Betsy Bates

LOS ANGELES — Nuclear cardiology scans performed in the emergency department can not only reduce admission rates by ruling out acute coronary syndromes, but also sound the alert on patients who warrant further testing despite normal laboratory tests, ECGs, and even coronary angioplasty.

“You need to detect those unstable anginas. Otherwise, you'll have a lot of potential events walking out your door,” Jack A. Ziffer, M.D., medical director of nuclear cardiology for Baptist Cardiac and Vascular Institute, Miami, and Baptist Hospital of Miami, said at a meeting sponsored by the American College of Cardiology.

Other acute coronary syndromes can be missed as well, even by angiography, which misses 3% of MIs and fails to diagnose significant pathology in a third of patients with elevated troponin levels, Dr. Ziffer said at the meeting, cosponsored by the American Society of Nuclear Cardiology and Cedars-Sinai Medical Center.

Spontaneous thrombolysis, prolonged vasospasm, injury location and patient anatomy, and misinterpretation may lead to false-negative test outcomes that might result in a patient being inappropriately discharged. Nuclear cardiology offers a quick, comprehensive look at perfusion and function that can be very helpful in clarifying diagnoses.

Dr. Ziffer described his emergency department (ED) protocol, which has been adopted by Cedars-Sinai and other medical centers. Any patient who presents with symptoms suggestive of a suspected acute coronary syndrome is injected with radionuclide in the ED in preparation for a nuclear scan. A thorough history is taken, laboratory values are assessed, and an ECG and angiogram are performed. Treatment is started based on severity of symptoms and test results. Meanwhile, nuclear imaging is performed after about 30-45 minutes, once some hepatic clearance has been achieved.

Two paradigms direct the myocardial perfusion and function studies ordered for the patient:

▸ In a patient with ongoing chest pain: A rest MIBI (99mTc sestamibi) with gated single-photon emission computed tomography (gSPECT) scan is performed. If this test is normal, along with all other testing, the patient is sent home. If questions are raised, a stress MIBI test is ordered and/or the patient is admitted to the coronary care unit.

▸ In a patient whose pain has resolved: A rest thallium SPECT test is performed, and if questions arise, a stress MIBI gSPECT test follows, with results determining whether a patient will be admitted or can go home.

MRI can be helpful, but it cannot determine the age of an infarct and poses a practical challenge, since few MRI units operate in the middle of the night. Nuclear imaging “is straightforward and can be delivered 24/7,” Dr. Ziffer said.

Even an angiogram, which details anatomy, “doesn't necessarily tell you what you need to know,” he said. “Coronary arteries can be patent and provide blood to nonviable myocardium. They can be occluded and have perfectly normal myocardium.”

Perfusion, ejection fraction, wall motion, and wall thickening are all clues to underlying abnormalities that can be assessed with nuclear studies. Polar maps, for example, quantify wall thickness throughout the heart, which can be helpful when wall motion is not clear. “These are really very powerful tools. When you see 8% thickening and 19%, that's less than normal. You ought to see 30% thickening in normal myocardium, or 40%,” he said.

Wall motion is another adjunctive clue within scans performed in the acute setting. “If a defect is present, we ask the question, 'Is wall motion normal or abnormal?' Normal wall motion does not mean that it's an artifact,” he said. It may mean the patient has abnormal perfusion, but that the treatment initiated in the ED was effective in treating unstable angina, or that the patient has suffered a small infarct in an area where wall motion cannot be seen.

When wall motion is abnormal, the patient is more likely to have unstable angina and persistent stunning, or an infarct “age unknown; it could be 30 years ago, could be 2 minutes ago, or impending,” he said.

Dr. Ziffer stressed that interpretation of nuclear studies requires an understanding of the impact of the delay between injecting and imaging. Perfusion parameters reflect the situation at the time the patient was injected, while cardiac function parameters are assessed in real time, while the patient is under the camera. “Sometimes the perfusion abnormalities we see may not reflect, in patients with resolved pain, for example, the entire jeopardized area.”

He described the case of an obese 63-year-old woman with hypertension, with now-resolved chest pain, whose resting scan was normal. Her ejection fraction was 78% and her wall motion parameters were in the normal range. Interpretation of her stress test was complicated by “tremendous breast attenuation” that obscured a significant portion of the heart. The scan should have been repeated with the patient in the prone position, but the patient was discharged. She arrived back in the ER 3 days later with a very large infarct.

Discrete perfusion defects in a 67-year-old man with atypical epicardial pain. Courtesy Dr. Jack A. Ziffer

LOS ANGELES — Nuclear cardiology scans performed in the emergency department can not only reduce admission rates by ruling out acute coronary syndromes, but also sound the alert on patients who warrant further testing despite normal laboratory tests, ECGs, and even coronary angioplasty.

“You need to detect those unstable anginas. Otherwise, you'll have a lot of potential events walking out your door,” Jack A. Ziffer, M.D., medical director of nuclear cardiology for Baptist Cardiac and Vascular Institute, Miami, and Baptist Hospital of Miami, said at a meeting sponsored by the American College of Cardiology.

Other acute coronary syndromes can be missed as well, even by angiography, which misses 3% of MIs and fails to diagnose significant pathology in a third of patients with elevated troponin levels, Dr. Ziffer said at the meeting, cosponsored by the American Society of Nuclear Cardiology and Cedars-Sinai Medical Center.

Spontaneous thrombolysis, prolonged vasospasm, injury location and patient anatomy, and misinterpretation may lead to false-negative test outcomes that might result in a patient being inappropriately discharged. Nuclear cardiology offers a quick, comprehensive look at perfusion and function that can be very helpful in clarifying diagnoses.

Dr. Ziffer described his emergency department (ED) protocol, which has been adopted by Cedars-Sinai and other medical centers. Any patient who presents with symptoms suggestive of a suspected acute coronary syndrome is injected with radionuclide in the ED in preparation for a nuclear scan. A thorough history is taken, laboratory values are assessed, and an ECG and angiogram are performed. Treatment is started based on severity of symptoms and test results. Meanwhile, nuclear imaging is performed after about 30-45 minutes, once some hepatic clearance has been achieved.

Two paradigms direct the myocardial perfusion and function studies ordered for the patient:

▸ In a patient with ongoing chest pain: A rest MIBI (99mTc sestamibi) with gated single-photon emission computed tomography (gSPECT) scan is performed. If this test is normal, along with all other testing, the patient is sent home. If questions are raised, a stress MIBI test is ordered and/or the patient is admitted to the coronary care unit.

▸ In a patient whose pain has resolved: A rest thallium SPECT test is performed, and if questions arise, a stress MIBI gSPECT test follows, with results determining whether a patient will be admitted or can go home.

MRI can be helpful, but it cannot determine the age of an infarct and poses a practical challenge, since few MRI units operate in the middle of the night. Nuclear imaging “is straightforward and can be delivered 24/7,” Dr. Ziffer said.

Even an angiogram, which details anatomy, “doesn't necessarily tell you what you need to know,” he said. “Coronary arteries can be patent and provide blood to nonviable myocardium. They can be occluded and have perfectly normal myocardium.”

Perfusion, ejection fraction, wall motion, and wall thickening are all clues to underlying abnormalities that can be assessed with nuclear studies. Polar maps, for example, quantify wall thickness throughout the heart, which can be helpful when wall motion is not clear. “These are really very powerful tools. When you see 8% thickening and 19%, that's less than normal. You ought to see 30% thickening in normal myocardium, or 40%,” he said.

Wall motion is another adjunctive clue within scans performed in the acute setting. “If a defect is present, we ask the question, 'Is wall motion normal or abnormal?' Normal wall motion does not mean that it's an artifact,” he said. It may mean the patient has abnormal perfusion, but that the treatment initiated in the ED was effective in treating unstable angina, or that the patient has suffered a small infarct in an area where wall motion cannot be seen.

When wall motion is abnormal, the patient is more likely to have unstable angina and persistent stunning, or an infarct “age unknown; it could be 30 years ago, could be 2 minutes ago, or impending,” he said.

Dr. Ziffer stressed that interpretation of nuclear studies requires an understanding of the impact of the delay between injecting and imaging. Perfusion parameters reflect the situation at the time the patient was injected, while cardiac function parameters are assessed in real time, while the patient is under the camera. “Sometimes the perfusion abnormalities we see may not reflect, in patients with resolved pain, for example, the entire jeopardized area.”

He described the case of an obese 63-year-old woman with hypertension, with now-resolved chest pain, whose resting scan was normal. Her ejection fraction was 78% and her wall motion parameters were in the normal range. Interpretation of her stress test was complicated by “tremendous breast attenuation” that obscured a significant portion of the heart. The scan should have been repeated with the patient in the prone position, but the patient was discharged. She arrived back in the ER 3 days later with a very large infarct.

Discrete perfusion defects in a 67-year-old man with atypical epicardial pain. Courtesy Dr. Jack A. Ziffer

LOS ANGELES — Nuclear cardiology scans performed in the emergency department can not only reduce admission rates by ruling out acute coronary syndromes, but also sound the alert on patients who warrant further testing despite normal laboratory tests, ECGs, and even coronary angioplasty.

“You need to detect those unstable anginas. Otherwise, you'll have a lot of potential events walking out your door,” Jack A. Ziffer, M.D., medical director of nuclear cardiology for Baptist Cardiac and Vascular Institute, Miami, and Baptist Hospital of Miami, said at a meeting sponsored by the American College of Cardiology.

Other acute coronary syndromes can be missed as well, even by angiography, which misses 3% of MIs and fails to diagnose significant pathology in a third of patients with elevated troponin levels, Dr. Ziffer said at the meeting, cosponsored by the American Society of Nuclear Cardiology and Cedars-Sinai Medical Center.

Spontaneous thrombolysis, prolonged vasospasm, injury location and patient anatomy, and misinterpretation may lead to false-negative test outcomes that might result in a patient being inappropriately discharged. Nuclear cardiology offers a quick, comprehensive look at perfusion and function that can be very helpful in clarifying diagnoses.

Dr. Ziffer described his emergency department (ED) protocol, which has been adopted by Cedars-Sinai and other medical centers. Any patient who presents with symptoms suggestive of a suspected acute coronary syndrome is injected with radionuclide in the ED in preparation for a nuclear scan. A thorough history is taken, laboratory values are assessed, and an ECG and angiogram are performed. Treatment is started based on severity of symptoms and test results. Meanwhile, nuclear imaging is performed after about 30-45 minutes, once some hepatic clearance has been achieved.

Two paradigms direct the myocardial perfusion and function studies ordered for the patient:

▸ In a patient with ongoing chest pain: A rest MIBI (99mTc sestamibi) with gated single-photon emission computed tomography (gSPECT) scan is performed. If this test is normal, along with all other testing, the patient is sent home. If questions are raised, a stress MIBI test is ordered and/or the patient is admitted to the coronary care unit.

▸ In a patient whose pain has resolved: A rest thallium SPECT test is performed, and if questions arise, a stress MIBI gSPECT test follows, with results determining whether a patient will be admitted or can go home.

MRI can be helpful, but it cannot determine the age of an infarct and poses a practical challenge, since few MRI units operate in the middle of the night. Nuclear imaging “is straightforward and can be delivered 24/7,” Dr. Ziffer said.

Even an angiogram, which details anatomy, “doesn't necessarily tell you what you need to know,” he said. “Coronary arteries can be patent and provide blood to nonviable myocardium. They can be occluded and have perfectly normal myocardium.”

Perfusion, ejection fraction, wall motion, and wall thickening are all clues to underlying abnormalities that can be assessed with nuclear studies. Polar maps, for example, quantify wall thickness throughout the heart, which can be helpful when wall motion is not clear. “These are really very powerful tools. When you see 8% thickening and 19%, that's less than normal. You ought to see 30% thickening in normal myocardium, or 40%,” he said.

Wall motion is another adjunctive clue within scans performed in the acute setting. “If a defect is present, we ask the question, 'Is wall motion normal or abnormal?' Normal wall motion does not mean that it's an artifact,” he said. It may mean the patient has abnormal perfusion, but that the treatment initiated in the ED was effective in treating unstable angina, or that the patient has suffered a small infarct in an area where wall motion cannot be seen.

When wall motion is abnormal, the patient is more likely to have unstable angina and persistent stunning, or an infarct “age unknown; it could be 30 years ago, could be 2 minutes ago, or impending,” he said.

Dr. Ziffer stressed that interpretation of nuclear studies requires an understanding of the impact of the delay between injecting and imaging. Perfusion parameters reflect the situation at the time the patient was injected, while cardiac function parameters are assessed in real time, while the patient is under the camera. “Sometimes the perfusion abnormalities we see may not reflect, in patients with resolved pain, for example, the entire jeopardized area.”

He described the case of an obese 63-year-old woman with hypertension, with now-resolved chest pain, whose resting scan was normal. Her ejection fraction was 78% and her wall motion parameters were in the normal range. Interpretation of her stress test was complicated by “tremendous breast attenuation” that obscured a significant portion of the heart. The scan should have been repeated with the patient in the prone position, but the patient was discharged. She arrived back in the ER 3 days later with a very large infarct.

Discrete perfusion defects in a 67-year-old man with atypical epicardial pain. Courtesy Dr. Jack A. Ziffer

LOS ANGELES — Nuclear cardiology scans performed in the emergency department can not only reduce admission rates by ruling out acute coronary syndrome (ACS), but also sound the alert on patients who warrant further testing despite normal laboratory tests, ECGs, and even coronary angioplasty.

“You need to detect those unstable anginas. Otherwise, you'll have a lot of potential events walking out your door,” Jack A. Ziffer, M.D., medical director of nuclear cardiology for Baptist Cardiac and Vascular Institute, Miami, and Baptist Hospital of Miami, said at a meeting sponsored by the American College of Cardiology.

Other ACSs can be missed as well, even by angiography, which misses 3% of MIs and fails to diagnose significant pathology in a third of patients with elevated troponin levels, Dr. Ziffer said at the meeting, cosponsored by the American Society of Nuclear Cardiology and Cedars-Sinai Medical Center.

Spontaneous thrombolysis, prolonged vasospasm, injury location and patient anatomy, and misinterpretation may lead to false-negative test outcomes that might result in a patient being inappropriately discharged. Nuclear cardiology offers a quick, comprehensive look at perfusion and function that can help in clarify diagnoses.

Dr. Ziffer described the emergency department (ED) protocol that has been adopted by Cedars-Sinai and other hospitals.

Any patient who presents with symptoms suggestive of a suspected ACS is injected with radionuclide in the ED in preparation for a nuclear scan. A thorough history is taken, laboratory values are assessed, and an ECG and angiogram are performed. Treatment is commenced based on severity of symptoms and test results. Meanwhile, nuclear imaging is performed after about 30-45 minutes, once some hepatic clearance has been achieved.

Two paradigms direct the myocardial perfusion and function studies ordered for the patient:

▸ In a patient with ongoing chest pain. A rest MIBI (99mTc sestamibi) with gated single-photon emission computed tomography (gSPECT) scan is performed. If this test is normal, along with all other testing, the patient is sent home. If questions are raised, a stress MIBI test is ordered and/or the patient is admitted to the coronary care unit.

▸ In a patient whose pain has resolved. A rest thallium SPECT test is performed, and if questions arise, a stress MIBI gSPECT test follows, with results determining whether a patient will be admitted or can go home.

MRI can be helpful, but it cannot determine the age of an infarct and poses a practical challenge, since few MRI units operate in the middle of the night. Nuclear imaging “is straightforward and can be delivered 24/7,” Dr. Ziffer said.

Even an angiogram, which details anatomy, “doesn't necessarily tell you what you need to know,” he said.

Perfusion, ejection fraction, wall motion, and wall thickening are all clues to underlying abnormalities that can be assessed with nuclear studies. Polar maps, for example, quantify wall thickness throughout the heart, which can be helpful when wall motion is not clear. “These are really very powerful tools. When you see 8% thickening and 19%, that's less than normal. You ought to see 30% thickening in normal myocardium, or 40%,” he said.

Wall motion is another adjunctive clue within scans performed in the acute setting. “If a defect is present, we ask the question, 'Is wall motion normal or abnormal?' Normal wall motion does not mean that it's an artifact,” he said. It may mean the patient has abnormal perfusion, but that the treatment initiated in the ED was effective in treating unstable angina, or that the patient has suffered a small infarct in an area where wall motion cannot be seen.

When wall motion is abnormal, the patient is more likely to have unstable angina and persistent stunning, or an infarct “age unknown: It could be 30 years ago, could be 2 minutes ago, or impending,” he said.

Dr. Ziffer stressed that interpretation of nuclear studies requires an understanding of the impact of the delay between injecting and imaging. Perfusion parameters reflect the situation at the time the patient was injected, while cardiac function parameters are assessed in real time, while the patient is under the camera. “Sometimes the perfusion abnormalities we see may not reflect, in patients with resolved pain, for example, the entire jeopardized area.”

A pattern of discrete perfusion defects was found in a 67-year-old man with atypical epicardial pain. Courtesy Dr. Jack A. Ziffer

LOS ANGELES — Nuclear cardiology scans performed in the emergency department can not only reduce admission rates by ruling out acute coronary syndrome (ACS), but also sound the alert on patients who warrant further testing despite normal laboratory tests, ECGs, and even coronary angioplasty.

“You need to detect those unstable anginas. Otherwise, you'll have a lot of potential events walking out your door,” Jack A. Ziffer, M.D., medical director of nuclear cardiology for Baptist Cardiac and Vascular Institute, Miami, and Baptist Hospital of Miami, said at a meeting sponsored by the American College of Cardiology.

Other ACSs can be missed as well, even by angiography, which misses 3% of MIs and fails to diagnose significant pathology in a third of patients with elevated troponin levels, Dr. Ziffer said at the meeting, cosponsored by the American Society of Nuclear Cardiology and Cedars-Sinai Medical Center.

Spontaneous thrombolysis, prolonged vasospasm, injury location and patient anatomy, and misinterpretation may lead to false-negative test outcomes that might result in a patient being inappropriately discharged. Nuclear cardiology offers a quick, comprehensive look at perfusion and function that can help in clarify diagnoses.

Dr. Ziffer described the emergency department (ED) protocol that has been adopted by Cedars-Sinai and other hospitals.

Any patient who presents with symptoms suggestive of a suspected ACS is injected with radionuclide in the ED in preparation for a nuclear scan. A thorough history is taken, laboratory values are assessed, and an ECG and angiogram are performed. Treatment is commenced based on severity of symptoms and test results. Meanwhile, nuclear imaging is performed after about 30-45 minutes, once some hepatic clearance has been achieved.

Two paradigms direct the myocardial perfusion and function studies ordered for the patient:

▸ In a patient with ongoing chest pain. A rest MIBI (99mTc sestamibi) with gated single-photon emission computed tomography (gSPECT) scan is performed. If this test is normal, along with all other testing, the patient is sent home. If questions are raised, a stress MIBI test is ordered and/or the patient is admitted to the coronary care unit.

▸ In a patient whose pain has resolved. A rest thallium SPECT test is performed, and if questions arise, a stress MIBI gSPECT test follows, with results determining whether a patient will be admitted or can go home.

MRI can be helpful, but it cannot determine the age of an infarct and poses a practical challenge, since few MRI units operate in the middle of the night. Nuclear imaging “is straightforward and can be delivered 24/7,” Dr. Ziffer said.

Even an angiogram, which details anatomy, “doesn't necessarily tell you what you need to know,” he said.

Perfusion, ejection fraction, wall motion, and wall thickening are all clues to underlying abnormalities that can be assessed with nuclear studies. Polar maps, for example, quantify wall thickness throughout the heart, which can be helpful when wall motion is not clear. “These are really very powerful tools. When you see 8% thickening and 19%, that's less than normal. You ought to see 30% thickening in normal myocardium, or 40%,” he said.

Wall motion is another adjunctive clue within scans performed in the acute setting. “If a defect is present, we ask the question, 'Is wall motion normal or abnormal?' Normal wall motion does not mean that it's an artifact,” he said. It may mean the patient has abnormal perfusion, but that the treatment initiated in the ED was effective in treating unstable angina, or that the patient has suffered a small infarct in an area where wall motion cannot be seen.

When wall motion is abnormal, the patient is more likely to have unstable angina and persistent stunning, or an infarct “age unknown: It could be 30 years ago, could be 2 minutes ago, or impending,” he said.

Dr. Ziffer stressed that interpretation of nuclear studies requires an understanding of the impact of the delay between injecting and imaging. Perfusion parameters reflect the situation at the time the patient was injected, while cardiac function parameters are assessed in real time, while the patient is under the camera. “Sometimes the perfusion abnormalities we see may not reflect, in patients with resolved pain, for example, the entire jeopardized area.”

A pattern of discrete perfusion defects was found in a 67-year-old man with atypical epicardial pain. Courtesy Dr. Jack A. Ziffer

LOS ANGELES — Nuclear cardiology scans performed in the emergency department can not only reduce admission rates by ruling out acute coronary syndrome (ACS), but also sound the alert on patients who warrant further testing despite normal laboratory tests, ECGs, and even coronary angioplasty.

“You need to detect those unstable anginas. Otherwise, you'll have a lot of potential events walking out your door,” Jack A. Ziffer, M.D., medical director of nuclear cardiology for Baptist Cardiac and Vascular Institute, Miami, and Baptist Hospital of Miami, said at a meeting sponsored by the American College of Cardiology.

Other ACSs can be missed as well, even by angiography, which misses 3% of MIs and fails to diagnose significant pathology in a third of patients with elevated troponin levels, Dr. Ziffer said at the meeting, cosponsored by the American Society of Nuclear Cardiology and Cedars-Sinai Medical Center.

Spontaneous thrombolysis, prolonged vasospasm, injury location and patient anatomy, and misinterpretation may lead to false-negative test outcomes that might result in a patient being inappropriately discharged. Nuclear cardiology offers a quick, comprehensive look at perfusion and function that can help in clarify diagnoses.

Dr. Ziffer described the emergency department (ED) protocol that has been adopted by Cedars-Sinai and other hospitals.

Any patient who presents with symptoms suggestive of a suspected ACS is injected with radionuclide in the ED in preparation for a nuclear scan. A thorough history is taken, laboratory values are assessed, and an ECG and angiogram are performed. Treatment is commenced based on severity of symptoms and test results. Meanwhile, nuclear imaging is performed after about 30-45 minutes, once some hepatic clearance has been achieved.

Two paradigms direct the myocardial perfusion and function studies ordered for the patient:

▸ In a patient with ongoing chest pain. A rest MIBI (99mTc sestamibi) with gated single-photon emission computed tomography (gSPECT) scan is performed. If this test is normal, along with all other testing, the patient is sent home. If questions are raised, a stress MIBI test is ordered and/or the patient is admitted to the coronary care unit.

▸ In a patient whose pain has resolved. A rest thallium SPECT test is performed, and if questions arise, a stress MIBI gSPECT test follows, with results determining whether a patient will be admitted or can go home.

MRI can be helpful, but it cannot determine the age of an infarct and poses a practical challenge, since few MRI units operate in the middle of the night. Nuclear imaging “is straightforward and can be delivered 24/7,” Dr. Ziffer said.

Even an angiogram, which details anatomy, “doesn't necessarily tell you what you need to know,” he said.

Perfusion, ejection fraction, wall motion, and wall thickening are all clues to underlying abnormalities that can be assessed with nuclear studies. Polar maps, for example, quantify wall thickness throughout the heart, which can be helpful when wall motion is not clear. “These are really very powerful tools. When you see 8% thickening and 19%, that's less than normal. You ought to see 30% thickening in normal myocardium, or 40%,” he said.

Wall motion is another adjunctive clue within scans performed in the acute setting. “If a defect is present, we ask the question, 'Is wall motion normal or abnormal?' Normal wall motion does not mean that it's an artifact,” he said. It may mean the patient has abnormal perfusion, but that the treatment initiated in the ED was effective in treating unstable angina, or that the patient has suffered a small infarct in an area where wall motion cannot be seen.

When wall motion is abnormal, the patient is more likely to have unstable angina and persistent stunning, or an infarct “age unknown: It could be 30 years ago, could be 2 minutes ago, or impending,” he said.

Dr. Ziffer stressed that interpretation of nuclear studies requires an understanding of the impact of the delay between injecting and imaging. Perfusion parameters reflect the situation at the time the patient was injected, while cardiac function parameters are assessed in real time, while the patient is under the camera. “Sometimes the perfusion abnormalities we see may not reflect, in patients with resolved pain, for example, the entire jeopardized area.”

A pattern of discrete perfusion defects was found in a 67-year-old man with atypical epicardial pain. Courtesy Dr. Jack A. Ziffer

RANCHO MIRAGE, CALIF. — Mothers who experience high levels of stress during early pregnancy appear to convey distress signals to their fetuses, prompting their fetuses to eventually produce high levels of hormones that speed delivery.

The phenomenon suggests the presence of a “placental clock” for parturition that may be set months before the onset of labor, said Curt A. Sandman, Ph.D., professor and vice chair of psychiatry at the University of California, Irvine.

The pattern was seen in a prospective evaluation of pregnant California women who happened to be enrolled in a comprehensive study of pregnancy outcomes when the magnitude 6.7 Northridge earthquake struck early the morning of Jan. 17, 1994, killing dozens of people and leveling thousands of homes.

Those subjects who were in their first trimester showed highly elevated levels of stress hormones, but those in their third trimester had much lower levels of stress hormones, Dr. Sandman said at a conference on sleep in infancy and childhood sponsored by the Annenberg Center for Health Sciences.

Months later, women who had been exposed to the stress of the earthquake early in pregnancy were significantly more likely than other mothers to deliver early.

“An early maternal message that it's a hostile world primes the placental clock for a CRH [corticotropin-releasing hormone] response later,” he said.

Subsequent studies in 550 consecutive pregnant subjects confirmed a consistent link between high levels of maternal cortisol early in pregnancy and elevated levels of placenta-derived CRH in the third trimester. Every 1 U of cortisol (μg/dL) measured at weeks 14-16 predicted 34 U of CRH (pg/dL) at 30-32 weeks' gestation.

Elevated CRH not only seems to speed delivery, but also appears to have profound consequences on the fetal response to stimuli and, later, a child's response to stress.

The complex interaction between maternal stress, fetal CRH, pregnancy outcomes, and infant and childhood behavior has been the target of studies conducted over more than 12 years as part of the women and children's health and well-being project at UCI, Dr. Sandman explained.

More than 1,000 women and 600-700 infants have been enrolled thus far in studies that begin with extensive prenatal assessment beginning at about 10 weeks' gestation. Neuroendocrine profiles assess the maternal stress axis, while ultrasound examinations and studies of fetal behavior continue throughout pregnancy.

Infant stress examinations begin with the routine first heel-stick test received in the nursery, when researchers take advantage of a naturally occurring opportunity to evaluate salivary cortisol. Babies' responses to the stress of immunizations are also measured and temperament analyses conducted at 6-8 weeks.

The children continue to be followed. Beginning at aged 5-7 years, they are assessed with cognitive tests and structural MRI.

A number of intriguing observations have emerged from the UCI studies, including evidence that suggests stress in the womb may have far-reaching consequences on health and behavior.

The metabolic story begins early in pregnancy, with an increase in neuropeptides from the maternal hypothalamic-pituitary-adrenal stress axis. Apparently in response, the placenta produces circulating CRH, which in turn downregulates the maternal stress system, blocking communication between the hypothalamus and pituitary. Both the quantity and the timing of stress hormone production is important.

“Women, as pregnancy advances, become immunized to the effects of stress,” explained Dr. Sandman, who said the finding explains why stress hormones were not as high in subjects who experienced the earthquake late in pregnancy. “When stress happens, matters,” he said.

Further research by the UCI group suggests that the fetus is very much influenced by stress signals. Fetuses exposed to high levels of stress hormones show a diminished ability to respond to new and familiar auditory stimuli. After birth, babies exposed early to high levels of stress hormones exhibit altered fear responses.

It may be that human fetuses exposed early to very high levels of stress hormones begin adapting very early to a perceived hostile environment by setting the scene for an early escape from the womb and altered fight-flight responses to new stimuli.

RANCHO MIRAGE, CALIF. — Mothers who experience high levels of stress during early pregnancy appear to convey distress signals to their fetuses, prompting their fetuses to eventually produce high levels of hormones that speed delivery.

The phenomenon suggests the presence of a “placental clock” for parturition that may be set months before the onset of labor, said Curt A. Sandman, Ph.D., professor and vice chair of psychiatry at the University of California, Irvine.

The pattern was seen in a prospective evaluation of pregnant California women who happened to be enrolled in a comprehensive study of pregnancy outcomes when the magnitude 6.7 Northridge earthquake struck early the morning of Jan. 17, 1994, killing dozens of people and leveling thousands of homes.

Those subjects who were in their first trimester showed highly elevated levels of stress hormones, but those in their third trimester had much lower levels of stress hormones, Dr. Sandman said at a conference on sleep in infancy and childhood sponsored by the Annenberg Center for Health Sciences.

Months later, women who had been exposed to the stress of the earthquake early in pregnancy were significantly more likely than other mothers to deliver early.

“An early maternal message that it's a hostile world primes the placental clock for a CRH [corticotropin-releasing hormone] response later,” he said.

Subsequent studies in 550 consecutive pregnant subjects confirmed a consistent link between high levels of maternal cortisol early in pregnancy and elevated levels of placenta-derived CRH in the third trimester. Every 1 U of cortisol (μg/dL) measured at weeks 14-16 predicted 34 U of CRH (pg/dL) at 30-32 weeks' gestation.

Elevated CRH not only seems to speed delivery, but also appears to have profound consequences on the fetal response to stimuli and, later, a child's response to stress.

The complex interaction between maternal stress, fetal CRH, pregnancy outcomes, and infant and childhood behavior has been the target of studies conducted over more than 12 years as part of the women and children's health and well-being project at UCI, Dr. Sandman explained.

More than 1,000 women and 600-700 infants have been enrolled thus far in studies that begin with extensive prenatal assessment beginning at about 10 weeks' gestation. Neuroendocrine profiles assess the maternal stress axis, while ultrasound examinations and studies of fetal behavior continue throughout pregnancy.

Infant stress examinations begin with the routine first heel-stick test received in the nursery, when researchers take advantage of a naturally occurring opportunity to evaluate salivary cortisol. Babies' responses to the stress of immunizations are also measured and temperament analyses conducted at 6-8 weeks.

The children continue to be followed. Beginning at aged 5-7 years, they are assessed with cognitive tests and structural MRI.

A number of intriguing observations have emerged from the UCI studies, including evidence that suggests stress in the womb may have far-reaching consequences on health and behavior.

The metabolic story begins early in pregnancy, with an increase in neuropeptides from the maternal hypothalamic-pituitary-adrenal stress axis. Apparently in response, the placenta produces circulating CRH, which in turn downregulates the maternal stress system, blocking communication between the hypothalamus and pituitary. Both the quantity and the timing of stress hormone production is important.

“Women, as pregnancy advances, become immunized to the effects of stress,” explained Dr. Sandman, who said the finding explains why stress hormones were not as high in subjects who experienced the earthquake late in pregnancy. “When stress happens, matters,” he said.

Further research by the UCI group suggests that the fetus is very much influenced by stress signals. Fetuses exposed to high levels of stress hormones show a diminished ability to respond to new and familiar auditory stimuli. After birth, babies exposed early to high levels of stress hormones exhibit altered fear responses.

It may be that human fetuses exposed early to very high levels of stress hormones begin adapting very early to a perceived hostile environment by setting the scene for an early escape from the womb and altered fight-flight responses to new stimuli.

RANCHO MIRAGE, CALIF. — Mothers who experience high levels of stress during early pregnancy appear to convey distress signals to their fetuses, prompting their fetuses to eventually produce high levels of hormones that speed delivery.

The phenomenon suggests the presence of a “placental clock” for parturition that may be set months before the onset of labor, said Curt A. Sandman, Ph.D., professor and vice chair of psychiatry at the University of California, Irvine.

The pattern was seen in a prospective evaluation of pregnant California women who happened to be enrolled in a comprehensive study of pregnancy outcomes when the magnitude 6.7 Northridge earthquake struck early the morning of Jan. 17, 1994, killing dozens of people and leveling thousands of homes.

Those subjects who were in their first trimester showed highly elevated levels of stress hormones, but those in their third trimester had much lower levels of stress hormones, Dr. Sandman said at a conference on sleep in infancy and childhood sponsored by the Annenberg Center for Health Sciences.

Months later, women who had been exposed to the stress of the earthquake early in pregnancy were significantly more likely than other mothers to deliver early.

“An early maternal message that it's a hostile world primes the placental clock for a CRH [corticotropin-releasing hormone] response later,” he said.

Subsequent studies in 550 consecutive pregnant subjects confirmed a consistent link between high levels of maternal cortisol early in pregnancy and elevated levels of placenta-derived CRH in the third trimester. Every 1 U of cortisol (μg/dL) measured at weeks 14-16 predicted 34 U of CRH (pg/dL) at 30-32 weeks' gestation.

Elevated CRH not only seems to speed delivery, but also appears to have profound consequences on the fetal response to stimuli and, later, a child's response to stress.

The complex interaction between maternal stress, fetal CRH, pregnancy outcomes, and infant and childhood behavior has been the target of studies conducted over more than 12 years as part of the women and children's health and well-being project at UCI, Dr. Sandman explained.

More than 1,000 women and 600-700 infants have been enrolled thus far in studies that begin with extensive prenatal assessment beginning at about 10 weeks' gestation. Neuroendocrine profiles assess the maternal stress axis, while ultrasound examinations and studies of fetal behavior continue throughout pregnancy.

Infant stress examinations begin with the routine first heel-stick test received in the nursery, when researchers take advantage of a naturally occurring opportunity to evaluate salivary cortisol. Babies' responses to the stress of immunizations are also measured and temperament analyses conducted at 6-8 weeks.

The children continue to be followed. Beginning at aged 5-7 years, they are assessed with cognitive tests and structural MRI.

A number of intriguing observations have emerged from the UCI studies, including evidence that suggests stress in the womb may have far-reaching consequences on health and behavior.

The metabolic story begins early in pregnancy, with an increase in neuropeptides from the maternal hypothalamic-pituitary-adrenal stress axis. Apparently in response, the placenta produces circulating CRH, which in turn downregulates the maternal stress system, blocking communication between the hypothalamus and pituitary. Both the quantity and the timing of stress hormone production is important.

“Women, as pregnancy advances, become immunized to the effects of stress,” explained Dr. Sandman, who said the finding explains why stress hormones were not as high in subjects who experienced the earthquake late in pregnancy. “When stress happens, matters,” he said.

Further research by the UCI group suggests that the fetus is very much influenced by stress signals. Fetuses exposed to high levels of stress hormones show a diminished ability to respond to new and familiar auditory stimuli. After birth, babies exposed early to high levels of stress hormones exhibit altered fear responses.

It may be that human fetuses exposed early to very high levels of stress hormones begin adapting very early to a perceived hostile environment by setting the scene for an early escape from the womb and altered fight-flight responses to new stimuli.

UNIVERSAL CITY, CALIF. — Routine health care of women of childbearing potential should include a recommendation for a full periodontal examination, and pregnant patients should be monitored for signs of periodontal disease, Todd Hartsfield, D.D.S., recommended.

Evidence compiled from many studies suggests that maternal periodontal disease may be responsible for 18% of preterm, low-birth-weight deliveries, he said at a meeting of the Obstetrical and Gynecological Assembly of Southern California.

Moreover, research suggests that in patients with periodontitis during the second trimester, deep instrumental cleaning, known among dentists as scaling and root planing, may substantially lower the risk of preterm delivery.

Many of the studies detailing periodontal risk have appeared in dental journals that most physicians never see, said Dr. Hartsfield, director of the Dental Clinical and Prevention Support Center of the Inter Tribal Council of Arizona in Phoenix.

“I'd like to see more interplay between our professions,” Dr. Hartsfield said during a special lecture at the meeting.

“The dentist and dental hygienist should be a part of the health team that is involved in caring for expectant mothers.”

He recommended several patient brochures offered by the American Dental Association, including “Women and Gum Disease,” “What is Scaling and Root Planing?” and “Gum Disease: The Warning Signs.”

Pregnancy gingivitis is likely to be noticed by patients and seen by physicians as red, puffy gums that bleed easily. At this stage, intensified oral care can reverse the process, so patients should be instructed to brush, floss, and rinse frequently, and to see a dentist regularly throughout pregnancy.

Periodontitis represents more serious disease, but is often painless and may go unnoticed by pregnant women and their physicians. Gums may not bleed or visibly recede. It occurs when soft plaque in the sulcus hardens into calculus that adheres firmly to the tooth, like barnacles on a ship, said Dr. Hartsfield.

At this point, no amount of brushing or flossing by the patient will reverse the process. But bacterial toxins have begun damaging tissue and may form elongated, infection-filled pockets that may extend up to 8 mm below the gum line. At its peak, periodontitis may cause a grapefruit-sized oral infection.

“What's bad for the mouth is bad for the body,” he explained. “Infections in the mouth spread through the body, causing infection at distant sites.”

Toxins stimulate the release of cytokines, including tumor necrosis factor-α, interleukin-1 β, and interleukin-4. This cytokine response may induce overproduction of the enzyme collagenase, which breaks down proteins, including the connective tissue that holds teeth in place.

The first sign of trouble may be a loosening or movement of the teeth.

Physicians can be alert to the possibility of pregnancy periodontitis by examining patients for signs of calculus and asking whether they have a family history of the disease. In up to 30% of cases, genetics may play a role.

Periodontitis has been linked to an increased risk for bacteremia, infective endocarditis, prosthetic device infection, heart attack, stroke, lung infections, and the control of blood sugar.

Of most interest to physicians, however, may be the connection between gum disease and preterm birth; the connection may be due to periodontal toxins crossing the placenta, the fetus mounting an inflammatory response, or both.

Animal evidence of the periodontal disease preterm birth link first surfaced in the late 1980s, and subsequent human studies followed:

▸ One early study found pregnant women with periodontal disease were 7-8 times more likely to have a premature low-birthweight (PLBW) baby than women who did not have periodontal disease (J. Periodontol. 1996;67[suppl. 10]:1103-13).

▸ It was found that prostaglandin E2 was significantly higher in gingival sulcus fluid in 48 mothers of PLBW infants than in controls (Ann. Periodontol. 1998;3:233-50).

▸ Poor periodontal health was determined to be an independent risk factor for PLBW in a case-control study of 55 pairs of women (Ann. Periodontol. 1998;3:206-12).

▸ Systemic distribution of maternal periodontal infection was confirmed (Ann. Periodontol. 2001;6:175-82).

▸ Research linked maternal periodontal disease to an increased risk for preeclampsia (Obstet. Gynecol. 2003;101:227-31).

▸ Studies in Chile and the United States demonstrated a reduction in the incidence of PLBW among women with periodontitis who underwent scaling and root planing during pregnancy.

▸ A study found that periodontitis and elevated amniotic fluid cytokine levels at 15-20 weeks' gestation served as markers of risk for preterm birth in high-risk pregnancies (J. Clin. Periodontol. 2005;32:45-52).

One review article that highlighted previous research concluded that periodontal disease may account for up to 18% of preterm births (Obstet. Gynecol. 2003;101:227-31).

What to Ask Patients Thinking Of Pregnancy

When was the last time you had your teeth cleaned?

Are your gums red and puffy?

Do your gums bleed when you brush and floss?

Are any of your teeth loose? Have you noticed any new spaces?

Have you noticed a change in your bite?

Have you noticed a bad taste in your mouth?

Do you have bad breath or been told you have bad breath?

Do you have any relatives who have had gum disease?

Source: Dr. Hartsfield

UNIVERSAL CITY, CALIF. — Routine health care of women of childbearing potential should include a recommendation for a full periodontal examination, and pregnant patients should be monitored for signs of periodontal disease, Todd Hartsfield, D.D.S., recommended.

Evidence compiled from many studies suggests that maternal periodontal disease may be responsible for 18% of preterm, low-birth-weight deliveries, he said at a meeting of the Obstetrical and Gynecological Assembly of Southern California.

Moreover, research suggests that in patients with periodontitis during the second trimester, deep instrumental cleaning, known among dentists as scaling and root planing, may substantially lower the risk of preterm delivery.

Many of the studies detailing periodontal risk have appeared in dental journals that most physicians never see, said Dr. Hartsfield, director of the Dental Clinical and Prevention Support Center of the Inter Tribal Council of Arizona in Phoenix.

“I'd like to see more interplay between our professions,” Dr. Hartsfield said during a special lecture at the meeting.

“The dentist and dental hygienist should be a part of the health team that is involved in caring for expectant mothers.”

He recommended several patient brochures offered by the American Dental Association, including “Women and Gum Disease,” “What is Scaling and Root Planing?” and “Gum Disease: The Warning Signs.”

Pregnancy gingivitis is likely to be noticed by patients and seen by physicians as red, puffy gums that bleed easily. At this stage, intensified oral care can reverse the process, so patients should be instructed to brush, floss, and rinse frequently, and to see a dentist regularly throughout pregnancy.

Periodontitis represents more serious disease, but is often painless and may go unnoticed by pregnant women and their physicians. Gums may not bleed or visibly recede. It occurs when soft plaque in the sulcus hardens into calculus that adheres firmly to the tooth, like barnacles on a ship, said Dr. Hartsfield.

At this point, no amount of brushing or flossing by the patient will reverse the process. But bacterial toxins have begun damaging tissue and may form elongated, infection-filled pockets that may extend up to 8 mm below the gum line. At its peak, periodontitis may cause a grapefruit-sized oral infection.

“What's bad for the mouth is bad for the body,” he explained. “Infections in the mouth spread through the body, causing infection at distant sites.”

Toxins stimulate the release of cytokines, including tumor necrosis factor-α, interleukin-1 β, and interleukin-4. This cytokine response may induce overproduction of the enzyme collagenase, which breaks down proteins, including the connective tissue that holds teeth in place.

The first sign of trouble may be a loosening or movement of the teeth.

Physicians can be alert to the possibility of pregnancy periodontitis by examining patients for signs of calculus and asking whether they have a family history of the disease. In up to 30% of cases, genetics may play a role.

Periodontitis has been linked to an increased risk for bacteremia, infective endocarditis, prosthetic device infection, heart attack, stroke, lung infections, and the control of blood sugar.

Of most interest to physicians, however, may be the connection between gum disease and preterm birth; the connection may be due to periodontal toxins crossing the placenta, the fetus mounting an inflammatory response, or both.

Animal evidence of the periodontal disease preterm birth link first surfaced in the late 1980s, and subsequent human studies followed:

▸ One early study found pregnant women with periodontal disease were 7-8 times more likely to have a premature low-birthweight (PLBW) baby than women who did not have periodontal disease (J. Periodontol. 1996;67[suppl. 10]:1103-13).

▸ It was found that prostaglandin E2 was significantly higher in gingival sulcus fluid in 48 mothers of PLBW infants than in controls (Ann. Periodontol. 1998;3:233-50).

▸ Poor periodontal health was determined to be an independent risk factor for PLBW in a case-control study of 55 pairs of women (Ann. Periodontol. 1998;3:206-12).

▸ Systemic distribution of maternal periodontal infection was confirmed (Ann. Periodontol. 2001;6:175-82).

▸ Research linked maternal periodontal disease to an increased risk for preeclampsia (Obstet. Gynecol. 2003;101:227-31).

▸ Studies in Chile and the United States demonstrated a reduction in the incidence of PLBW among women with periodontitis who underwent scaling and root planing during pregnancy.

▸ A study found that periodontitis and elevated amniotic fluid cytokine levels at 15-20 weeks' gestation served as markers of risk for preterm birth in high-risk pregnancies (J. Clin. Periodontol. 2005;32:45-52).

One review article that highlighted previous research concluded that periodontal disease may account for up to 18% of preterm births (Obstet. Gynecol. 2003;101:227-31).

What to Ask Patients Thinking Of Pregnancy

When was the last time you had your teeth cleaned?

Are your gums red and puffy?

Do your gums bleed when you brush and floss?

Are any of your teeth loose? Have you noticed any new spaces?

Have you noticed a change in your bite?

Have you noticed a bad taste in your mouth?

Do you have bad breath or been told you have bad breath?

Do you have any relatives who have had gum disease?

Source: Dr. Hartsfield

UNIVERSAL CITY, CALIF. — Routine health care of women of childbearing potential should include a recommendation for a full periodontal examination, and pregnant patients should be monitored for signs of periodontal disease, Todd Hartsfield, D.D.S., recommended.

Evidence compiled from many studies suggests that maternal periodontal disease may be responsible for 18% of preterm, low-birth-weight deliveries, he said at a meeting of the Obstetrical and Gynecological Assembly of Southern California.

Moreover, research suggests that in patients with periodontitis during the second trimester, deep instrumental cleaning, known among dentists as scaling and root planing, may substantially lower the risk of preterm delivery.

Many of the studies detailing periodontal risk have appeared in dental journals that most physicians never see, said Dr. Hartsfield, director of the Dental Clinical and Prevention Support Center of the Inter Tribal Council of Arizona in Phoenix.

“I'd like to see more interplay between our professions,” Dr. Hartsfield said during a special lecture at the meeting.

“The dentist and dental hygienist should be a part of the health team that is involved in caring for expectant mothers.”

He recommended several patient brochures offered by the American Dental Association, including “Women and Gum Disease,” “What is Scaling and Root Planing?” and “Gum Disease: The Warning Signs.”

Pregnancy gingivitis is likely to be noticed by patients and seen by physicians as red, puffy gums that bleed easily. At this stage, intensified oral care can reverse the process, so patients should be instructed to brush, floss, and rinse frequently, and to see a dentist regularly throughout pregnancy.

Periodontitis represents more serious disease, but is often painless and may go unnoticed by pregnant women and their physicians. Gums may not bleed or visibly recede. It occurs when soft plaque in the sulcus hardens into calculus that adheres firmly to the tooth, like barnacles on a ship, said Dr. Hartsfield.

At this point, no amount of brushing or flossing by the patient will reverse the process. But bacterial toxins have begun damaging tissue and may form elongated, infection-filled pockets that may extend up to 8 mm below the gum line. At its peak, periodontitis may cause a grapefruit-sized oral infection.

“What's bad for the mouth is bad for the body,” he explained. “Infections in the mouth spread through the body, causing infection at distant sites.”

Toxins stimulate the release of cytokines, including tumor necrosis factor-α, interleukin-1 β, and interleukin-4. This cytokine response may induce overproduction of the enzyme collagenase, which breaks down proteins, including the connective tissue that holds teeth in place.

The first sign of trouble may be a loosening or movement of the teeth.

Physicians can be alert to the possibility of pregnancy periodontitis by examining patients for signs of calculus and asking whether they have a family history of the disease. In up to 30% of cases, genetics may play a role.

Periodontitis has been linked to an increased risk for bacteremia, infective endocarditis, prosthetic device infection, heart attack, stroke, lung infections, and the control of blood sugar.

Of most interest to physicians, however, may be the connection between gum disease and preterm birth; the connection may be due to periodontal toxins crossing the placenta, the fetus mounting an inflammatory response, or both.

Animal evidence of the periodontal disease preterm birth link first surfaced in the late 1980s, and subsequent human studies followed:

▸ One early study found pregnant women with periodontal disease were 7-8 times more likely to have a premature low-birthweight (PLBW) baby than women who did not have periodontal disease (J. Periodontol. 1996;67[suppl. 10]:1103-13).

▸ It was found that prostaglandin E2 was significantly higher in gingival sulcus fluid in 48 mothers of PLBW infants than in controls (Ann. Periodontol. 1998;3:233-50).

▸ Poor periodontal health was determined to be an independent risk factor for PLBW in a case-control study of 55 pairs of women (Ann. Periodontol. 1998;3:206-12).

▸ Systemic distribution of maternal periodontal infection was confirmed (Ann. Periodontol. 2001;6:175-82).

▸ Research linked maternal periodontal disease to an increased risk for preeclampsia (Obstet. Gynecol. 2003;101:227-31).

▸ Studies in Chile and the United States demonstrated a reduction in the incidence of PLBW among women with periodontitis who underwent scaling and root planing during pregnancy.

▸ A study found that periodontitis and elevated amniotic fluid cytokine levels at 15-20 weeks' gestation served as markers of risk for preterm birth in high-risk pregnancies (J. Clin. Periodontol. 2005;32:45-52).

One review article that highlighted previous research concluded that periodontal disease may account for up to 18% of preterm births (Obstet. Gynecol. 2003;101:227-31).

What to Ask Patients Thinking Of Pregnancy

When was the last time you had your teeth cleaned?

Are your gums red and puffy?

Do your gums bleed when you brush and floss?

Are any of your teeth loose? Have you noticed any new spaces?

Have you noticed a change in your bite?

Have you noticed a bad taste in your mouth?

Do you have bad breath or been told you have bad breath?

Do you have any relatives who have had gum disease?

Source: Dr. Hartsfield

FLORENCE, ITALY — More than 60% of children and young adults with Down syndrome had notable skin and mucous membrane conditions in a study presented at the 13th Congress of the European Academy of Dermatology and Venereology.

“With increasing survival of Down [syndrome] cases, physicians must be more aware of the skin findings seen so frequently in this genetic disorder,” said Maryam Daneshpazhooh, M.D., a dermatologist at Razi Hospital in Tehran, Iran.

The presence of furrows on the dorsal surface of the tongue, called fissured tongue or scrotal tongue, occurs in about 2%-5% of the general population.

Fissured tongue, the most common mucocutaneous finding in the Iranian study, was seen in 28 of 100 subjects aged 3-20 years who were attending schools for children with special needs in the Karaj and Shahryar provinces, she reported.

The frequency of the condition in subjects with Down syndrome increased with the age of the patient, Dr. Daneshpazhooh said.

Hypertrophy of the tongue papillae, seen in 22 of 100 children, was the second most common finding.

The next most common finding was premature graying, observed in 14 members of the cohort. More than half of the oldest subjects—those who were aged 16-20 years—had prematurely gray hair. (See box.)

In contrast to data discovered in previous studies, which were conducted on institutionalized children, none of the Iranian children had infections or parasitic infestations at the time of the study.

Dr. Daneshpazhooh noted that all of the children with Down syndrome in her study lived at home, where infestations are less common than in institutions. Families may pay more attention to hygiene in children with Down syndrome than would institutional staff.

Mucocutaneous Findings in Children And Young Adults

FLORENCE, ITALY — More than 60% of children and young adults with Down syndrome had notable skin and mucous membrane conditions in a study presented at the 13th Congress of the European Academy of Dermatology and Venereology.

“With increasing survival of Down [syndrome] cases, physicians must be more aware of the skin findings seen so frequently in this genetic disorder,” said Maryam Daneshpazhooh, M.D., a dermatologist at Razi Hospital in Tehran, Iran.

The presence of furrows on the dorsal surface of the tongue, called fissured tongue or scrotal tongue, occurs in about 2%-5% of the general population.

Fissured tongue, the most common mucocutaneous finding in the Iranian study, was seen in 28 of 100 subjects aged 3-20 years who were attending schools for children with special needs in the Karaj and Shahryar provinces, she reported.

The frequency of the condition in subjects with Down syndrome increased with the age of the patient, Dr. Daneshpazhooh said.

Hypertrophy of the tongue papillae, seen in 22 of 100 children, was the second most common finding.

The next most common finding was premature graying, observed in 14 members of the cohort. More than half of the oldest subjects—those who were aged 16-20 years—had prematurely gray hair. (See box.)

In contrast to data discovered in previous studies, which were conducted on institutionalized children, none of the Iranian children had infections or parasitic infestations at the time of the study.

Dr. Daneshpazhooh noted that all of the children with Down syndrome in her study lived at home, where infestations are less common than in institutions. Families may pay more attention to hygiene in children with Down syndrome than would institutional staff.

Mucocutaneous Findings in Children And Young Adults

FLORENCE, ITALY — More than 60% of children and young adults with Down syndrome had notable skin and mucous membrane conditions in a study presented at the 13th Congress of the European Academy of Dermatology and Venereology.

“With increasing survival of Down [syndrome] cases, physicians must be more aware of the skin findings seen so frequently in this genetic disorder,” said Maryam Daneshpazhooh, M.D., a dermatologist at Razi Hospital in Tehran, Iran.

The presence of furrows on the dorsal surface of the tongue, called fissured tongue or scrotal tongue, occurs in about 2%-5% of the general population.

Fissured tongue, the most common mucocutaneous finding in the Iranian study, was seen in 28 of 100 subjects aged 3-20 years who were attending schools for children with special needs in the Karaj and Shahryar provinces, she reported.

The frequency of the condition in subjects with Down syndrome increased with the age of the patient, Dr. Daneshpazhooh said.

Hypertrophy of the tongue papillae, seen in 22 of 100 children, was the second most common finding.

The next most common finding was premature graying, observed in 14 members of the cohort. More than half of the oldest subjects—those who were aged 16-20 years—had prematurely gray hair. (See box.)

In contrast to data discovered in previous studies, which were conducted on institutionalized children, none of the Iranian children had infections or parasitic infestations at the time of the study.

Dr. Daneshpazhooh noted that all of the children with Down syndrome in her study lived at home, where infestations are less common than in institutions. Families may pay more attention to hygiene in children with Down syndrome than would institutional staff.

Mucocutaneous Findings in Children And Young Adults

PALM SPRINGS, CALIF. – A clear majority of administrators from managed care organizations believe pain management programs could save money for their organizations, but only a third have such programs in place, Dennis C. Turk, Ph.D., reported at the annual meeting of the American Academy of Pain Medicine.

Dr. Turk, professor of anesthesiology at the University of Washington in Seattle, analyzed the data from a survey completed by 74 administrators from managed care organizations (MCOs) ranging in size from 2,200 to 25 million patients.

The administrators considered back pain, headache, and fibromyalgia the most difficult pain management problems. Almost as many administrators (18 of 74) thought overtreatment of pain was more common as thought undertreatment of pain was more common (21 of 74).

Nearly half said the costs of treating chronic pain exceeded the costs of treating patients with other chronic diseases. They tended to believe the cost of diagnostic tests, rather than the cost of pain medication, was an impediment to pain management. They believed that good evidence supported the efficacy of rehabilitation programs (60%), but not nerve blocks (23%) or surgery (9%).

The administrators strongly advocated urine screening to monitor patients prescribed long-term opioids and the preferred use of sustained-release opioids for long-term prescriptions.

A definitive 84% of the administrators surveyed said pain management programs should emphasize self-management, but only 11% thought their organizations were doing a good job educating patients about the issue, Dr. Turk said.

Organon Pharmaceuticals USA Inc. and Ligand Pharmaceuticals Inc. sponsored the study.

PALM SPRINGS, CALIF. – A clear majority of administrators from managed care organizations believe pain management programs could save money for their organizations, but only a third have such programs in place, Dennis C. Turk, Ph.D., reported at the annual meeting of the American Academy of Pain Medicine.

Dr. Turk, professor of anesthesiology at the University of Washington in Seattle, analyzed the data from a survey completed by 74 administrators from managed care organizations (MCOs) ranging in size from 2,200 to 25 million patients.

The administrators considered back pain, headache, and fibromyalgia the most difficult pain management problems. Almost as many administrators (18 of 74) thought overtreatment of pain was more common as thought undertreatment of pain was more common (21 of 74).

Nearly half said the costs of treating chronic pain exceeded the costs of treating patients with other chronic diseases. They tended to believe the cost of diagnostic tests, rather than the cost of pain medication, was an impediment to pain management. They believed that good evidence supported the efficacy of rehabilitation programs (60%), but not nerve blocks (23%) or surgery (9%).

The administrators strongly advocated urine screening to monitor patients prescribed long-term opioids and the preferred use of sustained-release opioids for long-term prescriptions.

A definitive 84% of the administrators surveyed said pain management programs should emphasize self-management, but only 11% thought their organizations were doing a good job educating patients about the issue, Dr. Turk said.

Organon Pharmaceuticals USA Inc. and Ligand Pharmaceuticals Inc. sponsored the study.

PALM SPRINGS, CALIF. – A clear majority of administrators from managed care organizations believe pain management programs could save money for their organizations, but only a third have such programs in place, Dennis C. Turk, Ph.D., reported at the annual meeting of the American Academy of Pain Medicine.

Dr. Turk, professor of anesthesiology at the University of Washington in Seattle, analyzed the data from a survey completed by 74 administrators from managed care organizations (MCOs) ranging in size from 2,200 to 25 million patients.

The administrators considered back pain, headache, and fibromyalgia the most difficult pain management problems. Almost as many administrators (18 of 74) thought overtreatment of pain was more common as thought undertreatment of pain was more common (21 of 74).

Nearly half said the costs of treating chronic pain exceeded the costs of treating patients with other chronic diseases. They tended to believe the cost of diagnostic tests, rather than the cost of pain medication, was an impediment to pain management. They believed that good evidence supported the efficacy of rehabilitation programs (60%), but not nerve blocks (23%) or surgery (9%).

The administrators strongly advocated urine screening to monitor patients prescribed long-term opioids and the preferred use of sustained-release opioids for long-term prescriptions.

A definitive 84% of the administrators surveyed said pain management programs should emphasize self-management, but only 11% thought their organizations were doing a good job educating patients about the issue, Dr. Turk said.

Organon Pharmaceuticals USA Inc. and Ligand Pharmaceuticals Inc. sponsored the study.

LOS ANGELES — Clinical and imaging clues provide excellent guidance as to which patients would derive the most benefit from endoscopic pancreatic calculi removal, Robert H. Hawes, M.D., said at the 12th International Symposium on Pancreatic and Biliary Endoscopy sponsored by Cedars-Sinai Medical Center.

“The main issue when you're looking at patients with pancreatic stones or calcific chronic pancreatitis is pain relief,” said Dr. Hawes, professor of gastroenterology and hepatology at the Medical University of South Carolina in Charleston.

“We can talk about improving ductal drainage. We can talk about … improving functional deficits. We can talk about weight gain. We can talk about improving quality of life. But the fact of the matter is, the main issue is pain.”

Therefore, patients with chronic calcific pancreatitis who do not have pain should not be considered candidates for stone removal, he asserted.

Nor should stone removal be attempted in an effort to improve steatorrhea, which should be treated with enzymes.

Among patients who do experience pain, those living a “plateau-type existence” with chronic pancreatitis—suffering constant pain—are least likely to achieve significant relief by having calculi removed and obstructions of the main pancreatic duct alleviated, Dr. Hawes said.

The best candidates, he said, are those with chronic relapsing calcific pancreatitis. These are patients who are “cruising along fine” until they suffer periodic acute bouts of pancreatitis, complete with an elevation of enzymes, extreme pain, and often, nausea and vomiting.

Their chances of success with endoscopic intervention improve even more if they meet certain criteria evident on imaging studies, including:

▸ A large, dilated pancreatic duct.

▸ Three or fewer stones.

▸ Stones confined to the head and/or body of the pancreas.

▸ Stone size less than 10 mm.

▸ The absence of impacted stones.

▸ The absence of downstream strictures.

Ideal candidates can achieve dramatic results from sphincterotomy with endoscopic calculi removal, ideally in conjunction with extracorporeal shock wave lithotripsy (ESWL), he said.

Even without the advantage of adjunctive ESWL, increasingly considered “almost indispensable” in centers treating chronic pancreatitis, endoscopic techniques can be highly effective. A study published by Dr. Hawes and his colleagues showed endoscopic therapy to be effective in 83% of patients with chronic relapsing pancreatitis, compared with just 46% of those presenting with continuous pain (Gastrointest. Endosc. 1991;37:511-7).

Not every stone must be removed to achieve substantial pain relief, Dr. Hawes emphasized.

He stopped short of discouraging endoscopic therapy in patients with unrelenting pain, noting, “it's worth a try but may not help.”

Divergent rates of success for stone removal may be related to the fact that there are two underlying explanations for pain associated with chronic calcific pancreatitis, he said.

In pancreatic duct obstruction, pain results from parenchymal hypertension. This scenario responds well to ductal decompression. Pain associated with pancreatic and peripancreatic neural inflammation, most often associated with long-standing chronic disease, does not.

Careful imaging can point to whether endoscopic treatment should be undertaken and in some cases, bring to light massive stones and strictures that could be managed only by lithotripsy or surgical Whipple resection.

“I would strongly recommend that if you see patients with chronic pancreatitis, that you switch your gears from a reflex of just getting a CT scan to talking to your radiologist and getting geared up for high-quality MRI scanning … with secretin stimulation,” Dr. Hawes said.

No other modality gives such clear or important information in treatment planning for patients with chronic pancreatitis, he said.

Dr. Hawes disclosed that he has received grants from Olympus America Inc. and research support from Wilson-Cook Medical Inc. and Boston Scientific Corp., and he is a consultant for InScope.

LOS ANGELES — Clinical and imaging clues provide excellent guidance as to which patients would derive the most benefit from endoscopic pancreatic calculi removal, Robert H. Hawes, M.D., said at the 12th International Symposium on Pancreatic and Biliary Endoscopy sponsored by Cedars-Sinai Medical Center.

“The main issue when you're looking at patients with pancreatic stones or calcific chronic pancreatitis is pain relief,” said Dr. Hawes, professor of gastroenterology and hepatology at the Medical University of South Carolina in Charleston.

“We can talk about improving ductal drainage. We can talk about … improving functional deficits. We can talk about weight gain. We can talk about improving quality of life. But the fact of the matter is, the main issue is pain.”

Therefore, patients with chronic calcific pancreatitis who do not have pain should not be considered candidates for stone removal, he asserted.

Nor should stone removal be attempted in an effort to improve steatorrhea, which should be treated with enzymes.

Among patients who do experience pain, those living a “plateau-type existence” with chronic pancreatitis—suffering constant pain—are least likely to achieve significant relief by having calculi removed and obstructions of the main pancreatic duct alleviated, Dr. Hawes said.

The best candidates, he said, are those with chronic relapsing calcific pancreatitis. These are patients who are “cruising along fine” until they suffer periodic acute bouts of pancreatitis, complete with an elevation of enzymes, extreme pain, and often, nausea and vomiting.

Their chances of success with endoscopic intervention improve even more if they meet certain criteria evident on imaging studies, including:

▸ A large, dilated pancreatic duct.

▸ Three or fewer stones.

▸ Stones confined to the head and/or body of the pancreas.

▸ Stone size less than 10 mm.

▸ The absence of impacted stones.

▸ The absence of downstream strictures.

Ideal candidates can achieve dramatic results from sphincterotomy with endoscopic calculi removal, ideally in conjunction with extracorporeal shock wave lithotripsy (ESWL), he said.

Even without the advantage of adjunctive ESWL, increasingly considered “almost indispensable” in centers treating chronic pancreatitis, endoscopic techniques can be highly effective. A study published by Dr. Hawes and his colleagues showed endoscopic therapy to be effective in 83% of patients with chronic relapsing pancreatitis, compared with just 46% of those presenting with continuous pain (Gastrointest. Endosc. 1991;37:511-7).

Not every stone must be removed to achieve substantial pain relief, Dr. Hawes emphasized.

He stopped short of discouraging endoscopic therapy in patients with unrelenting pain, noting, “it's worth a try but may not help.”

Divergent rates of success for stone removal may be related to the fact that there are two underlying explanations for pain associated with chronic calcific pancreatitis, he said.

In pancreatic duct obstruction, pain results from parenchymal hypertension. This scenario responds well to ductal decompression. Pain associated with pancreatic and peripancreatic neural inflammation, most often associated with long-standing chronic disease, does not.

Careful imaging can point to whether endoscopic treatment should be undertaken and in some cases, bring to light massive stones and strictures that could be managed only by lithotripsy or surgical Whipple resection.

“I would strongly recommend that if you see patients with chronic pancreatitis, that you switch your gears from a reflex of just getting a CT scan to talking to your radiologist and getting geared up for high-quality MRI scanning … with secretin stimulation,” Dr. Hawes said.

No other modality gives such clear or important information in treatment planning for patients with chronic pancreatitis, he said.

Dr. Hawes disclosed that he has received grants from Olympus America Inc. and research support from Wilson-Cook Medical Inc. and Boston Scientific Corp., and he is a consultant for InScope.

LOS ANGELES — Clinical and imaging clues provide excellent guidance as to which patients would derive the most benefit from endoscopic pancreatic calculi removal, Robert H. Hawes, M.D., said at the 12th International Symposium on Pancreatic and Biliary Endoscopy sponsored by Cedars-Sinai Medical Center.

“The main issue when you're looking at patients with pancreatic stones or calcific chronic pancreatitis is pain relief,” said Dr. Hawes, professor of gastroenterology and hepatology at the Medical University of South Carolina in Charleston.

“We can talk about improving ductal drainage. We can talk about … improving functional deficits. We can talk about weight gain. We can talk about improving quality of life. But the fact of the matter is, the main issue is pain.”

Therefore, patients with chronic calcific pancreatitis who do not have pain should not be considered candidates for stone removal, he asserted.

Nor should stone removal be attempted in an effort to improve steatorrhea, which should be treated with enzymes.

Among patients who do experience pain, those living a “plateau-type existence” with chronic pancreatitis—suffering constant pain—are least likely to achieve significant relief by having calculi removed and obstructions of the main pancreatic duct alleviated, Dr. Hawes said.

The best candidates, he said, are those with chronic relapsing calcific pancreatitis. These are patients who are “cruising along fine” until they suffer periodic acute bouts of pancreatitis, complete with an elevation of enzymes, extreme pain, and often, nausea and vomiting.

Their chances of success with endoscopic intervention improve even more if they meet certain criteria evident on imaging studies, including:

▸ A large, dilated pancreatic duct.

▸ Three or fewer stones.

▸ Stones confined to the head and/or body of the pancreas.

▸ Stone size less than 10 mm.

▸ The absence of impacted stones.

▸ The absence of downstream strictures.

Ideal candidates can achieve dramatic results from sphincterotomy with endoscopic calculi removal, ideally in conjunction with extracorporeal shock wave lithotripsy (ESWL), he said.

Even without the advantage of adjunctive ESWL, increasingly considered “almost indispensable” in centers treating chronic pancreatitis, endoscopic techniques can be highly effective. A study published by Dr. Hawes and his colleagues showed endoscopic therapy to be effective in 83% of patients with chronic relapsing pancreatitis, compared with just 46% of those presenting with continuous pain (Gastrointest. Endosc. 1991;37:511-7).

Not every stone must be removed to achieve substantial pain relief, Dr. Hawes emphasized.

He stopped short of discouraging endoscopic therapy in patients with unrelenting pain, noting, “it's worth a try but may not help.”

Divergent rates of success for stone removal may be related to the fact that there are two underlying explanations for pain associated with chronic calcific pancreatitis, he said.

In pancreatic duct obstruction, pain results from parenchymal hypertension. This scenario responds well to ductal decompression. Pain associated with pancreatic and peripancreatic neural inflammation, most often associated with long-standing chronic disease, does not.

Careful imaging can point to whether endoscopic treatment should be undertaken and in some cases, bring to light massive stones and strictures that could be managed only by lithotripsy or surgical Whipple resection.

“I would strongly recommend that if you see patients with chronic pancreatitis, that you switch your gears from a reflex of just getting a CT scan to talking to your radiologist and getting geared up for high-quality MRI scanning … with secretin stimulation,” Dr. Hawes said.

No other modality gives such clear or important information in treatment planning for patients with chronic pancreatitis, he said.

Dr. Hawes disclosed that he has received grants from Olympus America Inc. and research support from Wilson-Cook Medical Inc. and Boston Scientific Corp., and he is a consultant for InScope.

LOS ANGELES — Management options for infections following acute pancreatitis have expanded in recent years, with enhancement of percutaneous and endoscopic techniques and improvements in laparoscopic alternatives to open surgery.

But open pancreatic necrosectomy still has a vital and sometimes lifesaving role, Nicholas N. Nissen, M.D., said at the 12th International Symposium on Pancreatic and Biliary Endoscopy sponsored by the Cedars-Sinai Medical Center.

Some form of debridement or drainage is imperative when peripancreatic infection is present, which happens in about 30%-50% of pancreatic necrosis cases, Dr. Nissen emphasized.

“The mortality rate for untreated infected pancreatic necrosis is 100% without drainage or debridement,” he noted.

The best treatment method for an individual patient depends on a number of factors, said Dr. Nissen, who has a special interest in minimally invasive surgery of the liver and pancreas at Cedars-Sinai.

He also serves on the surgical faculty at the University of California, Los Angeles.

Management considerations include:

▸ Duration of disease. During the early inflammatory phase of severe pancreatitis, the risk of infection is low. However, even 2-3 weeks after symptom onset, a CT scan may show evidence of early organization and loculation of peripancreatic fluid that may indicate a gathering infection.

▸ Stability of the patient. “A hemodynamically unstable patient or a patient in septic shock really doesn't belong in an interventional radiology unit having percutaneous drainage. They really belong in the operating room,” Dr. Nissen said.

▸ Local expertise. Some interventional radiologists are comfortable with cases that require aggressive drainage of necrotic peripancreatic fluid, while others really only want to handle pseudocysts. Surgical referral is a better alternative than pushing a radiologist beyond his or her limits.

▸ The likelihood of success. If a case seems likely to require multiple endoscopic treatments, surgery may be a wiser first option, as the extent of debridement can be much more aggressive with surgery and the likelihood of repeated procedures much lower.

▸ The need for other procedures. A patient with an infection who is also likely to need a cholecystectomy or another surgical procedure is best served by having one procedure—surgery.

Debridement may be accomplished via laparotomy, laparoscopy, endoscopic transgastric drainage, or a novel percutaneous technique called sinus tract endoscopy.

Percutaneous and endoscopic approaches work best when the infection is mostly liquid, without organized necrotic tissue, Dr. Nissen said.

Extensive infection and/or a dense necrotic bed without liquefaction, especially in an unstable patient, call for open pancreatic necrosectomy. “This is a fairly impressive procedure—dramatic for the surgeon and for the patient,” he said.

Wound complications, enteric fistulas, and bleeding often complicate the procedure, which carries a reported mortality of 20%-50%.

Most patients require repeated laparotomies; however, the surgery can be lifesaving in grave cases.

A rather large incision permits access for surgical instruments used to physically remove as much necrotic tissue as possible—ideally, up to 90%.

Other cases can be handled laparoscopically, even in the face of complications arising when a percutaneous drain fails to resolve symptoms of infection.

In one 26-year-old woman with mercaptopurine-induced pancreatitis, a CT scan performed 5 weeks after symptom onset appeared to show mostly fluid behind the stomach. The woman was symptomatic and feverish, and a percutaneous drain placed after aspiration of fluid was repeatedly malfunctioning.

Dr. Nissen showed a video demonstrating laparoscopic pancreatic debridement; large amounts of necrotic tissue were removed from behind the stomach using minimally invasive techniques.

The principal objective of surgery was to physically remove “wads” of necrotic tissue that could not be seen on the rather benign-appearing CT scan. A larger-bore drain was placed at the conclusion of surgery; the original drain had been too small to handle the large amount of necrotic tissue.

“Once that necrotic tissue is gone, there is a much better chance of this cavity collapsing around the drain, small leaks or big leaks closing, and of the sepsis resolving,” he said.

“Our ability to laparoscopically manage pancreatic necrosis and pancreatic fluid collections is an important advance in the field of pancreatic surgery.

“Techniques and practices are continuing to evolve and are increasingly reliant on the cooperative efforts of gastroenterologists, surgeons, and radiologists,” Dr. Nissen added.

Necrotic tissue (arrow) is removed from behind the stomach (S). The tube is a previously placed percutaneous drain. Courtesy Dr. Nicholas N. Nissen

LOS ANGELES — Management options for infections following acute pancreatitis have expanded in recent years, with enhancement of percutaneous and endoscopic techniques and improvements in laparoscopic alternatives to open surgery.

But open pancreatic necrosectomy still has a vital and sometimes lifesaving role, Nicholas N. Nissen, M.D., said at the 12th International Symposium on Pancreatic and Biliary Endoscopy sponsored by the Cedars-Sinai Medical Center.

Some form of debridement or drainage is imperative when peripancreatic infection is present, which happens in about 30%-50% of pancreatic necrosis cases, Dr. Nissen emphasized.

“The mortality rate for untreated infected pancreatic necrosis is 100% without drainage or debridement,” he noted.

The best treatment method for an individual patient depends on a number of factors, said Dr. Nissen, who has a special interest in minimally invasive surgery of the liver and pancreas at Cedars-Sinai.

He also serves on the surgical faculty at the University of California, Los Angeles.

Management considerations include:

▸ Duration of disease. During the early inflammatory phase of severe pancreatitis, the risk of infection is low. However, even 2-3 weeks after symptom onset, a CT scan may show evidence of early organization and loculation of peripancreatic fluid that may indicate a gathering infection.

▸ Stability of the patient. “A hemodynamically unstable patient or a patient in septic shock really doesn't belong in an interventional radiology unit having percutaneous drainage. They really belong in the operating room,” Dr. Nissen said.

▸ Local expertise. Some interventional radiologists are comfortable with cases that require aggressive drainage of necrotic peripancreatic fluid, while others really only want to handle pseudocysts. Surgical referral is a better alternative than pushing a radiologist beyond his or her limits.

▸ The likelihood of success. If a case seems likely to require multiple endoscopic treatments, surgery may be a wiser first option, as the extent of debridement can be much more aggressive with surgery and the likelihood of repeated procedures much lower.

▸ The need for other procedures. A patient with an infection who is also likely to need a cholecystectomy or another surgical procedure is best served by having one procedure—surgery.

Debridement may be accomplished via laparotomy, laparoscopy, endoscopic transgastric drainage, or a novel percutaneous technique called sinus tract endoscopy.

Percutaneous and endoscopic approaches work best when the infection is mostly liquid, without organized necrotic tissue, Dr. Nissen said.

Extensive infection and/or a dense necrotic bed without liquefaction, especially in an unstable patient, call for open pancreatic necrosectomy. “This is a fairly impressive procedure—dramatic for the surgeon and for the patient,” he said.

Wound complications, enteric fistulas, and bleeding often complicate the procedure, which carries a reported mortality of 20%-50%.

Most patients require repeated laparotomies; however, the surgery can be lifesaving in grave cases.

A rather large incision permits access for surgical instruments used to physically remove as much necrotic tissue as possible—ideally, up to 90%.

Other cases can be handled laparoscopically, even in the face of complications arising when a percutaneous drain fails to resolve symptoms of infection.

In one 26-year-old woman with mercaptopurine-induced pancreatitis, a CT scan performed 5 weeks after symptom onset appeared to show mostly fluid behind the stomach. The woman was symptomatic and feverish, and a percutaneous drain placed after aspiration of fluid was repeatedly malfunctioning.

Dr. Nissen showed a video demonstrating laparoscopic pancreatic debridement; large amounts of necrotic tissue were removed from behind the stomach using minimally invasive techniques.

The principal objective of surgery was to physically remove “wads” of necrotic tissue that could not be seen on the rather benign-appearing CT scan. A larger-bore drain was placed at the conclusion of surgery; the original drain had been too small to handle the large amount of necrotic tissue.

“Once that necrotic tissue is gone, there is a much better chance of this cavity collapsing around the drain, small leaks or big leaks closing, and of the sepsis resolving,” he said.

“Our ability to laparoscopically manage pancreatic necrosis and pancreatic fluid collections is an important advance in the field of pancreatic surgery.

“Techniques and practices are continuing to evolve and are increasingly reliant on the cooperative efforts of gastroenterologists, surgeons, and radiologists,” Dr. Nissen added.

Necrotic tissue (arrow) is removed from behind the stomach (S). The tube is a previously placed percutaneous drain. Courtesy Dr. Nicholas N. Nissen

LOS ANGELES — Management options for infections following acute pancreatitis have expanded in recent years, with enhancement of percutaneous and endoscopic techniques and improvements in laparoscopic alternatives to open surgery.

But open pancreatic necrosectomy still has a vital and sometimes lifesaving role, Nicholas N. Nissen, M.D., said at the 12th International Symposium on Pancreatic and Biliary Endoscopy sponsored by the Cedars-Sinai Medical Center.

Some form of debridement or drainage is imperative when peripancreatic infection is present, which happens in about 30%-50% of pancreatic necrosis cases, Dr. Nissen emphasized.

“The mortality rate for untreated infected pancreatic necrosis is 100% without drainage or debridement,” he noted.

The best treatment method for an individual patient depends on a number of factors, said Dr. Nissen, who has a special interest in minimally invasive surgery of the liver and pancreas at Cedars-Sinai.

He also serves on the surgical faculty at the University of California, Los Angeles.

Management considerations include:

▸ Duration of disease. During the early inflammatory phase of severe pancreatitis, the risk of infection is low. However, even 2-3 weeks after symptom onset, a CT scan may show evidence of early organization and loculation of peripancreatic fluid that may indicate a gathering infection.

▸ Stability of the patient. “A hemodynamically unstable patient or a patient in septic shock really doesn't belong in an interventional radiology unit having percutaneous drainage. They really belong in the operating room,” Dr. Nissen said.

▸ Local expertise. Some interventional radiologists are comfortable with cases that require aggressive drainage of necrotic peripancreatic fluid, while others really only want to handle pseudocysts. Surgical referral is a better alternative than pushing a radiologist beyond his or her limits.

▸ The likelihood of success. If a case seems likely to require multiple endoscopic treatments, surgery may be a wiser first option, as the extent of debridement can be much more aggressive with surgery and the likelihood of repeated procedures much lower.

▸ The need for other procedures. A patient with an infection who is also likely to need a cholecystectomy or another surgical procedure is best served by having one procedure—surgery.

Debridement may be accomplished via laparotomy, laparoscopy, endoscopic transgastric drainage, or a novel percutaneous technique called sinus tract endoscopy.

Percutaneous and endoscopic approaches work best when the infection is mostly liquid, without organized necrotic tissue, Dr. Nissen said.

Extensive infection and/or a dense necrotic bed without liquefaction, especially in an unstable patient, call for open pancreatic necrosectomy. “This is a fairly impressive procedure—dramatic for the surgeon and for the patient,” he said.

Wound complications, enteric fistulas, and bleeding often complicate the procedure, which carries a reported mortality of 20%-50%.

Most patients require repeated laparotomies; however, the surgery can be lifesaving in grave cases.

A rather large incision permits access for surgical instruments used to physically remove as much necrotic tissue as possible—ideally, up to 90%.

Other cases can be handled laparoscopically, even in the face of complications arising when a percutaneous drain fails to resolve symptoms of infection.

In one 26-year-old woman with mercaptopurine-induced pancreatitis, a CT scan performed 5 weeks after symptom onset appeared to show mostly fluid behind the stomach. The woman was symptomatic and feverish, and a percutaneous drain placed after aspiration of fluid was repeatedly malfunctioning.

Dr. Nissen showed a video demonstrating laparoscopic pancreatic debridement; large amounts of necrotic tissue were removed from behind the stomach using minimally invasive techniques.

The principal objective of surgery was to physically remove “wads” of necrotic tissue that could not be seen on the rather benign-appearing CT scan. A larger-bore drain was placed at the conclusion of surgery; the original drain had been too small to handle the large amount of necrotic tissue.

“Once that necrotic tissue is gone, there is a much better chance of this cavity collapsing around the drain, small leaks or big leaks closing, and of the sepsis resolving,” he said.

“Our ability to laparoscopically manage pancreatic necrosis and pancreatic fluid collections is an important advance in the field of pancreatic surgery.

“Techniques and practices are continuing to evolve and are increasingly reliant on the cooperative efforts of gastroenterologists, surgeons, and radiologists,” Dr. Nissen added.

Necrotic tissue (arrow) is removed from behind the stomach (S). The tube is a previously placed percutaneous drain. Courtesy Dr. Nicholas N. Nissen

UNIVERSAL CITY, CALIF. — Preimplantation genetic diagnosis is making embryo selection more of a science and less of a blastomere “beauty contest,” David L. Hill, Ph.D., told colleagues at a meeting of the Obstetrical and Gynecological Assembly of Southern California.

“We used to line up all the embryos and say, 'These two or three look pretty good to me. Let's go,'” said Dr. Hill, director of the ART Reproductive Center in Beverly Hills, Calif. “It was essentially a beauty contest.”

Embryologists are increasingly realizing that chromosomally abnormal embryos can appear to be developing properly and look quite normal at the blastocyst stage. As an example, he showed an embryo at days 3, 4, and 5 that were diagnosed with monosomy 13 using advanced preimplantation genetic diagnosis (PGD) technology.

“Monosomy 13 would never lead to a live birth. But it still can make an absolutely beautiful blastomere. We could easily select that very nice-looking embryo … lowering the implantation rate [for that patient] and possibly leaving a healthy embryo behind.”

Other normal-appearing blastocysts were shown to have trisomy 21 and monosomy 18; trisomy 13; or mosaicism 18.

These days, a five-cocktail probe can test blastocysts for autosomal trisomies such as Down syndrome; autosomal monosomies; X and Y numerical disorders such as Turner's syndrome and Klinefelter's syndrome; and translocations using fluorescent in situ hybridization (FISH).

The classic screen assesses chromosomes 13, 18, 21, X, and Y.

Other chromosomes can be added to the screening panel, and polymerase chain reaction technology can be used to custom-design probes for more than 200 specific hereditary diseases.

The FISH technique potentially extends the usefulness of PGD far beyond couples with a known familial disease to those concerned about miscarriage or birth defects associated with advanced maternal age or a history of recurrent pregnancy loss.

The natural aneuploidy rate in human embryos is very high, Dr. Hill explained.

Recent 5-chromosome panel FISH examinations of embryos from his center's in vitro fertilization program found an aneuploidy rate of 38% among 317 embryos from infertile women aged 37 or younger, 45% among 382 embryos from infertile women aged 38 or older, and 36% of 53 embryos from healthy, fertile ovum donors whose average age was 30.

In PGD, as in traditional in vitro fertilization, embryos are also assessed for morphology and growth before they are transferred. But perhaps because more is known about the chromosomal makeup of transferred embryos, the pregnancy rate following PGD appears to be higher than with normal in vitro fertilization.

Dr. Hill compared pregnancy rates among 441 non-PGD patients and 146 PGD patients who underwent in vitro fertilization at his institution. The average maternal age in both groups was identical, 37.

Although fewer embryos were transferred in PGD cases (2.4 vs.3.1), the pregnancy rate was signficantly higher after PGD (44% vs. 33%).

Among women aged 38 or older, the pregnancy rate was higher for 54 PGD patients, compared with 238 non-PGD patients (37% vs. 30%), although the number of PGD patients was too small for the difference to achieve statistical significance.

The accuracy of PGD-FISH can vary, Dr. Hill and his colleagues have found.

He noted the diagnosis is made from a single cell plucked from a six-cell embryo, and that he and his colleagues are “very conservative when we read the FISH signals.”

Signal overlap or split signals can be misleading, so he says he errs on the side of caution. “Your heart may want you to call it a normal embryo—you want this couple to have a good transfer.” But your head tells you, this is just not suitable.

In limited cases, an embryo with a chromosomal abnormality can self-correct, discarding the incorrect copies of a chromosome. Mosaicism can also occur.

Finally, some abnormalities are more likely than others to be misdiagnosed. Monosomies and trisomies are rarely falsely diagnosed. Recently, 146 embryos diagnosed by FISH as abnormal were studied as their development progressed in Dr. Hill's lab. Further analysis confirmed 122 were abnormal, for a positive predictive value of 83% and a negative predictive value of 81%, he said.

UNIVERSAL CITY, CALIF. — Preimplantation genetic diagnosis is making embryo selection more of a science and less of a blastomere “beauty contest,” David L. Hill, Ph.D., told colleagues at a meeting of the Obstetrical and Gynecological Assembly of Southern California.

“We used to line up all the embryos and say, 'These two or three look pretty good to me. Let's go,'” said Dr. Hill, director of the ART Reproductive Center in Beverly Hills, Calif. “It was essentially a beauty contest.”

Embryologists are increasingly realizing that chromosomally abnormal embryos can appear to be developing properly and look quite normal at the blastocyst stage. As an example, he showed an embryo at days 3, 4, and 5 that were diagnosed with monosomy 13 using advanced preimplantation genetic diagnosis (PGD) technology.

“Monosomy 13 would never lead to a live birth. But it still can make an absolutely beautiful blastomere. We could easily select that very nice-looking embryo … lowering the implantation rate [for that patient] and possibly leaving a healthy embryo behind.”

Other normal-appearing blastocysts were shown to have trisomy 21 and monosomy 18; trisomy 13; or mosaicism 18.

These days, a five-cocktail probe can test blastocysts for autosomal trisomies such as Down syndrome; autosomal monosomies; X and Y numerical disorders such as Turner's syndrome and Klinefelter's syndrome; and translocations using fluorescent in situ hybridization (FISH).

The classic screen assesses chromosomes 13, 18, 21, X, and Y.

Other chromosomes can be added to the screening panel, and polymerase chain reaction technology can be used to custom-design probes for more than 200 specific hereditary diseases.

The FISH technique potentially extends the usefulness of PGD far beyond couples with a known familial disease to those concerned about miscarriage or birth defects associated with advanced maternal age or a history of recurrent pregnancy loss.

The natural aneuploidy rate in human embryos is very high, Dr. Hill explained.

Recent 5-chromosome panel FISH examinations of embryos from his center's in vitro fertilization program found an aneuploidy rate of 38% among 317 embryos from infertile women aged 37 or younger, 45% among 382 embryos from infertile women aged 38 or older, and 36% of 53 embryos from healthy, fertile ovum donors whose average age was 30.

In PGD, as in traditional in vitro fertilization, embryos are also assessed for morphology and growth before they are transferred. But perhaps because more is known about the chromosomal makeup of transferred embryos, the pregnancy rate following PGD appears to be higher than with normal in vitro fertilization.

Dr. Hill compared pregnancy rates among 441 non-PGD patients and 146 PGD patients who underwent in vitro fertilization at his institution. The average maternal age in both groups was identical, 37.

Although fewer embryos were transferred in PGD cases (2.4 vs.3.1), the pregnancy rate was signficantly higher after PGD (44% vs. 33%).

Among women aged 38 or older, the pregnancy rate was higher for 54 PGD patients, compared with 238 non-PGD patients (37% vs. 30%), although the number of PGD patients was too small for the difference to achieve statistical significance.

The accuracy of PGD-FISH can vary, Dr. Hill and his colleagues have found.

He noted the diagnosis is made from a single cell plucked from a six-cell embryo, and that he and his colleagues are “very conservative when we read the FISH signals.”

Signal overlap or split signals can be misleading, so he says he errs on the side of caution. “Your heart may want you to call it a normal embryo—you want this couple to have a good transfer.” But your head tells you, this is just not suitable.

In limited cases, an embryo with a chromosomal abnormality can self-correct, discarding the incorrect copies of a chromosome. Mosaicism can also occur.

Finally, some abnormalities are more likely than others to be misdiagnosed. Monosomies and trisomies are rarely falsely diagnosed. Recently, 146 embryos diagnosed by FISH as abnormal were studied as their development progressed in Dr. Hill's lab. Further analysis confirmed 122 were abnormal, for a positive predictive value of 83% and a negative predictive value of 81%, he said.

UNIVERSAL CITY, CALIF. — Preimplantation genetic diagnosis is making embryo selection more of a science and less of a blastomere “beauty contest,” David L. Hill, Ph.D., told colleagues at a meeting of the Obstetrical and Gynecological Assembly of Southern California.

“We used to line up all the embryos and say, 'These two or three look pretty good to me. Let's go,'” said Dr. Hill, director of the ART Reproductive Center in Beverly Hills, Calif. “It was essentially a beauty contest.”

Embryologists are increasingly realizing that chromosomally abnormal embryos can appear to be developing properly and look quite normal at the blastocyst stage. As an example, he showed an embryo at days 3, 4, and 5 that were diagnosed with monosomy 13 using advanced preimplantation genetic diagnosis (PGD) technology.

“Monosomy 13 would never lead to a live birth. But it still can make an absolutely beautiful blastomere. We could easily select that very nice-looking embryo … lowering the implantation rate [for that patient] and possibly leaving a healthy embryo behind.”

Other normal-appearing blastocysts were shown to have trisomy 21 and monosomy 18; trisomy 13; or mosaicism 18.

These days, a five-cocktail probe can test blastocysts for autosomal trisomies such as Down syndrome; autosomal monosomies; X and Y numerical disorders such as Turner's syndrome and Klinefelter's syndrome; and translocations using fluorescent in situ hybridization (FISH).

The classic screen assesses chromosomes 13, 18, 21, X, and Y.

Other chromosomes can be added to the screening panel, and polymerase chain reaction technology can be used to custom-design probes for more than 200 specific hereditary diseases.

The FISH technique potentially extends the usefulness of PGD far beyond couples with a known familial disease to those concerned about miscarriage or birth defects associated with advanced maternal age or a history of recurrent pregnancy loss.

The natural aneuploidy rate in human embryos is very high, Dr. Hill explained.

Recent 5-chromosome panel FISH examinations of embryos from his center's in vitro fertilization program found an aneuploidy rate of 38% among 317 embryos from infertile women aged 37 or younger, 45% among 382 embryos from infertile women aged 38 or older, and 36% of 53 embryos from healthy, fertile ovum donors whose average age was 30.

In PGD, as in traditional in vitro fertilization, embryos are also assessed for morphology and growth before they are transferred. But perhaps because more is known about the chromosomal makeup of transferred embryos, the pregnancy rate following PGD appears to be higher than with normal in vitro fertilization.

Dr. Hill compared pregnancy rates among 441 non-PGD patients and 146 PGD patients who underwent in vitro fertilization at his institution. The average maternal age in both groups was identical, 37.

Although fewer embryos were transferred in PGD cases (2.4 vs.3.1), the pregnancy rate was signficantly higher after PGD (44% vs. 33%).

Among women aged 38 or older, the pregnancy rate was higher for 54 PGD patients, compared with 238 non-PGD patients (37% vs. 30%), although the number of PGD patients was too small for the difference to achieve statistical significance.

The accuracy of PGD-FISH can vary, Dr. Hill and his colleagues have found.

He noted the diagnosis is made from a single cell plucked from a six-cell embryo, and that he and his colleagues are “very conservative when we read the FISH signals.”

Signal overlap or split signals can be misleading, so he says he errs on the side of caution. “Your heart may want you to call it a normal embryo—you want this couple to have a good transfer.” But your head tells you, this is just not suitable.

In limited cases, an embryo with a chromosomal abnormality can self-correct, discarding the incorrect copies of a chromosome. Mosaicism can also occur.

Finally, some abnormalities are more likely than others to be misdiagnosed. Monosomies and trisomies are rarely falsely diagnosed. Recently, 146 embryos diagnosed by FISH as abnormal were studied as their development progressed in Dr. Hill's lab. Further analysis confirmed 122 were abnormal, for a positive predictive value of 83% and a negative predictive value of 81%, he said.

Self-injurious behavior in the form of “cutting” may not be as rare as child psychiatrists once believed, nor is it always a red flag for imminent suicide.

Instead, it may be an attempt by a severely disconnected, depressed teenager to gain focus and control, said Michael Jellinek, M.D., chief of child psychiatry at Massachusetts General Hospital in Boston.

“Cutting means different things to different individuals, and it occurs in a variety of settings and circumstances. Often, it's profoundly misunderstood,” Dr. Jellinek told this newspaper.

Child psychiatrists once assumed that cutting was a precursor to suicide. And although this is true in some cases—especially when self-inflicted wounds are deep and in potentially lethal locations—the majority of children and adolescents who purposefully cut themselves do not have an immediate wish or intent to kill themselves.

“I see superficial, repetitive cutting as a behavior that spans a wide spectrum of motivations, from a me-too form of self-expression to a sign of deep emotional pain and dissociation,” he said.

In its most benign form, cutting is an outgrowth of a societal change in which the body is used as a template.

“As technology makes our lives more anonymous, many young people communicate their individuality by using their bodies as canvases,” Dr. Jellinek said. Body piercings or tattoos may represent a spectrum of meaning that ranges from a display of fashion sense to a screaming need for recognition.

For example, piercings may be subtle, as in the piercing of an ear or navel, or extreme, as in multiple piercings involving the face, breasts, and genitals, he explained. Tattoos can be small, unobtrusive designs on the ankle or small of the back, or can constitute an aggressive, bodywide statement that is impossible to cover with clothing.

In this context, superficial decorative cutting may be the self-expression of a fairly untroubled adolescent who is copying a behavior from a more disturbed acquaintance, or a fad—and not necessarily a deviant one—that is followed by a group of friends, said Dr. Jellinek.

He cited a hypothetical patient, Brian, an otherwise well-functioning teenager who, after a sad experience or while very anxious during exam time, makes small cuts on his forearm with the sharp edge of a paper clip to mimic the cutting he's witnessed in a friend with major depression. He might tell other friends about this behavior as a means of seeking reassurance or empathy.

For another hypothetical patient, Maria, cutting may arise from acute depression and self-recrimination. She may have cut herself at a moment when she felt life was not worth living, not to actually take her life but as a suicidal gesture, a cry for help, and a punishment in which the external pain is a substitute for even more overwhelming inner pain.

Meanwhile, another adolescent, Katie, may secretly cut herself in a more serious, repetitive manner. Her wounds may form a pattern. She may cut herself obsessively every day, more deeply each time, hiding scars in various stages of healing as she pulls away from friends and family, drops out of activities, and sees her grades plummet.

It's vital for family physicians to realize that to Brian, Maria, and especially Katie, cutting feels like a solution, not a problem.

The cutting behavior awakens Katie from a disconnected emotional state to which she escapes when she is overwhelmed by despondency, anxiety, and low self-esteem. When she cuts—or even when she experiences the physical pain of a recent wound—she feels focused, appropriately punished, and a bit more in touch with herself. Cutting is something over which she has control.

“If you discover Katie's cutting and react with horror, you will unknowingly add to her sense of shame over a behavior that is the only way she has found to relieve her emotional torment,” Dr. Jellinek advised.

“Instead, if you notice injuries and explain in a nonjudgmental way that you know of teenagers who try to help themselves through difficult times by cutting, she may feel a tremendous sense of relief.”

He recommended that family physicians take the time to explain that they're willing to help the patient try to understand why he or she has chosen cutting as a solution, and what the real problem may be.

“Let her know that you may be able to help her find other alternatives that will help her achieve the same goal: feeling connected, strong, and in control.”

Dr. Jellinek characterized cutting as a highly complex symptom of deeper psychological issues. Sorting out the intrapsychic states of adolescents as they think about cutting and then cut themselves is a difficult task, even for a mental health clinician with experience and training in this area.

He tapped pediatricians and family physicians as important “first responders” who can help by being uncritical, understanding, and open to patients' explanations of their cutting behavior.

“Recognizing the cutting as a solution rather than as the whole problem is a critical first step,” he said.

Self-injurious behavior in the form of “cutting” may not be as rare as child psychiatrists once believed, nor is it always a red flag for imminent suicide.

Instead, it may be an attempt by a severely disconnected, depressed teenager to gain focus and control, said Michael Jellinek, M.D., chief of child psychiatry at Massachusetts General Hospital in Boston.

“Cutting means different things to different individuals, and it occurs in a variety of settings and circumstances. Often, it's profoundly misunderstood,” Dr. Jellinek told this newspaper.

Child psychiatrists once assumed that cutting was a precursor to suicide. And although this is true in some cases—especially when self-inflicted wounds are deep and in potentially lethal locations—the majority of children and adolescents who purposefully cut themselves do not have an immediate wish or intent to kill themselves.

“I see superficial, repetitive cutting as a behavior that spans a wide spectrum of motivations, from a me-too form of self-expression to a sign of deep emotional pain and dissociation,” he said.

In its most benign form, cutting is an outgrowth of a societal change in which the body is used as a template.

“As technology makes our lives more anonymous, many young people communicate their individuality by using their bodies as canvases,” Dr. Jellinek said. Body piercings or tattoos may represent a spectrum of meaning that ranges from a display of fashion sense to a screaming need for recognition.

For example, piercings may be subtle, as in the piercing of an ear or navel, or extreme, as in multiple piercings involving the face, breasts, and genitals, he explained. Tattoos can be small, unobtrusive designs on the ankle or small of the back, or can constitute an aggressive, bodywide statement that is impossible to cover with clothing.

In this context, superficial decorative cutting may be the self-expression of a fairly untroubled adolescent who is copying a behavior from a more disturbed acquaintance, or a fad—and not necessarily a deviant one—that is followed by a group of friends, said Dr. Jellinek.

He cited a hypothetical patient, Brian, an otherwise well-functioning teenager who, after a sad experience or while very anxious during exam time, makes small cuts on his forearm with the sharp edge of a paper clip to mimic the cutting he's witnessed in a friend with major depression. He might tell other friends about this behavior as a means of seeking reassurance or empathy.

For another hypothetical patient, Maria, cutting may arise from acute depression and self-recrimination. She may have cut herself at a moment when she felt life was not worth living, not to actually take her life but as a suicidal gesture, a cry for help, and a punishment in which the external pain is a substitute for even more overwhelming inner pain.

Meanwhile, another adolescent, Katie, may secretly cut herself in a more serious, repetitive manner. Her wounds may form a pattern. She may cut herself obsessively every day, more deeply each time, hiding scars in various stages of healing as she pulls away from friends and family, drops out of activities, and sees her grades plummet.

It's vital for family physicians to realize that to Brian, Maria, and especially Katie, cutting feels like a solution, not a problem.

The cutting behavior awakens Katie from a disconnected emotional state to which she escapes when she is overwhelmed by despondency, anxiety, and low self-esteem. When she cuts—or even when she experiences the physical pain of a recent wound—she feels focused, appropriately punished, and a bit more in touch with herself. Cutting is something over which she has control.

“If you discover Katie's cutting and react with horror, you will unknowingly add to her sense of shame over a behavior that is the only way she has found to relieve her emotional torment,” Dr. Jellinek advised.

“Instead, if you notice injuries and explain in a nonjudgmental way that you know of teenagers who try to help themselves through difficult times by cutting, she may feel a tremendous sense of relief.”

He recommended that family physicians take the time to explain that they're willing to help the patient try to understand why he or she has chosen cutting as a solution, and what the real problem may be.

“Let her know that you may be able to help her find other alternatives that will help her achieve the same goal: feeling connected, strong, and in control.”

Dr. Jellinek characterized cutting as a highly complex symptom of deeper psychological issues. Sorting out the intrapsychic states of adolescents as they think about cutting and then cut themselves is a difficult task, even for a mental health clinician with experience and training in this area.

He tapped pediatricians and family physicians as important “first responders” who can help by being uncritical, understanding, and open to patients' explanations of their cutting behavior.

“Recognizing the cutting as a solution rather than as the whole problem is a critical first step,” he said.

Self-injurious behavior in the form of “cutting” may not be as rare as child psychiatrists once believed, nor is it always a red flag for imminent suicide.

Instead, it may be an attempt by a severely disconnected, depressed teenager to gain focus and control, said Michael Jellinek, M.D., chief of child psychiatry at Massachusetts General Hospital in Boston.

“Cutting means different things to different individuals, and it occurs in a variety of settings and circumstances. Often, it's profoundly misunderstood,” Dr. Jellinek told this newspaper.

Child psychiatrists once assumed that cutting was a precursor to suicide. And although this is true in some cases—especially when self-inflicted wounds are deep and in potentially lethal locations—the majority of children and adolescents who purposefully cut themselves do not have an immediate wish or intent to kill themselves.

“I see superficial, repetitive cutting as a behavior that spans a wide spectrum of motivations, from a me-too form of self-expression to a sign of deep emotional pain and dissociation,” he said.

In its most benign form, cutting is an outgrowth of a societal change in which the body is used as a template.

“As technology makes our lives more anonymous, many young people communicate their individuality by using their bodies as canvases,” Dr. Jellinek said. Body piercings or tattoos may represent a spectrum of meaning that ranges from a display of fashion sense to a screaming need for recognition.

For example, piercings may be subtle, as in the piercing of an ear or navel, or extreme, as in multiple piercings involving the face, breasts, and genitals, he explained. Tattoos can be small, unobtrusive designs on the ankle or small of the back, or can constitute an aggressive, bodywide statement that is impossible to cover with clothing.

In this context, superficial decorative cutting may be the self-expression of a fairly untroubled adolescent who is copying a behavior from a more disturbed acquaintance, or a fad—and not necessarily a deviant one—that is followed by a group of friends, said Dr. Jellinek.

He cited a hypothetical patient, Brian, an otherwise well-functioning teenager who, after a sad experience or while very anxious during exam time, makes small cuts on his forearm with the sharp edge of a paper clip to mimic the cutting he's witnessed in a friend with major depression. He might tell other friends about this behavior as a means of seeking reassurance or empathy.

For another hypothetical patient, Maria, cutting may arise from acute depression and self-recrimination. She may have cut herself at a moment when she felt life was not worth living, not to actually take her life but as a suicidal gesture, a cry for help, and a punishment in which the external pain is a substitute for even more overwhelming inner pain.

Meanwhile, another adolescent, Katie, may secretly cut herself in a more serious, repetitive manner. Her wounds may form a pattern. She may cut herself obsessively every day, more deeply each time, hiding scars in various stages of healing as she pulls away from friends and family, drops out of activities, and sees her grades plummet.

It's vital for family physicians to realize that to Brian, Maria, and especially Katie, cutting feels like a solution, not a problem.

The cutting behavior awakens Katie from a disconnected emotional state to which she escapes when she is overwhelmed by despondency, anxiety, and low self-esteem. When she cuts—or even when she experiences the physical pain of a recent wound—she feels focused, appropriately punished, and a bit more in touch with herself. Cutting is something over which she has control.

“If you discover Katie's cutting and react with horror, you will unknowingly add to her sense of shame over a behavior that is the only way she has found to relieve her emotional torment,” Dr. Jellinek advised.

“Instead, if you notice injuries and explain in a nonjudgmental way that you know of teenagers who try to help themselves through difficult times by cutting, she may feel a tremendous sense of relief.”

He recommended that family physicians take the time to explain that they're willing to help the patient try to understand why he or she has chosen cutting as a solution, and what the real problem may be.

“Let her know that you may be able to help her find other alternatives that will help her achieve the same goal: feeling connected, strong, and in control.”

Dr. Jellinek characterized cutting as a highly complex symptom of deeper psychological issues. Sorting out the intrapsychic states of adolescents as they think about cutting and then cut themselves is a difficult task, even for a mental health clinician with experience and training in this area.

He tapped pediatricians and family physicians as important “first responders” who can help by being uncritical, understanding, and open to patients' explanations of their cutting behavior.

“Recognizing the cutting as a solution rather than as the whole problem is a critical first step,” he said.