Christine Kilgore

WASHINGTON – The rise in gestational diabetes cases demands new strategies for active postpartum care that will not only assist with prevention of type 2 diabetes, but will also prepare women for healthy subsequent pregnancies. New approaches to postpartum care aimed at preventing gestational diabetes in subsequent pregnancies were showcased during sessions at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

The problem is a growing one, with the prevalence of gestational diabetes mellitus (GDM) pregnancies ranging from 2% to 10% depending on screening criteria and demographics/population. The prevalence could rise as high as 18% if diagnostic criteria change in the United States to implement the single-step test recommended in 2008 by the International Association of Diabetes and Pregnancy Study Groups (IADPSG) and adopted by the American Diabetes Association and the World Health Organization.

For now, most U.S. obstetricians are continuing to use the two-step approach to diagnosing GDM, following the advice of a National Institutes of Health consensus development panel and the American College of Gynecologists and Obstetricians. Some physicians, however, are lowering their diagnostic thresholds to capture more at-risk women.

And in the meantime, the prevalence of obesity continues to rise, independently increasing the number of pregnancies complicated by GDM. An estimated 50% of GDM is caused by overweight and obesity, according to Dr. Wanda K. Nicholson, director of the diabetes and obesity core at the University of North Carolina’s Center for Women's Health Research in Chapel Hill.

"We’re not even able to manage our current body of patients," she said. "If we expand this number, we’ll definitely need to develop some new strategies." Studies have also shown that approximately 50% of patients with GDM are screened after delivery for persistent glucose intolerance.

"For most of us, preconception care is increasingly about postpartum care," said Dr. Thomas R. Moore, professor and chairman of the department of reproductive medicine at the University of California, San Diego. "We have to find ways of improving our postpartum follow-up [of GDM pregnancies]."

Follow-up should include checking glycemic status, educating and counseling patients on the risks to newborns of both high maternal HbA_1c levels and maternal obesity, assisting patients with nutritional and lifestyle change, advising the use of effective contraception until conditions are right for another pregnancy, and ensuring proper folic acid supplementation before conception is attempted, he said.

For ob.gyn. practices, more GDM can mean more physician appointments, more staff dedicated to coordinating visits with physicians and educators, expanded diabetes education, and expanded nutritional counseling. "In particular, many practices will need to expand their capacity for nutritional counseling," Dr. Nicholson said. "We know from large randomized trials that even for women with mild GDM, nutritional counseling makes a difference."

The literature hints at the possible promise of using telephonic nurse management and Internet-based self-monitoring and educational tools to enhance the postpartum care of new mothers who had GDM, she said.

At the University of North Carolina, a program called the Gestational Diabetes Management System (GooDMomS) offers women video-supported lessons on GDM, a Web and mobile self-monitoring diary in which they can track their weight and record time spent exercising postpartum, as well as forums to "ask the staff" questions and to communicate with other mothers. The system, which is being pilot-tested in an NIH-funded randomized study, is meant to enhance – not replace – basic postpartum care.

In terms of postpartum testing for type 2 diabetes, a recently published literature review suggests that systematic efforts to proactively contact patients can have an impact. Programs in which patients were contacted via phone calls, mailings, and other reminders increased postpartum testing rates from an average of 33% up to 60% (Prim. Care Diabetes 2013;7:177-86).

"We can’t even begin to deliver a preconception program to women until we know what her glycemic status is," emphasized Dr. Moore.

A meta-analysis published more than a decade ago showed an overall 80% reduction in the incidence of congenital malformations in women with diabetes who received preconception care as compared to those who did not receive such care. This study has increasingly relevance today, with more than 76 million women worldwide at risk of their pregnancies being complicated by pregestational (existing) diabetes or gestational diabetes, he said.

The analysis (QJM 2001;94:435-44) also showed that "only modest reductions in HbA_1c, averaging 17%, can have a profound impact," Dr. Moore said. The patient conversation must go beyond merely recommending that HbA_1c levels be as close to normal as possible before conception is attempted, he emphasized.

A recent report from the Maryland Pregnancy Risk Assessment Monitoring System (PRAMS) shows that women with diabetes were the least likely group among women with various preconception medical problems to report contraception use (Contraception 2013;88:263-8). "They had the lowest uptake on contraception," Dr. Moore said.

An estimate of the "downstream savings" of preventing type 2 diabetes in women with GDM was factored into one of two true cost-effectiveness analyses that have been published thus far of the IADPSG criteria, according to Dr. Aaron B. Caughey, chairman of the department of obstetrics and gynecology at the Oregon Health and Science University in Portland.

Both of the two published analyses concluded that the IADPSG criteria are cost effective, but one of them concluded that the criteria would be cost effective only if post-delivery care reduces diabetes incidence (Diabetes Care 2012;35:529-35).

"The short-term costs (of the one-step approach) are easy to figure out," said Dr. Caughey, an ob.gyn and health economist who also is director of the university’s Center for Women’s Health. "The long-term costs are really tough ... we don’t know, what the impact 20 years downstream is going to be."

Providers at Oregon Health and Science University have been encouraged to adopt the one-step approach and, thus far, the change has resulted in a doubling of GDM incidence from approximately 6% to 12%, he noted.

Dr. Caughey, Dr. Moore, and Dr. Nicholson each reported that they had no conflicts of interest to disclose.

WASHINGTON – The rise in gestational diabetes cases demands new strategies for active postpartum care that will not only assist with prevention of type 2 diabetes, but will also prepare women for healthy subsequent pregnancies. New approaches to postpartum care aimed at preventing gestational diabetes in subsequent pregnancies were showcased during sessions at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

The problem is a growing one, with the prevalence of gestational diabetes mellitus (GDM) pregnancies ranging from 2% to 10% depending on screening criteria and demographics/population. The prevalence could rise as high as 18% if diagnostic criteria change in the United States to implement the single-step test recommended in 2008 by the International Association of Diabetes and Pregnancy Study Groups (IADPSG) and adopted by the American Diabetes Association and the World Health Organization.

For now, most U.S. obstetricians are continuing to use the two-step approach to diagnosing GDM, following the advice of a National Institutes of Health consensus development panel and the American College of Gynecologists and Obstetricians. Some physicians, however, are lowering their diagnostic thresholds to capture more at-risk women.

And in the meantime, the prevalence of obesity continues to rise, independently increasing the number of pregnancies complicated by GDM. An estimated 50% of GDM is caused by overweight and obesity, according to Dr. Wanda K. Nicholson, director of the diabetes and obesity core at the University of North Carolina’s Center for Women's Health Research in Chapel Hill.

"We’re not even able to manage our current body of patients," she said. "If we expand this number, we’ll definitely need to develop some new strategies." Studies have also shown that approximately 50% of patients with GDM are screened after delivery for persistent glucose intolerance.

"For most of us, preconception care is increasingly about postpartum care," said Dr. Thomas R. Moore, professor and chairman of the department of reproductive medicine at the University of California, San Diego. "We have to find ways of improving our postpartum follow-up [of GDM pregnancies]."

Follow-up should include checking glycemic status, educating and counseling patients on the risks to newborns of both high maternal HbA_1c levels and maternal obesity, assisting patients with nutritional and lifestyle change, advising the use of effective contraception until conditions are right for another pregnancy, and ensuring proper folic acid supplementation before conception is attempted, he said.

For ob.gyn. practices, more GDM can mean more physician appointments, more staff dedicated to coordinating visits with physicians and educators, expanded diabetes education, and expanded nutritional counseling. "In particular, many practices will need to expand their capacity for nutritional counseling," Dr. Nicholson said. "We know from large randomized trials that even for women with mild GDM, nutritional counseling makes a difference."

The literature hints at the possible promise of using telephonic nurse management and Internet-based self-monitoring and educational tools to enhance the postpartum care of new mothers who had GDM, she said.

At the University of North Carolina, a program called the Gestational Diabetes Management System (GooDMomS) offers women video-supported lessons on GDM, a Web and mobile self-monitoring diary in which they can track their weight and record time spent exercising postpartum, as well as forums to "ask the staff" questions and to communicate with other mothers. The system, which is being pilot-tested in an NIH-funded randomized study, is meant to enhance – not replace – basic postpartum care.

In terms of postpartum testing for type 2 diabetes, a recently published literature review suggests that systematic efforts to proactively contact patients can have an impact. Programs in which patients were contacted via phone calls, mailings, and other reminders increased postpartum testing rates from an average of 33% up to 60% (Prim. Care Diabetes 2013;7:177-86).

"We can’t even begin to deliver a preconception program to women until we know what her glycemic status is," emphasized Dr. Moore.

A meta-analysis published more than a decade ago showed an overall 80% reduction in the incidence of congenital malformations in women with diabetes who received preconception care as compared to those who did not receive such care. This study has increasingly relevance today, with more than 76 million women worldwide at risk of their pregnancies being complicated by pregestational (existing) diabetes or gestational diabetes, he said.

The analysis (QJM 2001;94:435-44) also showed that "only modest reductions in HbA_1c, averaging 17%, can have a profound impact," Dr. Moore said. The patient conversation must go beyond merely recommending that HbA_1c levels be as close to normal as possible before conception is attempted, he emphasized.

A recent report from the Maryland Pregnancy Risk Assessment Monitoring System (PRAMS) shows that women with diabetes were the least likely group among women with various preconception medical problems to report contraception use (Contraception 2013;88:263-8). "They had the lowest uptake on contraception," Dr. Moore said.

An estimate of the "downstream savings" of preventing type 2 diabetes in women with GDM was factored into one of two true cost-effectiveness analyses that have been published thus far of the IADPSG criteria, according to Dr. Aaron B. Caughey, chairman of the department of obstetrics and gynecology at the Oregon Health and Science University in Portland.

Both of the two published analyses concluded that the IADPSG criteria are cost effective, but one of them concluded that the criteria would be cost effective only if post-delivery care reduces diabetes incidence (Diabetes Care 2012;35:529-35).

"The short-term costs (of the one-step approach) are easy to figure out," said Dr. Caughey, an ob.gyn and health economist who also is director of the university’s Center for Women’s Health. "The long-term costs are really tough ... we don’t know, what the impact 20 years downstream is going to be."

Providers at Oregon Health and Science University have been encouraged to adopt the one-step approach and, thus far, the change has resulted in a doubling of GDM incidence from approximately 6% to 12%, he noted.

Dr. Caughey, Dr. Moore, and Dr. Nicholson each reported that they had no conflicts of interest to disclose.

WASHINGTON – The rise in gestational diabetes cases demands new strategies for active postpartum care that will not only assist with prevention of type 2 diabetes, but will also prepare women for healthy subsequent pregnancies. New approaches to postpartum care aimed at preventing gestational diabetes in subsequent pregnancies were showcased during sessions at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

The problem is a growing one, with the prevalence of gestational diabetes mellitus (GDM) pregnancies ranging from 2% to 10% depending on screening criteria and demographics/population. The prevalence could rise as high as 18% if diagnostic criteria change in the United States to implement the single-step test recommended in 2008 by the International Association of Diabetes and Pregnancy Study Groups (IADPSG) and adopted by the American Diabetes Association and the World Health Organization.

For now, most U.S. obstetricians are continuing to use the two-step approach to diagnosing GDM, following the advice of a National Institutes of Health consensus development panel and the American College of Gynecologists and Obstetricians. Some physicians, however, are lowering their diagnostic thresholds to capture more at-risk women.

And in the meantime, the prevalence of obesity continues to rise, independently increasing the number of pregnancies complicated by GDM. An estimated 50% of GDM is caused by overweight and obesity, according to Dr. Wanda K. Nicholson, director of the diabetes and obesity core at the University of North Carolina’s Center for Women's Health Research in Chapel Hill.

"We’re not even able to manage our current body of patients," she said. "If we expand this number, we’ll definitely need to develop some new strategies." Studies have also shown that approximately 50% of patients with GDM are screened after delivery for persistent glucose intolerance.

"For most of us, preconception care is increasingly about postpartum care," said Dr. Thomas R. Moore, professor and chairman of the department of reproductive medicine at the University of California, San Diego. "We have to find ways of improving our postpartum follow-up [of GDM pregnancies]."

Follow-up should include checking glycemic status, educating and counseling patients on the risks to newborns of both high maternal HbA_1c levels and maternal obesity, assisting patients with nutritional and lifestyle change, advising the use of effective contraception until conditions are right for another pregnancy, and ensuring proper folic acid supplementation before conception is attempted, he said.

For ob.gyn. practices, more GDM can mean more physician appointments, more staff dedicated to coordinating visits with physicians and educators, expanded diabetes education, and expanded nutritional counseling. "In particular, many practices will need to expand their capacity for nutritional counseling," Dr. Nicholson said. "We know from large randomized trials that even for women with mild GDM, nutritional counseling makes a difference."

The literature hints at the possible promise of using telephonic nurse management and Internet-based self-monitoring and educational tools to enhance the postpartum care of new mothers who had GDM, she said.

At the University of North Carolina, a program called the Gestational Diabetes Management System (GooDMomS) offers women video-supported lessons on GDM, a Web and mobile self-monitoring diary in which they can track their weight and record time spent exercising postpartum, as well as forums to "ask the staff" questions and to communicate with other mothers. The system, which is being pilot-tested in an NIH-funded randomized study, is meant to enhance – not replace – basic postpartum care.

In terms of postpartum testing for type 2 diabetes, a recently published literature review suggests that systematic efforts to proactively contact patients can have an impact. Programs in which patients were contacted via phone calls, mailings, and other reminders increased postpartum testing rates from an average of 33% up to 60% (Prim. Care Diabetes 2013;7:177-86).

"We can’t even begin to deliver a preconception program to women until we know what her glycemic status is," emphasized Dr. Moore.

A meta-analysis published more than a decade ago showed an overall 80% reduction in the incidence of congenital malformations in women with diabetes who received preconception care as compared to those who did not receive such care. This study has increasingly relevance today, with more than 76 million women worldwide at risk of their pregnancies being complicated by pregestational (existing) diabetes or gestational diabetes, he said.

The analysis (QJM 2001;94:435-44) also showed that "only modest reductions in HbA_1c, averaging 17%, can have a profound impact," Dr. Moore said. The patient conversation must go beyond merely recommending that HbA_1c levels be as close to normal as possible before conception is attempted, he emphasized.

A recent report from the Maryland Pregnancy Risk Assessment Monitoring System (PRAMS) shows that women with diabetes were the least likely group among women with various preconception medical problems to report contraception use (Contraception 2013;88:263-8). "They had the lowest uptake on contraception," Dr. Moore said.

An estimate of the "downstream savings" of preventing type 2 diabetes in women with GDM was factored into one of two true cost-effectiveness analyses that have been published thus far of the IADPSG criteria, according to Dr. Aaron B. Caughey, chairman of the department of obstetrics and gynecology at the Oregon Health and Science University in Portland.

Both of the two published analyses concluded that the IADPSG criteria are cost effective, but one of them concluded that the criteria would be cost effective only if post-delivery care reduces diabetes incidence (Diabetes Care 2012;35:529-35).

"The short-term costs (of the one-step approach) are easy to figure out," said Dr. Caughey, an ob.gyn and health economist who also is director of the university’s Center for Women’s Health. "The long-term costs are really tough ... we don’t know, what the impact 20 years downstream is going to be."

Providers at Oregon Health and Science University have been encouraged to adopt the one-step approach and, thus far, the change has resulted in a doubling of GDM incidence from approximately 6% to 12%, he noted.

Dr. Caughey, Dr. Moore, and Dr. Nicholson each reported that they had no conflicts of interest to disclose.

WASHINGTON – Women with a history of gestational diabetes have a sustained long-term risk of developing type 2 diabetes, and this risk continues to be modifiable with either metformin or lifestyle intervention, according to a 10-year follow-up of women who participated in the National Institutes of Health–funded Diabetes Prevention Program trial.

"Even years out from their index pregnancy, women with a history of gestational diabetes are at a significantly increased and sustained risk [compared with women without a GDM history] of developing type 2 [diabetes] ... despite similar baseline metabolic status and despite similar clinical evidence of risk," said Dr. Vanita R. Aroda, who has served as a subinvestigator in the Diabetes Prevention Program (DPP).

Post-hoc analyses of follow-up data from the Diabetes Prevention Program Outcomes Study (DPPOS) show that while lifestyle intervention was similarly effective in reducing risk for all parous women (regardless of whether they had GDM), metformin was effective only in women with a history of GDM, Dr. Aroda reported at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

The original DPP enrolled more than 3,000 individuals at high risk of developing diabetes. Participants were at least 25 years old, were overweight or obese, and had impaired glucose tolerance with fasting plasma glucose levels of 92-125 mg/dL and glucose levels of 140-199 mg/dL 2 hours after a 75-g oral glucose tolerance test.

Approximately 2,100 of the participants were women, 350 of whom had GDM "about 12 years prior," explained Dr. Aroda of Georgetown University, Washington.

Participants were randomized in the main study to placebo, lifestyle intervention, or metformin for approximately 3 years. In women with a history of GDM, lifestyle intervention and metformin reduced the progression to diabetes over this time by 53% and 50%, compared with placebo.

The effects of metformin were greater in these women than in the population as a whole, for which the risk reduction from metformin was 31%. For women without a history of GDM, the risk reduction from metformin was insignificant. Lifestyle intervention – which involved at least 7% weight loss, 150 minutes of activity per week, and a low-fat diet – was similarly effective for all groups.

The long-term DPPOS began after the DPP concluded, with the majority of the original cohort continuing in the follow-up. All participants in the DPPOS received basic lifestyle education at this point, because of its proven benefits. Those originally randomized to the lifestyle group received additional education/support, while those originally assigned to receive metformin or placebo continued in these study groups.

At a mean of 10 years’ follow-up, women with a history of GDM in the placebo group had a 65% higher risk of developing type 2 diabetes compared with women without a history of GDM – despite the fact these women were approximately 9 years younger than those without the GDM history, and an average of 20 years past their index pregnancy, Dr. Aroda said.

Metformin and lifestyle reduced progression to diabetes similarly among those with a GDM history (41% and 35%), compared with placebo. These intervention effects were greater than in those without a GDM history, who saw a 28% risk reduction from lifestyle and an insignificant reduction with metformin.

"For women with a history of GDM, the effectiveness of the initial interventions – lifestyle and metformin – was sustained. There were very nice risk reductions with both," Dr. Aroda said.

The GDM and non-GDM cohorts of women had a similar baseline body mass index and similar fasting and post–oral glucose tolerance test glucose levels. It is not clear why women without prior GDM had a lesser response to metformin, but "it could be that these women had healthier beta-cell function," she said.

Dr. Aroda reported that she receives consulting fees and grant support from Novo Nordisk and Sanofi-Aventis, as well as grant support from Bristol-Myers Squibb, GlaxoSmithKline, Integrium, Takeda Pharmaceuticals, and Boehringer Ingelheim Vetmedica GmbH.

WASHINGTON – Women with a history of gestational diabetes have a sustained long-term risk of developing type 2 diabetes, and this risk continues to be modifiable with either metformin or lifestyle intervention, according to a 10-year follow-up of women who participated in the National Institutes of Health–funded Diabetes Prevention Program trial.

"Even years out from their index pregnancy, women with a history of gestational diabetes are at a significantly increased and sustained risk [compared with women without a GDM history] of developing type 2 [diabetes] ... despite similar baseline metabolic status and despite similar clinical evidence of risk," said Dr. Vanita R. Aroda, who has served as a subinvestigator in the Diabetes Prevention Program (DPP).

Post-hoc analyses of follow-up data from the Diabetes Prevention Program Outcomes Study (DPPOS) show that while lifestyle intervention was similarly effective in reducing risk for all parous women (regardless of whether they had GDM), metformin was effective only in women with a history of GDM, Dr. Aroda reported at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

The original DPP enrolled more than 3,000 individuals at high risk of developing diabetes. Participants were at least 25 years old, were overweight or obese, and had impaired glucose tolerance with fasting plasma glucose levels of 92-125 mg/dL and glucose levels of 140-199 mg/dL 2 hours after a 75-g oral glucose tolerance test.

Approximately 2,100 of the participants were women, 350 of whom had GDM "about 12 years prior," explained Dr. Aroda of Georgetown University, Washington.

Participants were randomized in the main study to placebo, lifestyle intervention, or metformin for approximately 3 years. In women with a history of GDM, lifestyle intervention and metformin reduced the progression to diabetes over this time by 53% and 50%, compared with placebo.

The effects of metformin were greater in these women than in the population as a whole, for which the risk reduction from metformin was 31%. For women without a history of GDM, the risk reduction from metformin was insignificant. Lifestyle intervention – which involved at least 7% weight loss, 150 minutes of activity per week, and a low-fat diet – was similarly effective for all groups.

The long-term DPPOS began after the DPP concluded, with the majority of the original cohort continuing in the follow-up. All participants in the DPPOS received basic lifestyle education at this point, because of its proven benefits. Those originally randomized to the lifestyle group received additional education/support, while those originally assigned to receive metformin or placebo continued in these study groups.

At a mean of 10 years’ follow-up, women with a history of GDM in the placebo group had a 65% higher risk of developing type 2 diabetes compared with women without a history of GDM – despite the fact these women were approximately 9 years younger than those without the GDM history, and an average of 20 years past their index pregnancy, Dr. Aroda said.

Metformin and lifestyle reduced progression to diabetes similarly among those with a GDM history (41% and 35%), compared with placebo. These intervention effects were greater than in those without a GDM history, who saw a 28% risk reduction from lifestyle and an insignificant reduction with metformin.

"For women with a history of GDM, the effectiveness of the initial interventions – lifestyle and metformin – was sustained. There were very nice risk reductions with both," Dr. Aroda said.

The GDM and non-GDM cohorts of women had a similar baseline body mass index and similar fasting and post–oral glucose tolerance test glucose levels. It is not clear why women without prior GDM had a lesser response to metformin, but "it could be that these women had healthier beta-cell function," she said.

Dr. Aroda reported that she receives consulting fees and grant support from Novo Nordisk and Sanofi-Aventis, as well as grant support from Bristol-Myers Squibb, GlaxoSmithKline, Integrium, Takeda Pharmaceuticals, and Boehringer Ingelheim Vetmedica GmbH.

WASHINGTON – Women with a history of gestational diabetes have a sustained long-term risk of developing type 2 diabetes, and this risk continues to be modifiable with either metformin or lifestyle intervention, according to a 10-year follow-up of women who participated in the National Institutes of Health–funded Diabetes Prevention Program trial.

"Even years out from their index pregnancy, women with a history of gestational diabetes are at a significantly increased and sustained risk [compared with women without a GDM history] of developing type 2 [diabetes] ... despite similar baseline metabolic status and despite similar clinical evidence of risk," said Dr. Vanita R. Aroda, who has served as a subinvestigator in the Diabetes Prevention Program (DPP).

Post-hoc analyses of follow-up data from the Diabetes Prevention Program Outcomes Study (DPPOS) show that while lifestyle intervention was similarly effective in reducing risk for all parous women (regardless of whether they had GDM), metformin was effective only in women with a history of GDM, Dr. Aroda reported at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

The original DPP enrolled more than 3,000 individuals at high risk of developing diabetes. Participants were at least 25 years old, were overweight or obese, and had impaired glucose tolerance with fasting plasma glucose levels of 92-125 mg/dL and glucose levels of 140-199 mg/dL 2 hours after a 75-g oral glucose tolerance test.

Approximately 2,100 of the participants were women, 350 of whom had GDM "about 12 years prior," explained Dr. Aroda of Georgetown University, Washington.

Participants were randomized in the main study to placebo, lifestyle intervention, or metformin for approximately 3 years. In women with a history of GDM, lifestyle intervention and metformin reduced the progression to diabetes over this time by 53% and 50%, compared with placebo.

The effects of metformin were greater in these women than in the population as a whole, for which the risk reduction from metformin was 31%. For women without a history of GDM, the risk reduction from metformin was insignificant. Lifestyle intervention – which involved at least 7% weight loss, 150 minutes of activity per week, and a low-fat diet – was similarly effective for all groups.

The long-term DPPOS began after the DPP concluded, with the majority of the original cohort continuing in the follow-up. All participants in the DPPOS received basic lifestyle education at this point, because of its proven benefits. Those originally randomized to the lifestyle group received additional education/support, while those originally assigned to receive metformin or placebo continued in these study groups.

At a mean of 10 years’ follow-up, women with a history of GDM in the placebo group had a 65% higher risk of developing type 2 diabetes compared with women without a history of GDM – despite the fact these women were approximately 9 years younger than those without the GDM history, and an average of 20 years past their index pregnancy, Dr. Aroda said.

Metformin and lifestyle reduced progression to diabetes similarly among those with a GDM history (41% and 35%), compared with placebo. These intervention effects were greater than in those without a GDM history, who saw a 28% risk reduction from lifestyle and an insignificant reduction with metformin.

"For women with a history of GDM, the effectiveness of the initial interventions – lifestyle and metformin – was sustained. There were very nice risk reductions with both," Dr. Aroda said.

The GDM and non-GDM cohorts of women had a similar baseline body mass index and similar fasting and post–oral glucose tolerance test glucose levels. It is not clear why women without prior GDM had a lesser response to metformin, but "it could be that these women had healthier beta-cell function," she said.

Dr. Aroda reported that she receives consulting fees and grant support from Novo Nordisk and Sanofi-Aventis, as well as grant support from Bristol-Myers Squibb, GlaxoSmithKline, Integrium, Takeda Pharmaceuticals, and Boehringer Ingelheim Vetmedica GmbH.

WASHINGTON – Women with a history of gestational diabetes have a sustained long-term risk of developing type 2 diabetes, and this risk continues to be modifiable with either metformin or lifestyle intervention, according to a 10-year follow-up of women who participated in the National Institutes of Health–funded Diabetes Prevention Program trial.

"Even years out from their index pregnancy, women with a history of gestational diabetes are at a significantly increased and sustained risk [compared with women without a GDM history] of developing type 2 [diabetes] ... despite similar baseline metabolic status and despite similar clinical evidence of risk," said Dr. Vanita R. Aroda, who has served as a subinvestigator in the Diabetes Prevention Program (DPP).

Post-hoc analyses of follow-up data from the Diabetes Prevention Program Outcomes Study (DPPOS) show that while lifestyle intervention was similarly effective in reducing risk for all parous women (regardless of whether they had GDM), metformin was effective only in women with a history of GDM, Dr. Aroda reported at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

The original DPP enrolled more than 3,000 individuals at high risk of developing diabetes. Participants were at least 25 years old, were overweight or obese, and had impaired glucose tolerance with fasting plasma glucose levels of 92-125 mg/dL and glucose levels of 140-199 mg/dL 2 hours after a 75-g oral glucose tolerance test.

Approximately 2,100 of the participants were women, 350 of whom had GDM "about 12 years prior," explained Dr. Aroda of Georgetown University, Washington.

Participants were randomized in the main study to placebo, lifestyle intervention, or metformin for approximately 3 years. In women with a history of GDM, lifestyle intervention and metformin reduced the progression to diabetes over this time by 53% and 50%, compared with placebo.

The effects of metformin were greater in these women than in the population as a whole, for which the risk reduction from metformin was 31%. For women without a history of GDM, the risk reduction from metformin was insignificant. Lifestyle intervention – which involved at least 7% weight loss, 150 minutes of activity per week, and a low-fat diet – was similarly effective for all groups.

The long-term DPPOS began after the DPP concluded, with the majority of the original cohort continuing in the follow-up. All participants in the DPPOS received basic lifestyle education at this point, because of its proven benefits. Those originally randomized to the lifestyle group received additional education/support, while those originally assigned to receive metformin or placebo continued in these study groups.

At a mean of 10 years’ follow-up, women with a history of GDM in the placebo group had a 65% higher risk of developing type 2 diabetes compared with women without a history of GDM – despite the fact these women were approximately 9 years younger than those without the GDM history, and an average of 20 years past their index pregnancy, Dr. Aroda said.

Metformin and lifestyle reduced progression to diabetes similarly among those with a GDM history (41% and 35%), compared with placebo. These intervention effects were greater than in those without a GDM history, who saw a 28% risk reduction from lifestyle and an insignificant reduction with metformin.

"For women with a history of GDM, the effectiveness of the initial interventions – lifestyle and metformin – was sustained. There were very nice risk reductions with both," Dr. Aroda said.

The GDM and non-GDM cohorts of women had a similar baseline body mass index and similar fasting and post–oral glucose tolerance test glucose levels. It is not clear why women without prior GDM had a lesser response to metformin, but "it could be that these women had healthier beta-cell function," she said.

Dr. Aroda reported that she receives consulting fees and grant support from Novo Nordisk and Sanofi-Aventis, as well as grant support from Bristol-Myers Squibb, GlaxoSmithKline, Integrium, Takeda Pharmaceuticals, and Boehringer Ingelheim Vetmedica GmbH.

WASHINGTON – Women with a history of gestational diabetes have a sustained long-term risk of developing type 2 diabetes, and this risk continues to be modifiable with either metformin or lifestyle intervention, according to a 10-year follow-up of women who participated in the National Institutes of Health–funded Diabetes Prevention Program trial.

"Even years out from their index pregnancy, women with a history of gestational diabetes are at a significantly increased and sustained risk [compared with women without a GDM history] of developing type 2 [diabetes] ... despite similar baseline metabolic status and despite similar clinical evidence of risk," said Dr. Vanita R. Aroda, who has served as a subinvestigator in the Diabetes Prevention Program (DPP).

Post-hoc analyses of follow-up data from the Diabetes Prevention Program Outcomes Study (DPPOS) show that while lifestyle intervention was similarly effective in reducing risk for all parous women (regardless of whether they had GDM), metformin was effective only in women with a history of GDM, Dr. Aroda reported at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

The original DPP enrolled more than 3,000 individuals at high risk of developing diabetes. Participants were at least 25 years old, were overweight or obese, and had impaired glucose tolerance with fasting plasma glucose levels of 92-125 mg/dL and glucose levels of 140-199 mg/dL 2 hours after a 75-g oral glucose tolerance test.

Approximately 2,100 of the participants were women, 350 of whom had GDM "about 12 years prior," explained Dr. Aroda of Georgetown University, Washington.

Participants were randomized in the main study to placebo, lifestyle intervention, or metformin for approximately 3 years. In women with a history of GDM, lifestyle intervention and metformin reduced the progression to diabetes over this time by 53% and 50%, compared with placebo.

The effects of metformin were greater in these women than in the population as a whole, for which the risk reduction from metformin was 31%. For women without a history of GDM, the risk reduction from metformin was insignificant. Lifestyle intervention – which involved at least 7% weight loss, 150 minutes of activity per week, and a low-fat diet – was similarly effective for all groups.

The long-term DPPOS began after the DPP concluded, with the majority of the original cohort continuing in the follow-up. All participants in the DPPOS received basic lifestyle education at this point, because of its proven benefits. Those originally randomized to the lifestyle group received additional education/support, while those originally assigned to receive metformin or placebo continued in these study groups.

At a mean of 10 years’ follow-up, women with a history of GDM in the placebo group had a 65% higher risk of developing type 2 diabetes compared with women without a history of GDM – despite the fact these women were approximately 9 years younger than those without the GDM history, and an average of 20 years past their index pregnancy, Dr. Aroda said.

Metformin and lifestyle reduced progression to diabetes similarly among those with a GDM history (41% and 35%), compared with placebo. These intervention effects were greater than in those without a GDM history, who saw a 28% risk reduction from lifestyle and an insignificant reduction with metformin.

"For women with a history of GDM, the effectiveness of the initial interventions – lifestyle and metformin – was sustained. There were very nice risk reductions with both," Dr. Aroda said.

The GDM and non-GDM cohorts of women had a similar baseline body mass index and similar fasting and post–oral glucose tolerance test glucose levels. It is not clear why women without prior GDM had a lesser response to metformin, but "it could be that these women had healthier beta-cell function," she said.

Dr. Aroda reported that she receives consulting fees and grant support from Novo Nordisk and Sanofi-Aventis, as well as grant support from Bristol-Myers Squibb, GlaxoSmithKline, Integrium, Takeda Pharmaceuticals, and Boehringer Ingelheim Vetmedica GmbH.

WASHINGTON – Women with a history of gestational diabetes have a sustained long-term risk of developing type 2 diabetes, and this risk continues to be modifiable with either metformin or lifestyle intervention, according to a 10-year follow-up of women who participated in the National Institutes of Health–funded Diabetes Prevention Program trial.

"Even years out from their index pregnancy, women with a history of gestational diabetes are at a significantly increased and sustained risk [compared with women without a GDM history] of developing type 2 [diabetes] ... despite similar baseline metabolic status and despite similar clinical evidence of risk," said Dr. Vanita R. Aroda, who has served as a subinvestigator in the Diabetes Prevention Program (DPP).

Post-hoc analyses of follow-up data from the Diabetes Prevention Program Outcomes Study (DPPOS) show that while lifestyle intervention was similarly effective in reducing risk for all parous women (regardless of whether they had GDM), metformin was effective only in women with a history of GDM, Dr. Aroda reported at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

The original DPP enrolled more than 3,000 individuals at high risk of developing diabetes. Participants were at least 25 years old, were overweight or obese, and had impaired glucose tolerance with fasting plasma glucose levels of 92-125 mg/dL and glucose levels of 140-199 mg/dL 2 hours after a 75-g oral glucose tolerance test.

Approximately 2,100 of the participants were women, 350 of whom had GDM "about 12 years prior," explained Dr. Aroda of Georgetown University, Washington.

Participants were randomized in the main study to placebo, lifestyle intervention, or metformin for approximately 3 years. In women with a history of GDM, lifestyle intervention and metformin reduced the progression to diabetes over this time by 53% and 50%, compared with placebo.

The effects of metformin were greater in these women than in the population as a whole, for which the risk reduction from metformin was 31%. For women without a history of GDM, the risk reduction from metformin was insignificant. Lifestyle intervention – which involved at least 7% weight loss, 150 minutes of activity per week, and a low-fat diet – was similarly effective for all groups.

The long-term DPPOS began after the DPP concluded, with the majority of the original cohort continuing in the follow-up. All participants in the DPPOS received basic lifestyle education at this point, because of its proven benefits. Those originally randomized to the lifestyle group received additional education/support, while those originally assigned to receive metformin or placebo continued in these study groups.

At a mean of 10 years’ follow-up, women with a history of GDM in the placebo group had a 65% higher risk of developing type 2 diabetes compared with women without a history of GDM – despite the fact these women were approximately 9 years younger than those without the GDM history, and an average of 20 years past their index pregnancy, Dr. Aroda said.

Metformin and lifestyle reduced progression to diabetes similarly among those with a GDM history (41% and 35%), compared with placebo. These intervention effects were greater than in those without a GDM history, who saw a 28% risk reduction from lifestyle and an insignificant reduction with metformin.

"For women with a history of GDM, the effectiveness of the initial interventions – lifestyle and metformin – was sustained. There were very nice risk reductions with both," Dr. Aroda said.

The GDM and non-GDM cohorts of women had a similar baseline body mass index and similar fasting and post–oral glucose tolerance test glucose levels. It is not clear why women without prior GDM had a lesser response to metformin, but "it could be that these women had healthier beta-cell function," she said.

Dr. Aroda reported that she receives consulting fees and grant support from Novo Nordisk and Sanofi-Aventis, as well as grant support from Bristol-Myers Squibb, GlaxoSmithKline, Integrium, Takeda Pharmaceuticals, and Boehringer Ingelheim Vetmedica GmbH.

WASHINGTON – High levels of concern with muscularity, or with both muscularity and thinness, were relatively common – and were associated with a risk of adverse outcomes – among adolescent boys participating in the ongoing Growing Up Today Study.

Male adolescents may not be recognized as having body shape concerns or weight-related disorders because of their gender and what likely are gender-specific presentations. This analysis of the GUTS cohort, however, should put such concerns and disorders on the radar screen for pediatricians and other clinicians, Alison E. Field, Sc.D., reported at the annual meeting of the Pediatric Academic Societies.

©vizion-photography/iStockphoto.com

The Growing Up Today Study – a National Institutes of Health–funded prospective cohort study established in 1996 to assess factors that influence weight change – has involved approximately 16,800 children (approximately 9,000 girls and 7,800 boys) who are offspring of women participating in the separate Nurses Health Study 2.

Questionnaires sent every 12-24 months to the boys participating in GUTS have assessed concerns with thinness, concerns with muscularity, use of products to enhance physique, bulimic behaviors, weight and height, depressive symptoms, drug use, and binge eating and drinking. To assess concerns about muscularity, for instance, boys were asked, "How frequently do you think about wanting to tone or define muscle?"

The analysis presented at the PAS meeting involved 5,527 male adolescents who had returned at least two questionnaires between 1999 and 2010. The boys ranged in age from 12 to 18 years in 1999.

Thinness itself was the least common concern. It was a significant concern of about 2% of boys aged 13-15 years, and the prevalence of the concern decreased in older age groups.

The prevalence of concerns and behaviors that included muscularity, on the other hand, was much higher, reported Dr. Field of the department of pediatrics at Harvard Medical School, Boston.

"Particularly troubling," Dr. Field said, was the prevalence of muscularity concerns coupled with the reported use of "potentially" unhealthy products (creatine supplements) and "definitely" unhealthy products (growth hormone or steroids). The prevalence grew from approximately 2% among 13- to 15-year-old boys, to about 7% among 16- to 18-year-old boys, to almost 9% among young men aged 19-22.

"A lot of these young men who are using unhealthy products to bulk up won’t be huge – not yet," said Dr. Field. "These are hard issues to assess, but it will be important for clinicians to probe."

Adolescent boys commonly want more muscularity, she said, but "we’re talking here about defining yourself around your physique and being willing to take on whatever it takes to achieve that."

Dr. Field and her coinvestigators used lagged analysis techniques to determine whether these concerns and behaviors led to certain adverse outcomes and risky behaviors.

Boys with thinness concerns, they found, were 2.5 times more likely than their peers without weight concerns to develop a high level of depressive symptoms (the top quartile of the Center for Epidemiologic Studies Depression Scale [CES-D] self-report scale) in the next 1-2 years.

Those with high concerns about both muscularity and thinness were more likely than their peers to start binge drinking frequently (odds ratio, 1.6) and using drugs (OR, 2.5) within the next 1-2 years, as were boys with high muscularity concerns who used supplements and other products to enhance physique (OR, 2.4 and 2, respectively).

The analysis also offers a window into the issue of eating disorders in males. Bulimia nervosa was rare across age groups, as was purging disorder until young adulthood, when the prevalence grew to just under 1% among males aged 23 years and older. The prevalence of meeting partial or full criteria for binge eating disorder (which for this analysis meant binge eating at least monthly), however, was much higher and grew with age, from almost 0.5% among boys aged 9-12, to more than 2% in the 19- to 22-year-old age group.

Research on disordered eating among males is tricky because most scales and other research tools have been validated for females only.

In terms of diagnosis, "the DSM-5 criteria [for eating disorders] have been improved for females, but we may not be capturing the problem for males," Dr. Field said. More discussion is needed, she said, on the possibility of gender differences.

Dr. Field reported no relevant financial disclosures.

WASHINGTON – High levels of concern with muscularity, or with both muscularity and thinness, were relatively common – and were associated with a risk of adverse outcomes – among adolescent boys participating in the ongoing Growing Up Today Study.

Male adolescents may not be recognized as having body shape concerns or weight-related disorders because of their gender and what likely are gender-specific presentations. This analysis of the GUTS cohort, however, should put such concerns and disorders on the radar screen for pediatricians and other clinicians, Alison E. Field, Sc.D., reported at the annual meeting of the Pediatric Academic Societies.

©vizion-photography/iStockphoto.com

The Growing Up Today Study – a National Institutes of Health–funded prospective cohort study established in 1996 to assess factors that influence weight change – has involved approximately 16,800 children (approximately 9,000 girls and 7,800 boys) who are offspring of women participating in the separate Nurses Health Study 2.

Questionnaires sent every 12-24 months to the boys participating in GUTS have assessed concerns with thinness, concerns with muscularity, use of products to enhance physique, bulimic behaviors, weight and height, depressive symptoms, drug use, and binge eating and drinking. To assess concerns about muscularity, for instance, boys were asked, "How frequently do you think about wanting to tone or define muscle?"

The analysis presented at the PAS meeting involved 5,527 male adolescents who had returned at least two questionnaires between 1999 and 2010. The boys ranged in age from 12 to 18 years in 1999.

Thinness itself was the least common concern. It was a significant concern of about 2% of boys aged 13-15 years, and the prevalence of the concern decreased in older age groups.

The prevalence of concerns and behaviors that included muscularity, on the other hand, was much higher, reported Dr. Field of the department of pediatrics at Harvard Medical School, Boston.

"Particularly troubling," Dr. Field said, was the prevalence of muscularity concerns coupled with the reported use of "potentially" unhealthy products (creatine supplements) and "definitely" unhealthy products (growth hormone or steroids). The prevalence grew from approximately 2% among 13- to 15-year-old boys, to about 7% among 16- to 18-year-old boys, to almost 9% among young men aged 19-22.

"A lot of these young men who are using unhealthy products to bulk up won’t be huge – not yet," said Dr. Field. "These are hard issues to assess, but it will be important for clinicians to probe."

Adolescent boys commonly want more muscularity, she said, but "we’re talking here about defining yourself around your physique and being willing to take on whatever it takes to achieve that."

Dr. Field and her coinvestigators used lagged analysis techniques to determine whether these concerns and behaviors led to certain adverse outcomes and risky behaviors.

Boys with thinness concerns, they found, were 2.5 times more likely than their peers without weight concerns to develop a high level of depressive symptoms (the top quartile of the Center for Epidemiologic Studies Depression Scale [CES-D] self-report scale) in the next 1-2 years.

Those with high concerns about both muscularity and thinness were more likely than their peers to start binge drinking frequently (odds ratio, 1.6) and using drugs (OR, 2.5) within the next 1-2 years, as were boys with high muscularity concerns who used supplements and other products to enhance physique (OR, 2.4 and 2, respectively).

The analysis also offers a window into the issue of eating disorders in males. Bulimia nervosa was rare across age groups, as was purging disorder until young adulthood, when the prevalence grew to just under 1% among males aged 23 years and older. The prevalence of meeting partial or full criteria for binge eating disorder (which for this analysis meant binge eating at least monthly), however, was much higher and grew with age, from almost 0.5% among boys aged 9-12, to more than 2% in the 19- to 22-year-old age group.

Research on disordered eating among males is tricky because most scales and other research tools have been validated for females only.

In terms of diagnosis, "the DSM-5 criteria [for eating disorders] have been improved for females, but we may not be capturing the problem for males," Dr. Field said. More discussion is needed, she said, on the possibility of gender differences.

Dr. Field reported no relevant financial disclosures.

WASHINGTON – High levels of concern with muscularity, or with both muscularity and thinness, were relatively common – and were associated with a risk of adverse outcomes – among adolescent boys participating in the ongoing Growing Up Today Study.

Male adolescents may not be recognized as having body shape concerns or weight-related disorders because of their gender and what likely are gender-specific presentations. This analysis of the GUTS cohort, however, should put such concerns and disorders on the radar screen for pediatricians and other clinicians, Alison E. Field, Sc.D., reported at the annual meeting of the Pediatric Academic Societies.

©vizion-photography/iStockphoto.com

The Growing Up Today Study – a National Institutes of Health–funded prospective cohort study established in 1996 to assess factors that influence weight change – has involved approximately 16,800 children (approximately 9,000 girls and 7,800 boys) who are offspring of women participating in the separate Nurses Health Study 2.

Questionnaires sent every 12-24 months to the boys participating in GUTS have assessed concerns with thinness, concerns with muscularity, use of products to enhance physique, bulimic behaviors, weight and height, depressive symptoms, drug use, and binge eating and drinking. To assess concerns about muscularity, for instance, boys were asked, "How frequently do you think about wanting to tone or define muscle?"

The analysis presented at the PAS meeting involved 5,527 male adolescents who had returned at least two questionnaires between 1999 and 2010. The boys ranged in age from 12 to 18 years in 1999.

Thinness itself was the least common concern. It was a significant concern of about 2% of boys aged 13-15 years, and the prevalence of the concern decreased in older age groups.

The prevalence of concerns and behaviors that included muscularity, on the other hand, was much higher, reported Dr. Field of the department of pediatrics at Harvard Medical School, Boston.

"Particularly troubling," Dr. Field said, was the prevalence of muscularity concerns coupled with the reported use of "potentially" unhealthy products (creatine supplements) and "definitely" unhealthy products (growth hormone or steroids). The prevalence grew from approximately 2% among 13- to 15-year-old boys, to about 7% among 16- to 18-year-old boys, to almost 9% among young men aged 19-22.

"A lot of these young men who are using unhealthy products to bulk up won’t be huge – not yet," said Dr. Field. "These are hard issues to assess, but it will be important for clinicians to probe."

Adolescent boys commonly want more muscularity, she said, but "we’re talking here about defining yourself around your physique and being willing to take on whatever it takes to achieve that."

Dr. Field and her coinvestigators used lagged analysis techniques to determine whether these concerns and behaviors led to certain adverse outcomes and risky behaviors.

Boys with thinness concerns, they found, were 2.5 times more likely than their peers without weight concerns to develop a high level of depressive symptoms (the top quartile of the Center for Epidemiologic Studies Depression Scale [CES-D] self-report scale) in the next 1-2 years.

Those with high concerns about both muscularity and thinness were more likely than their peers to start binge drinking frequently (odds ratio, 1.6) and using drugs (OR, 2.5) within the next 1-2 years, as were boys with high muscularity concerns who used supplements and other products to enhance physique (OR, 2.4 and 2, respectively).

The analysis also offers a window into the issue of eating disorders in males. Bulimia nervosa was rare across age groups, as was purging disorder until young adulthood, when the prevalence grew to just under 1% among males aged 23 years and older. The prevalence of meeting partial or full criteria for binge eating disorder (which for this analysis meant binge eating at least monthly), however, was much higher and grew with age, from almost 0.5% among boys aged 9-12, to more than 2% in the 19- to 22-year-old age group.

Research on disordered eating among males is tricky because most scales and other research tools have been validated for females only.

In terms of diagnosis, "the DSM-5 criteria [for eating disorders] have been improved for females, but we may not be capturing the problem for males," Dr. Field said. More discussion is needed, she said, on the possibility of gender differences.

Dr. Field reported no relevant financial disclosures.

WASHINGTON – Screening for chlamydia and gonorrhea infections using urine testing alone would have missed more than three-fourths of infections in a population of gay youth, a study has found.

"Urine screening alone is not a reliable proxy for all sites for gonorrhea and chlamydia infections in a youth men-who-have-sex-with-men population," reported Dr. Katie Plax at the annual meeting of the Pediatric Academic Societies (PAS).

Instead, it appears that triple screening – with pharyngeal and rectal testing done along with genital screening through urine tests – can enhance the detection of chlamydia and gonorrhea, especially in this high-risk population.

Dr. Plax and her coinvestigators screened 135 young men who have sex with men (MSM), aged 14-24 years, during 189 visits to a drop-in youth center in St. Louis that provides health and social services. Each of the youth had triple screening with nucleic acid simplification testing of urine, rectum, and pharyngeal specimens.

Of all the positive test results over the 12-month study, only 17% were from urine specimens, whereas 82% were in rectal or throat specimens. (There were 29 positive chlamydia tests in 26 of the 135 men, and 72 positive gonorrhea tests in 51 of the men. Twelve of the young men were positive for both infections.)

Urine screening alone would have missed 85% of chlamydia infections and 72% of gonorrhea infections, their analysis shows, while throat screening alone would have missed 88% of chlamydia infections and 43% of gonorrhea infections. Rectal screening had the highest yield, with the estimated rates of missed infections being 15% and 41%, respectively.

"More attention should be focused on the role that extragenital infections play," said Dr. Plax, director of the Adolescent Center at St. Louis Children’s Hospital and associate professor of pediatrics at Washington University in St. Louis. "For HIV-uninfected patients, this is a public health emergency, because we know that an STD [sexually transmitted disease] diagnosis is both a marker for potentially high-risk activity and also a potential cofactor for HIV acquisition."

Gonorrhea infections in particular "have been identified as one of the strongest and most consistent risk factors associated with HIV seroprevalence and HIV seroconversion," she said.

Almost half of the estimated 19 million new cases of sexually transmitted infections each year occur in youth aged 15-24 years, she noted. Moreover, the vast majority of gonorrhea and chlamydia infections – 85% – are asymptomatic.

The Centers for Disease Control and Prevention recommends routine laboratory screening for common STDs for all sexually active MSM, with screening tests selected based on types of reported intercourse. This is tricky to implement, Dr. Plax said, given that basic sexual history-taking still is challenging for many providers.

"We need to take better sexual histories. We can’t ask people, especially youth, are you gay, straight, or bisexual? They don’t identify that way," she noted. "You have to ask, do you have sex with men, women, or both?"

In another study reported at the PAS meeting, researchers found that physicians are documenting sexual histories and performing tests for sexually transmitted infections (STIs) infrequently in adolescent patients, including those who report sexual activity.

In this retrospective cross-sectional study of 1,000 randomly selected routine visits by patients aged 13-19 years, fewer than one-quarter of the patients had a documented sexual history. Of those who reported being sexually active, 38% underwent STI testing and 22% had ever undergone HIV testing specifically. Overall, only 2.6% of the patients had been tested for STIs in the year preceding their visit, and only 1.1% had been tested for HIV.

The patients were among 40,000 adolescents seeking care at 29 primary care practices affiliated with the Children’s Hospital of Philadelphia and the Children’s National Medical Center in Washington. The findings were reported by Rachel Witt, a medical student at the University of Pennsylvania, Philadelphia.

Dr. Plax reported that she and her coinvestigators had no disclosures. Ms. Witt had no disclosures.

WASHINGTON – Screening for chlamydia and gonorrhea infections using urine testing alone would have missed more than three-fourths of infections in a population of gay youth, a study has found.

"Urine screening alone is not a reliable proxy for all sites for gonorrhea and chlamydia infections in a youth men-who-have-sex-with-men population," reported Dr. Katie Plax at the annual meeting of the Pediatric Academic Societies (PAS).

Instead, it appears that triple screening – with pharyngeal and rectal testing done along with genital screening through urine tests – can enhance the detection of chlamydia and gonorrhea, especially in this high-risk population.

Dr. Plax and her coinvestigators screened 135 young men who have sex with men (MSM), aged 14-24 years, during 189 visits to a drop-in youth center in St. Louis that provides health and social services. Each of the youth had triple screening with nucleic acid simplification testing of urine, rectum, and pharyngeal specimens.

Of all the positive test results over the 12-month study, only 17% were from urine specimens, whereas 82% were in rectal or throat specimens. (There were 29 positive chlamydia tests in 26 of the 135 men, and 72 positive gonorrhea tests in 51 of the men. Twelve of the young men were positive for both infections.)

Urine screening alone would have missed 85% of chlamydia infections and 72% of gonorrhea infections, their analysis shows, while throat screening alone would have missed 88% of chlamydia infections and 43% of gonorrhea infections. Rectal screening had the highest yield, with the estimated rates of missed infections being 15% and 41%, respectively.

"More attention should be focused on the role that extragenital infections play," said Dr. Plax, director of the Adolescent Center at St. Louis Children’s Hospital and associate professor of pediatrics at Washington University in St. Louis. "For HIV-uninfected patients, this is a public health emergency, because we know that an STD [sexually transmitted disease] diagnosis is both a marker for potentially high-risk activity and also a potential cofactor for HIV acquisition."

Gonorrhea infections in particular "have been identified as one of the strongest and most consistent risk factors associated with HIV seroprevalence and HIV seroconversion," she said.

Almost half of the estimated 19 million new cases of sexually transmitted infections each year occur in youth aged 15-24 years, she noted. Moreover, the vast majority of gonorrhea and chlamydia infections – 85% – are asymptomatic.

The Centers for Disease Control and Prevention recommends routine laboratory screening for common STDs for all sexually active MSM, with screening tests selected based on types of reported intercourse. This is tricky to implement, Dr. Plax said, given that basic sexual history-taking still is challenging for many providers.

"We need to take better sexual histories. We can’t ask people, especially youth, are you gay, straight, or bisexual? They don’t identify that way," she noted. "You have to ask, do you have sex with men, women, or both?"

In another study reported at the PAS meeting, researchers found that physicians are documenting sexual histories and performing tests for sexually transmitted infections (STIs) infrequently in adolescent patients, including those who report sexual activity.

In this retrospective cross-sectional study of 1,000 randomly selected routine visits by patients aged 13-19 years, fewer than one-quarter of the patients had a documented sexual history. Of those who reported being sexually active, 38% underwent STI testing and 22% had ever undergone HIV testing specifically. Overall, only 2.6% of the patients had been tested for STIs in the year preceding their visit, and only 1.1% had been tested for HIV.

The patients were among 40,000 adolescents seeking care at 29 primary care practices affiliated with the Children’s Hospital of Philadelphia and the Children’s National Medical Center in Washington. The findings were reported by Rachel Witt, a medical student at the University of Pennsylvania, Philadelphia.

Dr. Plax reported that she and her coinvestigators had no disclosures. Ms. Witt had no disclosures.

WASHINGTON – Screening for chlamydia and gonorrhea infections using urine testing alone would have missed more than three-fourths of infections in a population of gay youth, a study has found.

"Urine screening alone is not a reliable proxy for all sites for gonorrhea and chlamydia infections in a youth men-who-have-sex-with-men population," reported Dr. Katie Plax at the annual meeting of the Pediatric Academic Societies (PAS).

Instead, it appears that triple screening – with pharyngeal and rectal testing done along with genital screening through urine tests – can enhance the detection of chlamydia and gonorrhea, especially in this high-risk population.

Dr. Plax and her coinvestigators screened 135 young men who have sex with men (MSM), aged 14-24 years, during 189 visits to a drop-in youth center in St. Louis that provides health and social services. Each of the youth had triple screening with nucleic acid simplification testing of urine, rectum, and pharyngeal specimens.

Of all the positive test results over the 12-month study, only 17% were from urine specimens, whereas 82% were in rectal or throat specimens. (There were 29 positive chlamydia tests in 26 of the 135 men, and 72 positive gonorrhea tests in 51 of the men. Twelve of the young men were positive for both infections.)

Urine screening alone would have missed 85% of chlamydia infections and 72% of gonorrhea infections, their analysis shows, while throat screening alone would have missed 88% of chlamydia infections and 43% of gonorrhea infections. Rectal screening had the highest yield, with the estimated rates of missed infections being 15% and 41%, respectively.

"More attention should be focused on the role that extragenital infections play," said Dr. Plax, director of the Adolescent Center at St. Louis Children’s Hospital and associate professor of pediatrics at Washington University in St. Louis. "For HIV-uninfected patients, this is a public health emergency, because we know that an STD [sexually transmitted disease] diagnosis is both a marker for potentially high-risk activity and also a potential cofactor for HIV acquisition."

Gonorrhea infections in particular "have been identified as one of the strongest and most consistent risk factors associated with HIV seroprevalence and HIV seroconversion," she said.

Almost half of the estimated 19 million new cases of sexually transmitted infections each year occur in youth aged 15-24 years, she noted. Moreover, the vast majority of gonorrhea and chlamydia infections – 85% – are asymptomatic.

The Centers for Disease Control and Prevention recommends routine laboratory screening for common STDs for all sexually active MSM, with screening tests selected based on types of reported intercourse. This is tricky to implement, Dr. Plax said, given that basic sexual history-taking still is challenging for many providers.

"We need to take better sexual histories. We can’t ask people, especially youth, are you gay, straight, or bisexual? They don’t identify that way," she noted. "You have to ask, do you have sex with men, women, or both?"

In another study reported at the PAS meeting, researchers found that physicians are documenting sexual histories and performing tests for sexually transmitted infections (STIs) infrequently in adolescent patients, including those who report sexual activity.

In this retrospective cross-sectional study of 1,000 randomly selected routine visits by patients aged 13-19 years, fewer than one-quarter of the patients had a documented sexual history. Of those who reported being sexually active, 38% underwent STI testing and 22% had ever undergone HIV testing specifically. Overall, only 2.6% of the patients had been tested for STIs in the year preceding their visit, and only 1.1% had been tested for HIV.

The patients were among 40,000 adolescents seeking care at 29 primary care practices affiliated with the Children’s Hospital of Philadelphia and the Children’s National Medical Center in Washington. The findings were reported by Rachel Witt, a medical student at the University of Pennsylvania, Philadelphia.

Dr. Plax reported that she and her coinvestigators had no disclosures. Ms. Witt had no disclosures.

WASHINGTON – Poverty-related disparities in school readiness are a "major public health crisis," in the opinion of Dr. Alan L. Mendelsohn and his colleagues at Bellevue Hospital Center in New York, and they have long been thinking about how to best take advantage of pediatric well-child care visits to promote parent-child interactions that can reduce these disparities.

One of the parenting interventions they are studying – a program called the Video Interaction Project (VIP) – already has been shown to enhance parent-child interactions at the 6-month mark.

Now, it seems that the parenting program can have a long-term impact as well – and that continuing the interventions into the 3- to 5-year age group can have further, independent effects on parent-child interactions.

"Our new findings provide support for interventions based in pediatric primary care to enhance parenting in both the infant and toddler years and the preschool periods," Dr. Mendelsohn, a pediatric developmental behavioral health specialist, reported at the annual meeting of the Pediatric Academic Societies.

Enhancing parent-child interactions, he believes, should improve language and cognitive social-emotional development and ultimately promote school readiness and school performance. Poor children are exposed to 75% fewer words, he noted.

In the VIP program, a child development specialist videotapes the parent and child interacting together with a book or a toy either before or after routine primary care visits. The parent and specialist then watch the video together, with the specialist reinforcing positive interactions, offering suggestions for further interaction, and promoting parent self-reflection. VIP families also receive parenting pamphlets and learning materials at each visit.

The project has been developed in two phases, with VIP 0-3 covering children from birth through 3 years of age, and VIP 3-5 covering the preschool years and entailing increasingly rich play and literacy activities. All told, from birth through 5 years, about 15 VIP sessions take place for each participating family.

The research is part of the Bellevue Project for Early Language, Literacy, and Educational Success (BELLE Project). New mothers were enrolled during the postpartum period at Bellevue Hospital Center and randomized to VIP 0-3 or control; then at age 3 years, the VIP and control families were re-randomized to receive either additional VIP during ages 3-5 years or to control during that period. At 54 months, investigators performed single-blind assessments of parenting and child development.

Bellevue Hospital Center is a public hospital serving families of low socioeconomic status throughout New York City. The 450 mothers enrolled in BELLE are primarily first-generation Hispanic/Latino immigrants. All had singleton, full-term uncomplicated births and spoke English or Spanish as their primary language.

A prior published analysis of the cohort showed enhanced infant-parent interactions as reflected by significantly higher StimQ scores in the VIP 0-3 group at 6 months of age (Arch. Pediatr. Adolesc. Med. 2011;165:33-41). Another analysis at 33 months showed lower levels of parenting stress and a greater likelihood of normal cognitive development in VIP children (J. Dev. Behav. Pediatr. 2007;28:206-12).

The StimQ is an office-based survey developed by Dr. Mendelsohn and others at New York University (NYU) for measuring cognitive stimulation in the homes of young children. It is validated for use in low-socioeconomic populations whose primary language is English or Spanish.

The new 54-month analysis used adaptations of three StimQ-Preschool subscales: Parent Verbal Responsivity, Reading Activities, and Parent Involvement in Developmental Advance, the last of which measures the number of different interactional activities occurring between the caregiver and child that promote cognitive development.

At 54 months, VIP 0-3 was associated with significant increases in scores for parent verbal responsivity (8.98 vs. 7.95) and reading (24.91 vs. 23.75), but only a minimal increase in the score for teaching activities. VIP 3-5 was independently associated with significant increases in verbal responsivity (9.14 vs. 7.99) and teaching (13.18 vs. 12.04), with a trend toward enhancements in reading, Dr. Mendelsohn reported.

"Importantly, the effects were independent, suggesting additive impacts for those receiving interventions during both periods," he said.

Among the next steps in their research are comprehensive assessments in the first grade.

"We also need to work on replication and on understanding whether this is equally effective in other low-income groups," Dr. Mendelsohn said. "We need to build on this burgeoning science ... but we don’t want to just dilute and spread."

Dr. Alan L. Mendelsohn reported no disclosures. VIP has been funded by the National Institute of Child Health and Human Development, the Marks Family Foundation, the Tiger Foundation, Children of Bellevue, and KiDS of NYU.

WASHINGTON – Poverty-related disparities in school readiness are a "major public health crisis," in the opinion of Dr. Alan L. Mendelsohn and his colleagues at Bellevue Hospital Center in New York, and they have long been thinking about how to best take advantage of pediatric well-child care visits to promote parent-child interactions that can reduce these disparities.

One of the parenting interventions they are studying – a program called the Video Interaction Project (VIP) – already has been shown to enhance parent-child interactions at the 6-month mark.

Now, it seems that the parenting program can have a long-term impact as well – and that continuing the interventions into the 3- to 5-year age group can have further, independent effects on parent-child interactions.

"Our new findings provide support for interventions based in pediatric primary care to enhance parenting in both the infant and toddler years and the preschool periods," Dr. Mendelsohn, a pediatric developmental behavioral health specialist, reported at the annual meeting of the Pediatric Academic Societies.

Enhancing parent-child interactions, he believes, should improve language and cognitive social-emotional development and ultimately promote school readiness and school performance. Poor children are exposed to 75% fewer words, he noted.

In the VIP program, a child development specialist videotapes the parent and child interacting together with a book or a toy either before or after routine primary care visits. The parent and specialist then watch the video together, with the specialist reinforcing positive interactions, offering suggestions for further interaction, and promoting parent self-reflection. VIP families also receive parenting pamphlets and learning materials at each visit.

The project has been developed in two phases, with VIP 0-3 covering children from birth through 3 years of age, and VIP 3-5 covering the preschool years and entailing increasingly rich play and literacy activities. All told, from birth through 5 years, about 15 VIP sessions take place for each participating family.

The research is part of the Bellevue Project for Early Language, Literacy, and Educational Success (BELLE Project). New mothers were enrolled during the postpartum period at Bellevue Hospital Center and randomized to VIP 0-3 or control; then at age 3 years, the VIP and control families were re-randomized to receive either additional VIP during ages 3-5 years or to control during that period. At 54 months, investigators performed single-blind assessments of parenting and child development.

Bellevue Hospital Center is a public hospital serving families of low socioeconomic status throughout New York City. The 450 mothers enrolled in BELLE are primarily first-generation Hispanic/Latino immigrants. All had singleton, full-term uncomplicated births and spoke English or Spanish as their primary language.

A prior published analysis of the cohort showed enhanced infant-parent interactions as reflected by significantly higher StimQ scores in the VIP 0-3 group at 6 months of age (Arch. Pediatr. Adolesc. Med. 2011;165:33-41). Another analysis at 33 months showed lower levels of parenting stress and a greater likelihood of normal cognitive development in VIP children (J. Dev. Behav. Pediatr. 2007;28:206-12).

The StimQ is an office-based survey developed by Dr. Mendelsohn and others at New York University (NYU) for measuring cognitive stimulation in the homes of young children. It is validated for use in low-socioeconomic populations whose primary language is English or Spanish.

The new 54-month analysis used adaptations of three StimQ-Preschool subscales: Parent Verbal Responsivity, Reading Activities, and Parent Involvement in Developmental Advance, the last of which measures the number of different interactional activities occurring between the caregiver and child that promote cognitive development.

At 54 months, VIP 0-3 was associated with significant increases in scores for parent verbal responsivity (8.98 vs. 7.95) and reading (24.91 vs. 23.75), but only a minimal increase in the score for teaching activities. VIP 3-5 was independently associated with significant increases in verbal responsivity (9.14 vs. 7.99) and teaching (13.18 vs. 12.04), with a trend toward enhancements in reading, Dr. Mendelsohn reported.

"Importantly, the effects were independent, suggesting additive impacts for those receiving interventions during both periods," he said.

Among the next steps in their research are comprehensive assessments in the first grade.

"We also need to work on replication and on understanding whether this is equally effective in other low-income groups," Dr. Mendelsohn said. "We need to build on this burgeoning science ... but we don’t want to just dilute and spread."

Dr. Alan L. Mendelsohn reported no disclosures. VIP has been funded by the National Institute of Child Health and Human Development, the Marks Family Foundation, the Tiger Foundation, Children of Bellevue, and KiDS of NYU.

WASHINGTON – Poverty-related disparities in school readiness are a "major public health crisis," in the opinion of Dr. Alan L. Mendelsohn and his colleagues at Bellevue Hospital Center in New York, and they have long been thinking about how to best take advantage of pediatric well-child care visits to promote parent-child interactions that can reduce these disparities.

One of the parenting interventions they are studying – a program called the Video Interaction Project (VIP) – already has been shown to enhance parent-child interactions at the 6-month mark.

Now, it seems that the parenting program can have a long-term impact as well – and that continuing the interventions into the 3- to 5-year age group can have further, independent effects on parent-child interactions.

"Our new findings provide support for interventions based in pediatric primary care to enhance parenting in both the infant and toddler years and the preschool periods," Dr. Mendelsohn, a pediatric developmental behavioral health specialist, reported at the annual meeting of the Pediatric Academic Societies.

Enhancing parent-child interactions, he believes, should improve language and cognitive social-emotional development and ultimately promote school readiness and school performance. Poor children are exposed to 75% fewer words, he noted.

In the VIP program, a child development specialist videotapes the parent and child interacting together with a book or a toy either before or after routine primary care visits. The parent and specialist then watch the video together, with the specialist reinforcing positive interactions, offering suggestions for further interaction, and promoting parent self-reflection. VIP families also receive parenting pamphlets and learning materials at each visit.

The project has been developed in two phases, with VIP 0-3 covering children from birth through 3 years of age, and VIP 3-5 covering the preschool years and entailing increasingly rich play and literacy activities. All told, from birth through 5 years, about 15 VIP sessions take place for each participating family.

The research is part of the Bellevue Project for Early Language, Literacy, and Educational Success (BELLE Project). New mothers were enrolled during the postpartum period at Bellevue Hospital Center and randomized to VIP 0-3 or control; then at age 3 years, the VIP and control families were re-randomized to receive either additional VIP during ages 3-5 years or to control during that period. At 54 months, investigators performed single-blind assessments of parenting and child development.

Bellevue Hospital Center is a public hospital serving families of low socioeconomic status throughout New York City. The 450 mothers enrolled in BELLE are primarily first-generation Hispanic/Latino immigrants. All had singleton, full-term uncomplicated births and spoke English or Spanish as their primary language.

A prior published analysis of the cohort showed enhanced infant-parent interactions as reflected by significantly higher StimQ scores in the VIP 0-3 group at 6 months of age (Arch. Pediatr. Adolesc. Med. 2011;165:33-41). Another analysis at 33 months showed lower levels of parenting stress and a greater likelihood of normal cognitive development in VIP children (J. Dev. Behav. Pediatr. 2007;28:206-12).

The StimQ is an office-based survey developed by Dr. Mendelsohn and others at New York University (NYU) for measuring cognitive stimulation in the homes of young children. It is validated for use in low-socioeconomic populations whose primary language is English or Spanish.

The new 54-month analysis used adaptations of three StimQ-Preschool subscales: Parent Verbal Responsivity, Reading Activities, and Parent Involvement in Developmental Advance, the last of which measures the number of different interactional activities occurring between the caregiver and child that promote cognitive development.

At 54 months, VIP 0-3 was associated with significant increases in scores for parent verbal responsivity (8.98 vs. 7.95) and reading (24.91 vs. 23.75), but only a minimal increase in the score for teaching activities. VIP 3-5 was independently associated with significant increases in verbal responsivity (9.14 vs. 7.99) and teaching (13.18 vs. 12.04), with a trend toward enhancements in reading, Dr. Mendelsohn reported.

"Importantly, the effects were independent, suggesting additive impacts for those receiving interventions during both periods," he said.

Among the next steps in their research are comprehensive assessments in the first grade.

"We also need to work on replication and on understanding whether this is equally effective in other low-income groups," Dr. Mendelsohn said. "We need to build on this burgeoning science ... but we don’t want to just dilute and spread."

Dr. Alan L. Mendelsohn reported no disclosures. VIP has been funded by the National Institute of Child Health and Human Development, the Marks Family Foundation, the Tiger Foundation, Children of Bellevue, and KiDS of NYU.

WASHINGTON – Several years after the U.S. Preventive Services Task Force recommended screening adolescents for depression in primary care, only half of pediatricians and other primary care providers are routinely using standardized instruments, according to a statewide survey of pediatricians, family physicians and nurse practitioners in Minnesota.

"In general, clinicians most frequently used clinical observation or overall impressions to identify adolescents experiencing depression [rather] than other methods," Lindsay Taliaferro, Ph.D., reported at the annual meeting of the Pediatric Academic Societies.

The estimated overall prevalence of major depressive disorder among adolescents is 5.6%, and the point prevalence in primary care settings is reported as ranging from 9% to 21%, according to the U.S. Preventive Services Task Force (USPSTF) recommendations.

Dr. Taliaferro and her colleagues at the University of Minnesota, Minneapolis, administered an online survey to a statewide sample of physicians and nurse practitioners (NPs) who provide direct ambulatory primary care services to adolescents aged 12-18 years. The clinicians were identified from lists obtained from the state’s boards of nursing and medical practice; there was a 20% response rate, which Dr. Taliaferro said is low but typical of such surveys.

The analytical sample included 127 pediatricians and 54 pediatric NPs, as well as 260 family physicians and 96 family medicine NPs.

Asked to report which depression identification practices they "usually/almost always" employ, 80% said they use clinical observation/overall impression, while 50% said they use a standardized written depression screening instrument, 40% use a "depression screening item within a comprehensive behavioral screening instrument," and 20% use a psychosocial interview (such as the HEADSS assessment, which stands for home, education and employment, activities, drugs, sexuality, suicide/depression).

There were no significant differences between physicians and nurse practitioners in the methods used to identify depression. There were differences, however, between pediatrics and family medicine in both the use of a psychosocial interview and the use of clinical observation/overall impression, with pediatric clinicians (both physicians and NPs) significantly more likely to report use of these methods, Dr. Taliaferro noted.

In another survey item, 75% of the pediatric providers reported routinely "asking about" depressive symptoms when providing health supervision. For family physicians and family nurse practitioners, this rate was 66%, she reported.

Asked if they had "ever" administered a standardized written depression instrument, 76% of providers indicated they had.

All told, Dr. Taliaferro said, it appears from the survey that "most [clinicians] don’t screen everyone, but instead are screening only high-risk patients after they identify some warning signs or in response to specific complaints."

The USPSTF issued its recommendation for adolescent screening in 2009, saying that clinicians should screen for major depressive disorder in adolescents (12- to 18-year-olds) when systems are in place to ensure accurate diagnosis, treatment, and follow-up.

"We all know that many adolescents in distress present with medical problems rather than psychological symptoms, and that adolescents may not verbalize their feelings or disclose their psychological issues without prompting from clinicians," said Dr. Taliaferro, who is now with the University of Missouri School of Health Professions, Columbia.

According to the task force, two screening instruments – the PHQ-A (the Patient Health Questionnaire–9 modified for adolescents) and the BDI-PC (Beck Depression Inventory for Primary Care) – have demonstrated good sensitivity and specificity for adolescents seen in primary care settings.

Dr. Taliaferro said after the meeting that "an overwhelming majority" of survey participants who use standardized instruments indicated that they use the PHQ-9, presumably the adolescent version. The PHQ-9 is integrated into the electronic medical record of many of the systems being utilized in primary care, she noted.

The investigators analyzed survey data to determine what factors were associated with use of a standardized written depression screening instrument and with inquiries about depression symptoms. Factors that increased the likelihood of administering a screening instrument included being female, being a family medicine clinician, having clear protocols for follow-up after depression, and feeling better prepared to address depression among adolescents.

Factors that increased the likelihood of asking about depression symptoms included believing more strongly that providers should be responsible for addressing depression among adolescents and being more familiar with recommendations regarding screening, Dr. Taliaferro reported.

Approximately 40% of participants reported having on-site mental health services that are available to their adolescent patients, she noted.

Dr. Taliaferro reported that she had no relevant financial disclosures. The investigators received funding for the survey from the Minnesota Department of Human Services.

WASHINGTON – Several years after the U.S. Preventive Services Task Force recommended screening adolescents for depression in primary care, only half of pediatricians and other primary care providers are routinely using standardized instruments, according to a statewide survey of pediatricians, family physicians and nurse practitioners in Minnesota.

"In general, clinicians most frequently used clinical observation or overall impressions to identify adolescents experiencing depression [rather] than other methods," Lindsay Taliaferro, Ph.D., reported at the annual meeting of the Pediatric Academic Societies.

The estimated overall prevalence of major depressive disorder among adolescents is 5.6%, and the point prevalence in primary care settings is reported as ranging from 9% to 21%, according to the U.S. Preventive Services Task Force (USPSTF) recommendations.

Dr. Taliaferro and her colleagues at the University of Minnesota, Minneapolis, administered an online survey to a statewide sample of physicians and nurse practitioners (NPs) who provide direct ambulatory primary care services to adolescents aged 12-18 years. The clinicians were identified from lists obtained from the state’s boards of nursing and medical practice; there was a 20% response rate, which Dr. Taliaferro said is low but typical of such surveys.

The analytical sample included 127 pediatricians and 54 pediatric NPs, as well as 260 family physicians and 96 family medicine NPs.

Asked to report which depression identification practices they "usually/almost always" employ, 80% said they use clinical observation/overall impression, while 50% said they use a standardized written depression screening instrument, 40% use a "depression screening item within a comprehensive behavioral screening instrument," and 20% use a psychosocial interview (such as the HEADSS assessment, which stands for home, education and employment, activities, drugs, sexuality, suicide/depression).

There were no significant differences between physicians and nurse practitioners in the methods used to identify depression. There were differences, however, between pediatrics and family medicine in both the use of a psychosocial interview and the use of clinical observation/overall impression, with pediatric clinicians (both physicians and NPs) significantly more likely to report use of these methods, Dr. Taliaferro noted.

In another survey item, 75% of the pediatric providers reported routinely "asking about" depressive symptoms when providing health supervision. For family physicians and family nurse practitioners, this rate was 66%, she reported.

Asked if they had "ever" administered a standardized written depression instrument, 76% of providers indicated they had.

All told, Dr. Taliaferro said, it appears from the survey that "most [clinicians] don’t screen everyone, but instead are screening only high-risk patients after they identify some warning signs or in response to specific complaints."

The USPSTF issued its recommendation for adolescent screening in 2009, saying that clinicians should screen for major depressive disorder in adolescents (12- to 18-year-olds) when systems are in place to ensure accurate diagnosis, treatment, and follow-up.

"We all know that many adolescents in distress present with medical problems rather than psychological symptoms, and that adolescents may not verbalize their feelings or disclose their psychological issues without prompting from clinicians," said Dr. Taliaferro, who is now with the University of Missouri School of Health Professions, Columbia.

According to the task force, two screening instruments – the PHQ-A (the Patient Health Questionnaire–9 modified for adolescents) and the BDI-PC (Beck Depression Inventory for Primary Care) – have demonstrated good sensitivity and specificity for adolescents seen in primary care settings.

Dr. Taliaferro said after the meeting that "an overwhelming majority" of survey participants who use standardized instruments indicated that they use the PHQ-9, presumably the adolescent version. The PHQ-9 is integrated into the electronic medical record of many of the systems being utilized in primary care, she noted.

The investigators analyzed survey data to determine what factors were associated with use of a standardized written depression screening instrument and with inquiries about depression symptoms. Factors that increased the likelihood of administering a screening instrument included being female, being a family medicine clinician, having clear protocols for follow-up after depression, and feeling better prepared to address depression among adolescents.

Factors that increased the likelihood of asking about depression symptoms included believing more strongly that providers should be responsible for addressing depression among adolescents and being more familiar with recommendations regarding screening, Dr. Taliaferro reported.

Approximately 40% of participants reported having on-site mental health services that are available to their adolescent patients, she noted.

Dr. Taliaferro reported that she had no relevant financial disclosures. The investigators received funding for the survey from the Minnesota Department of Human Services.

WASHINGTON – Several years after the U.S. Preventive Services Task Force recommended screening adolescents for depression in primary care, only half of pediatricians and other primary care providers are routinely using standardized instruments, according to a statewide survey of pediatricians, family physicians and nurse practitioners in Minnesota.

"In general, clinicians most frequently used clinical observation or overall impressions to identify adolescents experiencing depression [rather] than other methods," Lindsay Taliaferro, Ph.D., reported at the annual meeting of the Pediatric Academic Societies.

The estimated overall prevalence of major depressive disorder among adolescents is 5.6%, and the point prevalence in primary care settings is reported as ranging from 9% to 21%, according to the U.S. Preventive Services Task Force (USPSTF) recommendations.

Dr. Taliaferro and her colleagues at the University of Minnesota, Minneapolis, administered an online survey to a statewide sample of physicians and nurse practitioners (NPs) who provide direct ambulatory primary care services to adolescents aged 12-18 years. The clinicians were identified from lists obtained from the state’s boards of nursing and medical practice; there was a 20% response rate, which Dr. Taliaferro said is low but typical of such surveys.

The analytical sample included 127 pediatricians and 54 pediatric NPs, as well as 260 family physicians and 96 family medicine NPs.

Asked to report which depression identification practices they "usually/almost always" employ, 80% said they use clinical observation/overall impression, while 50% said they use a standardized written depression screening instrument, 40% use a "depression screening item within a comprehensive behavioral screening instrument," and 20% use a psychosocial interview (such as the HEADSS assessment, which stands for home, education and employment, activities, drugs, sexuality, suicide/depression).

There were no significant differences between physicians and nurse practitioners in the methods used to identify depression. There were differences, however, between pediatrics and family medicine in both the use of a psychosocial interview and the use of clinical observation/overall impression, with pediatric clinicians (both physicians and NPs) significantly more likely to report use of these methods, Dr. Taliaferro noted.

In another survey item, 75% of the pediatric providers reported routinely "asking about" depressive symptoms when providing health supervision. For family physicians and family nurse practitioners, this rate was 66%, she reported.

Asked if they had "ever" administered a standardized written depression instrument, 76% of providers indicated they had.

All told, Dr. Taliaferro said, it appears from the survey that "most [clinicians] don’t screen everyone, but instead are screening only high-risk patients after they identify some warning signs or in response to specific complaints."

The USPSTF issued its recommendation for adolescent screening in 2009, saying that clinicians should screen for major depressive disorder in adolescents (12- to 18-year-olds) when systems are in place to ensure accurate diagnosis, treatment, and follow-up.

"We all know that many adolescents in distress present with medical problems rather than psychological symptoms, and that adolescents may not verbalize their feelings or disclose their psychological issues without prompting from clinicians," said Dr. Taliaferro, who is now with the University of Missouri School of Health Professions, Columbia.

According to the task force, two screening instruments – the PHQ-A (the Patient Health Questionnaire–9 modified for adolescents) and the BDI-PC (Beck Depression Inventory for Primary Care) – have demonstrated good sensitivity and specificity for adolescents seen in primary care settings.

Dr. Taliaferro said after the meeting that "an overwhelming majority" of survey participants who use standardized instruments indicated that they use the PHQ-9, presumably the adolescent version. The PHQ-9 is integrated into the electronic medical record of many of the systems being utilized in primary care, she noted.

The investigators analyzed survey data to determine what factors were associated with use of a standardized written depression screening instrument and with inquiries about depression symptoms. Factors that increased the likelihood of administering a screening instrument included being female, being a family medicine clinician, having clear protocols for follow-up after depression, and feeling better prepared to address depression among adolescents.

Factors that increased the likelihood of asking about depression symptoms included believing more strongly that providers should be responsible for addressing depression among adolescents and being more familiar with recommendations regarding screening, Dr. Taliaferro reported.

Approximately 40% of participants reported having on-site mental health services that are available to their adolescent patients, she noted.

Dr. Taliaferro reported that she had no relevant financial disclosures. The investigators received funding for the survey from the Minnesota Department of Human Services.

WASHINGTON – Driving after marijuana use was common among college students at two large public universities who were randomly selected for phone interviews.

"Driving after marijuana use was significantly more common than driving under the influence of alcohol in college-age students, and males were much more likely ... which is consistent with a lot of the data on injury risk," reported Jennifer Whitehill, Ph.D., a postdoctoral fellow at the Harborview Injury Prevention and Research Center at the University of Washington, Seattle.

Among current marijuana users – defined as those who had used marijuana in the past 28 days – 31% said they drove after using it and 45% rode with a driver who had used it. The prevalence rates were 44% and 51%, respectively, among males and 9% and 35% among females, she reported at the annual meeting of the Pediatric Academic Societies.

The findings are especially important given new legislation that is likely to increase marijuana availability and further influence teens’ perception of risk.

The University of Washington, one of the two universities where the study took place, resides in one of two states that legalized the recreational use of marijuana in 2012. The study was conducted prior to passage of the law; continued research will provide "a good, natural longitudinal look" at attitudes and practices in light of the legislation, Dr. Whitehill said.

The literature thus far suggests a two- to threefold increase in crash risk for driving under the influence of marijuana, Dr. Whitehill said after the meeting.

One recent meta-analysis of information from nine prior studies showed that the risk of a crash was almost 2.7 times higher among marijuana users than nonusers (Epidemiol. Rev. 2012;34:65-72). Another review found an overall twofold increased risk, with risk estimates higher in studies of fatal collisions (BMJ 2012;344:e536).

However, the contribution of marijuana to the risk of crashes "can be a tricky thing to study and to isolate," she said, and research is attempting to determine the degree to which marijuana intoxication deteriorates driving performance.

Of 315 students who had just completed their freshman year, alcohol use was much more prevalent than marijuana use, as was expected – 65% said they had used alcohol in the past 28 days, compared with 21% who reported having used marijuana. Alcohol users were less likely to drive under the influence, however: 12% of males and 3% of females said they drove after drinking. More of the students – 21% of males and 12% of females – reported riding with a driver who had just consumed alcohol.

Researchers attempted to identify possible predictors and risk factors for impaired driving. They found that students who drove after marijuana use were 5.2 times as likely to have also been a passenger of a marijuana-using driver, and 2.5 times as likely to have also driven after alcohol use, as students who did not drive after using marijuana.

A younger age at the first use of marijuana was associated with a lower risk of driving under the influence of marijuana.

Students also were asked about their nonmedical use of stimulants and other prescription drugs. Four percent –a "relatively rare" prevalence – reported recent nonmedical prescription drug use, of which 11% said they drove after use, Dr. Whitehill reported.

The study did not measure the time between substance use and driving, she noted.

Dr. Whitehill reported that she had no relevant financial disclosures.

WASHINGTON – Driving after marijuana use was common among college students at two large public universities who were randomly selected for phone interviews.

"Driving after marijuana use was significantly more common than driving under the influence of alcohol in college-age students, and males were much more likely ... which is consistent with a lot of the data on injury risk," reported Jennifer Whitehill, Ph.D., a postdoctoral fellow at the Harborview Injury Prevention and Research Center at the University of Washington, Seattle.

Among current marijuana users – defined as those who had used marijuana in the past 28 days – 31% said they drove after using it and 45% rode with a driver who had used it. The prevalence rates were 44% and 51%, respectively, among males and 9% and 35% among females, she reported at the annual meeting of the Pediatric Academic Societies.

The findings are especially important given new legislation that is likely to increase marijuana availability and further influence teens’ perception of risk.

The University of Washington, one of the two universities where the study took place, resides in one of two states that legalized the recreational use of marijuana in 2012. The study was conducted prior to passage of the law; continued research will provide "a good, natural longitudinal look" at attitudes and practices in light of the legislation, Dr. Whitehill said.

The literature thus far suggests a two- to threefold increase in crash risk for driving under the influence of marijuana, Dr. Whitehill said after the meeting.

One recent meta-analysis of information from nine prior studies showed that the risk of a crash was almost 2.7 times higher among marijuana users than nonusers (Epidemiol. Rev. 2012;34:65-72). Another review found an overall twofold increased risk, with risk estimates higher in studies of fatal collisions (BMJ 2012;344:e536).

However, the contribution of marijuana to the risk of crashes "can be a tricky thing to study and to isolate," she said, and research is attempting to determine the degree to which marijuana intoxication deteriorates driving performance.

Of 315 students who had just completed their freshman year, alcohol use was much more prevalent than marijuana use, as was expected – 65% said they had used alcohol in the past 28 days, compared with 21% who reported having used marijuana. Alcohol users were less likely to drive under the influence, however: 12% of males and 3% of females said they drove after drinking. More of the students – 21% of males and 12% of females – reported riding with a driver who had just consumed alcohol.

Researchers attempted to identify possible predictors and risk factors for impaired driving. They found that students who drove after marijuana use were 5.2 times as likely to have also been a passenger of a marijuana-using driver, and 2.5 times as likely to have also driven after alcohol use, as students who did not drive after using marijuana.

A younger age at the first use of marijuana was associated with a lower risk of driving under the influence of marijuana.

Students also were asked about their nonmedical use of stimulants and other prescription drugs. Four percent –a "relatively rare" prevalence – reported recent nonmedical prescription drug use, of which 11% said they drove after use, Dr. Whitehill reported.

The study did not measure the time between substance use and driving, she noted.

Dr. Whitehill reported that she had no relevant financial disclosures.

WASHINGTON – Driving after marijuana use was common among college students at two large public universities who were randomly selected for phone interviews.

"Driving after marijuana use was significantly more common than driving under the influence of alcohol in college-age students, and males were much more likely ... which is consistent with a lot of the data on injury risk," reported Jennifer Whitehill, Ph.D., a postdoctoral fellow at the Harborview Injury Prevention and Research Center at the University of Washington, Seattle.

Among current marijuana users – defined as those who had used marijuana in the past 28 days – 31% said they drove after using it and 45% rode with a driver who had used it. The prevalence rates were 44% and 51%, respectively, among males and 9% and 35% among females, she reported at the annual meeting of the Pediatric Academic Societies.

The findings are especially important given new legislation that is likely to increase marijuana availability and further influence teens’ perception of risk.

The University of Washington, one of the two universities where the study took place, resides in one of two states that legalized the recreational use of marijuana in 2012. The study was conducted prior to passage of the law; continued research will provide "a good, natural longitudinal look" at attitudes and practices in light of the legislation, Dr. Whitehill said.

The literature thus far suggests a two- to threefold increase in crash risk for driving under the influence of marijuana, Dr. Whitehill said after the meeting.

One recent meta-analysis of information from nine prior studies showed that the risk of a crash was almost 2.7 times higher among marijuana users than nonusers (Epidemiol. Rev. 2012;34:65-72). Another review found an overall twofold increased risk, with risk estimates higher in studies of fatal collisions (BMJ 2012;344:e536).

However, the contribution of marijuana to the risk of crashes "can be a tricky thing to study and to isolate," she said, and research is attempting to determine the degree to which marijuana intoxication deteriorates driving performance.

Of 315 students who had just completed their freshman year, alcohol use was much more prevalent than marijuana use, as was expected – 65% said they had used alcohol in the past 28 days, compared with 21% who reported having used marijuana. Alcohol users were less likely to drive under the influence, however: 12% of males and 3% of females said they drove after drinking. More of the students – 21% of males and 12% of females – reported riding with a driver who had just consumed alcohol.

Researchers attempted to identify possible predictors and risk factors for impaired driving. They found that students who drove after marijuana use were 5.2 times as likely to have also been a passenger of a marijuana-using driver, and 2.5 times as likely to have also driven after alcohol use, as students who did not drive after using marijuana.

A younger age at the first use of marijuana was associated with a lower risk of driving under the influence of marijuana.

Students also were asked about their nonmedical use of stimulants and other prescription drugs. Four percent –a "relatively rare" prevalence – reported recent nonmedical prescription drug use, of which 11% said they drove after use, Dr. Whitehill reported.

The study did not measure the time between substance use and driving, she noted.

Dr. Whitehill reported that she had no relevant financial disclosures.