Kate Johnson

CHICAGO — Women who are obese when they are diagnosed with early stage breast cancer have poorer outcomes than do women of normal weight—yet another reason for physicians to encourage weight control in their patients, according to Penny R. Anderson, M.D., a radiation oncologist at Fox Chase Cancer Center in Philadelphia.

“Obesity at the time of diagnosis significantly predicts poorer outcomes,” she reported at the annual meeting of the Radiological Society of North America. “We found an increased risk of breast cancer death and distant metastases in obese women, compared with normal-weight patients, although they did not present with more advanced-stage disease.”

The study included more than 2,000 women with stage I/II breast cancer who underwent lumpectomy, axillary dissection, and radiation therapy with or without systemic therapy.

The median age of the women was 58 years, with 22% considered normal weight, 43% considered overweight, and 35% considered obese.

The study, which had a median follow-up of 61 months, compared women in the three weight categories to determine independent predictors of local failure, distant metastases, cause-specific survival, and overall survival.

It found that the actuarial 5-year rates of distant metastases, cause-specific survival, and overall survival were the worst in obese women.

There were some statistically significant baseline differences between the weight groups, with the obese group comprising more women who were older and postmenopausal. However, there were no statistically significant differences between the groups in terms of tumor size or number of involved lymph nodes, she said. In addition, the local failure rate was no worse in the obese women.

CHICAGO — Women who are obese when they are diagnosed with early stage breast cancer have poorer outcomes than do women of normal weight—yet another reason for physicians to encourage weight control in their patients, according to Penny R. Anderson, M.D., a radiation oncologist at Fox Chase Cancer Center in Philadelphia.

“Obesity at the time of diagnosis significantly predicts poorer outcomes,” she reported at the annual meeting of the Radiological Society of North America. “We found an increased risk of breast cancer death and distant metastases in obese women, compared with normal-weight patients, although they did not present with more advanced-stage disease.”

The study included more than 2,000 women with stage I/II breast cancer who underwent lumpectomy, axillary dissection, and radiation therapy with or without systemic therapy.

The median age of the women was 58 years, with 22% considered normal weight, 43% considered overweight, and 35% considered obese.

The study, which had a median follow-up of 61 months, compared women in the three weight categories to determine independent predictors of local failure, distant metastases, cause-specific survival, and overall survival.

It found that the actuarial 5-year rates of distant metastases, cause-specific survival, and overall survival were the worst in obese women.

There were some statistically significant baseline differences between the weight groups, with the obese group comprising more women who were older and postmenopausal. However, there were no statistically significant differences between the groups in terms of tumor size or number of involved lymph nodes, she said. In addition, the local failure rate was no worse in the obese women.

CHICAGO — Women who are obese when they are diagnosed with early stage breast cancer have poorer outcomes than do women of normal weight—yet another reason for physicians to encourage weight control in their patients, according to Penny R. Anderson, M.D., a radiation oncologist at Fox Chase Cancer Center in Philadelphia.

“Obesity at the time of diagnosis significantly predicts poorer outcomes,” she reported at the annual meeting of the Radiological Society of North America. “We found an increased risk of breast cancer death and distant metastases in obese women, compared with normal-weight patients, although they did not present with more advanced-stage disease.”

The study included more than 2,000 women with stage I/II breast cancer who underwent lumpectomy, axillary dissection, and radiation therapy with or without systemic therapy.

The median age of the women was 58 years, with 22% considered normal weight, 43% considered overweight, and 35% considered obese.

The study, which had a median follow-up of 61 months, compared women in the three weight categories to determine independent predictors of local failure, distant metastases, cause-specific survival, and overall survival.

It found that the actuarial 5-year rates of distant metastases, cause-specific survival, and overall survival were the worst in obese women.

There were some statistically significant baseline differences between the weight groups, with the obese group comprising more women who were older and postmenopausal. However, there were no statistically significant differences between the groups in terms of tumor size or number of involved lymph nodes, she said. In addition, the local failure rate was no worse in the obese women.

CHICAGO — Late breast cancer recurrence may be emerging as a new concern in patients participating in a study on tamoxifen versus tamoxifen plus radiotherapy treatment, according to a Canadian expert.

Researchers from Toronto's Princess Margaret Hospital recently showed that the 5-year breast cancer relapse rate was significantly lower in 386 women over age 50 who were treated with the combination of radiation and tamoxifen after lumpectomy, compared with 383 women who were treated with lumpectomy and tamoxifen alone (N. Engl. J. Med. 2004;351:963–70).

“But the 5-year results may not be the whole story,” lead investigator Anthony W. Fyles, M.D., reported at the annual meeting of the Radiological Society of North America.

A small cohort of the study subjects now have been followed for 8 years, and preliminary data from these 87 women suggest that late relapse rates may be creeping up in both treatment groups, said Dr. Fyles, professor of radiation oncology at the University of Toronto.

“It's quite a small number of women, and we need to follow more of them for longer lengths of time, but we are concerned that we are starting to see quite a few more relapses, Dr. Fyles told this newspaper.

The published study showed that at 5 years, the relapse rate was 0.6% in the combination therapy group versus 7.7% in the tamoxifen-only group. But the 8-year data, although still showing a distinct advantage to the combination therapy, reveal increased relapse rates in both groups: 3.5% in the combination therapy group, compared with 18% in the tamoxifen-only group, he said.

Of particular concern in the 8-year follow-up are patients over aged 70 with tumor sizes of 1–2 cm, Dr. Fyles said. In this group, women who received combination therapy had no relapses. However women who received tamoxifen alone had a relapse rate of 17.6%.

The study design involved treatment with tamoxifen for 5 years, and the sudden increase in relapses could be partly explained by the termination of tamoxifen therapy at the 5-year mark, Dr. Fyles said.

“Of course, now what we do in current practice is that we often add an aromatase inhibitor after patients stop the tamoxifen. We don't know yet whether this reduces the risk of relapse, but the available data on these agents suggest that they will lower the risk of late relapse,” for breast cancer patients, Dr. Fyles said at the meeting.

CHICAGO — Late breast cancer recurrence may be emerging as a new concern in patients participating in a study on tamoxifen versus tamoxifen plus radiotherapy treatment, according to a Canadian expert.

Researchers from Toronto's Princess Margaret Hospital recently showed that the 5-year breast cancer relapse rate was significantly lower in 386 women over age 50 who were treated with the combination of radiation and tamoxifen after lumpectomy, compared with 383 women who were treated with lumpectomy and tamoxifen alone (N. Engl. J. Med. 2004;351:963–70).

“But the 5-year results may not be the whole story,” lead investigator Anthony W. Fyles, M.D., reported at the annual meeting of the Radiological Society of North America.

A small cohort of the study subjects now have been followed for 8 years, and preliminary data from these 87 women suggest that late relapse rates may be creeping up in both treatment groups, said Dr. Fyles, professor of radiation oncology at the University of Toronto.

“It's quite a small number of women, and we need to follow more of them for longer lengths of time, but we are concerned that we are starting to see quite a few more relapses, Dr. Fyles told this newspaper.

The published study showed that at 5 years, the relapse rate was 0.6% in the combination therapy group versus 7.7% in the tamoxifen-only group. But the 8-year data, although still showing a distinct advantage to the combination therapy, reveal increased relapse rates in both groups: 3.5% in the combination therapy group, compared with 18% in the tamoxifen-only group, he said.

Of particular concern in the 8-year follow-up are patients over aged 70 with tumor sizes of 1–2 cm, Dr. Fyles said. In this group, women who received combination therapy had no relapses. However women who received tamoxifen alone had a relapse rate of 17.6%.

The study design involved treatment with tamoxifen for 5 years, and the sudden increase in relapses could be partly explained by the termination of tamoxifen therapy at the 5-year mark, Dr. Fyles said.

“Of course, now what we do in current practice is that we often add an aromatase inhibitor after patients stop the tamoxifen. We don't know yet whether this reduces the risk of relapse, but the available data on these agents suggest that they will lower the risk of late relapse,” for breast cancer patients, Dr. Fyles said at the meeting.

CHICAGO — Late breast cancer recurrence may be emerging as a new concern in patients participating in a study on tamoxifen versus tamoxifen plus radiotherapy treatment, according to a Canadian expert.

Researchers from Toronto's Princess Margaret Hospital recently showed that the 5-year breast cancer relapse rate was significantly lower in 386 women over age 50 who were treated with the combination of radiation and tamoxifen after lumpectomy, compared with 383 women who were treated with lumpectomy and tamoxifen alone (N. Engl. J. Med. 2004;351:963–70).

“But the 5-year results may not be the whole story,” lead investigator Anthony W. Fyles, M.D., reported at the annual meeting of the Radiological Society of North America.

A small cohort of the study subjects now have been followed for 8 years, and preliminary data from these 87 women suggest that late relapse rates may be creeping up in both treatment groups, said Dr. Fyles, professor of radiation oncology at the University of Toronto.

“It's quite a small number of women, and we need to follow more of them for longer lengths of time, but we are concerned that we are starting to see quite a few more relapses, Dr. Fyles told this newspaper.

The published study showed that at 5 years, the relapse rate was 0.6% in the combination therapy group versus 7.7% in the tamoxifen-only group. But the 8-year data, although still showing a distinct advantage to the combination therapy, reveal increased relapse rates in both groups: 3.5% in the combination therapy group, compared with 18% in the tamoxifen-only group, he said.

Of particular concern in the 8-year follow-up are patients over aged 70 with tumor sizes of 1–2 cm, Dr. Fyles said. In this group, women who received combination therapy had no relapses. However women who received tamoxifen alone had a relapse rate of 17.6%.

The study design involved treatment with tamoxifen for 5 years, and the sudden increase in relapses could be partly explained by the termination of tamoxifen therapy at the 5-year mark, Dr. Fyles said.

“Of course, now what we do in current practice is that we often add an aromatase inhibitor after patients stop the tamoxifen. We don't know yet whether this reduces the risk of relapse, but the available data on these agents suggest that they will lower the risk of late relapse,” for breast cancer patients, Dr. Fyles said at the meeting.

CHICAGO — Magnetic resonance spectroscopy can identify distinct abnormalities in the brain chemistry of patients with bipolar disorder, opening up the possibility for a definitive diagnostic test, John D. Port, M.D., said at the annual meeting of the Radiological Society of North America.

“We hope to eventually refine this into a clinically useful test that could shave years off a patient's time to diagnosis,” said Dr. Port of the department of radiology at the Mayo Clinic in Rochester, Minn.

Physicians “clearly [need] a tool to help diagnose bipolar disorder. We hope this technique will prove helpful by identifying metabolic markers of the disease,” he said.

Using a 3T long-bore MR scanner, which has twice the strength of scanners used in previous studies on bipolar disorder, the researchers scanned the brains of 21 patients with a clear diagnosis of bipolar disorder, and 21 healthy volunteers matched for age, sex, and dominant hand. The bipolar patients were medication naive and free of substance abuse.

Each scan took about 1 hour and enabled the analysis of 14 regions, and five metabolites within the brain tissue, Dr. Port said.

Compared with healthy individuals, bipolar patients had significantly different levels of certain metabolites in two brain areas that control behavior and movement.

In the right frontal white matter, myo-inositol was significantly increased, and in the right lentiform region, N-acetylaspartate, glutamate/glutamine, and creatine were significantly decreased in bipolar patients, compared with healthy normals, he told this newspaper.

In addition, the analysis was able to distinguish between various severities of bipolar disorder.

Patients with bipolar I illness had significantly lower choline levels in the left caudate region of the brain, compared with patients with bipolar II illness and bipolar illness not otherwise specified (BP-NOS).

Additionally, right anterior cingulate creatine levels were higher in bipolar I patients (BP-I), than in bipolar II (BP-II) patients.

And, finally, the researchers found differences in the right parietal white matter of BP-I patients, compared with other bipolar patients—a finding that they had not expected.

“BP-I patients had significantly higher levels of choline in their right parietal white matter, compared with BP-II patients, and more N-acetylaspartate in this region compared with BP-NOS patients,” Dr. Port said. “This was surprising to us, because until now, parietal white matter was not thought to be involved in psychiatric disease.”

Dr. Port said the pattern of metabolite abnormalities and locations form a “fingerprint” of bipolar disorder and its various subtypes. His research team, which includes two psychiatrists, is hoping to use this technique in the development of a diagnostic test. This will not only speed up the diagnosis of bipolar disorder, but might also help predict which patients would benefit from various treatments, he said.

An image of the brain of a bipolar disorder patient (upper left) is overlaid with a grid showing creatine levels (upper right). Yellow/gold areas have highest creatine levels. For a selected voxel (blue arrow), data confirm the creatine value. Courtesy Dr. John D. Port

CHICAGO — Magnetic resonance spectroscopy can identify distinct abnormalities in the brain chemistry of patients with bipolar disorder, opening up the possibility for a definitive diagnostic test, John D. Port, M.D., said at the annual meeting of the Radiological Society of North America.

“We hope to eventually refine this into a clinically useful test that could shave years off a patient's time to diagnosis,” said Dr. Port of the department of radiology at the Mayo Clinic in Rochester, Minn.

Physicians “clearly [need] a tool to help diagnose bipolar disorder. We hope this technique will prove helpful by identifying metabolic markers of the disease,” he said.

Using a 3T long-bore MR scanner, which has twice the strength of scanners used in previous studies on bipolar disorder, the researchers scanned the brains of 21 patients with a clear diagnosis of bipolar disorder, and 21 healthy volunteers matched for age, sex, and dominant hand. The bipolar patients were medication naive and free of substance abuse.

Each scan took about 1 hour and enabled the analysis of 14 regions, and five metabolites within the brain tissue, Dr. Port said.

Compared with healthy individuals, bipolar patients had significantly different levels of certain metabolites in two brain areas that control behavior and movement.

In the right frontal white matter, myo-inositol was significantly increased, and in the right lentiform region, N-acetylaspartate, glutamate/glutamine, and creatine were significantly decreased in bipolar patients, compared with healthy normals, he told this newspaper.

In addition, the analysis was able to distinguish between various severities of bipolar disorder.

Patients with bipolar I illness had significantly lower choline levels in the left caudate region of the brain, compared with patients with bipolar II illness and bipolar illness not otherwise specified (BP-NOS).

Additionally, right anterior cingulate creatine levels were higher in bipolar I patients (BP-I), than in bipolar II (BP-II) patients.

And, finally, the researchers found differences in the right parietal white matter of BP-I patients, compared with other bipolar patients—a finding that they had not expected.

“BP-I patients had significantly higher levels of choline in their right parietal white matter, compared with BP-II patients, and more N-acetylaspartate in this region compared with BP-NOS patients,” Dr. Port said. “This was surprising to us, because until now, parietal white matter was not thought to be involved in psychiatric disease.”

Dr. Port said the pattern of metabolite abnormalities and locations form a “fingerprint” of bipolar disorder and its various subtypes. His research team, which includes two psychiatrists, is hoping to use this technique in the development of a diagnostic test. This will not only speed up the diagnosis of bipolar disorder, but might also help predict which patients would benefit from various treatments, he said.

An image of the brain of a bipolar disorder patient (upper left) is overlaid with a grid showing creatine levels (upper right). Yellow/gold areas have highest creatine levels. For a selected voxel (blue arrow), data confirm the creatine value. Courtesy Dr. John D. Port

CHICAGO — Magnetic resonance spectroscopy can identify distinct abnormalities in the brain chemistry of patients with bipolar disorder, opening up the possibility for a definitive diagnostic test, John D. Port, M.D., said at the annual meeting of the Radiological Society of North America.

“We hope to eventually refine this into a clinically useful test that could shave years off a patient's time to diagnosis,” said Dr. Port of the department of radiology at the Mayo Clinic in Rochester, Minn.

Physicians “clearly [need] a tool to help diagnose bipolar disorder. We hope this technique will prove helpful by identifying metabolic markers of the disease,” he said.

Using a 3T long-bore MR scanner, which has twice the strength of scanners used in previous studies on bipolar disorder, the researchers scanned the brains of 21 patients with a clear diagnosis of bipolar disorder, and 21 healthy volunteers matched for age, sex, and dominant hand. The bipolar patients were medication naive and free of substance abuse.

Each scan took about 1 hour and enabled the analysis of 14 regions, and five metabolites within the brain tissue, Dr. Port said.

Compared with healthy individuals, bipolar patients had significantly different levels of certain metabolites in two brain areas that control behavior and movement.

In the right frontal white matter, myo-inositol was significantly increased, and in the right lentiform region, N-acetylaspartate, glutamate/glutamine, and creatine were significantly decreased in bipolar patients, compared with healthy normals, he told this newspaper.

In addition, the analysis was able to distinguish between various severities of bipolar disorder.

Patients with bipolar I illness had significantly lower choline levels in the left caudate region of the brain, compared with patients with bipolar II illness and bipolar illness not otherwise specified (BP-NOS).

Additionally, right anterior cingulate creatine levels were higher in bipolar I patients (BP-I), than in bipolar II (BP-II) patients.

And, finally, the researchers found differences in the right parietal white matter of BP-I patients, compared with other bipolar patients—a finding that they had not expected.

“BP-I patients had significantly higher levels of choline in their right parietal white matter, compared with BP-II patients, and more N-acetylaspartate in this region compared with BP-NOS patients,” Dr. Port said. “This was surprising to us, because until now, parietal white matter was not thought to be involved in psychiatric disease.”

Dr. Port said the pattern of metabolite abnormalities and locations form a “fingerprint” of bipolar disorder and its various subtypes. His research team, which includes two psychiatrists, is hoping to use this technique in the development of a diagnostic test. This will not only speed up the diagnosis of bipolar disorder, but might also help predict which patients would benefit from various treatments, he said.

An image of the brain of a bipolar disorder patient (upper left) is overlaid with a grid showing creatine levels (upper right). Yellow/gold areas have highest creatine levels. For a selected voxel (blue arrow), data confirm the creatine value. Courtesy Dr. John D. Port

Revised requirements for antidepressant labels that would omit references to a causal link between the drugs and suicide in children and adolescents have drawn mixed reactions.

“I think it's good that the FDA has shied away from making a blanket statement about causality,” said Adelaide Robb, M.D., medical director of inpatient psychiatry at Children's National Medical Center in Washington.

But she says the black box warning is extreme.

“I wish the black box wasn't there,” she told FAMILY PRACTICE NEWS. “I think it is overly cautious, and I think it will steer people away from [prescribing] treatment that can be very effective.”

The originally proposed wording for the labeling said, “A causal role for antidepressants in inducing suicidality has been established in pediatric patients.” However, before the new labeling was implemented, the Food and Drug Administration decided to soften the language.

Current wording reads, “Antidepressants increased the risk of suicidal thinking and behavior (suicidality) in short-term studies in children and adolescents with Major Depressive Disorder (MDD) and other psychiatric disorders.”

Manufacturers began implementing the new labeling in January, although packaging already in production or circulation was allowed to keep the old labeling.

The revised wording improves consistency and accuracy, according to FDA spokesperson Christine Parker. “[The decision] was based on feedback from several groups and individuals who expressed concern that [the causality sentence] was too broad a statement and might be misinterpreted, and thereby, misleading,” she told this newspaper.

Richard Gorman, M.D., chair of the American Academy of Pediatrics' committee on drugs, said he thinks the current labeling accurately reflects the data.

And he says the decision to drop the reference to causality has little implication for clinical care.

“Whether you say it's causal or that there's an increased risk of suicide—that's legal terminology. I don't think it makes much difference to the clinician. The message is pretty identical—which is that there is an increased risk of suicide when you use these medications,” he said in an interview.

Unlike Dr. Robb, Dr. Gorman does not believe that the black box warning will deter physicians from prescribing antidepressants when they are appropriate.

“I think they will be less likely to prescribe this medication for the borderline cases—but not for patients who meet the criteria for major depressive disorder. You would not give cancer chemotherapy to people who have colds. But you would have no hesitation giving it to people with cancer,” Dr. Gorman pointed out.

Revised requirements for antidepressant labels that would omit references to a causal link between the drugs and suicide in children and adolescents have drawn mixed reactions.

“I think it's good that the FDA has shied away from making a blanket statement about causality,” said Adelaide Robb, M.D., medical director of inpatient psychiatry at Children's National Medical Center in Washington.

But she says the black box warning is extreme.

“I wish the black box wasn't there,” she told FAMILY PRACTICE NEWS. “I think it is overly cautious, and I think it will steer people away from [prescribing] treatment that can be very effective.”

The originally proposed wording for the labeling said, “A causal role for antidepressants in inducing suicidality has been established in pediatric patients.” However, before the new labeling was implemented, the Food and Drug Administration decided to soften the language.

Current wording reads, “Antidepressants increased the risk of suicidal thinking and behavior (suicidality) in short-term studies in children and adolescents with Major Depressive Disorder (MDD) and other psychiatric disorders.”

Manufacturers began implementing the new labeling in January, although packaging already in production or circulation was allowed to keep the old labeling.

The revised wording improves consistency and accuracy, according to FDA spokesperson Christine Parker. “[The decision] was based on feedback from several groups and individuals who expressed concern that [the causality sentence] was too broad a statement and might be misinterpreted, and thereby, misleading,” she told this newspaper.

Richard Gorman, M.D., chair of the American Academy of Pediatrics' committee on drugs, said he thinks the current labeling accurately reflects the data.

And he says the decision to drop the reference to causality has little implication for clinical care.

“Whether you say it's causal or that there's an increased risk of suicide—that's legal terminology. I don't think it makes much difference to the clinician. The message is pretty identical—which is that there is an increased risk of suicide when you use these medications,” he said in an interview.

Unlike Dr. Robb, Dr. Gorman does not believe that the black box warning will deter physicians from prescribing antidepressants when they are appropriate.

“I think they will be less likely to prescribe this medication for the borderline cases—but not for patients who meet the criteria for major depressive disorder. You would not give cancer chemotherapy to people who have colds. But you would have no hesitation giving it to people with cancer,” Dr. Gorman pointed out.

Revised requirements for antidepressant labels that would omit references to a causal link between the drugs and suicide in children and adolescents have drawn mixed reactions.

“I think it's good that the FDA has shied away from making a blanket statement about causality,” said Adelaide Robb, M.D., medical director of inpatient psychiatry at Children's National Medical Center in Washington.

But she says the black box warning is extreme.

“I wish the black box wasn't there,” she told FAMILY PRACTICE NEWS. “I think it is overly cautious, and I think it will steer people away from [prescribing] treatment that can be very effective.”

The originally proposed wording for the labeling said, “A causal role for antidepressants in inducing suicidality has been established in pediatric patients.” However, before the new labeling was implemented, the Food and Drug Administration decided to soften the language.

Current wording reads, “Antidepressants increased the risk of suicidal thinking and behavior (suicidality) in short-term studies in children and adolescents with Major Depressive Disorder (MDD) and other psychiatric disorders.”

Manufacturers began implementing the new labeling in January, although packaging already in production or circulation was allowed to keep the old labeling.

The revised wording improves consistency and accuracy, according to FDA spokesperson Christine Parker. “[The decision] was based on feedback from several groups and individuals who expressed concern that [the causality sentence] was too broad a statement and might be misinterpreted, and thereby, misleading,” she told this newspaper.

Richard Gorman, M.D., chair of the American Academy of Pediatrics' committee on drugs, said he thinks the current labeling accurately reflects the data.

And he says the decision to drop the reference to causality has little implication for clinical care.

“Whether you say it's causal or that there's an increased risk of suicide—that's legal terminology. I don't think it makes much difference to the clinician. The message is pretty identical—which is that there is an increased risk of suicide when you use these medications,” he said in an interview.

Unlike Dr. Robb, Dr. Gorman does not believe that the black box warning will deter physicians from prescribing antidepressants when they are appropriate.

“I think they will be less likely to prescribe this medication for the borderline cases—but not for patients who meet the criteria for major depressive disorder. You would not give cancer chemotherapy to people who have colds. But you would have no hesitation giving it to people with cancer,” Dr. Gorman pointed out.

QUEBEC CITY — Magnetic resonance imagery and spectroscopy of the brain show decreased hippocampal volume in children with type 1 diabetes, and evidence of neuronal damage in a subgroup of those children who have hypoglycemic seizures, according to a new study.

These findings coincide with another study of children with type 1 diabetes, showing deficits in memory that are specifically tied to the hippocampal region, reported researchers from York University in Toronto.

“The hippocampus is quite sensitive to fluctuations in glucose, and also has a high number of insulin receptors—so if there is too much insulin, this can have an impact on functioning,” said Mary Desrochers, Ph.D., who supervised both studies. The results were presented as posters at the joint annual meeting of the Canadian Diabetes Association and the Canadian Society of Endocrinology and Metabolism.

The first study included 10 children with type 1 diabetes (aged 10–14 years, with an age of onset of less than 5 years), half of whom had severe hypoglycemic episodes. They were age-matched to 10 healthy controls.

MRI showed that all patients with diabetes had smaller hippocampal volumes than did controls. And MRI spectroscopy showed elevated levels of inositol and glutamate, suggestive of neuronal damage, in children with a history of hypoglycemic seizures.

“This tells us that overcontrol of hyperglycemia is possibly an issue,” Dr. Desrochers told this newspaper. “All of the children in this study had excellent glycemic control and some of the parents told us that they sometimes give their children extra injections of insulin. So that would be something to look into—whether overcontrol is playing a role in the incidence of hypoglycemic seizures.”

The study also looked at the neuropsychological functioning of the children and found a trend toward long-term (explicit) memory deficits associated with type 1 diabetes specifically in the areas of verbal and visual memory, functions that are controlled by the hippocampus. However, more conclusive evidence for memory deficits came from a separate study.

In that study, conducted by Ph.D. candidate Lila Elkhadem, explicit and implicit memory skills were compared in 15 children with type 1 diabetes and 17 healthy controls (mean age between 11 and 12 years).

Explicit memory is actively learned whereas implicit memory is information that is more passively absorbed, explained Dr. Desrochers.

“Implicit memory develops earlier and remains robust throughout life. It is what is learned every day, whereas explicit memory is involved when you tell someone they need to remember something,” she said.

The study found that in children with diabetes, implicit memory did not differ from controls, but explicit memory was affected.

“They remembered fewer words and fewer themes in stories, as well as fewer numbers in a digit span test,” Dr. Desrochers said. She added that there were some less significant problems with visual memory.

The study also examined the relationship between memory and both blood glucose fluctuations during the day and duration of diabetes. It found that children with more variation in their blood glucose levels performed worse on almost all types of memory tests, compared with children with more stable blood glucose levels. And longer duration of diabetes was associated with poorer performance.

Finally, the study also found that memory in children with diabetes was also affected by time of day—with significantly better performances noted in the morning.

The findings have implications for how children with type 1 diabetes should be scheduled and taught in school.

QUEBEC CITY — Magnetic resonance imagery and spectroscopy of the brain show decreased hippocampal volume in children with type 1 diabetes, and evidence of neuronal damage in a subgroup of those children who have hypoglycemic seizures, according to a new study.

These findings coincide with another study of children with type 1 diabetes, showing deficits in memory that are specifically tied to the hippocampal region, reported researchers from York University in Toronto.

“The hippocampus is quite sensitive to fluctuations in glucose, and also has a high number of insulin receptors—so if there is too much insulin, this can have an impact on functioning,” said Mary Desrochers, Ph.D., who supervised both studies. The results were presented as posters at the joint annual meeting of the Canadian Diabetes Association and the Canadian Society of Endocrinology and Metabolism.

The first study included 10 children with type 1 diabetes (aged 10–14 years, with an age of onset of less than 5 years), half of whom had severe hypoglycemic episodes. They were age-matched to 10 healthy controls.

MRI showed that all patients with diabetes had smaller hippocampal volumes than did controls. And MRI spectroscopy showed elevated levels of inositol and glutamate, suggestive of neuronal damage, in children with a history of hypoglycemic seizures.

“This tells us that overcontrol of hyperglycemia is possibly an issue,” Dr. Desrochers told this newspaper. “All of the children in this study had excellent glycemic control and some of the parents told us that they sometimes give their children extra injections of insulin. So that would be something to look into—whether overcontrol is playing a role in the incidence of hypoglycemic seizures.”

The study also looked at the neuropsychological functioning of the children and found a trend toward long-term (explicit) memory deficits associated with type 1 diabetes specifically in the areas of verbal and visual memory, functions that are controlled by the hippocampus. However, more conclusive evidence for memory deficits came from a separate study.

In that study, conducted by Ph.D. candidate Lila Elkhadem, explicit and implicit memory skills were compared in 15 children with type 1 diabetes and 17 healthy controls (mean age between 11 and 12 years).

Explicit memory is actively learned whereas implicit memory is information that is more passively absorbed, explained Dr. Desrochers.

“Implicit memory develops earlier and remains robust throughout life. It is what is learned every day, whereas explicit memory is involved when you tell someone they need to remember something,” she said.

The study found that in children with diabetes, implicit memory did not differ from controls, but explicit memory was affected.

“They remembered fewer words and fewer themes in stories, as well as fewer numbers in a digit span test,” Dr. Desrochers said. She added that there were some less significant problems with visual memory.

The study also examined the relationship between memory and both blood glucose fluctuations during the day and duration of diabetes. It found that children with more variation in their blood glucose levels performed worse on almost all types of memory tests, compared with children with more stable blood glucose levels. And longer duration of diabetes was associated with poorer performance.

Finally, the study also found that memory in children with diabetes was also affected by time of day—with significantly better performances noted in the morning.

The findings have implications for how children with type 1 diabetes should be scheduled and taught in school.

QUEBEC CITY — Magnetic resonance imagery and spectroscopy of the brain show decreased hippocampal volume in children with type 1 diabetes, and evidence of neuronal damage in a subgroup of those children who have hypoglycemic seizures, according to a new study.

These findings coincide with another study of children with type 1 diabetes, showing deficits in memory that are specifically tied to the hippocampal region, reported researchers from York University in Toronto.

“The hippocampus is quite sensitive to fluctuations in glucose, and also has a high number of insulin receptors—so if there is too much insulin, this can have an impact on functioning,” said Mary Desrochers, Ph.D., who supervised both studies. The results were presented as posters at the joint annual meeting of the Canadian Diabetes Association and the Canadian Society of Endocrinology and Metabolism.

The first study included 10 children with type 1 diabetes (aged 10–14 years, with an age of onset of less than 5 years), half of whom had severe hypoglycemic episodes. They were age-matched to 10 healthy controls.

MRI showed that all patients with diabetes had smaller hippocampal volumes than did controls. And MRI spectroscopy showed elevated levels of inositol and glutamate, suggestive of neuronal damage, in children with a history of hypoglycemic seizures.

“This tells us that overcontrol of hyperglycemia is possibly an issue,” Dr. Desrochers told this newspaper. “All of the children in this study had excellent glycemic control and some of the parents told us that they sometimes give their children extra injections of insulin. So that would be something to look into—whether overcontrol is playing a role in the incidence of hypoglycemic seizures.”

The study also looked at the neuropsychological functioning of the children and found a trend toward long-term (explicit) memory deficits associated with type 1 diabetes specifically in the areas of verbal and visual memory, functions that are controlled by the hippocampus. However, more conclusive evidence for memory deficits came from a separate study.

In that study, conducted by Ph.D. candidate Lila Elkhadem, explicit and implicit memory skills were compared in 15 children with type 1 diabetes and 17 healthy controls (mean age between 11 and 12 years).

Explicit memory is actively learned whereas implicit memory is information that is more passively absorbed, explained Dr. Desrochers.

“Implicit memory develops earlier and remains robust throughout life. It is what is learned every day, whereas explicit memory is involved when you tell someone they need to remember something,” she said.

The study found that in children with diabetes, implicit memory did not differ from controls, but explicit memory was affected.

“They remembered fewer words and fewer themes in stories, as well as fewer numbers in a digit span test,” Dr. Desrochers said. She added that there were some less significant problems with visual memory.

The study also examined the relationship between memory and both blood glucose fluctuations during the day and duration of diabetes. It found that children with more variation in their blood glucose levels performed worse on almost all types of memory tests, compared with children with more stable blood glucose levels. And longer duration of diabetes was associated with poorer performance.

Finally, the study also found that memory in children with diabetes was also affected by time of day—with significantly better performances noted in the morning.

The findings have implications for how children with type 1 diabetes should be scheduled and taught in school.

QUEBEC CITY — Noninvasive methods for identifying pediatric diabetic neuropathy are not as sensitive as conventional nerve conduction studies and should not be considered for screening purposes, Danièle Pacaud, M.D., said at the joint annual meeting of the Canadian Diabetes Association and the Canadian Society of Endocrinology and Metabolism.

“[Noninvasive methods are] fast, less painful, and they don't require a neurology referral, but unfortunately they are also not as good,” she reported regarding new research.

Long-standing diabetic neuropathy can be associated with serious complications such as foot ulcerations, amputations, nephropathy, myocardial infarction, and stroke, said lead investigator Dr. Pacaud, a pediatric endocrinologist at the Alberta Children's Hospital and the University of Calgary in Calgary, Alberta.

Early detection could reduce or delay such complications, but this condition can often exist subclinically, she said.

In adults, two inexpensive, rapid screening tests—the vibration perception thresholds (VPT), and the tactile perception thresholds (TPT)—have been recommended for detecting subclinical neuropathies. However, these tests have not been well assessed in children, she said.

The study compared VPT and TPT with the standard nerve conduction studies (NCS) in 73 children (mean age 13 years) with type 1 diabetes.

The NCS measures median and peroneal motor nerve conduction, as well as sural sensory nerve response. Two abnormalities on this test indicate diabetic neuropathy.

In VPT testing, subjects are asked to touch a box with their big toe and indicate whether it is vibrating. The amplitude of the vibrations is steadily decreased until the subjects cannot feel them.

In TPT, subjects are asked to indicate when they feel microfilaments that are applied to the plantar surface of the foot.

All children in the study were administered a neurological questionnaire by a research coordinator. They also underwent NCS and received a neurological exam by a neurologist. In addition, the children were given both the VPT and TPT by a research nurse. Finally, a research assistant performed a chart review to obtain information on hemoglobin A1c levels and duration of diabetes. All four investigators were blinded to the results obtained by the others.

The study found that, according to the standard NCS, diabetic neuropathy was common. Of the 73 subjects, 42 (57%) had two abnormalities on NCS, indicating diabetic neuropathy.

Of those abnormalities, 37 were picked up by VPT, 26 by neurological exam, and 19 by TPT.

“Compared to the gold standard NCS, neither the VPT, TPT, nor neurological exam was found to be acceptable as [a screening test],” Dr. Pacaud said.

Consistent with other reports, significant variables found to be related to the presence of neuropathy included age, height, degree of metabolic control, and an abnormal neurological exam.

Dr. Pacaud said the neurological symptoms questionnaire was not useful, because few patients experienced regular symptoms.

Although at present, early detection of subclinical diabetic neuropathy would not change a patient's treatment, there may soon be treatments available for this indication, Dr. Pacaud noted.

“At this point, the only treatment we would offer would be to reinforce the importance of metabolic control, which we are already trying to do. However, there are some specific therapies that are being tested, and once they become available it would be important to be able to use screening to identify which individuals would be able to benefit,” she told this newspaper, including aldose reductase inhibitors, certain nutritional supplements, and antioxidant therapies.

QUEBEC CITY — Noninvasive methods for identifying pediatric diabetic neuropathy are not as sensitive as conventional nerve conduction studies and should not be considered for screening purposes, Danièle Pacaud, M.D., said at the joint annual meeting of the Canadian Diabetes Association and the Canadian Society of Endocrinology and Metabolism.

“[Noninvasive methods are] fast, less painful, and they don't require a neurology referral, but unfortunately they are also not as good,” she reported regarding new research.

Long-standing diabetic neuropathy can be associated with serious complications such as foot ulcerations, amputations, nephropathy, myocardial infarction, and stroke, said lead investigator Dr. Pacaud, a pediatric endocrinologist at the Alberta Children's Hospital and the University of Calgary in Calgary, Alberta.

Early detection could reduce or delay such complications, but this condition can often exist subclinically, she said.

In adults, two inexpensive, rapid screening tests—the vibration perception thresholds (VPT), and the tactile perception thresholds (TPT)—have been recommended for detecting subclinical neuropathies. However, these tests have not been well assessed in children, she said.

The study compared VPT and TPT with the standard nerve conduction studies (NCS) in 73 children (mean age 13 years) with type 1 diabetes.

The NCS measures median and peroneal motor nerve conduction, as well as sural sensory nerve response. Two abnormalities on this test indicate diabetic neuropathy.

In VPT testing, subjects are asked to touch a box with their big toe and indicate whether it is vibrating. The amplitude of the vibrations is steadily decreased until the subjects cannot feel them.

In TPT, subjects are asked to indicate when they feel microfilaments that are applied to the plantar surface of the foot.

All children in the study were administered a neurological questionnaire by a research coordinator. They also underwent NCS and received a neurological exam by a neurologist. In addition, the children were given both the VPT and TPT by a research nurse. Finally, a research assistant performed a chart review to obtain information on hemoglobin A1c levels and duration of diabetes. All four investigators were blinded to the results obtained by the others.

The study found that, according to the standard NCS, diabetic neuropathy was common. Of the 73 subjects, 42 (57%) had two abnormalities on NCS, indicating diabetic neuropathy.

Of those abnormalities, 37 were picked up by VPT, 26 by neurological exam, and 19 by TPT.

“Compared to the gold standard NCS, neither the VPT, TPT, nor neurological exam was found to be acceptable as [a screening test],” Dr. Pacaud said.

Consistent with other reports, significant variables found to be related to the presence of neuropathy included age, height, degree of metabolic control, and an abnormal neurological exam.

Dr. Pacaud said the neurological symptoms questionnaire was not useful, because few patients experienced regular symptoms.

Although at present, early detection of subclinical diabetic neuropathy would not change a patient's treatment, there may soon be treatments available for this indication, Dr. Pacaud noted.

“At this point, the only treatment we would offer would be to reinforce the importance of metabolic control, which we are already trying to do. However, there are some specific therapies that are being tested, and once they become available it would be important to be able to use screening to identify which individuals would be able to benefit,” she told this newspaper, including aldose reductase inhibitors, certain nutritional supplements, and antioxidant therapies.

QUEBEC CITY — Noninvasive methods for identifying pediatric diabetic neuropathy are not as sensitive as conventional nerve conduction studies and should not be considered for screening purposes, Danièle Pacaud, M.D., said at the joint annual meeting of the Canadian Diabetes Association and the Canadian Society of Endocrinology and Metabolism.

“[Noninvasive methods are] fast, less painful, and they don't require a neurology referral, but unfortunately they are also not as good,” she reported regarding new research.

Long-standing diabetic neuropathy can be associated with serious complications such as foot ulcerations, amputations, nephropathy, myocardial infarction, and stroke, said lead investigator Dr. Pacaud, a pediatric endocrinologist at the Alberta Children's Hospital and the University of Calgary in Calgary, Alberta.

Early detection could reduce or delay such complications, but this condition can often exist subclinically, she said.

In adults, two inexpensive, rapid screening tests—the vibration perception thresholds (VPT), and the tactile perception thresholds (TPT)—have been recommended for detecting subclinical neuropathies. However, these tests have not been well assessed in children, she said.

The study compared VPT and TPT with the standard nerve conduction studies (NCS) in 73 children (mean age 13 years) with type 1 diabetes.

The NCS measures median and peroneal motor nerve conduction, as well as sural sensory nerve response. Two abnormalities on this test indicate diabetic neuropathy.

In VPT testing, subjects are asked to touch a box with their big toe and indicate whether it is vibrating. The amplitude of the vibrations is steadily decreased until the subjects cannot feel them.

In TPT, subjects are asked to indicate when they feel microfilaments that are applied to the plantar surface of the foot.

All children in the study were administered a neurological questionnaire by a research coordinator. They also underwent NCS and received a neurological exam by a neurologist. In addition, the children were given both the VPT and TPT by a research nurse. Finally, a research assistant performed a chart review to obtain information on hemoglobin A1c levels and duration of diabetes. All four investigators were blinded to the results obtained by the others.

The study found that, according to the standard NCS, diabetic neuropathy was common. Of the 73 subjects, 42 (57%) had two abnormalities on NCS, indicating diabetic neuropathy.

Of those abnormalities, 37 were picked up by VPT, 26 by neurological exam, and 19 by TPT.

“Compared to the gold standard NCS, neither the VPT, TPT, nor neurological exam was found to be acceptable as [a screening test],” Dr. Pacaud said.

Consistent with other reports, significant variables found to be related to the presence of neuropathy included age, height, degree of metabolic control, and an abnormal neurological exam.

Dr. Pacaud said the neurological symptoms questionnaire was not useful, because few patients experienced regular symptoms.

Although at present, early detection of subclinical diabetic neuropathy would not change a patient's treatment, there may soon be treatments available for this indication, Dr. Pacaud noted.

“At this point, the only treatment we would offer would be to reinforce the importance of metabolic control, which we are already trying to do. However, there are some specific therapies that are being tested, and once they become available it would be important to be able to use screening to identify which individuals would be able to benefit,” she told this newspaper, including aldose reductase inhibitors, certain nutritional supplements, and antioxidant therapies.

The benefits of vaccinating the elderly population against influenza may be substantially less than previously thought, and concentrating immunization efforts on the younger population with high-risk conditions might result in better outcomes, according to two separate studies.

Alternatively, funneling the limited vaccine supply to school-aged children could result in indirect community-wide protection, another group suggests.

Although the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) is currently finalizing new vaccination guidelines based on three tiers of priority (see related story on p. 1), debate continues among researchers worldwide over the best way to use the limited vaccine supply.

Vaccinating the Elderly

Even as ACIP's proposed new guidelines place the elderly population in the first tier of vaccination priorities, a study from the National Institutes of Health (NIH) challenges the assumption that vaccinating this population results in decreased influenza-related mortality (Arch. Intern. Med. 2005;165:265–72).

Increased vaccination rates among the elderly population (aged 65 and older) since before 1980 should theoretically have substantially decreased pneumonia and influenza mortality rates in this age group, reported Lone Simonsen, Ph.D., an epidemiologist at the NIH, and colleagues.

But the authors documented no change in the number of deaths attributable to influenza. They used a cyclical regression model to generate estimates of national influenza-related mortality for 33 influenza seasons between 1968 and 2001, adjusting for the increase in average age of the elderly population over this time period, as well as for the increased frequency of influenza A-dominant seasons in the 1990s.

“Our findings indicate that the mortality benefits of influenza vaccination may be substantially less than previously thought,” they reported.

This difference between their findings and those of observational studies attributing as much as a 50% reduction in deaths among the elderly to influenza vaccination may be partly explained by a “hypothesis of disparity in vaccination: Very ill elderly people, whose fragile health would make them highly likely to die over the coming winter months, are less likely to be vaccinated during the autumn vaccination period,” they noted. Thus, some or all of the reduction in mortality observed in some of these studies was “not attributable to vaccination, but rather to underlying differences between vaccinated and unvaccinated cohorts,” they suggested.

Keiji Fukuda, M.D., an epidemiologist at the CDC, said the new study will not change ACIP's three-tiered priority guidelines for vaccination. The study's ability to draw conclusions about vaccination's effectiveness is “quite limited,” because it did not directly compare illness and death in vaccinated and unvaccinated people.

The authors “did not say that vaccine doesn't work,” he told this newspaper. “Based on these considerations, both CDC and NIH strongly believe that vaccination of the elderly must continue, even while we try to develop better ways to protect this most fragile and vulnerable of groups.”

Vaccinating the Old and the Young

In contrast with the NIH study, a separate study published in the same issue of the journal documented substantial benefits to vaccinating both elderly people as well as younger individuals who are at high risk of complications from influenza (Arch. Intern. Med. 2005;165:274–80).

This case-control study nested within the larger Dutch Prevention of Influenza, Surveillance, and Management (PRISMA) study included 8,593 subjects, reported Eelko Hak, Ph.D., of University Medical Center Utrecht, the Netherlands, and colleagues.

The subjects were grouped into three categories: high-risk children and adolescents aged 6 months to 17 years; high-risk adults aged 18–64 years; and people aged 65 years and older.

The study was conducted during the 1999–2000 influenza A epidemic and the two following influenza seasons, in which influenza activity was very mild.

Under Dutch guidelines, high-risk medical conditions include chronic bronchitis, emphysema, asthma, and other respiratory diseases; acute or chronic ischemic heart disease, heart failure, atrial fibrillation, and other heart disease; cerebrovascular disease; diabetes mellitus; chronic renal disease; chronic staphylococcal infection; and immune-related diseases.

Among the 411 high-risk children and adolescents, 58% (240) had been vaccinated against influenza, as had 70% of the 1,778 high-risk adults (1,246), and 81% of the 6,404 elderly people (5,197).

The study identified 1,920 patients who experienced 2,095 episodes of influenza. There were 320 deaths, 192 hospitalizations, and 1,583 GP visits.

Using incidence rates among unvaccinated subjects during the 1999–2000 influenza A epidemic and adjusting for age, gender, comorbidities, and health insurance coverage, the authors calculated the protective effect of vaccination in the cohort.

They found that among high-risk children, vaccination prevented 43% of GP visits for influenza, pneumonia, acute exacerbations of chronic lung disease, and acute otitis media.

Additionally, vaccination prevented 78% of deaths, 87% of hospitalizations, and 26% of GP visits among high-risk adults. And among elderly subjects, vaccination prevented 50% of deaths and 48% of hospitalizations.

“The results of our study lend strong support for the view that all high-risk persons benefit from annual influenza vaccination, regardless of age,” the authors said.

Vaccinating Children

But with such low vaccination rates in high-risk populations, vaccination strategies should be reconsidered, according to a commentary published in a separate journal (Am. J. Epidemiol. 2005;161:303–6).

Targeting school-aged children—the group most responsible for community-wide transmission—while maintaining immunization in high-risk and elderly individuals could greatly curtail the spread of influenza in the general population, according to Ira M. Longini Jr., Ph.D., and M. Elizabeth Halloran, M.D., of Emory University in Atlanta.

Mathematical models and evidence from community trials suggest that by vaccinating school-aged children, transmission can be reduced in the entire community, they reported.

“The best strategy for minimizing the number of influenza deaths and morbidity … would be to concentrate vaccine in the high-risk and high-transmitting population groups simultaneously,” they said. This could be achieved by targeting 70% of schoolchildren, as well as high-risk groups.

The benefits of vaccinating the elderly population against influenza may be substantially less than previously thought, and concentrating immunization efforts on the younger population with high-risk conditions might result in better outcomes, according to two separate studies.

Alternatively, funneling the limited vaccine supply to school-aged children could result in indirect community-wide protection, another group suggests.

Although the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) is currently finalizing new vaccination guidelines based on three tiers of priority (see related story on p. 1), debate continues among researchers worldwide over the best way to use the limited vaccine supply.

Vaccinating the Elderly

Even as ACIP's proposed new guidelines place the elderly population in the first tier of vaccination priorities, a study from the National Institutes of Health (NIH) challenges the assumption that vaccinating this population results in decreased influenza-related mortality (Arch. Intern. Med. 2005;165:265–72).

Increased vaccination rates among the elderly population (aged 65 and older) since before 1980 should theoretically have substantially decreased pneumonia and influenza mortality rates in this age group, reported Lone Simonsen, Ph.D., an epidemiologist at the NIH, and colleagues.

But the authors documented no change in the number of deaths attributable to influenza. They used a cyclical regression model to generate estimates of national influenza-related mortality for 33 influenza seasons between 1968 and 2001, adjusting for the increase in average age of the elderly population over this time period, as well as for the increased frequency of influenza A-dominant seasons in the 1990s.

“Our findings indicate that the mortality benefits of influenza vaccination may be substantially less than previously thought,” they reported.

This difference between their findings and those of observational studies attributing as much as a 50% reduction in deaths among the elderly to influenza vaccination may be partly explained by a “hypothesis of disparity in vaccination: Very ill elderly people, whose fragile health would make them highly likely to die over the coming winter months, are less likely to be vaccinated during the autumn vaccination period,” they noted. Thus, some or all of the reduction in mortality observed in some of these studies was “not attributable to vaccination, but rather to underlying differences between vaccinated and unvaccinated cohorts,” they suggested.

Keiji Fukuda, M.D., an epidemiologist at the CDC, said the new study will not change ACIP's three-tiered priority guidelines for vaccination. The study's ability to draw conclusions about vaccination's effectiveness is “quite limited,” because it did not directly compare illness and death in vaccinated and unvaccinated people.

The authors “did not say that vaccine doesn't work,” he told this newspaper. “Based on these considerations, both CDC and NIH strongly believe that vaccination of the elderly must continue, even while we try to develop better ways to protect this most fragile and vulnerable of groups.”

Vaccinating the Old and the Young

In contrast with the NIH study, a separate study published in the same issue of the journal documented substantial benefits to vaccinating both elderly people as well as younger individuals who are at high risk of complications from influenza (Arch. Intern. Med. 2005;165:274–80).

This case-control study nested within the larger Dutch Prevention of Influenza, Surveillance, and Management (PRISMA) study included 8,593 subjects, reported Eelko Hak, Ph.D., of University Medical Center Utrecht, the Netherlands, and colleagues.

The subjects were grouped into three categories: high-risk children and adolescents aged 6 months to 17 years; high-risk adults aged 18–64 years; and people aged 65 years and older.

The study was conducted during the 1999–2000 influenza A epidemic and the two following influenza seasons, in which influenza activity was very mild.

Under Dutch guidelines, high-risk medical conditions include chronic bronchitis, emphysema, asthma, and other respiratory diseases; acute or chronic ischemic heart disease, heart failure, atrial fibrillation, and other heart disease; cerebrovascular disease; diabetes mellitus; chronic renal disease; chronic staphylococcal infection; and immune-related diseases.

Among the 411 high-risk children and adolescents, 58% (240) had been vaccinated against influenza, as had 70% of the 1,778 high-risk adults (1,246), and 81% of the 6,404 elderly people (5,197).

The study identified 1,920 patients who experienced 2,095 episodes of influenza. There were 320 deaths, 192 hospitalizations, and 1,583 GP visits.

Using incidence rates among unvaccinated subjects during the 1999–2000 influenza A epidemic and adjusting for age, gender, comorbidities, and health insurance coverage, the authors calculated the protective effect of vaccination in the cohort.

They found that among high-risk children, vaccination prevented 43% of GP visits for influenza, pneumonia, acute exacerbations of chronic lung disease, and acute otitis media.

Additionally, vaccination prevented 78% of deaths, 87% of hospitalizations, and 26% of GP visits among high-risk adults. And among elderly subjects, vaccination prevented 50% of deaths and 48% of hospitalizations.

“The results of our study lend strong support for the view that all high-risk persons benefit from annual influenza vaccination, regardless of age,” the authors said.

Vaccinating Children

But with such low vaccination rates in high-risk populations, vaccination strategies should be reconsidered, according to a commentary published in a separate journal (Am. J. Epidemiol. 2005;161:303–6).

Targeting school-aged children—the group most responsible for community-wide transmission—while maintaining immunization in high-risk and elderly individuals could greatly curtail the spread of influenza in the general population, according to Ira M. Longini Jr., Ph.D., and M. Elizabeth Halloran, M.D., of Emory University in Atlanta.

Mathematical models and evidence from community trials suggest that by vaccinating school-aged children, transmission can be reduced in the entire community, they reported.

“The best strategy for minimizing the number of influenza deaths and morbidity … would be to concentrate vaccine in the high-risk and high-transmitting population groups simultaneously,” they said. This could be achieved by targeting 70% of schoolchildren, as well as high-risk groups.

The benefits of vaccinating the elderly population against influenza may be substantially less than previously thought, and concentrating immunization efforts on the younger population with high-risk conditions might result in better outcomes, according to two separate studies.

Alternatively, funneling the limited vaccine supply to school-aged children could result in indirect community-wide protection, another group suggests.

Although the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) is currently finalizing new vaccination guidelines based on three tiers of priority (see related story on p. 1), debate continues among researchers worldwide over the best way to use the limited vaccine supply.

Vaccinating the Elderly

Even as ACIP's proposed new guidelines place the elderly population in the first tier of vaccination priorities, a study from the National Institutes of Health (NIH) challenges the assumption that vaccinating this population results in decreased influenza-related mortality (Arch. Intern. Med. 2005;165:265–72).

Increased vaccination rates among the elderly population (aged 65 and older) since before 1980 should theoretically have substantially decreased pneumonia and influenza mortality rates in this age group, reported Lone Simonsen, Ph.D., an epidemiologist at the NIH, and colleagues.

But the authors documented no change in the number of deaths attributable to influenza. They used a cyclical regression model to generate estimates of national influenza-related mortality for 33 influenza seasons between 1968 and 2001, adjusting for the increase in average age of the elderly population over this time period, as well as for the increased frequency of influenza A-dominant seasons in the 1990s.

“Our findings indicate that the mortality benefits of influenza vaccination may be substantially less than previously thought,” they reported.

This difference between their findings and those of observational studies attributing as much as a 50% reduction in deaths among the elderly to influenza vaccination may be partly explained by a “hypothesis of disparity in vaccination: Very ill elderly people, whose fragile health would make them highly likely to die over the coming winter months, are less likely to be vaccinated during the autumn vaccination period,” they noted. Thus, some or all of the reduction in mortality observed in some of these studies was “not attributable to vaccination, but rather to underlying differences between vaccinated and unvaccinated cohorts,” they suggested.

Keiji Fukuda, M.D., an epidemiologist at the CDC, said the new study will not change ACIP's three-tiered priority guidelines for vaccination. The study's ability to draw conclusions about vaccination's effectiveness is “quite limited,” because it did not directly compare illness and death in vaccinated and unvaccinated people.

The authors “did not say that vaccine doesn't work,” he told this newspaper. “Based on these considerations, both CDC and NIH strongly believe that vaccination of the elderly must continue, even while we try to develop better ways to protect this most fragile and vulnerable of groups.”

Vaccinating the Old and the Young

In contrast with the NIH study, a separate study published in the same issue of the journal documented substantial benefits to vaccinating both elderly people as well as younger individuals who are at high risk of complications from influenza (Arch. Intern. Med. 2005;165:274–80).

This case-control study nested within the larger Dutch Prevention of Influenza, Surveillance, and Management (PRISMA) study included 8,593 subjects, reported Eelko Hak, Ph.D., of University Medical Center Utrecht, the Netherlands, and colleagues.

The subjects were grouped into three categories: high-risk children and adolescents aged 6 months to 17 years; high-risk adults aged 18–64 years; and people aged 65 years and older.

The study was conducted during the 1999–2000 influenza A epidemic and the two following influenza seasons, in which influenza activity was very mild.

Under Dutch guidelines, high-risk medical conditions include chronic bronchitis, emphysema, asthma, and other respiratory diseases; acute or chronic ischemic heart disease, heart failure, atrial fibrillation, and other heart disease; cerebrovascular disease; diabetes mellitus; chronic renal disease; chronic staphylococcal infection; and immune-related diseases.

Among the 411 high-risk children and adolescents, 58% (240) had been vaccinated against influenza, as had 70% of the 1,778 high-risk adults (1,246), and 81% of the 6,404 elderly people (5,197).

The study identified 1,920 patients who experienced 2,095 episodes of influenza. There were 320 deaths, 192 hospitalizations, and 1,583 GP visits.

Using incidence rates among unvaccinated subjects during the 1999–2000 influenza A epidemic and adjusting for age, gender, comorbidities, and health insurance coverage, the authors calculated the protective effect of vaccination in the cohort.

They found that among high-risk children, vaccination prevented 43% of GP visits for influenza, pneumonia, acute exacerbations of chronic lung disease, and acute otitis media.

Additionally, vaccination prevented 78% of deaths, 87% of hospitalizations, and 26% of GP visits among high-risk adults. And among elderly subjects, vaccination prevented 50% of deaths and 48% of hospitalizations.

“The results of our study lend strong support for the view that all high-risk persons benefit from annual influenza vaccination, regardless of age,” the authors said.

Vaccinating Children

But with such low vaccination rates in high-risk populations, vaccination strategies should be reconsidered, according to a commentary published in a separate journal (Am. J. Epidemiol. 2005;161:303–6).

Targeting school-aged children—the group most responsible for community-wide transmission—while maintaining immunization in high-risk and elderly individuals could greatly curtail the spread of influenza in the general population, according to Ira M. Longini Jr., Ph.D., and M. Elizabeth Halloran, M.D., of Emory University in Atlanta.

Mathematical models and evidence from community trials suggest that by vaccinating school-aged children, transmission can be reduced in the entire community, they reported.

“The best strategy for minimizing the number of influenza deaths and morbidity … would be to concentrate vaccine in the high-risk and high-transmitting population groups simultaneously,” they said. This could be achieved by targeting 70% of schoolchildren, as well as high-risk groups.

Biomarkers of intra-amniotic infection and inflammation can be rapidly detected in amniotic fluid using proteomic analysis. And the identification of a distinctive biomarker profile can predict imminent preterm delivery with 100% accuracy, opening the door to future treatments, results of a recent study suggest.

“We are probably at a turning point in the history of preterm labor diagnosis,” lead author Irina Buhimschi, M.D., of Yale University, New Haven, and her associates wrote (BJOG 2005;112:173-81). She conducted the research with Catalin S. Buhimschi, M.D., also of Yale, and Rob Christner of Ciphergen Biosystems, Fremont, Calif.

“We think this proteomic analysis will be the diagnostic platform of the future from which many diseases will be diagnosed,” Dr. Irina Buhimschi commented in an interview.

The discovery could help identify preterm labor patients who might benefit from intervention “before the battle is completely lost,” she explained.

Although amniotic fluid cultures can detect infection, they have limited clinical utility because results are not quickly available. “By the time you have the result, the patient has already delivered, and the baby is in neonatal intensive care—so the only benefit of the test is to confirm the decision of the physician. In the case of [proteomic analysis], the result can be available within 50 minutes or less and has the potential of being useful for clinical decision making,” she said.

Using proteomic analysis, the team analyzed frozen amniotic fluid samples from 77 women with symptoms of preterm labor or preterm, premature rupture of membranes, and a known outcome (stage 1). The findings were then applied to samples from 24 symptomatic patients whose outcomes were not known to the investigators (stage 2).

The analysis identified a distinctive profile of four proteins present in patients who went on to preterm delivery but absent in patients whose symptoms subsided and who did not give birth prematurely.

This profile consisted of three out of four biomarkers of infection and inflammation, including human neutrophil defensin-1 and -2 and calgranulins A and C.

“If there were just two of the biomarkers present, the symptoms might either spontaneously resolve or get worse. It was only when three or four were present that imminent delivery could be predicted,” Dr. Buhimschi said.

The analysis involved a sophisticated algorithm called mass restricted (MR) analysis, and patients were given an MR score based on their levels of these four proteins.

The scoring system had 100% sensitivity and specificity for predicting which patients would deliver prematurely. Patients with an MR score of 3-4 had a median amniocentesis-to-delivery interval of 2 days, compared with a median of 51 days for patients with MR scores of 0-2.

Although it is generally accepted that a large proportion of preterm deliveries are caused by infection and inflammation, previous attempts at treating all preterm labor patients with antibiotics have failed to reverse the process. This may be partly because patients whose preterm labor is caused by factors other than infection and inflammation do not respond to antibiotic therapy, Dr. Buhimschi said.

“It is reasonable to think that those who respond to antibiotics will be only those in whom the preterm labor is caused by an infection and inflammation—and our approach is able to identify those patients,” she said. In addition, the identification of specific biomarkers of preterm delivery holds potential for research into pathology-specific treatments, she said.

The research was funded by the National Institutes of Health and Ciphergen Biosystems. Dr. Buhimschi said the NIH has agreed to fund further investigations into the application of this research.

Biomarkers of intra-amniotic infection and inflammation can be rapidly detected in amniotic fluid using proteomic analysis. And the identification of a distinctive biomarker profile can predict imminent preterm delivery with 100% accuracy, opening the door to future treatments, results of a recent study suggest.

“We are probably at a turning point in the history of preterm labor diagnosis,” lead author Irina Buhimschi, M.D., of Yale University, New Haven, and her associates wrote (BJOG 2005;112:173-81). She conducted the research with Catalin S. Buhimschi, M.D., also of Yale, and Rob Christner of Ciphergen Biosystems, Fremont, Calif.

“We think this proteomic analysis will be the diagnostic platform of the future from which many diseases will be diagnosed,” Dr. Irina Buhimschi commented in an interview.

The discovery could help identify preterm labor patients who might benefit from intervention “before the battle is completely lost,” she explained.

Although amniotic fluid cultures can detect infection, they have limited clinical utility because results are not quickly available. “By the time you have the result, the patient has already delivered, and the baby is in neonatal intensive care—so the only benefit of the test is to confirm the decision of the physician. In the case of [proteomic analysis], the result can be available within 50 minutes or less and has the potential of being useful for clinical decision making,” she said.

Using proteomic analysis, the team analyzed frozen amniotic fluid samples from 77 women with symptoms of preterm labor or preterm, premature rupture of membranes, and a known outcome (stage 1). The findings were then applied to samples from 24 symptomatic patients whose outcomes were not known to the investigators (stage 2).

The analysis identified a distinctive profile of four proteins present in patients who went on to preterm delivery but absent in patients whose symptoms subsided and who did not give birth prematurely.

This profile consisted of three out of four biomarkers of infection and inflammation, including human neutrophil defensin-1 and -2 and calgranulins A and C.

“If there were just two of the biomarkers present, the symptoms might either spontaneously resolve or get worse. It was only when three or four were present that imminent delivery could be predicted,” Dr. Buhimschi said.

The analysis involved a sophisticated algorithm called mass restricted (MR) analysis, and patients were given an MR score based on their levels of these four proteins.

The scoring system had 100% sensitivity and specificity for predicting which patients would deliver prematurely. Patients with an MR score of 3-4 had a median amniocentesis-to-delivery interval of 2 days, compared with a median of 51 days for patients with MR scores of 0-2.

Although it is generally accepted that a large proportion of preterm deliveries are caused by infection and inflammation, previous attempts at treating all preterm labor patients with antibiotics have failed to reverse the process. This may be partly because patients whose preterm labor is caused by factors other than infection and inflammation do not respond to antibiotic therapy, Dr. Buhimschi said.

“It is reasonable to think that those who respond to antibiotics will be only those in whom the preterm labor is caused by an infection and inflammation—and our approach is able to identify those patients,” she said. In addition, the identification of specific biomarkers of preterm delivery holds potential for research into pathology-specific treatments, she said.

The research was funded by the National Institutes of Health and Ciphergen Biosystems. Dr. Buhimschi said the NIH has agreed to fund further investigations into the application of this research.

Biomarkers of intra-amniotic infection and inflammation can be rapidly detected in amniotic fluid using proteomic analysis. And the identification of a distinctive biomarker profile can predict imminent preterm delivery with 100% accuracy, opening the door to future treatments, results of a recent study suggest.

“We are probably at a turning point in the history of preterm labor diagnosis,” lead author Irina Buhimschi, M.D., of Yale University, New Haven, and her associates wrote (BJOG 2005;112:173-81). She conducted the research with Catalin S. Buhimschi, M.D., also of Yale, and Rob Christner of Ciphergen Biosystems, Fremont, Calif.

“We think this proteomic analysis will be the diagnostic platform of the future from which many diseases will be diagnosed,” Dr. Irina Buhimschi commented in an interview.

The discovery could help identify preterm labor patients who might benefit from intervention “before the battle is completely lost,” she explained.

Although amniotic fluid cultures can detect infection, they have limited clinical utility because results are not quickly available. “By the time you have the result, the patient has already delivered, and the baby is in neonatal intensive care—so the only benefit of the test is to confirm the decision of the physician. In the case of [proteomic analysis], the result can be available within 50 minutes or less and has the potential of being useful for clinical decision making,” she said.

Using proteomic analysis, the team analyzed frozen amniotic fluid samples from 77 women with symptoms of preterm labor or preterm, premature rupture of membranes, and a known outcome (stage 1). The findings were then applied to samples from 24 symptomatic patients whose outcomes were not known to the investigators (stage 2).

The analysis identified a distinctive profile of four proteins present in patients who went on to preterm delivery but absent in patients whose symptoms subsided and who did not give birth prematurely.

This profile consisted of three out of four biomarkers of infection and inflammation, including human neutrophil defensin-1 and -2 and calgranulins A and C.

“If there were just two of the biomarkers present, the symptoms might either spontaneously resolve or get worse. It was only when three or four were present that imminent delivery could be predicted,” Dr. Buhimschi said.

The analysis involved a sophisticated algorithm called mass restricted (MR) analysis, and patients were given an MR score based on their levels of these four proteins.

The scoring system had 100% sensitivity and specificity for predicting which patients would deliver prematurely. Patients with an MR score of 3-4 had a median amniocentesis-to-delivery interval of 2 days, compared with a median of 51 days for patients with MR scores of 0-2.

Although it is generally accepted that a large proportion of preterm deliveries are caused by infection and inflammation, previous attempts at treating all preterm labor patients with antibiotics have failed to reverse the process. This may be partly because patients whose preterm labor is caused by factors other than infection and inflammation do not respond to antibiotic therapy, Dr. Buhimschi said.

“It is reasonable to think that those who respond to antibiotics will be only those in whom the preterm labor is caused by an infection and inflammation—and our approach is able to identify those patients,” she said. In addition, the identification of specific biomarkers of preterm delivery holds potential for research into pathology-specific treatments, she said.

The research was funded by the National Institutes of Health and Ciphergen Biosystems. Dr. Buhimschi said the NIH has agreed to fund further investigations into the application of this research.

Women who do not conceive within 1 year of trying may face an increased risk of their babies dying by the first month post partum, according to Danish researchers.

“Subfecundity may be associated with an increased risk of neonatal death and should be included as a risk indicator in neonatal care,” reported Olga Basso, Ph.D., and Jørn Olsen, M.D., from the Danish Epidemiology Center at the University of Aarhus in Denmark (BMJ [Epub ahead of print], Feb. 4, 2005. Article DOI number: 10.1136/bmj.38336.616806.8F).

“Unlike advanced age, or pregnancy following in vitro fertilization, a period of infertility is not routinely considered a risk factor in pregnancy,” Dr. Basso told this newspaper. “We think it would be advisable to include this when evaluating pregnant women, because it is possible that some complications might be noticed earlier,” she said.

The study analyzed 27,329 singleton births and 66 deaths recorded in the Danish national birth cohort. The analysis was restricted to primiparous women, 73.5% of whom had no previous pregnancies.

The women were grouped by waiting time to pregnancy: up to 2 months (reference group); 3-12 months; more than 12 months with no infertility treatment; more than 12 months with infertility treatment; and those who hadn't planned their pregnancy.

After adjustment for maternal age, body mass index, smoking, and social class (derived from the mother's job title), the analysis found an increased risk of neonatal death associated with increasing time to pregnancy.

Women who reported trying to conceive for more than 12 months had an odds ratio (OR) of 2.80 for neonatal death. Within this group, there was little difference in risk between those who reported infertility treatment (OR 2.21), and those who reported none (OR 3.38).

The authors noted potential weaknesses in their data. About 35% of eligible women participated in the study, and the mother's job title may be a poor proxy for social class (even though adjustment for confounders did not change the estimates). Moreover, subfertile women who do not seek fertility treatment may also not seek or receive adequate prenatal care.

The researchers noted that the findings do not indicate a causal relationship.

“Our finding needs … to be corroborated elsewhere before it can be stated that a long time to pregnancy increases the risk of neonatal death,” they said.

Women who do not conceive within 1 year of trying may face an increased risk of their babies dying by the first month post partum, according to Danish researchers.

“Subfecundity may be associated with an increased risk of neonatal death and should be included as a risk indicator in neonatal care,” reported Olga Basso, Ph.D., and Jørn Olsen, M.D., from the Danish Epidemiology Center at the University of Aarhus in Denmark (BMJ [Epub ahead of print], Feb. 4, 2005. Article DOI number: 10.1136/bmj.38336.616806.8F).

“Unlike advanced age, or pregnancy following in vitro fertilization, a period of infertility is not routinely considered a risk factor in pregnancy,” Dr. Basso told this newspaper. “We think it would be advisable to include this when evaluating pregnant women, because it is possible that some complications might be noticed earlier,” she said.

The study analyzed 27,329 singleton births and 66 deaths recorded in the Danish national birth cohort. The analysis was restricted to primiparous women, 73.5% of whom had no previous pregnancies.

The women were grouped by waiting time to pregnancy: up to 2 months (reference group); 3-12 months; more than 12 months with no infertility treatment; more than 12 months with infertility treatment; and those who hadn't planned their pregnancy.

After adjustment for maternal age, body mass index, smoking, and social class (derived from the mother's job title), the analysis found an increased risk of neonatal death associated with increasing time to pregnancy.

Women who reported trying to conceive for more than 12 months had an odds ratio (OR) of 2.80 for neonatal death. Within this group, there was little difference in risk between those who reported infertility treatment (OR 2.21), and those who reported none (OR 3.38).

The authors noted potential weaknesses in their data. About 35% of eligible women participated in the study, and the mother's job title may be a poor proxy for social class (even though adjustment for confounders did not change the estimates). Moreover, subfertile women who do not seek fertility treatment may also not seek or receive adequate prenatal care.

The researchers noted that the findings do not indicate a causal relationship.

“Our finding needs … to be corroborated elsewhere before it can be stated that a long time to pregnancy increases the risk of neonatal death,” they said.

Women who do not conceive within 1 year of trying may face an increased risk of their babies dying by the first month post partum, according to Danish researchers.

“Subfecundity may be associated with an increased risk of neonatal death and should be included as a risk indicator in neonatal care,” reported Olga Basso, Ph.D., and Jørn Olsen, M.D., from the Danish Epidemiology Center at the University of Aarhus in Denmark (BMJ [Epub ahead of print], Feb. 4, 2005. Article DOI number: 10.1136/bmj.38336.616806.8F).

“Unlike advanced age, or pregnancy following in vitro fertilization, a period of infertility is not routinely considered a risk factor in pregnancy,” Dr. Basso told this newspaper. “We think it would be advisable to include this when evaluating pregnant women, because it is possible that some complications might be noticed earlier,” she said.

The study analyzed 27,329 singleton births and 66 deaths recorded in the Danish national birth cohort. The analysis was restricted to primiparous women, 73.5% of whom had no previous pregnancies.

The women were grouped by waiting time to pregnancy: up to 2 months (reference group); 3-12 months; more than 12 months with no infertility treatment; more than 12 months with infertility treatment; and those who hadn't planned their pregnancy.

After adjustment for maternal age, body mass index, smoking, and social class (derived from the mother's job title), the analysis found an increased risk of neonatal death associated with increasing time to pregnancy.

Women who reported trying to conceive for more than 12 months had an odds ratio (OR) of 2.80 for neonatal death. Within this group, there was little difference in risk between those who reported infertility treatment (OR 2.21), and those who reported none (OR 3.38).

The authors noted potential weaknesses in their data. About 35% of eligible women participated in the study, and the mother's job title may be a poor proxy for social class (even though adjustment for confounders did not change the estimates). Moreover, subfertile women who do not seek fertility treatment may also not seek or receive adequate prenatal care.

The researchers noted that the findings do not indicate a causal relationship.

“Our finding needs … to be corroborated elsewhere before it can be stated that a long time to pregnancy increases the risk of neonatal death,” they said.

CHICAGO — Magnetic resonance imaging can pick up acute cervical spine trauma that is not visible on computed tomography scans, and should be considered in certain trauma patients, according to a study presented at the annual meeting of the Radiological Society of North America.

“Certainly, there is an added cost to ordering an MRI, compared to CT, but when you consider it in the context of such potential catastrophic consequences as quadriplegia, it may not be so expensive,” remarked Joseph Jen-Sho Chen, a 4th-year medical student at the University of Pittsburgh, who presented the research.

Although CT screening is widely accepted as being the standard of care for acute cervical spine injuries, it is not perfect, Mr. Chen told this newspaper.

“CT is very good for finding bone fractures, but it is known to be very poor for finding soft tissue, ligamentous, and spinal cord injuries, which are much better diagnosed by MRI,” he said.

He estimated that the cost of an MRI is about double that of a CT scan.

In his retrospective review, he assessed the benefit of MRI within 72 hours of a negative CT scan of the cervical spine in 91 level I and II trauma patients.

Almost half (45%) of the cases involved motor vehicle accidents, 29% involved falls, 10% involved other vehicles, 8% involved assault, 4% involved sports, and the rest involved pedestrian/vehicle or occupational accidents.

One-third of the patients presented with focal neurologic deficits, one-third had neck pain, 21% had mental status changes, and 18% were obtunded.

Of the 91 patients, 43 had positive CT findings, 5 had equivocal findings, and 43 had a negative CT, he said.

Of those patients with a negative CT, 34 had a negative MRI, but 9 (21%) had positive MRI findings.

Additional findings uncovered by MRI included cord compressions (five patients), cord contusion/edema (four), ligamentous injuries (three), epidural hemorrhage (two), and prevertebral edema (one).

Three of these patients had minor changes to their management based on the additional MRI findings (extended cervical collars) and six had major changes that involved surgery, he said.

Mr. Chen said five of the six patients with additional findings on MRI would likely have received an MRI in most settings, because they had focal neurologic deficits, which is considered an indication for MRI.

However, one patient might not have been referred for MRI in many hospitals because his only complaint was neck pain, Mr. Chen said.

“Definitely patients with focal neurologic deficits should go on to MRI after a negative CT but also I think [it's necessary for] patients whose physical symptoms don't match with the CT scan … like this patient with severe neck pain and no CT findings,” he said.

CT of a trauma patient shows no evidence of osseous injury.

MRI, 36 hours later, shows injuries and cord contusion. Photos courtesy Joseph Jen-Sho Chen

CHICAGO — Magnetic resonance imaging can pick up acute cervical spine trauma that is not visible on computed tomography scans, and should be considered in certain trauma patients, according to a study presented at the annual meeting of the Radiological Society of North America.

“Certainly, there is an added cost to ordering an MRI, compared to CT, but when you consider it in the context of such potential catastrophic consequences as quadriplegia, it may not be so expensive,” remarked Joseph Jen-Sho Chen, a 4th-year medical student at the University of Pittsburgh, who presented the research.

Although CT screening is widely accepted as being the standard of care for acute cervical spine injuries, it is not perfect, Mr. Chen told this newspaper.

“CT is very good for finding bone fractures, but it is known to be very poor for finding soft tissue, ligamentous, and spinal cord injuries, which are much better diagnosed by MRI,” he said.

He estimated that the cost of an MRI is about double that of a CT scan.

In his retrospective review, he assessed the benefit of MRI within 72 hours of a negative CT scan of the cervical spine in 91 level I and II trauma patients.

Almost half (45%) of the cases involved motor vehicle accidents, 29% involved falls, 10% involved other vehicles, 8% involved assault, 4% involved sports, and the rest involved pedestrian/vehicle or occupational accidents.

One-third of the patients presented with focal neurologic deficits, one-third had neck pain, 21% had mental status changes, and 18% were obtunded.

Of the 91 patients, 43 had positive CT findings, 5 had equivocal findings, and 43 had a negative CT, he said.

Of those patients with a negative CT, 34 had a negative MRI, but 9 (21%) had positive MRI findings.

Additional findings uncovered by MRI included cord compressions (five patients), cord contusion/edema (four), ligamentous injuries (three), epidural hemorrhage (two), and prevertebral edema (one).

Three of these patients had minor changes to their management based on the additional MRI findings (extended cervical collars) and six had major changes that involved surgery, he said.

Mr. Chen said five of the six patients with additional findings on MRI would likely have received an MRI in most settings, because they had focal neurologic deficits, which is considered an indication for MRI.

However, one patient might not have been referred for MRI in many hospitals because his only complaint was neck pain, Mr. Chen said.

“Definitely patients with focal neurologic deficits should go on to MRI after a negative CT but also I think [it's necessary for] patients whose physical symptoms don't match with the CT scan … like this patient with severe neck pain and no CT findings,” he said.

CT of a trauma patient shows no evidence of osseous injury.

MRI, 36 hours later, shows injuries and cord contusion. Photos courtesy Joseph Jen-Sho Chen

CHICAGO — Magnetic resonance imaging can pick up acute cervical spine trauma that is not visible on computed tomography scans, and should be considered in certain trauma patients, according to a study presented at the annual meeting of the Radiological Society of North America.

“Certainly, there is an added cost to ordering an MRI, compared to CT, but when you consider it in the context of such potential catastrophic consequences as quadriplegia, it may not be so expensive,” remarked Joseph Jen-Sho Chen, a 4th-year medical student at the University of Pittsburgh, who presented the research.

Although CT screening is widely accepted as being the standard of care for acute cervical spine injuries, it is not perfect, Mr. Chen told this newspaper.

“CT is very good for finding bone fractures, but it is known to be very poor for finding soft tissue, ligamentous, and spinal cord injuries, which are much better diagnosed by MRI,” he said.

He estimated that the cost of an MRI is about double that of a CT scan.

In his retrospective review, he assessed the benefit of MRI within 72 hours of a negative CT scan of the cervical spine in 91 level I and II trauma patients.

Almost half (45%) of the cases involved motor vehicle accidents, 29% involved falls, 10% involved other vehicles, 8% involved assault, 4% involved sports, and the rest involved pedestrian/vehicle or occupational accidents.

One-third of the patients presented with focal neurologic deficits, one-third had neck pain, 21% had mental status changes, and 18% were obtunded.

Of the 91 patients, 43 had positive CT findings, 5 had equivocal findings, and 43 had a negative CT, he said.

Of those patients with a negative CT, 34 had a negative MRI, but 9 (21%) had positive MRI findings.

Additional findings uncovered by MRI included cord compressions (five patients), cord contusion/edema (four), ligamentous injuries (three), epidural hemorrhage (two), and prevertebral edema (one).

Three of these patients had minor changes to their management based on the additional MRI findings (extended cervical collars) and six had major changes that involved surgery, he said.

Mr. Chen said five of the six patients with additional findings on MRI would likely have received an MRI in most settings, because they had focal neurologic deficits, which is considered an indication for MRI.

However, one patient might not have been referred for MRI in many hospitals because his only complaint was neck pain, Mr. Chen said.

“Definitely patients with focal neurologic deficits should go on to MRI after a negative CT but also I think [it's necessary for] patients whose physical symptoms don't match with the CT scan … like this patient with severe neck pain and no CT findings,” he said.

CT of a trauma patient shows no evidence of osseous injury.

MRI, 36 hours later, shows injuries and cord contusion. Photos courtesy Joseph Jen-Sho Chen