Timothy F. Kirn

LAS VEGAS — Drug-eluting stents have not worked as well in the peripheral vasculature as they have in the coronary arteries, but that doesn't mean that investigations should be abandoned, Gary Ansel, M.D., said at a meeting on vascular interventions sponsored by Medical Media Communications.

So far, clinical trials in which drug-eluting stents were compared with bare stents in the periphery have shown that restenosis in distant vessels is a different process, said Dr. Ansel, a peripheral vascular disease specialist who practices in Columbus, Ohio.

Trials in the renal arteries and the superficial femoral artery have not shown any demonstrable benefit from drug elution, but there has been some indication of benefit. In addition, most of the trials have been small and, therefore, not definitive.

The findings of the Sirolimus-Coated Cordis SMART Nitinol Self-Expanding Stent for the Treatment of Obstructing Superficial Femoral Artery Disease (SIROCCO) trial, for example, suggested that the drug sirolimus might have had some positive benefit for distant vessels, and that a significant benefit might be found with longer follow-up of the patients.

The trials have been complicated by the fact that the bare nitinol stents used for comparison have performed better than was expected at the outset of the trials, Dr. Ansel added.

On the negative side, one study of sirolimus in renal arteries suggested the drug may have an adverse effect on kidney function.

Drugs still considered worth investigating in stent trials include paclitaxel and bisphosphonates.

The way to get better results with stents in the periphery may not be in the use of a different agent, but, rather, in using stents with different drug delivery rates from those in coronary stents, Dr. Ansel said.

LAS VEGAS — Drug-eluting stents have not worked as well in the peripheral vasculature as they have in the coronary arteries, but that doesn't mean that investigations should be abandoned, Gary Ansel, M.D., said at a meeting on vascular interventions sponsored by Medical Media Communications.

So far, clinical trials in which drug-eluting stents were compared with bare stents in the periphery have shown that restenosis in distant vessels is a different process, said Dr. Ansel, a peripheral vascular disease specialist who practices in Columbus, Ohio.

Trials in the renal arteries and the superficial femoral artery have not shown any demonstrable benefit from drug elution, but there has been some indication of benefit. In addition, most of the trials have been small and, therefore, not definitive.

The findings of the Sirolimus-Coated Cordis SMART Nitinol Self-Expanding Stent for the Treatment of Obstructing Superficial Femoral Artery Disease (SIROCCO) trial, for example, suggested that the drug sirolimus might have had some positive benefit for distant vessels, and that a significant benefit might be found with longer follow-up of the patients.

The trials have been complicated by the fact that the bare nitinol stents used for comparison have performed better than was expected at the outset of the trials, Dr. Ansel added.

On the negative side, one study of sirolimus in renal arteries suggested the drug may have an adverse effect on kidney function.

Drugs still considered worth investigating in stent trials include paclitaxel and bisphosphonates.

The way to get better results with stents in the periphery may not be in the use of a different agent, but, rather, in using stents with different drug delivery rates from those in coronary stents, Dr. Ansel said.

LAS VEGAS — Drug-eluting stents have not worked as well in the peripheral vasculature as they have in the coronary arteries, but that doesn't mean that investigations should be abandoned, Gary Ansel, M.D., said at a meeting on vascular interventions sponsored by Medical Media Communications.

So far, clinical trials in which drug-eluting stents were compared with bare stents in the periphery have shown that restenosis in distant vessels is a different process, said Dr. Ansel, a peripheral vascular disease specialist who practices in Columbus, Ohio.

Trials in the renal arteries and the superficial femoral artery have not shown any demonstrable benefit from drug elution, but there has been some indication of benefit. In addition, most of the trials have been small and, therefore, not definitive.

The findings of the Sirolimus-Coated Cordis SMART Nitinol Self-Expanding Stent for the Treatment of Obstructing Superficial Femoral Artery Disease (SIROCCO) trial, for example, suggested that the drug sirolimus might have had some positive benefit for distant vessels, and that a significant benefit might be found with longer follow-up of the patients.

The trials have been complicated by the fact that the bare nitinol stents used for comparison have performed better than was expected at the outset of the trials, Dr. Ansel added.

On the negative side, one study of sirolimus in renal arteries suggested the drug may have an adverse effect on kidney function.

Drugs still considered worth investigating in stent trials include paclitaxel and bisphosphonates.

The way to get better results with stents in the periphery may not be in the use of a different agent, but, rather, in using stents with different drug delivery rates from those in coronary stents, Dr. Ansel said.

CHICAGO — Only 13% of U.S. patients who are diagnosed with hepatocellular carcinoma receive potentially curative therapy, Hashem B. El-Serag, M.D., said at the annual Digestive Disease Week.

Moreover, only one-third of those patients with single lesions get potentially curative therapy, according to Dr. El-Serag of Baylor College of Medicine, Houston.

In other countries, potentially curative therapy appears to be used at much higher rates: 40% of all hepatocellular carcinoma patients in a series from Barcelona recieved such therapy as did 30% of all patients aged over 75 years in Italy.

“There is significant underutilization of potentially curative therapy, even among those with favorable clinical features,” said Dr. El-Serag.

He and his colleagues examined data for a nationwide cancer registry. This registry is now linked to Medicare data. “The reasons for this observation need to be examined and corrected,” Dr. El-Serag said.

Dr. El-Serag's study included data from 2,963 patients with hepatocellular carcinoma who were diagnosed between 1992 and 1999 and who were entered into any 1 of 11 different regional cancer registries.

In addition to the 13% of patients who received potentially curative therapy, 4% received transarterial chemoablation and 35% received systemic chemotherapy or radiotherapy. The other 48% of the patients received no treatment at all.

The study found that age and ethnicity affected which patients received potentially curative therapy.

Among those aged 65–74 years, the rate of the use of potentially curative therapy was 17%, and among racial groups, Asian people had the highest rate of potentially curative therapy—24%—because they had more single and small tumors.

But neither of those characteristics had as strong an influence on rate as did the region where the cancer was diagnosed, Dr. El-Serag said, although he did not identify which regions had the highest or lowest rates.

The rates of attempted therapy did increase over time in the study, but this improvement was not dramatic, he added. For example, between 1992 and 1995, 53% of patients received no treatment. But the rate fell to 43% between 1996 and 1999.

Many physicians have had too dismal a view of the prognosis of hepatocellular carcinoma, and that perception does not appear to have changed much between 1999 and the present, Dr. El-Serag said. Specifically, the majority of physicians still do not know that liver transplantation is an option for liver cancer, he added.

CHICAGO — Only 13% of U.S. patients who are diagnosed with hepatocellular carcinoma receive potentially curative therapy, Hashem B. El-Serag, M.D., said at the annual Digestive Disease Week.

Moreover, only one-third of those patients with single lesions get potentially curative therapy, according to Dr. El-Serag of Baylor College of Medicine, Houston.

In other countries, potentially curative therapy appears to be used at much higher rates: 40% of all hepatocellular carcinoma patients in a series from Barcelona recieved such therapy as did 30% of all patients aged over 75 years in Italy.

“There is significant underutilization of potentially curative therapy, even among those with favorable clinical features,” said Dr. El-Serag.

He and his colleagues examined data for a nationwide cancer registry. This registry is now linked to Medicare data. “The reasons for this observation need to be examined and corrected,” Dr. El-Serag said.

Dr. El-Serag's study included data from 2,963 patients with hepatocellular carcinoma who were diagnosed between 1992 and 1999 and who were entered into any 1 of 11 different regional cancer registries.

In addition to the 13% of patients who received potentially curative therapy, 4% received transarterial chemoablation and 35% received systemic chemotherapy or radiotherapy. The other 48% of the patients received no treatment at all.

The study found that age and ethnicity affected which patients received potentially curative therapy.

Among those aged 65–74 years, the rate of the use of potentially curative therapy was 17%, and among racial groups, Asian people had the highest rate of potentially curative therapy—24%—because they had more single and small tumors.

But neither of those characteristics had as strong an influence on rate as did the region where the cancer was diagnosed, Dr. El-Serag said, although he did not identify which regions had the highest or lowest rates.

The rates of attempted therapy did increase over time in the study, but this improvement was not dramatic, he added. For example, between 1992 and 1995, 53% of patients received no treatment. But the rate fell to 43% between 1996 and 1999.

Many physicians have had too dismal a view of the prognosis of hepatocellular carcinoma, and that perception does not appear to have changed much between 1999 and the present, Dr. El-Serag said. Specifically, the majority of physicians still do not know that liver transplantation is an option for liver cancer, he added.

CHICAGO — Only 13% of U.S. patients who are diagnosed with hepatocellular carcinoma receive potentially curative therapy, Hashem B. El-Serag, M.D., said at the annual Digestive Disease Week.

Moreover, only one-third of those patients with single lesions get potentially curative therapy, according to Dr. El-Serag of Baylor College of Medicine, Houston.

In other countries, potentially curative therapy appears to be used at much higher rates: 40% of all hepatocellular carcinoma patients in a series from Barcelona recieved such therapy as did 30% of all patients aged over 75 years in Italy.

“There is significant underutilization of potentially curative therapy, even among those with favorable clinical features,” said Dr. El-Serag.

He and his colleagues examined data for a nationwide cancer registry. This registry is now linked to Medicare data. “The reasons for this observation need to be examined and corrected,” Dr. El-Serag said.

Dr. El-Serag's study included data from 2,963 patients with hepatocellular carcinoma who were diagnosed between 1992 and 1999 and who were entered into any 1 of 11 different regional cancer registries.

In addition to the 13% of patients who received potentially curative therapy, 4% received transarterial chemoablation and 35% received systemic chemotherapy or radiotherapy. The other 48% of the patients received no treatment at all.

The study found that age and ethnicity affected which patients received potentially curative therapy.

Among those aged 65–74 years, the rate of the use of potentially curative therapy was 17%, and among racial groups, Asian people had the highest rate of potentially curative therapy—24%—because they had more single and small tumors.

But neither of those characteristics had as strong an influence on rate as did the region where the cancer was diagnosed, Dr. El-Serag said, although he did not identify which regions had the highest or lowest rates.

The rates of attempted therapy did increase over time in the study, but this improvement was not dramatic, he added. For example, between 1992 and 1995, 53% of patients received no treatment. But the rate fell to 43% between 1996 and 1999.

Many physicians have had too dismal a view of the prognosis of hepatocellular carcinoma, and that perception does not appear to have changed much between 1999 and the present, Dr. El-Serag said. Specifically, the majority of physicians still do not know that liver transplantation is an option for liver cancer, he added.

VANCOUVER, B.C. — Two new studies presented at the Sixth World Congress on Melanoma have linked tanning bed use and melanoma.

“The year 2005 sees the first real, indisputable evidence that tanning bed use contributes to melanoma risk,” said Philippe Autier, M.D., of the Jules Bordet Institute, Brussels, the chair of the session at which the studies were presented.

The larger of the two studies looked at tanning bed use by 106,000 Scandinavian women enrolled in a lifestyle study in the early 1990s, part of which involved a survey in which they were asked if they used tanning equipment, when, and for how long.

When the survey was repeated with a portion of the subjects 5 years after the initial one, the answers of 79% of surveys agreed completely with how the subjects had answered before, and 96% had a high, but not exact, agreement, which suggested that the reports were very accurate, said Marit Bragelien Veierød, Ph.D., of the department of biostatistics at the University of Oslo.

With the data broken into age groups by decade, those in the 20- to 29-year age group who used tanning equipment one or more times a month had a 57% higher relative risk of melanoma, those in the 30- to 39-year age group had a 44% increased risk, and those in the 40- to 49-year age group a had 69% higher risk.

By comparing all those who reported having ever used tanning equipment with those who had never used it, the study showed that there was an increased relative risk of 33% associated with tanning equipment.

In the second study, investigators compared tanning equipment use in subjects enrolled in the international Genes, Environment, and Melanoma Study who had single primary melanomas (406 cases) with those who had multiple primary melanomas (125 cases).

Overall, 29% of the subjects had used tanning equipment, and the mean age at initial diagnosis of melanoma in those who had used it was 10 years younger than it was those who had never used it, said Maria Chiu, of Cancer Care Ontario, in Toronto.

When adjusted for age and sex, the data indicated that tanning equipment use was associated with a higher risk of multiple melanomas, with an odds ratio of 1.68.

For those in the highest quartile of frequency of use, the odds ratio was 1.87. For those whose first exposure was before age 20 years, the odds ratio was 2.63, Ms. Chiu said.

The data indicate a strong dose response to tanning equipment use, Ms. Chiu added.

Previous studies in which investigators had attempted to associate tanning bed use with melanoma were generally inconclusive, probably because they tended to be too small to determine statistical power, the investigators and others said at the meeting.

VANCOUVER, B.C. — Two new studies presented at the Sixth World Congress on Melanoma have linked tanning bed use and melanoma.

“The year 2005 sees the first real, indisputable evidence that tanning bed use contributes to melanoma risk,” said Philippe Autier, M.D., of the Jules Bordet Institute, Brussels, the chair of the session at which the studies were presented.

The larger of the two studies looked at tanning bed use by 106,000 Scandinavian women enrolled in a lifestyle study in the early 1990s, part of which involved a survey in which they were asked if they used tanning equipment, when, and for how long.

When the survey was repeated with a portion of the subjects 5 years after the initial one, the answers of 79% of surveys agreed completely with how the subjects had answered before, and 96% had a high, but not exact, agreement, which suggested that the reports were very accurate, said Marit Bragelien Veierød, Ph.D., of the department of biostatistics at the University of Oslo.

With the data broken into age groups by decade, those in the 20- to 29-year age group who used tanning equipment one or more times a month had a 57% higher relative risk of melanoma, those in the 30- to 39-year age group had a 44% increased risk, and those in the 40- to 49-year age group a had 69% higher risk.

By comparing all those who reported having ever used tanning equipment with those who had never used it, the study showed that there was an increased relative risk of 33% associated with tanning equipment.

In the second study, investigators compared tanning equipment use in subjects enrolled in the international Genes, Environment, and Melanoma Study who had single primary melanomas (406 cases) with those who had multiple primary melanomas (125 cases).

Overall, 29% of the subjects had used tanning equipment, and the mean age at initial diagnosis of melanoma in those who had used it was 10 years younger than it was those who had never used it, said Maria Chiu, of Cancer Care Ontario, in Toronto.

When adjusted for age and sex, the data indicated that tanning equipment use was associated with a higher risk of multiple melanomas, with an odds ratio of 1.68.

For those in the highest quartile of frequency of use, the odds ratio was 1.87. For those whose first exposure was before age 20 years, the odds ratio was 2.63, Ms. Chiu said.

The data indicate a strong dose response to tanning equipment use, Ms. Chiu added.

Previous studies in which investigators had attempted to associate tanning bed use with melanoma were generally inconclusive, probably because they tended to be too small to determine statistical power, the investigators and others said at the meeting.

VANCOUVER, B.C. — Two new studies presented at the Sixth World Congress on Melanoma have linked tanning bed use and melanoma.

“The year 2005 sees the first real, indisputable evidence that tanning bed use contributes to melanoma risk,” said Philippe Autier, M.D., of the Jules Bordet Institute, Brussels, the chair of the session at which the studies were presented.

The larger of the two studies looked at tanning bed use by 106,000 Scandinavian women enrolled in a lifestyle study in the early 1990s, part of which involved a survey in which they were asked if they used tanning equipment, when, and for how long.

When the survey was repeated with a portion of the subjects 5 years after the initial one, the answers of 79% of surveys agreed completely with how the subjects had answered before, and 96% had a high, but not exact, agreement, which suggested that the reports were very accurate, said Marit Bragelien Veierød, Ph.D., of the department of biostatistics at the University of Oslo.

With the data broken into age groups by decade, those in the 20- to 29-year age group who used tanning equipment one or more times a month had a 57% higher relative risk of melanoma, those in the 30- to 39-year age group had a 44% increased risk, and those in the 40- to 49-year age group a had 69% higher risk.

By comparing all those who reported having ever used tanning equipment with those who had never used it, the study showed that there was an increased relative risk of 33% associated with tanning equipment.

In the second study, investigators compared tanning equipment use in subjects enrolled in the international Genes, Environment, and Melanoma Study who had single primary melanomas (406 cases) with those who had multiple primary melanomas (125 cases).

Overall, 29% of the subjects had used tanning equipment, and the mean age at initial diagnosis of melanoma in those who had used it was 10 years younger than it was those who had never used it, said Maria Chiu, of Cancer Care Ontario, in Toronto.

When adjusted for age and sex, the data indicated that tanning equipment use was associated with a higher risk of multiple melanomas, with an odds ratio of 1.68.

For those in the highest quartile of frequency of use, the odds ratio was 1.87. For those whose first exposure was before age 20 years, the odds ratio was 2.63, Ms. Chiu said.

The data indicate a strong dose response to tanning equipment use, Ms. Chiu added.

Previous studies in which investigators had attempted to associate tanning bed use with melanoma were generally inconclusive, probably because they tended to be too small to determine statistical power, the investigators and others said at the meeting.

CHICAGO — Many individuals diagnosed with irritable bowel syndrome could actually have pelvic floor dysfunction, a condition that can be much more remediable, according to a study conducted at the Mayo Clinic.

Considerable overlap exists in the symptoms of pelvic floor dysfunction and irritable bowel syndrome (IBS), particularly constipation-predominant irritable bowel syndrome, even though the Rome diagnostic criteria for functional bowel disorders consider the two distinctly separate entities, Christopher N. Andrews, M.D., the main investigator of the study, said in a poster presentation at the annual Digestive Disease Week.

The study showed that few patients who present with straining, lumpy or hard stools, or a sensation of incomplete evacuation get a pelvic floor work-up as they should. Those with pelvic floor dysfunction probably could be helped by biofeedback training of the pelvic floor muscles, Dr. Andrews said in an interview.

The study included 450 patients being seen at the Mayo Clinic, Rochester, Minn.; 77% of participants were women. The patients either had diagnosed IBS or were undergoing a scintigraphic GI transit study. The patients filled out a questionnaire to help investigators determine if they had symptoms the Rome criteria listed with pelvic floor dysfunction. Study investigators reviewed patients' medical records to see if the subjects had received anorectal defecation testing.

A total of 194 of the patients had at least two symptoms of pelvic floor dysfunction as outlined by the Rome criteria. But only 50 patients (11%) had undergone pelvic floor dysfunction testing, usually balloon-expulsion manometry. Of those 50 patients, 13 (26%) had an abnormal test result. Patients with constipation-predominant IBS were more likely to get testing, but they were also more likely to have overlapping symptoms and an abnormal test result.

Of the 78 patients with constipation-predominant IBS, 76 had at least two symptoms of pelvic floor dysfunction. Of those patients, 24 (32%) underwent testing, and among those tested, 8 (33%) had an abnormal test result.

Anorectal defecation testing of patients with IBS-type symptoms is thought to have become more common at highly specialized centers in recent years, Dr. Andrews said in the interview. But if the rate of testing is so low at the Mayo Clinic, it is probably not done enough anywhere.

One problem that may discourage testing is that there are different tests but no real standards concerning which to use, he added.

The Rome criteria symptoms of pelvic floor dysfunction include straining when defecating more than 25% of the time, lumpy or hard stools more than 25% of the time, incomplete evacuation more than 25% of the time, sensation of anorectal blocking more than 25% of the time, manual maneuvers to facilitate defecation more than 25% of the time, or one or fewer defecations per week.

CHICAGO — Many individuals diagnosed with irritable bowel syndrome could actually have pelvic floor dysfunction, a condition that can be much more remediable, according to a study conducted at the Mayo Clinic.

Considerable overlap exists in the symptoms of pelvic floor dysfunction and irritable bowel syndrome (IBS), particularly constipation-predominant irritable bowel syndrome, even though the Rome diagnostic criteria for functional bowel disorders consider the two distinctly separate entities, Christopher N. Andrews, M.D., the main investigator of the study, said in a poster presentation at the annual Digestive Disease Week.

The study showed that few patients who present with straining, lumpy or hard stools, or a sensation of incomplete evacuation get a pelvic floor work-up as they should. Those with pelvic floor dysfunction probably could be helped by biofeedback training of the pelvic floor muscles, Dr. Andrews said in an interview.

The study included 450 patients being seen at the Mayo Clinic, Rochester, Minn.; 77% of participants were women. The patients either had diagnosed IBS or were undergoing a scintigraphic GI transit study. The patients filled out a questionnaire to help investigators determine if they had symptoms the Rome criteria listed with pelvic floor dysfunction. Study investigators reviewed patients' medical records to see if the subjects had received anorectal defecation testing.

A total of 194 of the patients had at least two symptoms of pelvic floor dysfunction as outlined by the Rome criteria. But only 50 patients (11%) had undergone pelvic floor dysfunction testing, usually balloon-expulsion manometry. Of those 50 patients, 13 (26%) had an abnormal test result. Patients with constipation-predominant IBS were more likely to get testing, but they were also more likely to have overlapping symptoms and an abnormal test result.

Of the 78 patients with constipation-predominant IBS, 76 had at least two symptoms of pelvic floor dysfunction. Of those patients, 24 (32%) underwent testing, and among those tested, 8 (33%) had an abnormal test result.

Anorectal defecation testing of patients with IBS-type symptoms is thought to have become more common at highly specialized centers in recent years, Dr. Andrews said in the interview. But if the rate of testing is so low at the Mayo Clinic, it is probably not done enough anywhere.

One problem that may discourage testing is that there are different tests but no real standards concerning which to use, he added.

The Rome criteria symptoms of pelvic floor dysfunction include straining when defecating more than 25% of the time, lumpy or hard stools more than 25% of the time, incomplete evacuation more than 25% of the time, sensation of anorectal blocking more than 25% of the time, manual maneuvers to facilitate defecation more than 25% of the time, or one or fewer defecations per week.

CHICAGO — Many individuals diagnosed with irritable bowel syndrome could actually have pelvic floor dysfunction, a condition that can be much more remediable, according to a study conducted at the Mayo Clinic.

Considerable overlap exists in the symptoms of pelvic floor dysfunction and irritable bowel syndrome (IBS), particularly constipation-predominant irritable bowel syndrome, even though the Rome diagnostic criteria for functional bowel disorders consider the two distinctly separate entities, Christopher N. Andrews, M.D., the main investigator of the study, said in a poster presentation at the annual Digestive Disease Week.

The study showed that few patients who present with straining, lumpy or hard stools, or a sensation of incomplete evacuation get a pelvic floor work-up as they should. Those with pelvic floor dysfunction probably could be helped by biofeedback training of the pelvic floor muscles, Dr. Andrews said in an interview.

The study included 450 patients being seen at the Mayo Clinic, Rochester, Minn.; 77% of participants were women. The patients either had diagnosed IBS or were undergoing a scintigraphic GI transit study. The patients filled out a questionnaire to help investigators determine if they had symptoms the Rome criteria listed with pelvic floor dysfunction. Study investigators reviewed patients' medical records to see if the subjects had received anorectal defecation testing.

A total of 194 of the patients had at least two symptoms of pelvic floor dysfunction as outlined by the Rome criteria. But only 50 patients (11%) had undergone pelvic floor dysfunction testing, usually balloon-expulsion manometry. Of those 50 patients, 13 (26%) had an abnormal test result. Patients with constipation-predominant IBS were more likely to get testing, but they were also more likely to have overlapping symptoms and an abnormal test result.

Of the 78 patients with constipation-predominant IBS, 76 had at least two symptoms of pelvic floor dysfunction. Of those patients, 24 (32%) underwent testing, and among those tested, 8 (33%) had an abnormal test result.

Anorectal defecation testing of patients with IBS-type symptoms is thought to have become more common at highly specialized centers in recent years, Dr. Andrews said in the interview. But if the rate of testing is so low at the Mayo Clinic, it is probably not done enough anywhere.

One problem that may discourage testing is that there are different tests but no real standards concerning which to use, he added.

The Rome criteria symptoms of pelvic floor dysfunction include straining when defecating more than 25% of the time, lumpy or hard stools more than 25% of the time, incomplete evacuation more than 25% of the time, sensation of anorectal blocking more than 25% of the time, manual maneuvers to facilitate defecation more than 25% of the time, or one or fewer defecations per week.

NAPLES, FLA. — Several new technologies are becoming available to follow and visualize melanomas, but practicing dermatologists will be best served if they focus on learning dermoscopy, Harold S. Rabinovitz, M.D., said at the annual meeting of the Florida Society for Dermatology and Dermatologic Surgery.

Current estimates are that about 15% of U.S. dermatologists use dermoscopy, said Dr. Rabinovitz, of the department of dermatology at the University of Miami.

Even experienced dermatologists are not perfect at differentiating between malignant melanoma and benign melanocytic nevi, he said. Studies have found the overall diagnostic accuracy of dermatologists to be about 65%. Dermoscopy improves diagnostic accuracy over visual inspection by about 15%, Dr. Rabinovitz said.

Once dermoscopy technique is learned, it does not take much extra time to do, which makes it convenient and practical. The obstacle is learning to do dermoscopy well, he added.

"There is a steep learning curve," he said. "In dermoscopy, a little knowledge is worse than no knowledge. It is only a diagnostic aid, as pathology is the reference standard."

The other melanoma-diagnosing technologies that are available or in development, he said, are impractical or their future is uncertain.

For instance, total-body photography, even with today's digital photography and computer software, requires too much time to take and review the photographs. When Dr. Rabinovitz does total-body photography for appropriate, high-risk patients, he says he gives patients CD copies of the digital photos. When they have a concern about a particular nevus, they can compare it to the photographic record. "Full-body photography, in my opinion, is for the patients."

Confocal imaging, like dermoscopy, allows visualization of structures below the surface, but on the horizontal plane. This imaging system is being used in several studies, including one on tracking imiquimod treatment of in situ melanoma. But confocal imaging is a research tool and probably will remain one, he said, because dermoscopy is available, and because biopsy will remain the standard of diagnosis.

Image-analyzing computer programs for use with dermoscopy and photography are in development, and could have great promise because the computer might be able to pick up things the eye may miss, he said. But their introduction into the market is probably at least a few years away, even if problems in analyzing some histologic features can be worked out.

"My advice to you is to learn dermoscopy," Dr. Rabinovitz said. "Over the years, I believe this will be an important tool and aid for dermatologists in the management of their patients."

Dr. Rabinovitz said he knows of four companies that sell dermoscopy equipment. He did not recommend any one product, but he did advise that the best course of action is to buy the latest model of equipment.

NAPLES, FLA. — Several new technologies are becoming available to follow and visualize melanomas, but practicing dermatologists will be best served if they focus on learning dermoscopy, Harold S. Rabinovitz, M.D., said at the annual meeting of the Florida Society for Dermatology and Dermatologic Surgery.

Current estimates are that about 15% of U.S. dermatologists use dermoscopy, said Dr. Rabinovitz, of the department of dermatology at the University of Miami.

Even experienced dermatologists are not perfect at differentiating between malignant melanoma and benign melanocytic nevi, he said. Studies have found the overall diagnostic accuracy of dermatologists to be about 65%. Dermoscopy improves diagnostic accuracy over visual inspection by about 15%, Dr. Rabinovitz said.

Once dermoscopy technique is learned, it does not take much extra time to do, which makes it convenient and practical. The obstacle is learning to do dermoscopy well, he added.

"There is a steep learning curve," he said. "In dermoscopy, a little knowledge is worse than no knowledge. It is only a diagnostic aid, as pathology is the reference standard."

The other melanoma-diagnosing technologies that are available or in development, he said, are impractical or their future is uncertain.

For instance, total-body photography, even with today's digital photography and computer software, requires too much time to take and review the photographs. When Dr. Rabinovitz does total-body photography for appropriate, high-risk patients, he says he gives patients CD copies of the digital photos. When they have a concern about a particular nevus, they can compare it to the photographic record. "Full-body photography, in my opinion, is for the patients."

Confocal imaging, like dermoscopy, allows visualization of structures below the surface, but on the horizontal plane. This imaging system is being used in several studies, including one on tracking imiquimod treatment of in situ melanoma. But confocal imaging is a research tool and probably will remain one, he said, because dermoscopy is available, and because biopsy will remain the standard of diagnosis.

Image-analyzing computer programs for use with dermoscopy and photography are in development, and could have great promise because the computer might be able to pick up things the eye may miss, he said. But their introduction into the market is probably at least a few years away, even if problems in analyzing some histologic features can be worked out.

"My advice to you is to learn dermoscopy," Dr. Rabinovitz said. "Over the years, I believe this will be an important tool and aid for dermatologists in the management of their patients."

Dr. Rabinovitz said he knows of four companies that sell dermoscopy equipment. He did not recommend any one product, but he did advise that the best course of action is to buy the latest model of equipment.

NAPLES, FLA. — Several new technologies are becoming available to follow and visualize melanomas, but practicing dermatologists will be best served if they focus on learning dermoscopy, Harold S. Rabinovitz, M.D., said at the annual meeting of the Florida Society for Dermatology and Dermatologic Surgery.

Current estimates are that about 15% of U.S. dermatologists use dermoscopy, said Dr. Rabinovitz, of the department of dermatology at the University of Miami.

Even experienced dermatologists are not perfect at differentiating between malignant melanoma and benign melanocytic nevi, he said. Studies have found the overall diagnostic accuracy of dermatologists to be about 65%. Dermoscopy improves diagnostic accuracy over visual inspection by about 15%, Dr. Rabinovitz said.

Once dermoscopy technique is learned, it does not take much extra time to do, which makes it convenient and practical. The obstacle is learning to do dermoscopy well, he added.

"There is a steep learning curve," he said. "In dermoscopy, a little knowledge is worse than no knowledge. It is only a diagnostic aid, as pathology is the reference standard."

The other melanoma-diagnosing technologies that are available or in development, he said, are impractical or their future is uncertain.

For instance, total-body photography, even with today's digital photography and computer software, requires too much time to take and review the photographs. When Dr. Rabinovitz does total-body photography for appropriate, high-risk patients, he says he gives patients CD copies of the digital photos. When they have a concern about a particular nevus, they can compare it to the photographic record. "Full-body photography, in my opinion, is for the patients."

Confocal imaging, like dermoscopy, allows visualization of structures below the surface, but on the horizontal plane. This imaging system is being used in several studies, including one on tracking imiquimod treatment of in situ melanoma. But confocal imaging is a research tool and probably will remain one, he said, because dermoscopy is available, and because biopsy will remain the standard of diagnosis.

Image-analyzing computer programs for use with dermoscopy and photography are in development, and could have great promise because the computer might be able to pick up things the eye may miss, he said. But their introduction into the market is probably at least a few years away, even if problems in analyzing some histologic features can be worked out.

"My advice to you is to learn dermoscopy," Dr. Rabinovitz said. "Over the years, I believe this will be an important tool and aid for dermatologists in the management of their patients."

Dr. Rabinovitz said he knows of four companies that sell dermoscopy equipment. He did not recommend any one product, but he did advise that the best course of action is to buy the latest model of equipment.

CHICAGO — Individuals with gastroesophageal reflux fare better when they see a doctor than when they treat themselves with over-the-counter medications, but even for the majority of those patients, symptoms are not totally resolved, Roger Jones, M.D., said at the annual Digestive Disease Week.

In a multinational survey of 1,908 individuals with gastroesophageal reflux disease (GERD), 81% of those who had never seen a doctor for the condition but who took over-the-counter medications continued to have unresolved symptoms.

That compared with 68% of patients with a formal diagnosis taking a prescription medicine, Dr. Jones, a professor of general practice at the Guy's, King's, and St. Thomas' School of Medicine, London, said in a poster presentation.

The researchers surveyed persons who had previously been identified by a larger telephone survey conducted in the United States and three European countries. Half of the people in the group had been given a formal diagnosis of GERD, and the other half were individuals who reported two or more episodes of heartburn in the week prior to being contacted, but who had never consulted a physician about their symptoms.

Of those without a diagnosis, 78% (721) reported taking over-the-counter medications. About two-thirds (65%) of those who had taken over-the-counter medications said their symptoms were improved since first taking medication. Still, 81% had residual symptoms.

Of those with a diagnosis, 74% (727 patients) had a prescription, and 80% of those had some improvement since first taking their prescribed medication. Eighty-seven percent of 537 patients receiving a proton pump inhibitor either alone or in combination reported improvement. Ninety-one percent of those taking only a proton pump inhibitor reported some improvement. Still, 68% of those taking a prescription drug continued to have residual symptoms.

The investigators had no trouble finding individuals with heartburn for their survey, Dr. Jones noted. Results of previous surveys have suggested that as many as one-third of adults experience reflux symptoms.

Previous studies have noted that the most common reason proton pump inhibitors do not work as well as they might is a lack of full compliance with a daily regimen.

CHICAGO — Individuals with gastroesophageal reflux fare better when they see a doctor than when they treat themselves with over-the-counter medications, but even for the majority of those patients, symptoms are not totally resolved, Roger Jones, M.D., said at the annual Digestive Disease Week.

In a multinational survey of 1,908 individuals with gastroesophageal reflux disease (GERD), 81% of those who had never seen a doctor for the condition but who took over-the-counter medications continued to have unresolved symptoms.

That compared with 68% of patients with a formal diagnosis taking a prescription medicine, Dr. Jones, a professor of general practice at the Guy's, King's, and St. Thomas' School of Medicine, London, said in a poster presentation.

The researchers surveyed persons who had previously been identified by a larger telephone survey conducted in the United States and three European countries. Half of the people in the group had been given a formal diagnosis of GERD, and the other half were individuals who reported two or more episodes of heartburn in the week prior to being contacted, but who had never consulted a physician about their symptoms.

Of those without a diagnosis, 78% (721) reported taking over-the-counter medications. About two-thirds (65%) of those who had taken over-the-counter medications said their symptoms were improved since first taking medication. Still, 81% had residual symptoms.

Of those with a diagnosis, 74% (727 patients) had a prescription, and 80% of those had some improvement since first taking their prescribed medication. Eighty-seven percent of 537 patients receiving a proton pump inhibitor either alone or in combination reported improvement. Ninety-one percent of those taking only a proton pump inhibitor reported some improvement. Still, 68% of those taking a prescription drug continued to have residual symptoms.

The investigators had no trouble finding individuals with heartburn for their survey, Dr. Jones noted. Results of previous surveys have suggested that as many as one-third of adults experience reflux symptoms.

Previous studies have noted that the most common reason proton pump inhibitors do not work as well as they might is a lack of full compliance with a daily regimen.

CHICAGO — Individuals with gastroesophageal reflux fare better when they see a doctor than when they treat themselves with over-the-counter medications, but even for the majority of those patients, symptoms are not totally resolved, Roger Jones, M.D., said at the annual Digestive Disease Week.

In a multinational survey of 1,908 individuals with gastroesophageal reflux disease (GERD), 81% of those who had never seen a doctor for the condition but who took over-the-counter medications continued to have unresolved symptoms.

That compared with 68% of patients with a formal diagnosis taking a prescription medicine, Dr. Jones, a professor of general practice at the Guy's, King's, and St. Thomas' School of Medicine, London, said in a poster presentation.

The researchers surveyed persons who had previously been identified by a larger telephone survey conducted in the United States and three European countries. Half of the people in the group had been given a formal diagnosis of GERD, and the other half were individuals who reported two or more episodes of heartburn in the week prior to being contacted, but who had never consulted a physician about their symptoms.

Of those without a diagnosis, 78% (721) reported taking over-the-counter medications. About two-thirds (65%) of those who had taken over-the-counter medications said their symptoms were improved since first taking medication. Still, 81% had residual symptoms.

Of those with a diagnosis, 74% (727 patients) had a prescription, and 80% of those had some improvement since first taking their prescribed medication. Eighty-seven percent of 537 patients receiving a proton pump inhibitor either alone or in combination reported improvement. Ninety-one percent of those taking only a proton pump inhibitor reported some improvement. Still, 68% of those taking a prescription drug continued to have residual symptoms.

The investigators had no trouble finding individuals with heartburn for their survey, Dr. Jones noted. Results of previous surveys have suggested that as many as one-third of adults experience reflux symptoms.

Previous studies have noted that the most common reason proton pump inhibitors do not work as well as they might is a lack of full compliance with a daily regimen.

SNOWMASS, COLO. — Lyme disease patients without erythema migrans were thought to be rare—until they showed up frequently in a large trial of the Lyme disease vaccine, Linda K. Bockenstedt, M.D., said at a symposium sponsored by the American College of Rheumatology.

In that trial, 269 cases of Lyme disease were detected by serum assay, of which 42, or about 16%, involved patients without erythema migrans. However, those patients did have flulike symptoms, such as malaise, fever, myalgia, migratory arthralgias, occipital headache, and neck stiffness. They did not have any upper respiratory symptoms, such as cough.

Additionally, Dr. Bockenstedt, of the rheumatology section at Yale University, New Haven, Conn., noted that there may soon be a way to monitor Lyme disease treatment.

A new enzyme-linked immunoabsorbent assay for Lyme disease, the C6 ELISA (Immunetics Inc.), tests for a single small peptide expressed by the Borrelia burgdorferi spirochete during active infection, instead of the whole organism.

Research has shown that antibody titers to this antigen drop fourfold when an infected individual has been successfully treated. Dr. Bockenstedt added that forthcoming study results will confirm the ability of the assay to adequately detect a drop in the antigen level.

SNOWMASS, COLO. — Lyme disease patients without erythema migrans were thought to be rare—until they showed up frequently in a large trial of the Lyme disease vaccine, Linda K. Bockenstedt, M.D., said at a symposium sponsored by the American College of Rheumatology.

In that trial, 269 cases of Lyme disease were detected by serum assay, of which 42, or about 16%, involved patients without erythema migrans. However, those patients did have flulike symptoms, such as malaise, fever, myalgia, migratory arthralgias, occipital headache, and neck stiffness. They did not have any upper respiratory symptoms, such as cough.

Additionally, Dr. Bockenstedt, of the rheumatology section at Yale University, New Haven, Conn., noted that there may soon be a way to monitor Lyme disease treatment.

A new enzyme-linked immunoabsorbent assay for Lyme disease, the C6 ELISA (Immunetics Inc.), tests for a single small peptide expressed by the Borrelia burgdorferi spirochete during active infection, instead of the whole organism.

Research has shown that antibody titers to this antigen drop fourfold when an infected individual has been successfully treated. Dr. Bockenstedt added that forthcoming study results will confirm the ability of the assay to adequately detect a drop in the antigen level.

SNOWMASS, COLO. — Lyme disease patients without erythema migrans were thought to be rare—until they showed up frequently in a large trial of the Lyme disease vaccine, Linda K. Bockenstedt, M.D., said at a symposium sponsored by the American College of Rheumatology.

In that trial, 269 cases of Lyme disease were detected by serum assay, of which 42, or about 16%, involved patients without erythema migrans. However, those patients did have flulike symptoms, such as malaise, fever, myalgia, migratory arthralgias, occipital headache, and neck stiffness. They did not have any upper respiratory symptoms, such as cough.

Additionally, Dr. Bockenstedt, of the rheumatology section at Yale University, New Haven, Conn., noted that there may soon be a way to monitor Lyme disease treatment.

A new enzyme-linked immunoabsorbent assay for Lyme disease, the C6 ELISA (Immunetics Inc.), tests for a single small peptide expressed by the Borrelia burgdorferi spirochete during active infection, instead of the whole organism.

Research has shown that antibody titers to this antigen drop fourfold when an infected individual has been successfully treated. Dr. Bockenstedt added that forthcoming study results will confirm the ability of the assay to adequately detect a drop in the antigen level.

JACKSON HOLE, WYO. — Procedural ultrasound for use in placing central venous catheters and performing thoracentesis and arthrocentesis will make life easier, faster, and safer for emergency physicians, Luis Haro, M.D., said at a meeting on high-risk emergency medicine.

Procedural ultrasound for the emergency department is so new that even most professors in academic centers do not know how to do it, said Dr. Haro of the department of emergency medicine at the Mayo Clinic, Rochester, Minn.

But soon everyone will use it, he predicted. The advantages are clear, and, according to a survey, 60% of emergency departments have ultrasound capabilities, although they may not be doing procedures, Dr. Haro said at the meeting, sponsored by the Mayo Clinic.

At the clinic, the emergency department already has three ultrasound machines that can be used for procedural ultrasound, Dr. Haro said.

“This is cutting edge,” he added. “In our institution, we do a 6-hour ultrasound lecture for our physicians.”

Mastering the techniques is not difficult, since most emergency physicians know how to do these procedures blindly, Dr. Haro said.

The trick is mastering the concepts of ultrasound technology, and even that is basically simple, Dr. Haro said.

The concepts are these: First, for a procedure, one does not necessarily want the biggest ultrasound probe, but a probe that produces a linear field of view rather than a pie-shaped one. Second, procedures are generally about locating or evacuating fluid, and fluid is dark or black in an ultrasound picture. And third, lower-frequency waves penetrate deeper into tissue than higher-frequency waves.

The use of ultrasound for placing a central line can significantly reduce the likelihood of missing the jugular vein and hitting the carotid artery, he said. In one study, arterial puncture occurred 7% of the time when the procedure was done blindly. That rate was reduced to 1% with ultrasound. Minor complications also are reduced.

According to the literature, physicians correctly place a central line on the first try less than 40% of the time when they do it blindly. But with ultrasound, they succeed the first time about 80% of the time.

Studies also have shown that ultrasound-guided central vein catheterizations take an average of about 2 minutes less than blind catheterization, and they are revealing things about nuances of anatomy not previously appreciated, Dr. Haro said.

Similar advantages have been demonstrated for ultrasound-guided arthrocentesis and thoracentesis.

In arthrocentesis, ultrasound is used for evaluating the knee or other large joints before performing the procedure, rather than for guiding the needle, which is not that difficult.

Ultrasound clearly shows if puffiness represents fluid inside or outside the joint, Dr. Haro said.

In thoracentesis, the results of studies have clearly shown a reduced risk of pneumothorax, he added.

Given the simplicity and benefits of ultrasound, all emergency physicians who are able should give it a try, Dr. Haro suggested.

“You're doing these procedures all the time,” he said. “You do arthrocentesis. You do thoracentesis. You place central lines. You're already doing it blindly, so just take an extra look if you have a probe there.”

JACKSON HOLE, WYO. — Procedural ultrasound for use in placing central venous catheters and performing thoracentesis and arthrocentesis will make life easier, faster, and safer for emergency physicians, Luis Haro, M.D., said at a meeting on high-risk emergency medicine.

Procedural ultrasound for the emergency department is so new that even most professors in academic centers do not know how to do it, said Dr. Haro of the department of emergency medicine at the Mayo Clinic, Rochester, Minn.

But soon everyone will use it, he predicted. The advantages are clear, and, according to a survey, 60% of emergency departments have ultrasound capabilities, although they may not be doing procedures, Dr. Haro said at the meeting, sponsored by the Mayo Clinic.

At the clinic, the emergency department already has three ultrasound machines that can be used for procedural ultrasound, Dr. Haro said.

“This is cutting edge,” he added. “In our institution, we do a 6-hour ultrasound lecture for our physicians.”

Mastering the techniques is not difficult, since most emergency physicians know how to do these procedures blindly, Dr. Haro said.

The trick is mastering the concepts of ultrasound technology, and even that is basically simple, Dr. Haro said.

The concepts are these: First, for a procedure, one does not necessarily want the biggest ultrasound probe, but a probe that produces a linear field of view rather than a pie-shaped one. Second, procedures are generally about locating or evacuating fluid, and fluid is dark or black in an ultrasound picture. And third, lower-frequency waves penetrate deeper into tissue than higher-frequency waves.

The use of ultrasound for placing a central line can significantly reduce the likelihood of missing the jugular vein and hitting the carotid artery, he said. In one study, arterial puncture occurred 7% of the time when the procedure was done blindly. That rate was reduced to 1% with ultrasound. Minor complications also are reduced.

According to the literature, physicians correctly place a central line on the first try less than 40% of the time when they do it blindly. But with ultrasound, they succeed the first time about 80% of the time.

Studies also have shown that ultrasound-guided central vein catheterizations take an average of about 2 minutes less than blind catheterization, and they are revealing things about nuances of anatomy not previously appreciated, Dr. Haro said.

Similar advantages have been demonstrated for ultrasound-guided arthrocentesis and thoracentesis.

In arthrocentesis, ultrasound is used for evaluating the knee or other large joints before performing the procedure, rather than for guiding the needle, which is not that difficult.

Ultrasound clearly shows if puffiness represents fluid inside or outside the joint, Dr. Haro said.

In thoracentesis, the results of studies have clearly shown a reduced risk of pneumothorax, he added.

Given the simplicity and benefits of ultrasound, all emergency physicians who are able should give it a try, Dr. Haro suggested.

“You're doing these procedures all the time,” he said. “You do arthrocentesis. You do thoracentesis. You place central lines. You're already doing it blindly, so just take an extra look if you have a probe there.”

JACKSON HOLE, WYO. — Procedural ultrasound for use in placing central venous catheters and performing thoracentesis and arthrocentesis will make life easier, faster, and safer for emergency physicians, Luis Haro, M.D., said at a meeting on high-risk emergency medicine.

Procedural ultrasound for the emergency department is so new that even most professors in academic centers do not know how to do it, said Dr. Haro of the department of emergency medicine at the Mayo Clinic, Rochester, Minn.

But soon everyone will use it, he predicted. The advantages are clear, and, according to a survey, 60% of emergency departments have ultrasound capabilities, although they may not be doing procedures, Dr. Haro said at the meeting, sponsored by the Mayo Clinic.

At the clinic, the emergency department already has three ultrasound machines that can be used for procedural ultrasound, Dr. Haro said.

“This is cutting edge,” he added. “In our institution, we do a 6-hour ultrasound lecture for our physicians.”

Mastering the techniques is not difficult, since most emergency physicians know how to do these procedures blindly, Dr. Haro said.

The trick is mastering the concepts of ultrasound technology, and even that is basically simple, Dr. Haro said.

The concepts are these: First, for a procedure, one does not necessarily want the biggest ultrasound probe, but a probe that produces a linear field of view rather than a pie-shaped one. Second, procedures are generally about locating or evacuating fluid, and fluid is dark or black in an ultrasound picture. And third, lower-frequency waves penetrate deeper into tissue than higher-frequency waves.

The use of ultrasound for placing a central line can significantly reduce the likelihood of missing the jugular vein and hitting the carotid artery, he said. In one study, arterial puncture occurred 7% of the time when the procedure was done blindly. That rate was reduced to 1% with ultrasound. Minor complications also are reduced.

According to the literature, physicians correctly place a central line on the first try less than 40% of the time when they do it blindly. But with ultrasound, they succeed the first time about 80% of the time.

Studies also have shown that ultrasound-guided central vein catheterizations take an average of about 2 minutes less than blind catheterization, and they are revealing things about nuances of anatomy not previously appreciated, Dr. Haro said.

Similar advantages have been demonstrated for ultrasound-guided arthrocentesis and thoracentesis.

In arthrocentesis, ultrasound is used for evaluating the knee or other large joints before performing the procedure, rather than for guiding the needle, which is not that difficult.

Ultrasound clearly shows if puffiness represents fluid inside or outside the joint, Dr. Haro said.

In thoracentesis, the results of studies have clearly shown a reduced risk of pneumothorax, he added.

Given the simplicity and benefits of ultrasound, all emergency physicians who are able should give it a try, Dr. Haro suggested.

“You're doing these procedures all the time,” he said. “You do arthrocentesis. You do thoracentesis. You place central lines. You're already doing it blindly, so just take an extra look if you have a probe there.”

KEYSTONE, COLO. — The rules are simple and straightforward about when a physician should allow an athlete with an upper respiratory tract infection to return to play.

It is the clinical evaluation that is not always so easy, said Lisa R. Callahan, M.D., at the annual meeting of the American Orthopedic Society for Sports Medicine.

The general rule is that when athletes have symptoms only above the neck, such as nasal congestion or a sore throat, they can participate, but only at 50% normal intensity, said Dr. Callahan, the medical director of the Women's Sports Medicine Center at the Hospital for Special Surgery, New York.

If symptoms are below the neck, such as myalgias, shortness of breath, or vomiting, the athlete should not participate.

But the real concern is myocarditis, which can arise with a number of viral, bacterial, and fungal infections. And, much of the time, this kind of myocarditis is going to have very vague clinical signs and symptoms, Dr. Callahan said.

Most individuals with myocarditis associated with an infection will make a complete recovery. But it is estimated that infection-related myocarditis may be the cause of 20% of fatal arrhythmias in athletes.

The most important sign to evaluate when looking for myocarditis in an athlete is tachycardia, remembering that many athletes will normally have a low resting heart rate, and possibly also tachypnea, Dr. Callahan said.

Other general symptoms of myocarditis include fatigue, fluid retention, palpitations, and fever. Patients may have normal laboratory values or may have an elevated white blood cell count or erythrocyte sedimentation rate. Chest x-ray and ECG may be normal in some cases.

The list of infectious agents known to be associated with myocarditis is long, but examples include cytomegalovirus; Coxsackie, influenza, and Epstein-Barr viruses; salmonella, staphylococcus, streptococcus, and clostridia; and Candida and histoplasmosis.

Myocarditis can have two stages: the infectious stage, lasting 7–14 days, when the virus directly kills myocytes; and, sometimes, an immune response stage, which occurs later and can have a variable duration.

Physicians concerned about myocarditis should be alert for its other specific signs, such as chest pain, new onset of exertion-associated dyspnea, or changes in heart rate or blood pressure. Prolonged fatigue and low-grade fever are also signs of myocarditis.

According to guidelines from the American College of Cardiology, an athlete who has had myocarditis should have two echocardiograms, one at 3 months and one at 6 months, before returning to sports participation.

The American Academy of Pediatrics suggests that an athlete with a fever should be disqualified from exercise, as fever increases cardiac demand in a number of ways, Dr. Callahan noted.

In general, exercise has been shown definitively to improve immune function. However, very strenuous activity, such as that engaged in by marathoners, can suppress neutrophil function and curb natural killer cells.

Athletes tend to have a high caloric demand, due to a high metabolism, and fever also increases caloric demand, so athletes with a fever should be encouraged to eat, she said.

KEYSTONE, COLO. — The rules are simple and straightforward about when a physician should allow an athlete with an upper respiratory tract infection to return to play.

It is the clinical evaluation that is not always so easy, said Lisa R. Callahan, M.D., at the annual meeting of the American Orthopedic Society for Sports Medicine.

The general rule is that when athletes have symptoms only above the neck, such as nasal congestion or a sore throat, they can participate, but only at 50% normal intensity, said Dr. Callahan, the medical director of the Women's Sports Medicine Center at the Hospital for Special Surgery, New York.

If symptoms are below the neck, such as myalgias, shortness of breath, or vomiting, the athlete should not participate.

But the real concern is myocarditis, which can arise with a number of viral, bacterial, and fungal infections. And, much of the time, this kind of myocarditis is going to have very vague clinical signs and symptoms, Dr. Callahan said.

Most individuals with myocarditis associated with an infection will make a complete recovery. But it is estimated that infection-related myocarditis may be the cause of 20% of fatal arrhythmias in athletes.

The most important sign to evaluate when looking for myocarditis in an athlete is tachycardia, remembering that many athletes will normally have a low resting heart rate, and possibly also tachypnea, Dr. Callahan said.

Other general symptoms of myocarditis include fatigue, fluid retention, palpitations, and fever. Patients may have normal laboratory values or may have an elevated white blood cell count or erythrocyte sedimentation rate. Chest x-ray and ECG may be normal in some cases.

The list of infectious agents known to be associated with myocarditis is long, but examples include cytomegalovirus; Coxsackie, influenza, and Epstein-Barr viruses; salmonella, staphylococcus, streptococcus, and clostridia; and Candida and histoplasmosis.

Myocarditis can have two stages: the infectious stage, lasting 7–14 days, when the virus directly kills myocytes; and, sometimes, an immune response stage, which occurs later and can have a variable duration.

Physicians concerned about myocarditis should be alert for its other specific signs, such as chest pain, new onset of exertion-associated dyspnea, or changes in heart rate or blood pressure. Prolonged fatigue and low-grade fever are also signs of myocarditis.

According to guidelines from the American College of Cardiology, an athlete who has had myocarditis should have two echocardiograms, one at 3 months and one at 6 months, before returning to sports participation.

The American Academy of Pediatrics suggests that an athlete with a fever should be disqualified from exercise, as fever increases cardiac demand in a number of ways, Dr. Callahan noted.

In general, exercise has been shown definitively to improve immune function. However, very strenuous activity, such as that engaged in by marathoners, can suppress neutrophil function and curb natural killer cells.

Athletes tend to have a high caloric demand, due to a high metabolism, and fever also increases caloric demand, so athletes with a fever should be encouraged to eat, she said.

KEYSTONE, COLO. — The rules are simple and straightforward about when a physician should allow an athlete with an upper respiratory tract infection to return to play.

It is the clinical evaluation that is not always so easy, said Lisa R. Callahan, M.D., at the annual meeting of the American Orthopedic Society for Sports Medicine.

The general rule is that when athletes have symptoms only above the neck, such as nasal congestion or a sore throat, they can participate, but only at 50% normal intensity, said Dr. Callahan, the medical director of the Women's Sports Medicine Center at the Hospital for Special Surgery, New York.

If symptoms are below the neck, such as myalgias, shortness of breath, or vomiting, the athlete should not participate.

But the real concern is myocarditis, which can arise with a number of viral, bacterial, and fungal infections. And, much of the time, this kind of myocarditis is going to have very vague clinical signs and symptoms, Dr. Callahan said.

Most individuals with myocarditis associated with an infection will make a complete recovery. But it is estimated that infection-related myocarditis may be the cause of 20% of fatal arrhythmias in athletes.

The most important sign to evaluate when looking for myocarditis in an athlete is tachycardia, remembering that many athletes will normally have a low resting heart rate, and possibly also tachypnea, Dr. Callahan said.

Other general symptoms of myocarditis include fatigue, fluid retention, palpitations, and fever. Patients may have normal laboratory values or may have an elevated white blood cell count or erythrocyte sedimentation rate. Chest x-ray and ECG may be normal in some cases.

The list of infectious agents known to be associated with myocarditis is long, but examples include cytomegalovirus; Coxsackie, influenza, and Epstein-Barr viruses; salmonella, staphylococcus, streptococcus, and clostridia; and Candida and histoplasmosis.

Myocarditis can have two stages: the infectious stage, lasting 7–14 days, when the virus directly kills myocytes; and, sometimes, an immune response stage, which occurs later and can have a variable duration.

Physicians concerned about myocarditis should be alert for its other specific signs, such as chest pain, new onset of exertion-associated dyspnea, or changes in heart rate or blood pressure. Prolonged fatigue and low-grade fever are also signs of myocarditis.

According to guidelines from the American College of Cardiology, an athlete who has had myocarditis should have two echocardiograms, one at 3 months and one at 6 months, before returning to sports participation.

The American Academy of Pediatrics suggests that an athlete with a fever should be disqualified from exercise, as fever increases cardiac demand in a number of ways, Dr. Callahan noted.

In general, exercise has been shown definitively to improve immune function. However, very strenuous activity, such as that engaged in by marathoners, can suppress neutrophil function and curb natural killer cells.

Athletes tend to have a high caloric demand, due to a high metabolism, and fever also increases caloric demand, so athletes with a fever should be encouraged to eat, she said.

RANCHO MIRAGE, CALIF. — Antibiotic use needs to be aggressive in cystic fibrosis, even if it is not exactly clear which antibiotics to use and when to use them in any particular case, Peggy Radford, M.D., said at a pediatric pulmonology meeting sponsored by the American College of Chest Physicians.

The median survival of cystic fibrosis patients has increased dramatically since the 1940s, and the increase is related to the development of more antibiotic drugs.

With penicillin and streptomycin, median survival rose to about 10 years in 1960. It rose to about 15 years in 1970, following the introduction of carbenicillin and gentamicin. With ceftazidime and ciprofloxacin in the 1980s, median survival rose to almost 30 years. It is now known to be at least 33 years and may actually be about 40 years, said Dr. Radford, director of the cystic fibrosis center at Phoenix Children's Hospital.

Clinical trials are often lacking the nuances of antibiotic treatment, which makes prescribing antibiotics something of an intellectual challenge, she said.

However, there is clinical evidence to guide current practice in some areas:

▸ Prophylaxis. In younger children, Staphylococcus aureus is the organism that most often colonizes the lungs of cystic fibrosis patients. It is not until age 4–5 years that Pseudomonas aeruginosa colonization becomes more prevalent.

One placebo-controlled study looked at 119 children younger than 2 years who were treated prophylactically with cephalexin for 5–7 years. Treated children were less likely to have a positive culture for staphylococcus than were those treated with placebo (6% vs. 30%) but were more likely to have a positive culture for P. aeruginosa (26% vs. 14%). The researchers concluded, therefore, that long-term antistaphylococcus prophylaxis should not be recommended.

▸ Eradication of asymptomatic colonization. P. aeruginosa is the organism most highly associated with lung function decline in cystic fibrosis, and it has become clear that when P. aeruginosa infection becomes chronic, the colonizing organism develops a mucoid phenotype that makes eradication problematic. So it would appear early detection is adantageous.

Two studies have investigated early eradication with tobramycin, Dr. Radford said at the meeting, which was also sponsored by the American Academy of Pediatrics.

In one study, 15 patients in whom P. aeruginosa infection was detected for the first time were treated with inhaled tobramycin (80 mg twice daily) for 1 year. At the end of the year, 14 had negative cultures and negative pseudomonal serum antibody titers. The negative status was maintained for a year following treatment. Pulmonary function was at the same level that it was prior to intervention, and remained at that level for the 2-year trial and follow-up.

A second, placebo-controlled, early-treatment trial was planned with an enrollment of 98 patients with P. aeruginosa colonization; all of those patients were less than 6 years of age. But the effect of treatment was so positive in the first 21 patients, the study was halted. All eight treated patients were free of P. aeruginosa infection with bronchoalveolar lavage, compared with only 1 of 13 placebo patients.

▸ Acute exacerbations. Depending on lung function, cystic fibrosis patients have a 30%–80% incidence of annual acute exacerbations, Dr. Radford said.

In most cystic fibrosis centers, these infections are treated empirically, assuming that the most likely pathogen is P. aeruginosa, followed by staphylococcus.

There are very few clinical trials comparing treatment regimens, but one investigation recently looked at whether P. aeruginosa susceptibility made a clinically important difference in how successful treatment was with intravenous tobramycin and ceftazidime. Seventy-seven patients who were in a placebo arm of a tobramycin trial and had an exacerbation were treated. Fifty-four had an improvement in their spirometry measurements following treatment, 14 had no change, and 9 worsened. The investigators concluded that reduced susceptibility was probably not likely to be a clinical problem.

Some practitioners also add rifampin to a regimen of tobramycin and ceftazidime because, although rifampin itself has little activity against P. aeruginosa, laboratory studies suggest it may have synergy with the other two agents and therefore can help fight against mucoid colonization.

▸ Chronic infection suppression. In addition to inhaled tobramycin treatment, many centers now offer long-term macrolide therapy to suppress chronic infection. In a study of azithromycin at 250 mg or 500 mg, 3 days a week for 168 days, the treatment improved spirometry measures 6% and decreased hospital stays almost 50%. Patients also had a weight gain.

RANCHO MIRAGE, CALIF. — Antibiotic use needs to be aggressive in cystic fibrosis, even if it is not exactly clear which antibiotics to use and when to use them in any particular case, Peggy Radford, M.D., said at a pediatric pulmonology meeting sponsored by the American College of Chest Physicians.

The median survival of cystic fibrosis patients has increased dramatically since the 1940s, and the increase is related to the development of more antibiotic drugs.

With penicillin and streptomycin, median survival rose to about 10 years in 1960. It rose to about 15 years in 1970, following the introduction of carbenicillin and gentamicin. With ceftazidime and ciprofloxacin in the 1980s, median survival rose to almost 30 years. It is now known to be at least 33 years and may actually be about 40 years, said Dr. Radford, director of the cystic fibrosis center at Phoenix Children's Hospital.

Clinical trials are often lacking the nuances of antibiotic treatment, which makes prescribing antibiotics something of an intellectual challenge, she said.

However, there is clinical evidence to guide current practice in some areas:

▸ Prophylaxis. In younger children, Staphylococcus aureus is the organism that most often colonizes the lungs of cystic fibrosis patients. It is not until age 4–5 years that Pseudomonas aeruginosa colonization becomes more prevalent.

One placebo-controlled study looked at 119 children younger than 2 years who were treated prophylactically with cephalexin for 5–7 years. Treated children were less likely to have a positive culture for staphylococcus than were those treated with placebo (6% vs. 30%) but were more likely to have a positive culture for P. aeruginosa (26% vs. 14%). The researchers concluded, therefore, that long-term antistaphylococcus prophylaxis should not be recommended.

▸ Eradication of asymptomatic colonization. P. aeruginosa is the organism most highly associated with lung function decline in cystic fibrosis, and it has become clear that when P. aeruginosa infection becomes chronic, the colonizing organism develops a mucoid phenotype that makes eradication problematic. So it would appear early detection is adantageous.

Two studies have investigated early eradication with tobramycin, Dr. Radford said at the meeting, which was also sponsored by the American Academy of Pediatrics.

In one study, 15 patients in whom P. aeruginosa infection was detected for the first time were treated with inhaled tobramycin (80 mg twice daily) for 1 year. At the end of the year, 14 had negative cultures and negative pseudomonal serum antibody titers. The negative status was maintained for a year following treatment. Pulmonary function was at the same level that it was prior to intervention, and remained at that level for the 2-year trial and follow-up.

A second, placebo-controlled, early-treatment trial was planned with an enrollment of 98 patients with P. aeruginosa colonization; all of those patients were less than 6 years of age. But the effect of treatment was so positive in the first 21 patients, the study was halted. All eight treated patients were free of P. aeruginosa infection with bronchoalveolar lavage, compared with only 1 of 13 placebo patients.

▸ Acute exacerbations. Depending on lung function, cystic fibrosis patients have a 30%–80% incidence of annual acute exacerbations, Dr. Radford said.

In most cystic fibrosis centers, these infections are treated empirically, assuming that the most likely pathogen is P. aeruginosa, followed by staphylococcus.

There are very few clinical trials comparing treatment regimens, but one investigation recently looked at whether P. aeruginosa susceptibility made a clinically important difference in how successful treatment was with intravenous tobramycin and ceftazidime. Seventy-seven patients who were in a placebo arm of a tobramycin trial and had an exacerbation were treated. Fifty-four had an improvement in their spirometry measurements following treatment, 14 had no change, and 9 worsened. The investigators concluded that reduced susceptibility was probably not likely to be a clinical problem.

Some practitioners also add rifampin to a regimen of tobramycin and ceftazidime because, although rifampin itself has little activity against P. aeruginosa, laboratory studies suggest it may have synergy with the other two agents and therefore can help fight against mucoid colonization.

▸ Chronic infection suppression. In addition to inhaled tobramycin treatment, many centers now offer long-term macrolide therapy to suppress chronic infection. In a study of azithromycin at 250 mg or 500 mg, 3 days a week for 168 days, the treatment improved spirometry measures 6% and decreased hospital stays almost 50%. Patients also had a weight gain.

RANCHO MIRAGE, CALIF. — Antibiotic use needs to be aggressive in cystic fibrosis, even if it is not exactly clear which antibiotics to use and when to use them in any particular case, Peggy Radford, M.D., said at a pediatric pulmonology meeting sponsored by the American College of Chest Physicians.

The median survival of cystic fibrosis patients has increased dramatically since the 1940s, and the increase is related to the development of more antibiotic drugs.

With penicillin and streptomycin, median survival rose to about 10 years in 1960. It rose to about 15 years in 1970, following the introduction of carbenicillin and gentamicin. With ceftazidime and ciprofloxacin in the 1980s, median survival rose to almost 30 years. It is now known to be at least 33 years and may actually be about 40 years, said Dr. Radford, director of the cystic fibrosis center at Phoenix Children's Hospital.

Clinical trials are often lacking the nuances of antibiotic treatment, which makes prescribing antibiotics something of an intellectual challenge, she said.

However, there is clinical evidence to guide current practice in some areas:

▸ Prophylaxis. In younger children, Staphylococcus aureus is the organism that most often colonizes the lungs of cystic fibrosis patients. It is not until age 4–5 years that Pseudomonas aeruginosa colonization becomes more prevalent.

One placebo-controlled study looked at 119 children younger than 2 years who were treated prophylactically with cephalexin for 5–7 years. Treated children were less likely to have a positive culture for staphylococcus than were those treated with placebo (6% vs. 30%) but were more likely to have a positive culture for P. aeruginosa (26% vs. 14%). The researchers concluded, therefore, that long-term antistaphylococcus prophylaxis should not be recommended.

▸ Eradication of asymptomatic colonization. P. aeruginosa is the organism most highly associated with lung function decline in cystic fibrosis, and it has become clear that when P. aeruginosa infection becomes chronic, the colonizing organism develops a mucoid phenotype that makes eradication problematic. So it would appear early detection is adantageous.

Two studies have investigated early eradication with tobramycin, Dr. Radford said at the meeting, which was also sponsored by the American Academy of Pediatrics.

In one study, 15 patients in whom P. aeruginosa infection was detected for the first time were treated with inhaled tobramycin (80 mg twice daily) for 1 year. At the end of the year, 14 had negative cultures and negative pseudomonal serum antibody titers. The negative status was maintained for a year following treatment. Pulmonary function was at the same level that it was prior to intervention, and remained at that level for the 2-year trial and follow-up.

A second, placebo-controlled, early-treatment trial was planned with an enrollment of 98 patients with P. aeruginosa colonization; all of those patients were less than 6 years of age. But the effect of treatment was so positive in the first 21 patients, the study was halted. All eight treated patients were free of P. aeruginosa infection with bronchoalveolar lavage, compared with only 1 of 13 placebo patients.

▸ Acute exacerbations. Depending on lung function, cystic fibrosis patients have a 30%–80% incidence of annual acute exacerbations, Dr. Radford said.

In most cystic fibrosis centers, these infections are treated empirically, assuming that the most likely pathogen is P. aeruginosa, followed by staphylococcus.

There are very few clinical trials comparing treatment regimens, but one investigation recently looked at whether P. aeruginosa susceptibility made a clinically important difference in how successful treatment was with intravenous tobramycin and ceftazidime. Seventy-seven patients who were in a placebo arm of a tobramycin trial and had an exacerbation were treated. Fifty-four had an improvement in their spirometry measurements following treatment, 14 had no change, and 9 worsened. The investigators concluded that reduced susceptibility was probably not likely to be a clinical problem.

Some practitioners also add rifampin to a regimen of tobramycin and ceftazidime because, although rifampin itself has little activity against P. aeruginosa, laboratory studies suggest it may have synergy with the other two agents and therefore can help fight against mucoid colonization.

▸ Chronic infection suppression. In addition to inhaled tobramycin treatment, many centers now offer long-term macrolide therapy to suppress chronic infection. In a study of azithromycin at 250 mg or 500 mg, 3 days a week for 168 days, the treatment improved spirometry measures 6% and decreased hospital stays almost 50%. Patients also had a weight gain.