Kate Johnson

SAN DIEGO — A longitudinal pigmented streak beneath the nail could either be a benign melanonychia striata or a far-from-benign subungual melanoma, but despite the vast difference in prognosis, the two conditions are very difficult to tell apart clinically, Dr. Constance Nagi said at a melanoma update sponsored by the Scripps Clinic.

“When it's melanoma, patients often present with late-stage disease, because there is frequently a delay in the correct diagnosis,” she warned, adding that late-stage subungual melanoma carries a 5-year survival rate of 16%–61%. The delay often occurs because it is mistaken for infection or inflammation resulting from trauma.

To add to this confusion, both types of lesions can develop as a result of trauma, and thus both are more commonly seen on thumbs, index fingers, and great toes. Furthermore, melanonychia striata can sometimes be an early sign of melanoma, she noted. Despite these similarities, there are some key clues that distinguish melanonychia striata from subungual melanoma, said Dr. Nagi, clinical professor of medicine/dermatology at the University of California, San Diego.

Hutchinson's sign, though not always present, is a valuable clue to melanoma diagnosis. This periungual spread of pigmentation to the proximal or lateral nail folds is usually a late sign of melanoma, though absence of it does not imply a benign lesion, she said.

Be suspicious of benign melanonychia striata—usually occurring as a black, brown, or tan longitudinal streak within the nail—if it suddenly darkens or widens, or if it has blurred lateral borders. Additionally, the presence of nail dystrophy, either partial or complete, is a suspicious sign, she pointed out. The sudden appearance of a nail streak in a single digit in adult life also warrants careful examination; this is especially true for patients who are at increased risk for melanoma or have a history of it.

Dr. Nagi warned that subungual melanoma is often asymptomatic and that up to 25% of cases can be amelanotic, so it is easily mistaken for pyogenic granuloma, chronic granulation tissue, or mycobacterial infection with nail dystrophy.

“When in doubt, biopsy,” she advised, adding that complete excision of the lesion should be considered, if feasible. Patients should be informed preoperatively about the possibility that the biopsy could result in permanent nail dystrophy.

Nail streaks, both benign and malignant, are more common in dark-skinned people than in whites, Dr. Nagi said. Benign melanonychia striata is uncommon in whites but occurs in virtually 100% of African Americans by age 50 years.

A melanonychia striata in a patient's index finger; on biopsy the striata showed a benign melanocytic lesion.

This melanotic melanoma on a patient's fingertip presented as a pyogenic granulomalike lesion. Photos courtesy Dr. Constance Nagi

SAN DIEGO — A longitudinal pigmented streak beneath the nail could either be a benign melanonychia striata or a far-from-benign subungual melanoma, but despite the vast difference in prognosis, the two conditions are very difficult to tell apart clinically, Dr. Constance Nagi said at a melanoma update sponsored by the Scripps Clinic.

“When it's melanoma, patients often present with late-stage disease, because there is frequently a delay in the correct diagnosis,” she warned, adding that late-stage subungual melanoma carries a 5-year survival rate of 16%–61%. The delay often occurs because it is mistaken for infection or inflammation resulting from trauma.

To add to this confusion, both types of lesions can develop as a result of trauma, and thus both are more commonly seen on thumbs, index fingers, and great toes. Furthermore, melanonychia striata can sometimes be an early sign of melanoma, she noted. Despite these similarities, there are some key clues that distinguish melanonychia striata from subungual melanoma, said Dr. Nagi, clinical professor of medicine/dermatology at the University of California, San Diego.

Hutchinson's sign, though not always present, is a valuable clue to melanoma diagnosis. This periungual spread of pigmentation to the proximal or lateral nail folds is usually a late sign of melanoma, though absence of it does not imply a benign lesion, she said.

Be suspicious of benign melanonychia striata—usually occurring as a black, brown, or tan longitudinal streak within the nail—if it suddenly darkens or widens, or if it has blurred lateral borders. Additionally, the presence of nail dystrophy, either partial or complete, is a suspicious sign, she pointed out. The sudden appearance of a nail streak in a single digit in adult life also warrants careful examination; this is especially true for patients who are at increased risk for melanoma or have a history of it.

Dr. Nagi warned that subungual melanoma is often asymptomatic and that up to 25% of cases can be amelanotic, so it is easily mistaken for pyogenic granuloma, chronic granulation tissue, or mycobacterial infection with nail dystrophy.

“When in doubt, biopsy,” she advised, adding that complete excision of the lesion should be considered, if feasible. Patients should be informed preoperatively about the possibility that the biopsy could result in permanent nail dystrophy.

Nail streaks, both benign and malignant, are more common in dark-skinned people than in whites, Dr. Nagi said. Benign melanonychia striata is uncommon in whites but occurs in virtually 100% of African Americans by age 50 years.

A melanonychia striata in a patient's index finger; on biopsy the striata showed a benign melanocytic lesion.

This melanotic melanoma on a patient's fingertip presented as a pyogenic granulomalike lesion. Photos courtesy Dr. Constance Nagi

SAN DIEGO — A longitudinal pigmented streak beneath the nail could either be a benign melanonychia striata or a far-from-benign subungual melanoma, but despite the vast difference in prognosis, the two conditions are very difficult to tell apart clinically, Dr. Constance Nagi said at a melanoma update sponsored by the Scripps Clinic.

“When it's melanoma, patients often present with late-stage disease, because there is frequently a delay in the correct diagnosis,” she warned, adding that late-stage subungual melanoma carries a 5-year survival rate of 16%–61%. The delay often occurs because it is mistaken for infection or inflammation resulting from trauma.

To add to this confusion, both types of lesions can develop as a result of trauma, and thus both are more commonly seen on thumbs, index fingers, and great toes. Furthermore, melanonychia striata can sometimes be an early sign of melanoma, she noted. Despite these similarities, there are some key clues that distinguish melanonychia striata from subungual melanoma, said Dr. Nagi, clinical professor of medicine/dermatology at the University of California, San Diego.

Hutchinson's sign, though not always present, is a valuable clue to melanoma diagnosis. This periungual spread of pigmentation to the proximal or lateral nail folds is usually a late sign of melanoma, though absence of it does not imply a benign lesion, she said.

Be suspicious of benign melanonychia striata—usually occurring as a black, brown, or tan longitudinal streak within the nail—if it suddenly darkens or widens, or if it has blurred lateral borders. Additionally, the presence of nail dystrophy, either partial or complete, is a suspicious sign, she pointed out. The sudden appearance of a nail streak in a single digit in adult life also warrants careful examination; this is especially true for patients who are at increased risk for melanoma or have a history of it.

Dr. Nagi warned that subungual melanoma is often asymptomatic and that up to 25% of cases can be amelanotic, so it is easily mistaken for pyogenic granuloma, chronic granulation tissue, or mycobacterial infection with nail dystrophy.

“When in doubt, biopsy,” she advised, adding that complete excision of the lesion should be considered, if feasible. Patients should be informed preoperatively about the possibility that the biopsy could result in permanent nail dystrophy.

Nail streaks, both benign and malignant, are more common in dark-skinned people than in whites, Dr. Nagi said. Benign melanonychia striata is uncommon in whites but occurs in virtually 100% of African Americans by age 50 years.

A melanonychia striata in a patient's index finger; on biopsy the striata showed a benign melanocytic lesion.

This melanotic melanoma on a patient's fingertip presented as a pyogenic granulomalike lesion. Photos courtesy Dr. Constance Nagi

SAN ANTONIO — Primary care physicians may be able to quickly and accurately assess and stratify an adolescent's 1-year risk of developing new-onset major depression using a 20-item checklist, Dr. Benjamin W. Van Voorhees said at the annual meeting of the Society for Prevention Research.

The information could then help physicians guide patients and parents toward reducing the risk by using a variety of therapeutic interventions, including a Web-based approach that he has developed and is now testing, said Dr. Van Voorhees, a pediatrician and internist at the University of Chicago.

“Primary care physicians use a brief list of questions to stratify a person's 10-year risk of cardiovascular disease and to guide their interventions, so we wanted to make this depression risk model just as easy to use in the primary care setting,” he said in an interview.

Primary care providers now have no alternative to medications or psychotherapy referrals for patients with mild to moderate depression symptoms, he said. “We are trying to create an alternative—to reshape the current paradigm,” Dr. Van Voorhees said.

He and his colleagues developed their depression risk prediction model using data from the National Longitudinal Study of Adolescent Health, which involved 6,504 adolescents in grades 7 through 12. Baseline data on the subjects, collected in 1995, included home, school, and parent surveys. Follow-up data were collected 1 year later on 4,791 subjects.

Using a subsample of 3,814 subjects, none of whom had major depression at baseline, Dr. Van Voorhees identified 15 independent variables that could be used to predict the patient's development of major depression in the coming year. The model, which has a sensitivity of 74% and a specificity of 87%, includes the adolescent's social connectedness, quality of life, mood, and other factors.

His research group plans to formally test the prediction model in a prospective study of youth at risk for developing major depression.

In a separate analysis of the same subset, Dr. Van Voorhees also identified factors that appeared to protect against the development of depression. For example, on a personal level, an adolescent's self-rated health, adequate sleep, and self-efficacy seemed protective. On a family and community level, participation, attachment, and competence seemed protective. “My idea is that if we have a good risk prediction model, we can basically calculate an adolescent's risk at a well-child visit and then give that information to the child and parent,” he said. “Then they can choose whether they want to be involved in a preventive intervention.

“We believe that such interventions could be done at low cost and, if designed well, could be efficacious and very acceptable to patients and physicians in community settings.”

Patients identified as having moderate risk might consider improving the protective factors in their lives, although whether changes in these areas could actually reduce risk still needs to be explored in a randomized, controlled trial, he added.

For patients identified as having higher depression risk, he suggests a more structured intervention such as Project CATCH-IT, a combined primary care/Web-based intervention that he has developed. Designed for adolescents at moderate to high risk for depression, this program involves an initial “motivational interview” with a primary care physician aimed at helping the adolescent identify personal goals and understand how depression could jeopardize those goals.

During this session, the primary care physician also focuses on boosting the adolescent's motivation to change and increasing his or her interest in the Web-based intervention (a demonstration can be seen at www.animateband.com/siteX/Untitled-1.html

The intervention concludes with a follow-up visit with the primary care physician. If no benefit is observed at this stage, Dr. Van Voorhees recommends face-to-face sessions with a mental health professional.

In a pilot test of Project CATCH-IT, Dr. Van Voorhees' group observed benefits among 14 late adolescents who were at high risk for depression (Can. Child Adolesc. Psychiatry Rev. 2005;14:40–3). “Completers experienced favorable changes in known risk factors with effect sizes similar to those of other preventive interventions for depression,” they wrote. However, with no control group in the study, “we cannot know to what degree these changes would have occurred without an intervention,” they added.

The aim of depression risk prediction and early intervention is to prevent the development of more serious mental illness, but Dr. Van Voorhees cautions about the potential adverse effects of this approach. “When you are dealing with young people who may be vulnerable and somewhat pessimistic, telling them that they are at risk for depression may make them feel stigmatized,” he said. “So the way we approach this is to talk in terms of resiliency.

“We tell them they have high, medium, or low resiliency. High resiliency would mean almost no risk of depression, whereas low would mean they need to take care of themselves.”

SAN ANTONIO — Primary care physicians may be able to quickly and accurately assess and stratify an adolescent's 1-year risk of developing new-onset major depression using a 20-item checklist, Dr. Benjamin W. Van Voorhees said at the annual meeting of the Society for Prevention Research.

The information could then help physicians guide patients and parents toward reducing the risk by using a variety of therapeutic interventions, including a Web-based approach that he has developed and is now testing, said Dr. Van Voorhees, a pediatrician and internist at the University of Chicago.

“Primary care physicians use a brief list of questions to stratify a person's 10-year risk of cardiovascular disease and to guide their interventions, so we wanted to make this depression risk model just as easy to use in the primary care setting,” he said in an interview.

Primary care providers now have no alternative to medications or psychotherapy referrals for patients with mild to moderate depression symptoms, he said. “We are trying to create an alternative—to reshape the current paradigm,” Dr. Van Voorhees said.

He and his colleagues developed their depression risk prediction model using data from the National Longitudinal Study of Adolescent Health, which involved 6,504 adolescents in grades 7 through 12. Baseline data on the subjects, collected in 1995, included home, school, and parent surveys. Follow-up data were collected 1 year later on 4,791 subjects.

Using a subsample of 3,814 subjects, none of whom had major depression at baseline, Dr. Van Voorhees identified 15 independent variables that could be used to predict the patient's development of major depression in the coming year. The model, which has a sensitivity of 74% and a specificity of 87%, includes the adolescent's social connectedness, quality of life, mood, and other factors.

His research group plans to formally test the prediction model in a prospective study of youth at risk for developing major depression.

In a separate analysis of the same subset, Dr. Van Voorhees also identified factors that appeared to protect against the development of depression. For example, on a personal level, an adolescent's self-rated health, adequate sleep, and self-efficacy seemed protective. On a family and community level, participation, attachment, and competence seemed protective. “My idea is that if we have a good risk prediction model, we can basically calculate an adolescent's risk at a well-child visit and then give that information to the child and parent,” he said. “Then they can choose whether they want to be involved in a preventive intervention.

“We believe that such interventions could be done at low cost and, if designed well, could be efficacious and very acceptable to patients and physicians in community settings.”

Patients identified as having moderate risk might consider improving the protective factors in their lives, although whether changes in these areas could actually reduce risk still needs to be explored in a randomized, controlled trial, he added.

For patients identified as having higher depression risk, he suggests a more structured intervention such as Project CATCH-IT, a combined primary care/Web-based intervention that he has developed. Designed for adolescents at moderate to high risk for depression, this program involves an initial “motivational interview” with a primary care physician aimed at helping the adolescent identify personal goals and understand how depression could jeopardize those goals.

During this session, the primary care physician also focuses on boosting the adolescent's motivation to change and increasing his or her interest in the Web-based intervention (a demonstration can be seen at www.animateband.com/siteX/Untitled-1.html

The intervention concludes with a follow-up visit with the primary care physician. If no benefit is observed at this stage, Dr. Van Voorhees recommends face-to-face sessions with a mental health professional.

In a pilot test of Project CATCH-IT, Dr. Van Voorhees' group observed benefits among 14 late adolescents who were at high risk for depression (Can. Child Adolesc. Psychiatry Rev. 2005;14:40–3). “Completers experienced favorable changes in known risk factors with effect sizes similar to those of other preventive interventions for depression,” they wrote. However, with no control group in the study, “we cannot know to what degree these changes would have occurred without an intervention,” they added.

The aim of depression risk prediction and early intervention is to prevent the development of more serious mental illness, but Dr. Van Voorhees cautions about the potential adverse effects of this approach. “When you are dealing with young people who may be vulnerable and somewhat pessimistic, telling them that they are at risk for depression may make them feel stigmatized,” he said. “So the way we approach this is to talk in terms of resiliency.

“We tell them they have high, medium, or low resiliency. High resiliency would mean almost no risk of depression, whereas low would mean they need to take care of themselves.”

SAN ANTONIO — Primary care physicians may be able to quickly and accurately assess and stratify an adolescent's 1-year risk of developing new-onset major depression using a 20-item checklist, Dr. Benjamin W. Van Voorhees said at the annual meeting of the Society for Prevention Research.

The information could then help physicians guide patients and parents toward reducing the risk by using a variety of therapeutic interventions, including a Web-based approach that he has developed and is now testing, said Dr. Van Voorhees, a pediatrician and internist at the University of Chicago.

“Primary care physicians use a brief list of questions to stratify a person's 10-year risk of cardiovascular disease and to guide their interventions, so we wanted to make this depression risk model just as easy to use in the primary care setting,” he said in an interview.

Primary care providers now have no alternative to medications or psychotherapy referrals for patients with mild to moderate depression symptoms, he said. “We are trying to create an alternative—to reshape the current paradigm,” Dr. Van Voorhees said.

He and his colleagues developed their depression risk prediction model using data from the National Longitudinal Study of Adolescent Health, which involved 6,504 adolescents in grades 7 through 12. Baseline data on the subjects, collected in 1995, included home, school, and parent surveys. Follow-up data were collected 1 year later on 4,791 subjects.

Using a subsample of 3,814 subjects, none of whom had major depression at baseline, Dr. Van Voorhees identified 15 independent variables that could be used to predict the patient's development of major depression in the coming year. The model, which has a sensitivity of 74% and a specificity of 87%, includes the adolescent's social connectedness, quality of life, mood, and other factors.

His research group plans to formally test the prediction model in a prospective study of youth at risk for developing major depression.

In a separate analysis of the same subset, Dr. Van Voorhees also identified factors that appeared to protect against the development of depression. For example, on a personal level, an adolescent's self-rated health, adequate sleep, and self-efficacy seemed protective. On a family and community level, participation, attachment, and competence seemed protective. “My idea is that if we have a good risk prediction model, we can basically calculate an adolescent's risk at a well-child visit and then give that information to the child and parent,” he said. “Then they can choose whether they want to be involved in a preventive intervention.

“We believe that such interventions could be done at low cost and, if designed well, could be efficacious and very acceptable to patients and physicians in community settings.”

Patients identified as having moderate risk might consider improving the protective factors in their lives, although whether changes in these areas could actually reduce risk still needs to be explored in a randomized, controlled trial, he added.

For patients identified as having higher depression risk, he suggests a more structured intervention such as Project CATCH-IT, a combined primary care/Web-based intervention that he has developed. Designed for adolescents at moderate to high risk for depression, this program involves an initial “motivational interview” with a primary care physician aimed at helping the adolescent identify personal goals and understand how depression could jeopardize those goals.

During this session, the primary care physician also focuses on boosting the adolescent's motivation to change and increasing his or her interest in the Web-based intervention (a demonstration can be seen at www.animateband.com/siteX/Untitled-1.html

The intervention concludes with a follow-up visit with the primary care physician. If no benefit is observed at this stage, Dr. Van Voorhees recommends face-to-face sessions with a mental health professional.

In a pilot test of Project CATCH-IT, Dr. Van Voorhees' group observed benefits among 14 late adolescents who were at high risk for depression (Can. Child Adolesc. Psychiatry Rev. 2005;14:40–3). “Completers experienced favorable changes in known risk factors with effect sizes similar to those of other preventive interventions for depression,” they wrote. However, with no control group in the study, “we cannot know to what degree these changes would have occurred without an intervention,” they added.

The aim of depression risk prediction and early intervention is to prevent the development of more serious mental illness, but Dr. Van Voorhees cautions about the potential adverse effects of this approach. “When you are dealing with young people who may be vulnerable and somewhat pessimistic, telling them that they are at risk for depression may make them feel stigmatized,” he said. “So the way we approach this is to talk in terms of resiliency.

“We tell them they have high, medium, or low resiliency. High resiliency would mean almost no risk of depression, whereas low would mean they need to take care of themselves.”

BOSTON — Regular, moderate exercise can help control ventricular rate in patients with permanent atrial fibrillation, according to a study presented as a poster at the annual meeting of the Heart Rhythm Society.

“Patients with atrial fibrillation [AF] find it difficult to exercise, so this is a new idea,” Dr. Jurgita Plisiene, a cardiologist at University Hospital in Aachen, Germany, said in an interview.

Ventricular rate increases during exercise, making it difficult for patients to improve their exercise capacity. But 4 months of twice-weekly exercise, involving walking or jogging for 60 minutes, increased exercise capacity in her 10 subjects with permanent AF, while at the same time regulating their ventricular rate.

The patients had a mean age of 59 years and a mean 10 years' duration of permanent AF. They undertook individualized, physician-directed exercise programs tailored to their physical capacity. Physical exercise tests and Holter ECG recordings were performed at baseline and after 4 months.

The study found that the exercise program decreased the subjects' mean ventricular rate by 12%. The mean rate at rest decreased from 87 to 78 beats per minute, and at almost every exercise level a significant ventricular rate decrease was observed.

In addition, overall exercise capacity, as estimated by repeated lactate measurements and by questionnaires, also significantly improved.

BOSTON — Regular, moderate exercise can help control ventricular rate in patients with permanent atrial fibrillation, according to a study presented as a poster at the annual meeting of the Heart Rhythm Society.

“Patients with atrial fibrillation [AF] find it difficult to exercise, so this is a new idea,” Dr. Jurgita Plisiene, a cardiologist at University Hospital in Aachen, Germany, said in an interview.

Ventricular rate increases during exercise, making it difficult for patients to improve their exercise capacity. But 4 months of twice-weekly exercise, involving walking or jogging for 60 minutes, increased exercise capacity in her 10 subjects with permanent AF, while at the same time regulating their ventricular rate.

The patients had a mean age of 59 years and a mean 10 years' duration of permanent AF. They undertook individualized, physician-directed exercise programs tailored to their physical capacity. Physical exercise tests and Holter ECG recordings were performed at baseline and after 4 months.

The study found that the exercise program decreased the subjects' mean ventricular rate by 12%. The mean rate at rest decreased from 87 to 78 beats per minute, and at almost every exercise level a significant ventricular rate decrease was observed.

In addition, overall exercise capacity, as estimated by repeated lactate measurements and by questionnaires, also significantly improved.

BOSTON — Regular, moderate exercise can help control ventricular rate in patients with permanent atrial fibrillation, according to a study presented as a poster at the annual meeting of the Heart Rhythm Society.

“Patients with atrial fibrillation [AF] find it difficult to exercise, so this is a new idea,” Dr. Jurgita Plisiene, a cardiologist at University Hospital in Aachen, Germany, said in an interview.

Ventricular rate increases during exercise, making it difficult for patients to improve their exercise capacity. But 4 months of twice-weekly exercise, involving walking or jogging for 60 minutes, increased exercise capacity in her 10 subjects with permanent AF, while at the same time regulating their ventricular rate.

The patients had a mean age of 59 years and a mean 10 years' duration of permanent AF. They undertook individualized, physician-directed exercise programs tailored to their physical capacity. Physical exercise tests and Holter ECG recordings were performed at baseline and after 4 months.

The study found that the exercise program decreased the subjects' mean ventricular rate by 12%. The mean rate at rest decreased from 87 to 78 beats per minute, and at almost every exercise level a significant ventricular rate decrease was observed.

In addition, overall exercise capacity, as estimated by repeated lactate measurements and by questionnaires, also significantly improved.

BOSTON — New studies showing conflicting results about the effect of fish oil on the heart add weight to the notion that perhaps age and health status influence whether omega-3 fatty acids prevent or promote cardiac arrhythmias, Dr. Anthony Aizer said.

His study, which he presented at the annual meeting of the Heart Rhythm Society, linked increased fish consumption with a higher risk of developing atrial fibrillation (AF) in healthy male physicians (aged 40–84 years) who were enrolled in the previously reported Physicians' Health Study (N. Engl. J. Med. 1989;321:129–35).

The findings corroborate recently published results from the Danish Diet, Cancer, and Health study (Am. J. Clin. Nutr. 2005;81:50–4), but contrast with data from the Cardiovascular Health study (Circulation 2004;110:368–73), said Dr. Aizer, an electrophysiologist at New York University Medical Center.

“One hypothesis is that omega-3 fatty acids have some effects on the autonomic nervous system—in particular, by increasing parasympathetic tone. In generally healthy individuals without CVD, it is sometimes thought that an increase in autonomic tone may play a role in the development of AF,” he said in an interview. “In contrast, in older, less healthy individuals it's possible that other effects are more significant. In certain individuals, the effect of omega-3 fatty acids that enhance cardiac tissue refractoriness may have a more significant impact, thereby preventing AF.”

Dr. Aizer's analysis of the Physicians' Health Study included 17,679 men who had completed a fish consumption questionnaire in 1983 and of whom 7% reported AF 15 years later. He found that men who reported eating five or more fish meals per week had a 55% higher rate of AF, compared with men who ate fish only once a month.

But two other smaller studies that were presented as posters at the meeting reported the cardiac benefits of omega-3 fatty acids.

A prospective study of six patients with paroxysmal AF showed that an infusion of 100 mL of omega-3 fatty acids resulted in an increase in atrial refractoriness, a reduction in AF inducibility, and a prolongation of fibrillatory cycle length, reported Dr. Hercules E. Mavrakis, from Heraklion University Hospital in Heraklion, Crete, Greece.

And another study of 26 patients with inducible ventricular tachycardia (VT) at 3 or more months post myocardial infarction showed strong benefits of oral omega-3 fatty acid capsules (180 mg eicosapentaenoic acid and 120 mg docosahexaenoic acid) daily, compared with placebo, over a 40-day treatment period, reported Dr. Glenn D. Young from the Cardiovascular Research Centre in Adelaide, Australia.

At the end of the study, VT was no longer inducible in 5 of the 12 treated patients, and 5 of the remaining 7 patients required more aggressive stimulation to induce arrhythmia. By contrast, in the 14 control patients, VT was no longer inducible in only 1 patient, and 3 of the remaining 13 patients required more aggressive inducement.

“Statistically, it was a very significant result. There seems to be a direct effect of fish oil in preventing ventricular tachycardia,” Dr. Young said in an interview. “People can achieve that level with only [two or three] oily fish meals a week.”

Dr. Aizer said his finding of a higher incidence of AF with increased fish consumption cannot be interpreted as causal. “This wasn't a randomized, controlled trial [of fish consumption]—there could always be an association of fish with some other factor that's causing the atrial fibrillation.”

And he noted that another important association within this same cohort was a reduced rate of sudden cardiac death in those who ate more fish.

“The message of this study is not to stop eating fish,” he stressed. Rather, it suggests that “population groups play a significant role in what's going on, and that needs to be considered in terms of further analysis.”

BOSTON — New studies showing conflicting results about the effect of fish oil on the heart add weight to the notion that perhaps age and health status influence whether omega-3 fatty acids prevent or promote cardiac arrhythmias, Dr. Anthony Aizer said.

His study, which he presented at the annual meeting of the Heart Rhythm Society, linked increased fish consumption with a higher risk of developing atrial fibrillation (AF) in healthy male physicians (aged 40–84 years) who were enrolled in the previously reported Physicians' Health Study (N. Engl. J. Med. 1989;321:129–35).

The findings corroborate recently published results from the Danish Diet, Cancer, and Health study (Am. J. Clin. Nutr. 2005;81:50–4), but contrast with data from the Cardiovascular Health study (Circulation 2004;110:368–73), said Dr. Aizer, an electrophysiologist at New York University Medical Center.

“One hypothesis is that omega-3 fatty acids have some effects on the autonomic nervous system—in particular, by increasing parasympathetic tone. In generally healthy individuals without CVD, it is sometimes thought that an increase in autonomic tone may play a role in the development of AF,” he said in an interview. “In contrast, in older, less healthy individuals it's possible that other effects are more significant. In certain individuals, the effect of omega-3 fatty acids that enhance cardiac tissue refractoriness may have a more significant impact, thereby preventing AF.”

Dr. Aizer's analysis of the Physicians' Health Study included 17,679 men who had completed a fish consumption questionnaire in 1983 and of whom 7% reported AF 15 years later. He found that men who reported eating five or more fish meals per week had a 55% higher rate of AF, compared with men who ate fish only once a month.

But two other smaller studies that were presented as posters at the meeting reported the cardiac benefits of omega-3 fatty acids.

A prospective study of six patients with paroxysmal AF showed that an infusion of 100 mL of omega-3 fatty acids resulted in an increase in atrial refractoriness, a reduction in AF inducibility, and a prolongation of fibrillatory cycle length, reported Dr. Hercules E. Mavrakis, from Heraklion University Hospital in Heraklion, Crete, Greece.

And another study of 26 patients with inducible ventricular tachycardia (VT) at 3 or more months post myocardial infarction showed strong benefits of oral omega-3 fatty acid capsules (180 mg eicosapentaenoic acid and 120 mg docosahexaenoic acid) daily, compared with placebo, over a 40-day treatment period, reported Dr. Glenn D. Young from the Cardiovascular Research Centre in Adelaide, Australia.

At the end of the study, VT was no longer inducible in 5 of the 12 treated patients, and 5 of the remaining 7 patients required more aggressive stimulation to induce arrhythmia. By contrast, in the 14 control patients, VT was no longer inducible in only 1 patient, and 3 of the remaining 13 patients required more aggressive inducement.

“Statistically, it was a very significant result. There seems to be a direct effect of fish oil in preventing ventricular tachycardia,” Dr. Young said in an interview. “People can achieve that level with only [two or three] oily fish meals a week.”

Dr. Aizer said his finding of a higher incidence of AF with increased fish consumption cannot be interpreted as causal. “This wasn't a randomized, controlled trial [of fish consumption]—there could always be an association of fish with some other factor that's causing the atrial fibrillation.”

And he noted that another important association within this same cohort was a reduced rate of sudden cardiac death in those who ate more fish.

“The message of this study is not to stop eating fish,” he stressed. Rather, it suggests that “population groups play a significant role in what's going on, and that needs to be considered in terms of further analysis.”

BOSTON — New studies showing conflicting results about the effect of fish oil on the heart add weight to the notion that perhaps age and health status influence whether omega-3 fatty acids prevent or promote cardiac arrhythmias, Dr. Anthony Aizer said.

His study, which he presented at the annual meeting of the Heart Rhythm Society, linked increased fish consumption with a higher risk of developing atrial fibrillation (AF) in healthy male physicians (aged 40–84 years) who were enrolled in the previously reported Physicians' Health Study (N. Engl. J. Med. 1989;321:129–35).

The findings corroborate recently published results from the Danish Diet, Cancer, and Health study (Am. J. Clin. Nutr. 2005;81:50–4), but contrast with data from the Cardiovascular Health study (Circulation 2004;110:368–73), said Dr. Aizer, an electrophysiologist at New York University Medical Center.

“One hypothesis is that omega-3 fatty acids have some effects on the autonomic nervous system—in particular, by increasing parasympathetic tone. In generally healthy individuals without CVD, it is sometimes thought that an increase in autonomic tone may play a role in the development of AF,” he said in an interview. “In contrast, in older, less healthy individuals it's possible that other effects are more significant. In certain individuals, the effect of omega-3 fatty acids that enhance cardiac tissue refractoriness may have a more significant impact, thereby preventing AF.”

Dr. Aizer's analysis of the Physicians' Health Study included 17,679 men who had completed a fish consumption questionnaire in 1983 and of whom 7% reported AF 15 years later. He found that men who reported eating five or more fish meals per week had a 55% higher rate of AF, compared with men who ate fish only once a month.

But two other smaller studies that were presented as posters at the meeting reported the cardiac benefits of omega-3 fatty acids.

A prospective study of six patients with paroxysmal AF showed that an infusion of 100 mL of omega-3 fatty acids resulted in an increase in atrial refractoriness, a reduction in AF inducibility, and a prolongation of fibrillatory cycle length, reported Dr. Hercules E. Mavrakis, from Heraklion University Hospital in Heraklion, Crete, Greece.

And another study of 26 patients with inducible ventricular tachycardia (VT) at 3 or more months post myocardial infarction showed strong benefits of oral omega-3 fatty acid capsules (180 mg eicosapentaenoic acid and 120 mg docosahexaenoic acid) daily, compared with placebo, over a 40-day treatment period, reported Dr. Glenn D. Young from the Cardiovascular Research Centre in Adelaide, Australia.

At the end of the study, VT was no longer inducible in 5 of the 12 treated patients, and 5 of the remaining 7 patients required more aggressive stimulation to induce arrhythmia. By contrast, in the 14 control patients, VT was no longer inducible in only 1 patient, and 3 of the remaining 13 patients required more aggressive inducement.

“Statistically, it was a very significant result. There seems to be a direct effect of fish oil in preventing ventricular tachycardia,” Dr. Young said in an interview. “People can achieve that level with only [two or three] oily fish meals a week.”

Dr. Aizer said his finding of a higher incidence of AF with increased fish consumption cannot be interpreted as causal. “This wasn't a randomized, controlled trial [of fish consumption]—there could always be an association of fish with some other factor that's causing the atrial fibrillation.”

And he noted that another important association within this same cohort was a reduced rate of sudden cardiac death in those who ate more fish.

“The message of this study is not to stop eating fish,” he stressed. Rather, it suggests that “population groups play a significant role in what's going on, and that needs to be considered in terms of further analysis.”

PRAGUE — Results of the longest follow-up study of children conceived through intracytoplasmic sperm injection are reassuring despite the finding that they have a significantly increased rate of two major malformations, reported Dr. Florence Belva, an investigator in the study.

“The absolute risk of major malformations should be interpreted with caution and may be due to our study design,” Dr. Belva reported in a press conference at the annual meeting of the European Society of Human Reproduction and Embryology.

Her study compared 150 8-year-old children conceived through intracytoplasmic sperm injection (ICSI) with 147 spontaneously conceived control children. The only demographic difference between the two groups was maternal age, which was significantly greater in the ICSI children, compared with controls (32 years vs. 30 years), said Dr. Belva, a pediatrician and research assistant at the Center for Medical Genetics, Vrije University in Brussels.

Parents were asked to complete detailed questionnaires about their children's medical histories, and the children underwent extensive physical examinations, which included a neurologic work-up.

The only difference found between the two groups was an increase in the rate of major malformations, defined as malformations causing functional impairment and/or requiring surgery. The rate was 10% in ICSI children and 3% in the control children, which translates into a relative risk of 2.9 for a major malformation in the ICSI group.

The differences in major malformations between the two groups were in the rate of naevus flammeus (two cases in the ICSI group, and none in the control group) and inguinal hernia requiring surgery (five cases in the ICSI group and one in the control group).

Dr. Belva said her finding of an increased rate of major malformations in ICSI children was consistent with those of other studies; however, she said, the 10% rate was higher than has been previously reported.

“This may be because we had stricter definitions of major malformation to make sure we did not miss anything. Also our follow-up of 8 years is the longest, because other studies only followed children to 5 years of age. We found additional malformations between 5 and 8 years, which would not have been included in the shorter studies,” she said.

These findings are reassuring for parents, as long as they are carefully explained, said Dr. Sherman J. Silber of the Infertility Center of St. Louis. “I am concerned that the public may think that ICSI children have three times the rate of all major malformations, when it is simply an increase in inguinal hernias,” he said.

Similarly, Dr. Joe Leigh Simpson noted the importance of putting the results in perspective. “In the United States our definition of major malformation is normally death, severe malfunction, or structural anomalies requiring surgery,” said the professor and chair of obstetrics and gynecology at Baylor College of Medicine in Houston.

Source: Dr. Weisman

PRAGUE — Results of the longest follow-up study of children conceived through intracytoplasmic sperm injection are reassuring despite the finding that they have a significantly increased rate of two major malformations, reported Dr. Florence Belva, an investigator in the study.

“The absolute risk of major malformations should be interpreted with caution and may be due to our study design,” Dr. Belva reported in a press conference at the annual meeting of the European Society of Human Reproduction and Embryology.

Her study compared 150 8-year-old children conceived through intracytoplasmic sperm injection (ICSI) with 147 spontaneously conceived control children. The only demographic difference between the two groups was maternal age, which was significantly greater in the ICSI children, compared with controls (32 years vs. 30 years), said Dr. Belva, a pediatrician and research assistant at the Center for Medical Genetics, Vrije University in Brussels.

Parents were asked to complete detailed questionnaires about their children's medical histories, and the children underwent extensive physical examinations, which included a neurologic work-up.

The only difference found between the two groups was an increase in the rate of major malformations, defined as malformations causing functional impairment and/or requiring surgery. The rate was 10% in ICSI children and 3% in the control children, which translates into a relative risk of 2.9 for a major malformation in the ICSI group.

The differences in major malformations between the two groups were in the rate of naevus flammeus (two cases in the ICSI group, and none in the control group) and inguinal hernia requiring surgery (five cases in the ICSI group and one in the control group).

Dr. Belva said her finding of an increased rate of major malformations in ICSI children was consistent with those of other studies; however, she said, the 10% rate was higher than has been previously reported.

“This may be because we had stricter definitions of major malformation to make sure we did not miss anything. Also our follow-up of 8 years is the longest, because other studies only followed children to 5 years of age. We found additional malformations between 5 and 8 years, which would not have been included in the shorter studies,” she said.

These findings are reassuring for parents, as long as they are carefully explained, said Dr. Sherman J. Silber of the Infertility Center of St. Louis. “I am concerned that the public may think that ICSI children have three times the rate of all major malformations, when it is simply an increase in inguinal hernias,” he said.

Similarly, Dr. Joe Leigh Simpson noted the importance of putting the results in perspective. “In the United States our definition of major malformation is normally death, severe malfunction, or structural anomalies requiring surgery,” said the professor and chair of obstetrics and gynecology at Baylor College of Medicine in Houston.

Source: Dr. Weisman

PRAGUE — Results of the longest follow-up study of children conceived through intracytoplasmic sperm injection are reassuring despite the finding that they have a significantly increased rate of two major malformations, reported Dr. Florence Belva, an investigator in the study.

“The absolute risk of major malformations should be interpreted with caution and may be due to our study design,” Dr. Belva reported in a press conference at the annual meeting of the European Society of Human Reproduction and Embryology.

Her study compared 150 8-year-old children conceived through intracytoplasmic sperm injection (ICSI) with 147 spontaneously conceived control children. The only demographic difference between the two groups was maternal age, which was significantly greater in the ICSI children, compared with controls (32 years vs. 30 years), said Dr. Belva, a pediatrician and research assistant at the Center for Medical Genetics, Vrije University in Brussels.

Parents were asked to complete detailed questionnaires about their children's medical histories, and the children underwent extensive physical examinations, which included a neurologic work-up.

The only difference found between the two groups was an increase in the rate of major malformations, defined as malformations causing functional impairment and/or requiring surgery. The rate was 10% in ICSI children and 3% in the control children, which translates into a relative risk of 2.9 for a major malformation in the ICSI group.

The differences in major malformations between the two groups were in the rate of naevus flammeus (two cases in the ICSI group, and none in the control group) and inguinal hernia requiring surgery (five cases in the ICSI group and one in the control group).

Dr. Belva said her finding of an increased rate of major malformations in ICSI children was consistent with those of other studies; however, she said, the 10% rate was higher than has been previously reported.

“This may be because we had stricter definitions of major malformation to make sure we did not miss anything. Also our follow-up of 8 years is the longest, because other studies only followed children to 5 years of age. We found additional malformations between 5 and 8 years, which would not have been included in the shorter studies,” she said.

These findings are reassuring for parents, as long as they are carefully explained, said Dr. Sherman J. Silber of the Infertility Center of St. Louis. “I am concerned that the public may think that ICSI children have three times the rate of all major malformations, when it is simply an increase in inguinal hernias,” he said.

Similarly, Dr. Joe Leigh Simpson noted the importance of putting the results in perspective. “In the United States our definition of major malformation is normally death, severe malfunction, or structural anomalies requiring surgery,” said the professor and chair of obstetrics and gynecology at Baylor College of Medicine in Houston.

Source: Dr. Weisman

PRAGUE — If given the choice between a singleton or twins, many patients undergoing in-vitro fertilization would prefer twins, according to several studies presented at the annual meeting of the European Society for Human Reproduction and Embryology.

At a time when many fertility clinics are actively trying to reduce their multiple birth rates by limiting the number of embryos they transfer after in-vitro fertilization (IVF), this patient attitude goes against most physicians' concepts of treatment success, said Dr. Graham Scotland, an investigator on one of the studies.

It has been assumed that much of the patient drive for transferring more than one IVF embryo has been linked to increasing their chances of becoming pregnant with a singleton.

But a Danish study has found that while this is true for some couples, almost 60% simply want twins. Dr. Hans Jakob Ingerslev surveyed 588 couples using a 56-item questionnaire and found that 96% wanted two or more children in their family. Roughly 58% of the couples preferred twins, 38% preferred one child at a time, and the rest had no preference, said Dr. Ingerslev of the fertility clinic at Skejby Sygehus, a large university hospital in Aarhus (Denmark).

There were 60 couples in which the female partner wanted twins but the male wanted singletons—giving female gender an odds ratio of 1.65 for wanting twins.

Asked if they would accept a single embryo transfer (SET) if they were given an unlimited number of free cycles, 73% of couples said no. Moreover, offered free IVF treatment to conceive a second child later, 68% said no, Dr. Ingerslev said.

Among subjects who did not want twins, 24% cited risks to the fetus as their reason, while 18% cited maternal risks and 11% cited obstetric complications. Among those wanting twins, 23% cited wanting their child to have a sibling and 22% said they had a positive attitude about twins.

“Counseling these patients is a challenge,” he said.

Another study uncovered the depth of some patients' reluctance to accept SET, although it is unclear whether their motivation was for twins specifically or simply to increase their chances of pregnancy. In a survey of 81 couples waiting for IVF treatment, Dr. Scotland asked patients to weigh the possibility of treatment failure against the types of complications they could face if they were to conceive twins.

In general, patients preferred the idea of having twin-related complications such as a child with physical or cognitive impairment over the prospect of treatment failure and childlessness, said Dr. Scotland, from the University of Aberdeen in Scotland. However, they ranked perinatal death as less desirable than treatment failure.

“This is an interesting and surprising finding. Perhaps we should listen more carefully to the values of our patients who want double-embryo transfer,” said Dr. Scotland, noting that the absolute risks of conceiving twins are low, and the chances of twin-related complications are even lower.

“For some of these outcomes you're looking at something like 1% of twin pregnancies that will experience these adverse outcomes. Particularly difficult is that when you listen to a patient's values you have to weigh that against the fact that the risk is to another person—to the future offspring,” he said in an interview.

Indeed it is important to remember that most twin pregnancies have no complications, added California fertility specialist Dr. David Adamson. “While it is absolutely true that the birth defect rate and the abnormality rate is higher in twin pregnancies compared to singleton pregnancies, we still have to remember that the vast majority of twin pregnancies end up with two healthy babies,” he said in an interview. “That is not to say that we should be trying to get twins because we shouldn't—but we cannot make the argument that all [twin] pregnancies turn out as a bad outcome, that is absolutely not true.”

Educating patients about the risks of twin pregnancies can decrease some but not all interest in transferring more than one embryo, reported Dr. Ginny Ryan from the University of Iowa Hospitals in Iowa City. Previous work by her group has shown that IVF patients are three times more likely to desire twins, compared with a fertile population (30% vs. 10%).

In a new study, her group surveyed 120 patients waiting for IVF about their knowledge of fetal and maternal risks associated with twin pregnancies and then gave them an educational session about these risks. Although 30% of the group indicated a desire for twins prior to the educational session, this number dropped to 14% after the session. And whereas 78% of the group wanted a double-embryo transfer before the educational campaign, this dropped to 39% afterward, she said.

However, delving deeper into the issue, patients were asked about their acceptance of SET if it meant it could reduce their chances of becoming pregnant. With this prospect, 50% said they would opt for a double-embryo transfer.

Moreover, when asked whether SET would be acceptable to them if it gave them an equal chance at pregnancy compared with double-embryo transfer, 25% of the subjects said no.

Shortly after this study, Dr. Ryan's clinic implemented a mandatory SET program for women considered high risk for multiple pregnancy, so she could not evaluate whether the education campaign resulted in fewer women choosing double-embryo transfer.

However, she said the study highlights the fact that despite education, a substantial number of patients still want twins.

“While patient desires should be acknowledged, it is equally important to balance this against clinical judgment regarding the health of the patient, offspring, and society,” Dr. Ryan said.

PRAGUE — If given the choice between a singleton or twins, many patients undergoing in-vitro fertilization would prefer twins, according to several studies presented at the annual meeting of the European Society for Human Reproduction and Embryology.

At a time when many fertility clinics are actively trying to reduce their multiple birth rates by limiting the number of embryos they transfer after in-vitro fertilization (IVF), this patient attitude goes against most physicians' concepts of treatment success, said Dr. Graham Scotland, an investigator on one of the studies.

It has been assumed that much of the patient drive for transferring more than one IVF embryo has been linked to increasing their chances of becoming pregnant with a singleton.

But a Danish study has found that while this is true for some couples, almost 60% simply want twins. Dr. Hans Jakob Ingerslev surveyed 588 couples using a 56-item questionnaire and found that 96% wanted two or more children in their family. Roughly 58% of the couples preferred twins, 38% preferred one child at a time, and the rest had no preference, said Dr. Ingerslev of the fertility clinic at Skejby Sygehus, a large university hospital in Aarhus (Denmark).

There were 60 couples in which the female partner wanted twins but the male wanted singletons—giving female gender an odds ratio of 1.65 for wanting twins.

Asked if they would accept a single embryo transfer (SET) if they were given an unlimited number of free cycles, 73% of couples said no. Moreover, offered free IVF treatment to conceive a second child later, 68% said no, Dr. Ingerslev said.

Among subjects who did not want twins, 24% cited risks to the fetus as their reason, while 18% cited maternal risks and 11% cited obstetric complications. Among those wanting twins, 23% cited wanting their child to have a sibling and 22% said they had a positive attitude about twins.

“Counseling these patients is a challenge,” he said.

Another study uncovered the depth of some patients' reluctance to accept SET, although it is unclear whether their motivation was for twins specifically or simply to increase their chances of pregnancy. In a survey of 81 couples waiting for IVF treatment, Dr. Scotland asked patients to weigh the possibility of treatment failure against the types of complications they could face if they were to conceive twins.

In general, patients preferred the idea of having twin-related complications such as a child with physical or cognitive impairment over the prospect of treatment failure and childlessness, said Dr. Scotland, from the University of Aberdeen in Scotland. However, they ranked perinatal death as less desirable than treatment failure.

“This is an interesting and surprising finding. Perhaps we should listen more carefully to the values of our patients who want double-embryo transfer,” said Dr. Scotland, noting that the absolute risks of conceiving twins are low, and the chances of twin-related complications are even lower.

“For some of these outcomes you're looking at something like 1% of twin pregnancies that will experience these adverse outcomes. Particularly difficult is that when you listen to a patient's values you have to weigh that against the fact that the risk is to another person—to the future offspring,” he said in an interview.

Indeed it is important to remember that most twin pregnancies have no complications, added California fertility specialist Dr. David Adamson. “While it is absolutely true that the birth defect rate and the abnormality rate is higher in twin pregnancies compared to singleton pregnancies, we still have to remember that the vast majority of twin pregnancies end up with two healthy babies,” he said in an interview. “That is not to say that we should be trying to get twins because we shouldn't—but we cannot make the argument that all [twin] pregnancies turn out as a bad outcome, that is absolutely not true.”

Educating patients about the risks of twin pregnancies can decrease some but not all interest in transferring more than one embryo, reported Dr. Ginny Ryan from the University of Iowa Hospitals in Iowa City. Previous work by her group has shown that IVF patients are three times more likely to desire twins, compared with a fertile population (30% vs. 10%).

In a new study, her group surveyed 120 patients waiting for IVF about their knowledge of fetal and maternal risks associated with twin pregnancies and then gave them an educational session about these risks. Although 30% of the group indicated a desire for twins prior to the educational session, this number dropped to 14% after the session. And whereas 78% of the group wanted a double-embryo transfer before the educational campaign, this dropped to 39% afterward, she said.

However, delving deeper into the issue, patients were asked about their acceptance of SET if it meant it could reduce their chances of becoming pregnant. With this prospect, 50% said they would opt for a double-embryo transfer.

Moreover, when asked whether SET would be acceptable to them if it gave them an equal chance at pregnancy compared with double-embryo transfer, 25% of the subjects said no.

Shortly after this study, Dr. Ryan's clinic implemented a mandatory SET program for women considered high risk for multiple pregnancy, so she could not evaluate whether the education campaign resulted in fewer women choosing double-embryo transfer.

However, she said the study highlights the fact that despite education, a substantial number of patients still want twins.

“While patient desires should be acknowledged, it is equally important to balance this against clinical judgment regarding the health of the patient, offspring, and society,” Dr. Ryan said.

PRAGUE — If given the choice between a singleton or twins, many patients undergoing in-vitro fertilization would prefer twins, according to several studies presented at the annual meeting of the European Society for Human Reproduction and Embryology.

At a time when many fertility clinics are actively trying to reduce their multiple birth rates by limiting the number of embryos they transfer after in-vitro fertilization (IVF), this patient attitude goes against most physicians' concepts of treatment success, said Dr. Graham Scotland, an investigator on one of the studies.

It has been assumed that much of the patient drive for transferring more than one IVF embryo has been linked to increasing their chances of becoming pregnant with a singleton.

But a Danish study has found that while this is true for some couples, almost 60% simply want twins. Dr. Hans Jakob Ingerslev surveyed 588 couples using a 56-item questionnaire and found that 96% wanted two or more children in their family. Roughly 58% of the couples preferred twins, 38% preferred one child at a time, and the rest had no preference, said Dr. Ingerslev of the fertility clinic at Skejby Sygehus, a large university hospital in Aarhus (Denmark).

There were 60 couples in which the female partner wanted twins but the male wanted singletons—giving female gender an odds ratio of 1.65 for wanting twins.

Asked if they would accept a single embryo transfer (SET) if they were given an unlimited number of free cycles, 73% of couples said no. Moreover, offered free IVF treatment to conceive a second child later, 68% said no, Dr. Ingerslev said.

Among subjects who did not want twins, 24% cited risks to the fetus as their reason, while 18% cited maternal risks and 11% cited obstetric complications. Among those wanting twins, 23% cited wanting their child to have a sibling and 22% said they had a positive attitude about twins.

“Counseling these patients is a challenge,” he said.

Another study uncovered the depth of some patients' reluctance to accept SET, although it is unclear whether their motivation was for twins specifically or simply to increase their chances of pregnancy. In a survey of 81 couples waiting for IVF treatment, Dr. Scotland asked patients to weigh the possibility of treatment failure against the types of complications they could face if they were to conceive twins.

In general, patients preferred the idea of having twin-related complications such as a child with physical or cognitive impairment over the prospect of treatment failure and childlessness, said Dr. Scotland, from the University of Aberdeen in Scotland. However, they ranked perinatal death as less desirable than treatment failure.

“This is an interesting and surprising finding. Perhaps we should listen more carefully to the values of our patients who want double-embryo transfer,” said Dr. Scotland, noting that the absolute risks of conceiving twins are low, and the chances of twin-related complications are even lower.

“For some of these outcomes you're looking at something like 1% of twin pregnancies that will experience these adverse outcomes. Particularly difficult is that when you listen to a patient's values you have to weigh that against the fact that the risk is to another person—to the future offspring,” he said in an interview.

Indeed it is important to remember that most twin pregnancies have no complications, added California fertility specialist Dr. David Adamson. “While it is absolutely true that the birth defect rate and the abnormality rate is higher in twin pregnancies compared to singleton pregnancies, we still have to remember that the vast majority of twin pregnancies end up with two healthy babies,” he said in an interview. “That is not to say that we should be trying to get twins because we shouldn't—but we cannot make the argument that all [twin] pregnancies turn out as a bad outcome, that is absolutely not true.”

Educating patients about the risks of twin pregnancies can decrease some but not all interest in transferring more than one embryo, reported Dr. Ginny Ryan from the University of Iowa Hospitals in Iowa City. Previous work by her group has shown that IVF patients are three times more likely to desire twins, compared with a fertile population (30% vs. 10%).

In a new study, her group surveyed 120 patients waiting for IVF about their knowledge of fetal and maternal risks associated with twin pregnancies and then gave them an educational session about these risks. Although 30% of the group indicated a desire for twins prior to the educational session, this number dropped to 14% after the session. And whereas 78% of the group wanted a double-embryo transfer before the educational campaign, this dropped to 39% afterward, she said.

However, delving deeper into the issue, patients were asked about their acceptance of SET if it meant it could reduce their chances of becoming pregnant. With this prospect, 50% said they would opt for a double-embryo transfer.

Moreover, when asked whether SET would be acceptable to them if it gave them an equal chance at pregnancy compared with double-embryo transfer, 25% of the subjects said no.

Shortly after this study, Dr. Ryan's clinic implemented a mandatory SET program for women considered high risk for multiple pregnancy, so she could not evaluate whether the education campaign resulted in fewer women choosing double-embryo transfer.

However, she said the study highlights the fact that despite education, a substantial number of patients still want twins.

“While patient desires should be acknowledged, it is equally important to balance this against clinical judgment regarding the health of the patient, offspring, and society,” Dr. Ryan said.

SAN ANTONIO — A depression prevention course offered during pregnancy significantly reduced the incidence of major depressive episodes before delivery in a group of Hispanic women at high risk for depression, reported Huynh-Nhu Le, Ph.D., at the annual meeting of the Society for Prevention Research. She expects the intervention will ultimately result in reduced rates of postpartum depression as well.

“A lot of research is now moving away from the idea of postpartum depression to a more general idea of pregnancy-related depression. Technically, postpartum depression occurs up to 4 weeks after birth—but in some cases, it may have started before delivery. What we're trying to do is prevent these women from becoming more depressed,” she said in an interview. “To do this, we need to integrate mental health screening into primary care settings.”

Her study included 143 Hispanic women, aged 18–35 years, who were less than 24 weeks pregnant. All were considered at high risk for depression based on their history of depression or a score of 16 or higher on the Center for Epidemiologic Studies Depression Scale (CES-D). The women were randomized either to usual care or to an eight-session intervention that taught them mood regulation skills and provided information about parenting and child development.

Preliminary results from the intervention, measured 8 weeks before delivery, showed a significant decrease in the incidence of major depressive episodes in treated vs. nontreated women (1% vs. 7%), said Dr. Le of George Washington University, Washington.

SAN ANTONIO — A depression prevention course offered during pregnancy significantly reduced the incidence of major depressive episodes before delivery in a group of Hispanic women at high risk for depression, reported Huynh-Nhu Le, Ph.D., at the annual meeting of the Society for Prevention Research. She expects the intervention will ultimately result in reduced rates of postpartum depression as well.

“A lot of research is now moving away from the idea of postpartum depression to a more general idea of pregnancy-related depression. Technically, postpartum depression occurs up to 4 weeks after birth—but in some cases, it may have started before delivery. What we're trying to do is prevent these women from becoming more depressed,” she said in an interview. “To do this, we need to integrate mental health screening into primary care settings.”

Her study included 143 Hispanic women, aged 18–35 years, who were less than 24 weeks pregnant. All were considered at high risk for depression based on their history of depression or a score of 16 or higher on the Center for Epidemiologic Studies Depression Scale (CES-D). The women were randomized either to usual care or to an eight-session intervention that taught them mood regulation skills and provided information about parenting and child development.

Preliminary results from the intervention, measured 8 weeks before delivery, showed a significant decrease in the incidence of major depressive episodes in treated vs. nontreated women (1% vs. 7%), said Dr. Le of George Washington University, Washington.

SAN ANTONIO — A depression prevention course offered during pregnancy significantly reduced the incidence of major depressive episodes before delivery in a group of Hispanic women at high risk for depression, reported Huynh-Nhu Le, Ph.D., at the annual meeting of the Society for Prevention Research. She expects the intervention will ultimately result in reduced rates of postpartum depression as well.

“A lot of research is now moving away from the idea of postpartum depression to a more general idea of pregnancy-related depression. Technically, postpartum depression occurs up to 4 weeks after birth—but in some cases, it may have started before delivery. What we're trying to do is prevent these women from becoming more depressed,” she said in an interview. “To do this, we need to integrate mental health screening into primary care settings.”

Her study included 143 Hispanic women, aged 18–35 years, who were less than 24 weeks pregnant. All were considered at high risk for depression based on their history of depression or a score of 16 or higher on the Center for Epidemiologic Studies Depression Scale (CES-D). The women were randomized either to usual care or to an eight-session intervention that taught them mood regulation skills and provided information about parenting and child development.

Preliminary results from the intervention, measured 8 weeks before delivery, showed a significant decrease in the incidence of major depressive episodes in treated vs. nontreated women (1% vs. 7%), said Dr. Le of George Washington University, Washington.

CHICAGO — In these days of evidence-based medicine, the art of the medical profession may sometimes get lost in the science. But keeping a few simple tricks up one's sleeve can often save valuable time for children with acute problems, Dr. Robert A. Wiebe said at a meeting sponsored by the American College of Emergency Physicians.

Appendicitis

Dr. Wiebe, director of emergency services at Children's Medical Center in Dallas, gave an example of acute appendicitis: painful, potentially life threatening, and yet often vague in its presentation. “Looking at the current perforation rate, we are not doing a good job at identifying these kids early.”

Despite the availability and the evidence supporting computed tomography and ultrasound for diagnosing this condition, he advocates a simpler approach.

Watching a patient's eyes during physical examination can reveal a great deal, said Dr. Wiebe, professor of pediatrics in the division of pediatric emergency medicine at University of Texas Southwestern Medical Center at Dallas. He cited an 18-year-old journal article that changed his approach when he first read it (BMJ 1988;297:837). The authors noted that among patients found to have appendicitis, only 4% closed their eyes on physical examination, compared with 33% who did not have appendicitis. “Voluntary guarding occurs when the patient sees the doctor's hand near a tender area,” Dr. Wiebe explained. In contrast, “a patient aware that there is no pain may consciously or unconsciously close [his or her] eyes during the exam.”

Sudden movements also offer valuable insight in cases of suspected appendicitis, he added. “Pain with sudden movement has good specificity for this.” Asking the patient and parents about pain on the car ride to the hospital is one way to assess this. In addition, asking the patient to reach up and do a “high five” or to hop off the examining table is another way. According to the American Pediatric Surgical Association, “holding a hand above the child's head and challenging him or her to jump and touch is irresistible to most children except those in whom pain is produced,” he noted.

Bacterial Meningitis

Pain on movement also is a telltale sign in infants with suspected bacterial meningitis, he said. “It's not unusual to go quite some time, maybe even through an entire residency program, before seeing a case of bacterial meningitis these days,” he said. “When a case comes in, it's hard to recognize, and unfortunately it will likely be in a younger child who has not yet been immunized.”

He advocates the “bounce test”—bouncing the infant fairly vigorously on one's knee—as a good screening tool. Children with bacterial meningitis will cry and arch their backs to protect the sensory nerve while you are bouncing them. “For viral meningitis, this is less reliable,” he said. “This test has high sensitivity and very low specificity.”

Retropharyngeal Abscess

“Bolte's sign” is another simple, fast screen—this time for retropharyngeal abscess, said Dr. Wiebe. First described in 2003, it is based on the simple fact that “kids won't look up when their retropharyngeal space is filled with pus” (Pediatrics 2003;111:1394–8). The study of 64 patients, median age 36 months, found that 45% demonstrated limited neck extension on physical examination, 36.5% had torticollis, 12.5% had limited neck flexion, 1.5% had stridor, and 1.5% had wheezing. “Think [retropharyngeal abscess] when a child will not fully extend his neck to look up,” he advised.

Hypertrophic Pyloric Stenosis

He recommends removing the baby's shirt and feeding between 2 and 4 ounces of Pedialyte while keeping one hand on the baby's abdomen. “The baby will usually stop feeding and look very calm for a short period before you see the reverse peristaltic wave and projectile vomiting,” he said. Immediately after the vomiting, the abdominal wall relaxes and the pylorus remains in spasm, making it easy to palpate.

Most surgeons will usually require an ultrasound confirmation. However, starting with this approach usually saves some time. “We have been diagnosing infants earlier. It is usually a 4-week diagnosis rather than a 6-week one.”?

CHICAGO — In these days of evidence-based medicine, the art of the medical profession may sometimes get lost in the science. But keeping a few simple tricks up one's sleeve can often save valuable time for children with acute problems, Dr. Robert A. Wiebe said at a meeting sponsored by the American College of Emergency Physicians.

Appendicitis

Dr. Wiebe, director of emergency services at Children's Medical Center in Dallas, gave an example of acute appendicitis: painful, potentially life threatening, and yet often vague in its presentation. “Looking at the current perforation rate, we are not doing a good job at identifying these kids early.”

Despite the availability and the evidence supporting computed tomography and ultrasound for diagnosing this condition, he advocates a simpler approach.

Watching a patient's eyes during physical examination can reveal a great deal, said Dr. Wiebe, professor of pediatrics in the division of pediatric emergency medicine at University of Texas Southwestern Medical Center at Dallas. He cited an 18-year-old journal article that changed his approach when he first read it (BMJ 1988;297:837). The authors noted that among patients found to have appendicitis, only 4% closed their eyes on physical examination, compared with 33% who did not have appendicitis. “Voluntary guarding occurs when the patient sees the doctor's hand near a tender area,” Dr. Wiebe explained. In contrast, “a patient aware that there is no pain may consciously or unconsciously close [his or her] eyes during the exam.”

Sudden movements also offer valuable insight in cases of suspected appendicitis, he added. “Pain with sudden movement has good specificity for this.” Asking the patient and parents about pain on the car ride to the hospital is one way to assess this. In addition, asking the patient to reach up and do a “high five” or to hop off the examining table is another way. According to the American Pediatric Surgical Association, “holding a hand above the child's head and challenging him or her to jump and touch is irresistible to most children except those in whom pain is produced,” he noted.

Bacterial Meningitis

Pain on movement also is a telltale sign in infants with suspected bacterial meningitis, he said. “It's not unusual to go quite some time, maybe even through an entire residency program, before seeing a case of bacterial meningitis these days,” he said. “When a case comes in, it's hard to recognize, and unfortunately it will likely be in a younger child who has not yet been immunized.”

He advocates the “bounce test”—bouncing the infant fairly vigorously on one's knee—as a good screening tool. Children with bacterial meningitis will cry and arch their backs to protect the sensory nerve while you are bouncing them. “For viral meningitis, this is less reliable,” he said. “This test has high sensitivity and very low specificity.”

Retropharyngeal Abscess

“Bolte's sign” is another simple, fast screen—this time for retropharyngeal abscess, said Dr. Wiebe. First described in 2003, it is based on the simple fact that “kids won't look up when their retropharyngeal space is filled with pus” (Pediatrics 2003;111:1394–8). The study of 64 patients, median age 36 months, found that 45% demonstrated limited neck extension on physical examination, 36.5% had torticollis, 12.5% had limited neck flexion, 1.5% had stridor, and 1.5% had wheezing. “Think [retropharyngeal abscess] when a child will not fully extend his neck to look up,” he advised.

Hypertrophic Pyloric Stenosis

He recommends removing the baby's shirt and feeding between 2 and 4 ounces of Pedialyte while keeping one hand on the baby's abdomen. “The baby will usually stop feeding and look very calm for a short period before you see the reverse peristaltic wave and projectile vomiting,” he said. Immediately after the vomiting, the abdominal wall relaxes and the pylorus remains in spasm, making it easy to palpate.

Most surgeons will usually require an ultrasound confirmation. However, starting with this approach usually saves some time. “We have been diagnosing infants earlier. It is usually a 4-week diagnosis rather than a 6-week one.”?

CHICAGO — In these days of evidence-based medicine, the art of the medical profession may sometimes get lost in the science. But keeping a few simple tricks up one's sleeve can often save valuable time for children with acute problems, Dr. Robert A. Wiebe said at a meeting sponsored by the American College of Emergency Physicians.

Appendicitis

Dr. Wiebe, director of emergency services at Children's Medical Center in Dallas, gave an example of acute appendicitis: painful, potentially life threatening, and yet often vague in its presentation. “Looking at the current perforation rate, we are not doing a good job at identifying these kids early.”

Despite the availability and the evidence supporting computed tomography and ultrasound for diagnosing this condition, he advocates a simpler approach.

Watching a patient's eyes during physical examination can reveal a great deal, said Dr. Wiebe, professor of pediatrics in the division of pediatric emergency medicine at University of Texas Southwestern Medical Center at Dallas. He cited an 18-year-old journal article that changed his approach when he first read it (BMJ 1988;297:837). The authors noted that among patients found to have appendicitis, only 4% closed their eyes on physical examination, compared with 33% who did not have appendicitis. “Voluntary guarding occurs when the patient sees the doctor's hand near a tender area,” Dr. Wiebe explained. In contrast, “a patient aware that there is no pain may consciously or unconsciously close [his or her] eyes during the exam.”

Sudden movements also offer valuable insight in cases of suspected appendicitis, he added. “Pain with sudden movement has good specificity for this.” Asking the patient and parents about pain on the car ride to the hospital is one way to assess this. In addition, asking the patient to reach up and do a “high five” or to hop off the examining table is another way. According to the American Pediatric Surgical Association, “holding a hand above the child's head and challenging him or her to jump and touch is irresistible to most children except those in whom pain is produced,” he noted.

Bacterial Meningitis

Pain on movement also is a telltale sign in infants with suspected bacterial meningitis, he said. “It's not unusual to go quite some time, maybe even through an entire residency program, before seeing a case of bacterial meningitis these days,” he said. “When a case comes in, it's hard to recognize, and unfortunately it will likely be in a younger child who has not yet been immunized.”

He advocates the “bounce test”—bouncing the infant fairly vigorously on one's knee—as a good screening tool. Children with bacterial meningitis will cry and arch their backs to protect the sensory nerve while you are bouncing them. “For viral meningitis, this is less reliable,” he said. “This test has high sensitivity and very low specificity.”

Retropharyngeal Abscess

“Bolte's sign” is another simple, fast screen—this time for retropharyngeal abscess, said Dr. Wiebe. First described in 2003, it is based on the simple fact that “kids won't look up when their retropharyngeal space is filled with pus” (Pediatrics 2003;111:1394–8). The study of 64 patients, median age 36 months, found that 45% demonstrated limited neck extension on physical examination, 36.5% had torticollis, 12.5% had limited neck flexion, 1.5% had stridor, and 1.5% had wheezing. “Think [retropharyngeal abscess] when a child will not fully extend his neck to look up,” he advised.

Hypertrophic Pyloric Stenosis

He recommends removing the baby's shirt and feeding between 2 and 4 ounces of Pedialyte while keeping one hand on the baby's abdomen. “The baby will usually stop feeding and look very calm for a short period before you see the reverse peristaltic wave and projectile vomiting,” he said. Immediately after the vomiting, the abdominal wall relaxes and the pylorus remains in spasm, making it easy to palpate.

Most surgeons will usually require an ultrasound confirmation. However, starting with this approach usually saves some time. “We have been diagnosing infants earlier. It is usually a 4-week diagnosis rather than a 6-week one.”?

CHICAGO — A child's death from unsuspected meningococcal disease can keenly heighten an emergency physician's awareness that there are few clues about which children with fever and petechiae are safe to send home, Dr. Jane Knapp said at a meeting sponsored by the American College of Emergency Physicians.

“You can't pick them out,” cautioned Dr. Knapp, professor of pediatrics at the University of Missouri-Kansas City and a pediatric emergency physician at Children's Mercy Hospital in Kansas City, Mo. “But we can't admit every child with fever and petechiae.”

Neither clinical nor hematologic features are reliable predictors of meningococcal infection, she added.

Dr. Knapp presented a case from early in her career of a 7-year-old boy who was afebrile on admission. Mental status changes followed by the development of a petechial rash in the emergency department prompted treatment for meningococcemia, but he died shortly afterward.

The case highlights the fact that lack of fever is not always a reassuring sign and does not exclude meningococcal infection, she said.

One study of 24 children with meningococcal disease found that 5 had axillary temperatures of less than 37.5° C (Arch. Dis. Child. 2001;85:218).

Another study of 381 febrile children with meningococcal infection found that 10% did not have a petechial/purpuric rash, although they did appear unwell (Pediatrics 1999;103:E20). An additional 45 (12%) of the children had what the authors called “unsuspected meningococcal disease” (UMD), meaning they were seen in the hospital and discharged with a later positive culture. Of those 45 children, 24 were recalled when their blood culture results came in positive, 14 returned because they had worsened or developed a rash, 5 returned for a scheduled follow-up, and 2 returned because of persistent fever. Two children in the UMD group died after returning to the hospital—one 6 hours and the other 12 hours later.

Comparing the children with UMD to a control group of culture-negative febrile patients, the authors found that the UMD group was on average significantly younger (9 months vs. 14 months), with 82% of them aged between 3 and 36 months. The UMD group also had significantly higher band counts on average (14 vs. 7), compared with the culture-negative patients. However, the authors concluded that the predictive value of the band count is low in this group, because UMD is uncommon in young febrile pediatric patients.

“That study suggests that neither the clinical examination nor the CBC [complete blood count] reliably distinguishes young children with UMD from those with viral illnesses,” Dr. Knapp said.

Because this is an area of legal risk for physicians, she said, they are left with a perplexing challenge. One guideline to follow for managing children with a nonblanching rash is whether they appear unwell. If they appear unwell, Dr. Knapp suggested simply admitting them and treating for invasive meningococcal infection. “Could you compromise and send someone home with antibiotics?” she asked. “I would be pretty liberal.”

CHICAGO — A child's death from unsuspected meningococcal disease can keenly heighten an emergency physician's awareness that there are few clues about which children with fever and petechiae are safe to send home, Dr. Jane Knapp said at a meeting sponsored by the American College of Emergency Physicians.

“You can't pick them out,” cautioned Dr. Knapp, professor of pediatrics at the University of Missouri-Kansas City and a pediatric emergency physician at Children's Mercy Hospital in Kansas City, Mo. “But we can't admit every child with fever and petechiae.”

Neither clinical nor hematologic features are reliable predictors of meningococcal infection, she added.

Dr. Knapp presented a case from early in her career of a 7-year-old boy who was afebrile on admission. Mental status changes followed by the development of a petechial rash in the emergency department prompted treatment for meningococcemia, but he died shortly afterward.

The case highlights the fact that lack of fever is not always a reassuring sign and does not exclude meningococcal infection, she said.

One study of 24 children with meningococcal disease found that 5 had axillary temperatures of less than 37.5° C (Arch. Dis. Child. 2001;85:218).

Another study of 381 febrile children with meningococcal infection found that 10% did not have a petechial/purpuric rash, although they did appear unwell (Pediatrics 1999;103:E20). An additional 45 (12%) of the children had what the authors called “unsuspected meningococcal disease” (UMD), meaning they were seen in the hospital and discharged with a later positive culture. Of those 45 children, 24 were recalled when their blood culture results came in positive, 14 returned because they had worsened or developed a rash, 5 returned for a scheduled follow-up, and 2 returned because of persistent fever. Two children in the UMD group died after returning to the hospital—one 6 hours and the other 12 hours later.

Comparing the children with UMD to a control group of culture-negative febrile patients, the authors found that the UMD group was on average significantly younger (9 months vs. 14 months), with 82% of them aged between 3 and 36 months. The UMD group also had significantly higher band counts on average (14 vs. 7), compared with the culture-negative patients. However, the authors concluded that the predictive value of the band count is low in this group, because UMD is uncommon in young febrile pediatric patients.

“That study suggests that neither the clinical examination nor the CBC [complete blood count] reliably distinguishes young children with UMD from those with viral illnesses,” Dr. Knapp said.

Because this is an area of legal risk for physicians, she said, they are left with a perplexing challenge. One guideline to follow for managing children with a nonblanching rash is whether they appear unwell. If they appear unwell, Dr. Knapp suggested simply admitting them and treating for invasive meningococcal infection. “Could you compromise and send someone home with antibiotics?” she asked. “I would be pretty liberal.”

CHICAGO — A child's death from unsuspected meningococcal disease can keenly heighten an emergency physician's awareness that there are few clues about which children with fever and petechiae are safe to send home, Dr. Jane Knapp said at a meeting sponsored by the American College of Emergency Physicians.

“You can't pick them out,” cautioned Dr. Knapp, professor of pediatrics at the University of Missouri-Kansas City and a pediatric emergency physician at Children's Mercy Hospital in Kansas City, Mo. “But we can't admit every child with fever and petechiae.”

Neither clinical nor hematologic features are reliable predictors of meningococcal infection, she added.

Dr. Knapp presented a case from early in her career of a 7-year-old boy who was afebrile on admission. Mental status changes followed by the development of a petechial rash in the emergency department prompted treatment for meningococcemia, but he died shortly afterward.

The case highlights the fact that lack of fever is not always a reassuring sign and does not exclude meningococcal infection, she said.

One study of 24 children with meningococcal disease found that 5 had axillary temperatures of less than 37.5° C (Arch. Dis. Child. 2001;85:218).

Another study of 381 febrile children with meningococcal infection found that 10% did not have a petechial/purpuric rash, although they did appear unwell (Pediatrics 1999;103:E20). An additional 45 (12%) of the children had what the authors called “unsuspected meningococcal disease” (UMD), meaning they were seen in the hospital and discharged with a later positive culture. Of those 45 children, 24 were recalled when their blood culture results came in positive, 14 returned because they had worsened or developed a rash, 5 returned for a scheduled follow-up, and 2 returned because of persistent fever. Two children in the UMD group died after returning to the hospital—one 6 hours and the other 12 hours later.

Comparing the children with UMD to a control group of culture-negative febrile patients, the authors found that the UMD group was on average significantly younger (9 months vs. 14 months), with 82% of them aged between 3 and 36 months. The UMD group also had significantly higher band counts on average (14 vs. 7), compared with the culture-negative patients. However, the authors concluded that the predictive value of the band count is low in this group, because UMD is uncommon in young febrile pediatric patients.

“That study suggests that neither the clinical examination nor the CBC [complete blood count] reliably distinguishes young children with UMD from those with viral illnesses,” Dr. Knapp said.

Because this is an area of legal risk for physicians, she said, they are left with a perplexing challenge. One guideline to follow for managing children with a nonblanching rash is whether they appear unwell. If they appear unwell, Dr. Knapp suggested simply admitting them and treating for invasive meningococcal infection. “Could you compromise and send someone home with antibiotics?” she asked. “I would be pretty liberal.”

SAN ANTONIO — Primary care physicians may be able to quickly and accurately assess and stratify an adolescent's 1-year risk of developing new-onset major depression using a 20-item checklist, Dr. Benjamin W. Van Voorhees said at the annual meeting of the Society for Prevention Research.

The information could then help physicians guide patients and parents toward reducing the risk using a variety of therapeutic interventions, including a Web-based approach that he has developed and is now testing, said Dr. Van Voorhees, a pediatrician and internist at the University of Chicago.

“Primary care physicians use a brief list of questions to stratify a person's 10-year risk of cardiovascular disease and to guide their interventions, so we wanted to make this depression risk model just as easy to use in the primary care setting,” he said in an interview.

He said primary care providers now have no alternative to medications or psychotherapy referrals for patients with mild to moderate depression symptoms. “We are trying to create an alternative—to reshape the current paradigm,” Dr. Van Voorhees said.

He and his colleagues developed their depression risk prediction model using data from the National Longitudinal Study of Adolescent Health, which involved 6,504 adolescents in grades 7 through 12. Baseline data on the subjects, collected in 1995, included home, school, and parent surveys. Follow-up data were collected 1 year later on 4,791 subjects.

Using a subsample of 3,814 subjects, none of whom had major depression at baseline and for whom 1-year follow-up data were available, Dr. Van Voorhees identified gender, ethnicity, weight, height, and age as well as 15 independent variables that could be used to predict the patient's development of major depression in the coming year. The model, which has a sensitivity of 74% and a specificity of 87%, includes information on the adolescent's social connectedness, quality of life, mood, and other factors.

His research group plans to formally test the prediction model in a prospective study of youth at risk for developing major depression.

In a separate analysis of the same subset, Dr. Van Voorhees also identified a list of factors that appeared to protect against the development of depression. For example, on a personal level, an adolescent's self-rated health, adequate sleep, and self-efficacy seemed protective. On a family and community level, participation, attachment, and competence seemed protective.

“My idea is that if we have a good risk prediction model, we can basically calculate an adolescent's risk at a well-child visit and then give that information to the child and parent,” he said. “Then they can choose whether they want to be involved in a preventive intervention.

“We believe that such interventions could be done at low cost and, if designed well, could be efficacious and very acceptable to patients and physicians in community settings.”

He suggests patients identified as having moderate risk might consider improving the protective factors in their lives, although whether changes in these areas could actually reduce risk is something that still needs to be explored in a randomized, controlled trial, he added.

For patients identified as having higher depression risk, he suggests a more structured intervention such as Project CATCH-IT, a combined primary care/Web-based intervention that he has developed.

Project CATCH-IT, designed for adolescents who are at moderate to high risk for depression, involves an initial “motivational interview” with a primary care physician aimed at helping the adolescent identify personal goals and understand how depression could jeopardize those goals.

During this session, the primary care physician also focuses on boosting the adolescent's motivation to change and increasing his or her interest in the Web-based intervention (a demonstration can be seen at www.animateband.com/siteX/Untitled-1.html

The intervention concludes with a follow-up visit with the primary care physician. If no benefit is observed at this stage, Dr. Van Voorhees advises face-to-face sessions with a mental health professional.

In a pilot test of Project CATCH-IT, Dr. Van Voorhees' group observed benefits of the intervention among 14 late adolescents who were at high risk for depression (Can. Child Adolesc. Psychiatry Rev. 2005;14:40–3). “Completers experienced favorable changes in known risk factors with effect sizes similar to those of other preventive interventions for depression,” they wrote. However, with no control group in the study, “we cannot know to what degree these changes would have occurred without an intervention,” they added.

Dr. Van Voorhees is now enrolling primary care practices to test the intervention in a larger study.

The aim of depression risk prediction and early intervention is to prevent the development of more serious mental illness, but Dr. Van Voorhees cautions about the potential adverse effects of this approach. “When you are dealing with young people who may be vulnerable and somewhat pessimistic, telling them that they are at risk for depression may make them feel stigmatized,” he said. “So the way we approach this is to talk in terms of resiliency.

“We tell them they have high, medium, or low resiliency. High resiliency would mean almost no risk of depression, whereas low would mean they need to take care of themselves.”

SAN ANTONIO — Primary care physicians may be able to quickly and accurately assess and stratify an adolescent's 1-year risk of developing new-onset major depression using a 20-item checklist, Dr. Benjamin W. Van Voorhees said at the annual meeting of the Society for Prevention Research.

The information could then help physicians guide patients and parents toward reducing the risk using a variety of therapeutic interventions, including a Web-based approach that he has developed and is now testing, said Dr. Van Voorhees, a pediatrician and internist at the University of Chicago.

“Primary care physicians use a brief list of questions to stratify a person's 10-year risk of cardiovascular disease and to guide their interventions, so we wanted to make this depression risk model just as easy to use in the primary care setting,” he said in an interview.

He said primary care providers now have no alternative to medications or psychotherapy referrals for patients with mild to moderate depression symptoms. “We are trying to create an alternative—to reshape the current paradigm,” Dr. Van Voorhees said.

He and his colleagues developed their depression risk prediction model using data from the National Longitudinal Study of Adolescent Health, which involved 6,504 adolescents in grades 7 through 12. Baseline data on the subjects, collected in 1995, included home, school, and parent surveys. Follow-up data were collected 1 year later on 4,791 subjects.

Using a subsample of 3,814 subjects, none of whom had major depression at baseline and for whom 1-year follow-up data were available, Dr. Van Voorhees identified gender, ethnicity, weight, height, and age as well as 15 independent variables that could be used to predict the patient's development of major depression in the coming year. The model, which has a sensitivity of 74% and a specificity of 87%, includes information on the adolescent's social connectedness, quality of life, mood, and other factors.

His research group plans to formally test the prediction model in a prospective study of youth at risk for developing major depression.

In a separate analysis of the same subset, Dr. Van Voorhees also identified a list of factors that appeared to protect against the development of depression. For example, on a personal level, an adolescent's self-rated health, adequate sleep, and self-efficacy seemed protective. On a family and community level, participation, attachment, and competence seemed protective.

“My idea is that if we have a good risk prediction model, we can basically calculate an adolescent's risk at a well-child visit and then give that information to the child and parent,” he said. “Then they can choose whether they want to be involved in a preventive intervention.

“We believe that such interventions could be done at low cost and, if designed well, could be efficacious and very acceptable to patients and physicians in community settings.”

He suggests patients identified as having moderate risk might consider improving the protective factors in their lives, although whether changes in these areas could actually reduce risk is something that still needs to be explored in a randomized, controlled trial, he added.

For patients identified as having higher depression risk, he suggests a more structured intervention such as Project CATCH-IT, a combined primary care/Web-based intervention that he has developed.

Project CATCH-IT, designed for adolescents who are at moderate to high risk for depression, involves an initial “motivational interview” with a primary care physician aimed at helping the adolescent identify personal goals and understand how depression could jeopardize those goals.

During this session, the primary care physician also focuses on boosting the adolescent's motivation to change and increasing his or her interest in the Web-based intervention (a demonstration can be seen at www.animateband.com/siteX/Untitled-1.html

The intervention concludes with a follow-up visit with the primary care physician. If no benefit is observed at this stage, Dr. Van Voorhees advises face-to-face sessions with a mental health professional.

In a pilot test of Project CATCH-IT, Dr. Van Voorhees' group observed benefits of the intervention among 14 late adolescents who were at high risk for depression (Can. Child Adolesc. Psychiatry Rev. 2005;14:40–3). “Completers experienced favorable changes in known risk factors with effect sizes similar to those of other preventive interventions for depression,” they wrote. However, with no control group in the study, “we cannot know to what degree these changes would have occurred without an intervention,” they added.

Dr. Van Voorhees is now enrolling primary care practices to test the intervention in a larger study.

The aim of depression risk prediction and early intervention is to prevent the development of more serious mental illness, but Dr. Van Voorhees cautions about the potential adverse effects of this approach. “When you are dealing with young people who may be vulnerable and somewhat pessimistic, telling them that they are at risk for depression may make them feel stigmatized,” he said. “So the way we approach this is to talk in terms of resiliency.

“We tell them they have high, medium, or low resiliency. High resiliency would mean almost no risk of depression, whereas low would mean they need to take care of themselves.”

SAN ANTONIO — Primary care physicians may be able to quickly and accurately assess and stratify an adolescent's 1-year risk of developing new-onset major depression using a 20-item checklist, Dr. Benjamin W. Van Voorhees said at the annual meeting of the Society for Prevention Research.

The information could then help physicians guide patients and parents toward reducing the risk using a variety of therapeutic interventions, including a Web-based approach that he has developed and is now testing, said Dr. Van Voorhees, a pediatrician and internist at the University of Chicago.

“Primary care physicians use a brief list of questions to stratify a person's 10-year risk of cardiovascular disease and to guide their interventions, so we wanted to make this depression risk model just as easy to use in the primary care setting,” he said in an interview.

He said primary care providers now have no alternative to medications or psychotherapy referrals for patients with mild to moderate depression symptoms. “We are trying to create an alternative—to reshape the current paradigm,” Dr. Van Voorhees said.

He and his colleagues developed their depression risk prediction model using data from the National Longitudinal Study of Adolescent Health, which involved 6,504 adolescents in grades 7 through 12. Baseline data on the subjects, collected in 1995, included home, school, and parent surveys. Follow-up data were collected 1 year later on 4,791 subjects.

Using a subsample of 3,814 subjects, none of whom had major depression at baseline and for whom 1-year follow-up data were available, Dr. Van Voorhees identified gender, ethnicity, weight, height, and age as well as 15 independent variables that could be used to predict the patient's development of major depression in the coming year. The model, which has a sensitivity of 74% and a specificity of 87%, includes information on the adolescent's social connectedness, quality of life, mood, and other factors.

His research group plans to formally test the prediction model in a prospective study of youth at risk for developing major depression.

In a separate analysis of the same subset, Dr. Van Voorhees also identified a list of factors that appeared to protect against the development of depression. For example, on a personal level, an adolescent's self-rated health, adequate sleep, and self-efficacy seemed protective. On a family and community level, participation, attachment, and competence seemed protective.

“My idea is that if we have a good risk prediction model, we can basically calculate an adolescent's risk at a well-child visit and then give that information to the child and parent,” he said. “Then they can choose whether they want to be involved in a preventive intervention.

“We believe that such interventions could be done at low cost and, if designed well, could be efficacious and very acceptable to patients and physicians in community settings.”

He suggests patients identified as having moderate risk might consider improving the protective factors in their lives, although whether changes in these areas could actually reduce risk is something that still needs to be explored in a randomized, controlled trial, he added.

For patients identified as having higher depression risk, he suggests a more structured intervention such as Project CATCH-IT, a combined primary care/Web-based intervention that he has developed.

Project CATCH-IT, designed for adolescents who are at moderate to high risk for depression, involves an initial “motivational interview” with a primary care physician aimed at helping the adolescent identify personal goals and understand how depression could jeopardize those goals.

During this session, the primary care physician also focuses on boosting the adolescent's motivation to change and increasing his or her interest in the Web-based intervention (a demonstration can be seen at www.animateband.com/siteX/Untitled-1.html

The intervention concludes with a follow-up visit with the primary care physician. If no benefit is observed at this stage, Dr. Van Voorhees advises face-to-face sessions with a mental health professional.

In a pilot test of Project CATCH-IT, Dr. Van Voorhees' group observed benefits of the intervention among 14 late adolescents who were at high risk for depression (Can. Child Adolesc. Psychiatry Rev. 2005;14:40–3). “Completers experienced favorable changes in known risk factors with effect sizes similar to those of other preventive interventions for depression,” they wrote. However, with no control group in the study, “we cannot know to what degree these changes would have occurred without an intervention,” they added.

Dr. Van Voorhees is now enrolling primary care practices to test the intervention in a larger study.

The aim of depression risk prediction and early intervention is to prevent the development of more serious mental illness, but Dr. Van Voorhees cautions about the potential adverse effects of this approach. “When you are dealing with young people who may be vulnerable and somewhat pessimistic, telling them that they are at risk for depression may make them feel stigmatized,” he said. “So the way we approach this is to talk in terms of resiliency.

“We tell them they have high, medium, or low resiliency. High resiliency would mean almost no risk of depression, whereas low would mean they need to take care of themselves.”