Heidi Splete

Disuse of hormone therapy might have fueled a significant drop in breast cancer detection rates in recent years, but a plateau in screening mammography among women older than 45 years also contributed to the decline, according to new data from an American Cancer Society study published in Breast Cancer Research.

To assess women's breast cancer trends over the period before the results of the Women's Health Initiative brought to light the possibility of a link between hormone therapy and an increased risk of breast cancer, Dr. Ahmedin Jemal and colleagues at the American Cancer Society reviewed data from the nine oldest Surveillance, Epidemiology, and End Results cancer registries (Breast Cancer Res. 2007;9:R28 [Epub doi:10.1186/1186/bcr1672]).

Based on these registries, 394,891 invasive and 59,837 in situ breast cancer cases were diagnosed in U.S. women aged 40 years and older from 1975 through 2003.

Age-specific incidence of invasive breast cancer declined in all 5-year age brackets for women aged 45 years and older between 1999 and 2003, although the degree of the decline varied among the age groups. The decrease in breast cancer incidence among most women younger than 60 years or older than 69 years began in 1998 or 1999. By contrast, the decrease in breast cancer incidence among women aged 60–64 years and 65–69 years occurred from 2002 to 2003 (the most recent year for which data are available). The largest percentage decreases occurred from 2002 to 2003 among women aged 55–59 years (11.3%), 60–64 years (10.6%), and 65–69 years (14.3%).

A joint analysis of tumor size and stage showed that overall, the incidence of small tumors (2 cm or less) decreased by 4.1% per year from 2000 through 2003 and the incidence of localized disease decreased by 3.1% per year from 1999 through 2003. No decrease in the incidence of larger tumors or advanced-stage disease was found during these periods. Also, in situ disease rates were stable from 2000 through 2003 after increasing since 1981.

Trend data based on receptor status showed an annual increase in the incidence of both estrogen receptor-positive tumors and progestin receptor-positive tumors from 1990 to 2000, followed by a 9.1% drop from 2002 to 2003 for both of these types. Estrogen receptor-negative and progestin receptor-negative tumors also showed their largest overall decreases in incidence, 4.8% and 6.9% respectively, between 2002 and 2003.

The drop in incidence that began in 1998 coincides with a plateau in screening mammography, and the types of cancers detected by mammography were the types that had a decrease in incidence (small tumors and localized disease). Data from the National Health Interview Survey show that the percentage of women aged 40 years and older who reported having a mammogram within the past 2 years was 70.3% in 1999, 70.4% in 2000, and 69.5% in 2003.

“Typically, incidence rates decrease when the penetrance of a screening test reaches a plateau due to a reduced pool of undiagnosed prevalent cases,” the researchers wrote.

The sharp declines in breast cancer from 2002 to 2003 that were reported at a breast cancer symposium sponsored by the Cancer Therapy and Research Center last year might have been due in part to a reduced use of hormone therapy in response to data from the Women's Health Initiative that linked hormone therapy to an increased risk of breast cancer. The sharp drop was observed mainly in estrogen receptor-positive tumors in a subset of women aged 50–69 years.

“Clearly there are many of us who feel that [the] drop in breast cancer detection rate has many factors,” Dr. Len Lichtenfeld, deputy chief medical officer for the American Cancer Society, said in an interview. But from a clinical standpoint, the findings represent a decline in detection, not necessarily an absence of cancer cases.

Clinically, the findings represent a decline in detection, not necessarily an absence of cancer cases. DR. LICHTENFELD

Disuse of hormone therapy might have fueled a significant drop in breast cancer detection rates in recent years, but a plateau in screening mammography among women older than 45 years also contributed to the decline, according to new data from an American Cancer Society study published in Breast Cancer Research.

To assess women's breast cancer trends over the period before the results of the Women's Health Initiative brought to light the possibility of a link between hormone therapy and an increased risk of breast cancer, Dr. Ahmedin Jemal and colleagues at the American Cancer Society reviewed data from the nine oldest Surveillance, Epidemiology, and End Results cancer registries (Breast Cancer Res. 2007;9:R28 [Epub doi:10.1186/1186/bcr1672]).

Based on these registries, 394,891 invasive and 59,837 in situ breast cancer cases were diagnosed in U.S. women aged 40 years and older from 1975 through 2003.

Age-specific incidence of invasive breast cancer declined in all 5-year age brackets for women aged 45 years and older between 1999 and 2003, although the degree of the decline varied among the age groups. The decrease in breast cancer incidence among most women younger than 60 years or older than 69 years began in 1998 or 1999. By contrast, the decrease in breast cancer incidence among women aged 60–64 years and 65–69 years occurred from 2002 to 2003 (the most recent year for which data are available). The largest percentage decreases occurred from 2002 to 2003 among women aged 55–59 years (11.3%), 60–64 years (10.6%), and 65–69 years (14.3%).

A joint analysis of tumor size and stage showed that overall, the incidence of small tumors (2 cm or less) decreased by 4.1% per year from 2000 through 2003 and the incidence of localized disease decreased by 3.1% per year from 1999 through 2003. No decrease in the incidence of larger tumors or advanced-stage disease was found during these periods. Also, in situ disease rates were stable from 2000 through 2003 after increasing since 1981.

Trend data based on receptor status showed an annual increase in the incidence of both estrogen receptor-positive tumors and progestin receptor-positive tumors from 1990 to 2000, followed by a 9.1% drop from 2002 to 2003 for both of these types. Estrogen receptor-negative and progestin receptor-negative tumors also showed their largest overall decreases in incidence, 4.8% and 6.9% respectively, between 2002 and 2003.

The drop in incidence that began in 1998 coincides with a plateau in screening mammography, and the types of cancers detected by mammography were the types that had a decrease in incidence (small tumors and localized disease). Data from the National Health Interview Survey show that the percentage of women aged 40 years and older who reported having a mammogram within the past 2 years was 70.3% in 1999, 70.4% in 2000, and 69.5% in 2003.

“Typically, incidence rates decrease when the penetrance of a screening test reaches a plateau due to a reduced pool of undiagnosed prevalent cases,” the researchers wrote.

The sharp declines in breast cancer from 2002 to 2003 that were reported at a breast cancer symposium sponsored by the Cancer Therapy and Research Center last year might have been due in part to a reduced use of hormone therapy in response to data from the Women's Health Initiative that linked hormone therapy to an increased risk of breast cancer. The sharp drop was observed mainly in estrogen receptor-positive tumors in a subset of women aged 50–69 years.

“Clearly there are many of us who feel that [the] drop in breast cancer detection rate has many factors,” Dr. Len Lichtenfeld, deputy chief medical officer for the American Cancer Society, said in an interview. But from a clinical standpoint, the findings represent a decline in detection, not necessarily an absence of cancer cases.

Clinically, the findings represent a decline in detection, not necessarily an absence of cancer cases. DR. LICHTENFELD

Disuse of hormone therapy might have fueled a significant drop in breast cancer detection rates in recent years, but a plateau in screening mammography among women older than 45 years also contributed to the decline, according to new data from an American Cancer Society study published in Breast Cancer Research.

To assess women's breast cancer trends over the period before the results of the Women's Health Initiative brought to light the possibility of a link between hormone therapy and an increased risk of breast cancer, Dr. Ahmedin Jemal and colleagues at the American Cancer Society reviewed data from the nine oldest Surveillance, Epidemiology, and End Results cancer registries (Breast Cancer Res. 2007;9:R28 [Epub doi:10.1186/1186/bcr1672]).

Based on these registries, 394,891 invasive and 59,837 in situ breast cancer cases were diagnosed in U.S. women aged 40 years and older from 1975 through 2003.

Age-specific incidence of invasive breast cancer declined in all 5-year age brackets for women aged 45 years and older between 1999 and 2003, although the degree of the decline varied among the age groups. The decrease in breast cancer incidence among most women younger than 60 years or older than 69 years began in 1998 or 1999. By contrast, the decrease in breast cancer incidence among women aged 60–64 years and 65–69 years occurred from 2002 to 2003 (the most recent year for which data are available). The largest percentage decreases occurred from 2002 to 2003 among women aged 55–59 years (11.3%), 60–64 years (10.6%), and 65–69 years (14.3%).

A joint analysis of tumor size and stage showed that overall, the incidence of small tumors (2 cm or less) decreased by 4.1% per year from 2000 through 2003 and the incidence of localized disease decreased by 3.1% per year from 1999 through 2003. No decrease in the incidence of larger tumors or advanced-stage disease was found during these periods. Also, in situ disease rates were stable from 2000 through 2003 after increasing since 1981.

Trend data based on receptor status showed an annual increase in the incidence of both estrogen receptor-positive tumors and progestin receptor-positive tumors from 1990 to 2000, followed by a 9.1% drop from 2002 to 2003 for both of these types. Estrogen receptor-negative and progestin receptor-negative tumors also showed their largest overall decreases in incidence, 4.8% and 6.9% respectively, between 2002 and 2003.

The drop in incidence that began in 1998 coincides with a plateau in screening mammography, and the types of cancers detected by mammography were the types that had a decrease in incidence (small tumors and localized disease). Data from the National Health Interview Survey show that the percentage of women aged 40 years and older who reported having a mammogram within the past 2 years was 70.3% in 1999, 70.4% in 2000, and 69.5% in 2003.

“Typically, incidence rates decrease when the penetrance of a screening test reaches a plateau due to a reduced pool of undiagnosed prevalent cases,” the researchers wrote.

The sharp declines in breast cancer from 2002 to 2003 that were reported at a breast cancer symposium sponsored by the Cancer Therapy and Research Center last year might have been due in part to a reduced use of hormone therapy in response to data from the Women's Health Initiative that linked hormone therapy to an increased risk of breast cancer. The sharp drop was observed mainly in estrogen receptor-positive tumors in a subset of women aged 50–69 years.

“Clearly there are many of us who feel that [the] drop in breast cancer detection rate has many factors,” Dr. Len Lichtenfeld, deputy chief medical officer for the American Cancer Society, said in an interview. But from a clinical standpoint, the findings represent a decline in detection, not necessarily an absence of cancer cases.

Clinically, the findings represent a decline in detection, not necessarily an absence of cancer cases. DR. LICHTENFELD

WASHINGTON — High blood pressure remains a real and growing problem that, if left untreated, could increase in prevalence by 60% over the next 2 decades, Dr. Richard Roberts said at a press briefing on hypertension.

“If action is not taken soon, both in the [United States] and around the world, there will be significant public health consequences,” said Dr. Roberts, a family physician and professor in the department of family medicine at the University of Wisconsin, Madison.

Dr. Roberts spoke on behalf of a coalition of 14 medical groups and voluntary health organizations that commissioned a report to compile the latest information about high blood pressure and its impact on health care systems. The report, “High Blood Pressure and Health Policy: Where We Are and Where We Need to Go Next,” serves as a call to action for health policy makers and physicians.

Citing data from the National Health and Nutrition Examination Survey (NHANES), the report documents that the prevalence of high blood pressure in adults in the United States increased from 25% in 1988–1994 to 29% in 1999–2002. In addition, the growing problem of high blood pressure in children is expected to contribute to the overall increase in prevalence over the next 20 years.

“What makes this such a serious threat is that it can't be prevented easily nor diagnosed and treated easily. It's a tough disease,” Dr. Roberts said. “I'm a family doctor in the trenches doing this every day, and it's probably one of the toughest things that we struggle with.”

The report, which was sponsored by an unrestricted educational grant from Novartis AG, calls for an international effort to address five public policy goals:

▸ Recognize that high blood pressure is a global health priority.

▸ Achieve global consensus on standards for managing high blood pressure.

▸ Empower family doctors to be the first lines of defense against high blood pressure on a global level.

▸ Educate patients about treatment options and acknowledge the difficulties of adhering to lifestyle changes and medication regimens.

▸ Conduct long-term clinical and epidemiologic studies on the costs and benefits of aggressively treating high blood pressure based on emerging trends and scientific research.

“More than 90% of us will have high blood pressure if we live long enough,” Dr. Michael A. Weber, professor of medicine at the State University of New York, Brooklyn, said during the briefing.

“The good news is, we can do plenty about it,” he said.

Losing weight and becoming more physically active are among the best ways to keep hypertension from developing, especially for young people. But for many people, regular adherence to medication may be necessary to keep their blood pressure at a healthy level, said Dr. Weber, chair of the American Society of Hypertension's Specialist Program and one of the coauthors of the report.

He suggested that patients would benefit from more education about the condition. “You don't know when you have high blood pressure; it is a totally asymptomatic condition. The only way you know you have high blood pressure is to have it measured, and if it is high, you must get it under control,” he said.

“The effort is worth it,” he emphasized. “When we treat high blood pressure well, we can reduce the probability of heart attacks by 40%–50%.”

Similarly, keeping high blood pressure under control can reduce the incidence of stroke and cut down on the number of patients who will eventually require kidney dialysis.

“If all of us work together, we can take a big bite out of this enormous problem,” concluded Dr. Weber, who serves as a consultant for several pharmaceutical companies including Novartis and Merck & Co.

WASHINGTON — High blood pressure remains a real and growing problem that, if left untreated, could increase in prevalence by 60% over the next 2 decades, Dr. Richard Roberts said at a press briefing on hypertension.

“If action is not taken soon, both in the [United States] and around the world, there will be significant public health consequences,” said Dr. Roberts, a family physician and professor in the department of family medicine at the University of Wisconsin, Madison.

Dr. Roberts spoke on behalf of a coalition of 14 medical groups and voluntary health organizations that commissioned a report to compile the latest information about high blood pressure and its impact on health care systems. The report, “High Blood Pressure and Health Policy: Where We Are and Where We Need to Go Next,” serves as a call to action for health policy makers and physicians.

Citing data from the National Health and Nutrition Examination Survey (NHANES), the report documents that the prevalence of high blood pressure in adults in the United States increased from 25% in 1988–1994 to 29% in 1999–2002. In addition, the growing problem of high blood pressure in children is expected to contribute to the overall increase in prevalence over the next 20 years.

“What makes this such a serious threat is that it can't be prevented easily nor diagnosed and treated easily. It's a tough disease,” Dr. Roberts said. “I'm a family doctor in the trenches doing this every day, and it's probably one of the toughest things that we struggle with.”

The report, which was sponsored by an unrestricted educational grant from Novartis AG, calls for an international effort to address five public policy goals:

▸ Recognize that high blood pressure is a global health priority.

▸ Achieve global consensus on standards for managing high blood pressure.

▸ Empower family doctors to be the first lines of defense against high blood pressure on a global level.

▸ Educate patients about treatment options and acknowledge the difficulties of adhering to lifestyle changes and medication regimens.

▸ Conduct long-term clinical and epidemiologic studies on the costs and benefits of aggressively treating high blood pressure based on emerging trends and scientific research.

“More than 90% of us will have high blood pressure if we live long enough,” Dr. Michael A. Weber, professor of medicine at the State University of New York, Brooklyn, said during the briefing.

“The good news is, we can do plenty about it,” he said.

Losing weight and becoming more physically active are among the best ways to keep hypertension from developing, especially for young people. But for many people, regular adherence to medication may be necessary to keep their blood pressure at a healthy level, said Dr. Weber, chair of the American Society of Hypertension's Specialist Program and one of the coauthors of the report.

He suggested that patients would benefit from more education about the condition. “You don't know when you have high blood pressure; it is a totally asymptomatic condition. The only way you know you have high blood pressure is to have it measured, and if it is high, you must get it under control,” he said.

“The effort is worth it,” he emphasized. “When we treat high blood pressure well, we can reduce the probability of heart attacks by 40%–50%.”

Similarly, keeping high blood pressure under control can reduce the incidence of stroke and cut down on the number of patients who will eventually require kidney dialysis.

“If all of us work together, we can take a big bite out of this enormous problem,” concluded Dr. Weber, who serves as a consultant for several pharmaceutical companies including Novartis and Merck & Co.

WASHINGTON — High blood pressure remains a real and growing problem that, if left untreated, could increase in prevalence by 60% over the next 2 decades, Dr. Richard Roberts said at a press briefing on hypertension.

“If action is not taken soon, both in the [United States] and around the world, there will be significant public health consequences,” said Dr. Roberts, a family physician and professor in the department of family medicine at the University of Wisconsin, Madison.

Dr. Roberts spoke on behalf of a coalition of 14 medical groups and voluntary health organizations that commissioned a report to compile the latest information about high blood pressure and its impact on health care systems. The report, “High Blood Pressure and Health Policy: Where We Are and Where We Need to Go Next,” serves as a call to action for health policy makers and physicians.

Citing data from the National Health and Nutrition Examination Survey (NHANES), the report documents that the prevalence of high blood pressure in adults in the United States increased from 25% in 1988–1994 to 29% in 1999–2002. In addition, the growing problem of high blood pressure in children is expected to contribute to the overall increase in prevalence over the next 20 years.

“What makes this such a serious threat is that it can't be prevented easily nor diagnosed and treated easily. It's a tough disease,” Dr. Roberts said. “I'm a family doctor in the trenches doing this every day, and it's probably one of the toughest things that we struggle with.”

The report, which was sponsored by an unrestricted educational grant from Novartis AG, calls for an international effort to address five public policy goals:

▸ Recognize that high blood pressure is a global health priority.

▸ Achieve global consensus on standards for managing high blood pressure.

▸ Empower family doctors to be the first lines of defense against high blood pressure on a global level.

▸ Educate patients about treatment options and acknowledge the difficulties of adhering to lifestyle changes and medication regimens.

▸ Conduct long-term clinical and epidemiologic studies on the costs and benefits of aggressively treating high blood pressure based on emerging trends and scientific research.

“More than 90% of us will have high blood pressure if we live long enough,” Dr. Michael A. Weber, professor of medicine at the State University of New York, Brooklyn, said during the briefing.

“The good news is, we can do plenty about it,” he said.

Losing weight and becoming more physically active are among the best ways to keep hypertension from developing, especially for young people. But for many people, regular adherence to medication may be necessary to keep their blood pressure at a healthy level, said Dr. Weber, chair of the American Society of Hypertension's Specialist Program and one of the coauthors of the report.

He suggested that patients would benefit from more education about the condition. “You don't know when you have high blood pressure; it is a totally asymptomatic condition. The only way you know you have high blood pressure is to have it measured, and if it is high, you must get it under control,” he said.

“The effort is worth it,” he emphasized. “When we treat high blood pressure well, we can reduce the probability of heart attacks by 40%–50%.”

Similarly, keeping high blood pressure under control can reduce the incidence of stroke and cut down on the number of patients who will eventually require kidney dialysis.

“If all of us work together, we can take a big bite out of this enormous problem,” concluded Dr. Weber, who serves as a consultant for several pharmaceutical companies including Novartis and Merck & Co.

WASHINGTON — Patient safety problems in hospitals often stem from a lack of teamwork and poor communication, James Battles, Ph.D., said at a conference sponsored by the National Patient Safety Foundation.

“In health care, if we don't have good teamwork, patients die,” said Dr. Battles, the senior service fellow for patient safety at the Agency for Healthcare Research and Quality (AHRQ).

“Teamwork is not unique to health care, and what we know about teamwork research comes from a number of disciplines, namely the military,” he said.

In the wake of “To Err Is Human,” the 1999 Institute of Medicine report that raised awareness of medical errors and called for better teamwork among physicians, AHRQ partnered with the Department of Defense to develop a teamwork training program. The resulting Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program was designed to help doctors and hospitals integrate teamwork principles into their daily activities as a way to reduce clinical errors and to improve patient outcomes, patient satisfaction, and hospital staff satisfaction.

Poor communication and other teamwork issues usually are to blame when a serious medical error occurs in a hospital, case studies have shown.

“There is a growing scientific body of literature that indicates that medical teamwork can improve the quality of the clinical process,” Dr. Battles said.

One key characteristic of successful teams is a shared mental model, which means that members of the team are “on the same page” and have a mutual sense of trust and a sense of being part of a team working toward a common goal. Each member of a successful team knows his or her role. And the most successful teams have supportive leadership.

Physicians can download materials from the AHRQ Web site and customize them to suit their practices. TeamSTEPPS became widely available in November 2006, and about 50 medical centers across the United States have used the program to improve teamwork and patient safety in their facilities, Dr. Battles said.

TeamSTEPPS offers ways to transform hospital culture by addressing the root causes of serious safety problems, particularly failures of communication.

“The program offers an excellent model and thorough instruction on how an institution can alter [its] culture and support enhanced teamwork,” Dr. Mark V. Williams, professor of medicine at Emory University in Atlanta and director of the Emory Hospital Medicine Unit, said in an interview.

“It especially empowers nurses and other health care staff to speak up and alert their colleagues and physicians when patient safety is at risk,” said Dr. Williams, who is evaluating the TeamSTEPPS program for possible use at Emory.

Key team events that make up the TeamSTEPPS program include briefs, huddles, debriefs, and conflict resolution, Heidi King, director of DOD's Healthcare Team Coordination Program, said at the meeting.

A brief is a short gathering of caregivers to review what is scheduled for the day. Topics include assignments, a review of relevant patient data, plans for specific patients, staff availability and workload, and resources.

“The idea is that we are creating words that people can use, when we say 'get together for a brief or a huddle,' everyone knows what is meant,” Ms. King said. “What we call the 'huddle' is for problem solving and to reestablish situation awareness. An example of a huddle: When a core care team, such as a surgical team or ob.gyn. team, meets for a quick review prior to a specific procedure.”

The debriefing is the step in which quality improvement occurs. Team members meet after the procedure or the next day to review events, even if everything went well the previous day. “This is where patient safety needs to take place, on the front lines of patient care,” Ms. King said.

A debriefing may include conflict resolution. The TeamSTEPPS material offers a constructive approach to resolving conflicts among team members in a four-step process called the DESC:

▸ Describe the specific situation or behavior that caused conflict.

▸ Express how the situation made you feel and what your concerns are.

▸ Suggest alternatives and seek agreement.

▸ Consequences should be stated in terms of the impact on team goals.

The outcomes of the training can be measured by improvements in four core skill areas: leadership, situation monitoring, mutual support, and communication.

Program participants develop a combination of knowledge (of the shared goals), attitudes (of mutual trust and support), and skills (related to accuracy, efficiency, and safety) that ultimately improve patient safety, Ms. King said.

“The big thing is sustaining the changes in attitude,” Ms. King said. “Implement the training in one section of the hospital, start monitoring what is going on, and communicate about what is working and not working, and then expand the training to other areas of the hospital,” she advised.

To change a hospital culture with teamwork training, create opportunities for team members to practice what they learned, and celebrate success as a way to promote progress, she added.

Barriers to good teamwork include inconsistency in team activity, lack of information sharing, hierarchy, defensiveness, varying communication styles, overwork, misinterpretation of cues, and confusion about one's role. The TeamSTEPPS strategies of better communication through briefs and huddles, as well as through feedback, patient advocacy, and mutual support, can combat these problems, Ms. King said, and result in mutual trust, improved performance, and patient safety.

Developing a team mentality is easier said than done. “We all train separately, and we come together and are expected to work together,” she acknowledged.

But physicians can learn the concept of better teamwork as a way to improve patient safety, said Dr. Alison Clay, who participates in TeamSTEPPS at Duke University in Durham, N.C.

TeamSTEPPS at Duke began in the pediatric ICU and it has spread to the operating room. “We are taking it to different parts of the hospital,” said Dr. Clay, an internist with appointments to the departments of surgery, and of internal medicine and pulmonary critical care at Duke. The program is likely to move next to the hospital wards and hospitalists and attending physicians, and then to clinics, she said.

The program starts with lectures and conversation and then proceeds to use of simulations and a debriefing to assess how the participants worked as a team.

Dr. Clay has participated in the TeamSTEPPS curriculum, and she has trained to coach others in teamwork building in her role as the capstone course director for fourth-year medical students.

Dr. Clay has a unique perspective on patient safety: She was a victim of a medical error at Duke when she arrived at the emergency department as a patient and went into respiratory arrest after being given a medication meant for the patient across the hall.

“That's why communication is important,” said Dr. Clay, who has shared her experience as a patient to emphasize the need for better patient safety measures.

“Concurrent with TeamSTEPPS, [there] are other efforts to teach safety involving all members of the team,” Dr. Clay noted. “People have to … be open to the concept [of] using better teamwork to solve the problem.”

For more information about TeamSTEPPS or to review and order materials, visit www.ahrq.gov/qual/teamstepps

WASHINGTON — Patient safety problems in hospitals often stem from a lack of teamwork and poor communication, James Battles, Ph.D., said at a conference sponsored by the National Patient Safety Foundation.

“In health care, if we don't have good teamwork, patients die,” said Dr. Battles, the senior service fellow for patient safety at the Agency for Healthcare Research and Quality (AHRQ).

“Teamwork is not unique to health care, and what we know about teamwork research comes from a number of disciplines, namely the military,” he said.

In the wake of “To Err Is Human,” the 1999 Institute of Medicine report that raised awareness of medical errors and called for better teamwork among physicians, AHRQ partnered with the Department of Defense to develop a teamwork training program. The resulting Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program was designed to help doctors and hospitals integrate teamwork principles into their daily activities as a way to reduce clinical errors and to improve patient outcomes, patient satisfaction, and hospital staff satisfaction.

Poor communication and other teamwork issues usually are to blame when a serious medical error occurs in a hospital, case studies have shown.

“There is a growing scientific body of literature that indicates that medical teamwork can improve the quality of the clinical process,” Dr. Battles said.

One key characteristic of successful teams is a shared mental model, which means that members of the team are “on the same page” and have a mutual sense of trust and a sense of being part of a team working toward a common goal. Each member of a successful team knows his or her role. And the most successful teams have supportive leadership.

Physicians can download materials from the AHRQ Web site and customize them to suit their practices. TeamSTEPPS became widely available in November 2006, and about 50 medical centers across the United States have used the program to improve teamwork and patient safety in their facilities, Dr. Battles said.

TeamSTEPPS offers ways to transform hospital culture by addressing the root causes of serious safety problems, particularly failures of communication.

“The program offers an excellent model and thorough instruction on how an institution can alter [its] culture and support enhanced teamwork,” Dr. Mark V. Williams, professor of medicine at Emory University in Atlanta and director of the Emory Hospital Medicine Unit, said in an interview.

“It especially empowers nurses and other health care staff to speak up and alert their colleagues and physicians when patient safety is at risk,” said Dr. Williams, who is evaluating the TeamSTEPPS program for possible use at Emory.

Key team events that make up the TeamSTEPPS program include briefs, huddles, debriefs, and conflict resolution, Heidi King, director of DOD's Healthcare Team Coordination Program, said at the meeting.

A brief is a short gathering of caregivers to review what is scheduled for the day. Topics include assignments, a review of relevant patient data, plans for specific patients, staff availability and workload, and resources.

“The idea is that we are creating words that people can use, when we say 'get together for a brief or a huddle,' everyone knows what is meant,” Ms. King said. “What we call the 'huddle' is for problem solving and to reestablish situation awareness. An example of a huddle: When a core care team, such as a surgical team or ob.gyn. team, meets for a quick review prior to a specific procedure.”

The debriefing is the step in which quality improvement occurs. Team members meet after the procedure or the next day to review events, even if everything went well the previous day. “This is where patient safety needs to take place, on the front lines of patient care,” Ms. King said.

A debriefing may include conflict resolution. The TeamSTEPPS material offers a constructive approach to resolving conflicts among team members in a four-step process called the DESC:

▸ Describe the specific situation or behavior that caused conflict.

▸ Express how the situation made you feel and what your concerns are.

▸ Suggest alternatives and seek agreement.

▸ Consequences should be stated in terms of the impact on team goals.

The outcomes of the training can be measured by improvements in four core skill areas: leadership, situation monitoring, mutual support, and communication.

Program participants develop a combination of knowledge (of the shared goals), attitudes (of mutual trust and support), and skills (related to accuracy, efficiency, and safety) that ultimately improve patient safety, Ms. King said.

“The big thing is sustaining the changes in attitude,” Ms. King said. “Implement the training in one section of the hospital, start monitoring what is going on, and communicate about what is working and not working, and then expand the training to other areas of the hospital,” she advised.

To change a hospital culture with teamwork training, create opportunities for team members to practice what they learned, and celebrate success as a way to promote progress, she added.

Barriers to good teamwork include inconsistency in team activity, lack of information sharing, hierarchy, defensiveness, varying communication styles, overwork, misinterpretation of cues, and confusion about one's role. The TeamSTEPPS strategies of better communication through briefs and huddles, as well as through feedback, patient advocacy, and mutual support, can combat these problems, Ms. King said, and result in mutual trust, improved performance, and patient safety.

Developing a team mentality is easier said than done. “We all train separately, and we come together and are expected to work together,” she acknowledged.

But physicians can learn the concept of better teamwork as a way to improve patient safety, said Dr. Alison Clay, who participates in TeamSTEPPS at Duke University in Durham, N.C.

TeamSTEPPS at Duke began in the pediatric ICU and it has spread to the operating room. “We are taking it to different parts of the hospital,” said Dr. Clay, an internist with appointments to the departments of surgery, and of internal medicine and pulmonary critical care at Duke. The program is likely to move next to the hospital wards and hospitalists and attending physicians, and then to clinics, she said.

The program starts with lectures and conversation and then proceeds to use of simulations and a debriefing to assess how the participants worked as a team.

Dr. Clay has participated in the TeamSTEPPS curriculum, and she has trained to coach others in teamwork building in her role as the capstone course director for fourth-year medical students.

Dr. Clay has a unique perspective on patient safety: She was a victim of a medical error at Duke when she arrived at the emergency department as a patient and went into respiratory arrest after being given a medication meant for the patient across the hall.

“That's why communication is important,” said Dr. Clay, who has shared her experience as a patient to emphasize the need for better patient safety measures.

“Concurrent with TeamSTEPPS, [there] are other efforts to teach safety involving all members of the team,” Dr. Clay noted. “People have to … be open to the concept [of] using better teamwork to solve the problem.”

For more information about TeamSTEPPS or to review and order materials, visit www.ahrq.gov/qual/teamstepps

WASHINGTON — Patient safety problems in hospitals often stem from a lack of teamwork and poor communication, James Battles, Ph.D., said at a conference sponsored by the National Patient Safety Foundation.

“In health care, if we don't have good teamwork, patients die,” said Dr. Battles, the senior service fellow for patient safety at the Agency for Healthcare Research and Quality (AHRQ).

“Teamwork is not unique to health care, and what we know about teamwork research comes from a number of disciplines, namely the military,” he said.

In the wake of “To Err Is Human,” the 1999 Institute of Medicine report that raised awareness of medical errors and called for better teamwork among physicians, AHRQ partnered with the Department of Defense to develop a teamwork training program. The resulting Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program was designed to help doctors and hospitals integrate teamwork principles into their daily activities as a way to reduce clinical errors and to improve patient outcomes, patient satisfaction, and hospital staff satisfaction.

Poor communication and other teamwork issues usually are to blame when a serious medical error occurs in a hospital, case studies have shown.

“There is a growing scientific body of literature that indicates that medical teamwork can improve the quality of the clinical process,” Dr. Battles said.

One key characteristic of successful teams is a shared mental model, which means that members of the team are “on the same page” and have a mutual sense of trust and a sense of being part of a team working toward a common goal. Each member of a successful team knows his or her role. And the most successful teams have supportive leadership.

Physicians can download materials from the AHRQ Web site and customize them to suit their practices. TeamSTEPPS became widely available in November 2006, and about 50 medical centers across the United States have used the program to improve teamwork and patient safety in their facilities, Dr. Battles said.

TeamSTEPPS offers ways to transform hospital culture by addressing the root causes of serious safety problems, particularly failures of communication.

“The program offers an excellent model and thorough instruction on how an institution can alter [its] culture and support enhanced teamwork,” Dr. Mark V. Williams, professor of medicine at Emory University in Atlanta and director of the Emory Hospital Medicine Unit, said in an interview.

“It especially empowers nurses and other health care staff to speak up and alert their colleagues and physicians when patient safety is at risk,” said Dr. Williams, who is evaluating the TeamSTEPPS program for possible use at Emory.

Key team events that make up the TeamSTEPPS program include briefs, huddles, debriefs, and conflict resolution, Heidi King, director of DOD's Healthcare Team Coordination Program, said at the meeting.

A brief is a short gathering of caregivers to review what is scheduled for the day. Topics include assignments, a review of relevant patient data, plans for specific patients, staff availability and workload, and resources.

“The idea is that we are creating words that people can use, when we say 'get together for a brief or a huddle,' everyone knows what is meant,” Ms. King said. “What we call the 'huddle' is for problem solving and to reestablish situation awareness. An example of a huddle: When a core care team, such as a surgical team or ob.gyn. team, meets for a quick review prior to a specific procedure.”

The debriefing is the step in which quality improvement occurs. Team members meet after the procedure or the next day to review events, even if everything went well the previous day. “This is where patient safety needs to take place, on the front lines of patient care,” Ms. King said.

A debriefing may include conflict resolution. The TeamSTEPPS material offers a constructive approach to resolving conflicts among team members in a four-step process called the DESC:

▸ Describe the specific situation or behavior that caused conflict.

▸ Express how the situation made you feel and what your concerns are.

▸ Suggest alternatives and seek agreement.

▸ Consequences should be stated in terms of the impact on team goals.

The outcomes of the training can be measured by improvements in four core skill areas: leadership, situation monitoring, mutual support, and communication.

Program participants develop a combination of knowledge (of the shared goals), attitudes (of mutual trust and support), and skills (related to accuracy, efficiency, and safety) that ultimately improve patient safety, Ms. King said.

“The big thing is sustaining the changes in attitude,” Ms. King said. “Implement the training in one section of the hospital, start monitoring what is going on, and communicate about what is working and not working, and then expand the training to other areas of the hospital,” she advised.

To change a hospital culture with teamwork training, create opportunities for team members to practice what they learned, and celebrate success as a way to promote progress, she added.

Barriers to good teamwork include inconsistency in team activity, lack of information sharing, hierarchy, defensiveness, varying communication styles, overwork, misinterpretation of cues, and confusion about one's role. The TeamSTEPPS strategies of better communication through briefs and huddles, as well as through feedback, patient advocacy, and mutual support, can combat these problems, Ms. King said, and result in mutual trust, improved performance, and patient safety.

Developing a team mentality is easier said than done. “We all train separately, and we come together and are expected to work together,” she acknowledged.

But physicians can learn the concept of better teamwork as a way to improve patient safety, said Dr. Alison Clay, who participates in TeamSTEPPS at Duke University in Durham, N.C.

TeamSTEPPS at Duke began in the pediatric ICU and it has spread to the operating room. “We are taking it to different parts of the hospital,” said Dr. Clay, an internist with appointments to the departments of surgery, and of internal medicine and pulmonary critical care at Duke. The program is likely to move next to the hospital wards and hospitalists and attending physicians, and then to clinics, she said.

The program starts with lectures and conversation and then proceeds to use of simulations and a debriefing to assess how the participants worked as a team.

Dr. Clay has participated in the TeamSTEPPS curriculum, and she has trained to coach others in teamwork building in her role as the capstone course director for fourth-year medical students.

Dr. Clay has a unique perspective on patient safety: She was a victim of a medical error at Duke when she arrived at the emergency department as a patient and went into respiratory arrest after being given a medication meant for the patient across the hall.

“That's why communication is important,” said Dr. Clay, who has shared her experience as a patient to emphasize the need for better patient safety measures.

“Concurrent with TeamSTEPPS, [there] are other efforts to teach safety involving all members of the team,” Dr. Clay noted. “People have to … be open to the concept [of] using better teamwork to solve the problem.”

For more information about TeamSTEPPS or to review and order materials, visit www.ahrq.gov/qual/teamstepps

Disuse of hormone therapy might have fueled a significant drop in breast cancer detection rates in recent years, but a plateau in screening mammography among women older than 45 years also contributed to the decline, according to new data from an American Cancer Society study published in Breast Cancer Research.

To assess women's breast cancer trends over the period before the results of the Women's Health Initiative brought to light the possibility of a link between hormone therapy and an increased risk of breast cancer, Dr. Ahmedin Jemal and colleagues at the American Cancer Society reviewed data from the nine oldest Surveillance, Epidemiology, and End Results cancer registries (Breast Cancer Res. 2007;9:R28 [Epub doi:10.1186/1186/bcr1672]).

Based on these registries, the researchers found that 394,891 invasive and 59,837 in situ breast cancer cases were diagnosed in U.S. women aged 40 years and older from 1975 through 2003.

Age-specific incidence of invasive breast cancer declined in all 5-year age brackets for women aged 45 years and older between 1999 and 2003, although the degree of the decline varied among the age groups. The decrease in breast cancer incidence among most women younger than 60 years or older than 69 years began in 1998 or 1999. By contrast, the decrease in breast cancer incidence among women aged 60–64 years and 65–69 years occurred from 2002 to 2003 (the most recent year for which data are available). The largest percentage decreases occurred from 2002 to 2003 among women aged 55–59 years (11.3%), 60–64 years (10.6%), and 65–69 years (14.3%).

A joint analysis of tumor size and stage showed that overall, the incidence of small tumors (2 cm or less) decreased by 4.1% per year from 2000 through 2003 and the incidence of localized disease decreased by 3.1% per year from 1999 through 2003. No decrease in the incidence of larger tumors or advanced-stage disease was found during these periods.

Also, in situ disease rates were stable from 2000 through 2003 after increasing since 1981.

Trend data based on receptor status showed an annual increase in the incidence of both estrogen receptor-positive tumors and progestin receptor-positive tumors from 1990 to 2000, followed by a 9.1% drop from 2002 to 2003 for both of these types. Estrogen receptor-negative and progestin receptor-negative tumors also showed their largest overall decreases in incidence, 4.8% and 6.9% respectively, between 2002 and 2003.

Two patterns of breast cancer trends emerged from the study.

First, the drop in incidence that began in 1998 coincides with a plateau in screening mammography, and the types of cancers detected by mammography were the types that had a decrease in incidence (small tumors and localized disease). Data from the National Health Interview Survey show that the percentage of women aged 40 years and older who reported having a mammogram within the past 2 years was 70.3% in 1999, 70.4% in 2000, and 69.5% in 2003.

“Typically, incidence rates decrease when the penetrance of a screening test reaches a plateau due to a reduced pool of undiagnosed prevalent cases,” the researchers wrote.

Second, the sharp declines in breast cancer from 2002 to 2003 that were reported at a breast cancer symposium sponsored by the Cancer Therapy and Research Center last year might have been due in part to a reduced use of hormone therapy in response to data from the Women's Health Initiative that linked hormone therapy to an increased risk of breast cancer. The sharp drop was observed mainly in estrogen receptor-positive tumors in a subset of women aged 50–69 years.

“Clearly there are many of us who feel that [the] drop in breast cancer detection rate has many factors,” Dr. Len Lichtenfeld, deputy chief medical officer for the American Cancer Society, said in an interview.

“You can't dismiss the impact of stopping hormones on the decreased detection of breast cancer, but the current article supports what we know, which is that the incidence of mammography is also declining,” he said.

But from a clinical standpoint, the findings represent a decline in detection, not necessarily an absence of cancer cases.

“I don't know any experts that think that breast cancer has gone away; there are breast cancers that have not been detected,” Dr. Lichtenfeld said.

The decline in the numbers of women having mammograms might include a lack of access or a woman's belief that if she has had one mammogram, she doesn't need additional mammograms, he noted. “The falloff in detection is much greater than one would have expected from hormones alone.”

'The falloff in detection is much greater than one would have expected from hormones alone.' DR. LICHTENFELD

Disuse of hormone therapy might have fueled a significant drop in breast cancer detection rates in recent years, but a plateau in screening mammography among women older than 45 years also contributed to the decline, according to new data from an American Cancer Society study published in Breast Cancer Research.

To assess women's breast cancer trends over the period before the results of the Women's Health Initiative brought to light the possibility of a link between hormone therapy and an increased risk of breast cancer, Dr. Ahmedin Jemal and colleagues at the American Cancer Society reviewed data from the nine oldest Surveillance, Epidemiology, and End Results cancer registries (Breast Cancer Res. 2007;9:R28 [Epub doi:10.1186/1186/bcr1672]).

Based on these registries, the researchers found that 394,891 invasive and 59,837 in situ breast cancer cases were diagnosed in U.S. women aged 40 years and older from 1975 through 2003.

Age-specific incidence of invasive breast cancer declined in all 5-year age brackets for women aged 45 years and older between 1999 and 2003, although the degree of the decline varied among the age groups. The decrease in breast cancer incidence among most women younger than 60 years or older than 69 years began in 1998 or 1999. By contrast, the decrease in breast cancer incidence among women aged 60–64 years and 65–69 years occurred from 2002 to 2003 (the most recent year for which data are available). The largest percentage decreases occurred from 2002 to 2003 among women aged 55–59 years (11.3%), 60–64 years (10.6%), and 65–69 years (14.3%).

A joint analysis of tumor size and stage showed that overall, the incidence of small tumors (2 cm or less) decreased by 4.1% per year from 2000 through 2003 and the incidence of localized disease decreased by 3.1% per year from 1999 through 2003. No decrease in the incidence of larger tumors or advanced-stage disease was found during these periods.

Also, in situ disease rates were stable from 2000 through 2003 after increasing since 1981.

Trend data based on receptor status showed an annual increase in the incidence of both estrogen receptor-positive tumors and progestin receptor-positive tumors from 1990 to 2000, followed by a 9.1% drop from 2002 to 2003 for both of these types. Estrogen receptor-negative and progestin receptor-negative tumors also showed their largest overall decreases in incidence, 4.8% and 6.9% respectively, between 2002 and 2003.

Two patterns of breast cancer trends emerged from the study.

First, the drop in incidence that began in 1998 coincides with a plateau in screening mammography, and the types of cancers detected by mammography were the types that had a decrease in incidence (small tumors and localized disease). Data from the National Health Interview Survey show that the percentage of women aged 40 years and older who reported having a mammogram within the past 2 years was 70.3% in 1999, 70.4% in 2000, and 69.5% in 2003.

“Typically, incidence rates decrease when the penetrance of a screening test reaches a plateau due to a reduced pool of undiagnosed prevalent cases,” the researchers wrote.

Second, the sharp declines in breast cancer from 2002 to 2003 that were reported at a breast cancer symposium sponsored by the Cancer Therapy and Research Center last year might have been due in part to a reduced use of hormone therapy in response to data from the Women's Health Initiative that linked hormone therapy to an increased risk of breast cancer. The sharp drop was observed mainly in estrogen receptor-positive tumors in a subset of women aged 50–69 years.

“Clearly there are many of us who feel that [the] drop in breast cancer detection rate has many factors,” Dr. Len Lichtenfeld, deputy chief medical officer for the American Cancer Society, said in an interview.

“You can't dismiss the impact of stopping hormones on the decreased detection of breast cancer, but the current article supports what we know, which is that the incidence of mammography is also declining,” he said.

But from a clinical standpoint, the findings represent a decline in detection, not necessarily an absence of cancer cases.

“I don't know any experts that think that breast cancer has gone away; there are breast cancers that have not been detected,” Dr. Lichtenfeld said.

The decline in the numbers of women having mammograms might include a lack of access or a woman's belief that if she has had one mammogram, she doesn't need additional mammograms, he noted. “The falloff in detection is much greater than one would have expected from hormones alone.”

'The falloff in detection is much greater than one would have expected from hormones alone.' DR. LICHTENFELD

Disuse of hormone therapy might have fueled a significant drop in breast cancer detection rates in recent years, but a plateau in screening mammography among women older than 45 years also contributed to the decline, according to new data from an American Cancer Society study published in Breast Cancer Research.

To assess women's breast cancer trends over the period before the results of the Women's Health Initiative brought to light the possibility of a link between hormone therapy and an increased risk of breast cancer, Dr. Ahmedin Jemal and colleagues at the American Cancer Society reviewed data from the nine oldest Surveillance, Epidemiology, and End Results cancer registries (Breast Cancer Res. 2007;9:R28 [Epub doi:10.1186/1186/bcr1672]).

Based on these registries, the researchers found that 394,891 invasive and 59,837 in situ breast cancer cases were diagnosed in U.S. women aged 40 years and older from 1975 through 2003.

Age-specific incidence of invasive breast cancer declined in all 5-year age brackets for women aged 45 years and older between 1999 and 2003, although the degree of the decline varied among the age groups. The decrease in breast cancer incidence among most women younger than 60 years or older than 69 years began in 1998 or 1999. By contrast, the decrease in breast cancer incidence among women aged 60–64 years and 65–69 years occurred from 2002 to 2003 (the most recent year for which data are available). The largest percentage decreases occurred from 2002 to 2003 among women aged 55–59 years (11.3%), 60–64 years (10.6%), and 65–69 years (14.3%).

A joint analysis of tumor size and stage showed that overall, the incidence of small tumors (2 cm or less) decreased by 4.1% per year from 2000 through 2003 and the incidence of localized disease decreased by 3.1% per year from 1999 through 2003. No decrease in the incidence of larger tumors or advanced-stage disease was found during these periods.

Also, in situ disease rates were stable from 2000 through 2003 after increasing since 1981.

Trend data based on receptor status showed an annual increase in the incidence of both estrogen receptor-positive tumors and progestin receptor-positive tumors from 1990 to 2000, followed by a 9.1% drop from 2002 to 2003 for both of these types. Estrogen receptor-negative and progestin receptor-negative tumors also showed their largest overall decreases in incidence, 4.8% and 6.9% respectively, between 2002 and 2003.

Two patterns of breast cancer trends emerged from the study.

First, the drop in incidence that began in 1998 coincides with a plateau in screening mammography, and the types of cancers detected by mammography were the types that had a decrease in incidence (small tumors and localized disease). Data from the National Health Interview Survey show that the percentage of women aged 40 years and older who reported having a mammogram within the past 2 years was 70.3% in 1999, 70.4% in 2000, and 69.5% in 2003.

“Typically, incidence rates decrease when the penetrance of a screening test reaches a plateau due to a reduced pool of undiagnosed prevalent cases,” the researchers wrote.

Second, the sharp declines in breast cancer from 2002 to 2003 that were reported at a breast cancer symposium sponsored by the Cancer Therapy and Research Center last year might have been due in part to a reduced use of hormone therapy in response to data from the Women's Health Initiative that linked hormone therapy to an increased risk of breast cancer. The sharp drop was observed mainly in estrogen receptor-positive tumors in a subset of women aged 50–69 years.

“Clearly there are many of us who feel that [the] drop in breast cancer detection rate has many factors,” Dr. Len Lichtenfeld, deputy chief medical officer for the American Cancer Society, said in an interview.

“You can't dismiss the impact of stopping hormones on the decreased detection of breast cancer, but the current article supports what we know, which is that the incidence of mammography is also declining,” he said.

But from a clinical standpoint, the findings represent a decline in detection, not necessarily an absence of cancer cases.

“I don't know any experts that think that breast cancer has gone away; there are breast cancers that have not been detected,” Dr. Lichtenfeld said.

The decline in the numbers of women having mammograms might include a lack of access or a woman's belief that if she has had one mammogram, she doesn't need additional mammograms, he noted. “The falloff in detection is much greater than one would have expected from hormones alone.”

'The falloff in detection is much greater than one would have expected from hormones alone.' DR. LICHTENFELD

LAS VEGAS — Imaging techniques can help to confirm stress fractures and distinguish them from other conditions, Dr. Christopher Beaulieu said at a symposium on emergency medicine sponsored by Stanford University.

“I don't call it a stress fracture unless I can point to the fracture line on the image, otherwise [it is] a stress reaction or stress response,” said Dr. Beaulieu of Stanford (Calif.) University. A stress reaction or response can be diagnosed if MR or other imaging shows periosteal or marrow edema without a fracture line.

If a stress fracture is confirmed, the patient must take time off from the offending activity to allow the bone to heal, but if a fracture has not occurred, the patient may be able to continue activities with modifications to prevent a full fracture.

Stress injuries to bone occur when the skeleton is unable to withstand submaximal forces acting over time, and they fall into two categories: stress (or fatigue) fractures and insufficiency fractures. Stress fractures occur when normal bones are subjected to abnormal forces, and they are common in new athletes and in military recruits. Insufficiency fractures occur when abnormal bones can't sustain normal forces, and they occur primarily in patients with bone conditions such as osteoporosis or Paget's disease.

A clinical history of overuse is the key to a stress fracture diagnosis. Risk factors for stress fractures include increased mileage, running on a hard surface, and a poor choice of shoes. Biomechanics and bone mineral density also contribute to stress fractures, as do female gender, amenorrhea, and poor nutrition or eating disorders.

To maximize the imaging of a possible stress fracture, use local coils and high quality T2-weighted imaging, Dr. Beaulieu said. “A high-quality localized image, a negative scan almost entirely excludes a significant bony stress injury.” A fat suppression image also helps in identifying a stress fracture.

MRI of a stress fracture in a runner shows a low-signal fracture line (red arrows).

MRI with fat suppression shows edema around the low-signal fracture. Photos courtesy Dr. Christopher Beaulieu

LAS VEGAS — Imaging techniques can help to confirm stress fractures and distinguish them from other conditions, Dr. Christopher Beaulieu said at a symposium on emergency medicine sponsored by Stanford University.

“I don't call it a stress fracture unless I can point to the fracture line on the image, otherwise [it is] a stress reaction or stress response,” said Dr. Beaulieu of Stanford (Calif.) University. A stress reaction or response can be diagnosed if MR or other imaging shows periosteal or marrow edema without a fracture line.

If a stress fracture is confirmed, the patient must take time off from the offending activity to allow the bone to heal, but if a fracture has not occurred, the patient may be able to continue activities with modifications to prevent a full fracture.

Stress injuries to bone occur when the skeleton is unable to withstand submaximal forces acting over time, and they fall into two categories: stress (or fatigue) fractures and insufficiency fractures. Stress fractures occur when normal bones are subjected to abnormal forces, and they are common in new athletes and in military recruits. Insufficiency fractures occur when abnormal bones can't sustain normal forces, and they occur primarily in patients with bone conditions such as osteoporosis or Paget's disease.

A clinical history of overuse is the key to a stress fracture diagnosis. Risk factors for stress fractures include increased mileage, running on a hard surface, and a poor choice of shoes. Biomechanics and bone mineral density also contribute to stress fractures, as do female gender, amenorrhea, and poor nutrition or eating disorders.

To maximize the imaging of a possible stress fracture, use local coils and high quality T2-weighted imaging, Dr. Beaulieu said. “A high-quality localized image, a negative scan almost entirely excludes a significant bony stress injury.” A fat suppression image also helps in identifying a stress fracture.

MRI of a stress fracture in a runner shows a low-signal fracture line (red arrows).

MRI with fat suppression shows edema around the low-signal fracture. Photos courtesy Dr. Christopher Beaulieu

LAS VEGAS — Imaging techniques can help to confirm stress fractures and distinguish them from other conditions, Dr. Christopher Beaulieu said at a symposium on emergency medicine sponsored by Stanford University.

“I don't call it a stress fracture unless I can point to the fracture line on the image, otherwise [it is] a stress reaction or stress response,” said Dr. Beaulieu of Stanford (Calif.) University. A stress reaction or response can be diagnosed if MR or other imaging shows periosteal or marrow edema without a fracture line.

If a stress fracture is confirmed, the patient must take time off from the offending activity to allow the bone to heal, but if a fracture has not occurred, the patient may be able to continue activities with modifications to prevent a full fracture.

Stress injuries to bone occur when the skeleton is unable to withstand submaximal forces acting over time, and they fall into two categories: stress (or fatigue) fractures and insufficiency fractures. Stress fractures occur when normal bones are subjected to abnormal forces, and they are common in new athletes and in military recruits. Insufficiency fractures occur when abnormal bones can't sustain normal forces, and they occur primarily in patients with bone conditions such as osteoporosis or Paget's disease.

A clinical history of overuse is the key to a stress fracture diagnosis. Risk factors for stress fractures include increased mileage, running on a hard surface, and a poor choice of shoes. Biomechanics and bone mineral density also contribute to stress fractures, as do female gender, amenorrhea, and poor nutrition or eating disorders.

To maximize the imaging of a possible stress fracture, use local coils and high quality T2-weighted imaging, Dr. Beaulieu said. “A high-quality localized image, a negative scan almost entirely excludes a significant bony stress injury.” A fat suppression image also helps in identifying a stress fracture.

MRI of a stress fracture in a runner shows a low-signal fracture line (red arrows).

MRI with fat suppression shows edema around the low-signal fracture. Photos courtesy Dr. Christopher Beaulieu

WASHINGTON – Prompt, short-term treatment with antidepressants is associated with significantly improved physical, cognitive, and survival outcomes in stroke patients–regardless of whether they have symptoms of depression, Dr. Robert Robinson said at the annual meeting of the American Academy of Clinical Psychiatrists.

“Perhaps all patients who suffer a stroke should be evaluated by a psychiatrist and treated with antidepressants, because [these drugs] appear to improve their recovery,” said Dr. Robinson, who serves on the speakers' bureau for Forest Laboratories Inc. He also serves as a consultant for Hamilton Pharmaceuticals Inc. and Avanir Pharmaceuticals.

Data from recent studies have shown that antidepressants have beneficial effects on physical and cognitive recovery (as well as on mortality) after a stroke and that these effects may last for several years, said Dr. Robinson, professor and head of the department of psychiatry at the University of Iowa, Iowa City.

Dr. Robinson shared data that he collected in collaboration with his colleague at the university, Dr. Kenji Narushima, on 34 stroke patients who were treated with nortriptyline, fluoxetine, or a placebo starting within a month of having a stroke (average of 19 days after the stroke) and 28 patients who began treatment more than a month after the stroke (J. Nerv. Ment. Dis. 2003;191:645–52).

The nortriptyline doses were 25 mg/day for the first week, which then was increased to 50 mg/day for weeks 2–3, 75 mg/day for weeks 4–6, and 100 mg/day for the final 6 weeks.

The fluoxetine dosage started at 10 mg/day for the first 3 weeks, which then was increased to 20 mg/day for weeks 4–6, 30 mg/day for weeks 7–9, and 40 mg/day for the final 3 weeks, the investigators reported.

The patients who were treated early had a significantly better recovery in activities of daily living than did those who were treated later, even after a logistic regression analysis controlled for several factors, including existing depression, motor impairment, and psychiatric history. The finding suggests that patients who are given antidepressants–whether they are depressed or not–within the first month after a stroke recover better than if they are given antidepressants at a later date, Dr. Robinson said.

Similarly, a study of cognitive outcomes based on executive function tests showed that patients who were treated with antidepressants within a month of a stroke scored significantly higher at 21 months' follow-up, compared with patients who received a placebo.

The improvements were independent of any diagnosis of depression at the start of treatment.

Not all patients respond to antidepressant medication, but those who do seem to gain a cognitive effect that lasts, Dr. Robinson said.

Stroke patients who receive antidepressants also tend to live longer.

Dr. Robinson cited results from a randomized study of 104 stroke patients on which he was a coinvestigator. The patients received 12 weeks of either nortriptyline or a placebo, and 68% of the nortriptyline patients were alive after 9 years, compared with 36% of placebo patients.

Interestingly, the placebo patients were significantly more likely to have died of cardiovascular events, while the patients who took antidepressants were more likely to have died from other causes (Am. J. Psychiatry 2003;160:1823–9).

The long-term benefits from only 12 weeks of antidepressant therapy are remarkable, Dr. Robinson said, although the mechanism of action that drives the benefits remains uncertain.

One possible explanation for the long-term effect is that the antidepressants foster nerve growth, and the growth of new nerves may protect against a future stroke. “But where the neurogenesis is occurring is something that is a particularly intriguing question,” Dr. Robinson said. Neurogenesis may be involved in a neurophysiologic mechanism that turns on or off for extended periods of time in response to antidepressants, but more research is needed, he said.

“A major goal of clinical psychiatry is to see how our treatments affect outcome,” he added.

Antidepressants foster nerve growth, and growth of new nerves may protect against a future stroke. DR. ROBINSON

ELSEVIER GLOBAL MEDICAL NEWS

WASHINGTON – Prompt, short-term treatment with antidepressants is associated with significantly improved physical, cognitive, and survival outcomes in stroke patients–regardless of whether they have symptoms of depression, Dr. Robert Robinson said at the annual meeting of the American Academy of Clinical Psychiatrists.

“Perhaps all patients who suffer a stroke should be evaluated by a psychiatrist and treated with antidepressants, because [these drugs] appear to improve their recovery,” said Dr. Robinson, who serves on the speakers' bureau for Forest Laboratories Inc. He also serves as a consultant for Hamilton Pharmaceuticals Inc. and Avanir Pharmaceuticals.

Data from recent studies have shown that antidepressants have beneficial effects on physical and cognitive recovery (as well as on mortality) after a stroke and that these effects may last for several years, said Dr. Robinson, professor and head of the department of psychiatry at the University of Iowa, Iowa City.

Dr. Robinson shared data that he collected in collaboration with his colleague at the university, Dr. Kenji Narushima, on 34 stroke patients who were treated with nortriptyline, fluoxetine, or a placebo starting within a month of having a stroke (average of 19 days after the stroke) and 28 patients who began treatment more than a month after the stroke (J. Nerv. Ment. Dis. 2003;191:645–52).

The nortriptyline doses were 25 mg/day for the first week, which then was increased to 50 mg/day for weeks 2–3, 75 mg/day for weeks 4–6, and 100 mg/day for the final 6 weeks.

The fluoxetine dosage started at 10 mg/day for the first 3 weeks, which then was increased to 20 mg/day for weeks 4–6, 30 mg/day for weeks 7–9, and 40 mg/day for the final 3 weeks, the investigators reported.

The patients who were treated early had a significantly better recovery in activities of daily living than did those who were treated later, even after a logistic regression analysis controlled for several factors, including existing depression, motor impairment, and psychiatric history. The finding suggests that patients who are given antidepressants–whether they are depressed or not–within the first month after a stroke recover better than if they are given antidepressants at a later date, Dr. Robinson said.

Similarly, a study of cognitive outcomes based on executive function tests showed that patients who were treated with antidepressants within a month of a stroke scored significantly higher at 21 months' follow-up, compared with patients who received a placebo.

The improvements were independent of any diagnosis of depression at the start of treatment.

Not all patients respond to antidepressant medication, but those who do seem to gain a cognitive effect that lasts, Dr. Robinson said.

Stroke patients who receive antidepressants also tend to live longer.

Dr. Robinson cited results from a randomized study of 104 stroke patients on which he was a coinvestigator. The patients received 12 weeks of either nortriptyline or a placebo, and 68% of the nortriptyline patients were alive after 9 years, compared with 36% of placebo patients.

Interestingly, the placebo patients were significantly more likely to have died of cardiovascular events, while the patients who took antidepressants were more likely to have died from other causes (Am. J. Psychiatry 2003;160:1823–9).

The long-term benefits from only 12 weeks of antidepressant therapy are remarkable, Dr. Robinson said, although the mechanism of action that drives the benefits remains uncertain.

One possible explanation for the long-term effect is that the antidepressants foster nerve growth, and the growth of new nerves may protect against a future stroke. “But where the neurogenesis is occurring is something that is a particularly intriguing question,” Dr. Robinson said. Neurogenesis may be involved in a neurophysiologic mechanism that turns on or off for extended periods of time in response to antidepressants, but more research is needed, he said.

“A major goal of clinical psychiatry is to see how our treatments affect outcome,” he added.

Antidepressants foster nerve growth, and growth of new nerves may protect against a future stroke. DR. ROBINSON

ELSEVIER GLOBAL MEDICAL NEWS

WASHINGTON – Prompt, short-term treatment with antidepressants is associated with significantly improved physical, cognitive, and survival outcomes in stroke patients–regardless of whether they have symptoms of depression, Dr. Robert Robinson said at the annual meeting of the American Academy of Clinical Psychiatrists.

“Perhaps all patients who suffer a stroke should be evaluated by a psychiatrist and treated with antidepressants, because [these drugs] appear to improve their recovery,” said Dr. Robinson, who serves on the speakers' bureau for Forest Laboratories Inc. He also serves as a consultant for Hamilton Pharmaceuticals Inc. and Avanir Pharmaceuticals.

Data from recent studies have shown that antidepressants have beneficial effects on physical and cognitive recovery (as well as on mortality) after a stroke and that these effects may last for several years, said Dr. Robinson, professor and head of the department of psychiatry at the University of Iowa, Iowa City.

Dr. Robinson shared data that he collected in collaboration with his colleague at the university, Dr. Kenji Narushima, on 34 stroke patients who were treated with nortriptyline, fluoxetine, or a placebo starting within a month of having a stroke (average of 19 days after the stroke) and 28 patients who began treatment more than a month after the stroke (J. Nerv. Ment. Dis. 2003;191:645–52).

The nortriptyline doses were 25 mg/day for the first week, which then was increased to 50 mg/day for weeks 2–3, 75 mg/day for weeks 4–6, and 100 mg/day for the final 6 weeks.

The fluoxetine dosage started at 10 mg/day for the first 3 weeks, which then was increased to 20 mg/day for weeks 4–6, 30 mg/day for weeks 7–9, and 40 mg/day for the final 3 weeks, the investigators reported.

The patients who were treated early had a significantly better recovery in activities of daily living than did those who were treated later, even after a logistic regression analysis controlled for several factors, including existing depression, motor impairment, and psychiatric history. The finding suggests that patients who are given antidepressants–whether they are depressed or not–within the first month after a stroke recover better than if they are given antidepressants at a later date, Dr. Robinson said.

Similarly, a study of cognitive outcomes based on executive function tests showed that patients who were treated with antidepressants within a month of a stroke scored significantly higher at 21 months' follow-up, compared with patients who received a placebo.

The improvements were independent of any diagnosis of depression at the start of treatment.

Not all patients respond to antidepressant medication, but those who do seem to gain a cognitive effect that lasts, Dr. Robinson said.

Stroke patients who receive antidepressants also tend to live longer.

Dr. Robinson cited results from a randomized study of 104 stroke patients on which he was a coinvestigator. The patients received 12 weeks of either nortriptyline or a placebo, and 68% of the nortriptyline patients were alive after 9 years, compared with 36% of placebo patients.

Interestingly, the placebo patients were significantly more likely to have died of cardiovascular events, while the patients who took antidepressants were more likely to have died from other causes (Am. J. Psychiatry 2003;160:1823–9).

The long-term benefits from only 12 weeks of antidepressant therapy are remarkable, Dr. Robinson said, although the mechanism of action that drives the benefits remains uncertain.

One possible explanation for the long-term effect is that the antidepressants foster nerve growth, and the growth of new nerves may protect against a future stroke. “But where the neurogenesis is occurring is something that is a particularly intriguing question,” Dr. Robinson said. Neurogenesis may be involved in a neurophysiologic mechanism that turns on or off for extended periods of time in response to antidepressants, but more research is needed, he said.

“A major goal of clinical psychiatry is to see how our treatments affect outcome,” he added.

Antidepressants foster nerve growth, and growth of new nerves may protect against a future stroke. DR. ROBINSON

ELSEVIER GLOBAL MEDICAL NEWS

Melatonin may help children with attention-deficit/hyperactivity disorder get more sleep, but behavior benefits are negligible, said Kristiaan B. Van der Heijden, Ph.D., of the Epilepsy Center Kempenhaeghe, Heeze, the Netherlands, and colleagues.

Surprisingly, melatonin had no significant effect on behavior, cognitive improvement, or quality of life. “We expected such improvements because sleep problems and sleep deprivation in children were associated with behavioral disturbances,” they said (J. Am. Acad. Child Adolesc. Psychiatry 2007;46:233–41).

The findings did confirm that melatonin improves sleep. In the randomized, double-blind study, 105 children aged 6–12 years took daily doses of 3 mg or 6 mg of melatonin (depending on their weight) or a placebo for 4 weeks.

The children who received melatonin fell asleep an average of 27 minutes earlier than at baseline, and those who took placebo fell asleep an average of 11 minutes later.

In addition, total sleep time increased by an average of 20 minutes in the melatonin group, and decreased by an average of 14 minutes in the placebo group.

Five patients in the melatonin group reported adverse events, including headache, hyperactivity, dizziness, and abdominal pain, but none of these patients discontinued the medication or withdrew from the study, and none required treatment for the adverse reactions.

Melatonin should be prescribed only for persistent and severe cases of insomnia, given the lack of additional benefits and the lack of systematic studies of the long-term effects of consistent melatonin use, the investigators wrote.

Melatonin may help children with attention-deficit/hyperactivity disorder get more sleep, but behavior benefits are negligible, said Kristiaan B. Van der Heijden, Ph.D., of the Epilepsy Center Kempenhaeghe, Heeze, the Netherlands, and colleagues.

Surprisingly, melatonin had no significant effect on behavior, cognitive improvement, or quality of life. “We expected such improvements because sleep problems and sleep deprivation in children were associated with behavioral disturbances,” they said (J. Am. Acad. Child Adolesc. Psychiatry 2007;46:233–41).

The findings did confirm that melatonin improves sleep. In the randomized, double-blind study, 105 children aged 6–12 years took daily doses of 3 mg or 6 mg of melatonin (depending on their weight) or a placebo for 4 weeks.

The children who received melatonin fell asleep an average of 27 minutes earlier than at baseline, and those who took placebo fell asleep an average of 11 minutes later.

In addition, total sleep time increased by an average of 20 minutes in the melatonin group, and decreased by an average of 14 minutes in the placebo group.

Five patients in the melatonin group reported adverse events, including headache, hyperactivity, dizziness, and abdominal pain, but none of these patients discontinued the medication or withdrew from the study, and none required treatment for the adverse reactions.

Melatonin should be prescribed only for persistent and severe cases of insomnia, given the lack of additional benefits and the lack of systematic studies of the long-term effects of consistent melatonin use, the investigators wrote.

Melatonin may help children with attention-deficit/hyperactivity disorder get more sleep, but behavior benefits are negligible, said Kristiaan B. Van der Heijden, Ph.D., of the Epilepsy Center Kempenhaeghe, Heeze, the Netherlands, and colleagues.

Surprisingly, melatonin had no significant effect on behavior, cognitive improvement, or quality of life. “We expected such improvements because sleep problems and sleep deprivation in children were associated with behavioral disturbances,” they said (J. Am. Acad. Child Adolesc. Psychiatry 2007;46:233–41).

The findings did confirm that melatonin improves sleep. In the randomized, double-blind study, 105 children aged 6–12 years took daily doses of 3 mg or 6 mg of melatonin (depending on their weight) or a placebo for 4 weeks.

The children who received melatonin fell asleep an average of 27 minutes earlier than at baseline, and those who took placebo fell asleep an average of 11 minutes later.

In addition, total sleep time increased by an average of 20 minutes in the melatonin group, and decreased by an average of 14 minutes in the placebo group.

Five patients in the melatonin group reported adverse events, including headache, hyperactivity, dizziness, and abdominal pain, but none of these patients discontinued the medication or withdrew from the study, and none required treatment for the adverse reactions.

Melatonin should be prescribed only for persistent and severe cases of insomnia, given the lack of additional benefits and the lack of systematic studies of the long-term effects of consistent melatonin use, the investigators wrote.

LAS VEGAS — Magnetic resonance images of the fetal chest can be a clinically useful addition to ultrasound to examine lung masses and identify underdeveloped lungs, Dr. Erika Rubesova said at a symposium on emergency medicine sponsored by Stanford (Calif.) University.

With MRI, “You will have a better characterization of the chest masses and you can perform measurements of the lung,” said Dr. Rubesova, a radiologist at the university.

A fetal MRI provides a greater tissue contrast than ultrasound, and features such as lung volume and signal intensity are easier to see, she noted.

As for the safety of a fetal MRI, the safety committee of the Society for Magnetic Resonance Imaging recommends that the risks and benefits of fetal MRI be assessed on a case-by-case basis and that MR procedures are indicated in pregnant women if other nonionizing imaging techniques are inadequate or if the MRI can provide information that could only be otherwise acquired using radiation technology. However, the Food and Drug Administration states that the safety of MR during pregnancy has not been proved definitively, Dr. Rubesova said.

“The FDA does not require a contraindication to the use of MRI for fetal imaging in device labeling,” Dr. Julia Carey-Corrado, an ob.gyn. at the FDA's Center for Devices and Radiological Health, said in an interview. “But the FDA does recommend that device labeling contain the following statement: 'The safety of magnetic resonance examination has not been completely established for embryos and fetuses,'” she said.

“We view ultrasound as the standard of care for fetal imaging, but MR can be viewed as a reasonable second-line imaging modality if you aren't getting enough information from ultrasound and you are concerned about a complex abnormality,” Dr. Carey-Corrado added.

To perform an MRI of the fetal lung, place the patient in the most comfortable position possible and focus on the fetal lung as best you can to minimize the blurriness associated with fetal movement, Dr. Rubesova said.

Dr. Rubesova usually uses 1.5-T and T2-weighted images. “You should be able to see both of the lungs and the airway,” she said. “And the diaphragm sometimes appears as a dark line above the liver.”

Congenital lung lesions fall into three broad categories: congenital cystic adenomatoid malformations, sequestrations, and bronchogenic cysts.

A congenital cystic adenomatoid malformation (CCAM) usually occurs early in fetal development, and the lesions are categorized based on size. In general, lesions larger than 2 mm are associated with a better prognosis for the infant than smaller lesions, so the ability to measure the lesions based on MRI data is useful for clinicians.

Sequestrations (also known as bronchopulmonary sequestrations) occur when a piece of the developing lung branches off from the main airway (but remains connected to it) and the lung fails to develop normally. Bronchogenic cysts form when a branch of the developing airway separates completely from the main bronchotracheal tree.

Data collected by researchers at Brown University, Providence, R.I., suggest that 1 in 3,000 infants has a congenital lung lesion. These masses compress the developing lung, and they may displace other organs in the chest. Large lung masses may cause fetal heart failure in severe cases because the pressure of the masses causes an abnormal accumulation of fluid around the heart, lungs, or abdomen.

The “horseshoe lung” is a characteristic image that is associated with CCAM, sequestrations, and bronchogenic fistulae. A fetal MRI can show the horseshoe shape of an underdeveloped lung, and the lung masses appear as areas of high signal intensity on a T2-weighted image, Dr. Rubesova noted.

There is no rush to perform fetal lung MRI procedures in cases of large lesions where the prognosis is good and termination of the pregnancy is unlikely, Dr. Rubesova said. The best time to get an accurate fetal MRI of these lesions is late in the third trimester because the fetus has less room to move, so the image is sharper. In these cases, the MRI helps parents and physicians plan for neonatal care that will allow the lungs to develop as completely as possible.

The outcome for most newborns with congenital lung masses is good, although congenital lung hypoplasia accounts for 10%–15% of all neonatal deaths, Dr. Rubesova noted. Sometimes the masses will shrink substantially by the time of birth, and in other cases the lesions can be surgically removed after birth to reduce the risk of recurrent infections such as pneumonia.

LAS VEGAS — Magnetic resonance images of the fetal chest can be a clinically useful addition to ultrasound to examine lung masses and identify underdeveloped lungs, Dr. Erika Rubesova said at a symposium on emergency medicine sponsored by Stanford (Calif.) University.

With MRI, “You will have a better characterization of the chest masses and you can perform measurements of the lung,” said Dr. Rubesova, a radiologist at the university.

A fetal MRI provides a greater tissue contrast than ultrasound, and features such as lung volume and signal intensity are easier to see, she noted.

As for the safety of a fetal MRI, the safety committee of the Society for Magnetic Resonance Imaging recommends that the risks and benefits of fetal MRI be assessed on a case-by-case basis and that MR procedures are indicated in pregnant women if other nonionizing imaging techniques are inadequate or if the MRI can provide information that could only be otherwise acquired using radiation technology. However, the Food and Drug Administration states that the safety of MR during pregnancy has not been proved definitively, Dr. Rubesova said.

“The FDA does not require a contraindication to the use of MRI for fetal imaging in device labeling,” Dr. Julia Carey-Corrado, an ob.gyn. at the FDA's Center for Devices and Radiological Health, said in an interview. “But the FDA does recommend that device labeling contain the following statement: 'The safety of magnetic resonance examination has not been completely established for embryos and fetuses,'” she said.

“We view ultrasound as the standard of care for fetal imaging, but MR can be viewed as a reasonable second-line imaging modality if you aren't getting enough information from ultrasound and you are concerned about a complex abnormality,” Dr. Carey-Corrado added.

To perform an MRI of the fetal lung, place the patient in the most comfortable position possible and focus on the fetal lung as best you can to minimize the blurriness associated with fetal movement, Dr. Rubesova said.

Dr. Rubesova usually uses 1.5-T and T2-weighted images. “You should be able to see both of the lungs and the airway,” she said. “And the diaphragm sometimes appears as a dark line above the liver.”

Congenital lung lesions fall into three broad categories: congenital cystic adenomatoid malformations, sequestrations, and bronchogenic cysts.

A congenital cystic adenomatoid malformation (CCAM) usually occurs early in fetal development, and the lesions are categorized based on size. In general, lesions larger than 2 mm are associated with a better prognosis for the infant than smaller lesions, so the ability to measure the lesions based on MRI data is useful for clinicians.

Sequestrations (also known as bronchopulmonary sequestrations) occur when a piece of the developing lung branches off from the main airway (but remains connected to it) and the lung fails to develop normally. Bronchogenic cysts form when a branch of the developing airway separates completely from the main bronchotracheal tree.

Data collected by researchers at Brown University, Providence, R.I., suggest that 1 in 3,000 infants has a congenital lung lesion. These masses compress the developing lung, and they may displace other organs in the chest. Large lung masses may cause fetal heart failure in severe cases because the pressure of the masses causes an abnormal accumulation of fluid around the heart, lungs, or abdomen.

The “horseshoe lung” is a characteristic image that is associated with CCAM, sequestrations, and bronchogenic fistulae. A fetal MRI can show the horseshoe shape of an underdeveloped lung, and the lung masses appear as areas of high signal intensity on a T2-weighted image, Dr. Rubesova noted.

There is no rush to perform fetal lung MRI procedures in cases of large lesions where the prognosis is good and termination of the pregnancy is unlikely, Dr. Rubesova said. The best time to get an accurate fetal MRI of these lesions is late in the third trimester because the fetus has less room to move, so the image is sharper. In these cases, the MRI helps parents and physicians plan for neonatal care that will allow the lungs to develop as completely as possible.

The outcome for most newborns with congenital lung masses is good, although congenital lung hypoplasia accounts for 10%–15% of all neonatal deaths, Dr. Rubesova noted. Sometimes the masses will shrink substantially by the time of birth, and in other cases the lesions can be surgically removed after birth to reduce the risk of recurrent infections such as pneumonia.

LAS VEGAS — Magnetic resonance images of the fetal chest can be a clinically useful addition to ultrasound to examine lung masses and identify underdeveloped lungs, Dr. Erika Rubesova said at a symposium on emergency medicine sponsored by Stanford (Calif.) University.

With MRI, “You will have a better characterization of the chest masses and you can perform measurements of the lung,” said Dr. Rubesova, a radiologist at the university.

A fetal MRI provides a greater tissue contrast than ultrasound, and features such as lung volume and signal intensity are easier to see, she noted.

As for the safety of a fetal MRI, the safety committee of the Society for Magnetic Resonance Imaging recommends that the risks and benefits of fetal MRI be assessed on a case-by-case basis and that MR procedures are indicated in pregnant women if other nonionizing imaging techniques are inadequate or if the MRI can provide information that could only be otherwise acquired using radiation technology. However, the Food and Drug Administration states that the safety of MR during pregnancy has not been proved definitively, Dr. Rubesova said.

“The FDA does not require a contraindication to the use of MRI for fetal imaging in device labeling,” Dr. Julia Carey-Corrado, an ob.gyn. at the FDA's Center for Devices and Radiological Health, said in an interview. “But the FDA does recommend that device labeling contain the following statement: 'The safety of magnetic resonance examination has not been completely established for embryos and fetuses,'” she said.

“We view ultrasound as the standard of care for fetal imaging, but MR can be viewed as a reasonable second-line imaging modality if you aren't getting enough information from ultrasound and you are concerned about a complex abnormality,” Dr. Carey-Corrado added.

To perform an MRI of the fetal lung, place the patient in the most comfortable position possible and focus on the fetal lung as best you can to minimize the blurriness associated with fetal movement, Dr. Rubesova said.

Dr. Rubesova usually uses 1.5-T and T2-weighted images. “You should be able to see both of the lungs and the airway,” she said. “And the diaphragm sometimes appears as a dark line above the liver.”

Congenital lung lesions fall into three broad categories: congenital cystic adenomatoid malformations, sequestrations, and bronchogenic cysts.

A congenital cystic adenomatoid malformation (CCAM) usually occurs early in fetal development, and the lesions are categorized based on size. In general, lesions larger than 2 mm are associated with a better prognosis for the infant than smaller lesions, so the ability to measure the lesions based on MRI data is useful for clinicians.

Sequestrations (also known as bronchopulmonary sequestrations) occur when a piece of the developing lung branches off from the main airway (but remains connected to it) and the lung fails to develop normally. Bronchogenic cysts form when a branch of the developing airway separates completely from the main bronchotracheal tree.

Data collected by researchers at Brown University, Providence, R.I., suggest that 1 in 3,000 infants has a congenital lung lesion. These masses compress the developing lung, and they may displace other organs in the chest. Large lung masses may cause fetal heart failure in severe cases because the pressure of the masses causes an abnormal accumulation of fluid around the heart, lungs, or abdomen.

The “horseshoe lung” is a characteristic image that is associated with CCAM, sequestrations, and bronchogenic fistulae. A fetal MRI can show the horseshoe shape of an underdeveloped lung, and the lung masses appear as areas of high signal intensity on a T2-weighted image, Dr. Rubesova noted.

There is no rush to perform fetal lung MRI procedures in cases of large lesions where the prognosis is good and termination of the pregnancy is unlikely, Dr. Rubesova said. The best time to get an accurate fetal MRI of these lesions is late in the third trimester because the fetus has less room to move, so the image is sharper. In these cases, the MRI helps parents and physicians plan for neonatal care that will allow the lungs to develop as completely as possible.

The outcome for most newborns with congenital lung masses is good, although congenital lung hypoplasia accounts for 10%–15% of all neonatal deaths, Dr. Rubesova noted. Sometimes the masses will shrink substantially by the time of birth, and in other cases the lesions can be surgically removed after birth to reduce the risk of recurrent infections such as pneumonia.

LAS VEGAS — Magnetic resonance imaging can help physicians evaluate an anterior cruciate ligament tear and plan surgery to repair an ACL injury, said Dr. Kathryn Stevens at a symposium on emergency medicine sponsored by Stanford University.

MRI identifies additional bony or cartilage injuries—notably, injuries to the posterolateral corner of the knee—that increase the risk of knee instability when coupled with an ACL tear, said Dr. Stevens, a diagnostic radiologist at Stanford (Calif.) University.

“If you don't recognize posterolateral corner structures when you go in to do an ACL repair, the ACL graft is more likely to fail,” she said.

Always look at the posterolateral corner structures on an MRI of the knee prior to surgery, she emphasized. Prompt imaging is helpful because surgery within 3 weeks of injury yields the most effective results, she noted.

The ACL consists of two bundles of dense connective tissue, the anteromedial and the posterolateral bundles. ACL tears typically occur when a person slows down or changes direction quickly and are most common in younger athletes whose sports involve quick starts, stops, and pivots, such as basketball, soccer, and skiing, said Dr. Stevens.

Although MRI is not essential for diagnosing an ACL tear, some physicians opt to order images for confirmation. Diagnostic criteria for an ACL tear that are visible on an MRI include an empty notch on a coronal image, an edematous mass, and a wavy contour to the knee. Indirect signs of an ACL tear that are visible on an MRI include the “kissing contusions” where the edges of the leg bones barely touch. Kissing contusions identify cartilage involvement in ACL tears, especially if the image shows that the posterior horn of the lateral meniscus is no longer covered by the knee.

The posterolateral corner structures consist of three layers. Attachment points for the patellar retinaculum, the iliotibial band, and the biceps tendon are all found in the first layer; the lateral collateral ligament in the second layer; and the arcuate and fabellofibular ligaments in the third layer.

Common posterolateral corner injuries include an arcuate fracture (a tearing away of the fibula at the point where the arcuate ligament attaches to the knee) and a Segond fracture (a tearing away of the meniscotibial part of the lateral capsular ligament). More than 90% of Segond fractures are associated with ACL tears, Dr. Stevens said.

Posterolateral corner injuries are relatively rare but can compromise the success of ACL surgery. Such injuries are receiving more attention, in part because they can be better identified with current imaging techniques, she added.

After surgery, MRI can be used to evaluate graft alignment and to identify instability or infection. When ACL surgery doesn't go well, MRI can identify graft impingement or graft rupture. Graft impingement will show up as increased signal intensity within two-thirds of the graft area; graft rupture will show up as increased signal intensity in the general area where the graft should be, Dr. Stevens said.

Coronal CT and coronal T2 FS images show an avulsion fracture of Gerdy's tubercle (white arrow, left) and an avulsion of the iliotibial band (black arrows, right). Photos courtesy Dr. Kathryn Stevens

LAS VEGAS — Magnetic resonance imaging can help physicians evaluate an anterior cruciate ligament tear and plan surgery to repair an ACL injury, said Dr. Kathryn Stevens at a symposium on emergency medicine sponsored by Stanford University.

MRI identifies additional bony or cartilage injuries—notably, injuries to the posterolateral corner of the knee—that increase the risk of knee instability when coupled with an ACL tear, said Dr. Stevens, a diagnostic radiologist at Stanford (Calif.) University.

“If you don't recognize posterolateral corner structures when you go in to do an ACL repair, the ACL graft is more likely to fail,” she said.

Always look at the posterolateral corner structures on an MRI of the knee prior to surgery, she emphasized. Prompt imaging is helpful because surgery within 3 weeks of injury yields the most effective results, she noted.

The ACL consists of two bundles of dense connective tissue, the anteromedial and the posterolateral bundles. ACL tears typically occur when a person slows down or changes direction quickly and are most common in younger athletes whose sports involve quick starts, stops, and pivots, such as basketball, soccer, and skiing, said Dr. Stevens.

Although MRI is not essential for diagnosing an ACL tear, some physicians opt to order images for confirmation. Diagnostic criteria for an ACL tear that are visible on an MRI include an empty notch on a coronal image, an edematous mass, and a wavy contour to the knee. Indirect signs of an ACL tear that are visible on an MRI include the “kissing contusions” where the edges of the leg bones barely touch. Kissing contusions identify cartilage involvement in ACL tears, especially if the image shows that the posterior horn of the lateral meniscus is no longer covered by the knee.

The posterolateral corner structures consist of three layers. Attachment points for the patellar retinaculum, the iliotibial band, and the biceps tendon are all found in the first layer; the lateral collateral ligament in the second layer; and the arcuate and fabellofibular ligaments in the third layer.

Common posterolateral corner injuries include an arcuate fracture (a tearing away of the fibula at the point where the arcuate ligament attaches to the knee) and a Segond fracture (a tearing away of the meniscotibial part of the lateral capsular ligament). More than 90% of Segond fractures are associated with ACL tears, Dr. Stevens said.

Posterolateral corner injuries are relatively rare but can compromise the success of ACL surgery. Such injuries are receiving more attention, in part because they can be better identified with current imaging techniques, she added.

After surgery, MRI can be used to evaluate graft alignment and to identify instability or infection. When ACL surgery doesn't go well, MRI can identify graft impingement or graft rupture. Graft impingement will show up as increased signal intensity within two-thirds of the graft area; graft rupture will show up as increased signal intensity in the general area where the graft should be, Dr. Stevens said.

Coronal CT and coronal T2 FS images show an avulsion fracture of Gerdy's tubercle (white arrow, left) and an avulsion of the iliotibial band (black arrows, right). Photos courtesy Dr. Kathryn Stevens

LAS VEGAS — Magnetic resonance imaging can help physicians evaluate an anterior cruciate ligament tear and plan surgery to repair an ACL injury, said Dr. Kathryn Stevens at a symposium on emergency medicine sponsored by Stanford University.

MRI identifies additional bony or cartilage injuries—notably, injuries to the posterolateral corner of the knee—that increase the risk of knee instability when coupled with an ACL tear, said Dr. Stevens, a diagnostic radiologist at Stanford (Calif.) University.

“If you don't recognize posterolateral corner structures when you go in to do an ACL repair, the ACL graft is more likely to fail,” she said.

Always look at the posterolateral corner structures on an MRI of the knee prior to surgery, she emphasized. Prompt imaging is helpful because surgery within 3 weeks of injury yields the most effective results, she noted.

The ACL consists of two bundles of dense connective tissue, the anteromedial and the posterolateral bundles. ACL tears typically occur when a person slows down or changes direction quickly and are most common in younger athletes whose sports involve quick starts, stops, and pivots, such as basketball, soccer, and skiing, said Dr. Stevens.

Although MRI is not essential for diagnosing an ACL tear, some physicians opt to order images for confirmation. Diagnostic criteria for an ACL tear that are visible on an MRI include an empty notch on a coronal image, an edematous mass, and a wavy contour to the knee. Indirect signs of an ACL tear that are visible on an MRI include the “kissing contusions” where the edges of the leg bones barely touch. Kissing contusions identify cartilage involvement in ACL tears, especially if the image shows that the posterior horn of the lateral meniscus is no longer covered by the knee.

The posterolateral corner structures consist of three layers. Attachment points for the patellar retinaculum, the iliotibial band, and the biceps tendon are all found in the first layer; the lateral collateral ligament in the second layer; and the arcuate and fabellofibular ligaments in the third layer.

Common posterolateral corner injuries include an arcuate fracture (a tearing away of the fibula at the point where the arcuate ligament attaches to the knee) and a Segond fracture (a tearing away of the meniscotibial part of the lateral capsular ligament). More than 90% of Segond fractures are associated with ACL tears, Dr. Stevens said.

Posterolateral corner injuries are relatively rare but can compromise the success of ACL surgery. Such injuries are receiving more attention, in part because they can be better identified with current imaging techniques, she added.

After surgery, MRI can be used to evaluate graft alignment and to identify instability or infection. When ACL surgery doesn't go well, MRI can identify graft impingement or graft rupture. Graft impingement will show up as increased signal intensity within two-thirds of the graft area; graft rupture will show up as increased signal intensity in the general area where the graft should be, Dr. Stevens said.

Coronal CT and coronal T2 FS images show an avulsion fracture of Gerdy's tubercle (white arrow, left) and an avulsion of the iliotibial band (black arrows, right). Photos courtesy Dr. Kathryn Stevens

Most patients with heart conditions don't need to take antibiotics to reduce the risk of infection prior to a dental procedure, according to revised American Heart Association guidelines.

The new guidelines represent a change from previous recommendations, which advised that patients with any heart abnormality, from mild valve prolapse to severe birth defects, should take amoxicillin prior to a dental procedure to reduce the risk of developing infective endocarditis (IE), an infection of the heart's valves or inner lining.

Many types of fungi and bacteria can cause the infection, and dental procedures had been seen as opening the door for these organisms to attack vulnerable patients.

But the guidelines writing group, led by Dr. Walter Wilson of the Mayo Clinic in Rochester, Minn., reviewed the latest research and found no significant evidence that taking antibiotics before a dental procedure prevents IE in patients who are at risk for infections (doi:10.1161/circulationaha.106.183095).

In addition, no prospective randomized placebo-controlled studies have shown that antibiotic use prior to a dental procedure prevents IE, although research in this area is limited by the range of dental procedures and overall low incidence of IE. And daily activities such as toothbrushing and flossing cause transient bacteremia, and far more frequently than dental procedures.

In fact, severe adverse events resulting from IE are associated with only a small subgroup of cardiac conditions, the writing group noted, and these patients should continue to receive antibiotics prior to dental procedures.

The cardiac patients who should continue to receive antibiotics prior to dental procedures because of their increased risk for severe complications from IE are those with prosthetic cardiac valves or previous episodes of infective endocarditis, and heart transplant patients who have developed abnormal cardiac valves.

In addition, patients with cardiac disease who meet the following criteria should continue to receive antibiotics prior to dental procedures:

▸ Patients with repaired congenital heart disease (CHD) who have remaining defects at or near the site of a patch or prosthetic that inhibit the healing of the heart vessels' inner surfaces.

▸ Patients with unrepaired cyanotic CHD, including those with palliative shunts or conduits.

▸ Patients with repaired CHD with no remaining defects who are within 6 months of the procedure (because the inner vessel surfaces are still healing).

The patients who meet the criteria for increased IE risk should receive antibiotics prior to any dental procedure that involves work on the gums, the apex of the tooth, or perforation of oral mucosa. The guidelines apply to children as well as adults and have been endorsed by the Infectious Diseases Society of America and the Pediatric Infectious Disease Society as well as approved by the American Dental Association.

The preexisting guidelines for antibiotics use to prevent IE were last revised in 1997, and they called for 2 g of amoxicillin to be given orally 1 hour before a procedure.

But amoxicillin use carries risks of its own, including fostering the development of amoxicillin-resistant organisms, and data have not supported any reduced risk of IE as a result of prophylactic antibiotic use prior to dental procedures.

The new guidelines emphasize that antibiotic use should be based on the odds of a heart patient having a severe adverse reaction if he or she developed IE, rather than lumping all heart patients together as being at increased risk for IE.

“In fact, maintaining good oral health and hygiene appears to be more protective than prophylactic antibiotics,” Dr. Wilson said in a statement. Dr. Wilson had no financial disclosures related to his work on the guidelines.

Similarly, only cardiac patients who meet the above criteria need to receive antibiotics prior to respiratory tract, skin, or musculoskeletal procedures, and antibiotic use only to prevent IE is no longer recommended for any cardiac patients prior to gastrointestinal procedures, according to the new guidelines.

Physicians might need to reassure patients with heart conditions other than the high-risk conditions specified in the guidelines that their risk for developing IE is low, and remind them that the ability of antibiotics to reduce the risk of IE is equally low, the writing group noted.

Most patients with heart conditions don't need to take antibiotics to reduce the risk of infection prior to a dental procedure, according to revised American Heart Association guidelines.

The new guidelines represent a change from previous recommendations, which advised that patients with any heart abnormality, from mild valve prolapse to severe birth defects, should take amoxicillin prior to a dental procedure to reduce the risk of developing infective endocarditis (IE), an infection of the heart's valves or inner lining.

Many types of fungi and bacteria can cause the infection, and dental procedures had been seen as opening the door for these organisms to attack vulnerable patients.

But the guidelines writing group, led by Dr. Walter Wilson of the Mayo Clinic in Rochester, Minn., reviewed the latest research and found no significant evidence that taking antibiotics before a dental procedure prevents IE in patients who are at risk for infections (doi:10.1161/circulationaha.106.183095).

In addition, no prospective randomized placebo-controlled studies have shown that antibiotic use prior to a dental procedure prevents IE, although research in this area is limited by the range of dental procedures and overall low incidence of IE. And daily activities such as toothbrushing and flossing cause transient bacteremia, and far more frequently than dental procedures.

In fact, severe adverse events resulting from IE are associated with only a small subgroup of cardiac conditions, the writing group noted, and these patients should continue to receive antibiotics prior to dental procedures.

The cardiac patients who should continue to receive antibiotics prior to dental procedures because of their increased risk for severe complications from IE are those with prosthetic cardiac valves or previous episodes of infective endocarditis, and heart transplant patients who have developed abnormal cardiac valves.

In addition, patients with cardiac disease who meet the following criteria should continue to receive antibiotics prior to dental procedures:

▸ Patients with repaired congenital heart disease (CHD) who have remaining defects at or near the site of a patch or prosthetic that inhibit the healing of the heart vessels' inner surfaces.

▸ Patients with unrepaired cyanotic CHD, including those with palliative shunts or conduits.

▸ Patients with repaired CHD with no remaining defects who are within 6 months of the procedure (because the inner vessel surfaces are still healing).

The patients who meet the criteria for increased IE risk should receive antibiotics prior to any dental procedure that involves work on the gums, the apex of the tooth, or perforation of oral mucosa. The guidelines apply to children as well as adults and have been endorsed by the Infectious Diseases Society of America and the Pediatric Infectious Disease Society as well as approved by the American Dental Association.

The preexisting guidelines for antibiotics use to prevent IE were last revised in 1997, and they called for 2 g of amoxicillin to be given orally 1 hour before a procedure.

But amoxicillin use carries risks of its own, including fostering the development of amoxicillin-resistant organisms, and data have not supported any reduced risk of IE as a result of prophylactic antibiotic use prior to dental procedures.

The new guidelines emphasize that antibiotic use should be based on the odds of a heart patient having a severe adverse reaction if he or she developed IE, rather than lumping all heart patients together as being at increased risk for IE.

“In fact, maintaining good oral health and hygiene appears to be more protective than prophylactic antibiotics,” Dr. Wilson said in a statement. Dr. Wilson had no financial disclosures related to his work on the guidelines.

Similarly, only cardiac patients who meet the above criteria need to receive antibiotics prior to respiratory tract, skin, or musculoskeletal procedures, and antibiotic use only to prevent IE is no longer recommended for any cardiac patients prior to gastrointestinal procedures, according to the new guidelines.

Physicians might need to reassure patients with heart conditions other than the high-risk conditions specified in the guidelines that their risk for developing IE is low, and remind them that the ability of antibiotics to reduce the risk of IE is equally low, the writing group noted.

Most patients with heart conditions don't need to take antibiotics to reduce the risk of infection prior to a dental procedure, according to revised American Heart Association guidelines.

The new guidelines represent a change from previous recommendations, which advised that patients with any heart abnormality, from mild valve prolapse to severe birth defects, should take amoxicillin prior to a dental procedure to reduce the risk of developing infective endocarditis (IE), an infection of the heart's valves or inner lining.

Many types of fungi and bacteria can cause the infection, and dental procedures had been seen as opening the door for these organisms to attack vulnerable patients.

But the guidelines writing group, led by Dr. Walter Wilson of the Mayo Clinic in Rochester, Minn., reviewed the latest research and found no significant evidence that taking antibiotics before a dental procedure prevents IE in patients who are at risk for infections (doi:10.1161/circulationaha.106.183095).

In addition, no prospective randomized placebo-controlled studies have shown that antibiotic use prior to a dental procedure prevents IE, although research in this area is limited by the range of dental procedures and overall low incidence of IE. And daily activities such as toothbrushing and flossing cause transient bacteremia, and far more frequently than dental procedures.

In fact, severe adverse events resulting from IE are associated with only a small subgroup of cardiac conditions, the writing group noted, and these patients should continue to receive antibiotics prior to dental procedures.

The cardiac patients who should continue to receive antibiotics prior to dental procedures because of their increased risk for severe complications from IE are those with prosthetic cardiac valves or previous episodes of infective endocarditis, and heart transplant patients who have developed abnormal cardiac valves.

In addition, patients with cardiac disease who meet the following criteria should continue to receive antibiotics prior to dental procedures:

▸ Patients with repaired congenital heart disease (CHD) who have remaining defects at or near the site of a patch or prosthetic that inhibit the healing of the heart vessels' inner surfaces.

▸ Patients with unrepaired cyanotic CHD, including those with palliative shunts or conduits.

▸ Patients with repaired CHD with no remaining defects who are within 6 months of the procedure (because the inner vessel surfaces are still healing).

The patients who meet the criteria for increased IE risk should receive antibiotics prior to any dental procedure that involves work on the gums, the apex of the tooth, or perforation of oral mucosa. The guidelines apply to children as well as adults and have been endorsed by the Infectious Diseases Society of America and the Pediatric Infectious Disease Society as well as approved by the American Dental Association.

The preexisting guidelines for antibiotics use to prevent IE were last revised in 1997, and they called for 2 g of amoxicillin to be given orally 1 hour before a procedure.

But amoxicillin use carries risks of its own, including fostering the development of amoxicillin-resistant organisms, and data have not supported any reduced risk of IE as a result of prophylactic antibiotic use prior to dental procedures.

The new guidelines emphasize that antibiotic use should be based on the odds of a heart patient having a severe adverse reaction if he or she developed IE, rather than lumping all heart patients together as being at increased risk for IE.

“In fact, maintaining good oral health and hygiene appears to be more protective than prophylactic antibiotics,” Dr. Wilson said in a statement. Dr. Wilson had no financial disclosures related to his work on the guidelines.

Similarly, only cardiac patients who meet the above criteria need to receive antibiotics prior to respiratory tract, skin, or musculoskeletal procedures, and antibiotic use only to prevent IE is no longer recommended for any cardiac patients prior to gastrointestinal procedures, according to the new guidelines.

Physicians might need to reassure patients with heart conditions other than the high-risk conditions specified in the guidelines that their risk for developing IE is low, and remind them that the ability of antibiotics to reduce the risk of IE is equally low, the writing group noted.