.

“The average patient goes through 13 physicians before he or she finds a doctor who will help with their pain,” Warner said in an interview, adding that an ongoing effort to get the pain care bill into the full committee might bear fruit this year.

CHICAGO — Highly cross-linked polyethylene bearing surfaces in total hip arthroplasties have passed their first long-term longitudinal trial with flying colors, according to a blue-ribbon poster presented at the annual meeting of the American College of Orthopaedic Surgeons.

“After a minimum of five years follow-up of patients all done at Massachusetts General Hospital, there were no signs of radiographic osteolysis either on the acetabular or femoral sides, and this is the earliest point where you might normally start to see that with conventional polyethylene,” Charles R. Bragdon, Ph.D., said in an interview.

Electron beam irradiated highly cross-linked polyethylene (HXLPE) is created by taking standard high-density polyethylene and irradiating it, which increases cross-linking and improves wear characteristics. The material then goes through “a melting step which allows the free radicals generated during radiation to extinguish themselves and form more cross-linking. With the free radicals gone, there's no long-term oxidation, so the properties you get do not change over time,” Dr. Bragdon said explained.

HXLPE has been used as total hip arthroplasty bearing surface for nearly 8 years, according to Dr. Bragdon and his colleagues at the Orthopaedic Biomechanics and Biomaterials Laboratory at Massachusetts General Hospital in Boston. Radiostereometric analysis (RSA) has shown little additional femoral head penetration after the early bedding-in period; however, such studies have been performed on relatively small groups of patients, the authors continued. Using standardized measures, the Boston group studied femoral head penetration in 77 primary total hip replacements in 70 patients with HXLPE liners, with either a 28-mm or 32-mm femoral head.

The average total femoral head penetration was calculated based on the total penetration from the initial postoperative film to the longest follow-up film.

“During the first year following surgery, there was about 100 microns of head penetration into the polyethylene,” Dr. Bragdon said. “Thereafter … [there was] no measurable wear of this material at 5 years,” he said. In addition, there was no significant difference in the average penetration rate or the steady state wear rates between the 28-mm and 32-mm groups.

“These results are encouraging for lysis in the long term because we've shown in the past that lysis and wear tend to go hand in hand; we think our study bodes well for 7–15 years' follow-up,” said Dr. Bragdon, adding that continued follow-up will be necessary to evaluate the material's clinical and radiographic durability.

Dr. Bragdon predicted that these more durable replacements will further reduce the average age of both knee and hip recipients. “Cross-linked polyethylene's introduction has been in hip arthroplasty, but now it's also being used in knees because knee components also suffer from wear and osteolysis.”

Osteolysis was seen on x-ray 7 years after placement of a conventional polyethylene liner for total hip arthroplasty (left). No osteolysis was seen 6 years later with a highly cross-linked polyethylene liner (right). Photos courtesy Dr. Meridith Greene

CHICAGO — Highly cross-linked polyethylene bearing surfaces in total hip arthroplasties have passed their first long-term longitudinal trial with flying colors, according to a blue-ribbon poster presented at the annual meeting of the American College of Orthopaedic Surgeons.

“After a minimum of five years follow-up of patients all done at Massachusetts General Hospital, there were no signs of radiographic osteolysis either on the acetabular or femoral sides, and this is the earliest point where you might normally start to see that with conventional polyethylene,” Charles R. Bragdon, Ph.D., said in an interview.

Electron beam irradiated highly cross-linked polyethylene (HXLPE) is created by taking standard high-density polyethylene and irradiating it, which increases cross-linking and improves wear characteristics. The material then goes through “a melting step which allows the free radicals generated during radiation to extinguish themselves and form more cross-linking. With the free radicals gone, there's no long-term oxidation, so the properties you get do not change over time,” Dr. Bragdon said explained.

HXLPE has been used as total hip arthroplasty bearing surface for nearly 8 years, according to Dr. Bragdon and his colleagues at the Orthopaedic Biomechanics and Biomaterials Laboratory at Massachusetts General Hospital in Boston. Radiostereometric analysis (RSA) has shown little additional femoral head penetration after the early bedding-in period; however, such studies have been performed on relatively small groups of patients, the authors continued. Using standardized measures, the Boston group studied femoral head penetration in 77 primary total hip replacements in 70 patients with HXLPE liners, with either a 28-mm or 32-mm femoral head.

The average total femoral head penetration was calculated based on the total penetration from the initial postoperative film to the longest follow-up film.

“During the first year following surgery, there was about 100 microns of head penetration into the polyethylene,” Dr. Bragdon said. “Thereafter … [there was] no measurable wear of this material at 5 years,” he said. In addition, there was no significant difference in the average penetration rate or the steady state wear rates between the 28-mm and 32-mm groups.

“These results are encouraging for lysis in the long term because we've shown in the past that lysis and wear tend to go hand in hand; we think our study bodes well for 7–15 years' follow-up,” said Dr. Bragdon, adding that continued follow-up will be necessary to evaluate the material's clinical and radiographic durability.

Dr. Bragdon predicted that these more durable replacements will further reduce the average age of both knee and hip recipients. “Cross-linked polyethylene's introduction has been in hip arthroplasty, but now it's also being used in knees because knee components also suffer from wear and osteolysis.”

Osteolysis was seen on x-ray 7 years after placement of a conventional polyethylene liner for total hip arthroplasty (left). No osteolysis was seen 6 years later with a highly cross-linked polyethylene liner (right). Photos courtesy Dr. Meridith Greene

CHICAGO — Highly cross-linked polyethylene bearing surfaces in total hip arthroplasties have passed their first long-term longitudinal trial with flying colors, according to a blue-ribbon poster presented at the annual meeting of the American College of Orthopaedic Surgeons.

“After a minimum of five years follow-up of patients all done at Massachusetts General Hospital, there were no signs of radiographic osteolysis either on the acetabular or femoral sides, and this is the earliest point where you might normally start to see that with conventional polyethylene,” Charles R. Bragdon, Ph.D., said in an interview.

Electron beam irradiated highly cross-linked polyethylene (HXLPE) is created by taking standard high-density polyethylene and irradiating it, which increases cross-linking and improves wear characteristics. The material then goes through “a melting step which allows the free radicals generated during radiation to extinguish themselves and form more cross-linking. With the free radicals gone, there's no long-term oxidation, so the properties you get do not change over time,” Dr. Bragdon said explained.

HXLPE has been used as total hip arthroplasty bearing surface for nearly 8 years, according to Dr. Bragdon and his colleagues at the Orthopaedic Biomechanics and Biomaterials Laboratory at Massachusetts General Hospital in Boston. Radiostereometric analysis (RSA) has shown little additional femoral head penetration after the early bedding-in period; however, such studies have been performed on relatively small groups of patients, the authors continued. Using standardized measures, the Boston group studied femoral head penetration in 77 primary total hip replacements in 70 patients with HXLPE liners, with either a 28-mm or 32-mm femoral head.

The average total femoral head penetration was calculated based on the total penetration from the initial postoperative film to the longest follow-up film.

“During the first year following surgery, there was about 100 microns of head penetration into the polyethylene,” Dr. Bragdon said. “Thereafter … [there was] no measurable wear of this material at 5 years,” he said. In addition, there was no significant difference in the average penetration rate or the steady state wear rates between the 28-mm and 32-mm groups.

“These results are encouraging for lysis in the long term because we've shown in the past that lysis and wear tend to go hand in hand; we think our study bodes well for 7–15 years' follow-up,” said Dr. Bragdon, adding that continued follow-up will be necessary to evaluate the material's clinical and radiographic durability.

Dr. Bragdon predicted that these more durable replacements will further reduce the average age of both knee and hip recipients. “Cross-linked polyethylene's introduction has been in hip arthroplasty, but now it's also being used in knees because knee components also suffer from wear and osteolysis.”

Osteolysis was seen on x-ray 7 years after placement of a conventional polyethylene liner for total hip arthroplasty (left). No osteolysis was seen 6 years later with a highly cross-linked polyethylene liner (right). Photos courtesy Dr. Meridith Greene

CHICAGO — Early treatment of ankylosing spondylitis may or may not prevent structural damage but it certainly improves quality of life and the ability to function, Dr. John Davis told a symposium of the American College of Rheumatology.

Dr. Davis pointed to four reasons for why ankylosing spondylitis (AS) is typically diagnosed about 8 years after disease onset: low awareness of the spondyloarthritis among nonrheumatologists; the erroneous belief among rheumatologists that AS is a “man's disease”; the difficulty in differentiating between mechanical and inflammatory back pain; and reliance on radiologic sacroiliitis, which is a late feature of AS.

Dr. Davis, who directs the Clinical Trials Center at the University of California, San Francisco, noted that the Spondylitis Association of America guidelines call for a thorough physical exam including x-rays, individual medical history, and any family history of AS, as well as blood work that includes a test for HLA-B27 antigen. Important signs of AS include pain that has persisted longer than 3 months, back pain, and stiffness that worsen with immobility but ease with physical activity, and a positive response to NSAIDs.

Research efforts are now focusing on three TNF inhibitors. Phase III trials of three biologics showed good responses that were maintained at over 2 years (etanercept and infliximab) and 24 weeks (adalimumab). All three drugs significantly outperformed placebo in phase III studies using the Assessment in AS (ASAS) International Working Group criteria and the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). The BASDAI form contains six visual analog scales (“none” to “very severe”) on fatigue, neck, back or hip pain, joint pain and swelling, tender areas, and morning stiffness. “If you use the BASDAI as an outcome measure you should expect about a 50% improvement in the BASDAI 50 in all the anti-TNF studies,” Dr. Davis explained, adding that physicians can print out the one-page form and have patients fill it out in their offices. The form is available at www.spondylitis.org/physician_resources/cme/basdai.pdf

In studies using the ASAS 5/6 Improvement Criteria, patient responses to tumor necrosis factor (TNF) inhibition approached 50%. Under this protocol, said Dr. Davis, patients had to have an improvement of at least 20% in four of five domains, including patient global, pain, function, inflammation, C-reactive protein, and/or spinal mobility. “Also, total spinal fusion is not a contraindication for using anti-TNF agents, as about 10% of patients who enrolled in the adalimumab study could have had total spinal fusion yet they responded to that drug,” he said, stressing that because anti-TNF therapy is lifelong, patients need to understand its risks and benefits.

International guidelines for treating patients with AS have been modified by the Spondyloarthritis Research and Treatment Network (SPARTAN) and are now in print (J. Rheumatol. 2006;33:978–82). “You can use the modified New York criteria or other evidence of spondyloarthropathy including inflammatory back pain, elevated acute phase reactants, rapid radiographic progression, spinal inflammation on imaging—including MRI—or, interestingly, ultrasound,” Dr. Davis explained, noting that French researchers found ultrasound to be especially useful in assessing enthesopathies.

“Your patient should have a BASDAI score of at least 4, and you as a physician should assign a moderate disease activity score on either a visual analog scale or the Likert scale. In general, there are three clinical presentations you need to keep in mind … the axial, peripheral arthritis excluding the hip, and the entheses. Pick out the predominant feature that you're going to treat and follow. All the manifestations should be treated with at least two courses of an NSAID, and those with significant arthritis or refractory enthesopathies should have failed either methotrexate or sulfasalazine at maximally tolerated doses for at least 3 months. For those with axial involvement, there's no requirement for nonbiologic disease-modifying antirheumatic drugs (DMARDs) and they should go directly to a biologic agent,” Dr. Davis said, adding that methotrexate and leflunomide have shown little evidence of efficacy in AS, while sulfasalizine has been shown to have effects mostly on peripheral manifestations. “Thalidomide and pamidronate interestingly have weak anti-TNF activity and have shown some clinical efficacy in small trials.”

Muscle relaxants can help, particularly when the patient is starting physical therapy. Corticosteroids injected into the sacroiliac joints alleviate refractory pain and topical corticosteroids are effective in treating acute anterior uveitis, Dr. Davis said.

After placing a patient on TNF blockade, expect a response (based on clinical trials and clinical experience) within 12 weeks. “And you want a change in your BASDAI score of at least 50% or two units, and a change in your physician global score of at least one.” Etanercept and infliximab have FDA approval, while approval of adalimumab is pending. Patients taking these medications should be screened for tuberculosis and consideration should be given to testing for hepatitis, especially in those from endemic areas, Dr. Davis said.

CHICAGO — Early treatment of ankylosing spondylitis may or may not prevent structural damage but it certainly improves quality of life and the ability to function, Dr. John Davis told a symposium of the American College of Rheumatology.

Dr. Davis pointed to four reasons for why ankylosing spondylitis (AS) is typically diagnosed about 8 years after disease onset: low awareness of the spondyloarthritis among nonrheumatologists; the erroneous belief among rheumatologists that AS is a “man's disease”; the difficulty in differentiating between mechanical and inflammatory back pain; and reliance on radiologic sacroiliitis, which is a late feature of AS.

Dr. Davis, who directs the Clinical Trials Center at the University of California, San Francisco, noted that the Spondylitis Association of America guidelines call for a thorough physical exam including x-rays, individual medical history, and any family history of AS, as well as blood work that includes a test for HLA-B27 antigen. Important signs of AS include pain that has persisted longer than 3 months, back pain, and stiffness that worsen with immobility but ease with physical activity, and a positive response to NSAIDs.

Research efforts are now focusing on three TNF inhibitors. Phase III trials of three biologics showed good responses that were maintained at over 2 years (etanercept and infliximab) and 24 weeks (adalimumab). All three drugs significantly outperformed placebo in phase III studies using the Assessment in AS (ASAS) International Working Group criteria and the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). The BASDAI form contains six visual analog scales (“none” to “very severe”) on fatigue, neck, back or hip pain, joint pain and swelling, tender areas, and morning stiffness. “If you use the BASDAI as an outcome measure you should expect about a 50% improvement in the BASDAI 50 in all the anti-TNF studies,” Dr. Davis explained, adding that physicians can print out the one-page form and have patients fill it out in their offices. The form is available at www.spondylitis.org/physician_resources/cme/basdai.pdf

In studies using the ASAS 5/6 Improvement Criteria, patient responses to tumor necrosis factor (TNF) inhibition approached 50%. Under this protocol, said Dr. Davis, patients had to have an improvement of at least 20% in four of five domains, including patient global, pain, function, inflammation, C-reactive protein, and/or spinal mobility. “Also, total spinal fusion is not a contraindication for using anti-TNF agents, as about 10% of patients who enrolled in the adalimumab study could have had total spinal fusion yet they responded to that drug,” he said, stressing that because anti-TNF therapy is lifelong, patients need to understand its risks and benefits.

International guidelines for treating patients with AS have been modified by the Spondyloarthritis Research and Treatment Network (SPARTAN) and are now in print (J. Rheumatol. 2006;33:978–82). “You can use the modified New York criteria or other evidence of spondyloarthropathy including inflammatory back pain, elevated acute phase reactants, rapid radiographic progression, spinal inflammation on imaging—including MRI—or, interestingly, ultrasound,” Dr. Davis explained, noting that French researchers found ultrasound to be especially useful in assessing enthesopathies.

“Your patient should have a BASDAI score of at least 4, and you as a physician should assign a moderate disease activity score on either a visual analog scale or the Likert scale. In general, there are three clinical presentations you need to keep in mind … the axial, peripheral arthritis excluding the hip, and the entheses. Pick out the predominant feature that you're going to treat and follow. All the manifestations should be treated with at least two courses of an NSAID, and those with significant arthritis or refractory enthesopathies should have failed either methotrexate or sulfasalazine at maximally tolerated doses for at least 3 months. For those with axial involvement, there's no requirement for nonbiologic disease-modifying antirheumatic drugs (DMARDs) and they should go directly to a biologic agent,” Dr. Davis said, adding that methotrexate and leflunomide have shown little evidence of efficacy in AS, while sulfasalizine has been shown to have effects mostly on peripheral manifestations. “Thalidomide and pamidronate interestingly have weak anti-TNF activity and have shown some clinical efficacy in small trials.”

Muscle relaxants can help, particularly when the patient is starting physical therapy. Corticosteroids injected into the sacroiliac joints alleviate refractory pain and topical corticosteroids are effective in treating acute anterior uveitis, Dr. Davis said.

After placing a patient on TNF blockade, expect a response (based on clinical trials and clinical experience) within 12 weeks. “And you want a change in your BASDAI score of at least 50% or two units, and a change in your physician global score of at least one.” Etanercept and infliximab have FDA approval, while approval of adalimumab is pending. Patients taking these medications should be screened for tuberculosis and consideration should be given to testing for hepatitis, especially in those from endemic areas, Dr. Davis said.

CHICAGO — Early treatment of ankylosing spondylitis may or may not prevent structural damage but it certainly improves quality of life and the ability to function, Dr. John Davis told a symposium of the American College of Rheumatology.

Dr. Davis pointed to four reasons for why ankylosing spondylitis (AS) is typically diagnosed about 8 years after disease onset: low awareness of the spondyloarthritis among nonrheumatologists; the erroneous belief among rheumatologists that AS is a “man's disease”; the difficulty in differentiating between mechanical and inflammatory back pain; and reliance on radiologic sacroiliitis, which is a late feature of AS.

Dr. Davis, who directs the Clinical Trials Center at the University of California, San Francisco, noted that the Spondylitis Association of America guidelines call for a thorough physical exam including x-rays, individual medical history, and any family history of AS, as well as blood work that includes a test for HLA-B27 antigen. Important signs of AS include pain that has persisted longer than 3 months, back pain, and stiffness that worsen with immobility but ease with physical activity, and a positive response to NSAIDs.

Research efforts are now focusing on three TNF inhibitors. Phase III trials of three biologics showed good responses that were maintained at over 2 years (etanercept and infliximab) and 24 weeks (adalimumab). All three drugs significantly outperformed placebo in phase III studies using the Assessment in AS (ASAS) International Working Group criteria and the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). The BASDAI form contains six visual analog scales (“none” to “very severe”) on fatigue, neck, back or hip pain, joint pain and swelling, tender areas, and morning stiffness. “If you use the BASDAI as an outcome measure you should expect about a 50% improvement in the BASDAI 50 in all the anti-TNF studies,” Dr. Davis explained, adding that physicians can print out the one-page form and have patients fill it out in their offices. The form is available at www.spondylitis.org/physician_resources/cme/basdai.pdf

In studies using the ASAS 5/6 Improvement Criteria, patient responses to tumor necrosis factor (TNF) inhibition approached 50%. Under this protocol, said Dr. Davis, patients had to have an improvement of at least 20% in four of five domains, including patient global, pain, function, inflammation, C-reactive protein, and/or spinal mobility. “Also, total spinal fusion is not a contraindication for using anti-TNF agents, as about 10% of patients who enrolled in the adalimumab study could have had total spinal fusion yet they responded to that drug,” he said, stressing that because anti-TNF therapy is lifelong, patients need to understand its risks and benefits.

International guidelines for treating patients with AS have been modified by the Spondyloarthritis Research and Treatment Network (SPARTAN) and are now in print (J. Rheumatol. 2006;33:978–82). “You can use the modified New York criteria or other evidence of spondyloarthropathy including inflammatory back pain, elevated acute phase reactants, rapid radiographic progression, spinal inflammation on imaging—including MRI—or, interestingly, ultrasound,” Dr. Davis explained, noting that French researchers found ultrasound to be especially useful in assessing enthesopathies.

“Your patient should have a BASDAI score of at least 4, and you as a physician should assign a moderate disease activity score on either a visual analog scale or the Likert scale. In general, there are three clinical presentations you need to keep in mind … the axial, peripheral arthritis excluding the hip, and the entheses. Pick out the predominant feature that you're going to treat and follow. All the manifestations should be treated with at least two courses of an NSAID, and those with significant arthritis or refractory enthesopathies should have failed either methotrexate or sulfasalazine at maximally tolerated doses for at least 3 months. For those with axial involvement, there's no requirement for nonbiologic disease-modifying antirheumatic drugs (DMARDs) and they should go directly to a biologic agent,” Dr. Davis said, adding that methotrexate and leflunomide have shown little evidence of efficacy in AS, while sulfasalizine has been shown to have effects mostly on peripheral manifestations. “Thalidomide and pamidronate interestingly have weak anti-TNF activity and have shown some clinical efficacy in small trials.”

Muscle relaxants can help, particularly when the patient is starting physical therapy. Corticosteroids injected into the sacroiliac joints alleviate refractory pain and topical corticosteroids are effective in treating acute anterior uveitis, Dr. Davis said.

After placing a patient on TNF blockade, expect a response (based on clinical trials and clinical experience) within 12 weeks. “And you want a change in your BASDAI score of at least 50% or two units, and a change in your physician global score of at least one.” Etanercept and infliximab have FDA approval, while approval of adalimumab is pending. Patients taking these medications should be screened for tuberculosis and consideration should be given to testing for hepatitis, especially in those from endemic areas, Dr. Davis said.

CHICAGO — A new era is emerging in the management of systemic sclerosis, and within 5 years the number of available drugs should resemble the sort of variety seen with other rheumatic disease treatment options, Dr. John Varga said at a symposium sponsored by the American College of Rheumatology.

Dr. Carol Black and her fellow investigators “looked at a systemic sclerosis population with associated pulmonary artery hypertension [PAH] before and after 2002 to determine the effect of introducing the endothelin-1 receptor antagonist,” in a retrospective study, said Dr. Varga, who is the Gallagher Research Professor in Rheumatology at Northwestern University, Chicago.

The investigators, of University College Medical School, London, divided patients into a “historical” control group of 47 patients studied before 2002 and a “current treatment era” group of 45 patients studied after 2002.

The historical cohort received basic treatment, including diuretics, digoxin, oxygen, and warfarin, and 27 patients in the group also received prostanoids. The “current treatment era” group got bosentan.

Survival rate in the historical control group was 68% at 1 year and 47% at 2 years, whereas in the current era treatment group survival was 81% and 71%, respectively, according to Kaplan-Meier analysis. In addition, vascular resistance was stabilized in the bosentan cohort (Heart 2006, Jan. 31;doi 10.1136/hrt.2005.069484 [Epub ahead of print]).

“These data are very helpful but are preliminary, and I think it will be very important to follow these patients to see how much of an improvement they [make],” said Dr. Varga. Blocking endothelin-1 may do more than just block vasoconstriction. Bosentan, through vascular proliferation or the production of new blood vessels, may promote vascular repair, according to the study.

Another promising drug in the same class as bosentan is sitaxsentan, which has received approval under the FDA's orphan drug program, but is not yet clinically available in the United States. Bosentan is currently being evaluated in patients with systemic sclerosis-associated interstitial lung disease, noted Dr. Varga.

In a recently completed multicenter, placebo-controlled study of patients with early disease and alveolitis, treatment with oral cyclophosphamide yielded significant benefit at 12 months.

Data from the Scleroderma Lung Study also show that bronchoalveolar lavage (BAL) did not influence outcome, which Dr. Varga said contradicts earlier findings from retrospective studies and calls into question the role of BAL.

Another promising avenue in treating sclerosis-associated PAH is to enhance nitric oxide by using phosphodiesterase inhibitors. “In a published British study, investigators compared sildenafil to endothelial receptor antagonists and the data are similar in terms of short-term symptomatic improvement and better exercise tolerance,” said Dr. Varga. Sildenafil has received FDA approval for the treatment of PAH (Am. J. Respir. Crit. Care Med. 2005;171:1292–7).

Prostacyclines also are available for treating PAH. “Inhaled iloprost, a stable analog of prostacycline, leads to clinical benefits. So there are a number of drugs and it's currently difficult to know where they fit in clinically.” Autologous hematopoietic stem cell transplantation (HSCT) induced marked improvement or complete remission in animal models of autoimmunity, as well as in some patients with lupus and rheumatoid arthritis, said Dr. Varga. A large multicenter trial comparing HSCT with monthly cyclophosphamide in patients with severe sclerosis is underway.

Another approach, explained Dr. Varga, may be to target autoimmunity and prevent the initial activation of fibroblasts using anticytokine antibodies to connective tissue growth factor or transforming growth factor β. This is similar to the approach in rheumatoid arthritis treatment using tumor necrosis factor-α inhibitors, said Dr. Varga. “A clinical trial with an antichemokine antibody looking at early lung diseases in scleroderma is planned for later this year,” he said.

CHICAGO — A new era is emerging in the management of systemic sclerosis, and within 5 years the number of available drugs should resemble the sort of variety seen with other rheumatic disease treatment options, Dr. John Varga said at a symposium sponsored by the American College of Rheumatology.

Dr. Carol Black and her fellow investigators “looked at a systemic sclerosis population with associated pulmonary artery hypertension [PAH] before and after 2002 to determine the effect of introducing the endothelin-1 receptor antagonist,” in a retrospective study, said Dr. Varga, who is the Gallagher Research Professor in Rheumatology at Northwestern University, Chicago.

The investigators, of University College Medical School, London, divided patients into a “historical” control group of 47 patients studied before 2002 and a “current treatment era” group of 45 patients studied after 2002.

The historical cohort received basic treatment, including diuretics, digoxin, oxygen, and warfarin, and 27 patients in the group also received prostanoids. The “current treatment era” group got bosentan.

Survival rate in the historical control group was 68% at 1 year and 47% at 2 years, whereas in the current era treatment group survival was 81% and 71%, respectively, according to Kaplan-Meier analysis. In addition, vascular resistance was stabilized in the bosentan cohort (Heart 2006, Jan. 31;doi 10.1136/hrt.2005.069484 [Epub ahead of print]).

“These data are very helpful but are preliminary, and I think it will be very important to follow these patients to see how much of an improvement they [make],” said Dr. Varga. Blocking endothelin-1 may do more than just block vasoconstriction. Bosentan, through vascular proliferation or the production of new blood vessels, may promote vascular repair, according to the study.

Another promising drug in the same class as bosentan is sitaxsentan, which has received approval under the FDA's orphan drug program, but is not yet clinically available in the United States. Bosentan is currently being evaluated in patients with systemic sclerosis-associated interstitial lung disease, noted Dr. Varga.

In a recently completed multicenter, placebo-controlled study of patients with early disease and alveolitis, treatment with oral cyclophosphamide yielded significant benefit at 12 months.

Data from the Scleroderma Lung Study also show that bronchoalveolar lavage (BAL) did not influence outcome, which Dr. Varga said contradicts earlier findings from retrospective studies and calls into question the role of BAL.

Another promising avenue in treating sclerosis-associated PAH is to enhance nitric oxide by using phosphodiesterase inhibitors. “In a published British study, investigators compared sildenafil to endothelial receptor antagonists and the data are similar in terms of short-term symptomatic improvement and better exercise tolerance,” said Dr. Varga. Sildenafil has received FDA approval for the treatment of PAH (Am. J. Respir. Crit. Care Med. 2005;171:1292–7).

Prostacyclines also are available for treating PAH. “Inhaled iloprost, a stable analog of prostacycline, leads to clinical benefits. So there are a number of drugs and it's currently difficult to know where they fit in clinically.” Autologous hematopoietic stem cell transplantation (HSCT) induced marked improvement or complete remission in animal models of autoimmunity, as well as in some patients with lupus and rheumatoid arthritis, said Dr. Varga. A large multicenter trial comparing HSCT with monthly cyclophosphamide in patients with severe sclerosis is underway.

Another approach, explained Dr. Varga, may be to target autoimmunity and prevent the initial activation of fibroblasts using anticytokine antibodies to connective tissue growth factor or transforming growth factor β. This is similar to the approach in rheumatoid arthritis treatment using tumor necrosis factor-α inhibitors, said Dr. Varga. “A clinical trial with an antichemokine antibody looking at early lung diseases in scleroderma is planned for later this year,” he said.

CHICAGO — A new era is emerging in the management of systemic sclerosis, and within 5 years the number of available drugs should resemble the sort of variety seen with other rheumatic disease treatment options, Dr. John Varga said at a symposium sponsored by the American College of Rheumatology.

Dr. Carol Black and her fellow investigators “looked at a systemic sclerosis population with associated pulmonary artery hypertension [PAH] before and after 2002 to determine the effect of introducing the endothelin-1 receptor antagonist,” in a retrospective study, said Dr. Varga, who is the Gallagher Research Professor in Rheumatology at Northwestern University, Chicago.

The investigators, of University College Medical School, London, divided patients into a “historical” control group of 47 patients studied before 2002 and a “current treatment era” group of 45 patients studied after 2002.

The historical cohort received basic treatment, including diuretics, digoxin, oxygen, and warfarin, and 27 patients in the group also received prostanoids. The “current treatment era” group got bosentan.

Survival rate in the historical control group was 68% at 1 year and 47% at 2 years, whereas in the current era treatment group survival was 81% and 71%, respectively, according to Kaplan-Meier analysis. In addition, vascular resistance was stabilized in the bosentan cohort (Heart 2006, Jan. 31;doi 10.1136/hrt.2005.069484 [Epub ahead of print]).

“These data are very helpful but are preliminary, and I think it will be very important to follow these patients to see how much of an improvement they [make],” said Dr. Varga. Blocking endothelin-1 may do more than just block vasoconstriction. Bosentan, through vascular proliferation or the production of new blood vessels, may promote vascular repair, according to the study.

Another promising drug in the same class as bosentan is sitaxsentan, which has received approval under the FDA's orphan drug program, but is not yet clinically available in the United States. Bosentan is currently being evaluated in patients with systemic sclerosis-associated interstitial lung disease, noted Dr. Varga.

In a recently completed multicenter, placebo-controlled study of patients with early disease and alveolitis, treatment with oral cyclophosphamide yielded significant benefit at 12 months.

Data from the Scleroderma Lung Study also show that bronchoalveolar lavage (BAL) did not influence outcome, which Dr. Varga said contradicts earlier findings from retrospective studies and calls into question the role of BAL.

Another promising avenue in treating sclerosis-associated PAH is to enhance nitric oxide by using phosphodiesterase inhibitors. “In a published British study, investigators compared sildenafil to endothelial receptor antagonists and the data are similar in terms of short-term symptomatic improvement and better exercise tolerance,” said Dr. Varga. Sildenafil has received FDA approval for the treatment of PAH (Am. J. Respir. Crit. Care Med. 2005;171:1292–7).

Prostacyclines also are available for treating PAH. “Inhaled iloprost, a stable analog of prostacycline, leads to clinical benefits. So there are a number of drugs and it's currently difficult to know where they fit in clinically.” Autologous hematopoietic stem cell transplantation (HSCT) induced marked improvement or complete remission in animal models of autoimmunity, as well as in some patients with lupus and rheumatoid arthritis, said Dr. Varga. A large multicenter trial comparing HSCT with monthly cyclophosphamide in patients with severe sclerosis is underway.

Another approach, explained Dr. Varga, may be to target autoimmunity and prevent the initial activation of fibroblasts using anticytokine antibodies to connective tissue growth factor or transforming growth factor β. This is similar to the approach in rheumatoid arthritis treatment using tumor necrosis factor-α inhibitors, said Dr. Varga. “A clinical trial with an antichemokine antibody looking at early lung diseases in scleroderma is planned for later this year,” he said.

Medicare consumers are underutilizing colorectal cancer screening, according to the authors of a National Cancer Institute study conducted after initiation of the Medicare colorectal cancer screening benefit.

The study, conducted in North and South Carolina, relied on data from a 2001 telephone survey of a random sample of 2,004 eligible Medicare consumers. The analysis was based on the 1,901 with no history of CRC (Am. J. Prev. Med. 2006;30:313–9).

The strongest predictors of adherence to Medicare-covered testing intervals were elevated CRC risk, having a checkup in the past year, and having a usual source of care. The influence of a physician's recommendation also was evident.

“Almost all of the Medicare consumers who had received CRC tests indicated that they had also received a physician recommendation, while only 7% who had never been tested reported receiving a recommendation,” said Carrie N. Klabunde, Ph.D., of the National Cancer Institute, and her associates.

Overall, 72% of Medicare consumers reported receiving a recommendation to have a CRC test. Of those who had never been tested, lack of knowledge or awareness of the need for CRC screening, followed by the physician's not ordering the test, were the most commonly cited reasons.

When asked about colonoscopy, half of those interviewed said they had never heard of it. Similarly, 62% had never heard of fecal occult blood testing and 63% had never heard of sigmoidoscopy.

“These results are especially concerning because over 90% of consumers reported having a usual source of health care, and nearly 90% had a routine or preventive health care visit in the past 12 months,” the authors said.

In a separate analysis, the investigators found that only 57% of whites and 39% of blacks reported adhering to current Medicare-covered testing intervals, and one-quarter of whites and nearly one-half of blacks had “never” been tested.

“Despite the increased risk for CRC due to age, and insurance coverage for screening and treatment through Medicare, almost half of enrollees are not current with CRC screening recommendations,” the authors said (Am. J. Prev. Med. 2006;30:320–6).

“Improving initial test use among African American Medicare consumers is a necessary step toward increased compliance with guideline-based testing,” they said.

Medicare consumers are underutilizing colorectal cancer screening, according to the authors of a National Cancer Institute study conducted after initiation of the Medicare colorectal cancer screening benefit.

The study, conducted in North and South Carolina, relied on data from a 2001 telephone survey of a random sample of 2,004 eligible Medicare consumers. The analysis was based on the 1,901 with no history of CRC (Am. J. Prev. Med. 2006;30:313–9).

The strongest predictors of adherence to Medicare-covered testing intervals were elevated CRC risk, having a checkup in the past year, and having a usual source of care. The influence of a physician's recommendation also was evident.

“Almost all of the Medicare consumers who had received CRC tests indicated that they had also received a physician recommendation, while only 7% who had never been tested reported receiving a recommendation,” said Carrie N. Klabunde, Ph.D., of the National Cancer Institute, and her associates.

Overall, 72% of Medicare consumers reported receiving a recommendation to have a CRC test. Of those who had never been tested, lack of knowledge or awareness of the need for CRC screening, followed by the physician's not ordering the test, were the most commonly cited reasons.

When asked about colonoscopy, half of those interviewed said they had never heard of it. Similarly, 62% had never heard of fecal occult blood testing and 63% had never heard of sigmoidoscopy.

“These results are especially concerning because over 90% of consumers reported having a usual source of health care, and nearly 90% had a routine or preventive health care visit in the past 12 months,” the authors said.

In a separate analysis, the investigators found that only 57% of whites and 39% of blacks reported adhering to current Medicare-covered testing intervals, and one-quarter of whites and nearly one-half of blacks had “never” been tested.

“Despite the increased risk for CRC due to age, and insurance coverage for screening and treatment through Medicare, almost half of enrollees are not current with CRC screening recommendations,” the authors said (Am. J. Prev. Med. 2006;30:320–6).

“Improving initial test use among African American Medicare consumers is a necessary step toward increased compliance with guideline-based testing,” they said.

Medicare consumers are underutilizing colorectal cancer screening, according to the authors of a National Cancer Institute study conducted after initiation of the Medicare colorectal cancer screening benefit.

The study, conducted in North and South Carolina, relied on data from a 2001 telephone survey of a random sample of 2,004 eligible Medicare consumers. The analysis was based on the 1,901 with no history of CRC (Am. J. Prev. Med. 2006;30:313–9).

The strongest predictors of adherence to Medicare-covered testing intervals were elevated CRC risk, having a checkup in the past year, and having a usual source of care. The influence of a physician's recommendation also was evident.

“Almost all of the Medicare consumers who had received CRC tests indicated that they had also received a physician recommendation, while only 7% who had never been tested reported receiving a recommendation,” said Carrie N. Klabunde, Ph.D., of the National Cancer Institute, and her associates.

Overall, 72% of Medicare consumers reported receiving a recommendation to have a CRC test. Of those who had never been tested, lack of knowledge or awareness of the need for CRC screening, followed by the physician's not ordering the test, were the most commonly cited reasons.

When asked about colonoscopy, half of those interviewed said they had never heard of it. Similarly, 62% had never heard of fecal occult blood testing and 63% had never heard of sigmoidoscopy.

“These results are especially concerning because over 90% of consumers reported having a usual source of health care, and nearly 90% had a routine or preventive health care visit in the past 12 months,” the authors said.

In a separate analysis, the investigators found that only 57% of whites and 39% of blacks reported adhering to current Medicare-covered testing intervals, and one-quarter of whites and nearly one-half of blacks had “never” been tested.

“Despite the increased risk for CRC due to age, and insurance coverage for screening and treatment through Medicare, almost half of enrollees are not current with CRC screening recommendations,” the authors said (Am. J. Prev. Med. 2006;30:320–6).

“Improving initial test use among African American Medicare consumers is a necessary step toward increased compliance with guideline-based testing,” they said.

Colorectal and endometrial cancers are the most frequent malignancies in people with Lynch syndrome, with respective cumulative risks of 60%–80% and 30%–50%.

The good news from a Dutch study is that a comprehensive screening program may cut the incidence of colorectal cancer (CRC) in this high-risk population by 70% (Gastroenterology 2006;130:665–71).

Cancer mortality in a large cohort of Lynch syndrome patients was compared with that in the general Dutch population by computation of the standard mortality ratio (SMR)—which is observed deaths/expected deaths—and absolute excess risk of death.

Lynch syndrome, also known as hereditary nonpolyposis colorectal cancer, is a rare disorder that usually causes the development of colorectal, endometrial, and other forms of cancer.

The study evaluated the effectiveness of a large-scale cancer surveillance program. More than 2,700 individuals in 140 families fulfilled the selection criteria for being mutation carriers, putative carriers, or first-degree relatives of carriers.

The SMR for CRC decreased significantly between 1960 and 2004, from 32 to 10. In contrast, there was no significant change in the SMRs for all other cancers, including endometrial cancer (EC).

Among those who did not have a surveillance colonoscopy (1,073 patients), the SMR was 23.9, versus 6.5 for the group that had the test. The death rate for all cancers—barring CRC—was higher among women than men.

“The most frequent causes of death in the total cohort were CRC, EC, brain tumor, lung cancer, and cancer of the stomach,” the authors said. Although the CRC death rate decreased after initiation of the registry and screening program, the SMR increased significantly for cancers of the small bowel, brain, kidney, ovaries, pancreas, and stomach.

“A striking finding in the present study,” the authors observed, “was that there was no difference in EC mortality between relatives from hMLH1/hMSH2 and hMSH6 (germ line mutation) families despite the reported higher risk of EC in MSH6 mutation carriers compared with the risk in MLH1 and MSH2 mutation carriers” (Gastroenterology 2004;127:17–25).

“Although the observed decrease in CRC mortality since the start of large-scale surveillance programs is encouraging, the mortality because of this cancer is still relatively high,” and thus long-term studies are needed, they wrote.

Colorectal and endometrial cancers are the most frequent malignancies in people with Lynch syndrome, with respective cumulative risks of 60%–80% and 30%–50%.

The good news from a Dutch study is that a comprehensive screening program may cut the incidence of colorectal cancer (CRC) in this high-risk population by 70% (Gastroenterology 2006;130:665–71).

Cancer mortality in a large cohort of Lynch syndrome patients was compared with that in the general Dutch population by computation of the standard mortality ratio (SMR)—which is observed deaths/expected deaths—and absolute excess risk of death.

Lynch syndrome, also known as hereditary nonpolyposis colorectal cancer, is a rare disorder that usually causes the development of colorectal, endometrial, and other forms of cancer.

The study evaluated the effectiveness of a large-scale cancer surveillance program. More than 2,700 individuals in 140 families fulfilled the selection criteria for being mutation carriers, putative carriers, or first-degree relatives of carriers.

The SMR for CRC decreased significantly between 1960 and 2004, from 32 to 10. In contrast, there was no significant change in the SMRs for all other cancers, including endometrial cancer (EC).

Among those who did not have a surveillance colonoscopy (1,073 patients), the SMR was 23.9, versus 6.5 for the group that had the test. The death rate for all cancers—barring CRC—was higher among women than men.

“The most frequent causes of death in the total cohort were CRC, EC, brain tumor, lung cancer, and cancer of the stomach,” the authors said. Although the CRC death rate decreased after initiation of the registry and screening program, the SMR increased significantly for cancers of the small bowel, brain, kidney, ovaries, pancreas, and stomach.

“A striking finding in the present study,” the authors observed, “was that there was no difference in EC mortality between relatives from hMLH1/hMSH2 and hMSH6 (germ line mutation) families despite the reported higher risk of EC in MSH6 mutation carriers compared with the risk in MLH1 and MSH2 mutation carriers” (Gastroenterology 2004;127:17–25).

“Although the observed decrease in CRC mortality since the start of large-scale surveillance programs is encouraging, the mortality because of this cancer is still relatively high,” and thus long-term studies are needed, they wrote.

Colorectal and endometrial cancers are the most frequent malignancies in people with Lynch syndrome, with respective cumulative risks of 60%–80% and 30%–50%.

The good news from a Dutch study is that a comprehensive screening program may cut the incidence of colorectal cancer (CRC) in this high-risk population by 70% (Gastroenterology 2006;130:665–71).

Cancer mortality in a large cohort of Lynch syndrome patients was compared with that in the general Dutch population by computation of the standard mortality ratio (SMR)—which is observed deaths/expected deaths—and absolute excess risk of death.

Lynch syndrome, also known as hereditary nonpolyposis colorectal cancer, is a rare disorder that usually causes the development of colorectal, endometrial, and other forms of cancer.

The study evaluated the effectiveness of a large-scale cancer surveillance program. More than 2,700 individuals in 140 families fulfilled the selection criteria for being mutation carriers, putative carriers, or first-degree relatives of carriers.

The SMR for CRC decreased significantly between 1960 and 2004, from 32 to 10. In contrast, there was no significant change in the SMRs for all other cancers, including endometrial cancer (EC).

Among those who did not have a surveillance colonoscopy (1,073 patients), the SMR was 23.9, versus 6.5 for the group that had the test. The death rate for all cancers—barring CRC—was higher among women than men.

“The most frequent causes of death in the total cohort were CRC, EC, brain tumor, lung cancer, and cancer of the stomach,” the authors said. Although the CRC death rate decreased after initiation of the registry and screening program, the SMR increased significantly for cancers of the small bowel, brain, kidney, ovaries, pancreas, and stomach.

“A striking finding in the present study,” the authors observed, “was that there was no difference in EC mortality between relatives from hMLH1/hMSH2 and hMSH6 (germ line mutation) families despite the reported higher risk of EC in MSH6 mutation carriers compared with the risk in MLH1 and MSH2 mutation carriers” (Gastroenterology 2004;127:17–25).

“Although the observed decrease in CRC mortality since the start of large-scale surveillance programs is encouraging, the mortality because of this cancer is still relatively high,” and thus long-term studies are needed, they wrote.

CHICAGO — Tricuspid valve annuloplasty of the donor heart before orthotopic transplantation provides short- and long-term benefits, according to a 6-year study.

“Clearly, tricuspid annuloplasty, in the immediate postoperative period, augments myocardial function. Long term, there's a reduction in tricuspid regurgitation and less deterioration of renal function,” said Dr. Valluvan Jeevanandam. “Considering the advantages and how simple and quick a procedure this is, I think it should be used routinely as part of the orthotopic heart transplantation procedure.”

Tricuspid regurgitation (TR) is a common and significant complication after orthotopic heart transplantation (OHT), and there are no published reports on the long-term results of prophylactic tricuspid valve annuloplasty (TVA), Dr. Jeevanandam told the annual meeting of the Society of Thoracic Surgeons.

The incidence of TR following OHT ranges from 47% to 98%. “This incidence correlates with implant technique, endomyocardial biopsies, allograft dysfunction with right ventricle dilatation, and pulmonary hypertension, while greater than moderate TR is associated with right-sided heart failure symptoms, renal and hepatic dysfunction, and decreased long-term survival,” said Dr. Jeevanandam, who is now with the University of Chicago.

Donor recipients, none of whom had TR to begin with, were randomized to one of two groups: Group A underwent bicaval orthotopic heart transplantation (bOHT), and group B received a heart plus DeVega TVA. During April 1997-April 1998, 94 heart transplants were performed at Temple University in Philadelphia; of those, 60 met the criteria for comparison. The exclusion criteria included multiple organ transplantation, retransplantation, and low donor-recipient weight ratio.

Outcome data were prospectively obtained intraoperatively, at 1 month, at 1 year, and annually up to 6 years, he said.

Intraoperatively, the TVA group (B) required an average of 19 minutes less reperfusion time and had significantly lower central venous pressure and a larger gap between mean pulmonary artery and central venous pressures.

Regarding TR severity, group B showed significantly lower regurgitation readings up to year 6; at the end of follow-up, 36% of group A patients had TR levels at or above 2, compared with 0% in group B. There was a significant correlation between a TR of 2 or greater and increased risk of death, Dr. Jeevanandam said.

Differences in renal function were not significant until year 6, when group A experienced a spike in mean creatinine level to 2.9 mg/dL; at that point, the difference in creatine levels was two points in group B's favor. As with TR, a creatinine level of 2.5 mg/dL or higher was associated with a significantly higher risk of death.

“The immediate intraoperative complications were similar [between] groups; however, the under 10-day mortality was statistically higher in the group without annuloplasty. Initially, we thought this would portend better long-term prognosis and survival, but that difference disappeared at 1 year.” By the end of the study, cardiac mortality was more common in group A, and though the cardiac survival was higher in group B, in the end, the cumulative survival was the same, he said.

Tricuspid valve annuloplasty is a relatively simple and quick procedure. The tricuspid valve is easy to access through the open inferior vena cava of the donor organ. This eliminates the need to open the right atrium. Courtesy Dr. Valluvan Jeevanandam

CHICAGO — Tricuspid valve annuloplasty of the donor heart before orthotopic transplantation provides short- and long-term benefits, according to a 6-year study.

“Clearly, tricuspid annuloplasty, in the immediate postoperative period, augments myocardial function. Long term, there's a reduction in tricuspid regurgitation and less deterioration of renal function,” said Dr. Valluvan Jeevanandam. “Considering the advantages and how simple and quick a procedure this is, I think it should be used routinely as part of the orthotopic heart transplantation procedure.”

Tricuspid regurgitation (TR) is a common and significant complication after orthotopic heart transplantation (OHT), and there are no published reports on the long-term results of prophylactic tricuspid valve annuloplasty (TVA), Dr. Jeevanandam told the annual meeting of the Society of Thoracic Surgeons.

The incidence of TR following OHT ranges from 47% to 98%. “This incidence correlates with implant technique, endomyocardial biopsies, allograft dysfunction with right ventricle dilatation, and pulmonary hypertension, while greater than moderate TR is associated with right-sided heart failure symptoms, renal and hepatic dysfunction, and decreased long-term survival,” said Dr. Jeevanandam, who is now with the University of Chicago.

Donor recipients, none of whom had TR to begin with, were randomized to one of two groups: Group A underwent bicaval orthotopic heart transplantation (bOHT), and group B received a heart plus DeVega TVA. During April 1997-April 1998, 94 heart transplants were performed at Temple University in Philadelphia; of those, 60 met the criteria for comparison. The exclusion criteria included multiple organ transplantation, retransplantation, and low donor-recipient weight ratio.

Outcome data were prospectively obtained intraoperatively, at 1 month, at 1 year, and annually up to 6 years, he said.

Intraoperatively, the TVA group (B) required an average of 19 minutes less reperfusion time and had significantly lower central venous pressure and a larger gap between mean pulmonary artery and central venous pressures.

Regarding TR severity, group B showed significantly lower regurgitation readings up to year 6; at the end of follow-up, 36% of group A patients had TR levels at or above 2, compared with 0% in group B. There was a significant correlation between a TR of 2 or greater and increased risk of death, Dr. Jeevanandam said.

Differences in renal function were not significant until year 6, when group A experienced a spike in mean creatinine level to 2.9 mg/dL; at that point, the difference in creatine levels was two points in group B's favor. As with TR, a creatinine level of 2.5 mg/dL or higher was associated with a significantly higher risk of death.

“The immediate intraoperative complications were similar [between] groups; however, the under 10-day mortality was statistically higher in the group without annuloplasty. Initially, we thought this would portend better long-term prognosis and survival, but that difference disappeared at 1 year.” By the end of the study, cardiac mortality was more common in group A, and though the cardiac survival was higher in group B, in the end, the cumulative survival was the same, he said.

Tricuspid valve annuloplasty is a relatively simple and quick procedure. The tricuspid valve is easy to access through the open inferior vena cava of the donor organ. This eliminates the need to open the right atrium. Courtesy Dr. Valluvan Jeevanandam

CHICAGO — Tricuspid valve annuloplasty of the donor heart before orthotopic transplantation provides short- and long-term benefits, according to a 6-year study.

“Clearly, tricuspid annuloplasty, in the immediate postoperative period, augments myocardial function. Long term, there's a reduction in tricuspid regurgitation and less deterioration of renal function,” said Dr. Valluvan Jeevanandam. “Considering the advantages and how simple and quick a procedure this is, I think it should be used routinely as part of the orthotopic heart transplantation procedure.”

Tricuspid regurgitation (TR) is a common and significant complication after orthotopic heart transplantation (OHT), and there are no published reports on the long-term results of prophylactic tricuspid valve annuloplasty (TVA), Dr. Jeevanandam told the annual meeting of the Society of Thoracic Surgeons.

The incidence of TR following OHT ranges from 47% to 98%. “This incidence correlates with implant technique, endomyocardial biopsies, allograft dysfunction with right ventricle dilatation, and pulmonary hypertension, while greater than moderate TR is associated with right-sided heart failure symptoms, renal and hepatic dysfunction, and decreased long-term survival,” said Dr. Jeevanandam, who is now with the University of Chicago.

Donor recipients, none of whom had TR to begin with, were randomized to one of two groups: Group A underwent bicaval orthotopic heart transplantation (bOHT), and group B received a heart plus DeVega TVA. During April 1997-April 1998, 94 heart transplants were performed at Temple University in Philadelphia; of those, 60 met the criteria for comparison. The exclusion criteria included multiple organ transplantation, retransplantation, and low donor-recipient weight ratio.

Outcome data were prospectively obtained intraoperatively, at 1 month, at 1 year, and annually up to 6 years, he said.

Intraoperatively, the TVA group (B) required an average of 19 minutes less reperfusion time and had significantly lower central venous pressure and a larger gap between mean pulmonary artery and central venous pressures.

Regarding TR severity, group B showed significantly lower regurgitation readings up to year 6; at the end of follow-up, 36% of group A patients had TR levels at or above 2, compared with 0% in group B. There was a significant correlation between a TR of 2 or greater and increased risk of death, Dr. Jeevanandam said.

Differences in renal function were not significant until year 6, when group A experienced a spike in mean creatinine level to 2.9 mg/dL; at that point, the difference in creatine levels was two points in group B's favor. As with TR, a creatinine level of 2.5 mg/dL or higher was associated with a significantly higher risk of death.

“The immediate intraoperative complications were similar [between] groups; however, the under 10-day mortality was statistically higher in the group without annuloplasty. Initially, we thought this would portend better long-term prognosis and survival, but that difference disappeared at 1 year.” By the end of the study, cardiac mortality was more common in group A, and though the cardiac survival was higher in group B, in the end, the cumulative survival was the same, he said.

Tricuspid valve annuloplasty is a relatively simple and quick procedure. The tricuspid valve is easy to access through the open inferior vena cava of the donor organ. This eliminates the need to open the right atrium. Courtesy Dr. Valluvan Jeevanandam

SAN DIEGO — Reimbursement for pulsed radiofrequency, an experimental treatment for some types of chronic pain, now requires the use of unlisted procedure code 64999, as designated by the American Medical Association's Current Procedural Terminology (CPT).

The designation follows extended debate over a proposal by the North American Spine Society to assign pulsed radiofrequency to category 3 in the CPT section on emerging technology, said Dr. Eduardo M. Fraifeld, chairman of the Coding and Reimbursement Committee of the American Academy of Pain Medicine (AAPM).

“When seeking reimbursement for pulsed radiofrequency, it is incorrect to use codes for radiofrequency ablation, including 64626 and 64627, which are neurolytic codes,” Dr. Fraifeld explained at the annual meeting of the AAPM.

In another pain-therapy CPT code overhaul, the AAPM's Coding and Reimbursement Committee eliminated the “Sedation With or Without Analgesia (Conscious Sedation)” category (99141–42) and replaced it with “Moderate (Conscious) Sedation.” The new category has three codes for drug administration by the same physician performing the diagnostic or therapeutic service (99143–45) and three codes requiring an additional independent observer to monitor the patient (99148–50). These two categories are then broken down into three subcategories, which include under age 5 first 30 minutes intraservice time, age 5 and older first 30 minutes intraservice time, and an add-on code for each additional 15 minutes intraservice time, Dr. Fraifeld said.

Other deletions this year include eight evaluation and management codes for “Follow-up Inpatient Consultations” (99261–3) and “Confirmatory Consultations” (99271–5).

SAN DIEGO — Reimbursement for pulsed radiofrequency, an experimental treatment for some types of chronic pain, now requires the use of unlisted procedure code 64999, as designated by the American Medical Association's Current Procedural Terminology (CPT).

The designation follows extended debate over a proposal by the North American Spine Society to assign pulsed radiofrequency to category 3 in the CPT section on emerging technology, said Dr. Eduardo M. Fraifeld, chairman of the Coding and Reimbursement Committee of the American Academy of Pain Medicine (AAPM).

“When seeking reimbursement for pulsed radiofrequency, it is incorrect to use codes for radiofrequency ablation, including 64626 and 64627, which are neurolytic codes,” Dr. Fraifeld explained at the annual meeting of the AAPM.

In another pain-therapy CPT code overhaul, the AAPM's Coding and Reimbursement Committee eliminated the “Sedation With or Without Analgesia (Conscious Sedation)” category (99141–42) and replaced it with “Moderate (Conscious) Sedation.” The new category has three codes for drug administration by the same physician performing the diagnostic or therapeutic service (99143–45) and three codes requiring an additional independent observer to monitor the patient (99148–50). These two categories are then broken down into three subcategories, which include under age 5 first 30 minutes intraservice time, age 5 and older first 30 minutes intraservice time, and an add-on code for each additional 15 minutes intraservice time, Dr. Fraifeld said.

Other deletions this year include eight evaluation and management codes for “Follow-up Inpatient Consultations” (99261–3) and “Confirmatory Consultations” (99271–5).

SAN DIEGO — Reimbursement for pulsed radiofrequency, an experimental treatment for some types of chronic pain, now requires the use of unlisted procedure code 64999, as designated by the American Medical Association's Current Procedural Terminology (CPT).

The designation follows extended debate over a proposal by the North American Spine Society to assign pulsed radiofrequency to category 3 in the CPT section on emerging technology, said Dr. Eduardo M. Fraifeld, chairman of the Coding and Reimbursement Committee of the American Academy of Pain Medicine (AAPM).

“When seeking reimbursement for pulsed radiofrequency, it is incorrect to use codes for radiofrequency ablation, including 64626 and 64627, which are neurolytic codes,” Dr. Fraifeld explained at the annual meeting of the AAPM.

In another pain-therapy CPT code overhaul, the AAPM's Coding and Reimbursement Committee eliminated the “Sedation With or Without Analgesia (Conscious Sedation)” category (99141–42) and replaced it with “Moderate (Conscious) Sedation.” The new category has three codes for drug administration by the same physician performing the diagnostic or therapeutic service (99143–45) and three codes requiring an additional independent observer to monitor the patient (99148–50). These two categories are then broken down into three subcategories, which include under age 5 first 30 minutes intraservice time, age 5 and older first 30 minutes intraservice time, and an add-on code for each additional 15 minutes intraservice time, Dr. Fraifeld said.

Other deletions this year include eight evaluation and management codes for “Follow-up Inpatient Consultations” (99261–3) and “Confirmatory Consultations” (99271–5).

Aversion to colonoscopy and lack of physician communication are major reasons Americans avoid colon cancer screening, according to a survey of 1,200 people aged 50 to 70 years.

The survey, conducted in February by Harris Interactive, suggests that three out of four eligible Americans are not being screened regularly for this second leading cause of cancer death, a screening rate far lower than rates reported for breast, cervical, and prostate cancers. Only one-third of respondents said they had been screened at least once for colon cancer.

The primary reasons for not being screened included, “don't want to have a colonoscopy” (28%), “doctor did not discuss screening with them” (26%), “did not have any symptoms” (24%), “did not feel they were at risk” (17%), “did not follow through on MD [doctor] recommendations” (9%), “did not know they should be screened” (8%), “did not have time” (5%), and “embarrassed to discuss screening with MD” (4%). Respondents were able to select from more than one category.

Screening rates were highest among those who claimed to be the most knowledgeable about colon cancer. Only 35% of those that considered themselves lacking knowledge about colon cancer had ever been screened. On the other hand, 79% of respondents who felt they were “knowledgeable” or “very knowledgeable” had been screened.

A personal or family history of the disease was reported by one in five people. However, only half of respondents considered themselves knowledgeable about the disease, and far fewer understood the need for, and benefits of, screening. More than a third of adults said they were in “excellent” or “very good” health, and three-quarters felt they were doing a good job of managing their own health.

The survey also asked respondents why they would not undergo a colonoscopy—which is still considered the most accurate screening test—in the future. Topping that list was “invasiveness” (20%), followed by “laxatives/enemas,” “preparation,” “general inconvenience,” “embarrassment or lack of privacy,” “time off from work required,” “safety,” and “dietary and medication restrictions.”

Aversion to colonoscopy and lack of physician communication are major reasons Americans avoid colon cancer screening, according to a survey of 1,200 people aged 50 to 70 years.

The survey, conducted in February by Harris Interactive, suggests that three out of four eligible Americans are not being screened regularly for this second leading cause of cancer death, a screening rate far lower than rates reported for breast, cervical, and prostate cancers. Only one-third of respondents said they had been screened at least once for colon cancer.

The primary reasons for not being screened included, “don't want to have a colonoscopy” (28%), “doctor did not discuss screening with them” (26%), “did not have any symptoms” (24%), “did not feel they were at risk” (17%), “did not follow through on MD [doctor] recommendations” (9%), “did not know they should be screened” (8%), “did not have time” (5%), and “embarrassed to discuss screening with MD” (4%). Respondents were able to select from more than one category.

Screening rates were highest among those who claimed to be the most knowledgeable about colon cancer. Only 35% of those that considered themselves lacking knowledge about colon cancer had ever been screened. On the other hand, 79% of respondents who felt they were “knowledgeable” or “very knowledgeable” had been screened.

A personal or family history of the disease was reported by one in five people. However, only half of respondents considered themselves knowledgeable about the disease, and far fewer understood the need for, and benefits of, screening. More than a third of adults said they were in “excellent” or “very good” health, and three-quarters felt they were doing a good job of managing their own health.

The survey also asked respondents why they would not undergo a colonoscopy—which is still considered the most accurate screening test—in the future. Topping that list was “invasiveness” (20%), followed by “laxatives/enemas,” “preparation,” “general inconvenience,” “embarrassment or lack of privacy,” “time off from work required,” “safety,” and “dietary and medication restrictions.”

Aversion to colonoscopy and lack of physician communication are major reasons Americans avoid colon cancer screening, according to a survey of 1,200 people aged 50 to 70 years.

The survey, conducted in February by Harris Interactive, suggests that three out of four eligible Americans are not being screened regularly for this second leading cause of cancer death, a screening rate far lower than rates reported for breast, cervical, and prostate cancers. Only one-third of respondents said they had been screened at least once for colon cancer.

The primary reasons for not being screened included, “don't want to have a colonoscopy” (28%), “doctor did not discuss screening with them” (26%), “did not have any symptoms” (24%), “did not feel they were at risk” (17%), “did not follow through on MD [doctor] recommendations” (9%), “did not know they should be screened” (8%), “did not have time” (5%), and “embarrassed to discuss screening with MD” (4%). Respondents were able to select from more than one category.

Screening rates were highest among those who claimed to be the most knowledgeable about colon cancer. Only 35% of those that considered themselves lacking knowledge about colon cancer had ever been screened. On the other hand, 79% of respondents who felt they were “knowledgeable” or “very knowledgeable” had been screened.

A personal or family history of the disease was reported by one in five people. However, only half of respondents considered themselves knowledgeable about the disease, and far fewer understood the need for, and benefits of, screening. More than a third of adults said they were in “excellent” or “very good” health, and three-quarters felt they were doing a good job of managing their own health.

The survey also asked respondents why they would not undergo a colonoscopy—which is still considered the most accurate screening test—in the future. Topping that list was “invasiveness” (20%), followed by “laxatives/enemas,” “preparation,” “general inconvenience,” “embarrassment or lack of privacy,” “time off from work required,” “safety,” and “dietary and medication restrictions.”

CHICAGO – Carotid artery stenting appeared to improve cognitive function based on the results of what investigators said is the first study to look at perfusion and diffusion-weighted imaging before and after stenting.

“We found that stenting of the carotid artery significantly increased cognitive speed,” Dr. Iris Grunwald said at the Radiological Society of North America annual meeting. Studies of brain function following carotid endarterectomy have produced mixed results, and there is no consensus in the literature as to whether carotid intervention improves cognition.

Dr. Grunwald and her colleagues at the Saarland University Clinic in Homburg, performed carotid artery stenting on 29 patients. Mean age was 68 years and mean degree of stenosis was 90%. People were excluded from the study if they had paresis in the upper extremity, impairment in eyesight, and/or hemianopsia. Those with psychiatric disease or insufficient command of language also were excluded.

Stents were implanted in the left carotid artery in 18 patients. All the patients were asymptomatic and right handed. Thus speech-related functions were primarily left-brain functions in these patients, Dr. Grunwald explained.

Perfusion and diffusion-weighted magnetic resonance imaging (MRI) was performed 24 hours before and 48 hours after intervention (see images). All patients were tested using the Mini-Mental State Examination (MMSE) and symbol digit test and subtests of the CERAD battery. Cognitive speed was assessed with the modified trail making test (ZVT) and the Stroop colored word test.

Findings from the Beck Depression Inventory showed that none of the patients suffered from depression. Mean improvements in cognitive speed ranged from 3% on the ZVT number connection test to almost 7% on the Stroop colored word test.

“Stenting of the internal carotid artery seems to improve functions that involve cognitive speed, regardless of the patient's age, the side of stenosis and the degree of stenosis,” Dr. Grunwald said. “Some patients showed [more] improvement after stent placement than others. The higher the degree of stenosis, the more marked was the perfusion deficit. Post-stenting perfusion increased in 17 of the 18 patients, though in 9 of them the increase was described as “slight.” Increased brain perfusion correlated with increased memory function but did not quite reach statistical significance.

Perfusion and diffusion-weighted MRIs show impaired cerebral blood flow (red) in a carotid stenosis patient.

Placement of a carotid stent in the same patient restored cerebral blood flow to closer-to-normal (green) levels. Photos courtesy Dr. Iris Grunwald

CHICAGO – Carotid artery stenting appeared to improve cognitive function based on the results of what investigators said is the first study to look at perfusion and diffusion-weighted imaging before and after stenting.

“We found that stenting of the carotid artery significantly increased cognitive speed,” Dr. Iris Grunwald said at the Radiological Society of North America annual meeting. Studies of brain function following carotid endarterectomy have produced mixed results, and there is no consensus in the literature as to whether carotid intervention improves cognition.

Dr. Grunwald and her colleagues at the Saarland University Clinic in Homburg, performed carotid artery stenting on 29 patients. Mean age was 68 years and mean degree of stenosis was 90%. People were excluded from the study if they had paresis in the upper extremity, impairment in eyesight, and/or hemianopsia. Those with psychiatric disease or insufficient command of language also were excluded.

Stents were implanted in the left carotid artery in 18 patients. All the patients were asymptomatic and right handed. Thus speech-related functions were primarily left-brain functions in these patients, Dr. Grunwald explained.

Perfusion and diffusion-weighted magnetic resonance imaging (MRI) was performed 24 hours before and 48 hours after intervention (see images). All patients were tested using the Mini-Mental State Examination (MMSE) and symbol digit test and subtests of the CERAD battery. Cognitive speed was assessed with the modified trail making test (ZVT) and the Stroop colored word test.

Findings from the Beck Depression Inventory showed that none of the patients suffered from depression. Mean improvements in cognitive speed ranged from 3% on the ZVT number connection test to almost 7% on the Stroop colored word test.

“Stenting of the internal carotid artery seems to improve functions that involve cognitive speed, regardless of the patient's age, the side of stenosis and the degree of stenosis,” Dr. Grunwald said. “Some patients showed [more] improvement after stent placement than others. The higher the degree of stenosis, the more marked was the perfusion deficit. Post-stenting perfusion increased in 17 of the 18 patients, though in 9 of them the increase was described as “slight.” Increased brain perfusion correlated with increased memory function but did not quite reach statistical significance.

Perfusion and diffusion-weighted MRIs show impaired cerebral blood flow (red) in a carotid stenosis patient.

Placement of a carotid stent in the same patient restored cerebral blood flow to closer-to-normal (green) levels. Photos courtesy Dr. Iris Grunwald

CHICAGO – Carotid artery stenting appeared to improve cognitive function based on the results of what investigators said is the first study to look at perfusion and diffusion-weighted imaging before and after stenting.

“We found that stenting of the carotid artery significantly increased cognitive speed,” Dr. Iris Grunwald said at the Radiological Society of North America annual meeting. Studies of brain function following carotid endarterectomy have produced mixed results, and there is no consensus in the literature as to whether carotid intervention improves cognition.

Dr. Grunwald and her colleagues at the Saarland University Clinic in Homburg, performed carotid artery stenting on 29 patients. Mean age was 68 years and mean degree of stenosis was 90%. People were excluded from the study if they had paresis in the upper extremity, impairment in eyesight, and/or hemianopsia. Those with psychiatric disease or insufficient command of language also were excluded.

Stents were implanted in the left carotid artery in 18 patients. All the patients were asymptomatic and right handed. Thus speech-related functions were primarily left-brain functions in these patients, Dr. Grunwald explained.

Perfusion and diffusion-weighted magnetic resonance imaging (MRI) was performed 24 hours before and 48 hours after intervention (see images). All patients were tested using the Mini-Mental State Examination (MMSE) and symbol digit test and subtests of the CERAD battery. Cognitive speed was assessed with the modified trail making test (ZVT) and the Stroop colored word test.

Findings from the Beck Depression Inventory showed that none of the patients suffered from depression. Mean improvements in cognitive speed ranged from 3% on the ZVT number connection test to almost 7% on the Stroop colored word test.

“Stenting of the internal carotid artery seems to improve functions that involve cognitive speed, regardless of the patient's age, the side of stenosis and the degree of stenosis,” Dr. Grunwald said. “Some patients showed [more] improvement after stent placement than others. The higher the degree of stenosis, the more marked was the perfusion deficit. Post-stenting perfusion increased in 17 of the 18 patients, though in 9 of them the increase was described as “slight.” Increased brain perfusion correlated with increased memory function but did not quite reach statistical significance.

Perfusion and diffusion-weighted MRIs show impaired cerebral blood flow (red) in a carotid stenosis patient.

Placement of a carotid stent in the same patient restored cerebral blood flow to closer-to-normal (green) levels. Photos courtesy Dr. Iris Grunwald