Damian McNamara

MIAMI — A one-page instrument to screen and identify adolescents at risk for alcohol use can be easily implemented in a primary care setting, although reimbursement and additional counseling time are concerns, Dr. John Femino said at the annual conference of the American Society of Addiction Medicine.

The focus on primary care physicians to screen and intervene regarding adolescent alcohol use and other behavioral issues is an important shift,” said Dr. Femino, an internist who is the medical director of a detoxification and recovery center in North Kingstown, R.I. It makes sense because “primary care physicians are seeing every kid in every school district we see.”

Rhode Island has led the United States for 4 consecutive years as the state with the highest drinking-related deaths among teenagers, mostly associated with motor vehicle accidents. “This project came out of a need in the community. A primary care task force group reached out to physicians for help,” Dr. Femino said.

The South County Physicians' Initiative Behavioral Health Screening (BHS) program includes a one-page, self-administered instrument specifically designed for busy primary care settings. Patients or a parent must sign a permission form, and they also receive a primary prevention educational package. Physicians can quickly score the screening instrument during the visit.

In a preliminary study, 886 patients aged 12–21 years were screened over 3 months at one of four private practices in Rhode Island. Results support its efficacy. “Everyone could do it. The identification went up,” Dr. Femino said.

Although the screen is rapid, most providers—once they identified a child in trouble—said they spent additional time at the same visit counseling the patient. “Just think of your well-child visits doubling in length,” said Dr. Femito.

A total of 36% screened positive for at least one behavioral concern, and 25%–-both boys and girls—checked off and met criteria for an eating disorder.

Although screening is effective, there are barriers to effectively addressing alcohol use problems in teenagers. Among physicians, those barriers include time constraints, reimbursement and “a fear of ticking off the parent.” Among children, concerns focus on confidentiality, and among parents, the belief that alcohol and drug use is part of normal teenage experimentation presents a barrier to adolescent screening programs. Parents also might fear the stigma associated with substance abuse.

Another concern is that insurance labeling via the Medical Information Bureau would create lifelong stigmatization by placing the teenager in a high-risk category for health, disability, or life insurance eligibility or premium ratings, Dr. Femino said. “We were very sensitive as to which billing codes we could use to avoid this. It is possible to figure out how to get paid for prevention and counseling. There are new codes, but it's tricky.”

MIAMI — A one-page instrument to screen and identify adolescents at risk for alcohol use can be easily implemented in a primary care setting, although reimbursement and additional counseling time are concerns, Dr. John Femino said at the annual conference of the American Society of Addiction Medicine.

The focus on primary care physicians to screen and intervene regarding adolescent alcohol use and other behavioral issues is an important shift,” said Dr. Femino, an internist who is the medical director of a detoxification and recovery center in North Kingstown, R.I. It makes sense because “primary care physicians are seeing every kid in every school district we see.”

Rhode Island has led the United States for 4 consecutive years as the state with the highest drinking-related deaths among teenagers, mostly associated with motor vehicle accidents. “This project came out of a need in the community. A primary care task force group reached out to physicians for help,” Dr. Femino said.

The South County Physicians' Initiative Behavioral Health Screening (BHS) program includes a one-page, self-administered instrument specifically designed for busy primary care settings. Patients or a parent must sign a permission form, and they also receive a primary prevention educational package. Physicians can quickly score the screening instrument during the visit.

In a preliminary study, 886 patients aged 12–21 years were screened over 3 months at one of four private practices in Rhode Island. Results support its efficacy. “Everyone could do it. The identification went up,” Dr. Femino said.

Although the screen is rapid, most providers—once they identified a child in trouble—said they spent additional time at the same visit counseling the patient. “Just think of your well-child visits doubling in length,” said Dr. Femito.

A total of 36% screened positive for at least one behavioral concern, and 25%–-both boys and girls—checked off and met criteria for an eating disorder.

Although screening is effective, there are barriers to effectively addressing alcohol use problems in teenagers. Among physicians, those barriers include time constraints, reimbursement and “a fear of ticking off the parent.” Among children, concerns focus on confidentiality, and among parents, the belief that alcohol and drug use is part of normal teenage experimentation presents a barrier to adolescent screening programs. Parents also might fear the stigma associated with substance abuse.

Another concern is that insurance labeling via the Medical Information Bureau would create lifelong stigmatization by placing the teenager in a high-risk category for health, disability, or life insurance eligibility or premium ratings, Dr. Femino said. “We were very sensitive as to which billing codes we could use to avoid this. It is possible to figure out how to get paid for prevention and counseling. There are new codes, but it's tricky.”

MIAMI — A one-page instrument to screen and identify adolescents at risk for alcohol use can be easily implemented in a primary care setting, although reimbursement and additional counseling time are concerns, Dr. John Femino said at the annual conference of the American Society of Addiction Medicine.

The focus on primary care physicians to screen and intervene regarding adolescent alcohol use and other behavioral issues is an important shift,” said Dr. Femino, an internist who is the medical director of a detoxification and recovery center in North Kingstown, R.I. It makes sense because “primary care physicians are seeing every kid in every school district we see.”

Rhode Island has led the United States for 4 consecutive years as the state with the highest drinking-related deaths among teenagers, mostly associated with motor vehicle accidents. “This project came out of a need in the community. A primary care task force group reached out to physicians for help,” Dr. Femino said.

The South County Physicians' Initiative Behavioral Health Screening (BHS) program includes a one-page, self-administered instrument specifically designed for busy primary care settings. Patients or a parent must sign a permission form, and they also receive a primary prevention educational package. Physicians can quickly score the screening instrument during the visit.

In a preliminary study, 886 patients aged 12–21 years were screened over 3 months at one of four private practices in Rhode Island. Results support its efficacy. “Everyone could do it. The identification went up,” Dr. Femino said.

Although the screen is rapid, most providers—once they identified a child in trouble—said they spent additional time at the same visit counseling the patient. “Just think of your well-child visits doubling in length,” said Dr. Femito.

A total of 36% screened positive for at least one behavioral concern, and 25%–-both boys and girls—checked off and met criteria for an eating disorder.

Although screening is effective, there are barriers to effectively addressing alcohol use problems in teenagers. Among physicians, those barriers include time constraints, reimbursement and “a fear of ticking off the parent.” Among children, concerns focus on confidentiality, and among parents, the belief that alcohol and drug use is part of normal teenage experimentation presents a barrier to adolescent screening programs. Parents also might fear the stigma associated with substance abuse.

Another concern is that insurance labeling via the Medical Information Bureau would create lifelong stigmatization by placing the teenager in a high-risk category for health, disability, or life insurance eligibility or premium ratings, Dr. Femino said. “We were very sensitive as to which billing codes we could use to avoid this. It is possible to figure out how to get paid for prevention and counseling. There are new codes, but it's tricky.”

CHAMPIONSGATE, FLA. — There are trade-offs to consider in the surgical choices to excise mesh from a woman with prior abdominal sacrocolpopexy, according to a study presented at the annual meeting of the Society of Gynecologic Surgeons.

Transvaginal approaches are less invasive but can take up to three attempts for full resolution of symptoms. On the other hand, one transabdominal laparotomy can and did resolve symptoms but was associated with more serious adverse outcomes, Dr. Mary M. South said.

Dr. South and her associates compared three techniques used to excise eroded mesh at Duke University Medical Center in Durham, N.C., between 1997 and 2006. The retrospective analysis included 17 women who had transvaginal surgery with endoscopy, 14 who had open transvaginal excision, and 7 who abdominal excision through laparotomy. All patients had a prior abdominal sacrocolpopexy and were identified from CPT codes, said Dr. South of the division of urogynecology at Duke.

“The objective is well defined, but this paper runs into trouble with the use of the term 'open' transvaginal excision,” said study discussant Dr. Robert W. Lobel, an obstetrician and gynecologist in private practice in Albany, N.Y.

Complications were the biggest distinction. Only minor postoperative complications were reported with either transvaginal approach, compared with more serious intraoperative and postoperative events with abdominal excision. For example, two patients in the laparotomy group experienced bowel injury during removal of adhesions; one required a bowel repair and the other, a resection. One patient had a postoperative wound infection with breakdown, and another was readmitted to the hospital for postoperative fever and antibiotics. Another abdominal excision patient had an acute coronary event and was transferred to the cardiology department.

Laparotomy was 100% successful in resolving symptoms, Dr. South said. The combined success with a transvaginal approach was 53%, including 7 of 17 patients in the endoscopy group and 9 of 13 patients in the open group (complete follow-up data was unavailable for 1 patient).

Of these 16 successful patients, 12 had symptom resolution on the first transvaginal excision attempt, 1 on the second attempt, and 3 on the third, Dr. South said at the meeting, which was jointly sponsored by the American College of Surgeons.

Dr. Lobel asked Dr. South why surgeons chose one transvaginal approach over the other. “This was a retrospective review. From 1997 to 2003, we [excised only] what we were able to visualize. Since then, we've only used the scope,” she said. “We believe the scope allows us to better completely remove the mesh.”

“I would definitely agree that a transvaginal approach is better than abdominal, but you did not have enough power to say that endoscopic removal is better than traditional transvaginal excision,” Dr. Lobel said.

Dr. Lobel also inquired if any transvaginal surgery patients had complete symptom resolution despite incomplete mesh removal. Of the 14 open transvaginal surgeries, 12 were incomplete removals, Dr. South said. “Both patients with complete removal had complete resolution symptoms.” Among the incomplete removals, seven reported symptom resolution.

In the group who had transvaginal surgery with endoscopy, there were two successes among 10 incomplete removal patients and five successes among five complete mesh excisions. Symptom resolution was unknown for the other two patients.

Despite the criticism from study discussant Dr. Lobel, Dr. South said, “We stick by our basic take-home message. If you completely remove the mesh, you will have complete resolution of symptoms. But if you only partially remove the mesh, it's hit or miss whether you will get resolution of symptoms.”

CHAMPIONSGATE, FLA. — There are trade-offs to consider in the surgical choices to excise mesh from a woman with prior abdominal sacrocolpopexy, according to a study presented at the annual meeting of the Society of Gynecologic Surgeons.

Transvaginal approaches are less invasive but can take up to three attempts for full resolution of symptoms. On the other hand, one transabdominal laparotomy can and did resolve symptoms but was associated with more serious adverse outcomes, Dr. Mary M. South said.

Dr. South and her associates compared three techniques used to excise eroded mesh at Duke University Medical Center in Durham, N.C., between 1997 and 2006. The retrospective analysis included 17 women who had transvaginal surgery with endoscopy, 14 who had open transvaginal excision, and 7 who abdominal excision through laparotomy. All patients had a prior abdominal sacrocolpopexy and were identified from CPT codes, said Dr. South of the division of urogynecology at Duke.

“The objective is well defined, but this paper runs into trouble with the use of the term 'open' transvaginal excision,” said study discussant Dr. Robert W. Lobel, an obstetrician and gynecologist in private practice in Albany, N.Y.

Complications were the biggest distinction. Only minor postoperative complications were reported with either transvaginal approach, compared with more serious intraoperative and postoperative events with abdominal excision. For example, two patients in the laparotomy group experienced bowel injury during removal of adhesions; one required a bowel repair and the other, a resection. One patient had a postoperative wound infection with breakdown, and another was readmitted to the hospital for postoperative fever and antibiotics. Another abdominal excision patient had an acute coronary event and was transferred to the cardiology department.

Laparotomy was 100% successful in resolving symptoms, Dr. South said. The combined success with a transvaginal approach was 53%, including 7 of 17 patients in the endoscopy group and 9 of 13 patients in the open group (complete follow-up data was unavailable for 1 patient).

Of these 16 successful patients, 12 had symptom resolution on the first transvaginal excision attempt, 1 on the second attempt, and 3 on the third, Dr. South said at the meeting, which was jointly sponsored by the American College of Surgeons.

Dr. Lobel asked Dr. South why surgeons chose one transvaginal approach over the other. “This was a retrospective review. From 1997 to 2003, we [excised only] what we were able to visualize. Since then, we've only used the scope,” she said. “We believe the scope allows us to better completely remove the mesh.”

“I would definitely agree that a transvaginal approach is better than abdominal, but you did not have enough power to say that endoscopic removal is better than traditional transvaginal excision,” Dr. Lobel said.

Dr. Lobel also inquired if any transvaginal surgery patients had complete symptom resolution despite incomplete mesh removal. Of the 14 open transvaginal surgeries, 12 were incomplete removals, Dr. South said. “Both patients with complete removal had complete resolution symptoms.” Among the incomplete removals, seven reported symptom resolution.

In the group who had transvaginal surgery with endoscopy, there were two successes among 10 incomplete removal patients and five successes among five complete mesh excisions. Symptom resolution was unknown for the other two patients.

Despite the criticism from study discussant Dr. Lobel, Dr. South said, “We stick by our basic take-home message. If you completely remove the mesh, you will have complete resolution of symptoms. But if you only partially remove the mesh, it's hit or miss whether you will get resolution of symptoms.”

CHAMPIONSGATE, FLA. — There are trade-offs to consider in the surgical choices to excise mesh from a woman with prior abdominal sacrocolpopexy, according to a study presented at the annual meeting of the Society of Gynecologic Surgeons.

Transvaginal approaches are less invasive but can take up to three attempts for full resolution of symptoms. On the other hand, one transabdominal laparotomy can and did resolve symptoms but was associated with more serious adverse outcomes, Dr. Mary M. South said.

Dr. South and her associates compared three techniques used to excise eroded mesh at Duke University Medical Center in Durham, N.C., between 1997 and 2006. The retrospective analysis included 17 women who had transvaginal surgery with endoscopy, 14 who had open transvaginal excision, and 7 who abdominal excision through laparotomy. All patients had a prior abdominal sacrocolpopexy and were identified from CPT codes, said Dr. South of the division of urogynecology at Duke.

“The objective is well defined, but this paper runs into trouble with the use of the term 'open' transvaginal excision,” said study discussant Dr. Robert W. Lobel, an obstetrician and gynecologist in private practice in Albany, N.Y.

Complications were the biggest distinction. Only minor postoperative complications were reported with either transvaginal approach, compared with more serious intraoperative and postoperative events with abdominal excision. For example, two patients in the laparotomy group experienced bowel injury during removal of adhesions; one required a bowel repair and the other, a resection. One patient had a postoperative wound infection with breakdown, and another was readmitted to the hospital for postoperative fever and antibiotics. Another abdominal excision patient had an acute coronary event and was transferred to the cardiology department.

Laparotomy was 100% successful in resolving symptoms, Dr. South said. The combined success with a transvaginal approach was 53%, including 7 of 17 patients in the endoscopy group and 9 of 13 patients in the open group (complete follow-up data was unavailable for 1 patient).

Of these 16 successful patients, 12 had symptom resolution on the first transvaginal excision attempt, 1 on the second attempt, and 3 on the third, Dr. South said at the meeting, which was jointly sponsored by the American College of Surgeons.

Dr. Lobel asked Dr. South why surgeons chose one transvaginal approach over the other. “This was a retrospective review. From 1997 to 2003, we [excised only] what we were able to visualize. Since then, we've only used the scope,” she said. “We believe the scope allows us to better completely remove the mesh.”

“I would definitely agree that a transvaginal approach is better than abdominal, but you did not have enough power to say that endoscopic removal is better than traditional transvaginal excision,” Dr. Lobel said.

Dr. Lobel also inquired if any transvaginal surgery patients had complete symptom resolution despite incomplete mesh removal. Of the 14 open transvaginal surgeries, 12 were incomplete removals, Dr. South said. “Both patients with complete removal had complete resolution symptoms.” Among the incomplete removals, seven reported symptom resolution.

In the group who had transvaginal surgery with endoscopy, there were two successes among 10 incomplete removal patients and five successes among five complete mesh excisions. Symptom resolution was unknown for the other two patients.

Despite the criticism from study discussant Dr. Lobel, Dr. South said, “We stick by our basic take-home message. If you completely remove the mesh, you will have complete resolution of symptoms. But if you only partially remove the mesh, it's hit or miss whether you will get resolution of symptoms.”

MIAMI — A shortage of ophthalmologists willing or able to screen for retinopathy of prematurity is hampering implementation of updated guidelines released last year, Dr. Roberto Warman said at a pediatric update sponsored by Miami Children's Hospital.

“There is a major manpower crisis in management of retinopathy of prematurity. Because of liability concerns, very few ophthalmologists are interested in screening these babies and even fewer are willing to treat,” said Dr. Warman, director of the division of ophthalmology at the hospital.

The revised screening and treatment guidelines contain some “important changes,” Dr. Warman said. “The most important issue is gestational age.” All premature infants born at a gestation of 32 weeks or less or weighing 1,500 g or less should be screened. Select infants born with a birth weight from 1,500 g to 2,000 g and an unstable clinical course also should be screened.

Timing is important because retinopathy of prematurity (ROP) is a progressive condition if left unchecked. The guideline authors wrote, “Effective care now requires that at-risk infants receive carefully timed retinal examinations by an ophthalmologist who is experienced in the examination of preterm infants for ROP and that all pediatricians who care for these at-risk preterm infants be aware of this timing” (Pediatrics 2006;117:572–6; erratum Pediatrics 2006;118:1324).

Target the first exam for 4–6 weeks of age, Dr. Warman said. This will be approximately 31 weeks since last menstruation for infants born at 22–27 weeks of gestation. The guidelines recommend a topical anesthetic to reduce discomfort, pupil dilation, and then binocular indirect ophthalmoscopy to detect ROP.

“We have a small window of opportunity to treat,” Dr. Warman said. If the initial exam unequivocally demonstrates that the retina is fully vascularized in both eyes, then a second examination is not required.

Otherwise, the guidelines recommend close follow-up—the timing and frequency of which is determined by the degree and location of initial retinal findings. The guidelines were updated by the American Academy of Pediatrics, the American Academy of Ophthalmology, and the American Association for Pediatric Ophthalmology and Strabismus in February 2006.

ROP occurs only in immature retinal tissue. The condition can progress to tractional retinal detachment and functional or complete blindness. “We are trying to prevent a patient with scars in the retina. Although the retina is not detached, scars can cause serious visual impairment,” Dr. Warman said.

A marked decrease in the incidence of adverse outcomes is possible with advancements in peripheral retinal ablative therapy using laser photocoagulation, the authors noted.

Tight oxygen level monitoring in the hours after birth is another recommendation, Dr. Warman said.

“Still the best thing we can do is keep oxygen levels within guidelines in the neonatal intensive care unit and have great nursing to monitor well.”

Retinal detachment surgery is now performed during active disease, Dr. Warman said. “But this creates a problem because very few specialists are willing and able to do this surgery in these tiny patients.”

Direct injection of vascular endothelial growth factors is being performed in other countries “with great results,” Dr. Warman said. This area of research is “very exciting,” he added. A study sponsored by the National Institutes of Health to assess the safety and efficacy of this therapy is scheduled to start soon.

Timing is important because ROP is a progressive condition if left unchecked, as seen in this Stage 3 disease.

Here is an example of ROP with scarring in the posterior pole with cicatricial changes and with dragging vessels. PHOTOS COURTESY DR. ROBERTO WARMAN

MIAMI — A shortage of ophthalmologists willing or able to screen for retinopathy of prematurity is hampering implementation of updated guidelines released last year, Dr. Roberto Warman said at a pediatric update sponsored by Miami Children's Hospital.

“There is a major manpower crisis in management of retinopathy of prematurity. Because of liability concerns, very few ophthalmologists are interested in screening these babies and even fewer are willing to treat,” said Dr. Warman, director of the division of ophthalmology at the hospital.

The revised screening and treatment guidelines contain some “important changes,” Dr. Warman said. “The most important issue is gestational age.” All premature infants born at a gestation of 32 weeks or less or weighing 1,500 g or less should be screened. Select infants born with a birth weight from 1,500 g to 2,000 g and an unstable clinical course also should be screened.

Timing is important because retinopathy of prematurity (ROP) is a progressive condition if left unchecked. The guideline authors wrote, “Effective care now requires that at-risk infants receive carefully timed retinal examinations by an ophthalmologist who is experienced in the examination of preterm infants for ROP and that all pediatricians who care for these at-risk preterm infants be aware of this timing” (Pediatrics 2006;117:572–6; erratum Pediatrics 2006;118:1324).

Target the first exam for 4–6 weeks of age, Dr. Warman said. This will be approximately 31 weeks since last menstruation for infants born at 22–27 weeks of gestation. The guidelines recommend a topical anesthetic to reduce discomfort, pupil dilation, and then binocular indirect ophthalmoscopy to detect ROP.

“We have a small window of opportunity to treat,” Dr. Warman said. If the initial exam unequivocally demonstrates that the retina is fully vascularized in both eyes, then a second examination is not required.

Otherwise, the guidelines recommend close follow-up—the timing and frequency of which is determined by the degree and location of initial retinal findings. The guidelines were updated by the American Academy of Pediatrics, the American Academy of Ophthalmology, and the American Association for Pediatric Ophthalmology and Strabismus in February 2006.

ROP occurs only in immature retinal tissue. The condition can progress to tractional retinal detachment and functional or complete blindness. “We are trying to prevent a patient with scars in the retina. Although the retina is not detached, scars can cause serious visual impairment,” Dr. Warman said.

A marked decrease in the incidence of adverse outcomes is possible with advancements in peripheral retinal ablative therapy using laser photocoagulation, the authors noted.

Tight oxygen level monitoring in the hours after birth is another recommendation, Dr. Warman said.

“Still the best thing we can do is keep oxygen levels within guidelines in the neonatal intensive care unit and have great nursing to monitor well.”

Retinal detachment surgery is now performed during active disease, Dr. Warman said. “But this creates a problem because very few specialists are willing and able to do this surgery in these tiny patients.”

Direct injection of vascular endothelial growth factors is being performed in other countries “with great results,” Dr. Warman said. This area of research is “very exciting,” he added. A study sponsored by the National Institutes of Health to assess the safety and efficacy of this therapy is scheduled to start soon.

Timing is important because ROP is a progressive condition if left unchecked, as seen in this Stage 3 disease.

Here is an example of ROP with scarring in the posterior pole with cicatricial changes and with dragging vessels. PHOTOS COURTESY DR. ROBERTO WARMAN

MIAMI — A shortage of ophthalmologists willing or able to screen for retinopathy of prematurity is hampering implementation of updated guidelines released last year, Dr. Roberto Warman said at a pediatric update sponsored by Miami Children's Hospital.

“There is a major manpower crisis in management of retinopathy of prematurity. Because of liability concerns, very few ophthalmologists are interested in screening these babies and even fewer are willing to treat,” said Dr. Warman, director of the division of ophthalmology at the hospital.

The revised screening and treatment guidelines contain some “important changes,” Dr. Warman said. “The most important issue is gestational age.” All premature infants born at a gestation of 32 weeks or less or weighing 1,500 g or less should be screened. Select infants born with a birth weight from 1,500 g to 2,000 g and an unstable clinical course also should be screened.

Timing is important because retinopathy of prematurity (ROP) is a progressive condition if left unchecked. The guideline authors wrote, “Effective care now requires that at-risk infants receive carefully timed retinal examinations by an ophthalmologist who is experienced in the examination of preterm infants for ROP and that all pediatricians who care for these at-risk preterm infants be aware of this timing” (Pediatrics 2006;117:572–6; erratum Pediatrics 2006;118:1324).

Target the first exam for 4–6 weeks of age, Dr. Warman said. This will be approximately 31 weeks since last menstruation for infants born at 22–27 weeks of gestation. The guidelines recommend a topical anesthetic to reduce discomfort, pupil dilation, and then binocular indirect ophthalmoscopy to detect ROP.

“We have a small window of opportunity to treat,” Dr. Warman said. If the initial exam unequivocally demonstrates that the retina is fully vascularized in both eyes, then a second examination is not required.

Otherwise, the guidelines recommend close follow-up—the timing and frequency of which is determined by the degree and location of initial retinal findings. The guidelines were updated by the American Academy of Pediatrics, the American Academy of Ophthalmology, and the American Association for Pediatric Ophthalmology and Strabismus in February 2006.

ROP occurs only in immature retinal tissue. The condition can progress to tractional retinal detachment and functional or complete blindness. “We are trying to prevent a patient with scars in the retina. Although the retina is not detached, scars can cause serious visual impairment,” Dr. Warman said.

A marked decrease in the incidence of adverse outcomes is possible with advancements in peripheral retinal ablative therapy using laser photocoagulation, the authors noted.

Tight oxygen level monitoring in the hours after birth is another recommendation, Dr. Warman said.

“Still the best thing we can do is keep oxygen levels within guidelines in the neonatal intensive care unit and have great nursing to monitor well.”

Retinal detachment surgery is now performed during active disease, Dr. Warman said. “But this creates a problem because very few specialists are willing and able to do this surgery in these tiny patients.”

Direct injection of vascular endothelial growth factors is being performed in other countries “with great results,” Dr. Warman said. This area of research is “very exciting,” he added. A study sponsored by the National Institutes of Health to assess the safety and efficacy of this therapy is scheduled to start soon.

Timing is important because ROP is a progressive condition if left unchecked, as seen in this Stage 3 disease.

Here is an example of ROP with scarring in the posterior pole with cicatricial changes and with dragging vessels. PHOTOS COURTESY DR. ROBERTO WARMAN

BIRMINGHAM, ENGLAND — Referral of a child with inflammatory arthritis is likely to be delayed if diagnosis is based solely on blood tests and not on physical findings, according to initial study results presented at the annual meeting of the British Society for Rheumatology.

Faced with a paucity of data, researchers launched the first large-scale prospective study to assess a relationship between presenting symptoms and time to juvenile arthritis diagnosis. “Studies have not included all children with juvenile arthritis. They have been retrospective case reviews or cross-sectional studies. We decided to include all comers and look at them over 5 years,” Dr. Kimme Hyrich commented in an interview during a poster session at the meeting.

The Childhood Arthritis Prospective Study (CAPS) includes children aged 16 years or younger with new inflammatory arthritis in at least one joint that persists for 2 weeks or more. Not surprisingly, results among the first 494 participants indicate that children who present with clear diagnostic signs wait the shortest time before seeing a pediatric rheumatologist. However, children who present with joint pain or stiffness but normal erythrocyte sedimentation rate (ESR) tend to experience a long delay before reaching specialty care, even if they have a high joint count.

An unexpected finding was how long a significant minority of patients waited, Dr. Hyrich said. “It is concerning that one-fifth of children had to wait more than 1 year.” Dr. Hyrich is a clinical lecturer and consultant rheumatologist, Arthritis Research Campaign Epidemiology Unit, the University of Manchester, England.

The median age of participants is 7 years. A total of 64% are girls, 49% have oligoarthritis, and 14% have rheumatoid factor-negative polyarthritis. The remainder was equally divided among other subtypes of inflammatory arthritis.

About 30% of referrals to the CAPS study come from general practitioners, 30% from general pediatricians, and 20%–30% from orthopedists. The remainder comes from various other sources, Dr. Hyrich said.

The median overall time from symptom onset to pediatric rheumatology consult was 3.9 months. Referrals were quickest when the child experienced a related casualty (1.2 months). General practitioner referrals were a median 4.8 months after symptom onset, and referrals from other medical specialists took a median 6.5 months.

If a child presents with foot pain and no laboratory evidence of arthritis, for example, the diagnosis might not be complete, Dr. Hyrich said. “The doctor might think it is a mechanical issue.”

The median total delay was longest for rheumatoid factor-positive children with polyarthritis (7.2 months) and shortest for children with systemic arthritis (1 month).

Participants who waited 4 months or more before seeing a pediatric rheumatologist were more likely to be older (median 8 years vs. 6 years), to have a higher joint count (median 2 vs. 1), and to have a lower ESR (14 mm/hour vs. 32 mm/hour), compared with children who were seen sooner. There were no significant differences between the shorter and longer delay groups on the Childhood Health Assessment Questionnaire, Physician's Global Assessment, Parent's General Evaluation of Well-Being, or pain scores.

The findings indicate that if blood tests do not indicate inflammation, the diagnosis of juvenile inflammatory arthritis might be overlooked and the initiation of appropriate therapies delayed, Dr. Hyrich said.

“The study is ongoing. Our ultimate aim is to recruit about 1,100 children, and now we have about 600.”

BIRMINGHAM, ENGLAND — Referral of a child with inflammatory arthritis is likely to be delayed if diagnosis is based solely on blood tests and not on physical findings, according to initial study results presented at the annual meeting of the British Society for Rheumatology.

Faced with a paucity of data, researchers launched the first large-scale prospective study to assess a relationship between presenting symptoms and time to juvenile arthritis diagnosis. “Studies have not included all children with juvenile arthritis. They have been retrospective case reviews or cross-sectional studies. We decided to include all comers and look at them over 5 years,” Dr. Kimme Hyrich commented in an interview during a poster session at the meeting.

The Childhood Arthritis Prospective Study (CAPS) includes children aged 16 years or younger with new inflammatory arthritis in at least one joint that persists for 2 weeks or more. Not surprisingly, results among the first 494 participants indicate that children who present with clear diagnostic signs wait the shortest time before seeing a pediatric rheumatologist. However, children who present with joint pain or stiffness but normal erythrocyte sedimentation rate (ESR) tend to experience a long delay before reaching specialty care, even if they have a high joint count.

An unexpected finding was how long a significant minority of patients waited, Dr. Hyrich said. “It is concerning that one-fifth of children had to wait more than 1 year.” Dr. Hyrich is a clinical lecturer and consultant rheumatologist, Arthritis Research Campaign Epidemiology Unit, the University of Manchester, England.

The median age of participants is 7 years. A total of 64% are girls, 49% have oligoarthritis, and 14% have rheumatoid factor-negative polyarthritis. The remainder was equally divided among other subtypes of inflammatory arthritis.

About 30% of referrals to the CAPS study come from general practitioners, 30% from general pediatricians, and 20%–30% from orthopedists. The remainder comes from various other sources, Dr. Hyrich said.

The median overall time from symptom onset to pediatric rheumatology consult was 3.9 months. Referrals were quickest when the child experienced a related casualty (1.2 months). General practitioner referrals were a median 4.8 months after symptom onset, and referrals from other medical specialists took a median 6.5 months.

If a child presents with foot pain and no laboratory evidence of arthritis, for example, the diagnosis might not be complete, Dr. Hyrich said. “The doctor might think it is a mechanical issue.”

The median total delay was longest for rheumatoid factor-positive children with polyarthritis (7.2 months) and shortest for children with systemic arthritis (1 month).

Participants who waited 4 months or more before seeing a pediatric rheumatologist were more likely to be older (median 8 years vs. 6 years), to have a higher joint count (median 2 vs. 1), and to have a lower ESR (14 mm/hour vs. 32 mm/hour), compared with children who were seen sooner. There were no significant differences between the shorter and longer delay groups on the Childhood Health Assessment Questionnaire, Physician's Global Assessment, Parent's General Evaluation of Well-Being, or pain scores.

The findings indicate that if blood tests do not indicate inflammation, the diagnosis of juvenile inflammatory arthritis might be overlooked and the initiation of appropriate therapies delayed, Dr. Hyrich said.

“The study is ongoing. Our ultimate aim is to recruit about 1,100 children, and now we have about 600.”

BIRMINGHAM, ENGLAND — Referral of a child with inflammatory arthritis is likely to be delayed if diagnosis is based solely on blood tests and not on physical findings, according to initial study results presented at the annual meeting of the British Society for Rheumatology.

Faced with a paucity of data, researchers launched the first large-scale prospective study to assess a relationship between presenting symptoms and time to juvenile arthritis diagnosis. “Studies have not included all children with juvenile arthritis. They have been retrospective case reviews or cross-sectional studies. We decided to include all comers and look at them over 5 years,” Dr. Kimme Hyrich commented in an interview during a poster session at the meeting.

The Childhood Arthritis Prospective Study (CAPS) includes children aged 16 years or younger with new inflammatory arthritis in at least one joint that persists for 2 weeks or more. Not surprisingly, results among the first 494 participants indicate that children who present with clear diagnostic signs wait the shortest time before seeing a pediatric rheumatologist. However, children who present with joint pain or stiffness but normal erythrocyte sedimentation rate (ESR) tend to experience a long delay before reaching specialty care, even if they have a high joint count.

An unexpected finding was how long a significant minority of patients waited, Dr. Hyrich said. “It is concerning that one-fifth of children had to wait more than 1 year.” Dr. Hyrich is a clinical lecturer and consultant rheumatologist, Arthritis Research Campaign Epidemiology Unit, the University of Manchester, England.

The median age of participants is 7 years. A total of 64% are girls, 49% have oligoarthritis, and 14% have rheumatoid factor-negative polyarthritis. The remainder was equally divided among other subtypes of inflammatory arthritis.

About 30% of referrals to the CAPS study come from general practitioners, 30% from general pediatricians, and 20%–30% from orthopedists. The remainder comes from various other sources, Dr. Hyrich said.

The median overall time from symptom onset to pediatric rheumatology consult was 3.9 months. Referrals were quickest when the child experienced a related casualty (1.2 months). General practitioner referrals were a median 4.8 months after symptom onset, and referrals from other medical specialists took a median 6.5 months.

If a child presents with foot pain and no laboratory evidence of arthritis, for example, the diagnosis might not be complete, Dr. Hyrich said. “The doctor might think it is a mechanical issue.”

The median total delay was longest for rheumatoid factor-positive children with polyarthritis (7.2 months) and shortest for children with systemic arthritis (1 month).

Participants who waited 4 months or more before seeing a pediatric rheumatologist were more likely to be older (median 8 years vs. 6 years), to have a higher joint count (median 2 vs. 1), and to have a lower ESR (14 mm/hour vs. 32 mm/hour), compared with children who were seen sooner. There were no significant differences between the shorter and longer delay groups on the Childhood Health Assessment Questionnaire, Physician's Global Assessment, Parent's General Evaluation of Well-Being, or pain scores.

The findings indicate that if blood tests do not indicate inflammation, the diagnosis of juvenile inflammatory arthritis might be overlooked and the initiation of appropriate therapies delayed, Dr. Hyrich said.

“The study is ongoing. Our ultimate aim is to recruit about 1,100 children, and now we have about 600.”

FORT MYERS, FLA. – Depression and/or impulsivity do not get in the way of behavioral change for trauma patients who have participated in a brief motivational intervention for alcohol abuse, results of a study presented at the annual meeting of the Eastern Association for the Surgery of Trauma show.

Researchers performed a secondary analysis of data from the DELTA project, an ongoing study funded by the National Institute on Alcohol Abuse and Alcoholism. DELTA is a randomized controlled trial aimed at demonstrating that a brief intervention was effective in reducing alcohol use among 497 trauma patients. In the current study, researchers surveyed 248 participants at 12 months and found no significant differences in decreases in alcohol use between participants who reported depression and/or impulsivity, compared with those who did not, Dr. Gabriel E. Ryb said at the meeting, sponsored by Wake Forest Unversity.

The findings may only apply to mild to moderate problem drinkers because researchers excluded severely alcohol-dependent patients, said study discussant Dr. Michael Aboutanos.

“The reason we excluded the severe alcohol dependence patients … [was] … we assumed they would not be responsive to brief interventions,” said Dr. Ryb, a trauma surgeon and researcher at the National Study Center for Trauma and Emergency Medical Systems, University of Maryland, Baltimore.

In addition, the investigators should have assessed patients using validated depression and impulsivity assessment tools instead of self-reports, said Dr. Aboutanos, who serves as director of the Injury Prevention Program and on the surgery faculty at Virginia Commonwealth University, Richmond. Therefore, this secondary analysis may be limited by the design of the initial study.

“I essentially agree with criticisms relating to the study being a post hoc analysis,” Dr. Ryb said. “I also agree that more rigorous assessment of the psychologic state is needed.”

Despite his criticisms, Dr. Aboutanos said, “The finding that neither impulsivity nor depression diminishes alcohol use intervention will be welcome by clinicians. I applaud their efforts for completing this study in a very difficult population.”

Patients reported depression and impulsivity on the initial questionnaire. A total of 217 responded yes to the depressive indicator and 280 responded no. Not surprisingly, depression was associated with higher drinking rates.

“The co-occurrence of depression and alcohol abuse has been well studied,” Dr. Ryb said. “Alcohol use disorders occur in a lot of trauma patients. There is also a high incidence of psychiatric illness in the trauma population.”

Impulsivity is associated with risky behavior within the trauma population, Dr. Ryb said. Patients rated their impulsivity on scale of 1 to 4, according to this statement: “I often act on the spur of the moment without stopping to think.” Impulsive patients reported increased alcohol use in the 90 days preinjury (an average of 237 drinks), compared with nonimpulsive participants (190 drinks). Similarly, the impulsive group reported a higher average number of binge drinking episodes (23), compared with the nonimpulsive patients (17).

The researchers assessed change in average number of drinks and average binge drinking at 12 months after the brief intervention. The motivational intervention consists of a 20-minute interview, feedback letter, and two follow-up telephone calls. “Essentially, everyone showed improvement after the interventions,” Dr. Ryb said.

They found that impulsivity, but not depression, was associated with an average 50 more alcoholic drinks and 4.2 more binge episodes at 12 months. However, overall decreases in the impulsive patients were not significantly different from any other patients in the study. Therefore, “impulsivity, depression, intervention type, and other covariates were not predictive of behavior change.”

Limitations of the study include its 50% follow-up rate, Dr. Ryb said. In addition, this study did not address any causal relationship between alcohol abuse and impulsivity.

FORT MYERS, FLA. – Depression and/or impulsivity do not get in the way of behavioral change for trauma patients who have participated in a brief motivational intervention for alcohol abuse, results of a study presented at the annual meeting of the Eastern Association for the Surgery of Trauma show.

Researchers performed a secondary analysis of data from the DELTA project, an ongoing study funded by the National Institute on Alcohol Abuse and Alcoholism. DELTA is a randomized controlled trial aimed at demonstrating that a brief intervention was effective in reducing alcohol use among 497 trauma patients. In the current study, researchers surveyed 248 participants at 12 months and found no significant differences in decreases in alcohol use between participants who reported depression and/or impulsivity, compared with those who did not, Dr. Gabriel E. Ryb said at the meeting, sponsored by Wake Forest Unversity.

The findings may only apply to mild to moderate problem drinkers because researchers excluded severely alcohol-dependent patients, said study discussant Dr. Michael Aboutanos.

“The reason we excluded the severe alcohol dependence patients … [was] … we assumed they would not be responsive to brief interventions,” said Dr. Ryb, a trauma surgeon and researcher at the National Study Center for Trauma and Emergency Medical Systems, University of Maryland, Baltimore.

In addition, the investigators should have assessed patients using validated depression and impulsivity assessment tools instead of self-reports, said Dr. Aboutanos, who serves as director of the Injury Prevention Program and on the surgery faculty at Virginia Commonwealth University, Richmond. Therefore, this secondary analysis may be limited by the design of the initial study.

“I essentially agree with criticisms relating to the study being a post hoc analysis,” Dr. Ryb said. “I also agree that more rigorous assessment of the psychologic state is needed.”

Despite his criticisms, Dr. Aboutanos said, “The finding that neither impulsivity nor depression diminishes alcohol use intervention will be welcome by clinicians. I applaud their efforts for completing this study in a very difficult population.”

Patients reported depression and impulsivity on the initial questionnaire. A total of 217 responded yes to the depressive indicator and 280 responded no. Not surprisingly, depression was associated with higher drinking rates.

“The co-occurrence of depression and alcohol abuse has been well studied,” Dr. Ryb said. “Alcohol use disorders occur in a lot of trauma patients. There is also a high incidence of psychiatric illness in the trauma population.”

Impulsivity is associated with risky behavior within the trauma population, Dr. Ryb said. Patients rated their impulsivity on scale of 1 to 4, according to this statement: “I often act on the spur of the moment without stopping to think.” Impulsive patients reported increased alcohol use in the 90 days preinjury (an average of 237 drinks), compared with nonimpulsive participants (190 drinks). Similarly, the impulsive group reported a higher average number of binge drinking episodes (23), compared with the nonimpulsive patients (17).

The researchers assessed change in average number of drinks and average binge drinking at 12 months after the brief intervention. The motivational intervention consists of a 20-minute interview, feedback letter, and two follow-up telephone calls. “Essentially, everyone showed improvement after the interventions,” Dr. Ryb said.

They found that impulsivity, but not depression, was associated with an average 50 more alcoholic drinks and 4.2 more binge episodes at 12 months. However, overall decreases in the impulsive patients were not significantly different from any other patients in the study. Therefore, “impulsivity, depression, intervention type, and other covariates were not predictive of behavior change.”

Limitations of the study include its 50% follow-up rate, Dr. Ryb said. In addition, this study did not address any causal relationship between alcohol abuse and impulsivity.

FORT MYERS, FLA. – Depression and/or impulsivity do not get in the way of behavioral change for trauma patients who have participated in a brief motivational intervention for alcohol abuse, results of a study presented at the annual meeting of the Eastern Association for the Surgery of Trauma show.

Researchers performed a secondary analysis of data from the DELTA project, an ongoing study funded by the National Institute on Alcohol Abuse and Alcoholism. DELTA is a randomized controlled trial aimed at demonstrating that a brief intervention was effective in reducing alcohol use among 497 trauma patients. In the current study, researchers surveyed 248 participants at 12 months and found no significant differences in decreases in alcohol use between participants who reported depression and/or impulsivity, compared with those who did not, Dr. Gabriel E. Ryb said at the meeting, sponsored by Wake Forest Unversity.

The findings may only apply to mild to moderate problem drinkers because researchers excluded severely alcohol-dependent patients, said study discussant Dr. Michael Aboutanos.

“The reason we excluded the severe alcohol dependence patients … [was] … we assumed they would not be responsive to brief interventions,” said Dr. Ryb, a trauma surgeon and researcher at the National Study Center for Trauma and Emergency Medical Systems, University of Maryland, Baltimore.

In addition, the investigators should have assessed patients using validated depression and impulsivity assessment tools instead of self-reports, said Dr. Aboutanos, who serves as director of the Injury Prevention Program and on the surgery faculty at Virginia Commonwealth University, Richmond. Therefore, this secondary analysis may be limited by the design of the initial study.

“I essentially agree with criticisms relating to the study being a post hoc analysis,” Dr. Ryb said. “I also agree that more rigorous assessment of the psychologic state is needed.”

Despite his criticisms, Dr. Aboutanos said, “The finding that neither impulsivity nor depression diminishes alcohol use intervention will be welcome by clinicians. I applaud their efforts for completing this study in a very difficult population.”

Patients reported depression and impulsivity on the initial questionnaire. A total of 217 responded yes to the depressive indicator and 280 responded no. Not surprisingly, depression was associated with higher drinking rates.

“The co-occurrence of depression and alcohol abuse has been well studied,” Dr. Ryb said. “Alcohol use disorders occur in a lot of trauma patients. There is also a high incidence of psychiatric illness in the trauma population.”

Impulsivity is associated with risky behavior within the trauma population, Dr. Ryb said. Patients rated their impulsivity on scale of 1 to 4, according to this statement: “I often act on the spur of the moment without stopping to think.” Impulsive patients reported increased alcohol use in the 90 days preinjury (an average of 237 drinks), compared with nonimpulsive participants (190 drinks). Similarly, the impulsive group reported a higher average number of binge drinking episodes (23), compared with the nonimpulsive patients (17).

The researchers assessed change in average number of drinks and average binge drinking at 12 months after the brief intervention. The motivational intervention consists of a 20-minute interview, feedback letter, and two follow-up telephone calls. “Essentially, everyone showed improvement after the interventions,” Dr. Ryb said.

They found that impulsivity, but not depression, was associated with an average 50 more alcoholic drinks and 4.2 more binge episodes at 12 months. However, overall decreases in the impulsive patients were not significantly different from any other patients in the study. Therefore, “impulsivity, depression, intervention type, and other covariates were not predictive of behavior change.”

Limitations of the study include its 50% follow-up rate, Dr. Ryb said. In addition, this study did not address any causal relationship between alcohol abuse and impulsivity.

CHAMPIONSGATE, FLA. — Despite good surgical outcomes, women undergoing pelvic organ prolapse surgery with or without urinary incontinence repair do not report improved sexual function, primarily because of significant postoperative vaginal pain, according to a prospective study presented at the annual meeting of the Society of Gynecologic Surgeons.

A total of 49 out of 51 women completed the Female Sexual Function Index (FSFI) and other measures before and after vaginal surgery. Vaginal bulging, dryness, and low desire were the chief preoperative complaints. Although some reported dryness and low desire after surgery as well, pain emerged as a significant postoperative barrier to sexual function, Dr. Rachel N. Pauls said.

“It is important to address these issues with patients preoperatively and in the postoperative period. Our goal is not to introduce problems after surgery to correct vaginal anatomy,” Dr. Pauls said at the meeting, which was jointly sponsored by the American College of Surgeons.

“Prospective studies looking at the effects of surgery on sexual function are sorely needed,” study discussant Dr. Rebecca G. Rogers said. “This one features the use of a validated questionnaire and a high follow-up rate.”

The FSFI addresses sexual frequency, degree of bother from sexual symptoms, and barriers to sexual activity. Participants also completed short forms of the Urogenital Distress Inventory (UDI) and the Incontinence Impact Questionnaire (IIQ).

Nearly all respondents, 48 of 49, reported they were sexually active. Mean age was 54 years and mean body mass index was 27 kg/m

At 6 months postoperatively, participants were mailed questionnaires and asked to describe any changes to sexual function.

Space was included for women to add comments. Ten women listed improvements and 19 listed problems, including 5 who said they had lower sexual desire. “A total of 12 reported vaginal pains, ranging from mild in 3 to severe in 9,” said Dr. Pauls, a urogynecologist in the department of obstetrics, Good Samaritan Hospital, Cincinnati.

The surgeries yielded significant improvements in prolapse stage, UDI, and IIQ scores. However, there were no differences in the FSFI domain or total scores before and after surgery, Dr. Pauls said. “A generic quality-of-life questionnaire may not be sensitive enough for assessing sexual function in women with prolapse and/or incontinence,” said Dr. Rogers, director of the division of urogynecology, University of New Mexico Health Sciences Center, Albuquerque.

Despite no overall change, Dr. Rogers asked how many individual participants had improved or worsened FSFI scores. Dr. Pauls replied that 47% reported a deterioration, a mean 5.4 points difference, and 53% noted an improvement, a mean 3.7 points difference. “And those who deteriorated had a higher mean age of 56 vs. 50 years,” she added.

Dr. Rogers asked if the researchers accounted for differences among the 22% who had a bilateral salpingo-oophorectomy at time of surgery. “We did not control for this factor, but the scores for women who had BSO and those who did not were not significantly different,” Dr. Pauls said.

A follow-up period that may have been too short for symptom resolution is a possible limitation of the study, Dr. Pauls said. Lack of vaginal diameter measurement and omission of prolapse and bowel function questionnaires are other potential shortcomings.

A meeting attendee asked if Dr. Pauls and her associates made any clinical recommendations based on the reports of vaginal dryness or pain. She replied, “This was a postal survey, but we did follow-up with those who reported pain.”

CHAMPIONSGATE, FLA. — Despite good surgical outcomes, women undergoing pelvic organ prolapse surgery with or without urinary incontinence repair do not report improved sexual function, primarily because of significant postoperative vaginal pain, according to a prospective study presented at the annual meeting of the Society of Gynecologic Surgeons.

A total of 49 out of 51 women completed the Female Sexual Function Index (FSFI) and other measures before and after vaginal surgery. Vaginal bulging, dryness, and low desire were the chief preoperative complaints. Although some reported dryness and low desire after surgery as well, pain emerged as a significant postoperative barrier to sexual function, Dr. Rachel N. Pauls said.

“It is important to address these issues with patients preoperatively and in the postoperative period. Our goal is not to introduce problems after surgery to correct vaginal anatomy,” Dr. Pauls said at the meeting, which was jointly sponsored by the American College of Surgeons.

“Prospective studies looking at the effects of surgery on sexual function are sorely needed,” study discussant Dr. Rebecca G. Rogers said. “This one features the use of a validated questionnaire and a high follow-up rate.”

The FSFI addresses sexual frequency, degree of bother from sexual symptoms, and barriers to sexual activity. Participants also completed short forms of the Urogenital Distress Inventory (UDI) and the Incontinence Impact Questionnaire (IIQ).

Nearly all respondents, 48 of 49, reported they were sexually active. Mean age was 54 years and mean body mass index was 27 kg/m

At 6 months postoperatively, participants were mailed questionnaires and asked to describe any changes to sexual function.

Space was included for women to add comments. Ten women listed improvements and 19 listed problems, including 5 who said they had lower sexual desire. “A total of 12 reported vaginal pains, ranging from mild in 3 to severe in 9,” said Dr. Pauls, a urogynecologist in the department of obstetrics, Good Samaritan Hospital, Cincinnati.

The surgeries yielded significant improvements in prolapse stage, UDI, and IIQ scores. However, there were no differences in the FSFI domain or total scores before and after surgery, Dr. Pauls said. “A generic quality-of-life questionnaire may not be sensitive enough for assessing sexual function in women with prolapse and/or incontinence,” said Dr. Rogers, director of the division of urogynecology, University of New Mexico Health Sciences Center, Albuquerque.

Despite no overall change, Dr. Rogers asked how many individual participants had improved or worsened FSFI scores. Dr. Pauls replied that 47% reported a deterioration, a mean 5.4 points difference, and 53% noted an improvement, a mean 3.7 points difference. “And those who deteriorated had a higher mean age of 56 vs. 50 years,” she added.

Dr. Rogers asked if the researchers accounted for differences among the 22% who had a bilateral salpingo-oophorectomy at time of surgery. “We did not control for this factor, but the scores for women who had BSO and those who did not were not significantly different,” Dr. Pauls said.

A follow-up period that may have been too short for symptom resolution is a possible limitation of the study, Dr. Pauls said. Lack of vaginal diameter measurement and omission of prolapse and bowel function questionnaires are other potential shortcomings.

A meeting attendee asked if Dr. Pauls and her associates made any clinical recommendations based on the reports of vaginal dryness or pain. She replied, “This was a postal survey, but we did follow-up with those who reported pain.”

CHAMPIONSGATE, FLA. — Despite good surgical outcomes, women undergoing pelvic organ prolapse surgery with or without urinary incontinence repair do not report improved sexual function, primarily because of significant postoperative vaginal pain, according to a prospective study presented at the annual meeting of the Society of Gynecologic Surgeons.

A total of 49 out of 51 women completed the Female Sexual Function Index (FSFI) and other measures before and after vaginal surgery. Vaginal bulging, dryness, and low desire were the chief preoperative complaints. Although some reported dryness and low desire after surgery as well, pain emerged as a significant postoperative barrier to sexual function, Dr. Rachel N. Pauls said.

“It is important to address these issues with patients preoperatively and in the postoperative period. Our goal is not to introduce problems after surgery to correct vaginal anatomy,” Dr. Pauls said at the meeting, which was jointly sponsored by the American College of Surgeons.

“Prospective studies looking at the effects of surgery on sexual function are sorely needed,” study discussant Dr. Rebecca G. Rogers said. “This one features the use of a validated questionnaire and a high follow-up rate.”

The FSFI addresses sexual frequency, degree of bother from sexual symptoms, and barriers to sexual activity. Participants also completed short forms of the Urogenital Distress Inventory (UDI) and the Incontinence Impact Questionnaire (IIQ).

Nearly all respondents, 48 of 49, reported they were sexually active. Mean age was 54 years and mean body mass index was 27 kg/m

At 6 months postoperatively, participants were mailed questionnaires and asked to describe any changes to sexual function.

Space was included for women to add comments. Ten women listed improvements and 19 listed problems, including 5 who said they had lower sexual desire. “A total of 12 reported vaginal pains, ranging from mild in 3 to severe in 9,” said Dr. Pauls, a urogynecologist in the department of obstetrics, Good Samaritan Hospital, Cincinnati.

The surgeries yielded significant improvements in prolapse stage, UDI, and IIQ scores. However, there were no differences in the FSFI domain or total scores before and after surgery, Dr. Pauls said. “A generic quality-of-life questionnaire may not be sensitive enough for assessing sexual function in women with prolapse and/or incontinence,” said Dr. Rogers, director of the division of urogynecology, University of New Mexico Health Sciences Center, Albuquerque.

Despite no overall change, Dr. Rogers asked how many individual participants had improved or worsened FSFI scores. Dr. Pauls replied that 47% reported a deterioration, a mean 5.4 points difference, and 53% noted an improvement, a mean 3.7 points difference. “And those who deteriorated had a higher mean age of 56 vs. 50 years,” she added.

Dr. Rogers asked if the researchers accounted for differences among the 22% who had a bilateral salpingo-oophorectomy at time of surgery. “We did not control for this factor, but the scores for women who had BSO and those who did not were not significantly different,” Dr. Pauls said.

A follow-up period that may have been too short for symptom resolution is a possible limitation of the study, Dr. Pauls said. Lack of vaginal diameter measurement and omission of prolapse and bowel function questionnaires are other potential shortcomings.

A meeting attendee asked if Dr. Pauls and her associates made any clinical recommendations based on the reports of vaginal dryness or pain. She replied, “This was a postal survey, but we did follow-up with those who reported pain.”

CHAMPIONSGATE, FLA. — First-degree relatives of a woman with pelvic organ prolapse have at least a fourfold increased risk of developing the condition, according to a large genetic database study presented at the annual meeting of the Society of Gynecologic Surgeons.

Investigators found a nonsignificant increased risk for second-degree relatives and a significantly higher risk among third-degree relatives of the 1,292 women with pelvic organ prolapse studied in the Utah Population Database.

“It could be a function of second-degree relatives being older and having no [diagnostic] codes because they have died, or they are young and have yet to develop these conditions,” Dr. Peggy Norton said at the meeting, which was jointly sponsored by the American College of Surgeons.

“Little is known about the etiology or natural history of pelvic organ prolapse. Many complex diseases with unknown mechanisms have been found to have genetic etiologies, beginning with evidence of heritability and resulting in discovery of specific gene mutations,” said Dr. Norton, chief of the division of urogynecology and pelvic reconstructive surgery at the University of Utah in Salt Lake City.

“Any standard gyn. textbook lists a genetic risk for prolapse, although with very little data,” study discussant Dr. Anne K. Wiskind said.

Several studies published in 2006 proposed a familial pattern to pelvic organ prolapse. For example, investigators in one study identified 10 patients aged under 55 years with a family pattern of prolapse (Int. Urogynecol. J. Pelvic Floor Dysfunct. 2006;17:498–501).

The inheritance pattern of pelvic organ prolapse within the families revealed both maternal and paternal transmissions. Relative risk to siblings of affected patients was five times the risk for the general population.

The current study utilizes the Utah Population Database. Beginning in 1994, 2.2 million individuals with genealogic records of three generations or more were linked to ICD and CPT diagnosis codes at the University of Utah.

“My initial bias was, how can this be generalizable from a uniform, Caucasian, Mormon population? But Mormons have a large, heterogeneous gene pool,” said Dr. Wiskind, an ob.gyn. in private practice in Atlanta.

Dr. Norton and her associates identified first-, second-, and third-degree female relatives of the 1,292 probands with prolapse. One aim was to see which relatives had a diagnostic and/or procedure code for the condition as well. Age- and parity-matched women from a general database were used as a control group.

“We found at least a fourfold increased risk in first-degree relatives, such as sisters and daughters, compared to the first-degree relatives of controls,” Dr. Norton said. The difference was statistically significant (relative risk, 4.15). In contrast, second-degree relatives had a relative risk of 1.20 and third-degree relatives had a relative risk of 1.24.

“Some of those age- and parity-matched controls will have some degree of prolapse—so it will be underestimation,” Dr. Norton said. In addition, “the relative risk in the database is not the same as the disease risk in the population.”

Data have only been collected since 1994, which is a limitation of the study, Dr. Norton said. “It's easier in the cancer registries—there are 40 years of data in Utah.”

The study findings have important clinical and research implications, Dr. Norton said. “Heritability is an important risk factor for pelvic organ prolapse that may be identified before major promoting events, such as childbirth.” In addition, the identification of high-risk pedigrees may allow scientists to search for genetic mutations.

A meeting attendee commented that family analysis of women with pelvic organ prolapse also can reveal a higher incidence of umbilical and inguinal hernias in male relatives.

“We submitted an abstract to ACS on that topic,” Dr. Norton said.

The current study was supported by a grant from the National Institutes of Child Health and Human Development.

“The NIH is now adding all Utah hospital data, not just from the University of Utah, to be completed in next year,” Dr. Norton said. “It should be interesting to see what happens.”

CHAMPIONSGATE, FLA. — First-degree relatives of a woman with pelvic organ prolapse have at least a fourfold increased risk of developing the condition, according to a large genetic database study presented at the annual meeting of the Society of Gynecologic Surgeons.

Investigators found a nonsignificant increased risk for second-degree relatives and a significantly higher risk among third-degree relatives of the 1,292 women with pelvic organ prolapse studied in the Utah Population Database.

“It could be a function of second-degree relatives being older and having no [diagnostic] codes because they have died, or they are young and have yet to develop these conditions,” Dr. Peggy Norton said at the meeting, which was jointly sponsored by the American College of Surgeons.

“Little is known about the etiology or natural history of pelvic organ prolapse. Many complex diseases with unknown mechanisms have been found to have genetic etiologies, beginning with evidence of heritability and resulting in discovery of specific gene mutations,” said Dr. Norton, chief of the division of urogynecology and pelvic reconstructive surgery at the University of Utah in Salt Lake City.

“Any standard gyn. textbook lists a genetic risk for prolapse, although with very little data,” study discussant Dr. Anne K. Wiskind said.

Several studies published in 2006 proposed a familial pattern to pelvic organ prolapse. For example, investigators in one study identified 10 patients aged under 55 years with a family pattern of prolapse (Int. Urogynecol. J. Pelvic Floor Dysfunct. 2006;17:498–501).

The inheritance pattern of pelvic organ prolapse within the families revealed both maternal and paternal transmissions. Relative risk to siblings of affected patients was five times the risk for the general population.

The current study utilizes the Utah Population Database. Beginning in 1994, 2.2 million individuals with genealogic records of three generations or more were linked to ICD and CPT diagnosis codes at the University of Utah.

“My initial bias was, how can this be generalizable from a uniform, Caucasian, Mormon population? But Mormons have a large, heterogeneous gene pool,” said Dr. Wiskind, an ob.gyn. in private practice in Atlanta.

Dr. Norton and her associates identified first-, second-, and third-degree female relatives of the 1,292 probands with prolapse. One aim was to see which relatives had a diagnostic and/or procedure code for the condition as well. Age- and parity-matched women from a general database were used as a control group.

“We found at least a fourfold increased risk in first-degree relatives, such as sisters and daughters, compared to the first-degree relatives of controls,” Dr. Norton said. The difference was statistically significant (relative risk, 4.15). In contrast, second-degree relatives had a relative risk of 1.20 and third-degree relatives had a relative risk of 1.24.

“Some of those age- and parity-matched controls will have some degree of prolapse—so it will be underestimation,” Dr. Norton said. In addition, “the relative risk in the database is not the same as the disease risk in the population.”

Data have only been collected since 1994, which is a limitation of the study, Dr. Norton said. “It's easier in the cancer registries—there are 40 years of data in Utah.”

The study findings have important clinical and research implications, Dr. Norton said. “Heritability is an important risk factor for pelvic organ prolapse that may be identified before major promoting events, such as childbirth.” In addition, the identification of high-risk pedigrees may allow scientists to search for genetic mutations.

A meeting attendee commented that family analysis of women with pelvic organ prolapse also can reveal a higher incidence of umbilical and inguinal hernias in male relatives.

“We submitted an abstract to ACS on that topic,” Dr. Norton said.

The current study was supported by a grant from the National Institutes of Child Health and Human Development.

“The NIH is now adding all Utah hospital data, not just from the University of Utah, to be completed in next year,” Dr. Norton said. “It should be interesting to see what happens.”

CHAMPIONSGATE, FLA. — First-degree relatives of a woman with pelvic organ prolapse have at least a fourfold increased risk of developing the condition, according to a large genetic database study presented at the annual meeting of the Society of Gynecologic Surgeons.

Investigators found a nonsignificant increased risk for second-degree relatives and a significantly higher risk among third-degree relatives of the 1,292 women with pelvic organ prolapse studied in the Utah Population Database.

“It could be a function of second-degree relatives being older and having no [diagnostic] codes because they have died, or they are young and have yet to develop these conditions,” Dr. Peggy Norton said at the meeting, which was jointly sponsored by the American College of Surgeons.

“Little is known about the etiology or natural history of pelvic organ prolapse. Many complex diseases with unknown mechanisms have been found to have genetic etiologies, beginning with evidence of heritability and resulting in discovery of specific gene mutations,” said Dr. Norton, chief of the division of urogynecology and pelvic reconstructive surgery at the University of Utah in Salt Lake City.

“Any standard gyn. textbook lists a genetic risk for prolapse, although with very little data,” study discussant Dr. Anne K. Wiskind said.

Several studies published in 2006 proposed a familial pattern to pelvic organ prolapse. For example, investigators in one study identified 10 patients aged under 55 years with a family pattern of prolapse (Int. Urogynecol. J. Pelvic Floor Dysfunct. 2006;17:498–501).

The inheritance pattern of pelvic organ prolapse within the families revealed both maternal and paternal transmissions. Relative risk to siblings of affected patients was five times the risk for the general population.

The current study utilizes the Utah Population Database. Beginning in 1994, 2.2 million individuals with genealogic records of three generations or more were linked to ICD and CPT diagnosis codes at the University of Utah.

“My initial bias was, how can this be generalizable from a uniform, Caucasian, Mormon population? But Mormons have a large, heterogeneous gene pool,” said Dr. Wiskind, an ob.gyn. in private practice in Atlanta.

Dr. Norton and her associates identified first-, second-, and third-degree female relatives of the 1,292 probands with prolapse. One aim was to see which relatives had a diagnostic and/or procedure code for the condition as well. Age- and parity-matched women from a general database were used as a control group.

“We found at least a fourfold increased risk in first-degree relatives, such as sisters and daughters, compared to the first-degree relatives of controls,” Dr. Norton said. The difference was statistically significant (relative risk, 4.15). In contrast, second-degree relatives had a relative risk of 1.20 and third-degree relatives had a relative risk of 1.24.

“Some of those age- and parity-matched controls will have some degree of prolapse—so it will be underestimation,” Dr. Norton said. In addition, “the relative risk in the database is not the same as the disease risk in the population.”

Data have only been collected since 1994, which is a limitation of the study, Dr. Norton said. “It's easier in the cancer registries—there are 40 years of data in Utah.”

The study findings have important clinical and research implications, Dr. Norton said. “Heritability is an important risk factor for pelvic organ prolapse that may be identified before major promoting events, such as childbirth.” In addition, the identification of high-risk pedigrees may allow scientists to search for genetic mutations.

A meeting attendee commented that family analysis of women with pelvic organ prolapse also can reveal a higher incidence of umbilical and inguinal hernias in male relatives.

“We submitted an abstract to ACS on that topic,” Dr. Norton said.

The current study was supported by a grant from the National Institutes of Child Health and Human Development.

“The NIH is now adding all Utah hospital data, not just from the University of Utah, to be completed in next year,” Dr. Norton said. “It should be interesting to see what happens.”

MIAMI — Pediatric back pain is rarely serious unless it persists or impairs daily functioning, Dr. Harry L. Shufflebarger said, and most cases of postural roundback are not of grave concern and will resolve over time, despite some significant parental anxiety.

Trunk asymmetry, or scoliosis, is managed according to severity, he said at a pediatric update sponsored by Miami Children's Hospital.

Avoid labeling pediatric patients with the “S word” until a definitive diagnosis is made, said Dr. Shufflebarger, chief of the division of spinal surgery at the hospital.

Back pain is common among pediatric patients. Approximately 10% of children under 10 years will complain of back pain, and about 50% of adolescents.

Approximately 80%–90% will have no identifiable organic etiology for their pain, even after an extensive work-up, he said. “In the absence of stiffness, loss of appetite, energy change, apathy, or obvious illness, back pain is unlikely to be anything significant.”

However, if back pain persists more than 3 months, it warrants further evaluation. Also be concerned if the pain is tied to a deformity, if it is rated significant by the patient or parent, if it wakes a patient at night, and/or if it interferes with function during school or social activities.

If an x-ray is negative, Dr. Shufflebarger suggested a second image with either a 3-phase technetium scan or a single-photo emission computed tomography scan.

A postural or asthenic roundback—also called a “hunchback”—is a frequent parental complaint, Dr. Shufflebarger said. “The best treatment is reassurance of parents that this is not a structural problem of the back and most children will outgrow it.”

A prone, voluntary hyperextension test can differentiate postural from structural kyphosis. An inability to flatten the thoracic kyphosis might point to structural kyphosis or Scheuermann's kyphosis, Dr. Shufflebarger said. More severe kyphosis curvature, 50 degrees or more, might require bracing or surgery, he added.

Scoliosis is a general term for multiple etiologies. It can be idiopathic, congenital, neuromuscular, or other (such as neurofibromatosis). Clinicians can assess trunk asymmetry with the Adams forward bend test and/or a scoliometer and radiographs. If the bend test is positive, order a spinal x-ray, Dr. Shufflebarger said. “But radiology reports are not always reliable, so review the images.”

Scoliosis is confirmed with an erect radiograph that shows a curve greater than 10 degrees and when the scoliometer test shows trunk asymmetry over 5 degrees.

Idiopathic scoliosis can be juvenile onset (4–10 years) or adolescent (over 10 years). About 3%–4% of seventh graders will test positive on school screening, with 1%–2% having true scoliosis.

Most children and adolescents referred to a specialist for further evaluation can wait, but some should not, Dr. Shufflebarger said. Risk of progression is the primary concern with idiopathic scoliosis in children. Patients with more growth potential are at higher risk of quick progression, including children at a Tanner stage less than 3, those who are premenarche, and children with open triradiate cartilages. A more expeditious consult with a specialist might be warranted if the angle of trunk rotation is greater than 10–12 degrees, he added.

The gender distribution of small curves (less than 20 degrees) will be 2:1 girls to boys.

Observation, bracing, and surgery are the scoliosis management options. Observation is generally recommended for curves less than 25 degrees. With these, a specialist should repeat an x-ray in 3–4 months to monitor for any progression, he said.

“Bracing is suggested for children and adolescents with curves of 25 degrees or greater or an observed 10-degree curvature change,” Dr. Shufflebarger said. “A custom-made underarm orthosis has to be worn 20 hours per day. It is effective for 60%–70% of patients. Brace failure is therefore 30%–40%.”

Surgery is usually indicated for patients with curves greater than 40 degrees, he said. “Rarely are these urgent referrals, and the risks of surgery are rare.”

The Adams forward bend test can be used to assess asymmetry (left). The patient's x-ray confirms the extent of spinal curvature, also shown corrected post surgery. Photos courtesy Dr. Harry L. Shufflebarger

MIAMI — Pediatric back pain is rarely serious unless it persists or impairs daily functioning, Dr. Harry L. Shufflebarger said, and most cases of postural roundback are not of grave concern and will resolve over time, despite some significant parental anxiety.

Trunk asymmetry, or scoliosis, is managed according to severity, he said at a pediatric update sponsored by Miami Children's Hospital.

Avoid labeling pediatric patients with the “S word” until a definitive diagnosis is made, said Dr. Shufflebarger, chief of the division of spinal surgery at the hospital.

Back pain is common among pediatric patients. Approximately 10% of children under 10 years will complain of back pain, and about 50% of adolescents.

Approximately 80%–90% will have no identifiable organic etiology for their pain, even after an extensive work-up, he said. “In the absence of stiffness, loss of appetite, energy change, apathy, or obvious illness, back pain is unlikely to be anything significant.”

However, if back pain persists more than 3 months, it warrants further evaluation. Also be concerned if the pain is tied to a deformity, if it is rated significant by the patient or parent, if it wakes a patient at night, and/or if it interferes with function during school or social activities.

If an x-ray is negative, Dr. Shufflebarger suggested a second image with either a 3-phase technetium scan or a single-photo emission computed tomography scan.

A postural or asthenic roundback—also called a “hunchback”—is a frequent parental complaint, Dr. Shufflebarger said. “The best treatment is reassurance of parents that this is not a structural problem of the back and most children will outgrow it.”

A prone, voluntary hyperextension test can differentiate postural from structural kyphosis. An inability to flatten the thoracic kyphosis might point to structural kyphosis or Scheuermann's kyphosis, Dr. Shufflebarger said. More severe kyphosis curvature, 50 degrees or more, might require bracing or surgery, he added.

Scoliosis is a general term for multiple etiologies. It can be idiopathic, congenital, neuromuscular, or other (such as neurofibromatosis). Clinicians can assess trunk asymmetry with the Adams forward bend test and/or a scoliometer and radiographs. If the bend test is positive, order a spinal x-ray, Dr. Shufflebarger said. “But radiology reports are not always reliable, so review the images.”

Scoliosis is confirmed with an erect radiograph that shows a curve greater than 10 degrees and when the scoliometer test shows trunk asymmetry over 5 degrees.

Idiopathic scoliosis can be juvenile onset (4–10 years) or adolescent (over 10 years). About 3%–4% of seventh graders will test positive on school screening, with 1%–2% having true scoliosis.

Most children and adolescents referred to a specialist for further evaluation can wait, but some should not, Dr. Shufflebarger said. Risk of progression is the primary concern with idiopathic scoliosis in children. Patients with more growth potential are at higher risk of quick progression, including children at a Tanner stage less than 3, those who are premenarche, and children with open triradiate cartilages. A more expeditious consult with a specialist might be warranted if the angle of trunk rotation is greater than 10–12 degrees, he added.

The gender distribution of small curves (less than 20 degrees) will be 2:1 girls to boys.

Observation, bracing, and surgery are the scoliosis management options. Observation is generally recommended for curves less than 25 degrees. With these, a specialist should repeat an x-ray in 3–4 months to monitor for any progression, he said.

“Bracing is suggested for children and adolescents with curves of 25 degrees or greater or an observed 10-degree curvature change,” Dr. Shufflebarger said. “A custom-made underarm orthosis has to be worn 20 hours per day. It is effective for 60%–70% of patients. Brace failure is therefore 30%–40%.”

Surgery is usually indicated for patients with curves greater than 40 degrees, he said. “Rarely are these urgent referrals, and the risks of surgery are rare.”

The Adams forward bend test can be used to assess asymmetry (left). The patient's x-ray confirms the extent of spinal curvature, also shown corrected post surgery. Photos courtesy Dr. Harry L. Shufflebarger

MIAMI — Pediatric back pain is rarely serious unless it persists or impairs daily functioning, Dr. Harry L. Shufflebarger said, and most cases of postural roundback are not of grave concern and will resolve over time, despite some significant parental anxiety.

Trunk asymmetry, or scoliosis, is managed according to severity, he said at a pediatric update sponsored by Miami Children's Hospital.

Avoid labeling pediatric patients with the “S word” until a definitive diagnosis is made, said Dr. Shufflebarger, chief of the division of spinal surgery at the hospital.

Back pain is common among pediatric patients. Approximately 10% of children under 10 years will complain of back pain, and about 50% of adolescents.

Approximately 80%–90% will have no identifiable organic etiology for their pain, even after an extensive work-up, he said. “In the absence of stiffness, loss of appetite, energy change, apathy, or obvious illness, back pain is unlikely to be anything significant.”

However, if back pain persists more than 3 months, it warrants further evaluation. Also be concerned if the pain is tied to a deformity, if it is rated significant by the patient or parent, if it wakes a patient at night, and/or if it interferes with function during school or social activities.

If an x-ray is negative, Dr. Shufflebarger suggested a second image with either a 3-phase technetium scan or a single-photo emission computed tomography scan.

A postural or asthenic roundback—also called a “hunchback”—is a frequent parental complaint, Dr. Shufflebarger said. “The best treatment is reassurance of parents that this is not a structural problem of the back and most children will outgrow it.”

A prone, voluntary hyperextension test can differentiate postural from structural kyphosis. An inability to flatten the thoracic kyphosis might point to structural kyphosis or Scheuermann's kyphosis, Dr. Shufflebarger said. More severe kyphosis curvature, 50 degrees or more, might require bracing or surgery, he added.

Scoliosis is a general term for multiple etiologies. It can be idiopathic, congenital, neuromuscular, or other (such as neurofibromatosis). Clinicians can assess trunk asymmetry with the Adams forward bend test and/or a scoliometer and radiographs. If the bend test is positive, order a spinal x-ray, Dr. Shufflebarger said. “But radiology reports are not always reliable, so review the images.”

Scoliosis is confirmed with an erect radiograph that shows a curve greater than 10 degrees and when the scoliometer test shows trunk asymmetry over 5 degrees.

Idiopathic scoliosis can be juvenile onset (4–10 years) or adolescent (over 10 years). About 3%–4% of seventh graders will test positive on school screening, with 1%–2% having true scoliosis.

Most children and adolescents referred to a specialist for further evaluation can wait, but some should not, Dr. Shufflebarger said. Risk of progression is the primary concern with idiopathic scoliosis in children. Patients with more growth potential are at higher risk of quick progression, including children at a Tanner stage less than 3, those who are premenarche, and children with open triradiate cartilages. A more expeditious consult with a specialist might be warranted if the angle of trunk rotation is greater than 10–12 degrees, he added.

The gender distribution of small curves (less than 20 degrees) will be 2:1 girls to boys.

Observation, bracing, and surgery are the scoliosis management options. Observation is generally recommended for curves less than 25 degrees. With these, a specialist should repeat an x-ray in 3–4 months to monitor for any progression, he said.

“Bracing is suggested for children and adolescents with curves of 25 degrees or greater or an observed 10-degree curvature change,” Dr. Shufflebarger said. “A custom-made underarm orthosis has to be worn 20 hours per day. It is effective for 60%–70% of patients. Brace failure is therefore 30%–40%.”

Surgery is usually indicated for patients with curves greater than 40 degrees, he said. “Rarely are these urgent referrals, and the risks of surgery are rare.”

The Adams forward bend test can be used to assess asymmetry (left). The patient's x-ray confirms the extent of spinal curvature, also shown corrected post surgery. Photos courtesy Dr. Harry L. Shufflebarger

MIAMI BEACH — Obstetrician-gynecologists can identify patients and families at risk for genetic cancers, provide appropriate referrals, and monitor patients with long-term follow-up, Talia Donenberg, a board-certified genetic counselor, said at an ob.gyn. conference sponsored by the University of Miami.

And they can meet with patients to review and update the management plan, update family history, and provide support as needed, said Ms. Donenberg of the Center for Cancer Prevention and Genetics, University of Miami.

Ovarian cancer has one of the highest frequencies of inheritance, at least 10%, she said. “It is important to define patient-specific risk.”

There are legal liability implications. “Now that we have commercially available genetic testing, it is important to discuss risk of other cancers for them and their family members,” Ms. Donenberg said. There is the issue of duty to warn. “So far there have been three lawsuits against physicians about failure to warn patients about a family predisposition.” In a recent case, a woman being treated for bilateral breast cancer claimed her physician never discussed her familial risk for ovarian cancer. The lawsuit was settled out of court.

Initial genetic counseling can take up to 2 hours at the multidisciplinary, high-risk screening clinic where Ms. Donenberg counsels and tests patients referred from primary care providers and specialists. One aim is to get at least a three-generation pedigree. “The accuracy of reporting breast cancer is higher than with ovarian cancer. When they report a family history, was it really ovarian cancer, or was it endometrial or cervical?”

Certain clues can help genetic counselors if a person's recollection is incomplete. For example, “it is inconsistent with ovarian cancer if a family member was diagnosed at age 30 and remained asymptomatic for another 30 years,” Ms. Donenberg said. Unusually early onset of cancer (younger than 50), multiple primary tumors in the same patient, and bilateral breast cancer are other indicators of hereditary cancer, she said. “Also, unusual cancers, such as male breast cancer, might tip us off.”

Begin genetic testing with an affected family member if possible, Ms. Donenberg said. “Often the proband is a woman who is unaffected but concerned.”

The clinic receives grant funding for testing of indigent patients. “This is extremely important because genetic testing is very expensive,” Ms. Donenberg said. It can cost more than $3,000 to look at both BRCA1 and BRCA2 genes. Most insurance companies will cover the testing if the right criteria are met, she added.

It costs considerably less—about $400—to test for a single mutation in an at-risk family member, Ms. Donenberg said.

In addition, it is less costly and easier to find a specific BRCA mutation in patients from certain populations with recurring founder mutations, such as Ashkenazi Jews.

Hereditary susceptibility to epithelial ovarian cancer for a BRCA1 carrier is 50%–60%, and for a BRCA2 carrier, the risk is 30%–40%, Ms. Donenberg said. Investigators have also calculated cumulative cancer risk by age in BRCA carriers (Science 2003;302:643-6).

BRCA-related ovarian cancer is often nonmucinous, poorly differentiated, and invasive. Borderline tumors are highly unlikely, Ms. Donenberg said. The mean age of onset is 52 years. Most of these cancers originate in the fallopian tubes.

BRCA-related ovarian cancer has been associated with a better response to chemotherapy and better overall prognosis (Cancer 2003;97:2187-95).

Management options for BRCA mutation carriers include prescription of oral contraceptives. Use of these agents for 5-6 years reduced breast cancer risk by 60% in one study (J. Natl. Cancer Inst. 2002;94:1773-9). Surveillance every 6 months starting at ages 25-35 is also suggested.

Prophylactic salpingo-oophorectomy is another option, Ms. Donenberg said. This surgery reduces risk of primary ovarian and fallopian cancers, “and we have data this can reduce breast cancer risk in premenopausal women (N. Engl. J. Med. 2002;346:1616-22).

“There is a large proportion of these women who already have occult ovarian cancer at time of a prophylactic procedure. This is something we have to keep in mind,” Ms. Donenberg said.

MIAMI BEACH — Obstetrician-gynecologists can identify patients and families at risk for genetic cancers, provide appropriate referrals, and monitor patients with long-term follow-up, Talia Donenberg, a board-certified genetic counselor, said at an ob.gyn. conference sponsored by the University of Miami.

And they can meet with patients to review and update the management plan, update family history, and provide support as needed, said Ms. Donenberg of the Center for Cancer Prevention and Genetics, University of Miami.

Ovarian cancer has one of the highest frequencies of inheritance, at least 10%, she said. “It is important to define patient-specific risk.”

There are legal liability implications. “Now that we have commercially available genetic testing, it is important to discuss risk of other cancers for them and their family members,” Ms. Donenberg said. There is the issue of duty to warn. “So far there have been three lawsuits against physicians about failure to warn patients about a family predisposition.” In a recent case, a woman being treated for bilateral breast cancer claimed her physician never discussed her familial risk for ovarian cancer. The lawsuit was settled out of court.

Initial genetic counseling can take up to 2 hours at the multidisciplinary, high-risk screening clinic where Ms. Donenberg counsels and tests patients referred from primary care providers and specialists. One aim is to get at least a three-generation pedigree. “The accuracy of reporting breast cancer is higher than with ovarian cancer. When they report a family history, was it really ovarian cancer, or was it endometrial or cervical?”

Certain clues can help genetic counselors if a person's recollection is incomplete. For example, “it is inconsistent with ovarian cancer if a family member was diagnosed at age 30 and remained asymptomatic for another 30 years,” Ms. Donenberg said. Unusually early onset of cancer (younger than 50), multiple primary tumors in the same patient, and bilateral breast cancer are other indicators of hereditary cancer, she said. “Also, unusual cancers, such as male breast cancer, might tip us off.”

Begin genetic testing with an affected family member if possible, Ms. Donenberg said. “Often the proband is a woman who is unaffected but concerned.”

The clinic receives grant funding for testing of indigent patients. “This is extremely important because genetic testing is very expensive,” Ms. Donenberg said. It can cost more than $3,000 to look at both BRCA1 and BRCA2 genes. Most insurance companies will cover the testing if the right criteria are met, she added.

It costs considerably less—about $400—to test for a single mutation in an at-risk family member, Ms. Donenberg said.

In addition, it is less costly and easier to find a specific BRCA mutation in patients from certain populations with recurring founder mutations, such as Ashkenazi Jews.

Hereditary susceptibility to epithelial ovarian cancer for a BRCA1 carrier is 50%–60%, and for a BRCA2 carrier, the risk is 30%–40%, Ms. Donenberg said. Investigators have also calculated cumulative cancer risk by age in BRCA carriers (Science 2003;302:643-6).

BRCA-related ovarian cancer is often nonmucinous, poorly differentiated, and invasive. Borderline tumors are highly unlikely, Ms. Donenberg said. The mean age of onset is 52 years. Most of these cancers originate in the fallopian tubes.

BRCA-related ovarian cancer has been associated with a better response to chemotherapy and better overall prognosis (Cancer 2003;97:2187-95).

Management options for BRCA mutation carriers include prescription of oral contraceptives. Use of these agents for 5-6 years reduced breast cancer risk by 60% in one study (J. Natl. Cancer Inst. 2002;94:1773-9). Surveillance every 6 months starting at ages 25-35 is also suggested.

Prophylactic salpingo-oophorectomy is another option, Ms. Donenberg said. This surgery reduces risk of primary ovarian and fallopian cancers, “and we have data this can reduce breast cancer risk in premenopausal women (N. Engl. J. Med. 2002;346:1616-22).

“There is a large proportion of these women who already have occult ovarian cancer at time of a prophylactic procedure. This is something we have to keep in mind,” Ms. Donenberg said.

MIAMI BEACH — Obstetrician-gynecologists can identify patients and families at risk for genetic cancers, provide appropriate referrals, and monitor patients with long-term follow-up, Talia Donenberg, a board-certified genetic counselor, said at an ob.gyn. conference sponsored by the University of Miami.

And they can meet with patients to review and update the management plan, update family history, and provide support as needed, said Ms. Donenberg of the Center for Cancer Prevention and Genetics, University of Miami.

Ovarian cancer has one of the highest frequencies of inheritance, at least 10%, she said. “It is important to define patient-specific risk.”

There are legal liability implications. “Now that we have commercially available genetic testing, it is important to discuss risk of other cancers for them and their family members,” Ms. Donenberg said. There is the issue of duty to warn. “So far there have been three lawsuits against physicians about failure to warn patients about a family predisposition.” In a recent case, a woman being treated for bilateral breast cancer claimed her physician never discussed her familial risk for ovarian cancer. The lawsuit was settled out of court.

Initial genetic counseling can take up to 2 hours at the multidisciplinary, high-risk screening clinic where Ms. Donenberg counsels and tests patients referred from primary care providers and specialists. One aim is to get at least a three-generation pedigree. “The accuracy of reporting breast cancer is higher than with ovarian cancer. When they report a family history, was it really ovarian cancer, or was it endometrial or cervical?”

Certain clues can help genetic counselors if a person's recollection is incomplete. For example, “it is inconsistent with ovarian cancer if a family member was diagnosed at age 30 and remained asymptomatic for another 30 years,” Ms. Donenberg said. Unusually early onset of cancer (younger than 50), multiple primary tumors in the same patient, and bilateral breast cancer are other indicators of hereditary cancer, she said. “Also, unusual cancers, such as male breast cancer, might tip us off.”

Begin genetic testing with an affected family member if possible, Ms. Donenberg said. “Often the proband is a woman who is unaffected but concerned.”

The clinic receives grant funding for testing of indigent patients. “This is extremely important because genetic testing is very expensive,” Ms. Donenberg said. It can cost more than $3,000 to look at both BRCA1 and BRCA2 genes. Most insurance companies will cover the testing if the right criteria are met, she added.

It costs considerably less—about $400—to test for a single mutation in an at-risk family member, Ms. Donenberg said.

In addition, it is less costly and easier to find a specific BRCA mutation in patients from certain populations with recurring founder mutations, such as Ashkenazi Jews.

Hereditary susceptibility to epithelial ovarian cancer for a BRCA1 carrier is 50%–60%, and for a BRCA2 carrier, the risk is 30%–40%, Ms. Donenberg said. Investigators have also calculated cumulative cancer risk by age in BRCA carriers (Science 2003;302:643-6).

BRCA-related ovarian cancer is often nonmucinous, poorly differentiated, and invasive. Borderline tumors are highly unlikely, Ms. Donenberg said. The mean age of onset is 52 years. Most of these cancers originate in the fallopian tubes.

BRCA-related ovarian cancer has been associated with a better response to chemotherapy and better overall prognosis (Cancer 2003;97:2187-95).

Management options for BRCA mutation carriers include prescription of oral contraceptives. Use of these agents for 5-6 years reduced breast cancer risk by 60% in one study (J. Natl. Cancer Inst. 2002;94:1773-9). Surveillance every 6 months starting at ages 25-35 is also suggested.

Prophylactic salpingo-oophorectomy is another option, Ms. Donenberg said. This surgery reduces risk of primary ovarian and fallopian cancers, “and we have data this can reduce breast cancer risk in premenopausal women (N. Engl. J. Med. 2002;346:1616-22).

“There is a large proportion of these women who already have occult ovarian cancer at time of a prophylactic procedure. This is something we have to keep in mind,” Ms. Donenberg said.

MIAMI BEACH — Nearly a year following its approval, the advantages and disadvantages of a contraceptive implant are becoming better known, but there are still no data on its efficacy in overweight or obese women, according to a presentation at an ob.gyn. conference sponsored by the University of Miami.

The Food and Drug Administration cleared Implanon (Organon International) for marketing in July 2006. It is the first single-rod, 68-mg etonogestrel, subdermal implant. The core is 40% ethylene vinyl acetate, which provides a slow, steady release of progestin for up to 3 years, according to clinical trials.

However, overweight and obese women were excluded from the preapproval studies. “This is kind of the kicker—efficacy in overweight women,” Dr. Paul M. Norris said. “There are no clinical trial data.” Women who weighed more than 130% of their ideal body weight were not studied. For physicians, such an exclusion would be “very impractical” in the United States, Dr. Norris added.

Implanon replaces the six-rod Norplant device, which was removed from the market following reports of product migration and side effects, Dr. Norris said. “The data on Norplant suggested it was still efficacious, although less so, in overweight patients. But I am not sure you can apply this finding to Implanon.”

Implanon is inserted in the subepidermal groove of a woman's arm between her biceps and triceps, about 6-8 inches up from the crux of elbow. Physicians can order Implanon only upon completion of a training program, sponsored by the manufacturer, on insertion and removal. “They were concerned about injections in other vital structures. So far, the programs have gone well,” said Dr. Norris, who is on the obstetrics and gynecology faculty at the University of Miami. He is on the speakers' bureau for Organon.

“The device to insert the implant looks like the Depo Provera syringe,” Dr. Norris said. “The blue placebo injector for practice has a pregnancy rate of about 85% so make sure you are using the white injector with the active ingredient!”

Insertion time is faster than the Norplant, about a mean of 1 minute, compared with 4 minutes for the Norplant, Dr. Norris said. The 4-cm-long, 2-mm-diameter Implanon rod is not radio-opaque. “If you lose an implant, you cannot palpate it 3 years later,” he said. “It is very easy to pick up on ultrasound, but you need at least a 10-MHz wand, which is not common in most ob.gyn. offices,” he said.

Implanon's contraceptive effects are reversible—a woman's fertility quickly returns after removal, according to the manufacturer.

The mean removal time for Implanon is 3 minutes, compared with 11 minutes for Norplant, Dr. Norris said. “This is the mean, and some cases can take almost an hour, and you end up saying words you wouldn't normally say.” In clinical trials, 1% of 923 participants experienced complications at implant insertion and 1.7% had complications at implant removal.

Contraindications include a known or suspected pregnancy. “It likely won't hurt the pregnancy, but it will not prevent a pregnancy if it is already there,” Dr. Norris said. History of or current thrombotic disease, history of breast cancer, hepatic tumors, active liver disease, and undiagnosed abnormal genital bleeding are other contraindications. “Make sure there is nothing serious going on before you place the Implanon.”

Bleeding changes were the most common reason women chose to stop Implanon treatment in clinical trials (cited by 11% of participants). Irregular bleeding and spotting is a common side effect, Dr. Norris said. In the studies, patients using Implanon reported an average of 18 days of bleeding or spotting every 90 days. “The problem is this is unpredictable,” he said. “With the pill or patch, you have a better idea when to anticipate bleeding or spotting.”

MIAMI BEACH — Nearly a year following its approval, the advantages and disadvantages of a contraceptive implant are becoming better known, but there are still no data on its efficacy in overweight or obese women, according to a presentation at an ob.gyn. conference sponsored by the University of Miami.

The Food and Drug Administration cleared Implanon (Organon International) for marketing in July 2006. It is the first single-rod, 68-mg etonogestrel, subdermal implant. The core is 40% ethylene vinyl acetate, which provides a slow, steady release of progestin for up to 3 years, according to clinical trials.

However, overweight and obese women were excluded from the preapproval studies. “This is kind of the kicker—efficacy in overweight women,” Dr. Paul M. Norris said. “There are no clinical trial data.” Women who weighed more than 130% of their ideal body weight were not studied. For physicians, such an exclusion would be “very impractical” in the United States, Dr. Norris added.

Implanon replaces the six-rod Norplant device, which was removed from the market following reports of product migration and side effects, Dr. Norris said. “The data on Norplant suggested it was still efficacious, although less so, in overweight patients. But I am not sure you can apply this finding to Implanon.”

Implanon is inserted in the subepidermal groove of a woman's arm between her biceps and triceps, about 6-8 inches up from the crux of elbow. Physicians can order Implanon only upon completion of a training program, sponsored by the manufacturer, on insertion and removal. “They were concerned about injections in other vital structures. So far, the programs have gone well,” said Dr. Norris, who is on the obstetrics and gynecology faculty at the University of Miami. He is on the speakers' bureau for Organon.

“The device to insert the implant looks like the Depo Provera syringe,” Dr. Norris said. “The blue placebo injector for practice has a pregnancy rate of about 85% so make sure you are using the white injector with the active ingredient!”

Insertion time is faster than the Norplant, about a mean of 1 minute, compared with 4 minutes for the Norplant, Dr. Norris said. The 4-cm-long, 2-mm-diameter Implanon rod is not radio-opaque. “If you lose an implant, you cannot palpate it 3 years later,” he said. “It is very easy to pick up on ultrasound, but you need at least a 10-MHz wand, which is not common in most ob.gyn. offices,” he said.

Implanon's contraceptive effects are reversible—a woman's fertility quickly returns after removal, according to the manufacturer.

The mean removal time for Implanon is 3 minutes, compared with 11 minutes for Norplant, Dr. Norris said. “This is the mean, and some cases can take almost an hour, and you end up saying words you wouldn't normally say.” In clinical trials, 1% of 923 participants experienced complications at implant insertion and 1.7% had complications at implant removal.

Contraindications include a known or suspected pregnancy. “It likely won't hurt the pregnancy, but it will not prevent a pregnancy if it is already there,” Dr. Norris said. History of or current thrombotic disease, history of breast cancer, hepatic tumors, active liver disease, and undiagnosed abnormal genital bleeding are other contraindications. “Make sure there is nothing serious going on before you place the Implanon.”

Bleeding changes were the most common reason women chose to stop Implanon treatment in clinical trials (cited by 11% of participants). Irregular bleeding and spotting is a common side effect, Dr. Norris said. In the studies, patients using Implanon reported an average of 18 days of bleeding or spotting every 90 days. “The problem is this is unpredictable,” he said. “With the pill or patch, you have a better idea when to anticipate bleeding or spotting.”

MIAMI BEACH — Nearly a year following its approval, the advantages and disadvantages of a contraceptive implant are becoming better known, but there are still no data on its efficacy in overweight or obese women, according to a presentation at an ob.gyn. conference sponsored by the University of Miami.

The Food and Drug Administration cleared Implanon (Organon International) for marketing in July 2006. It is the first single-rod, 68-mg etonogestrel, subdermal implant. The core is 40% ethylene vinyl acetate, which provides a slow, steady release of progestin for up to 3 years, according to clinical trials.

However, overweight and obese women were excluded from the preapproval studies. “This is kind of the kicker—efficacy in overweight women,” Dr. Paul M. Norris said. “There are no clinical trial data.” Women who weighed more than 130% of their ideal body weight were not studied. For physicians, such an exclusion would be “very impractical” in the United States, Dr. Norris added.

Implanon replaces the six-rod Norplant device, which was removed from the market following reports of product migration and side effects, Dr. Norris said. “The data on Norplant suggested it was still efficacious, although less so, in overweight patients. But I am not sure you can apply this finding to Implanon.”

Implanon is inserted in the subepidermal groove of a woman's arm between her biceps and triceps, about 6-8 inches up from the crux of elbow. Physicians can order Implanon only upon completion of a training program, sponsored by the manufacturer, on insertion and removal. “They were concerned about injections in other vital structures. So far, the programs have gone well,” said Dr. Norris, who is on the obstetrics and gynecology faculty at the University of Miami. He is on the speakers' bureau for Organon.

“The device to insert the implant looks like the Depo Provera syringe,” Dr. Norris said. “The blue placebo injector for practice has a pregnancy rate of about 85% so make sure you are using the white injector with the active ingredient!”

Insertion time is faster than the Norplant, about a mean of 1 minute, compared with 4 minutes for the Norplant, Dr. Norris said. The 4-cm-long, 2-mm-diameter Implanon rod is not radio-opaque. “If you lose an implant, you cannot palpate it 3 years later,” he said. “It is very easy to pick up on ultrasound, but you need at least a 10-MHz wand, which is not common in most ob.gyn. offices,” he said.

Implanon's contraceptive effects are reversible—a woman's fertility quickly returns after removal, according to the manufacturer.

The mean removal time for Implanon is 3 minutes, compared with 11 minutes for Norplant, Dr. Norris said. “This is the mean, and some cases can take almost an hour, and you end up saying words you wouldn't normally say.” In clinical trials, 1% of 923 participants experienced complications at implant insertion and 1.7% had complications at implant removal.

Contraindications include a known or suspected pregnancy. “It likely won't hurt the pregnancy, but it will not prevent a pregnancy if it is already there,” Dr. Norris said. History of or current thrombotic disease, history of breast cancer, hepatic tumors, active liver disease, and undiagnosed abnormal genital bleeding are other contraindications. “Make sure there is nothing serious going on before you place the Implanon.”

Bleeding changes were the most common reason women chose to stop Implanon treatment in clinical trials (cited by 11% of participants). Irregular bleeding and spotting is a common side effect, Dr. Norris said. In the studies, patients using Implanon reported an average of 18 days of bleeding or spotting every 90 days. “The problem is this is unpredictable,” he said. “With the pill or patch, you have a better idea when to anticipate bleeding or spotting.”