Laird Harrison

SAN FRANCISCO – It’s easy to find someone willing to take your money for a brain scan. It’s a lot harder to use these scans in understanding mental illness, according to Dr. Robert L. Hendren.

“We can’t really find the kind of images that can help us make the diagnosis of a mental disorder,” said Dr. Hendren, director of child and adolescent psychiatry at the University of California, San Francisco. Genetic, metabolic, and other kinds of screening for biomarkers are only slightly more useful, he said at the annual meeting of the American Academy of Pediatrics.

It still makes sense to look for biologic causes for mental illness. “Increasingly, we’re finding that disorders like conduct disorder have a neurological, neurodevelopmental etiology,” Dr. Hendren said. After all, brains grow and change as they interact with the environment.

And physicians need better tools for diagnosing such illnesses. Signs and symptoms don’t always fit neatly into the categories laid out in the Diagnostic and Statistical Manual of Mental Disorders.

So researchers have tried MRI and other approaches to look for patterns that might reveal mental illness. They have found some correlations.

And some imaging centers have leaped on these findings to market their services to families of children with mental illness. “You probably are aware of people doing that,” Dr. Hendren said. “Families will pay $3,000 or $4,000 to have these scans performed and shown to them. And then they get recommendations based on a good history that aren’t much different than if the scans had not been done.”

The problem is that researchers have not traced any common diagnosis to a particular site in the brain. Multiple sites may be involved.

Imaging can help only in very specific instances. Among the accepted indications for MRI include microcephaly, macrocephaly, unusual head shapes, regression, or an abnormal neurologic examination.

Some of the same limitations that apply to MRI apply to other types of tests for biomarkers. Researchers have realized that no single gene is responsible for autism, schizophrenia, or most of the other common mental disorders. “We’ve learned that these are very complex disorders with multiple genes involved,” Dr. Hendren said.

But when there is reason to believe genes are involved, genetic testing might be in order. For example, he said some experts recommend a comparative genomic hybridization array for various intellectual disabilities, developmental disorders, and autism. Autistic children also might benefit from further genetic tests, including a test for fragile X, since about 3% have this genetic condition.

Other authorities have recommended a chromosomal microarray for patients with developmental delay, intellectual disabilities, autism spectrum disorder, or multiple congenital anomalies. For patients with clear chromosomal rearrangements – or a family history of these rearrangements, or multiple miscarriages, G-banded karyotyping might be in order, Dr. Hendren said.

Metabolic screening also can yield some information about mental disorders, but is really worthwhile only in patients with clear signs of metabolic disorder, such as a history of lethargy, cyclic vomiting, early seizures, dysmorphisms, mental retardation, or regression. And if these tests are a part of newborn screening – as they often are – there’s no need to repeat them, he said.

Some authorities also recommend a complete blood count for mental disorders. Naturally, other tests, such as thyroid function, serum organic and amino acids, serum lactate and pyruvate, lead screening, iron deficiency, methyl CpG binding protein 2, and Wood’s lamp, might prove helpful when specific conditions are expected,. Most other tests are more controversial.

So while waiting for researchers to find a high-tech solution for diagnosing mental illness, what can physicians do to identify mental illness in their patients? “Evaluation should be guided by in-depth history and family history, and a good physical examination,” Dr. Hendren said.

He said he has received funding for clinical trials from Forest Laboratories, BioMarin, Curemark, the National Institute of Mental Health, and Autism Speaks.

SAN FRANCISCO – It’s easy to find someone willing to take your money for a brain scan. It’s a lot harder to use these scans in understanding mental illness, according to Dr. Robert L. Hendren.

“We can’t really find the kind of images that can help us make the diagnosis of a mental disorder,” said Dr. Hendren, director of child and adolescent psychiatry at the University of California, San Francisco. Genetic, metabolic, and other kinds of screening for biomarkers are only slightly more useful, he said at the annual meeting of the American Academy of Pediatrics.

It still makes sense to look for biologic causes for mental illness. “Increasingly, we’re finding that disorders like conduct disorder have a neurological, neurodevelopmental etiology,” Dr. Hendren said. After all, brains grow and change as they interact with the environment.

And physicians need better tools for diagnosing such illnesses. Signs and symptoms don’t always fit neatly into the categories laid out in the Diagnostic and Statistical Manual of Mental Disorders.

So researchers have tried MRI and other approaches to look for patterns that might reveal mental illness. They have found some correlations.

And some imaging centers have leaped on these findings to market their services to families of children with mental illness. “You probably are aware of people doing that,” Dr. Hendren said. “Families will pay $3,000 or $4,000 to have these scans performed and shown to them. And then they get recommendations based on a good history that aren’t much different than if the scans had not been done.”

The problem is that researchers have not traced any common diagnosis to a particular site in the brain. Multiple sites may be involved.

Imaging can help only in very specific instances. Among the accepted indications for MRI include microcephaly, macrocephaly, unusual head shapes, regression, or an abnormal neurologic examination.

Some of the same limitations that apply to MRI apply to other types of tests for biomarkers. Researchers have realized that no single gene is responsible for autism, schizophrenia, or most of the other common mental disorders. “We’ve learned that these are very complex disorders with multiple genes involved,” Dr. Hendren said.

But when there is reason to believe genes are involved, genetic testing might be in order. For example, he said some experts recommend a comparative genomic hybridization array for various intellectual disabilities, developmental disorders, and autism. Autistic children also might benefit from further genetic tests, including a test for fragile X, since about 3% have this genetic condition.

Other authorities have recommended a chromosomal microarray for patients with developmental delay, intellectual disabilities, autism spectrum disorder, or multiple congenital anomalies. For patients with clear chromosomal rearrangements – or a family history of these rearrangements, or multiple miscarriages, G-banded karyotyping might be in order, Dr. Hendren said.

Metabolic screening also can yield some information about mental disorders, but is really worthwhile only in patients with clear signs of metabolic disorder, such as a history of lethargy, cyclic vomiting, early seizures, dysmorphisms, mental retardation, or regression. And if these tests are a part of newborn screening – as they often are – there’s no need to repeat them, he said.

Some authorities also recommend a complete blood count for mental disorders. Naturally, other tests, such as thyroid function, serum organic and amino acids, serum lactate and pyruvate, lead screening, iron deficiency, methyl CpG binding protein 2, and Wood’s lamp, might prove helpful when specific conditions are expected,. Most other tests are more controversial.

So while waiting for researchers to find a high-tech solution for diagnosing mental illness, what can physicians do to identify mental illness in their patients? “Evaluation should be guided by in-depth history and family history, and a good physical examination,” Dr. Hendren said.

He said he has received funding for clinical trials from Forest Laboratories, BioMarin, Curemark, the National Institute of Mental Health, and Autism Speaks.

SAN FRANCISCO – It’s easy to find someone willing to take your money for a brain scan. It’s a lot harder to use these scans in understanding mental illness, according to Dr. Robert L. Hendren.

“We can’t really find the kind of images that can help us make the diagnosis of a mental disorder,” said Dr. Hendren, director of child and adolescent psychiatry at the University of California, San Francisco. Genetic, metabolic, and other kinds of screening for biomarkers are only slightly more useful, he said at the annual meeting of the American Academy of Pediatrics.

It still makes sense to look for biologic causes for mental illness. “Increasingly, we’re finding that disorders like conduct disorder have a neurological, neurodevelopmental etiology,” Dr. Hendren said. After all, brains grow and change as they interact with the environment.

And physicians need better tools for diagnosing such illnesses. Signs and symptoms don’t always fit neatly into the categories laid out in the Diagnostic and Statistical Manual of Mental Disorders.

So researchers have tried MRI and other approaches to look for patterns that might reveal mental illness. They have found some correlations.

And some imaging centers have leaped on these findings to market their services to families of children with mental illness. “You probably are aware of people doing that,” Dr. Hendren said. “Families will pay $3,000 or $4,000 to have these scans performed and shown to them. And then they get recommendations based on a good history that aren’t much different than if the scans had not been done.”

The problem is that researchers have not traced any common diagnosis to a particular site in the brain. Multiple sites may be involved.

Imaging can help only in very specific instances. Among the accepted indications for MRI include microcephaly, macrocephaly, unusual head shapes, regression, or an abnormal neurologic examination.

Some of the same limitations that apply to MRI apply to other types of tests for biomarkers. Researchers have realized that no single gene is responsible for autism, schizophrenia, or most of the other common mental disorders. “We’ve learned that these are very complex disorders with multiple genes involved,” Dr. Hendren said.

But when there is reason to believe genes are involved, genetic testing might be in order. For example, he said some experts recommend a comparative genomic hybridization array for various intellectual disabilities, developmental disorders, and autism. Autistic children also might benefit from further genetic tests, including a test for fragile X, since about 3% have this genetic condition.

Other authorities have recommended a chromosomal microarray for patients with developmental delay, intellectual disabilities, autism spectrum disorder, or multiple congenital anomalies. For patients with clear chromosomal rearrangements – or a family history of these rearrangements, or multiple miscarriages, G-banded karyotyping might be in order, Dr. Hendren said.

Metabolic screening also can yield some information about mental disorders, but is really worthwhile only in patients with clear signs of metabolic disorder, such as a history of lethargy, cyclic vomiting, early seizures, dysmorphisms, mental retardation, or regression. And if these tests are a part of newborn screening – as they often are – there’s no need to repeat them, he said.

Some authorities also recommend a complete blood count for mental disorders. Naturally, other tests, such as thyroid function, serum organic and amino acids, serum lactate and pyruvate, lead screening, iron deficiency, methyl CpG binding protein 2, and Wood’s lamp, might prove helpful when specific conditions are expected,. Most other tests are more controversial.

So while waiting for researchers to find a high-tech solution for diagnosing mental illness, what can physicians do to identify mental illness in their patients? “Evaluation should be guided by in-depth history and family history, and a good physical examination,” Dr. Hendren said.

He said he has received funding for clinical trials from Forest Laboratories, BioMarin, Curemark, the National Institute of Mental Health, and Autism Speaks.

SAN FRANCISCO – Displaying the influenza immunization status in an electronic clinic workflow tool was one of several factors that led to a 52% increase from 2008-2009 to 2009-2010 in the number of seasonal influenza vaccine doses that were administered in the pediatric primary care unit, according to Dr. Stuart T. Weinberg of the departments of pediatrics and biomedical informatics at Vanderbilt University Medical Center in Nashville, Tenn.

Such systems may become easier to implement because the Food and Drug Administration has announced that it may soon allow manufacturers to apply two-dimensional bar codes to vaccine bottles, Dr. Weinberg said in a presentation on computerizing immunization records at the meeting

The topic is of growing importance as the federal government pushes the use of electronic health records. Physicians and their patients stand to gain from implementing these systems, he said. “We don't do anything unless it improves care.”

At Vanderbilt, administrators added vaccination records to their proprietary EHR system. Now each time a patient registers at the medical center, the system displays information about whether the patient has been vaccinated. “The goal is that when every child comes in, we address the issue,” Dr. Weinberg said.

The Vanderbilt system displays codes in different colors to indicate patients' vaccination status. “We want it to be painfully obvious in the workflow,” he said.

Vaccine manufacturers are helping out by putting more and more information in bar codes on individual vials. At the presentation, Dr. Alice Loveys of the New York eHealth Collaborative demonstrated how easily a bar code reader can read the information and automatically enter it into an EHR.

Currently, the amount of information in the bar code is limited because the codes are linear. If the FDA allows two-dimensional codes, then information such as lot number, expiration date, manufacturer, and brand name might be included.

The codes can be read with inexpensive, commercially available readers that plug into computers' USB ports, said Dr. Loveys, and it is easy to teach staff how to use them. “This is fun technology, but you have to put it in their hands,” she said.

Not only does automatically entering the information save time, it can also reduce human error in transcribing what's written on a container, she said.

Another advantage of computerizing your records is that you can better estimate how much of each vaccine to buy in the future, said Dr. Loveys, who also has a private practice in Rochester, N.Y. Electronic health programs come with algorithms that are designed to do this kind of forecasting.

Complications can ensue when children receive immunizations from more than one institution. Regional data centers are beginning to collect this information, however, so that it can be collated and accessed by child care centers, camps, health centers, schools, and others who need it, the presenters said.

If you are looking to purchase a system, a good place to start is a regional extension center, which can provide advice, said Dr. Loveys, who runs such a center.

Think carefully before making a purchase, she advised. “When I see failed implementation, it's because they didn't spend enough time assessing what their needs are.”

Dr. Weinberg and Dr. Loveys said they had no further disclosures.

SAN FRANCISCO – Displaying the influenza immunization status in an electronic clinic workflow tool was one of several factors that led to a 52% increase from 2008-2009 to 2009-2010 in the number of seasonal influenza vaccine doses that were administered in the pediatric primary care unit, according to Dr. Stuart T. Weinberg of the departments of pediatrics and biomedical informatics at Vanderbilt University Medical Center in Nashville, Tenn.

Such systems may become easier to implement because the Food and Drug Administration has announced that it may soon allow manufacturers to apply two-dimensional bar codes to vaccine bottles, Dr. Weinberg said in a presentation on computerizing immunization records at the meeting

The topic is of growing importance as the federal government pushes the use of electronic health records. Physicians and their patients stand to gain from implementing these systems, he said. “We don't do anything unless it improves care.”

At Vanderbilt, administrators added vaccination records to their proprietary EHR system. Now each time a patient registers at the medical center, the system displays information about whether the patient has been vaccinated. “The goal is that when every child comes in, we address the issue,” Dr. Weinberg said.

The Vanderbilt system displays codes in different colors to indicate patients' vaccination status. “We want it to be painfully obvious in the workflow,” he said.

Vaccine manufacturers are helping out by putting more and more information in bar codes on individual vials. At the presentation, Dr. Alice Loveys of the New York eHealth Collaborative demonstrated how easily a bar code reader can read the information and automatically enter it into an EHR.

Currently, the amount of information in the bar code is limited because the codes are linear. If the FDA allows two-dimensional codes, then information such as lot number, expiration date, manufacturer, and brand name might be included.

The codes can be read with inexpensive, commercially available readers that plug into computers' USB ports, said Dr. Loveys, and it is easy to teach staff how to use them. “This is fun technology, but you have to put it in their hands,” she said.

Not only does automatically entering the information save time, it can also reduce human error in transcribing what's written on a container, she said.

Another advantage of computerizing your records is that you can better estimate how much of each vaccine to buy in the future, said Dr. Loveys, who also has a private practice in Rochester, N.Y. Electronic health programs come with algorithms that are designed to do this kind of forecasting.

Complications can ensue when children receive immunizations from more than one institution. Regional data centers are beginning to collect this information, however, so that it can be collated and accessed by child care centers, camps, health centers, schools, and others who need it, the presenters said.

If you are looking to purchase a system, a good place to start is a regional extension center, which can provide advice, said Dr. Loveys, who runs such a center.

Think carefully before making a purchase, she advised. “When I see failed implementation, it's because they didn't spend enough time assessing what their needs are.”

Dr. Weinberg and Dr. Loveys said they had no further disclosures.

SAN FRANCISCO – Displaying the influenza immunization status in an electronic clinic workflow tool was one of several factors that led to a 52% increase from 2008-2009 to 2009-2010 in the number of seasonal influenza vaccine doses that were administered in the pediatric primary care unit, according to Dr. Stuart T. Weinberg of the departments of pediatrics and biomedical informatics at Vanderbilt University Medical Center in Nashville, Tenn.

Such systems may become easier to implement because the Food and Drug Administration has announced that it may soon allow manufacturers to apply two-dimensional bar codes to vaccine bottles, Dr. Weinberg said in a presentation on computerizing immunization records at the meeting

The topic is of growing importance as the federal government pushes the use of electronic health records. Physicians and their patients stand to gain from implementing these systems, he said. “We don't do anything unless it improves care.”

At Vanderbilt, administrators added vaccination records to their proprietary EHR system. Now each time a patient registers at the medical center, the system displays information about whether the patient has been vaccinated. “The goal is that when every child comes in, we address the issue,” Dr. Weinberg said.

The Vanderbilt system displays codes in different colors to indicate patients' vaccination status. “We want it to be painfully obvious in the workflow,” he said.

Vaccine manufacturers are helping out by putting more and more information in bar codes on individual vials. At the presentation, Dr. Alice Loveys of the New York eHealth Collaborative demonstrated how easily a bar code reader can read the information and automatically enter it into an EHR.

Currently, the amount of information in the bar code is limited because the codes are linear. If the FDA allows two-dimensional codes, then information such as lot number, expiration date, manufacturer, and brand name might be included.

The codes can be read with inexpensive, commercially available readers that plug into computers' USB ports, said Dr. Loveys, and it is easy to teach staff how to use them. “This is fun technology, but you have to put it in their hands,” she said.

Not only does automatically entering the information save time, it can also reduce human error in transcribing what's written on a container, she said.

Another advantage of computerizing your records is that you can better estimate how much of each vaccine to buy in the future, said Dr. Loveys, who also has a private practice in Rochester, N.Y. Electronic health programs come with algorithms that are designed to do this kind of forecasting.

Complications can ensue when children receive immunizations from more than one institution. Regional data centers are beginning to collect this information, however, so that it can be collated and accessed by child care centers, camps, health centers, schools, and others who need it, the presenters said.

If you are looking to purchase a system, a good place to start is a regional extension center, which can provide advice, said Dr. Loveys, who runs such a center.

Think carefully before making a purchase, she advised. “When I see failed implementation, it's because they didn't spend enough time assessing what their needs are.”

Dr. Weinberg and Dr. Loveys said they had no further disclosures.

SAN FRANCISCO – It's hard to grow up in an orphanage – literally. Small stature figures prominently on a growing list of problems that children adopted from abroad bring to the United States, according to two adoption specialists.

“More children are being placed in-country,” said Dr. Elaine Schulte, medical director of the International Adoption Program at the Cleveland Clinic Children's Hospital, one of two speakers who outlined current trends in international adoption at the meeting. “Fewer healthy children are available for international adoption, and families are pushed to accept sicker children.”

The number of foreign adoptions to the United States has dropped roughly in half from 2004 to 2009, when it reached 12,753, according to figures from the U.S. Department of State that were cited by Dr. Schulte.

Those children available are more likely to come with serious medical problems. Among the most common are cleft lip and palate, congenital heart disease, Down syndrome, orthopedic problems, amniotic band deformities, and infectious disease such as hepatitis B and C and HIV.

Only 20% of internationally adopted children have no special medical or developmental issues; in 60%, these problems are mild to moderate and in the rest, severe, Dr. Schulte said.

Even before birth, most of these children suffer from their mother's substance exposures, malnutrition, or stress. After birth, some live through periods of abandonment before being taken into an orphanage.

When they arrive, they often face further malnutrition, abuse, and neglect because even well-intentioned caregivers don't have all the resources the children need, Dr. Schulte said. “These kids don't get talked to,” she said, displaying a photograph of children confined in rows of metal cribs in a barren room. “They lie in bed staring at the ceiling.”

Children coming from foster care generally fare better, but they may have changed homes frequently, leaving them with fear of abandonment.

Families who want to adopt get very little information about the children's backgrounds and health, and are getting even less time than in the past to decide whether to take these children home.

The adoption process itself can lead to health issues. The adopting families may encounter infectious diseases in the general population of the child's country, and they may be infected by the child they are adopting. “I always remind them that they have to take care of themselves,” said Dr. Schulte, herself the mother of two children adopted from China. “What are you going to do if you get sick, and you have to take care of the child?”

For example, 106 out of 100,000 children adopted from abroad carry hepatitis A, compared with 1 in 100,000 in the general population, she said. So the Centers for Disease Control and Prevention now recommends vaccination for this disease for anyone who will have close contact with a child arriving from a country with endemic hepatitis A. Dr. Schulte recommended hepatitis B immunization as well.

With such precautions in mind, the pediatrician should begin counseling the family before the adoption. A physician can help the family interpret whatever health records are available and formulate more questions. Dr. Schulte gave the example of a child whose photograph suggested fetal alcohol syndrome.

The physician also can prepare the family with community resources, such as a referral to an adoption specialist. (The American Academy of Pediatrics has a directory of such specialists.)

Physicians should schedule their first visits with adopted children a week or two after the children arrive home. If it's sooner than that, the parents will be too exhausted and won't have had time to closely observe their new children.

Dr. Schulte advised allowing at least 30 minutes for the appointment, because it's so important to carefully examine the child and query the new parents. The visit can be billed as a 99205 E/M visit.

The second speaker, Dr. Sarah H. Springer, medical director of the International Adoption Health Services of Western Pennsylvania, recommended a wide range of lab tests, including a CBC, lead level, stool test for ova and parasite (O&P) (3), rapid plasma regain (RPR) or VDRL (Venereal Disease Research Laboratory) tests for syphilis, hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (HbsAb), hepatitis B core antibody (HbcAb), hepatitis C virus (HCV), HIV-1 and HIV-2, and a tuberculin skin test (PPD) or an interferon gamma release assay (IGRA) test if the child is older than 5 years of age.

These should be rechecked after 6 months, because some diseases take that long to seroconvert.

Whatever immunization records the child brings are unlikely to meet the AAP and CDC standards. “You can't take anything you get from another country at face value,” said Dr. Springer, who is also with Kids Plus Pediatrics at the University of Pittsburgh Medical Center. One increasingly common exception is immunizations supervised by the U.S. State Department. Even if records do meet standards, the titers should be checked.

Otherwise, you'll often have to start from scratch, using the Red Book catch-up schedule. Note, however, that there is no pertussis coverage for children aged 7-11 years. One alternative is to use Tdap off-label. “You sometimes have to fight with the insurance company,” Dr. Springer said. “They say, 'You gave it at the wrong age.' And you say, 'Would you rather pay for pertussis?'”

Among the common psychosocial issues likely to crop up in this visit are the following:

▸ Malnourished youngsters may hide food in their pockets, their beds, or even their cheeks. They also may eat ravenously. Dr. Schulte's advice: Let them have as much food as they want so that they will lose their fear of scarcity.

▸ Some children are affectionate with everyone because they are so starved for attention. They must learn to distinguish between strangers and family.

▸ Some are stubborn or angry, testing to see whether their new families really want to keep them. Parents must simply insist that they will always be there for these children.

▸ Other children may cling to one parent, crying uncontrollably if left for even a minute. Dr. Schulte advised helping these children by playing with them on the floor until they let go, then getting up to leave, promising to return and fulfilling the promise each time. Caregivers can start with separations of a couple of minutes, then gradually increase the interval.

▸ Adopted children may not sleep well. Because they often fear abandonment, Dr. Schulte advised against using “cry-it-out” technique to teach them good sleep patterns.

▸ Many children rock themselves or display other self-stimulating behavior which they embraced because they did not get any other stimulation.

▸ Internationally adopted kids have elevated rates of schizophrenia, bipolar disease, fetal alcohol syndrome, attention-deficit/hyperactivity disorder (ADHD), and a host of other mental illnesses.

So after that first visit, see the children often. Many will grow swiftly, catching up to their normal height, overcoming emotional challenges, and recovering from illnesses. Others will need years of special education and other support.

Dr. Springer and Dr. Schulte said they had no conflicts of interest to report, but they did discuss an unapproved/investigative use of the Tdap vaccine.

SAN FRANCISCO – It's hard to grow up in an orphanage – literally. Small stature figures prominently on a growing list of problems that children adopted from abroad bring to the United States, according to two adoption specialists.

“More children are being placed in-country,” said Dr. Elaine Schulte, medical director of the International Adoption Program at the Cleveland Clinic Children's Hospital, one of two speakers who outlined current trends in international adoption at the meeting. “Fewer healthy children are available for international adoption, and families are pushed to accept sicker children.”

The number of foreign adoptions to the United States has dropped roughly in half from 2004 to 2009, when it reached 12,753, according to figures from the U.S. Department of State that were cited by Dr. Schulte.

Those children available are more likely to come with serious medical problems. Among the most common are cleft lip and palate, congenital heart disease, Down syndrome, orthopedic problems, amniotic band deformities, and infectious disease such as hepatitis B and C and HIV.

Only 20% of internationally adopted children have no special medical or developmental issues; in 60%, these problems are mild to moderate and in the rest, severe, Dr. Schulte said.

Even before birth, most of these children suffer from their mother's substance exposures, malnutrition, or stress. After birth, some live through periods of abandonment before being taken into an orphanage.

When they arrive, they often face further malnutrition, abuse, and neglect because even well-intentioned caregivers don't have all the resources the children need, Dr. Schulte said. “These kids don't get talked to,” she said, displaying a photograph of children confined in rows of metal cribs in a barren room. “They lie in bed staring at the ceiling.”

Children coming from foster care generally fare better, but they may have changed homes frequently, leaving them with fear of abandonment.

Families who want to adopt get very little information about the children's backgrounds and health, and are getting even less time than in the past to decide whether to take these children home.

The adoption process itself can lead to health issues. The adopting families may encounter infectious diseases in the general population of the child's country, and they may be infected by the child they are adopting. “I always remind them that they have to take care of themselves,” said Dr. Schulte, herself the mother of two children adopted from China. “What are you going to do if you get sick, and you have to take care of the child?”

For example, 106 out of 100,000 children adopted from abroad carry hepatitis A, compared with 1 in 100,000 in the general population, she said. So the Centers for Disease Control and Prevention now recommends vaccination for this disease for anyone who will have close contact with a child arriving from a country with endemic hepatitis A. Dr. Schulte recommended hepatitis B immunization as well.

With such precautions in mind, the pediatrician should begin counseling the family before the adoption. A physician can help the family interpret whatever health records are available and formulate more questions. Dr. Schulte gave the example of a child whose photograph suggested fetal alcohol syndrome.

The physician also can prepare the family with community resources, such as a referral to an adoption specialist. (The American Academy of Pediatrics has a directory of such specialists.)

Physicians should schedule their first visits with adopted children a week or two after the children arrive home. If it's sooner than that, the parents will be too exhausted and won't have had time to closely observe their new children.

Dr. Schulte advised allowing at least 30 minutes for the appointment, because it's so important to carefully examine the child and query the new parents. The visit can be billed as a 99205 E/M visit.

The second speaker, Dr. Sarah H. Springer, medical director of the International Adoption Health Services of Western Pennsylvania, recommended a wide range of lab tests, including a CBC, lead level, stool test for ova and parasite (O&P) (3), rapid plasma regain (RPR) or VDRL (Venereal Disease Research Laboratory) tests for syphilis, hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (HbsAb), hepatitis B core antibody (HbcAb), hepatitis C virus (HCV), HIV-1 and HIV-2, and a tuberculin skin test (PPD) or an interferon gamma release assay (IGRA) test if the child is older than 5 years of age.

These should be rechecked after 6 months, because some diseases take that long to seroconvert.

Whatever immunization records the child brings are unlikely to meet the AAP and CDC standards. “You can't take anything you get from another country at face value,” said Dr. Springer, who is also with Kids Plus Pediatrics at the University of Pittsburgh Medical Center. One increasingly common exception is immunizations supervised by the U.S. State Department. Even if records do meet standards, the titers should be checked.

Otherwise, you'll often have to start from scratch, using the Red Book catch-up schedule. Note, however, that there is no pertussis coverage for children aged 7-11 years. One alternative is to use Tdap off-label. “You sometimes have to fight with the insurance company,” Dr. Springer said. “They say, 'You gave it at the wrong age.' And you say, 'Would you rather pay for pertussis?'”

Among the common psychosocial issues likely to crop up in this visit are the following:

▸ Malnourished youngsters may hide food in their pockets, their beds, or even their cheeks. They also may eat ravenously. Dr. Schulte's advice: Let them have as much food as they want so that they will lose their fear of scarcity.

▸ Some children are affectionate with everyone because they are so starved for attention. They must learn to distinguish between strangers and family.

▸ Some are stubborn or angry, testing to see whether their new families really want to keep them. Parents must simply insist that they will always be there for these children.

▸ Other children may cling to one parent, crying uncontrollably if left for even a minute. Dr. Schulte advised helping these children by playing with them on the floor until they let go, then getting up to leave, promising to return and fulfilling the promise each time. Caregivers can start with separations of a couple of minutes, then gradually increase the interval.

▸ Adopted children may not sleep well. Because they often fear abandonment, Dr. Schulte advised against using “cry-it-out” technique to teach them good sleep patterns.

▸ Many children rock themselves or display other self-stimulating behavior which they embraced because they did not get any other stimulation.

▸ Internationally adopted kids have elevated rates of schizophrenia, bipolar disease, fetal alcohol syndrome, attention-deficit/hyperactivity disorder (ADHD), and a host of other mental illnesses.

So after that first visit, see the children often. Many will grow swiftly, catching up to their normal height, overcoming emotional challenges, and recovering from illnesses. Others will need years of special education and other support.

Dr. Springer and Dr. Schulte said they had no conflicts of interest to report, but they did discuss an unapproved/investigative use of the Tdap vaccine.

SAN FRANCISCO – It's hard to grow up in an orphanage – literally. Small stature figures prominently on a growing list of problems that children adopted from abroad bring to the United States, according to two adoption specialists.

“More children are being placed in-country,” said Dr. Elaine Schulte, medical director of the International Adoption Program at the Cleveland Clinic Children's Hospital, one of two speakers who outlined current trends in international adoption at the meeting. “Fewer healthy children are available for international adoption, and families are pushed to accept sicker children.”

The number of foreign adoptions to the United States has dropped roughly in half from 2004 to 2009, when it reached 12,753, according to figures from the U.S. Department of State that were cited by Dr. Schulte.

Those children available are more likely to come with serious medical problems. Among the most common are cleft lip and palate, congenital heart disease, Down syndrome, orthopedic problems, amniotic band deformities, and infectious disease such as hepatitis B and C and HIV.

Only 20% of internationally adopted children have no special medical or developmental issues; in 60%, these problems are mild to moderate and in the rest, severe, Dr. Schulte said.

Even before birth, most of these children suffer from their mother's substance exposures, malnutrition, or stress. After birth, some live through periods of abandonment before being taken into an orphanage.

When they arrive, they often face further malnutrition, abuse, and neglect because even well-intentioned caregivers don't have all the resources the children need, Dr. Schulte said. “These kids don't get talked to,” she said, displaying a photograph of children confined in rows of metal cribs in a barren room. “They lie in bed staring at the ceiling.”

Children coming from foster care generally fare better, but they may have changed homes frequently, leaving them with fear of abandonment.

Families who want to adopt get very little information about the children's backgrounds and health, and are getting even less time than in the past to decide whether to take these children home.

The adoption process itself can lead to health issues. The adopting families may encounter infectious diseases in the general population of the child's country, and they may be infected by the child they are adopting. “I always remind them that they have to take care of themselves,” said Dr. Schulte, herself the mother of two children adopted from China. “What are you going to do if you get sick, and you have to take care of the child?”

For example, 106 out of 100,000 children adopted from abroad carry hepatitis A, compared with 1 in 100,000 in the general population, she said. So the Centers for Disease Control and Prevention now recommends vaccination for this disease for anyone who will have close contact with a child arriving from a country with endemic hepatitis A. Dr. Schulte recommended hepatitis B immunization as well.

With such precautions in mind, the pediatrician should begin counseling the family before the adoption. A physician can help the family interpret whatever health records are available and formulate more questions. Dr. Schulte gave the example of a child whose photograph suggested fetal alcohol syndrome.

The physician also can prepare the family with community resources, such as a referral to an adoption specialist. (The American Academy of Pediatrics has a directory of such specialists.)

Physicians should schedule their first visits with adopted children a week or two after the children arrive home. If it's sooner than that, the parents will be too exhausted and won't have had time to closely observe their new children.

Dr. Schulte advised allowing at least 30 minutes for the appointment, because it's so important to carefully examine the child and query the new parents. The visit can be billed as a 99205 E/M visit.

The second speaker, Dr. Sarah H. Springer, medical director of the International Adoption Health Services of Western Pennsylvania, recommended a wide range of lab tests, including a CBC, lead level, stool test for ova and parasite (O&P) (3), rapid plasma regain (RPR) or VDRL (Venereal Disease Research Laboratory) tests for syphilis, hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (HbsAb), hepatitis B core antibody (HbcAb), hepatitis C virus (HCV), HIV-1 and HIV-2, and a tuberculin skin test (PPD) or an interferon gamma release assay (IGRA) test if the child is older than 5 years of age.

These should be rechecked after 6 months, because some diseases take that long to seroconvert.

Whatever immunization records the child brings are unlikely to meet the AAP and CDC standards. “You can't take anything you get from another country at face value,” said Dr. Springer, who is also with Kids Plus Pediatrics at the University of Pittsburgh Medical Center. One increasingly common exception is immunizations supervised by the U.S. State Department. Even if records do meet standards, the titers should be checked.

Otherwise, you'll often have to start from scratch, using the Red Book catch-up schedule. Note, however, that there is no pertussis coverage for children aged 7-11 years. One alternative is to use Tdap off-label. “You sometimes have to fight with the insurance company,” Dr. Springer said. “They say, 'You gave it at the wrong age.' And you say, 'Would you rather pay for pertussis?'”

Among the common psychosocial issues likely to crop up in this visit are the following:

▸ Malnourished youngsters may hide food in their pockets, their beds, or even their cheeks. They also may eat ravenously. Dr. Schulte's advice: Let them have as much food as they want so that they will lose their fear of scarcity.

▸ Some children are affectionate with everyone because they are so starved for attention. They must learn to distinguish between strangers and family.

▸ Some are stubborn or angry, testing to see whether their new families really want to keep them. Parents must simply insist that they will always be there for these children.

▸ Other children may cling to one parent, crying uncontrollably if left for even a minute. Dr. Schulte advised helping these children by playing with them on the floor until they let go, then getting up to leave, promising to return and fulfilling the promise each time. Caregivers can start with separations of a couple of minutes, then gradually increase the interval.

▸ Adopted children may not sleep well. Because they often fear abandonment, Dr. Schulte advised against using “cry-it-out” technique to teach them good sleep patterns.

▸ Many children rock themselves or display other self-stimulating behavior which they embraced because they did not get any other stimulation.

▸ Internationally adopted kids have elevated rates of schizophrenia, bipolar disease, fetal alcohol syndrome, attention-deficit/hyperactivity disorder (ADHD), and a host of other mental illnesses.

So after that first visit, see the children often. Many will grow swiftly, catching up to their normal height, overcoming emotional challenges, and recovering from illnesses. Others will need years of special education and other support.

Dr. Springer and Dr. Schulte said they had no conflicts of interest to report, but they did discuss an unapproved/investigative use of the Tdap vaccine.

SAN FRANCISCO – Displaying the influenza immunization status in an electronic clinic workflow tool was one of several factors that led to a 52% increase from 2008-2009 to 2009-2010 in the number of seasonal influenza vaccine doses that were administered in the pediatric primary care unit, according to Dr. Stuart T. Weinberg of the departments of pediatrics and biomedical informatics at Vanderbilt University Medical Center in Nashville, Tenn.

Such systems may become easier to implement because the Food and Drug Administration has announced that it may soon allow manufacturers to apply two-dimensional bar codes to vaccine bottles, Dr. Weinberg said in a presentation on computerizing immunization records at the meeting.

The topic is of growing importance as the federal government pushes the use of electronic health records. Physicians and their patients stand to gain from implementing these systems. “We don't do anything unless it improves care,” he said.

At Vanderbilt, administrators added vaccination records to their proprietary EHR system. Now each time a patient registers at the medical center, the system displays information about whether the patient has been vaccinated. “The goal is that when every child comes in, we address the issue,” Dr. Weinberg said.

The Vanderbilt system displays codes in different colors to indicate patients' vaccination status. “We want it to be painfully obvious in the workflow,” he said.

Vaccine manufacturers are helping out by putting more and more information in bar codes on individual vials. At the presentation, Dr. Alice Loveys of the New York eHealth Collaborative demonstrated how easily a bar code reader can read the information and automatically enter it into an EHR.

Currently, the amount of information in the bar code is limited because the codes are linear. If the FDA allows two-dimensional codes, then information such as lot number, expiration date, manufacturer, and brand name might be included.

The codes can be read with inexpensive, commercially available readers that plug into computers' USB ports, said Dr. Loveys, and it is easy to teach staff how to use them. “This is fun technology, but you have to put it in their hands,” she said.

Not only does automatically entering the information save time, it can also reduce human error in transcribing what's written on a container, she said.

Another advantage of computerizing your records is that you can better estimate how much of each vaccine to buy in the future, said Dr. Loveys, who also has a private practice in Rochester, N.Y. Electronic health programs come with algorithms that are designed to do this kind of forecasting.

Complications can ensue when children receive immunizations from more than one institution. Regional data centers are beginning to collect this information, however, so that it can be collated and accessed by child care centers, camps, health centers, schools, and others who need it, the presenters said.

If you are looking to purchase a system, a good place to start is a regional extension center, which can provide advice, said Dr. Loveys, who runs such a center.

Think carefully before making a purchase, she advised. “When I see failed implementation, it's because they didn't spend enough time assessing what their needs are.”

Dr. Weinberg and Dr. Loveys said that they had no disclosures.

SAN FRANCISCO – Displaying the influenza immunization status in an electronic clinic workflow tool was one of several factors that led to a 52% increase from 2008-2009 to 2009-2010 in the number of seasonal influenza vaccine doses that were administered in the pediatric primary care unit, according to Dr. Stuart T. Weinberg of the departments of pediatrics and biomedical informatics at Vanderbilt University Medical Center in Nashville, Tenn.

Such systems may become easier to implement because the Food and Drug Administration has announced that it may soon allow manufacturers to apply two-dimensional bar codes to vaccine bottles, Dr. Weinberg said in a presentation on computerizing immunization records at the meeting.

The topic is of growing importance as the federal government pushes the use of electronic health records. Physicians and their patients stand to gain from implementing these systems. “We don't do anything unless it improves care,” he said.

At Vanderbilt, administrators added vaccination records to their proprietary EHR system. Now each time a patient registers at the medical center, the system displays information about whether the patient has been vaccinated. “The goal is that when every child comes in, we address the issue,” Dr. Weinberg said.

The Vanderbilt system displays codes in different colors to indicate patients' vaccination status. “We want it to be painfully obvious in the workflow,” he said.

Vaccine manufacturers are helping out by putting more and more information in bar codes on individual vials. At the presentation, Dr. Alice Loveys of the New York eHealth Collaborative demonstrated how easily a bar code reader can read the information and automatically enter it into an EHR.

Currently, the amount of information in the bar code is limited because the codes are linear. If the FDA allows two-dimensional codes, then information such as lot number, expiration date, manufacturer, and brand name might be included.

The codes can be read with inexpensive, commercially available readers that plug into computers' USB ports, said Dr. Loveys, and it is easy to teach staff how to use them. “This is fun technology, but you have to put it in their hands,” she said.

Not only does automatically entering the information save time, it can also reduce human error in transcribing what's written on a container, she said.

Another advantage of computerizing your records is that you can better estimate how much of each vaccine to buy in the future, said Dr. Loveys, who also has a private practice in Rochester, N.Y. Electronic health programs come with algorithms that are designed to do this kind of forecasting.

Complications can ensue when children receive immunizations from more than one institution. Regional data centers are beginning to collect this information, however, so that it can be collated and accessed by child care centers, camps, health centers, schools, and others who need it, the presenters said.

If you are looking to purchase a system, a good place to start is a regional extension center, which can provide advice, said Dr. Loveys, who runs such a center.

Think carefully before making a purchase, she advised. “When I see failed implementation, it's because they didn't spend enough time assessing what their needs are.”

Dr. Weinberg and Dr. Loveys said that they had no disclosures.

SAN FRANCISCO – Displaying the influenza immunization status in an electronic clinic workflow tool was one of several factors that led to a 52% increase from 2008-2009 to 2009-2010 in the number of seasonal influenza vaccine doses that were administered in the pediatric primary care unit, according to Dr. Stuart T. Weinberg of the departments of pediatrics and biomedical informatics at Vanderbilt University Medical Center in Nashville, Tenn.

Such systems may become easier to implement because the Food and Drug Administration has announced that it may soon allow manufacturers to apply two-dimensional bar codes to vaccine bottles, Dr. Weinberg said in a presentation on computerizing immunization records at the meeting.

The topic is of growing importance as the federal government pushes the use of electronic health records. Physicians and their patients stand to gain from implementing these systems. “We don't do anything unless it improves care,” he said.

At Vanderbilt, administrators added vaccination records to their proprietary EHR system. Now each time a patient registers at the medical center, the system displays information about whether the patient has been vaccinated. “The goal is that when every child comes in, we address the issue,” Dr. Weinberg said.

The Vanderbilt system displays codes in different colors to indicate patients' vaccination status. “We want it to be painfully obvious in the workflow,” he said.

Vaccine manufacturers are helping out by putting more and more information in bar codes on individual vials. At the presentation, Dr. Alice Loveys of the New York eHealth Collaborative demonstrated how easily a bar code reader can read the information and automatically enter it into an EHR.

Currently, the amount of information in the bar code is limited because the codes are linear. If the FDA allows two-dimensional codes, then information such as lot number, expiration date, manufacturer, and brand name might be included.

The codes can be read with inexpensive, commercially available readers that plug into computers' USB ports, said Dr. Loveys, and it is easy to teach staff how to use them. “This is fun technology, but you have to put it in their hands,” she said.

Not only does automatically entering the information save time, it can also reduce human error in transcribing what's written on a container, she said.

Another advantage of computerizing your records is that you can better estimate how much of each vaccine to buy in the future, said Dr. Loveys, who also has a private practice in Rochester, N.Y. Electronic health programs come with algorithms that are designed to do this kind of forecasting.

Complications can ensue when children receive immunizations from more than one institution. Regional data centers are beginning to collect this information, however, so that it can be collated and accessed by child care centers, camps, health centers, schools, and others who need it, the presenters said.

If you are looking to purchase a system, a good place to start is a regional extension center, which can provide advice, said Dr. Loveys, who runs such a center.

Think carefully before making a purchase, she advised. “When I see failed implementation, it's because they didn't spend enough time assessing what their needs are.”

Dr. Weinberg and Dr. Loveys said that they had no disclosures.

SAN FRANCISCO – Research on desensitization looks promising, although it’s too early to offer it as a treatment for food allergies, according to Dr. Wesley Burks, chief of pediatric allergy and immunology at Duke University Medical Center, Durham, N.C.

In ongoing trials on patients with peanut allergies, researchers have administered gradually increasing doses of peanut flour and found that many patients can eventually consume peanuts without harm. What remains to be seen is how long this effect can last. "Can you develop tolerance from desensitization?" Dr. Burks asked at a plenary session at the meeting.

The question is important because food allergies have increased 18% from 1997 to 2007 and now affect 3.9% of all school-age children, according to the National Center for Health Statistics, Dr. Burks said.

The most common allergies are to milk, eggs, peanuts, tree nuts, shellfish, soy, and wheat, with peanuts allergy afflicting about one in a hundred kids. Peanut allergy is the most common cause of fatal food anaphylaxis.

Currently there is no way to cure patients of their allergies, although some children outgrow them. "The treatment is exclusion of only those foods that they are allergic to, not food groups," said Dr. Burks. Patients experiencing allergic reactions can be helped with self-injectable epinephrine and antihistamines.

One useful treatment undergoing research is anti-immunoglobulin. While it seems to help, it’s a long way from solving the problem. "Some people do not respond," said Dr. Burks. "It will be used as an adjunct." Also in the pipeline are some promising extracts of herbs used in traditional Chinese medicine. Finally, engineered recombinant proteins that might reduce immunoglobulin binding are also being researched.

For the desensitization studies, Dr. Burks and others are working on two routes of administering small amounts of the allergen: oral (swallowed with food) and sublingual (in which the allergen is placed under the tongue, where it dissolves and is absorbed). So far, the oral route has proved more effective in achieving desensitization.

In one blinded trial of the oral route, the patients started with 6 mg of peanut flour, then gradually worked up to 4,000 mg or more. (A whole peanut is 300 mg.)

The study enrolled 25 subjects, of which 16 were given peanut flour and 9 a placebo. The researchers found that the patients who had taken the flour were able to tolerate 5,000 mg at the end of the study, while the patients who had had only the placebo could tolerate less than 1,000 mg, a statistically significant difference (P = .008). "So the desensitization effect appears to be real," said Dr. Burks.

Of children who have been on the therapy for longer than 3 years, about 48% have been able to go off treatment and continue to meet a food challenge. By comparison, only about 10% or 15% of children would have outgrown the allergies during this time period. Another 32% had significantly lower peanut IgE levels and are still on treatment; they have not reached an IgE level low enough so they could they could be challenged. Around 20% of children, however, could not tolerate the treatment because of gastrointestinal effects.

The study revealed some interesting information about the etiology of food allergies. Immunoglobulin and regulatory T cells both increased until the 12th month of the study, then decreased. Proallergic peanut-specific cytokines decreased, while regulatory peanut-specific cytokines increased.

These trials continue, as Dr. Burks and his colleagues try to learn more about these biochemical reactions and conduct longer-term trials in search of an actual cure. Many families are clamoring for desensitization treatment because the allergies are such a burden, but they must be counseled that it’s still in the experimental stages.

"The right thing to do right now is appropriate diagnosis, and [then develop] a treatment and management plan," said Dr. Burks.

Dr. Burks disclosed he is on the advisory board of the Dannon Company Inc.; he is a consultant for McNeil Nutritionals LLC and Novartis; he has served on an expert panel for Nutricia; and he has received grants from the National Institutes of Health, the Food Allergy and Anaphylaxis Network, the Food Allergy Initiative, the Food Allergy Project, and the Wallace Research Foundation.

SAN FRANCISCO – Research on desensitization looks promising, although it’s too early to offer it as a treatment for food allergies, according to Dr. Wesley Burks, chief of pediatric allergy and immunology at Duke University Medical Center, Durham, N.C.

In ongoing trials on patients with peanut allergies, researchers have administered gradually increasing doses of peanut flour and found that many patients can eventually consume peanuts without harm. What remains to be seen is how long this effect can last. "Can you develop tolerance from desensitization?" Dr. Burks asked at a plenary session at the meeting.

The question is important because food allergies have increased 18% from 1997 to 2007 and now affect 3.9% of all school-age children, according to the National Center for Health Statistics, Dr. Burks said.

The most common allergies are to milk, eggs, peanuts, tree nuts, shellfish, soy, and wheat, with peanuts allergy afflicting about one in a hundred kids. Peanut allergy is the most common cause of fatal food anaphylaxis.

Currently there is no way to cure patients of their allergies, although some children outgrow them. "The treatment is exclusion of only those foods that they are allergic to, not food groups," said Dr. Burks. Patients experiencing allergic reactions can be helped with self-injectable epinephrine and antihistamines.

One useful treatment undergoing research is anti-immunoglobulin. While it seems to help, it’s a long way from solving the problem. "Some people do not respond," said Dr. Burks. "It will be used as an adjunct." Also in the pipeline are some promising extracts of herbs used in traditional Chinese medicine. Finally, engineered recombinant proteins that might reduce immunoglobulin binding are also being researched.

For the desensitization studies, Dr. Burks and others are working on two routes of administering small amounts of the allergen: oral (swallowed with food) and sublingual (in which the allergen is placed under the tongue, where it dissolves and is absorbed). So far, the oral route has proved more effective in achieving desensitization.

In one blinded trial of the oral route, the patients started with 6 mg of peanut flour, then gradually worked up to 4,000 mg or more. (A whole peanut is 300 mg.)

The study enrolled 25 subjects, of which 16 were given peanut flour and 9 a placebo. The researchers found that the patients who had taken the flour were able to tolerate 5,000 mg at the end of the study, while the patients who had had only the placebo could tolerate less than 1,000 mg, a statistically significant difference (P = .008). "So the desensitization effect appears to be real," said Dr. Burks.

Of children who have been on the therapy for longer than 3 years, about 48% have been able to go off treatment and continue to meet a food challenge. By comparison, only about 10% or 15% of children would have outgrown the allergies during this time period. Another 32% had significantly lower peanut IgE levels and are still on treatment; they have not reached an IgE level low enough so they could they could be challenged. Around 20% of children, however, could not tolerate the treatment because of gastrointestinal effects.

The study revealed some interesting information about the etiology of food allergies. Immunoglobulin and regulatory T cells both increased until the 12th month of the study, then decreased. Proallergic peanut-specific cytokines decreased, while regulatory peanut-specific cytokines increased.

These trials continue, as Dr. Burks and his colleagues try to learn more about these biochemical reactions and conduct longer-term trials in search of an actual cure. Many families are clamoring for desensitization treatment because the allergies are such a burden, but they must be counseled that it’s still in the experimental stages.

"The right thing to do right now is appropriate diagnosis, and [then develop] a treatment and management plan," said Dr. Burks.

Dr. Burks disclosed he is on the advisory board of the Dannon Company Inc.; he is a consultant for McNeil Nutritionals LLC and Novartis; he has served on an expert panel for Nutricia; and he has received grants from the National Institutes of Health, the Food Allergy and Anaphylaxis Network, the Food Allergy Initiative, the Food Allergy Project, and the Wallace Research Foundation.

SAN FRANCISCO – Research on desensitization looks promising, although it’s too early to offer it as a treatment for food allergies, according to Dr. Wesley Burks, chief of pediatric allergy and immunology at Duke University Medical Center, Durham, N.C.

In ongoing trials on patients with peanut allergies, researchers have administered gradually increasing doses of peanut flour and found that many patients can eventually consume peanuts without harm. What remains to be seen is how long this effect can last. "Can you develop tolerance from desensitization?" Dr. Burks asked at a plenary session at the meeting.

The question is important because food allergies have increased 18% from 1997 to 2007 and now affect 3.9% of all school-age children, according to the National Center for Health Statistics, Dr. Burks said.

The most common allergies are to milk, eggs, peanuts, tree nuts, shellfish, soy, and wheat, with peanuts allergy afflicting about one in a hundred kids. Peanut allergy is the most common cause of fatal food anaphylaxis.

Currently there is no way to cure patients of their allergies, although some children outgrow them. "The treatment is exclusion of only those foods that they are allergic to, not food groups," said Dr. Burks. Patients experiencing allergic reactions can be helped with self-injectable epinephrine and antihistamines.

One useful treatment undergoing research is anti-immunoglobulin. While it seems to help, it’s a long way from solving the problem. "Some people do not respond," said Dr. Burks. "It will be used as an adjunct." Also in the pipeline are some promising extracts of herbs used in traditional Chinese medicine. Finally, engineered recombinant proteins that might reduce immunoglobulin binding are also being researched.

For the desensitization studies, Dr. Burks and others are working on two routes of administering small amounts of the allergen: oral (swallowed with food) and sublingual (in which the allergen is placed under the tongue, where it dissolves and is absorbed). So far, the oral route has proved more effective in achieving desensitization.

In one blinded trial of the oral route, the patients started with 6 mg of peanut flour, then gradually worked up to 4,000 mg or more. (A whole peanut is 300 mg.)

The study enrolled 25 subjects, of which 16 were given peanut flour and 9 a placebo. The researchers found that the patients who had taken the flour were able to tolerate 5,000 mg at the end of the study, while the patients who had had only the placebo could tolerate less than 1,000 mg, a statistically significant difference (P = .008). "So the desensitization effect appears to be real," said Dr. Burks.

Of children who have been on the therapy for longer than 3 years, about 48% have been able to go off treatment and continue to meet a food challenge. By comparison, only about 10% or 15% of children would have outgrown the allergies during this time period. Another 32% had significantly lower peanut IgE levels and are still on treatment; they have not reached an IgE level low enough so they could they could be challenged. Around 20% of children, however, could not tolerate the treatment because of gastrointestinal effects.

The study revealed some interesting information about the etiology of food allergies. Immunoglobulin and regulatory T cells both increased until the 12th month of the study, then decreased. Proallergic peanut-specific cytokines decreased, while regulatory peanut-specific cytokines increased.

These trials continue, as Dr. Burks and his colleagues try to learn more about these biochemical reactions and conduct longer-term trials in search of an actual cure. Many families are clamoring for desensitization treatment because the allergies are such a burden, but they must be counseled that it’s still in the experimental stages.

"The right thing to do right now is appropriate diagnosis, and [then develop] a treatment and management plan," said Dr. Burks.

Dr. Burks disclosed he is on the advisory board of the Dannon Company Inc.; he is a consultant for McNeil Nutritionals LLC and Novartis; he has served on an expert panel for Nutricia; and he has received grants from the National Institutes of Health, the Food Allergy and Anaphylaxis Network, the Food Allergy Initiative, the Food Allergy Project, and the Wallace Research Foundation.

SAN FRANCISCO – Intraoperative neurophysiologic monitoring techniques may require modification for moyamoya disease because of a lack of sensitivity for new strokes, according to a retrospective study of 700 moyamoya revascularization cases.

The monitoring caught only 4 of 29 new strokes during procedures on 435 patients, said Dr. Viet Nguyen, a neurologist at Stanford (Calif.) University.

Intraoperative neurophysiologic monitoring (IONM) can help detect ischemia or hemorrhage during procedures in which patients cannot communicate sensations like numbness and tingling. But until now, no one had specifically examined how well it works in surgery for moyamoya disease.

Dr. Nguyen and his colleagues studied the effectiveness of IONM that was performed during superficial temporal artery–middle cerebral artery anastomosis or encephaloduroarteriosynangiosis.

For the monitoring, the researchers used bilateral upper-extremity somatosensory-evoked potentials (SSEPs) and eight-lead parasagittal scalp EEG.

They recorded postoperative events, including new strokes, new hemorrhages within the first postoperative day, and transient neurological events. They defined transient neurological events as postoperative symptoms that lasted longer than 24 hours but resolved completely and without new infarcts on MRI.

They defined permanent IONM changes as those that lasted through the end of monitoring. Transient IONM changes were those that resolved during the monitoring.

Three of the cases had intracerebral hemorrhage in the first postoperative day, but only one of these incidents caused a change in the IONM.

Transient IONM changes occurred in 19 cases. Most of these were speech or facial deficits that fluctuated over days without correlating infarcts detected by imaging. The IONM picked up a change in only one of these incidents.

These findings led the investigators to conclude that IONM is not adequately sensitive in moyamoya surgery.

On the other hand, the monitoring had 100% specificity.

"If we saw a permanent change, it indicated something bad was going to happen," Dr. Nguyen said.

Each of the four permanent changes they recorded was correlated with a serious event (three strokes and a hemorrhage). In contrast, only 2 of the 19 temporary IONM changes correlated with a postoperative event. These included one stroke and one transient neurological event.

One reason for the reduced sensitivity might be the difficulty of placing electrodes properly around the surgical site. Also, the criterion that was used to define an official drop in SSEPs – a decrease in the amplitude to less than 50% of baseline levels – might have been too high to detect mild ischemia. The surgeons’ interventions, such as increasing the median arterial pressure or unocclusion of the middle cerebral artery (MCA) distal branch following anastomosis to an extracranial artery, also might have reversed the IONM change while also averting a pending infarction, the investigators concluded.

The researchers had expected that the events would mostly come during the occlusion of the MCA, but they found that the IONM changes could occur during any part of the case. "We found that [occluding the MCA] was not the riskiest part of the procedure," Dr. Nguyen said.

He suggested that future research should include monitoring for ischemic changes in a broader territory, not just the area around the site of the procedure.

None of the investigators had relevant disclosures.

SAN FRANCISCO – Intraoperative neurophysiologic monitoring techniques may require modification for moyamoya disease because of a lack of sensitivity for new strokes, according to a retrospective study of 700 moyamoya revascularization cases.

The monitoring caught only 4 of 29 new strokes during procedures on 435 patients, said Dr. Viet Nguyen, a neurologist at Stanford (Calif.) University.

Intraoperative neurophysiologic monitoring (IONM) can help detect ischemia or hemorrhage during procedures in which patients cannot communicate sensations like numbness and tingling. But until now, no one had specifically examined how well it works in surgery for moyamoya disease.

Dr. Nguyen and his colleagues studied the effectiveness of IONM that was performed during superficial temporal artery–middle cerebral artery anastomosis or encephaloduroarteriosynangiosis.

For the monitoring, the researchers used bilateral upper-extremity somatosensory-evoked potentials (SSEPs) and eight-lead parasagittal scalp EEG.

They recorded postoperative events, including new strokes, new hemorrhages within the first postoperative day, and transient neurological events. They defined transient neurological events as postoperative symptoms that lasted longer than 24 hours but resolved completely and without new infarcts on MRI.

They defined permanent IONM changes as those that lasted through the end of monitoring. Transient IONM changes were those that resolved during the monitoring.

Three of the cases had intracerebral hemorrhage in the first postoperative day, but only one of these incidents caused a change in the IONM.

Transient IONM changes occurred in 19 cases. Most of these were speech or facial deficits that fluctuated over days without correlating infarcts detected by imaging. The IONM picked up a change in only one of these incidents.

These findings led the investigators to conclude that IONM is not adequately sensitive in moyamoya surgery.

On the other hand, the monitoring had 100% specificity.

"If we saw a permanent change, it indicated something bad was going to happen," Dr. Nguyen said.

Each of the four permanent changes they recorded was correlated with a serious event (three strokes and a hemorrhage). In contrast, only 2 of the 19 temporary IONM changes correlated with a postoperative event. These included one stroke and one transient neurological event.

One reason for the reduced sensitivity might be the difficulty of placing electrodes properly around the surgical site. Also, the criterion that was used to define an official drop in SSEPs – a decrease in the amplitude to less than 50% of baseline levels – might have been too high to detect mild ischemia. The surgeons’ interventions, such as increasing the median arterial pressure or unocclusion of the middle cerebral artery (MCA) distal branch following anastomosis to an extracranial artery, also might have reversed the IONM change while also averting a pending infarction, the investigators concluded.

The researchers had expected that the events would mostly come during the occlusion of the MCA, but they found that the IONM changes could occur during any part of the case. "We found that [occluding the MCA] was not the riskiest part of the procedure," Dr. Nguyen said.

He suggested that future research should include monitoring for ischemic changes in a broader territory, not just the area around the site of the procedure.

None of the investigators had relevant disclosures.

SAN FRANCISCO – Intraoperative neurophysiologic monitoring techniques may require modification for moyamoya disease because of a lack of sensitivity for new strokes, according to a retrospective study of 700 moyamoya revascularization cases.

The monitoring caught only 4 of 29 new strokes during procedures on 435 patients, said Dr. Viet Nguyen, a neurologist at Stanford (Calif.) University.

Intraoperative neurophysiologic monitoring (IONM) can help detect ischemia or hemorrhage during procedures in which patients cannot communicate sensations like numbness and tingling. But until now, no one had specifically examined how well it works in surgery for moyamoya disease.

Dr. Nguyen and his colleagues studied the effectiveness of IONM that was performed during superficial temporal artery–middle cerebral artery anastomosis or encephaloduroarteriosynangiosis.

For the monitoring, the researchers used bilateral upper-extremity somatosensory-evoked potentials (SSEPs) and eight-lead parasagittal scalp EEG.

They recorded postoperative events, including new strokes, new hemorrhages within the first postoperative day, and transient neurological events. They defined transient neurological events as postoperative symptoms that lasted longer than 24 hours but resolved completely and without new infarcts on MRI.

They defined permanent IONM changes as those that lasted through the end of monitoring. Transient IONM changes were those that resolved during the monitoring.

Three of the cases had intracerebral hemorrhage in the first postoperative day, but only one of these incidents caused a change in the IONM.

Transient IONM changes occurred in 19 cases. Most of these were speech or facial deficits that fluctuated over days without correlating infarcts detected by imaging. The IONM picked up a change in only one of these incidents.

These findings led the investigators to conclude that IONM is not adequately sensitive in moyamoya surgery.

On the other hand, the monitoring had 100% specificity.

"If we saw a permanent change, it indicated something bad was going to happen," Dr. Nguyen said.

Each of the four permanent changes they recorded was correlated with a serious event (three strokes and a hemorrhage). In contrast, only 2 of the 19 temporary IONM changes correlated with a postoperative event. These included one stroke and one transient neurological event.

One reason for the reduced sensitivity might be the difficulty of placing electrodes properly around the surgical site. Also, the criterion that was used to define an official drop in SSEPs – a decrease in the amplitude to less than 50% of baseline levels – might have been too high to detect mild ischemia. The surgeons’ interventions, such as increasing the median arterial pressure or unocclusion of the middle cerebral artery (MCA) distal branch following anastomosis to an extracranial artery, also might have reversed the IONM change while also averting a pending infarction, the investigators concluded.

The researchers had expected that the events would mostly come during the occlusion of the MCA, but they found that the IONM changes could occur during any part of the case. "We found that [occluding the MCA] was not the riskiest part of the procedure," Dr. Nguyen said.

He suggested that future research should include monitoring for ischemic changes in a broader territory, not just the area around the site of the procedure.

None of the investigators had relevant disclosures.

SAN FRANCISCO – Arterial spin labeling magnetic resonance imaging is much faster than and nearly as accurate as single-photon emission computed tomography for measuring blood flow in carotid stenosis, according to researchers from Kobe (Japan) University and Philips Healthcare Japan.

“It can be an alternative way to show stenosis with less invasiveness and cost,” said Dr. Yoshito Uchihashi, a neurosurgeon at the university who presented a poster on the topic at the annual meeting of the Congress of Neurological Surgeons.

Single-photon emission computed tomography (SPECT) is considered effective for measuring cerebral blood flow, but it requires the injection of a gamma-emitting radionuclide as a tracer into the patient’s bloodstream. A gamma camera detects the radiation from the radionuclide, and a computer uses a tomographic reconstruction to produce a three-dimensional image that shows blood circulation.

By contrast, in arterial spin labeling (ASL), a tracer is produced without injection by applying a 180-degree radiofrequency inversion pulse. This inverts the net magnetization of water molecules in the blood, effectively “labeling” them. As these molecules flow into areas of interest, their inverted spin reduces the total tissue magnetization, and “tag” images are made of these areas by MRI.

This image is compared with a control image that was made without labeling. The tag image is subtracted from the control image to create a perfusion image that shows the blood flow in each MRI slice.

To assess the effectiveness of ASL for carotid stenosis, Dr. Uchihashi and his colleagues used it to scan the cerebral blood flow of 20 healthy volunteers as a baseline. Then they repeated the imaging technique on 20 carotid stenosis patients who had undergone 123I-IMP-SPECT within the previous 3 days. The investigators used the techniques to predict the risk of hyperperfusion after carotid revascularization. They also assessed the patients’ vasoreactivity to acetazolamide using both imaging techniques. The scans of 12 surgically treated patients were made both before and after their operation.

To quantify their ASL results, they used quantitative STAR (signal targeting with alternating radiofrequency) labeling of arterial regions, a technique called QUASAR.

They found that ASL picked up a significant difference between the mean cerebral blood flow in the gray matter of the control volunteers and the carotid stenosis patients (P = .015).

Measurements of cerebral blood flow with the two imaging techniques were tightly correlated. ASL was equivalent to SPECT in detecting hypoperfusion, impaired vasoreactivity, and postoperative hyperfusion.

Dr. Uchihashi and his colleagues reported that the only weakness of ASL was that it tended to overestimate cerebral blood flow values, especially in regions with high perfusion.

On the other hand, ASL is much faster than SPECT, said Dr. Uchihashi. “The patient is only in bed for 6 minutes,” he said. By contrast, SPECT can take half an hour.

Dr. Uchihashi said he had nothing to disclose. One of his coauthors is an employee of Philips Healthcare Japan, the maker of the MRI scanner used in the study.

SAN FRANCISCO – Arterial spin labeling magnetic resonance imaging is much faster than and nearly as accurate as single-photon emission computed tomography for measuring blood flow in carotid stenosis, according to researchers from Kobe (Japan) University and Philips Healthcare Japan.

“It can be an alternative way to show stenosis with less invasiveness and cost,” said Dr. Yoshito Uchihashi, a neurosurgeon at the university who presented a poster on the topic at the annual meeting of the Congress of Neurological Surgeons.

Single-photon emission computed tomography (SPECT) is considered effective for measuring cerebral blood flow, but it requires the injection of a gamma-emitting radionuclide as a tracer into the patient’s bloodstream. A gamma camera detects the radiation from the radionuclide, and a computer uses a tomographic reconstruction to produce a three-dimensional image that shows blood circulation.

By contrast, in arterial spin labeling (ASL), a tracer is produced without injection by applying a 180-degree radiofrequency inversion pulse. This inverts the net magnetization of water molecules in the blood, effectively “labeling” them. As these molecules flow into areas of interest, their inverted spin reduces the total tissue magnetization, and “tag” images are made of these areas by MRI.

This image is compared with a control image that was made without labeling. The tag image is subtracted from the control image to create a perfusion image that shows the blood flow in each MRI slice.

To assess the effectiveness of ASL for carotid stenosis, Dr. Uchihashi and his colleagues used it to scan the cerebral blood flow of 20 healthy volunteers as a baseline. Then they repeated the imaging technique on 20 carotid stenosis patients who had undergone 123I-IMP-SPECT within the previous 3 days. The investigators used the techniques to predict the risk of hyperperfusion after carotid revascularization. They also assessed the patients’ vasoreactivity to acetazolamide using both imaging techniques. The scans of 12 surgically treated patients were made both before and after their operation.

To quantify their ASL results, they used quantitative STAR (signal targeting with alternating radiofrequency) labeling of arterial regions, a technique called QUASAR.

They found that ASL picked up a significant difference between the mean cerebral blood flow in the gray matter of the control volunteers and the carotid stenosis patients (P = .015).

Measurements of cerebral blood flow with the two imaging techniques were tightly correlated. ASL was equivalent to SPECT in detecting hypoperfusion, impaired vasoreactivity, and postoperative hyperfusion.

Dr. Uchihashi and his colleagues reported that the only weakness of ASL was that it tended to overestimate cerebral blood flow values, especially in regions with high perfusion.

On the other hand, ASL is much faster than SPECT, said Dr. Uchihashi. “The patient is only in bed for 6 minutes,” he said. By contrast, SPECT can take half an hour.

Dr. Uchihashi said he had nothing to disclose. One of his coauthors is an employee of Philips Healthcare Japan, the maker of the MRI scanner used in the study.

SAN FRANCISCO – Arterial spin labeling magnetic resonance imaging is much faster than and nearly as accurate as single-photon emission computed tomography for measuring blood flow in carotid stenosis, according to researchers from Kobe (Japan) University and Philips Healthcare Japan.

“It can be an alternative way to show stenosis with less invasiveness and cost,” said Dr. Yoshito Uchihashi, a neurosurgeon at the university who presented a poster on the topic at the annual meeting of the Congress of Neurological Surgeons.

Single-photon emission computed tomography (SPECT) is considered effective for measuring cerebral blood flow, but it requires the injection of a gamma-emitting radionuclide as a tracer into the patient’s bloodstream. A gamma camera detects the radiation from the radionuclide, and a computer uses a tomographic reconstruction to produce a three-dimensional image that shows blood circulation.

By contrast, in arterial spin labeling (ASL), a tracer is produced without injection by applying a 180-degree radiofrequency inversion pulse. This inverts the net magnetization of water molecules in the blood, effectively “labeling” them. As these molecules flow into areas of interest, their inverted spin reduces the total tissue magnetization, and “tag” images are made of these areas by MRI.

This image is compared with a control image that was made without labeling. The tag image is subtracted from the control image to create a perfusion image that shows the blood flow in each MRI slice.

To assess the effectiveness of ASL for carotid stenosis, Dr. Uchihashi and his colleagues used it to scan the cerebral blood flow of 20 healthy volunteers as a baseline. Then they repeated the imaging technique on 20 carotid stenosis patients who had undergone 123I-IMP-SPECT within the previous 3 days. The investigators used the techniques to predict the risk of hyperperfusion after carotid revascularization. They also assessed the patients’ vasoreactivity to acetazolamide using both imaging techniques. The scans of 12 surgically treated patients were made both before and after their operation.

To quantify their ASL results, they used quantitative STAR (signal targeting with alternating radiofrequency) labeling of arterial regions, a technique called QUASAR.

They found that ASL picked up a significant difference between the mean cerebral blood flow in the gray matter of the control volunteers and the carotid stenosis patients (P = .015).

Measurements of cerebral blood flow with the two imaging techniques were tightly correlated. ASL was equivalent to SPECT in detecting hypoperfusion, impaired vasoreactivity, and postoperative hyperfusion.

Dr. Uchihashi and his colleagues reported that the only weakness of ASL was that it tended to overestimate cerebral blood flow values, especially in regions with high perfusion.

On the other hand, ASL is much faster than SPECT, said Dr. Uchihashi. “The patient is only in bed for 6 minutes,” he said. By contrast, SPECT can take half an hour.

Dr. Uchihashi said he had nothing to disclose. One of his coauthors is an employee of Philips Healthcare Japan, the maker of the MRI scanner used in the study.

SAN FRANCISCO – Arterial spin labeling magnetic resonance imaging is much faster than and nearly as accurate as single-photon emission computed tomography for measuring blood flow in carotid stenosis, according to researchers from Kobe (Japan) University and Philips Healthcare Japan.

“It can be an alternative way to show stenosis with less invasiveness and cost,” said Dr. Yoshito Uchihashi, a neurosurgeon at the university who presented a poster on the topic at the annual meeting of the Congress of Neurological Surgeons.

Single-photon emission computed tomography (SPECT) is considered effective for measuring cerebral blood flow, but it requires the injection of a gamma-emitting radionuclide as a tracer into the patient’s bloodstream. A gamma camera detects the radiation from the radionuclide, and a computer uses a tomographic reconstruction to produce a three-dimensional image that shows blood circulation.

By contrast, in arterial spin labeling (ASL), a tracer is produced without injection by applying a 180-degree radiofrequency inversion pulse. This inverts the net magnetization of water molecules in the blood, effectively “labeling” them. As these molecules flow into areas of interest, their inverted spin reduces the total tissue magnetization, and “tag” images are made of these areas by MRI.

This image is compared with a control image that was made without labeling. The tag image is subtracted from the control image to create a perfusion image that shows the blood flow in each MRI slice.

To assess the effectiveness of ASL for carotid stenosis, Dr. Uchihashi and his colleagues used it to scan the cerebral blood flow of 20 healthy volunteers as a baseline. Then they repeated the imaging technique on 20 carotid stenosis patients who had undergone 123I-IMP-SPECT within the previous 3 days. The investigators used the techniques to predict the risk of hyperperfusion after carotid revascularization. They also assessed the patients’ vasoreactivity to acetazolamide using both imaging techniques. The scans of 12 surgically treated patients were made both before and after their operation.

To quantify their ASL results, they used quantitative STAR (signal targeting with alternating radiofrequency) labeling of arterial regions, a technique called QUASAR.

They found that ASL picked up a significant difference between the mean cerebral blood flow in the gray matter of the control volunteers and the carotid stenosis patients (P = .015).

Measurements of cerebral blood flow with the two imaging techniques were tightly correlated. ASL was equivalent to SPECT in detecting hypoperfusion, impaired vasoreactivity, and postoperative hyperfusion.

Dr. Uchihashi and his colleagues reported that the only weakness of ASL was that it tended to overestimate cerebral blood flow values, especially in regions with high perfusion.

On the other hand, ASL is much faster than SPECT, said Dr. Uchihashi. “The patient is only in bed for 6 minutes,” he said. By contrast, SPECT can take half an hour.

Dr. Uchihashi said he had nothing to disclose. One of his coauthors is an employee of Philips Healthcare Japan, the maker of the MRI scanner used in the study.

SAN FRANCISCO – Arterial spin labeling magnetic resonance imaging is much faster than and nearly as accurate as single-photon emission computed tomography for measuring blood flow in carotid stenosis, according to researchers from Kobe (Japan) University and Philips Healthcare Japan.

“It can be an alternative way to show stenosis with less invasiveness and cost,” said Dr. Yoshito Uchihashi, a neurosurgeon at the university who presented a poster on the topic at the annual meeting of the Congress of Neurological Surgeons.

Single-photon emission computed tomography (SPECT) is considered effective for measuring cerebral blood flow, but it requires the injection of a gamma-emitting radionuclide as a tracer into the patient’s bloodstream. A gamma camera detects the radiation from the radionuclide, and a computer uses a tomographic reconstruction to produce a three-dimensional image that shows blood circulation.

By contrast, in arterial spin labeling (ASL), a tracer is produced without injection by applying a 180-degree radiofrequency inversion pulse. This inverts the net magnetization of water molecules in the blood, effectively “labeling” them. As these molecules flow into areas of interest, their inverted spin reduces the total tissue magnetization, and “tag” images are made of these areas by MRI.

This image is compared with a control image that was made without labeling. The tag image is subtracted from the control image to create a perfusion image that shows the blood flow in each MRI slice.

To assess the effectiveness of ASL for carotid stenosis, Dr. Uchihashi and his colleagues used it to scan the cerebral blood flow of 20 healthy volunteers as a baseline. Then they repeated the imaging technique on 20 carotid stenosis patients who had undergone 123I-IMP-SPECT within the previous 3 days. The investigators used the techniques to predict the risk of hyperperfusion after carotid revascularization. They also assessed the patients’ vasoreactivity to acetazolamide using both imaging techniques. The scans of 12 surgically treated patients were made both before and after their operation.

To quantify their ASL results, they used quantitative STAR (signal targeting with alternating radiofrequency) labeling of arterial regions, a technique called QUASAR.

They found that ASL picked up a significant difference between the mean cerebral blood flow in the gray matter of the control volunteers and the carotid stenosis patients (P = .015).

Measurements of cerebral blood flow with the two imaging techniques were tightly correlated. ASL was equivalent to SPECT in detecting hypoperfusion, impaired vasoreactivity, and postoperative hyperfusion.

Dr. Uchihashi and his colleagues reported that the only weakness of ASL was that it tended to overestimate cerebral blood flow values, especially in regions with high perfusion.

On the other hand, ASL is much faster than SPECT, said Dr. Uchihashi. “The patient is only in bed for 6 minutes,” he said. By contrast, SPECT can take half an hour.

Dr. Uchihashi said he had nothing to disclose. One of his coauthors is an employee of Philips Healthcare Japan, the maker of the MRI scanner used in the study.

SAN FRANCISCO – Arterial spin labeling magnetic resonance imaging is much faster than and nearly as accurate as single-photon emission computed tomography for measuring blood flow in carotid stenosis, according to researchers from Kobe (Japan) University and Philips Healthcare Japan.

“It can be an alternative way to show stenosis with less invasiveness and cost,” said Dr. Yoshito Uchihashi, a neurosurgeon at the university who presented a poster on the topic at the annual meeting of the Congress of Neurological Surgeons.

Single-photon emission computed tomography (SPECT) is considered effective for measuring cerebral blood flow, but it requires the injection of a gamma-emitting radionuclide as a tracer into the patient’s bloodstream. A gamma camera detects the radiation from the radionuclide, and a computer uses a tomographic reconstruction to produce a three-dimensional image that shows blood circulation.

By contrast, in arterial spin labeling (ASL), a tracer is produced without injection by applying a 180-degree radiofrequency inversion pulse. This inverts the net magnetization of water molecules in the blood, effectively “labeling” them. As these molecules flow into areas of interest, their inverted spin reduces the total tissue magnetization, and “tag” images are made of these areas by MRI.

This image is compared with a control image that was made without labeling. The tag image is subtracted from the control image to create a perfusion image that shows the blood flow in each MRI slice.

To assess the effectiveness of ASL for carotid stenosis, Dr. Uchihashi and his colleagues used it to scan the cerebral blood flow of 20 healthy volunteers as a baseline. Then they repeated the imaging technique on 20 carotid stenosis patients who had undergone 123I-IMP-SPECT within the previous 3 days. The investigators used the techniques to predict the risk of hyperperfusion after carotid revascularization. They also assessed the patients’ vasoreactivity to acetazolamide using both imaging techniques. The scans of 12 surgically treated patients were made both before and after their operation.

To quantify their ASL results, they used quantitative STAR (signal targeting with alternating radiofrequency) labeling of arterial regions, a technique called QUASAR.

They found that ASL picked up a significant difference between the mean cerebral blood flow in the gray matter of the control volunteers and the carotid stenosis patients (P = .015).

Measurements of cerebral blood flow with the two imaging techniques were tightly correlated. ASL was equivalent to SPECT in detecting hypoperfusion, impaired vasoreactivity, and postoperative hyperfusion.

Dr. Uchihashi and his colleagues reported that the only weakness of ASL was that it tended to overestimate cerebral blood flow values, especially in regions with high perfusion.

On the other hand, ASL is much faster than SPECT, said Dr. Uchihashi. “The patient is only in bed for 6 minutes,” he said. By contrast, SPECT can take half an hour.

Dr. Uchihashi said he had nothing to disclose. One of his coauthors is an employee of Philips Healthcare Japan, the maker of the MRI scanner used in the study.

The annual risk of an intracranial aneurysm rupturing may be lower than most previous estimates, according to calculations based on data from a large Norwegian population-based study.

Although earlier studies have placed the annual risk of rupture at 0.5%-5%, Dr. Tomm Brostrup Müller of St. Olav’s Hospital/Trondheim (Norway) University Hospital and his colleagues came up with the figure of 0.83%.

Neurologists have long debated the management of unruptured intracranial aneurysms. “Our patients want to know the risk of rupture, and they want to know the risk of treatment,” he said at the annual meeting of the Congress of Neurological Surgeons. “We now have quite good data on the risk of treatment. The controversy is mainly related to the risk of rupture.”

Researchers have found two methods for estimating the risk of rupture. One is to look at the natural history of ruptured aneurysms in which a group of patients is followed over time. This provides some information about the size and location of the aneurysms most likely to rupture, but the data in all these studies are confounded by selection bias, Dr. Müller said.

The second method is to study a large population, dividing the incidence of ruptures by the prevalence of aneurysms. “We have good data on aneurysmal subarachnoid hemorrhage from all over the world,” Dr. Müller said. “However, the incidence of unruptured intracranial aneurysms is another story.” This may explain why previous studies have resulted in a wide range of estimates of risk.

The Norwegian researchers hoped to come up with a more accurate estimate of risk by studying more people for a longer period of time. So they used data from the Nord-Trøndelag Health Study (HUNT), one of the largest population-based studies ever conducted.

All inhabitants of the county of Nord-Trøndelag in central Norway older than 20 years were invited to participate. A total of 95,097 people were followed during 1984-1986 or during 1995-1997. The investigators recorded the number of aneurysmal subarachnoid hemorrhages that occurred in these first two waves of the study.

“To our knowledge, this is the first time that the incidence of unruptured intracranial aneurysms and the prevalence of subarachnoid hemorrhage has been established for one large population cohort,” he said.

The researchers then randomly selected 1,000 participants aged 50-65 years from the third wave of the study (which took place during 2006-2008) and scanned them with magnetic resonance angiography. They found that 19 participants had aneurysms: 17 had one aneurysm each, 1 had two aneurysms and 1 had three aneurysms. The prevalence was therefore 1.9%.

They verified all but two of these aneurysms either intraoperatively or by CT scan or digital subtraction angiography.

The aneurysms measured 2-6 mm in diameter in 13 cases and 7-9 mm in 9 cases.

Clinicians handled these aneurysms according to their practice. They treated two of the patients endovascularly and five surgically. In the patient with three aneurysms, they clipped two and coiled the other. They took a conservative approach with the remaining 11 patients, following up by MRI and CT.

From this survey, the investigators calculated the incidence of aneurysmal subarachnoid hemorrhage in participants aged 50-65 years as 15.7/100,000 person-years. Dividing the incidence by the prevalence (0.000157/0.019) yielded an annual rupture risk of 0.83%.

In the total HUNT population, the incidence of aneurysmal subarachnoid hemorrhage was 10.2/100,000 person years. If the annual rupture risk is the same in this population, that would mean its overall prevalence of unruptured intracranial aneurysms was 1.2%.

Dr. Müller said the study had limitations. People aged 50-65 years may not represent the whole population, though this age group is particularly relevant for the study of aneurysm ruptures. Also, the population-based approach does not allow for analysis of the size and location of aneurysms that rupture.

The investigators reported no relevant disclosures.

The annual risk of an intracranial aneurysm rupturing may be lower than most previous estimates, according to calculations based on data from a large Norwegian population-based study.

Although earlier studies have placed the annual risk of rupture at 0.5%-5%, Dr. Tomm Brostrup Müller of St. Olav’s Hospital/Trondheim (Norway) University Hospital and his colleagues came up with the figure of 0.83%.

Neurologists have long debated the management of unruptured intracranial aneurysms. “Our patients want to know the risk of rupture, and they want to know the risk of treatment,” he said at the annual meeting of the Congress of Neurological Surgeons. “We now have quite good data on the risk of treatment. The controversy is mainly related to the risk of rupture.”

Researchers have found two methods for estimating the risk of rupture. One is to look at the natural history of ruptured aneurysms in which a group of patients is followed over time. This provides some information about the size and location of the aneurysms most likely to rupture, but the data in all these studies are confounded by selection bias, Dr. Müller said.

The second method is to study a large population, dividing the incidence of ruptures by the prevalence of aneurysms. “We have good data on aneurysmal subarachnoid hemorrhage from all over the world,” Dr. Müller said. “However, the incidence of unruptured intracranial aneurysms is another story.” This may explain why previous studies have resulted in a wide range of estimates of risk.

The Norwegian researchers hoped to come up with a more accurate estimate of risk by studying more people for a longer period of time. So they used data from the Nord-Trøndelag Health Study (HUNT), one of the largest population-based studies ever conducted.

All inhabitants of the county of Nord-Trøndelag in central Norway older than 20 years were invited to participate. A total of 95,097 people were followed during 1984-1986 or during 1995-1997. The investigators recorded the number of aneurysmal subarachnoid hemorrhages that occurred in these first two waves of the study.

“To our knowledge, this is the first time that the incidence of unruptured intracranial aneurysms and the prevalence of subarachnoid hemorrhage has been established for one large population cohort,” he said.

The researchers then randomly selected 1,000 participants aged 50-65 years from the third wave of the study (which took place during 2006-2008) and scanned them with magnetic resonance angiography. They found that 19 participants had aneurysms: 17 had one aneurysm each, 1 had two aneurysms and 1 had three aneurysms. The prevalence was therefore 1.9%.

They verified all but two of these aneurysms either intraoperatively or by CT scan or digital subtraction angiography.

The aneurysms measured 2-6 mm in diameter in 13 cases and 7-9 mm in 9 cases.

Clinicians handled these aneurysms according to their practice. They treated two of the patients endovascularly and five surgically. In the patient with three aneurysms, they clipped two and coiled the other. They took a conservative approach with the remaining 11 patients, following up by MRI and CT.

From this survey, the investigators calculated the incidence of aneurysmal subarachnoid hemorrhage in participants aged 50-65 years as 15.7/100,000 person-years. Dividing the incidence by the prevalence (0.000157/0.019) yielded an annual rupture risk of 0.83%.

In the total HUNT population, the incidence of aneurysmal subarachnoid hemorrhage was 10.2/100,000 person years. If the annual rupture risk is the same in this population, that would mean its overall prevalence of unruptured intracranial aneurysms was 1.2%.

Dr. Müller said the study had limitations. People aged 50-65 years may not represent the whole population, though this age group is particularly relevant for the study of aneurysm ruptures. Also, the population-based approach does not allow for analysis of the size and location of aneurysms that rupture.

The investigators reported no relevant disclosures.

The annual risk of an intracranial aneurysm rupturing may be lower than most previous estimates, according to calculations based on data from a large Norwegian population-based study.

Although earlier studies have placed the annual risk of rupture at 0.5%-5%, Dr. Tomm Brostrup Müller of St. Olav’s Hospital/Trondheim (Norway) University Hospital and his colleagues came up with the figure of 0.83%.

Neurologists have long debated the management of unruptured intracranial aneurysms. “Our patients want to know the risk of rupture, and they want to know the risk of treatment,” he said at the annual meeting of the Congress of Neurological Surgeons. “We now have quite good data on the risk of treatment. The controversy is mainly related to the risk of rupture.”

Researchers have found two methods for estimating the risk of rupture. One is to look at the natural history of ruptured aneurysms in which a group of patients is followed over time. This provides some information about the size and location of the aneurysms most likely to rupture, but the data in all these studies are confounded by selection bias, Dr. Müller said.

The second method is to study a large population, dividing the incidence of ruptures by the prevalence of aneurysms. “We have good data on aneurysmal subarachnoid hemorrhage from all over the world,” Dr. Müller said. “However, the incidence of unruptured intracranial aneurysms is another story.” This may explain why previous studies have resulted in a wide range of estimates of risk.

The Norwegian researchers hoped to come up with a more accurate estimate of risk by studying more people for a longer period of time. So they used data from the Nord-Trøndelag Health Study (HUNT), one of the largest population-based studies ever conducted.

All inhabitants of the county of Nord-Trøndelag in central Norway older than 20 years were invited to participate. A total of 95,097 people were followed during 1984-1986 or during 1995-1997. The investigators recorded the number of aneurysmal subarachnoid hemorrhages that occurred in these first two waves of the study.

“To our knowledge, this is the first time that the incidence of unruptured intracranial aneurysms and the prevalence of subarachnoid hemorrhage has been established for one large population cohort,” he said.

The researchers then randomly selected 1,000 participants aged 50-65 years from the third wave of the study (which took place during 2006-2008) and scanned them with magnetic resonance angiography. They found that 19 participants had aneurysms: 17 had one aneurysm each, 1 had two aneurysms and 1 had three aneurysms. The prevalence was therefore 1.9%.

They verified all but two of these aneurysms either intraoperatively or by CT scan or digital subtraction angiography.

The aneurysms measured 2-6 mm in diameter in 13 cases and 7-9 mm in 9 cases.

Clinicians handled these aneurysms according to their practice. They treated two of the patients endovascularly and five surgically. In the patient with three aneurysms, they clipped two and coiled the other. They took a conservative approach with the remaining 11 patients, following up by MRI and CT.

From this survey, the investigators calculated the incidence of aneurysmal subarachnoid hemorrhage in participants aged 50-65 years as 15.7/100,000 person-years. Dividing the incidence by the prevalence (0.000157/0.019) yielded an annual rupture risk of 0.83%.

In the total HUNT population, the incidence of aneurysmal subarachnoid hemorrhage was 10.2/100,000 person years. If the annual rupture risk is the same in this population, that would mean its overall prevalence of unruptured intracranial aneurysms was 1.2%.

Dr. Müller said the study had limitations. People aged 50-65 years may not represent the whole population, though this age group is particularly relevant for the study of aneurysm ruptures. Also, the population-based approach does not allow for analysis of the size and location of aneurysms that rupture.

The investigators reported no relevant disclosures.

SAN FRANCISCO – Cognitive function improved for most patients in the year after they underwent endarterectomy for carotid stenosis, according to the results of an ongoing prospective study.

Benefits seem to come gradually from improved blood flow, said Dr. Zoher Ghogawala, a neurosurgeon at Yale University in New Haven, Conn., who reported on the study at the annual meeting of the Congress of Neurological Surgeons. “After 1 month, there was no change in any of the domains we measured,” he said. “However, if we followed these patients for a year, there was significant improvement.”

The benefit of surgery also appeared to be most pronounced in those with a right-sided lesion or impairment in middle cerebral artery blood flow.

Although carotid endarterectomy is a well-established technique to treat carotid stenosis as a means of preventing stroke, its effects on cognitive function are poorly understood, Dr. Ghogawala said.

To learn more, he and his colleagues enrolled 36 patients from three sites. Overall, 61% had right-sided stenosis and 39% had left-sided stenosis; 54% were male, and 14% were symptomatic at presentation.

To estimate the extent that these patients’ circulation was compromised, the researchers generated quantitative phase-contrast magnetic resonance angiography (qMRA) flow maps for their internal and middle cerebral arteries. This technology images blood flow in multiple phases of the cardiac cycle and then calculates volume, velocity, and direction.

The researchers used this technique because conventional MR techniques usually do not show changes in blood flow.

Using these data, they calculated the ratio of contralateral to ipsilateral flow rates. They found that 12 patients had middle cerebral artery (MCA) flow impairment (defined as at least 15% less flow than the contralateral side) and 18 had impairment of internal carotid artery flow.

Lower blood flows were associated with a higher rate of stenosis. “It’s what you might expect,” said Dr. Ghogawala, who also is director of the Wallace Trials Center at Greenwich (Conn.) Hospital.

Following surgery, new qMRA maps showed improved blood flow in these patients. Of the 12 patients who had preoperative impairment in MCA blood flow, 10 had improved flow after surgery.

After a month, there were no significant improvements in cognitive functioning. But in 29 patients who completed follow-up at 1 year, there was improvement in executive functioning (as measured by the Trail Making Test, Part B), verbal fluency (on the Controlled Oral Word Association FAS test), and memory (total recall score on the Hopkins Verbal Learning Test). The changes were statistically significant (P less than .05).

Scores improved on the Trail Making Test in all 9 patients with improvement in blood flow following surgery, compared with 8 of 20 patients with no improvement in blood flow.

The presence of a right-sided lesion and impairment in middle cerebral artery blood flow were both significant, independent predictors of improved Trail Making Test scores.

Dr. Ghogawala said that patients with those features may have benefited the most because their cognitive function had been most impaired by their constricted blood flow.

“Further study is needed to understand the cerebral flow limitations associated with reversible dementia in some patients,” he concluded.

Dr. Ghogawala disclosed that one of his coauthors received research support from VasSol Inc., the company that made the technology for producing the qMRA maps used in the study. Another coauthor owns shares in the company.

SAN FRANCISCO – Cognitive function improved for most patients in the year after they underwent endarterectomy for carotid stenosis, according to the results of an ongoing prospective study.

Benefits seem to come gradually from improved blood flow, said Dr. Zoher Ghogawala, a neurosurgeon at Yale University in New Haven, Conn., who reported on the study at the annual meeting of the Congress of Neurological Surgeons. “After 1 month, there was no change in any of the domains we measured,” he said. “However, if we followed these patients for a year, there was significant improvement.”

The benefit of surgery also appeared to be most pronounced in those with a right-sided lesion or impairment in middle cerebral artery blood flow.

Although carotid endarterectomy is a well-established technique to treat carotid stenosis as a means of preventing stroke, its effects on cognitive function are poorly understood, Dr. Ghogawala said.

To learn more, he and his colleagues enrolled 36 patients from three sites. Overall, 61% had right-sided stenosis and 39% had left-sided stenosis; 54% were male, and 14% were symptomatic at presentation.

To estimate the extent that these patients’ circulation was compromised, the researchers generated quantitative phase-contrast magnetic resonance angiography (qMRA) flow maps for their internal and middle cerebral arteries. This technology images blood flow in multiple phases of the cardiac cycle and then calculates volume, velocity, and direction.

The researchers used this technique because conventional MR techniques usually do not show changes in blood flow.

Using these data, they calculated the ratio of contralateral to ipsilateral flow rates. They found that 12 patients had middle cerebral artery (MCA) flow impairment (defined as at least 15% less flow than the contralateral side) and 18 had impairment of internal carotid artery flow.

Lower blood flows were associated with a higher rate of stenosis. “It’s what you might expect,” said Dr. Ghogawala, who also is director of the Wallace Trials Center at Greenwich (Conn.) Hospital.

Following surgery, new qMRA maps showed improved blood flow in these patients. Of the 12 patients who had preoperative impairment in MCA blood flow, 10 had improved flow after surgery.

After a month, there were no significant improvements in cognitive functioning. But in 29 patients who completed follow-up at 1 year, there was improvement in executive functioning (as measured by the Trail Making Test, Part B), verbal fluency (on the Controlled Oral Word Association FAS test), and memory (total recall score on the Hopkins Verbal Learning Test). The changes were statistically significant (P less than .05).

Scores improved on the Trail Making Test in all 9 patients with improvement in blood flow following surgery, compared with 8 of 20 patients with no improvement in blood flow.

The presence of a right-sided lesion and impairment in middle cerebral artery blood flow were both significant, independent predictors of improved Trail Making Test scores.

Dr. Ghogawala said that patients with those features may have benefited the most because their cognitive function had been most impaired by their constricted blood flow.

“Further study is needed to understand the cerebral flow limitations associated with reversible dementia in some patients,” he concluded.

Dr. Ghogawala disclosed that one of his coauthors received research support from VasSol Inc., the company that made the technology for producing the qMRA maps used in the study. Another coauthor owns shares in the company.

SAN FRANCISCO – Cognitive function improved for most patients in the year after they underwent endarterectomy for carotid stenosis, according to the results of an ongoing prospective study.

Benefits seem to come gradually from improved blood flow, said Dr. Zoher Ghogawala, a neurosurgeon at Yale University in New Haven, Conn., who reported on the study at the annual meeting of the Congress of Neurological Surgeons. “After 1 month, there was no change in any of the domains we measured,” he said. “However, if we followed these patients for a year, there was significant improvement.”

The benefit of surgery also appeared to be most pronounced in those with a right-sided lesion or impairment in middle cerebral artery blood flow.

Although carotid endarterectomy is a well-established technique to treat carotid stenosis as a means of preventing stroke, its effects on cognitive function are poorly understood, Dr. Ghogawala said.

To learn more, he and his colleagues enrolled 36 patients from three sites. Overall, 61% had right-sided stenosis and 39% had left-sided stenosis; 54% were male, and 14% were symptomatic at presentation.

To estimate the extent that these patients’ circulation was compromised, the researchers generated quantitative phase-contrast magnetic resonance angiography (qMRA) flow maps for their internal and middle cerebral arteries. This technology images blood flow in multiple phases of the cardiac cycle and then calculates volume, velocity, and direction.

The researchers used this technique because conventional MR techniques usually do not show changes in blood flow.

Using these data, they calculated the ratio of contralateral to ipsilateral flow rates. They found that 12 patients had middle cerebral artery (MCA) flow impairment (defined as at least 15% less flow than the contralateral side) and 18 had impairment of internal carotid artery flow.

Lower blood flows were associated with a higher rate of stenosis. “It’s what you might expect,” said Dr. Ghogawala, who also is director of the Wallace Trials Center at Greenwich (Conn.) Hospital.

Following surgery, new qMRA maps showed improved blood flow in these patients. Of the 12 patients who had preoperative impairment in MCA blood flow, 10 had improved flow after surgery.

After a month, there were no significant improvements in cognitive functioning. But in 29 patients who completed follow-up at 1 year, there was improvement in executive functioning (as measured by the Trail Making Test, Part B), verbal fluency (on the Controlled Oral Word Association FAS test), and memory (total recall score on the Hopkins Verbal Learning Test). The changes were statistically significant (P less than .05).

Scores improved on the Trail Making Test in all 9 patients with improvement in blood flow following surgery, compared with 8 of 20 patients with no improvement in blood flow.

The presence of a right-sided lesion and impairment in middle cerebral artery blood flow were both significant, independent predictors of improved Trail Making Test scores.

Dr. Ghogawala said that patients with those features may have benefited the most because their cognitive function had been most impaired by their constricted blood flow.

“Further study is needed to understand the cerebral flow limitations associated with reversible dementia in some patients,” he concluded.

Dr. Ghogawala disclosed that one of his coauthors received research support from VasSol Inc., the company that made the technology for producing the qMRA maps used in the study. Another coauthor owns shares in the company.