Sarah Pressman Lovinger

CHICAGO — Many women report vulvar and vaginal symptoms during pregnancy, but little is known about the frequency, severity, and timing of complaints such as vulvar pain, burning, itching, and dyspareunia, said Dr. Colleen M. Kennedy of the University of Iowa, Iowa City, in a poster presentation at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Vulvar and vaginal symptoms account for more than 10 million office visits annually and represent the most common gynecologic complaint.

To identify the prevalence rates of burning, itching, pain, and dyspareunia during pregnancy and in the 3 months post partum, and to determine how rates of vulvar and vaginal symptoms compare in pregnant and nonpregnant women, Dr. Kennedy and her colleagues evaluated 103 pregnant women recruited from the University of Iowa obstetrics clinics. Sixty-three of these participants completed the final postpartum survey. The study also included 122 nonpregnant women in a control group.

The participants had a mean age of 28 years and were mostly white (92%) and married or living with a partner (81%); most had completed some education beyond high school (86%).

The results showed that both vulvar and vaginal symptoms commonly occur in pregnancy. Pregnant women reported vulvar pain more frequently in their second and third trimesters than in the first trimester, but pregnant women and their nonpregnant controls reported the same level of severity. Vaginal discharge increased in frequency and severity in the second and third trimesters. Dyspareunia was less common in the first trimester than in subsequent trimesters, but reached its peak in the postpartum period, particularly in those women who gave birth vaginally. All other symptoms decreased during the postpartum period.

“Symptoms are dynamic and change [during pregnancy],” said Dr. Kennedy. Compared with nonpregnant controls, the pregnant women in the study did not have higher rates of vulvar pruritus and burning.

CHICAGO — Many women report vulvar and vaginal symptoms during pregnancy, but little is known about the frequency, severity, and timing of complaints such as vulvar pain, burning, itching, and dyspareunia, said Dr. Colleen M. Kennedy of the University of Iowa, Iowa City, in a poster presentation at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Vulvar and vaginal symptoms account for more than 10 million office visits annually and represent the most common gynecologic complaint.

To identify the prevalence rates of burning, itching, pain, and dyspareunia during pregnancy and in the 3 months post partum, and to determine how rates of vulvar and vaginal symptoms compare in pregnant and nonpregnant women, Dr. Kennedy and her colleagues evaluated 103 pregnant women recruited from the University of Iowa obstetrics clinics. Sixty-three of these participants completed the final postpartum survey. The study also included 122 nonpregnant women in a control group.

The participants had a mean age of 28 years and were mostly white (92%) and married or living with a partner (81%); most had completed some education beyond high school (86%).

The results showed that both vulvar and vaginal symptoms commonly occur in pregnancy. Pregnant women reported vulvar pain more frequently in their second and third trimesters than in the first trimester, but pregnant women and their nonpregnant controls reported the same level of severity. Vaginal discharge increased in frequency and severity in the second and third trimesters. Dyspareunia was less common in the first trimester than in subsequent trimesters, but reached its peak in the postpartum period, particularly in those women who gave birth vaginally. All other symptoms decreased during the postpartum period.

“Symptoms are dynamic and change [during pregnancy],” said Dr. Kennedy. Compared with nonpregnant controls, the pregnant women in the study did not have higher rates of vulvar pruritus and burning.

CHICAGO — Many women report vulvar and vaginal symptoms during pregnancy, but little is known about the frequency, severity, and timing of complaints such as vulvar pain, burning, itching, and dyspareunia, said Dr. Colleen M. Kennedy of the University of Iowa, Iowa City, in a poster presentation at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Vulvar and vaginal symptoms account for more than 10 million office visits annually and represent the most common gynecologic complaint.

To identify the prevalence rates of burning, itching, pain, and dyspareunia during pregnancy and in the 3 months post partum, and to determine how rates of vulvar and vaginal symptoms compare in pregnant and nonpregnant women, Dr. Kennedy and her colleagues evaluated 103 pregnant women recruited from the University of Iowa obstetrics clinics. Sixty-three of these participants completed the final postpartum survey. The study also included 122 nonpregnant women in a control group.

The participants had a mean age of 28 years and were mostly white (92%) and married or living with a partner (81%); most had completed some education beyond high school (86%).

The results showed that both vulvar and vaginal symptoms commonly occur in pregnancy. Pregnant women reported vulvar pain more frequently in their second and third trimesters than in the first trimester, but pregnant women and their nonpregnant controls reported the same level of severity. Vaginal discharge increased in frequency and severity in the second and third trimesters. Dyspareunia was less common in the first trimester than in subsequent trimesters, but reached its peak in the postpartum period, particularly in those women who gave birth vaginally. All other symptoms decreased during the postpartum period.

“Symptoms are dynamic and change [during pregnancy],” said Dr. Kennedy. Compared with nonpregnant controls, the pregnant women in the study did not have higher rates of vulvar pruritus and burning.

CHICAGO — You are caring for a gravid woman with very low platelets and hemolytic anemia. You diagnose her with HELLP syndrome and order a platelet transfusion. Is this the best management of a pregnant patient with thrombocytopenia at risk of bleeding?

Not always, according to Dr. James J. Martin Jr. of the University of Mississippi Medical Center in Jackson.

Thrombotic thrombocytopenic purpura (TTP) can masquerade as HELLP (hemolysis, elevated liver enzyme levels, and low platelet count) syndrome. Administering platelets to any patient with this rare but often fatal hematologic disorder can paradoxically worsen the patient's condition, leading to severe disability and death.

Physicians must always consider TTP when caring for pregnant women who present with low platelets.

“Obstetricians-gynecologists are really in a quandary,” Dr. Martin said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

“The main problem is differentiating between TTP and HELLP,” he said. “You need to do it right away,” he added.

While TTP is an extremely rare disease that affects only 4–11 patients per million population, the combination of low platelets, hemolytic anemia, renal failure, and mental status changes can be deadly if undiagnosed.

If physicians mistake TTP for HELLP syndrome and administer one or more platelet transfusions, they may aggravate the hemolytic state caused by absent or severely low levels of a von Willebrand factor-cleaving protease, a potentially fatal error.

Plasma therapy can help replete this protease—known as ADAMTS-13, a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13—and stop the destructive hemolysis that TTP causes. Maternal mortality caused by TTP can drop to less than 10% in women properly treated with plasma therapy.

Obstetricians lack a straightforward method to differentiate between TTP and HELLP syndrome. “We need a definite test for TTP,” said Dr. Martin.

To obtain more information about lab findings in pregnant women that could shed light on possible tests to ease diagnosis of these confounding disorders, Dr. Martin and his colleagues performed an extensive English-language literature search of pregnant patients with TTP, and uncovered 166 reported cases from 1955 to 2006. They excluded patients with hemolytic-uremic syndrome, postpartum renal failure, or severe preeclampsia/eclampsia/HELLP syndrome who lacked reasonable information that could diagnose TTP.

The researchers uncovered only seven papers published between 2002 and 2006 looking at ADAMTS-13 activity levels in suspected TTP patients. Additional analysis revealed that several common lab tests could help differentiate women who have TTP only from women who have TTP together with preeclampsia/HELLP syndrome. The researchers found that the ratio of lactate dehydrogenase (LDH) to serum glutamic oxaloacetic transaminase (SGOT) levels was considerably higher in patients with TTP only, compared to women with combined TTP/preeclampsia/HELLP syndrome.

Dr. Martin recommends testing for ADAMTS-13 levels in pregnant patients who have a LDH/SGOT ratio that exceeds 15. He also recommends this test early in pregnancy in women who have a history of TTP.

A rapid, reliable lab test could help physicians distinguish more easily between the common preeclampsia/HELLP syndromes and TTP, the deadly masquerader. Until then, physicians must keep in mind that pregnant patients who present with low platelets and hemolytic anemia could have TTP and act accordingly, Dr. Martin said.

CHICAGO — You are caring for a gravid woman with very low platelets and hemolytic anemia. You diagnose her with HELLP syndrome and order a platelet transfusion. Is this the best management of a pregnant patient with thrombocytopenia at risk of bleeding?

Not always, according to Dr. James J. Martin Jr. of the University of Mississippi Medical Center in Jackson.

Thrombotic thrombocytopenic purpura (TTP) can masquerade as HELLP (hemolysis, elevated liver enzyme levels, and low platelet count) syndrome. Administering platelets to any patient with this rare but often fatal hematologic disorder can paradoxically worsen the patient's condition, leading to severe disability and death.

Physicians must always consider TTP when caring for pregnant women who present with low platelets.

“Obstetricians-gynecologists are really in a quandary,” Dr. Martin said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

“The main problem is differentiating between TTP and HELLP,” he said. “You need to do it right away,” he added.

While TTP is an extremely rare disease that affects only 4–11 patients per million population, the combination of low platelets, hemolytic anemia, renal failure, and mental status changes can be deadly if undiagnosed.

If physicians mistake TTP for HELLP syndrome and administer one or more platelet transfusions, they may aggravate the hemolytic state caused by absent or severely low levels of a von Willebrand factor-cleaving protease, a potentially fatal error.

Plasma therapy can help replete this protease—known as ADAMTS-13, a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13—and stop the destructive hemolysis that TTP causes. Maternal mortality caused by TTP can drop to less than 10% in women properly treated with plasma therapy.

Obstetricians lack a straightforward method to differentiate between TTP and HELLP syndrome. “We need a definite test for TTP,” said Dr. Martin.

To obtain more information about lab findings in pregnant women that could shed light on possible tests to ease diagnosis of these confounding disorders, Dr. Martin and his colleagues performed an extensive English-language literature search of pregnant patients with TTP, and uncovered 166 reported cases from 1955 to 2006. They excluded patients with hemolytic-uremic syndrome, postpartum renal failure, or severe preeclampsia/eclampsia/HELLP syndrome who lacked reasonable information that could diagnose TTP.

The researchers uncovered only seven papers published between 2002 and 2006 looking at ADAMTS-13 activity levels in suspected TTP patients. Additional analysis revealed that several common lab tests could help differentiate women who have TTP only from women who have TTP together with preeclampsia/HELLP syndrome. The researchers found that the ratio of lactate dehydrogenase (LDH) to serum glutamic oxaloacetic transaminase (SGOT) levels was considerably higher in patients with TTP only, compared to women with combined TTP/preeclampsia/HELLP syndrome.

Dr. Martin recommends testing for ADAMTS-13 levels in pregnant patients who have a LDH/SGOT ratio that exceeds 15. He also recommends this test early in pregnancy in women who have a history of TTP.

A rapid, reliable lab test could help physicians distinguish more easily between the common preeclampsia/HELLP syndromes and TTP, the deadly masquerader. Until then, physicians must keep in mind that pregnant patients who present with low platelets and hemolytic anemia could have TTP and act accordingly, Dr. Martin said.

CHICAGO — You are caring for a gravid woman with very low platelets and hemolytic anemia. You diagnose her with HELLP syndrome and order a platelet transfusion. Is this the best management of a pregnant patient with thrombocytopenia at risk of bleeding?

Not always, according to Dr. James J. Martin Jr. of the University of Mississippi Medical Center in Jackson.

Thrombotic thrombocytopenic purpura (TTP) can masquerade as HELLP (hemolysis, elevated liver enzyme levels, and low platelet count) syndrome. Administering platelets to any patient with this rare but often fatal hematologic disorder can paradoxically worsen the patient's condition, leading to severe disability and death.

Physicians must always consider TTP when caring for pregnant women who present with low platelets.

“Obstetricians-gynecologists are really in a quandary,” Dr. Martin said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

“The main problem is differentiating between TTP and HELLP,” he said. “You need to do it right away,” he added.

While TTP is an extremely rare disease that affects only 4–11 patients per million population, the combination of low platelets, hemolytic anemia, renal failure, and mental status changes can be deadly if undiagnosed.

If physicians mistake TTP for HELLP syndrome and administer one or more platelet transfusions, they may aggravate the hemolytic state caused by absent or severely low levels of a von Willebrand factor-cleaving protease, a potentially fatal error.

Plasma therapy can help replete this protease—known as ADAMTS-13, a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13—and stop the destructive hemolysis that TTP causes. Maternal mortality caused by TTP can drop to less than 10% in women properly treated with plasma therapy.

Obstetricians lack a straightforward method to differentiate between TTP and HELLP syndrome. “We need a definite test for TTP,” said Dr. Martin.

To obtain more information about lab findings in pregnant women that could shed light on possible tests to ease diagnosis of these confounding disorders, Dr. Martin and his colleagues performed an extensive English-language literature search of pregnant patients with TTP, and uncovered 166 reported cases from 1955 to 2006. They excluded patients with hemolytic-uremic syndrome, postpartum renal failure, or severe preeclampsia/eclampsia/HELLP syndrome who lacked reasonable information that could diagnose TTP.

The researchers uncovered only seven papers published between 2002 and 2006 looking at ADAMTS-13 activity levels in suspected TTP patients. Additional analysis revealed that several common lab tests could help differentiate women who have TTP only from women who have TTP together with preeclampsia/HELLP syndrome. The researchers found that the ratio of lactate dehydrogenase (LDH) to serum glutamic oxaloacetic transaminase (SGOT) levels was considerably higher in patients with TTP only, compared to women with combined TTP/preeclampsia/HELLP syndrome.

Dr. Martin recommends testing for ADAMTS-13 levels in pregnant patients who have a LDH/SGOT ratio that exceeds 15. He also recommends this test early in pregnancy in women who have a history of TTP.

A rapid, reliable lab test could help physicians distinguish more easily between the common preeclampsia/HELLP syndromes and TTP, the deadly masquerader. Until then, physicians must keep in mind that pregnant patients who present with low platelets and hemolytic anemia could have TTP and act accordingly, Dr. Martin said.

CHICAGO — Hot flashes may be an indicator of the efficacy of adjuvant tamoxifen therapy in women who have completed breast cancer treatment, a new study suggests.

Data from a large prospective trial of breast cancer survivors on tamoxifen therapy show that women who experienced hot flashes had fewer breast cancer events than those who did not report hot flashes, according to Dr. Joanne E. Mortimer and colleagues at the University of California, San Diego's Moores Cancer Center in La Jolla.

“Our data suggest a relationship between side effects and efficacy of adjuvant tamoxifen,” Dr. Mortimer said at the annual meeting of the American Society of Clinical Oncology.

The study population was drawn from an ongoing study in 3,088 women, aged 18–70 years, with a history of breast cancer stage I (T1c)-III, who were randomly assigned to either the Women's Healthy Eating and Living (WHEL) Study diet or the National Cancer Institute (NCI)-based diet.

The NCI-based diet group, consisting of 1,551 women, formed the basis of the tamoxifen/hot flash study. Of these, 637 women were not taking an antiestrogen agent, 1 woman was taking anastrozole, 16 women were taking raloxifene, and data on vasomotor symptoms were not available in 33 women. A total of 864 women were on tamoxifen.

Among the participants taking tamoxifen, 674 reported experiencing hot flashes (78%) and 190 did not (22%). The mean age was 54 years in both groups. There was no significant difference in stage at diagnosis or hormone receptor status between women who reported hot flashes and those who did not. Time between diagnosis and study entry was statistically shorter in women reporting hot flashes.

With 7.3 years of follow-up, 127 women have developed recurrent disease or second primary tumors, said Dr. Mortimer, professor of clinical medicine and deputy director of clinical oncology at the Moores Cancer Center.

Women with hot flashes had significantly fewer breast cancer-specific events than women without hot flashes (12.9% vs. 21%). “Hot flashes were more predictive of outcome for tamoxifen-treated patients than were age, hormone-receptor status, or stage of the initial cancer when comparing stage I to II,” Dr. Mortimer stated.

During the same session at the meeting, preliminary results of a prospective observational trial of 297 women with breast cancer show that the estrogen-receptor gene ESR1 CG haplotype was associated with higher hot flash scores at baseline in premenopausal women.

Dr. Vered Stearns and associates in the Consortium on Breast Cancer pharmacogenomics conducted genotype analyses and prospectively collected medication records and hot flash diaries before and 1, 4, 8, and 12 months after starting tamoxifen. Postmenopausal women homozygous for ESR1 Pvull CC and ESR2-02 GG genotypes had the greatest increase in hot flash scores at 4 months.

Women with the ESR2-02 AA genotype had a significantly lower risk for developing tamoxifen-induced hot flashes, compared with women with AG or GG genotypes (relative risk 0.26), said Dr. Stearns, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore.

Oncologists are aware of the link between estrogen-receptor status and response to tamoxifen, but these data provide additional evidence that hot flashes and ESR gene variations may be related.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO — Hot flashes may be an indicator of the efficacy of adjuvant tamoxifen therapy in women who have completed breast cancer treatment, a new study suggests.

Data from a large prospective trial of breast cancer survivors on tamoxifen therapy show that women who experienced hot flashes had fewer breast cancer events than those who did not report hot flashes, according to Dr. Joanne E. Mortimer and colleagues at the University of California, San Diego's Moores Cancer Center in La Jolla.

“Our data suggest a relationship between side effects and efficacy of adjuvant tamoxifen,” Dr. Mortimer said at the annual meeting of the American Society of Clinical Oncology.

The study population was drawn from an ongoing study in 3,088 women, aged 18–70 years, with a history of breast cancer stage I (T1c)-III, who were randomly assigned to either the Women's Healthy Eating and Living (WHEL) Study diet or the National Cancer Institute (NCI)-based diet.

The NCI-based diet group, consisting of 1,551 women, formed the basis of the tamoxifen/hot flash study. Of these, 637 women were not taking an antiestrogen agent, 1 woman was taking anastrozole, 16 women were taking raloxifene, and data on vasomotor symptoms were not available in 33 women. A total of 864 women were on tamoxifen.

Among the participants taking tamoxifen, 674 reported experiencing hot flashes (78%) and 190 did not (22%). The mean age was 54 years in both groups. There was no significant difference in stage at diagnosis or hormone receptor status between women who reported hot flashes and those who did not. Time between diagnosis and study entry was statistically shorter in women reporting hot flashes.

With 7.3 years of follow-up, 127 women have developed recurrent disease or second primary tumors, said Dr. Mortimer, professor of clinical medicine and deputy director of clinical oncology at the Moores Cancer Center.

Women with hot flashes had significantly fewer breast cancer-specific events than women without hot flashes (12.9% vs. 21%). “Hot flashes were more predictive of outcome for tamoxifen-treated patients than were age, hormone-receptor status, or stage of the initial cancer when comparing stage I to II,” Dr. Mortimer stated.

During the same session at the meeting, preliminary results of a prospective observational trial of 297 women with breast cancer show that the estrogen-receptor gene ESR1 CG haplotype was associated with higher hot flash scores at baseline in premenopausal women.

Dr. Vered Stearns and associates in the Consortium on Breast Cancer pharmacogenomics conducted genotype analyses and prospectively collected medication records and hot flash diaries before and 1, 4, 8, and 12 months after starting tamoxifen. Postmenopausal women homozygous for ESR1 Pvull CC and ESR2-02 GG genotypes had the greatest increase in hot flash scores at 4 months.

Women with the ESR2-02 AA genotype had a significantly lower risk for developing tamoxifen-induced hot flashes, compared with women with AG or GG genotypes (relative risk 0.26), said Dr. Stearns, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore.

Oncologists are aware of the link between estrogen-receptor status and response to tamoxifen, but these data provide additional evidence that hot flashes and ESR gene variations may be related.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO — Hot flashes may be an indicator of the efficacy of adjuvant tamoxifen therapy in women who have completed breast cancer treatment, a new study suggests.

Data from a large prospective trial of breast cancer survivors on tamoxifen therapy show that women who experienced hot flashes had fewer breast cancer events than those who did not report hot flashes, according to Dr. Joanne E. Mortimer and colleagues at the University of California, San Diego's Moores Cancer Center in La Jolla.

“Our data suggest a relationship between side effects and efficacy of adjuvant tamoxifen,” Dr. Mortimer said at the annual meeting of the American Society of Clinical Oncology.

The study population was drawn from an ongoing study in 3,088 women, aged 18–70 years, with a history of breast cancer stage I (T1c)-III, who were randomly assigned to either the Women's Healthy Eating and Living (WHEL) Study diet or the National Cancer Institute (NCI)-based diet.

The NCI-based diet group, consisting of 1,551 women, formed the basis of the tamoxifen/hot flash study. Of these, 637 women were not taking an antiestrogen agent, 1 woman was taking anastrozole, 16 women were taking raloxifene, and data on vasomotor symptoms were not available in 33 women. A total of 864 women were on tamoxifen.

Among the participants taking tamoxifen, 674 reported experiencing hot flashes (78%) and 190 did not (22%). The mean age was 54 years in both groups. There was no significant difference in stage at diagnosis or hormone receptor status between women who reported hot flashes and those who did not. Time between diagnosis and study entry was statistically shorter in women reporting hot flashes.

With 7.3 years of follow-up, 127 women have developed recurrent disease or second primary tumors, said Dr. Mortimer, professor of clinical medicine and deputy director of clinical oncology at the Moores Cancer Center.

Women with hot flashes had significantly fewer breast cancer-specific events than women without hot flashes (12.9% vs. 21%). “Hot flashes were more predictive of outcome for tamoxifen-treated patients than were age, hormone-receptor status, or stage of the initial cancer when comparing stage I to II,” Dr. Mortimer stated.

During the same session at the meeting, preliminary results of a prospective observational trial of 297 women with breast cancer show that the estrogen-receptor gene ESR1 CG haplotype was associated with higher hot flash scores at baseline in premenopausal women.

Dr. Vered Stearns and associates in the Consortium on Breast Cancer pharmacogenomics conducted genotype analyses and prospectively collected medication records and hot flash diaries before and 1, 4, 8, and 12 months after starting tamoxifen. Postmenopausal women homozygous for ESR1 Pvull CC and ESR2-02 GG genotypes had the greatest increase in hot flash scores at 4 months.

Women with the ESR2-02 AA genotype had a significantly lower risk for developing tamoxifen-induced hot flashes, compared with women with AG or GG genotypes (relative risk 0.26), said Dr. Stearns, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore.

Oncologists are aware of the link between estrogen-receptor status and response to tamoxifen, but these data provide additional evidence that hot flashes and ESR gene variations may be related.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO – Patients with Alzheimer's disease face many challenges, including proper diagnosis, ongoing care, and burdened families. But older people who have immigrated to the United States from non-English speaking countries and may have Alzheimer's disease face even greater hurdles, according to Beth O'Grady, of the Coalition of Limited English Speaking Elderly, and her colleagues.

“It's important to reach low English proficiency communities because Alzheimer's disease [AD] is not well understood in these communities,” said Ms. O'Grady, speaking at a joint conference of the American Society on Aging and the National Council on Aging.

In an effort to improve the understanding and support for older adults who have cognitive impairment in these communities, Ms. O'Grady joined Melanie Chavin, of the Alzheimer's Association's Greater Illinois Chapter and Darby Morhardt, of Northwestern University, Chicago, to develop an outreach project for people with Alzheimer's disease and their families who speak little or no English.

The project coordinators first completed a 3-year research project that targeted physicians and families in communities that spoke primarily Polish, Russian, Korean, Chinese, and Spanish. They now are completing the second year of a 3-year project working with communities in which the primary languages spoken include Arabic, Assyrian, Bosnian, Hindi, and Urdu.

The project coordinators hope to increase the number of older adults in these communities who use their services by reaching out to limited English proficiency (LEP) communities and by determining the kind of additional support that patients and families need.

Lessons learned from the first 3-year project have already shaped efforts by the project coordinators to improve AD services in LEP communities. The coordinators discovered a lack of understanding among the community members about what AD is. They also realized that cultural differences play a big role in how certain ethnic groups respond to a diagnosis of AD in a family member. “Education [about AD] is very valuable, but it must be offered in a culturally sensitive way,” Ms. Chavin said.

In addition to educating communities about AD, the panelists also reached out to physicians in the LEP communities they were targeting to find out more about how they diagnosed and treated patients with memory loss. The physicians with whom the panelists interacted could speak the same language as their patients and generally worked as solo practitioners in small storefront clinics.

Getting physicians in the communities on board to recognize memory loss and cognitive impairment was one of the major hurdles that the program coordinators faced. The physicians in the communities did not always think that memory loss was a condition they needed to address, Ms. Morhardt said.

The panelists determined that time constraints often make proper diagnosis and treatment of patients with memory loss very challenging for many of the physicians working in the LEP communities. “The physicians were very busy and were not always open to the diagnostic guidelines,” said Ms. Morhardt, speaking about findings from the initial part of the project.

Lack of reimbursement for diagnosing dementia cut short the time physicians in the study would need to embark on a diagnostic plan. The solo practitioners also tended to be isolated and unaware of resources available to them, such as centers devoted to the diagnosis and treatment of AD at two academic institutions in Chicago.

CHICAGO – Patients with Alzheimer's disease face many challenges, including proper diagnosis, ongoing care, and burdened families. But older people who have immigrated to the United States from non-English speaking countries and may have Alzheimer's disease face even greater hurdles, according to Beth O'Grady, of the Coalition of Limited English Speaking Elderly, and her colleagues.

“It's important to reach low English proficiency communities because Alzheimer's disease [AD] is not well understood in these communities,” said Ms. O'Grady, speaking at a joint conference of the American Society on Aging and the National Council on Aging.

In an effort to improve the understanding and support for older adults who have cognitive impairment in these communities, Ms. O'Grady joined Melanie Chavin, of the Alzheimer's Association's Greater Illinois Chapter and Darby Morhardt, of Northwestern University, Chicago, to develop an outreach project for people with Alzheimer's disease and their families who speak little or no English.

The project coordinators first completed a 3-year research project that targeted physicians and families in communities that spoke primarily Polish, Russian, Korean, Chinese, and Spanish. They now are completing the second year of a 3-year project working with communities in which the primary languages spoken include Arabic, Assyrian, Bosnian, Hindi, and Urdu.

The project coordinators hope to increase the number of older adults in these communities who use their services by reaching out to limited English proficiency (LEP) communities and by determining the kind of additional support that patients and families need.

Lessons learned from the first 3-year project have already shaped efforts by the project coordinators to improve AD services in LEP communities. The coordinators discovered a lack of understanding among the community members about what AD is. They also realized that cultural differences play a big role in how certain ethnic groups respond to a diagnosis of AD in a family member. “Education [about AD] is very valuable, but it must be offered in a culturally sensitive way,” Ms. Chavin said.

In addition to educating communities about AD, the panelists also reached out to physicians in the LEP communities they were targeting to find out more about how they diagnosed and treated patients with memory loss. The physicians with whom the panelists interacted could speak the same language as their patients and generally worked as solo practitioners in small storefront clinics.

Getting physicians in the communities on board to recognize memory loss and cognitive impairment was one of the major hurdles that the program coordinators faced. The physicians in the communities did not always think that memory loss was a condition they needed to address, Ms. Morhardt said.

The panelists determined that time constraints often make proper diagnosis and treatment of patients with memory loss very challenging for many of the physicians working in the LEP communities. “The physicians were very busy and were not always open to the diagnostic guidelines,” said Ms. Morhardt, speaking about findings from the initial part of the project.

Lack of reimbursement for diagnosing dementia cut short the time physicians in the study would need to embark on a diagnostic plan. The solo practitioners also tended to be isolated and unaware of resources available to them, such as centers devoted to the diagnosis and treatment of AD at two academic institutions in Chicago.

CHICAGO – Patients with Alzheimer's disease face many challenges, including proper diagnosis, ongoing care, and burdened families. But older people who have immigrated to the United States from non-English speaking countries and may have Alzheimer's disease face even greater hurdles, according to Beth O'Grady, of the Coalition of Limited English Speaking Elderly, and her colleagues.

“It's important to reach low English proficiency communities because Alzheimer's disease [AD] is not well understood in these communities,” said Ms. O'Grady, speaking at a joint conference of the American Society on Aging and the National Council on Aging.

In an effort to improve the understanding and support for older adults who have cognitive impairment in these communities, Ms. O'Grady joined Melanie Chavin, of the Alzheimer's Association's Greater Illinois Chapter and Darby Morhardt, of Northwestern University, Chicago, to develop an outreach project for people with Alzheimer's disease and their families who speak little or no English.

The project coordinators first completed a 3-year research project that targeted physicians and families in communities that spoke primarily Polish, Russian, Korean, Chinese, and Spanish. They now are completing the second year of a 3-year project working with communities in which the primary languages spoken include Arabic, Assyrian, Bosnian, Hindi, and Urdu.

The project coordinators hope to increase the number of older adults in these communities who use their services by reaching out to limited English proficiency (LEP) communities and by determining the kind of additional support that patients and families need.

Lessons learned from the first 3-year project have already shaped efforts by the project coordinators to improve AD services in LEP communities. The coordinators discovered a lack of understanding among the community members about what AD is. They also realized that cultural differences play a big role in how certain ethnic groups respond to a diagnosis of AD in a family member. “Education [about AD] is very valuable, but it must be offered in a culturally sensitive way,” Ms. Chavin said.

In addition to educating communities about AD, the panelists also reached out to physicians in the LEP communities they were targeting to find out more about how they diagnosed and treated patients with memory loss. The physicians with whom the panelists interacted could speak the same language as their patients and generally worked as solo practitioners in small storefront clinics.

Getting physicians in the communities on board to recognize memory loss and cognitive impairment was one of the major hurdles that the program coordinators faced. The physicians in the communities did not always think that memory loss was a condition they needed to address, Ms. Morhardt said.

The panelists determined that time constraints often make proper diagnosis and treatment of patients with memory loss very challenging for many of the physicians working in the LEP communities. “The physicians were very busy and were not always open to the diagnostic guidelines,” said Ms. Morhardt, speaking about findings from the initial part of the project.

Lack of reimbursement for diagnosing dementia cut short the time physicians in the study would need to embark on a diagnostic plan. The solo practitioners also tended to be isolated and unaware of resources available to them, such as centers devoted to the diagnosis and treatment of AD at two academic institutions in Chicago.

CHICAGO — The Office of Inspector General will be looking more carefully at how all practices bill for radiology services. This issue is particularly important for rheumatology practices that provide in-office radiology services, Mark Painter said at a meeting of the American College of Rheumatology.

“Billing for radiology services has gone up significantly. OIG will be very carefully looking at your imaging services,” he said. “If you did not have an imaging machine, and now you do, that's going to be a flag.” He advises thoroughly documenting medical necessity in the chart for all imaging services they provide.

Mastering CPT coding guidelines can improve practice management. “You have to understand what the payers are doing,” said Mr. Painter, a medical coding and reimbursement consultant in Denver.

The federal government did not make a lot of changes in current procedural terminology coding this year because the coding is budget neutral, and those involved in making decisions about CPT codes are careful about adding new codes, Mr. Painter said. However, there have been changes in policy that are important to physicians, he said.

Mr. Painter said another concern for rheumatologists is the Tax Relief and Health Care Act of 2006. Although this program averted a 5% payout on the conversion factor, it is only temporary. The act did not put any policies in place that extend beyond 2007.

Rheumatologists should also be aware of recovery audit contractors, independent contractors who report to insurance companies about billing companies. Currently, only Florida, California, and New York permit these “bounty hunters” to peruse bills obtained from insurance carriers and to zero in on questionable billing.

“They are out looking for low-hanging fruit,” Mr. Painter noted about these contractors. “The place where rheumatology is most vulnerable is infusions.” He advised physicians to document what they are billing for and, when using infusions, to provide the lot numbers of the medications.

Congress also passed the multiple imaging reduction policy, a change in the final rule that was supposed to be phased in over a 3-year period, but is now frozen at a 25% reduction rate. Under this policy, Medicare reimburses 100% of the first radiology service, but reduces payment for the technical component of the second service by 25% on the same day. Though this act applies to both hospital and in-office imaging, rheumatologists with an in-office radiology service could see losses.

Mr. Painter also discussed pay-for-performance updates. He said that Congress and the Centers for Medicare and Medicaid Services (CMS) are very interested in moving payments toward evidence-based medicine.

Although CMS opened up pay for performance to the general medical community in 2006, little voluntary reporting took place. To improve this, the CMS is offering a 1.5% bonus to physicians who report on their Medicare patients. A 6-month trial program began July 1. Physicians who report on at least 80% of total visits qualify for the bonus.

The future of this program will depend on ongoing budgets. Congress has not yet set aside funding for 2008.

Both pay for performance and the Physician Quality Reporting Initiative rely on adequate data collection, said Mr. Painter. He said practices must move toward electronic health records to improve data collection for these initiatives. “Data are driving this,” he said.

CHICAGO — The Office of Inspector General will be looking more carefully at how all practices bill for radiology services. This issue is particularly important for rheumatology practices that provide in-office radiology services, Mark Painter said at a meeting of the American College of Rheumatology.

“Billing for radiology services has gone up significantly. OIG will be very carefully looking at your imaging services,” he said. “If you did not have an imaging machine, and now you do, that's going to be a flag.” He advises thoroughly documenting medical necessity in the chart for all imaging services they provide.

Mastering CPT coding guidelines can improve practice management. “You have to understand what the payers are doing,” said Mr. Painter, a medical coding and reimbursement consultant in Denver.

The federal government did not make a lot of changes in current procedural terminology coding this year because the coding is budget neutral, and those involved in making decisions about CPT codes are careful about adding new codes, Mr. Painter said. However, there have been changes in policy that are important to physicians, he said.

Mr. Painter said another concern for rheumatologists is the Tax Relief and Health Care Act of 2006. Although this program averted a 5% payout on the conversion factor, it is only temporary. The act did not put any policies in place that extend beyond 2007.

Rheumatologists should also be aware of recovery audit contractors, independent contractors who report to insurance companies about billing companies. Currently, only Florida, California, and New York permit these “bounty hunters” to peruse bills obtained from insurance carriers and to zero in on questionable billing.

“They are out looking for low-hanging fruit,” Mr. Painter noted about these contractors. “The place where rheumatology is most vulnerable is infusions.” He advised physicians to document what they are billing for and, when using infusions, to provide the lot numbers of the medications.

Congress also passed the multiple imaging reduction policy, a change in the final rule that was supposed to be phased in over a 3-year period, but is now frozen at a 25% reduction rate. Under this policy, Medicare reimburses 100% of the first radiology service, but reduces payment for the technical component of the second service by 25% on the same day. Though this act applies to both hospital and in-office imaging, rheumatologists with an in-office radiology service could see losses.

Mr. Painter also discussed pay-for-performance updates. He said that Congress and the Centers for Medicare and Medicaid Services (CMS) are very interested in moving payments toward evidence-based medicine.

Although CMS opened up pay for performance to the general medical community in 2006, little voluntary reporting took place. To improve this, the CMS is offering a 1.5% bonus to physicians who report on their Medicare patients. A 6-month trial program began July 1. Physicians who report on at least 80% of total visits qualify for the bonus.

The future of this program will depend on ongoing budgets. Congress has not yet set aside funding for 2008.

Both pay for performance and the Physician Quality Reporting Initiative rely on adequate data collection, said Mr. Painter. He said practices must move toward electronic health records to improve data collection for these initiatives. “Data are driving this,” he said.

CHICAGO — The Office of Inspector General will be looking more carefully at how all practices bill for radiology services. This issue is particularly important for rheumatology practices that provide in-office radiology services, Mark Painter said at a meeting of the American College of Rheumatology.

“Billing for radiology services has gone up significantly. OIG will be very carefully looking at your imaging services,” he said. “If you did not have an imaging machine, and now you do, that's going to be a flag.” He advises thoroughly documenting medical necessity in the chart for all imaging services they provide.

Mastering CPT coding guidelines can improve practice management. “You have to understand what the payers are doing,” said Mr. Painter, a medical coding and reimbursement consultant in Denver.

The federal government did not make a lot of changes in current procedural terminology coding this year because the coding is budget neutral, and those involved in making decisions about CPT codes are careful about adding new codes, Mr. Painter said. However, there have been changes in policy that are important to physicians, he said.

Mr. Painter said another concern for rheumatologists is the Tax Relief and Health Care Act of 2006. Although this program averted a 5% payout on the conversion factor, it is only temporary. The act did not put any policies in place that extend beyond 2007.

Rheumatologists should also be aware of recovery audit contractors, independent contractors who report to insurance companies about billing companies. Currently, only Florida, California, and New York permit these “bounty hunters” to peruse bills obtained from insurance carriers and to zero in on questionable billing.

“They are out looking for low-hanging fruit,” Mr. Painter noted about these contractors. “The place where rheumatology is most vulnerable is infusions.” He advised physicians to document what they are billing for and, when using infusions, to provide the lot numbers of the medications.

Congress also passed the multiple imaging reduction policy, a change in the final rule that was supposed to be phased in over a 3-year period, but is now frozen at a 25% reduction rate. Under this policy, Medicare reimburses 100% of the first radiology service, but reduces payment for the technical component of the second service by 25% on the same day. Though this act applies to both hospital and in-office imaging, rheumatologists with an in-office radiology service could see losses.

Mr. Painter also discussed pay-for-performance updates. He said that Congress and the Centers for Medicare and Medicaid Services (CMS) are very interested in moving payments toward evidence-based medicine.

Although CMS opened up pay for performance to the general medical community in 2006, little voluntary reporting took place. To improve this, the CMS is offering a 1.5% bonus to physicians who report on their Medicare patients. A 6-month trial program began July 1. Physicians who report on at least 80% of total visits qualify for the bonus.

The future of this program will depend on ongoing budgets. Congress has not yet set aside funding for 2008.

Both pay for performance and the Physician Quality Reporting Initiative rely on adequate data collection, said Mr. Painter. He said practices must move toward electronic health records to improve data collection for these initiatives. “Data are driving this,” he said.

CHICAGO – The development of guidelines to treat depression in the elderly using evidence-based research is important, said a panel of experts at a joint conference of the American Society on Aging and the National Council on Aging. However, inadequate research and an unwillingness among providers to rely on evidence-based research make the process challenging.

“The mental health community needs to do a better job of getting on the evidence-based bandwagon,” said Sharon Dumberg-Lee, a licensed certified social worker at the Council for Jewish Elderly in Chicago.

Depression Is Undertreated

Despite the lack of evidence-based treatment, mental health practitioners seem to agree that undertreated depression is a serious problem. “We care about depression because it's a fairly common psychiatric disorder, and because it causes a fair amount of morbidity,” said Dr. John Frederick, a psychiatrist at the University of Washington, Seattle. He noted that depression in older adults complicates chronic medical conditions and, if it is not properly treated, can lead to self-neglect, premature death, and suicide. But the importance of treating depression does not necessarily translate into adequate treatment. “Older adults are often suboptimally treated,” Dr. Frederick said.

Dr. Frederick worked with his colleague, Dr. Mark Snowden, on the Depression Special Interest Project, sponsored by the Centers for Disease Control and Prevention.

Working with other experts, they performed a literature review of research on the treatment of depression in community settings. The investigators looked at 174 studies, each with 25 or more participants, that evaluated community-dwelling adults who were at least 60 years old and in treatment for a wide range of depressive disorders. They determined that the research indicates that two types of treatment improve outcomes in this population: cognitive-behavioral therapy, and depression care management both in the home and in the primary care clinic.

Mixed Report on Interventions

The project also revealed certain interventions that the researchers said do not seem to benefit older adults who seek treatment for depression. These treatment modes included individual psychotherapy, education skills training, and exercise.

The project results not only indicated which treatments of depression in older adults are effective and which are not, but also helped the researchers to understand which areas need improvement. They specifically said that research on the prevention of depression and suicide is lacking. “Suicide is a very tough area to study,” he said.

Dr. Snowden pointed out the large gap between efficacy research and real-world practice. Many practitioners “treat patients all the time, and they get better,” he explained, even though the treatment plans and outcomes may not fit neatly into a publishable research study.

He urged psychiatrists and other community mental health providers to contribute to the knowledge base by participating in research projects.

Lynda A. Anderson, Ph.D., director of Health Aging Program at the CDC, shared her thoughts: “We already know there's a gap between evidence-based research and use in community settings,” she said. She stated that reaching out to social service agencies to promote evidence-based research is important.

CHICAGO – The development of guidelines to treat depression in the elderly using evidence-based research is important, said a panel of experts at a joint conference of the American Society on Aging and the National Council on Aging. However, inadequate research and an unwillingness among providers to rely on evidence-based research make the process challenging.

“The mental health community needs to do a better job of getting on the evidence-based bandwagon,” said Sharon Dumberg-Lee, a licensed certified social worker at the Council for Jewish Elderly in Chicago.

Depression Is Undertreated

Despite the lack of evidence-based treatment, mental health practitioners seem to agree that undertreated depression is a serious problem. “We care about depression because it's a fairly common psychiatric disorder, and because it causes a fair amount of morbidity,” said Dr. John Frederick, a psychiatrist at the University of Washington, Seattle. He noted that depression in older adults complicates chronic medical conditions and, if it is not properly treated, can lead to self-neglect, premature death, and suicide. But the importance of treating depression does not necessarily translate into adequate treatment. “Older adults are often suboptimally treated,” Dr. Frederick said.

Dr. Frederick worked with his colleague, Dr. Mark Snowden, on the Depression Special Interest Project, sponsored by the Centers for Disease Control and Prevention.

Working with other experts, they performed a literature review of research on the treatment of depression in community settings. The investigators looked at 174 studies, each with 25 or more participants, that evaluated community-dwelling adults who were at least 60 years old and in treatment for a wide range of depressive disorders. They determined that the research indicates that two types of treatment improve outcomes in this population: cognitive-behavioral therapy, and depression care management both in the home and in the primary care clinic.

Mixed Report on Interventions

The project also revealed certain interventions that the researchers said do not seem to benefit older adults who seek treatment for depression. These treatment modes included individual psychotherapy, education skills training, and exercise.

The project results not only indicated which treatments of depression in older adults are effective and which are not, but also helped the researchers to understand which areas need improvement. They specifically said that research on the prevention of depression and suicide is lacking. “Suicide is a very tough area to study,” he said.

Dr. Snowden pointed out the large gap between efficacy research and real-world practice. Many practitioners “treat patients all the time, and they get better,” he explained, even though the treatment plans and outcomes may not fit neatly into a publishable research study.

He urged psychiatrists and other community mental health providers to contribute to the knowledge base by participating in research projects.

Lynda A. Anderson, Ph.D., director of Health Aging Program at the CDC, shared her thoughts: “We already know there's a gap between evidence-based research and use in community settings,” she said. She stated that reaching out to social service agencies to promote evidence-based research is important.

CHICAGO – The development of guidelines to treat depression in the elderly using evidence-based research is important, said a panel of experts at a joint conference of the American Society on Aging and the National Council on Aging. However, inadequate research and an unwillingness among providers to rely on evidence-based research make the process challenging.

“The mental health community needs to do a better job of getting on the evidence-based bandwagon,” said Sharon Dumberg-Lee, a licensed certified social worker at the Council for Jewish Elderly in Chicago.

Depression Is Undertreated

Despite the lack of evidence-based treatment, mental health practitioners seem to agree that undertreated depression is a serious problem. “We care about depression because it's a fairly common psychiatric disorder, and because it causes a fair amount of morbidity,” said Dr. John Frederick, a psychiatrist at the University of Washington, Seattle. He noted that depression in older adults complicates chronic medical conditions and, if it is not properly treated, can lead to self-neglect, premature death, and suicide. But the importance of treating depression does not necessarily translate into adequate treatment. “Older adults are often suboptimally treated,” Dr. Frederick said.

Dr. Frederick worked with his colleague, Dr. Mark Snowden, on the Depression Special Interest Project, sponsored by the Centers for Disease Control and Prevention.

Working with other experts, they performed a literature review of research on the treatment of depression in community settings. The investigators looked at 174 studies, each with 25 or more participants, that evaluated community-dwelling adults who were at least 60 years old and in treatment for a wide range of depressive disorders. They determined that the research indicates that two types of treatment improve outcomes in this population: cognitive-behavioral therapy, and depression care management both in the home and in the primary care clinic.

Mixed Report on Interventions

The project also revealed certain interventions that the researchers said do not seem to benefit older adults who seek treatment for depression. These treatment modes included individual psychotherapy, education skills training, and exercise.

The project results not only indicated which treatments of depression in older adults are effective and which are not, but also helped the researchers to understand which areas need improvement. They specifically said that research on the prevention of depression and suicide is lacking. “Suicide is a very tough area to study,” he said.

Dr. Snowden pointed out the large gap between efficacy research and real-world practice. Many practitioners “treat patients all the time, and they get better,” he explained, even though the treatment plans and outcomes may not fit neatly into a publishable research study.

He urged psychiatrists and other community mental health providers to contribute to the knowledge base by participating in research projects.

Lynda A. Anderson, Ph.D., director of Health Aging Program at the CDC, shared her thoughts: “We already know there's a gap between evidence-based research and use in community settings,” she said. She stated that reaching out to social service agencies to promote evidence-based research is important.

CHICAGO — Physicians treating gout and other crystal deposition diseases should consider both new medications and new uses for already available drugs, Dr. Lloyd Klickstein said at a meeting sponsored by the American College of Rheumatology.

“Some of the most exciting news in 2006 was the new understanding of the role of IL-1 in crystal-induced arthritis,” Dr. Klickstein said.

Basic science research indicates that interleukin (IL)-1R is needed to signal gouty inflammation. An open-label study of 10 patients showed that treatment with anakinra, a recombinant interleukin-1RA inhibitor, effectively lessened the symptoms of acute gout.

Other new drugs for gout are also in clinical trials. The U.S. Food and Drug Administration is currently reviewing febuxostat, an oral drug that noncompetitively inhibits xanthine oxidase production.

“It is very unlikely to have any of the problems associated with allopurinol,” said Dr. Klickstein, of the Novartis Institutes for Biomedical Research in Cambridge, Mass. Approval of the drug seemed imminent early in 2006, but the agency seems stalled in its decision.

Researchers recently completed phase III trials assessing the safety and efficacy of puricase, a pegylated recombinant porcine uricase that is given subcutaneously.

For patients who have not responded to conventional therapy, clinicians may also consider using drugs currently available for other conditions. Fibric acid derivatives, such as losartan, can lower uric acid, and some patients may have improved symptoms with this drug, said Dr. Klickstein.

“These little changes can really make a difference,” he said. Sevelamer, a phosphate binder, also binds uric acid. Dr. Klickstein pointed out that this treatment is not used as often as it could be. Sevelamer is “an option we don't think about very often in rheumatology,” he said.

Rarely patients may need treatment with rasburicase, an aspergillus-derived enzyme used in tumor lysis syndrome. Although it can be effective in lowering uric acid, it can lead to allergic reactions and should not be used in patients with known glucose-6-phosphate dehydrogenase deficiency.

In addition to gout patients who do not respond well to traditional therapy, dialysis patients with musculoskeletal complaints also may benefit from treatment that does not rely on conventional therapy. Lowering phosphorus may be the key to treating musculoskeletal complaints, which affect half of the 0.12% of the U.S. population on dialysis.

Clinicians should start by measuring calcium phosphate and encourage a low-phosphate diet. But phosphates are present in many foods, so encouraging a low-phosphate diet may lead to minimal results. “This is always worth talking about, but it's not always successful,” said Dr. Klickstein.

Another approach is to try lanthanum or another phosphate binder. This drug requires gastric acid to work properly, so patients cannot take proton pump inhibitors concurrently. Patients who fail treatment with phosphate binders may respond better to calcimimetics. Cinacalcet, the only drug in its class currently available, treats the secondary hyperparathyroidism of renal disease by lowering phosphate.

Ultimately, patients with end-stage renal disease who do not respond to drug therapy may require nocturnal dialysis for the treatment of crystal arthropathies. Clinicians should not be put off by the complexity of arranging for this treatment if it leads to an improvement in symptoms. “Management can make a huge difference in people's lives so they can live without pain,” he said.

CHICAGO — Physicians treating gout and other crystal deposition diseases should consider both new medications and new uses for already available drugs, Dr. Lloyd Klickstein said at a meeting sponsored by the American College of Rheumatology.

“Some of the most exciting news in 2006 was the new understanding of the role of IL-1 in crystal-induced arthritis,” Dr. Klickstein said.

Basic science research indicates that interleukin (IL)-1R is needed to signal gouty inflammation. An open-label study of 10 patients showed that treatment with anakinra, a recombinant interleukin-1RA inhibitor, effectively lessened the symptoms of acute gout.

Other new drugs for gout are also in clinical trials. The U.S. Food and Drug Administration is currently reviewing febuxostat, an oral drug that noncompetitively inhibits xanthine oxidase production.

“It is very unlikely to have any of the problems associated with allopurinol,” said Dr. Klickstein, of the Novartis Institutes for Biomedical Research in Cambridge, Mass. Approval of the drug seemed imminent early in 2006, but the agency seems stalled in its decision.

Researchers recently completed phase III trials assessing the safety and efficacy of puricase, a pegylated recombinant porcine uricase that is given subcutaneously.

For patients who have not responded to conventional therapy, clinicians may also consider using drugs currently available for other conditions. Fibric acid derivatives, such as losartan, can lower uric acid, and some patients may have improved symptoms with this drug, said Dr. Klickstein.

“These little changes can really make a difference,” he said. Sevelamer, a phosphate binder, also binds uric acid. Dr. Klickstein pointed out that this treatment is not used as often as it could be. Sevelamer is “an option we don't think about very often in rheumatology,” he said.

Rarely patients may need treatment with rasburicase, an aspergillus-derived enzyme used in tumor lysis syndrome. Although it can be effective in lowering uric acid, it can lead to allergic reactions and should not be used in patients with known glucose-6-phosphate dehydrogenase deficiency.

In addition to gout patients who do not respond well to traditional therapy, dialysis patients with musculoskeletal complaints also may benefit from treatment that does not rely on conventional therapy. Lowering phosphorus may be the key to treating musculoskeletal complaints, which affect half of the 0.12% of the U.S. population on dialysis.

Clinicians should start by measuring calcium phosphate and encourage a low-phosphate diet. But phosphates are present in many foods, so encouraging a low-phosphate diet may lead to minimal results. “This is always worth talking about, but it's not always successful,” said Dr. Klickstein.

Another approach is to try lanthanum or another phosphate binder. This drug requires gastric acid to work properly, so patients cannot take proton pump inhibitors concurrently. Patients who fail treatment with phosphate binders may respond better to calcimimetics. Cinacalcet, the only drug in its class currently available, treats the secondary hyperparathyroidism of renal disease by lowering phosphate.

Ultimately, patients with end-stage renal disease who do not respond to drug therapy may require nocturnal dialysis for the treatment of crystal arthropathies. Clinicians should not be put off by the complexity of arranging for this treatment if it leads to an improvement in symptoms. “Management can make a huge difference in people's lives so they can live without pain,” he said.

CHICAGO — Physicians treating gout and other crystal deposition diseases should consider both new medications and new uses for already available drugs, Dr. Lloyd Klickstein said at a meeting sponsored by the American College of Rheumatology.

“Some of the most exciting news in 2006 was the new understanding of the role of IL-1 in crystal-induced arthritis,” Dr. Klickstein said.

Basic science research indicates that interleukin (IL)-1R is needed to signal gouty inflammation. An open-label study of 10 patients showed that treatment with anakinra, a recombinant interleukin-1RA inhibitor, effectively lessened the symptoms of acute gout.

Other new drugs for gout are also in clinical trials. The U.S. Food and Drug Administration is currently reviewing febuxostat, an oral drug that noncompetitively inhibits xanthine oxidase production.

“It is very unlikely to have any of the problems associated with allopurinol,” said Dr. Klickstein, of the Novartis Institutes for Biomedical Research in Cambridge, Mass. Approval of the drug seemed imminent early in 2006, but the agency seems stalled in its decision.

Researchers recently completed phase III trials assessing the safety and efficacy of puricase, a pegylated recombinant porcine uricase that is given subcutaneously.

For patients who have not responded to conventional therapy, clinicians may also consider using drugs currently available for other conditions. Fibric acid derivatives, such as losartan, can lower uric acid, and some patients may have improved symptoms with this drug, said Dr. Klickstein.

“These little changes can really make a difference,” he said. Sevelamer, a phosphate binder, also binds uric acid. Dr. Klickstein pointed out that this treatment is not used as often as it could be. Sevelamer is “an option we don't think about very often in rheumatology,” he said.

Rarely patients may need treatment with rasburicase, an aspergillus-derived enzyme used in tumor lysis syndrome. Although it can be effective in lowering uric acid, it can lead to allergic reactions and should not be used in patients with known glucose-6-phosphate dehydrogenase deficiency.

In addition to gout patients who do not respond well to traditional therapy, dialysis patients with musculoskeletal complaints also may benefit from treatment that does not rely on conventional therapy. Lowering phosphorus may be the key to treating musculoskeletal complaints, which affect half of the 0.12% of the U.S. population on dialysis.

Clinicians should start by measuring calcium phosphate and encourage a low-phosphate diet. But phosphates are present in many foods, so encouraging a low-phosphate diet may lead to minimal results. “This is always worth talking about, but it's not always successful,” said Dr. Klickstein.

Another approach is to try lanthanum or another phosphate binder. This drug requires gastric acid to work properly, so patients cannot take proton pump inhibitors concurrently. Patients who fail treatment with phosphate binders may respond better to calcimimetics. Cinacalcet, the only drug in its class currently available, treats the secondary hyperparathyroidism of renal disease by lowering phosphate.

Ultimately, patients with end-stage renal disease who do not respond to drug therapy may require nocturnal dialysis for the treatment of crystal arthropathies. Clinicians should not be put off by the complexity of arranging for this treatment if it leads to an improvement in symptoms. “Management can make a huge difference in people's lives so they can live without pain,” he said.

CHICAGO — Clinicians must become more aware of the prevalence and severity of inflammatory eye diseases, according to Dr. James Rosenbaum, of the Oregon Health and Science University in Portland.

“Uveitis is equal to diabetes as a cause of visual loss,” said Dr. Rosenbaum at an American College of Rheumatology meeting.

Physicians may encounter several types of autoimmune uveitis in their practices. Blau syndrome, the rarest form, is an autosomal dominant disorder that causes a granulomatous uveitis and synovitis. Sometimes mistaken for sarcoidosis, it can lead to chorioretinal scarring.

Another form, tubulointerstitial nephritis and uveitis (TINU), can present with systemic symptoms of fever, myalgias, and fatigue. The sedimentation rate usually is quite high. “TINU tends to be a disease of children,” said Dr. Rosenbaum. Patients respond to oral steroids. “TINU is a far more common disease than we think,” he said.

In addition to uveitis, patients with systemic autoimmune disorders can present with scleritis. Dr. Rosenbaum said 40% of patients with scleritis have a systemic disease, most commonly rheumatoid arthritis (RA). Those with RA generally present with the typical features of joint pain and stiffness, and later develop scleritis. It is important to check antineutrophil cytoplasmic antibody (ANCA) levels in patients with scleritis, because the ANCA-positive form of this disease is very different from the ANCA-negative form. Some medications, including bisphosphonates, can induce a local form of scleritis, but this is rare, says Dr. Rosenbaum. Withdrawing medication generally will help to clear up this form of scleritis.

The overall treatment of scleritis depends on the severity of the disease. In the absence of infection, Dr. Rosenbaum recommends an oral nonsteroidal drug but that often is not adequate to provide symptom relief. Oral steroids then can be attempted, but some patients will require methotrexate.

As in scleritis, the treatment of uveitis is individualized. Options include topical corticosteroids, dilating drops, oral and intramuscular steroids, immunosuppressive medications, and implants. “It is such a varied disease,” he said. “For some patients, drops are all that are needed.”

Indications for using immunosuppressive treatment in patients with uveitis include visual limitations that interfere with daily activities, failure of oral and/or periocular steroids, and active inflammation. Immunosuppressive treatment options include antimetabolites, cyclosporine, combination medications, alkylating agents, and in some cases, biologic therapy.

Dr. Rosenbaum urges consideration before using TNF inhibitors to treat uveitis. In 31 patients treated with infliximab at the Oregon Health and Science University, the rate of severe toxicity was high. Three patients developed drug-induced lupus, two developed malignancies, two had pulmonary emboli, and one had a myocardial infarction. Fluocinolone implants represent one of the few medications approved by the FDA for the local treatment of uveitis. The implants deliver steroids continually for 30 months following implantation. Patients who get this treatment face hurdles—100% of patients develop a cataract in the treated eye, and most (70%) develop glaucoma. Of these, a high percentage will need surgery to repair the glaucoma.

CHICAGO — Clinicians must become more aware of the prevalence and severity of inflammatory eye diseases, according to Dr. James Rosenbaum, of the Oregon Health and Science University in Portland.

“Uveitis is equal to diabetes as a cause of visual loss,” said Dr. Rosenbaum at an American College of Rheumatology meeting.

Physicians may encounter several types of autoimmune uveitis in their practices. Blau syndrome, the rarest form, is an autosomal dominant disorder that causes a granulomatous uveitis and synovitis. Sometimes mistaken for sarcoidosis, it can lead to chorioretinal scarring.

Another form, tubulointerstitial nephritis and uveitis (TINU), can present with systemic symptoms of fever, myalgias, and fatigue. The sedimentation rate usually is quite high. “TINU tends to be a disease of children,” said Dr. Rosenbaum. Patients respond to oral steroids. “TINU is a far more common disease than we think,” he said.

In addition to uveitis, patients with systemic autoimmune disorders can present with scleritis. Dr. Rosenbaum said 40% of patients with scleritis have a systemic disease, most commonly rheumatoid arthritis (RA). Those with RA generally present with the typical features of joint pain and stiffness, and later develop scleritis. It is important to check antineutrophil cytoplasmic antibody (ANCA) levels in patients with scleritis, because the ANCA-positive form of this disease is very different from the ANCA-negative form. Some medications, including bisphosphonates, can induce a local form of scleritis, but this is rare, says Dr. Rosenbaum. Withdrawing medication generally will help to clear up this form of scleritis.

The overall treatment of scleritis depends on the severity of the disease. In the absence of infection, Dr. Rosenbaum recommends an oral nonsteroidal drug but that often is not adequate to provide symptom relief. Oral steroids then can be attempted, but some patients will require methotrexate.

As in scleritis, the treatment of uveitis is individualized. Options include topical corticosteroids, dilating drops, oral and intramuscular steroids, immunosuppressive medications, and implants. “It is such a varied disease,” he said. “For some patients, drops are all that are needed.”

Indications for using immunosuppressive treatment in patients with uveitis include visual limitations that interfere with daily activities, failure of oral and/or periocular steroids, and active inflammation. Immunosuppressive treatment options include antimetabolites, cyclosporine, combination medications, alkylating agents, and in some cases, biologic therapy.

Dr. Rosenbaum urges consideration before using TNF inhibitors to treat uveitis. In 31 patients treated with infliximab at the Oregon Health and Science University, the rate of severe toxicity was high. Three patients developed drug-induced lupus, two developed malignancies, two had pulmonary emboli, and one had a myocardial infarction. Fluocinolone implants represent one of the few medications approved by the FDA for the local treatment of uveitis. The implants deliver steroids continually for 30 months following implantation. Patients who get this treatment face hurdles—100% of patients develop a cataract in the treated eye, and most (70%) develop glaucoma. Of these, a high percentage will need surgery to repair the glaucoma.

CHICAGO — Clinicians must become more aware of the prevalence and severity of inflammatory eye diseases, according to Dr. James Rosenbaum, of the Oregon Health and Science University in Portland.

“Uveitis is equal to diabetes as a cause of visual loss,” said Dr. Rosenbaum at an American College of Rheumatology meeting.

Physicians may encounter several types of autoimmune uveitis in their practices. Blau syndrome, the rarest form, is an autosomal dominant disorder that causes a granulomatous uveitis and synovitis. Sometimes mistaken for sarcoidosis, it can lead to chorioretinal scarring.

Another form, tubulointerstitial nephritis and uveitis (TINU), can present with systemic symptoms of fever, myalgias, and fatigue. The sedimentation rate usually is quite high. “TINU tends to be a disease of children,” said Dr. Rosenbaum. Patients respond to oral steroids. “TINU is a far more common disease than we think,” he said.

In addition to uveitis, patients with systemic autoimmune disorders can present with scleritis. Dr. Rosenbaum said 40% of patients with scleritis have a systemic disease, most commonly rheumatoid arthritis (RA). Those with RA generally present with the typical features of joint pain and stiffness, and later develop scleritis. It is important to check antineutrophil cytoplasmic antibody (ANCA) levels in patients with scleritis, because the ANCA-positive form of this disease is very different from the ANCA-negative form. Some medications, including bisphosphonates, can induce a local form of scleritis, but this is rare, says Dr. Rosenbaum. Withdrawing medication generally will help to clear up this form of scleritis.

The overall treatment of scleritis depends on the severity of the disease. In the absence of infection, Dr. Rosenbaum recommends an oral nonsteroidal drug but that often is not adequate to provide symptom relief. Oral steroids then can be attempted, but some patients will require methotrexate.

As in scleritis, the treatment of uveitis is individualized. Options include topical corticosteroids, dilating drops, oral and intramuscular steroids, immunosuppressive medications, and implants. “It is such a varied disease,” he said. “For some patients, drops are all that are needed.”

Indications for using immunosuppressive treatment in patients with uveitis include visual limitations that interfere with daily activities, failure of oral and/or periocular steroids, and active inflammation. Immunosuppressive treatment options include antimetabolites, cyclosporine, combination medications, alkylating agents, and in some cases, biologic therapy.

Dr. Rosenbaum urges consideration before using TNF inhibitors to treat uveitis. In 31 patients treated with infliximab at the Oregon Health and Science University, the rate of severe toxicity was high. Three patients developed drug-induced lupus, two developed malignancies, two had pulmonary emboli, and one had a myocardial infarction. Fluocinolone implants represent one of the few medications approved by the FDA for the local treatment of uveitis. The implants deliver steroids continually for 30 months following implantation. Patients who get this treatment face hurdles—100% of patients develop a cataract in the treated eye, and most (70%) develop glaucoma. Of these, a high percentage will need surgery to repair the glaucoma.

CHICAGO — Pediatric vasculitis, particularly vasculitis of the central nervous system, is more common than previously recognized, according to Dr. Rayfel Schneider of the Hospital for Sick Children in Toronto.

“Each month, there seem to be more and more consults for central nervous system vaculitis,” Dr. Schneider said at a meeting of the American College of Rheumatology.

Cutaneous polyarteritis nodosa (PAN) is much more common than the classic form of PAN in children, and tends to mimic juvenile rheumatoid arthritis. Dr. Schneider advises clinicians to examine the plantar surface of the feet in children suspected of having cutaneous PAN. Nodules found there are a characteristic feature. Children also present with fever, arthralgias and arthritis, splenomegaly, uveitis, and anemia.

A biopsy is needed for diagnosis, but punch biopsies do not go deep enough. The biopsy must include an artery for definitive diagnosis.

“Cutaneous PAN frequently follows a group A streptococcal infection,” said Dr. Schneider. He said children may require prophylactic penicillin for recurrent streptococcal infections. Children generally respond well to prednisone, though some require other immunosuppressive therapy, particularly with organ involvement.

Kawasaki disease, which has a female predominance and a peak incidence in 1-year-old children, presents with fever for at least 5 days and at least 4 of these other clinical findings: conjunctivitis, oral mucosal inflammation, cervical lymphadenopathy, hand and foot swelling, and a rash.

Children with Kawasaki disease are also at risk of aneurysms. According to Dr. Schneider, 25% of untreated children and 5% of treated children develop coronary artery aneurysms. Children may also develop aneurysms in their axillary, brachial, iliac, and femoral arteries.

Children with acute Kawasaki disease should receive intravenous immunoglobulin (IVIG) and aspirin. Children who do not respond to this regimen may need an additional IVIG treatment, pulsed methylprednisone, or infliximab.

Henoch-Schönlein purpura (HSP) is probably the most common form of pediatric vasculitis, but when HSP presents in an atypical fashion, treating physicians should also consider Wegener's granulomatosis in the differential diagnosis. Children with Wegener's commonly present with constitutional symptoms of fever, arthralgia, and weight loss. Glomerulonephritis, upper airway disease, and lung disease also occur in 80% or more of pediatric Wegener's cases. This form of vasculitis tends to affect older female children.

In addition to vasculitis presenting with a fever and a rash, children with CNS vasculitis may present with focal neurologic deficits. Most present with acute hemiparesis, hemisensory deficits, or fine motor deficits. About half present with headaches. Findings that occur infrequently include cognitive deficits and difficulty concentrating, mood and personality changes, and seizures.

According to Dr. Schneider, serum tests, such as the sedimentation rate and complete blood counts, are frequently normal in children with CNS vasculitis. While MRI can be very sensitive in ruling out the diagnosis, cerebrospinal fluid (CSF) findings add critical information. “If you have a perfectly normal MRI and CSF, you probably don't have CNS vasculitis,” he added.

Rarely, children require a brain biopsy for the diagnosis of CNS vasculitis. Children with neurologic signs and symptoms that suggest this condition, suggestive lesions on an MRI, and a normal CNS angiogram need a brain biopsy.

Testing both confirms the diagnosis of CNS vasculitis and indicates how severe it is. Children with neurocognitive dysfunction, multifocal and bilateral MRI lesions, and distal stenosis on angiogram most likely have progressive CNS vasculitis. “This is quite a devastating condition,” said Dr. Schneider.

CHICAGO — Pediatric vasculitis, particularly vasculitis of the central nervous system, is more common than previously recognized, according to Dr. Rayfel Schneider of the Hospital for Sick Children in Toronto.

“Each month, there seem to be more and more consults for central nervous system vaculitis,” Dr. Schneider said at a meeting of the American College of Rheumatology.

Cutaneous polyarteritis nodosa (PAN) is much more common than the classic form of PAN in children, and tends to mimic juvenile rheumatoid arthritis. Dr. Schneider advises clinicians to examine the plantar surface of the feet in children suspected of having cutaneous PAN. Nodules found there are a characteristic feature. Children also present with fever, arthralgias and arthritis, splenomegaly, uveitis, and anemia.

A biopsy is needed for diagnosis, but punch biopsies do not go deep enough. The biopsy must include an artery for definitive diagnosis.

“Cutaneous PAN frequently follows a group A streptococcal infection,” said Dr. Schneider. He said children may require prophylactic penicillin for recurrent streptococcal infections. Children generally respond well to prednisone, though some require other immunosuppressive therapy, particularly with organ involvement.

Kawasaki disease, which has a female predominance and a peak incidence in 1-year-old children, presents with fever for at least 5 days and at least 4 of these other clinical findings: conjunctivitis, oral mucosal inflammation, cervical lymphadenopathy, hand and foot swelling, and a rash.

Children with Kawasaki disease are also at risk of aneurysms. According to Dr. Schneider, 25% of untreated children and 5% of treated children develop coronary artery aneurysms. Children may also develop aneurysms in their axillary, brachial, iliac, and femoral arteries.

Children with acute Kawasaki disease should receive intravenous immunoglobulin (IVIG) and aspirin. Children who do not respond to this regimen may need an additional IVIG treatment, pulsed methylprednisone, or infliximab.

Henoch-Schönlein purpura (HSP) is probably the most common form of pediatric vasculitis, but when HSP presents in an atypical fashion, treating physicians should also consider Wegener's granulomatosis in the differential diagnosis. Children with Wegener's commonly present with constitutional symptoms of fever, arthralgia, and weight loss. Glomerulonephritis, upper airway disease, and lung disease also occur in 80% or more of pediatric Wegener's cases. This form of vasculitis tends to affect older female children.

In addition to vasculitis presenting with a fever and a rash, children with CNS vasculitis may present with focal neurologic deficits. Most present with acute hemiparesis, hemisensory deficits, or fine motor deficits. About half present with headaches. Findings that occur infrequently include cognitive deficits and difficulty concentrating, mood and personality changes, and seizures.

According to Dr. Schneider, serum tests, such as the sedimentation rate and complete blood counts, are frequently normal in children with CNS vasculitis. While MRI can be very sensitive in ruling out the diagnosis, cerebrospinal fluid (CSF) findings add critical information. “If you have a perfectly normal MRI and CSF, you probably don't have CNS vasculitis,” he added.

Rarely, children require a brain biopsy for the diagnosis of CNS vasculitis. Children with neurologic signs and symptoms that suggest this condition, suggestive lesions on an MRI, and a normal CNS angiogram need a brain biopsy.

Testing both confirms the diagnosis of CNS vasculitis and indicates how severe it is. Children with neurocognitive dysfunction, multifocal and bilateral MRI lesions, and distal stenosis on angiogram most likely have progressive CNS vasculitis. “This is quite a devastating condition,” said Dr. Schneider.

CHICAGO — Pediatric vasculitis, particularly vasculitis of the central nervous system, is more common than previously recognized, according to Dr. Rayfel Schneider of the Hospital for Sick Children in Toronto.

“Each month, there seem to be more and more consults for central nervous system vaculitis,” Dr. Schneider said at a meeting of the American College of Rheumatology.

Cutaneous polyarteritis nodosa (PAN) is much more common than the classic form of PAN in children, and tends to mimic juvenile rheumatoid arthritis. Dr. Schneider advises clinicians to examine the plantar surface of the feet in children suspected of having cutaneous PAN. Nodules found there are a characteristic feature. Children also present with fever, arthralgias and arthritis, splenomegaly, uveitis, and anemia.

A biopsy is needed for diagnosis, but punch biopsies do not go deep enough. The biopsy must include an artery for definitive diagnosis.

“Cutaneous PAN frequently follows a group A streptococcal infection,” said Dr. Schneider. He said children may require prophylactic penicillin for recurrent streptococcal infections. Children generally respond well to prednisone, though some require other immunosuppressive therapy, particularly with organ involvement.

Kawasaki disease, which has a female predominance and a peak incidence in 1-year-old children, presents with fever for at least 5 days and at least 4 of these other clinical findings: conjunctivitis, oral mucosal inflammation, cervical lymphadenopathy, hand and foot swelling, and a rash.

Children with Kawasaki disease are also at risk of aneurysms. According to Dr. Schneider, 25% of untreated children and 5% of treated children develop coronary artery aneurysms. Children may also develop aneurysms in their axillary, brachial, iliac, and femoral arteries.

Children with acute Kawasaki disease should receive intravenous immunoglobulin (IVIG) and aspirin. Children who do not respond to this regimen may need an additional IVIG treatment, pulsed methylprednisone, or infliximab.

Henoch-Schönlein purpura (HSP) is probably the most common form of pediatric vasculitis, but when HSP presents in an atypical fashion, treating physicians should also consider Wegener's granulomatosis in the differential diagnosis. Children with Wegener's commonly present with constitutional symptoms of fever, arthralgia, and weight loss. Glomerulonephritis, upper airway disease, and lung disease also occur in 80% or more of pediatric Wegener's cases. This form of vasculitis tends to affect older female children.

In addition to vasculitis presenting with a fever and a rash, children with CNS vasculitis may present with focal neurologic deficits. Most present with acute hemiparesis, hemisensory deficits, or fine motor deficits. About half present with headaches. Findings that occur infrequently include cognitive deficits and difficulty concentrating, mood and personality changes, and seizures.

According to Dr. Schneider, serum tests, such as the sedimentation rate and complete blood counts, are frequently normal in children with CNS vasculitis. While MRI can be very sensitive in ruling out the diagnosis, cerebrospinal fluid (CSF) findings add critical information. “If you have a perfectly normal MRI and CSF, you probably don't have CNS vasculitis,” he added.

Rarely, children require a brain biopsy for the diagnosis of CNS vasculitis. Children with neurologic signs and symptoms that suggest this condition, suggestive lesions on an MRI, and a normal CNS angiogram need a brain biopsy.

Testing both confirms the diagnosis of CNS vasculitis and indicates how severe it is. Children with neurocognitive dysfunction, multifocal and bilateral MRI lesions, and distal stenosis on angiogram most likely have progressive CNS vasculitis. “This is quite a devastating condition,” said Dr. Schneider.

CHICAGO — Although only 4%–8% of adults have palpable thyroid nodules, as many as 10%–50% of adults will have nodules whose presence is confirmed by ultrasound, Dr. Roberta M. diFlorio of Dartmouth Medical Center in Hitchcock, N.H., reported at the annual meeting of the Radiological Society of North America.

Nodules are also found incidentally on CT and MRI scans in 4%–16% of patients, according to Dr. diFlorio, assistant professor of radiology at Dartmouth. Autopsy studies have found even higher rates of thyroid nodules—30%–60%, she added.

To better understand radiology practice patterns for thyroid nodule management, Dr. diFlorio sent surveys to 106 Society of Radiologists in Ultrasound fellows in 2005. She received 50 responses (a 47% response rate) from 42 institutions.

One issue that especially interested Dr. diFlorio was the frequency with which radiology departments performed fine-needle aspiration (FNA) procedures to rule out malignant nodules. “This is the most common procedure we do in our department,” she noted.

To attempt to reduce the number of unnecessary thyroid biopsies and FNAs, the Society of Radiologists in Ultrasound released guidelines for managing thyroid nodules in 2005. The management recommendations were based on the size, shape, and character of the nodules as seen on ultrasound.

The survey found that most responding institutions (28) performed more than five thyroid aspirations per week. The ultrasound feature that most commonly triggered an aspiration was size, with 22 respondents reporting that the presence of a nodule greater than 1 cm on ultrasound would lead to an FNA. (Respondents could indicate that more than one ultrasound feature triggered an FNA.)

Thirteen respondents said that a dominant nodule would lead to an FNA, and 11 respondents said that a cold nodule would be a criterion for an FNA. Overall, 20% of respondents said that they routinely sample more than one nodule.

Despite the high prevalence of thyroid nodules, cancer rates remain low. About 5%–10% of palpable nodules are malignant, and similar malignancy rates—5%–13%–-have been found for nodules seen on ultrasound, Dr. diFlorio said.

Only about half of the respondents (22) reported that cells for cytology were routinely present in the aspirate.

Overall, the respondents confirmed that FNAs lead to a relatively low diagnostic yield for thyroid cancer, with 29 respondents reporting that 0%–10% of the FNA procedures are diagnostic, 11 respondents saying that 10%–20% of the procedures are diagnostic, and only 2 respondents indicating that more than 20% of the procedures lead to a diagnosis.

CHICAGO — Although only 4%–8% of adults have palpable thyroid nodules, as many as 10%–50% of adults will have nodules whose presence is confirmed by ultrasound, Dr. Roberta M. diFlorio of Dartmouth Medical Center in Hitchcock, N.H., reported at the annual meeting of the Radiological Society of North America.

Nodules are also found incidentally on CT and MRI scans in 4%–16% of patients, according to Dr. diFlorio, assistant professor of radiology at Dartmouth. Autopsy studies have found even higher rates of thyroid nodules—30%–60%, she added.

To better understand radiology practice patterns for thyroid nodule management, Dr. diFlorio sent surveys to 106 Society of Radiologists in Ultrasound fellows in 2005. She received 50 responses (a 47% response rate) from 42 institutions.

One issue that especially interested Dr. diFlorio was the frequency with which radiology departments performed fine-needle aspiration (FNA) procedures to rule out malignant nodules. “This is the most common procedure we do in our department,” she noted.

To attempt to reduce the number of unnecessary thyroid biopsies and FNAs, the Society of Radiologists in Ultrasound released guidelines for managing thyroid nodules in 2005. The management recommendations were based on the size, shape, and character of the nodules as seen on ultrasound.

The survey found that most responding institutions (28) performed more than five thyroid aspirations per week. The ultrasound feature that most commonly triggered an aspiration was size, with 22 respondents reporting that the presence of a nodule greater than 1 cm on ultrasound would lead to an FNA. (Respondents could indicate that more than one ultrasound feature triggered an FNA.)

Thirteen respondents said that a dominant nodule would lead to an FNA, and 11 respondents said that a cold nodule would be a criterion for an FNA. Overall, 20% of respondents said that they routinely sample more than one nodule.

Despite the high prevalence of thyroid nodules, cancer rates remain low. About 5%–10% of palpable nodules are malignant, and similar malignancy rates—5%–13%–-have been found for nodules seen on ultrasound, Dr. diFlorio said.

Only about half of the respondents (22) reported that cells for cytology were routinely present in the aspirate.

Overall, the respondents confirmed that FNAs lead to a relatively low diagnostic yield for thyroid cancer, with 29 respondents reporting that 0%–10% of the FNA procedures are diagnostic, 11 respondents saying that 10%–20% of the procedures are diagnostic, and only 2 respondents indicating that more than 20% of the procedures lead to a diagnosis.

CHICAGO — Although only 4%–8% of adults have palpable thyroid nodules, as many as 10%–50% of adults will have nodules whose presence is confirmed by ultrasound, Dr. Roberta M. diFlorio of Dartmouth Medical Center in Hitchcock, N.H., reported at the annual meeting of the Radiological Society of North America.

Nodules are also found incidentally on CT and MRI scans in 4%–16% of patients, according to Dr. diFlorio, assistant professor of radiology at Dartmouth. Autopsy studies have found even higher rates of thyroid nodules—30%–60%, she added.

To better understand radiology practice patterns for thyroid nodule management, Dr. diFlorio sent surveys to 106 Society of Radiologists in Ultrasound fellows in 2005. She received 50 responses (a 47% response rate) from 42 institutions.

One issue that especially interested Dr. diFlorio was the frequency with which radiology departments performed fine-needle aspiration (FNA) procedures to rule out malignant nodules. “This is the most common procedure we do in our department,” she noted.

To attempt to reduce the number of unnecessary thyroid biopsies and FNAs, the Society of Radiologists in Ultrasound released guidelines for managing thyroid nodules in 2005. The management recommendations were based on the size, shape, and character of the nodules as seen on ultrasound.

The survey found that most responding institutions (28) performed more than five thyroid aspirations per week. The ultrasound feature that most commonly triggered an aspiration was size, with 22 respondents reporting that the presence of a nodule greater than 1 cm on ultrasound would lead to an FNA. (Respondents could indicate that more than one ultrasound feature triggered an FNA.)

Thirteen respondents said that a dominant nodule would lead to an FNA, and 11 respondents said that a cold nodule would be a criterion for an FNA. Overall, 20% of respondents said that they routinely sample more than one nodule.

Despite the high prevalence of thyroid nodules, cancer rates remain low. About 5%–10% of palpable nodules are malignant, and similar malignancy rates—5%–13%–-have been found for nodules seen on ultrasound, Dr. diFlorio said.

Only about half of the respondents (22) reported that cells for cytology were routinely present in the aspirate.

Overall, the respondents confirmed that FNAs lead to a relatively low diagnostic yield for thyroid cancer, with 29 respondents reporting that 0%–10% of the FNA procedures are diagnostic, 11 respondents saying that 10%–20% of the procedures are diagnostic, and only 2 respondents indicating that more than 20% of the procedures lead to a diagnosis.