Diana Mahoney

Less than one-third of children with asthma between the ages of 2 and 17 years received the influenza vaccine during the 2004–2005 influenza season, according to the first national estimate of influenza vaccine coverage in children with asthma by the Centers for Disease Control and Prevention.

This rate is about three times higher than that reported for nonasthmatic children, but the “inadequate” numbers indicate “that opportunities for vaccination during health-care provider visits likely are being missed,” said Susan M. Brim of the CDC's National Center for Environmental Health and associates (MMWR, 2007 March 9;56:193–6).

With data from the 2005 National Health Interview Survey (NHIS)—a cross-sectional, household interview survey in the United States—the CDC investigators analyzed influenza vaccine coverage rates for the 5,124 youth aged 2–17 years represented in the database and determined that 29% of children with current asthma had received the influenza vaccine for the September 2004-February 2005 influenza season, compared with 10.3% of their nonasthmatic peers.

Of the children with current asthma, vaccine coverage was highest—at 32.9%–-in the 2- to 4-year-old age group, compared with 28% in both the 5- to 12-year-old and 13- to 17-year-old age categories. Children who had experienced an asthma attack or episode within the 12 months before the survey (35.9% of those with asthma) were more likely to have been vaccinated than children with current asthma but no past-year history of an asthmatic episode (20%). Children aged 5–12 years with current asthma and no past year history of an asthmatic episode had the lowest vaccination coverage rate, at 16.4%, in the asthma group, they wrote.

When the data were analyzed based on the number of health care visits per child during the 12 months preceding the survey, influenza vaccine coverage in children with asthma was directly related to the number of visits. “About 10.8% of children with current asthma who had one health-care visit in the preceding year were vaccinated, whereas 42.0% of children with [10 or more] visits were vaccinated,” the authors reported.

The results of the analysis could not be compared with previous years because the 2005 NHIS was the first to include questions on influenza vaccination in the child portion of the survey. “Analysis of NHIS data from 2006 and future years will allow determination of trends in national influenza vaccination coverage in children with asthma,” said the authors. Such monitoring is essential for the design of public health strategies for increasing influenza vaccination coverage that targets all children with asthma, particularly those with the lowest coverage rates, they stressed.

Less than one-third of children with asthma between the ages of 2 and 17 years received the influenza vaccine during the 2004–2005 influenza season, according to the first national estimate of influenza vaccine coverage in children with asthma by the Centers for Disease Control and Prevention.

This rate is about three times higher than that reported for nonasthmatic children, but the “inadequate” numbers indicate “that opportunities for vaccination during health-care provider visits likely are being missed,” said Susan M. Brim of the CDC's National Center for Environmental Health and associates (MMWR, 2007 March 9;56:193–6).

With data from the 2005 National Health Interview Survey (NHIS)—a cross-sectional, household interview survey in the United States—the CDC investigators analyzed influenza vaccine coverage rates for the 5,124 youth aged 2–17 years represented in the database and determined that 29% of children with current asthma had received the influenza vaccine for the September 2004-February 2005 influenza season, compared with 10.3% of their nonasthmatic peers.

Of the children with current asthma, vaccine coverage was highest—at 32.9%–-in the 2- to 4-year-old age group, compared with 28% in both the 5- to 12-year-old and 13- to 17-year-old age categories. Children who had experienced an asthma attack or episode within the 12 months before the survey (35.9% of those with asthma) were more likely to have been vaccinated than children with current asthma but no past-year history of an asthmatic episode (20%). Children aged 5–12 years with current asthma and no past year history of an asthmatic episode had the lowest vaccination coverage rate, at 16.4%, in the asthma group, they wrote.

When the data were analyzed based on the number of health care visits per child during the 12 months preceding the survey, influenza vaccine coverage in children with asthma was directly related to the number of visits. “About 10.8% of children with current asthma who had one health-care visit in the preceding year were vaccinated, whereas 42.0% of children with [10 or more] visits were vaccinated,” the authors reported.

The results of the analysis could not be compared with previous years because the 2005 NHIS was the first to include questions on influenza vaccination in the child portion of the survey. “Analysis of NHIS data from 2006 and future years will allow determination of trends in national influenza vaccination coverage in children with asthma,” said the authors. Such monitoring is essential for the design of public health strategies for increasing influenza vaccination coverage that targets all children with asthma, particularly those with the lowest coverage rates, they stressed.

Less than one-third of children with asthma between the ages of 2 and 17 years received the influenza vaccine during the 2004–2005 influenza season, according to the first national estimate of influenza vaccine coverage in children with asthma by the Centers for Disease Control and Prevention.

This rate is about three times higher than that reported for nonasthmatic children, but the “inadequate” numbers indicate “that opportunities for vaccination during health-care provider visits likely are being missed,” said Susan M. Brim of the CDC's National Center for Environmental Health and associates (MMWR, 2007 March 9;56:193–6).

With data from the 2005 National Health Interview Survey (NHIS)—a cross-sectional, household interview survey in the United States—the CDC investigators analyzed influenza vaccine coverage rates for the 5,124 youth aged 2–17 years represented in the database and determined that 29% of children with current asthma had received the influenza vaccine for the September 2004-February 2005 influenza season, compared with 10.3% of their nonasthmatic peers.

Of the children with current asthma, vaccine coverage was highest—at 32.9%–-in the 2- to 4-year-old age group, compared with 28% in both the 5- to 12-year-old and 13- to 17-year-old age categories. Children who had experienced an asthma attack or episode within the 12 months before the survey (35.9% of those with asthma) were more likely to have been vaccinated than children with current asthma but no past-year history of an asthmatic episode (20%). Children aged 5–12 years with current asthma and no past year history of an asthmatic episode had the lowest vaccination coverage rate, at 16.4%, in the asthma group, they wrote.

When the data were analyzed based on the number of health care visits per child during the 12 months preceding the survey, influenza vaccine coverage in children with asthma was directly related to the number of visits. “About 10.8% of children with current asthma who had one health-care visit in the preceding year were vaccinated, whereas 42.0% of children with [10 or more] visits were vaccinated,” the authors reported.

The results of the analysis could not be compared with previous years because the 2005 NHIS was the first to include questions on influenza vaccination in the child portion of the survey. “Analysis of NHIS data from 2006 and future years will allow determination of trends in national influenza vaccination coverage in children with asthma,” said the authors. Such monitoring is essential for the design of public health strategies for increasing influenza vaccination coverage that targets all children with asthma, particularly those with the lowest coverage rates, they stressed.

SAN FRANCISCO — Gestational weight at diagnosis and proportion of selective coagulations are predictive of perioperative prognosis in severe twin-to-twin transfusion syndrome treated by fetoscopic laser surgery, Dr. Julien Stirnemann said at the annual meeting of the Society for Maternal-Fetal Medicine.

The finding could improve risk stratification and counseling for patients undergoing the fetal intervention, said Dr. Stirnemann, of CHI Poissy Saint Germain in Paris.

In recent years, fetoscopic laser coagulation of the vascular anastomoses has significantly improved survival odds of affected infants in twin-to-twin transfusion syndrome (TTTS), one of the most complex pathologies in multiple gestation, Dr. Stirnemann said.

The current study looked at factors associated with a perioperative outcome in 323 consecutive monochorionic pregnancies complicated with severe TTTS and treated with selective laser coagulation. The selective laser surgery allows for the precise identification of vascular anastomoses vs. the nonselective technique, which targets all vessels crossing the intertwin membrane, he said.

The primary and secondary study outcomes were survival for more than 28 days of one or both twins, respectively, without severe impairment. For purposes of the investigation, severe impairment was defined as at least one of the following: intraventricular hemorrhage stage 3 or 4, periventricular leukomalacia, bronchopulmonary dysplasia, persistent renal failure at 28 days, or surgical necrotizing enterocolitis, Dr. Stirnemann said.

The maternal and pregnancy-related variables considered in the analysis included gestational age at diagnosis, Quintero staging, estimated fetal weight, and cervical length. The surgery-related factors included the need for a transplacental approach, the number and type (selective or nonselective) of coagulations, the percentage of selectivity per procedure (ratio of selective coagulations to the total number of coagulations), and the volume of amniotic fluid drained per procedure.

The overall survival rates were 65% for at least one twin and 28% for both twins, Dr. Stirnemann reported.

In a univariate analysis of survival without impairment of at least one twin, age at diagnosis, Quintero stage 1 or 2, estimated fetal weight (donor and recipient), number of selective coagulations above four, percentage of selectivity above 60%, and volume of drained amniotic fluid reached significance, he said. In multivariate analysis using stepwise logistic regression, “only recipients' estimated fetal weight and number of selective coagulations higher than four reach significance in the model, with odds ratios of 2.2 and 1.9, respectively,” he stated.

When the same analyses were conducted to assess survival without impairment of both twins, “favorable factors in the univariate analysis were maternal age, gestational age at diagnosis, Quintero stages 1 and 2, estimated fetal weight (donors and recipients), number of coagulations higher than seven, number of selective coagulations higher than four, and percentage of selectivity above 60%,” said Dr. Stirnemann. “Previous history of miscarriage and transplacental approach were significant adverse factors.”

In the multivariate analysis for this outcome, “donors' estimated fetal weight and percentage of selectivity above 60% were independent predictive factors of survival without impairment, with odds ratios of 1.95 and 1.85, respectively,” said Dr. Stirnemann. Additionally, history of miscarriage was a significant adverse factor for survival, with an odds ratio of 0.3, he said.

“Awareness of these prognostic factors should become part of the discussion when counseling patients about the risks associated with fetal intervention by laser photocoagulation for twin-to-twin transfusion syndrome,” he concluded.

SAN FRANCISCO — Gestational weight at diagnosis and proportion of selective coagulations are predictive of perioperative prognosis in severe twin-to-twin transfusion syndrome treated by fetoscopic laser surgery, Dr. Julien Stirnemann said at the annual meeting of the Society for Maternal-Fetal Medicine.

The finding could improve risk stratification and counseling for patients undergoing the fetal intervention, said Dr. Stirnemann, of CHI Poissy Saint Germain in Paris.

In recent years, fetoscopic laser coagulation of the vascular anastomoses has significantly improved survival odds of affected infants in twin-to-twin transfusion syndrome (TTTS), one of the most complex pathologies in multiple gestation, Dr. Stirnemann said.

The current study looked at factors associated with a perioperative outcome in 323 consecutive monochorionic pregnancies complicated with severe TTTS and treated with selective laser coagulation. The selective laser surgery allows for the precise identification of vascular anastomoses vs. the nonselective technique, which targets all vessels crossing the intertwin membrane, he said.

The primary and secondary study outcomes were survival for more than 28 days of one or both twins, respectively, without severe impairment. For purposes of the investigation, severe impairment was defined as at least one of the following: intraventricular hemorrhage stage 3 or 4, periventricular leukomalacia, bronchopulmonary dysplasia, persistent renal failure at 28 days, or surgical necrotizing enterocolitis, Dr. Stirnemann said.

The maternal and pregnancy-related variables considered in the analysis included gestational age at diagnosis, Quintero staging, estimated fetal weight, and cervical length. The surgery-related factors included the need for a transplacental approach, the number and type (selective or nonselective) of coagulations, the percentage of selectivity per procedure (ratio of selective coagulations to the total number of coagulations), and the volume of amniotic fluid drained per procedure.

The overall survival rates were 65% for at least one twin and 28% for both twins, Dr. Stirnemann reported.

In a univariate analysis of survival without impairment of at least one twin, age at diagnosis, Quintero stage 1 or 2, estimated fetal weight (donor and recipient), number of selective coagulations above four, percentage of selectivity above 60%, and volume of drained amniotic fluid reached significance, he said. In multivariate analysis using stepwise logistic regression, “only recipients' estimated fetal weight and number of selective coagulations higher than four reach significance in the model, with odds ratios of 2.2 and 1.9, respectively,” he stated.

When the same analyses were conducted to assess survival without impairment of both twins, “favorable factors in the univariate analysis were maternal age, gestational age at diagnosis, Quintero stages 1 and 2, estimated fetal weight (donors and recipients), number of coagulations higher than seven, number of selective coagulations higher than four, and percentage of selectivity above 60%,” said Dr. Stirnemann. “Previous history of miscarriage and transplacental approach were significant adverse factors.”

In the multivariate analysis for this outcome, “donors' estimated fetal weight and percentage of selectivity above 60% were independent predictive factors of survival without impairment, with odds ratios of 1.95 and 1.85, respectively,” said Dr. Stirnemann. Additionally, history of miscarriage was a significant adverse factor for survival, with an odds ratio of 0.3, he said.

“Awareness of these prognostic factors should become part of the discussion when counseling patients about the risks associated with fetal intervention by laser photocoagulation for twin-to-twin transfusion syndrome,” he concluded.

SAN FRANCISCO — Gestational weight at diagnosis and proportion of selective coagulations are predictive of perioperative prognosis in severe twin-to-twin transfusion syndrome treated by fetoscopic laser surgery, Dr. Julien Stirnemann said at the annual meeting of the Society for Maternal-Fetal Medicine.

The finding could improve risk stratification and counseling for patients undergoing the fetal intervention, said Dr. Stirnemann, of CHI Poissy Saint Germain in Paris.

In recent years, fetoscopic laser coagulation of the vascular anastomoses has significantly improved survival odds of affected infants in twin-to-twin transfusion syndrome (TTTS), one of the most complex pathologies in multiple gestation, Dr. Stirnemann said.

The current study looked at factors associated with a perioperative outcome in 323 consecutive monochorionic pregnancies complicated with severe TTTS and treated with selective laser coagulation. The selective laser surgery allows for the precise identification of vascular anastomoses vs. the nonselective technique, which targets all vessels crossing the intertwin membrane, he said.

The primary and secondary study outcomes were survival for more than 28 days of one or both twins, respectively, without severe impairment. For purposes of the investigation, severe impairment was defined as at least one of the following: intraventricular hemorrhage stage 3 or 4, periventricular leukomalacia, bronchopulmonary dysplasia, persistent renal failure at 28 days, or surgical necrotizing enterocolitis, Dr. Stirnemann said.

The maternal and pregnancy-related variables considered in the analysis included gestational age at diagnosis, Quintero staging, estimated fetal weight, and cervical length. The surgery-related factors included the need for a transplacental approach, the number and type (selective or nonselective) of coagulations, the percentage of selectivity per procedure (ratio of selective coagulations to the total number of coagulations), and the volume of amniotic fluid drained per procedure.

The overall survival rates were 65% for at least one twin and 28% for both twins, Dr. Stirnemann reported.

In a univariate analysis of survival without impairment of at least one twin, age at diagnosis, Quintero stage 1 or 2, estimated fetal weight (donor and recipient), number of selective coagulations above four, percentage of selectivity above 60%, and volume of drained amniotic fluid reached significance, he said. In multivariate analysis using stepwise logistic regression, “only recipients' estimated fetal weight and number of selective coagulations higher than four reach significance in the model, with odds ratios of 2.2 and 1.9, respectively,” he stated.

When the same analyses were conducted to assess survival without impairment of both twins, “favorable factors in the univariate analysis were maternal age, gestational age at diagnosis, Quintero stages 1 and 2, estimated fetal weight (donors and recipients), number of coagulations higher than seven, number of selective coagulations higher than four, and percentage of selectivity above 60%,” said Dr. Stirnemann. “Previous history of miscarriage and transplacental approach were significant adverse factors.”

In the multivariate analysis for this outcome, “donors' estimated fetal weight and percentage of selectivity above 60% were independent predictive factors of survival without impairment, with odds ratios of 1.95 and 1.85, respectively,” said Dr. Stirnemann. Additionally, history of miscarriage was a significant adverse factor for survival, with an odds ratio of 0.3, he said.

“Awareness of these prognostic factors should become part of the discussion when counseling patients about the risks associated with fetal intervention by laser photocoagulation for twin-to-twin transfusion syndrome,” he concluded.

SAN FRANCISCO — Ultrasound identification of placental cord insertion sites in monochorionic diamniotic twin gestations can identify pregnancies at higher risk for preterm delivery, twin-to-twin transfusion syndrome, and growth discordance, according to the findings of a retrospective study.

This information can be used to counsel patients with monochorionic diamniotic twin gestations regarding the potential fetal and neonatal morbidity and mortality risks, Dr. John Allbert reported in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

A cohort of 35 twin pregnancies referred by a single perinatologist for targeted ultrasound evaluation between November 2001 and November 2005 was included in the analysis. All of the pregnancies were monochorionic diamniotic and were at less than 22 weeks' gestation at the time of ultrasound. Additionally, at the time of evaluation, both fetuses in all of the pregnancies were anatomically normal and did not meet the criteria for diagnosis of twin-to-twin transfusion syndrome (TTTS), said Dr. Allbert.

Real-time ultrasound was used to locate the placental cord insertions (PCI), and the results were confirmed with color Doppler. The insertions were then categorized as velamentous, marginal (if less than 2 cm from the placental edge), or central (2 cm or more from the edge).

On the basis of the twin pair PCIs, the pregnancies were classified into one of three groups. In group 1, the twin pair PCIs were both central. In group 2, the PCIs were either central and marginal or both marginal, and in group 3, the twin pair PCIs were central and velamentous, Dr. Allbert explained.

Of the 35 pregnancies, 11 were classified into group 1, 17 into group 2, and 7 into group 3. The groups were compared using x2 analysis or Fisher exact test for the following outcome variables: gestational age at delivery, discordant growth, TTTS, need for amnioreduction, selective laser photocoagulation therapy, preterm labor, premature rupture of membranes, perinatal mortality, preeclampsia, and chorioamnionitis.

According to the results, “both marginal and velamentous cord insertions were significantly associated with growth discordance, earlier gestational age at delivery, and a higher incidence of twin-to-twin transfusion syndrome,” said Dr. Allbert.

Specifically, the mean gestational age at delivery in group 1 was 36.4 weeks, compared with 33.6 weeks and 31.6 weeks, in groups 2 and 3, respectively. Growth discordance of at least 20% was not observed in group 1, but did occur in 29.4% and 71.4% of groups 2 and 3, respectively.

Similarly, TTTS did not occur in group 1, but did occur in 35.3% of group 2 pregnancies and in 57.1% of group 3 pregnancies.

For group 1 pregnancies, in which both cord insertion sites were at least 2 cm from the placental edge, “the pregnancy risks appeared to be similar to those of dichorionic twins,” Dr. Allbert concluded.

SAN FRANCISCO — Ultrasound identification of placental cord insertion sites in monochorionic diamniotic twin gestations can identify pregnancies at higher risk for preterm delivery, twin-to-twin transfusion syndrome, and growth discordance, according to the findings of a retrospective study.

This information can be used to counsel patients with monochorionic diamniotic twin gestations regarding the potential fetal and neonatal morbidity and mortality risks, Dr. John Allbert reported in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

A cohort of 35 twin pregnancies referred by a single perinatologist for targeted ultrasound evaluation between November 2001 and November 2005 was included in the analysis. All of the pregnancies were monochorionic diamniotic and were at less than 22 weeks' gestation at the time of ultrasound. Additionally, at the time of evaluation, both fetuses in all of the pregnancies were anatomically normal and did not meet the criteria for diagnosis of twin-to-twin transfusion syndrome (TTTS), said Dr. Allbert.

Real-time ultrasound was used to locate the placental cord insertions (PCI), and the results were confirmed with color Doppler. The insertions were then categorized as velamentous, marginal (if less than 2 cm from the placental edge), or central (2 cm or more from the edge).

On the basis of the twin pair PCIs, the pregnancies were classified into one of three groups. In group 1, the twin pair PCIs were both central. In group 2, the PCIs were either central and marginal or both marginal, and in group 3, the twin pair PCIs were central and velamentous, Dr. Allbert explained.

Of the 35 pregnancies, 11 were classified into group 1, 17 into group 2, and 7 into group 3. The groups were compared using x2 analysis or Fisher exact test for the following outcome variables: gestational age at delivery, discordant growth, TTTS, need for amnioreduction, selective laser photocoagulation therapy, preterm labor, premature rupture of membranes, perinatal mortality, preeclampsia, and chorioamnionitis.

According to the results, “both marginal and velamentous cord insertions were significantly associated with growth discordance, earlier gestational age at delivery, and a higher incidence of twin-to-twin transfusion syndrome,” said Dr. Allbert.

Specifically, the mean gestational age at delivery in group 1 was 36.4 weeks, compared with 33.6 weeks and 31.6 weeks, in groups 2 and 3, respectively. Growth discordance of at least 20% was not observed in group 1, but did occur in 29.4% and 71.4% of groups 2 and 3, respectively.

Similarly, TTTS did not occur in group 1, but did occur in 35.3% of group 2 pregnancies and in 57.1% of group 3 pregnancies.

For group 1 pregnancies, in which both cord insertion sites were at least 2 cm from the placental edge, “the pregnancy risks appeared to be similar to those of dichorionic twins,” Dr. Allbert concluded.

SAN FRANCISCO — Ultrasound identification of placental cord insertion sites in monochorionic diamniotic twin gestations can identify pregnancies at higher risk for preterm delivery, twin-to-twin transfusion syndrome, and growth discordance, according to the findings of a retrospective study.

This information can be used to counsel patients with monochorionic diamniotic twin gestations regarding the potential fetal and neonatal morbidity and mortality risks, Dr. John Allbert reported in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

A cohort of 35 twin pregnancies referred by a single perinatologist for targeted ultrasound evaluation between November 2001 and November 2005 was included in the analysis. All of the pregnancies were monochorionic diamniotic and were at less than 22 weeks' gestation at the time of ultrasound. Additionally, at the time of evaluation, both fetuses in all of the pregnancies were anatomically normal and did not meet the criteria for diagnosis of twin-to-twin transfusion syndrome (TTTS), said Dr. Allbert.

Real-time ultrasound was used to locate the placental cord insertions (PCI), and the results were confirmed with color Doppler. The insertions were then categorized as velamentous, marginal (if less than 2 cm from the placental edge), or central (2 cm or more from the edge).

On the basis of the twin pair PCIs, the pregnancies were classified into one of three groups. In group 1, the twin pair PCIs were both central. In group 2, the PCIs were either central and marginal or both marginal, and in group 3, the twin pair PCIs were central and velamentous, Dr. Allbert explained.

Of the 35 pregnancies, 11 were classified into group 1, 17 into group 2, and 7 into group 3. The groups were compared using x2 analysis or Fisher exact test for the following outcome variables: gestational age at delivery, discordant growth, TTTS, need for amnioreduction, selective laser photocoagulation therapy, preterm labor, premature rupture of membranes, perinatal mortality, preeclampsia, and chorioamnionitis.

According to the results, “both marginal and velamentous cord insertions were significantly associated with growth discordance, earlier gestational age at delivery, and a higher incidence of twin-to-twin transfusion syndrome,” said Dr. Allbert.

Specifically, the mean gestational age at delivery in group 1 was 36.4 weeks, compared with 33.6 weeks and 31.6 weeks, in groups 2 and 3, respectively. Growth discordance of at least 20% was not observed in group 1, but did occur in 29.4% and 71.4% of groups 2 and 3, respectively.

Similarly, TTTS did not occur in group 1, but did occur in 35.3% of group 2 pregnancies and in 57.1% of group 3 pregnancies.

For group 1 pregnancies, in which both cord insertion sites were at least 2 cm from the placental edge, “the pregnancy risks appeared to be similar to those of dichorionic twins,” Dr. Allbert concluded.

SAN FRANCISCO — Long-term neurologic impairment among twin-to-twin transfusion syndrome survivors is mediated by perinatal factors but not by mode of treatment, reported Dr. Lisa Ortqvist at the annual meeting of the Society for Maternal-Fetal Medicine.

Gestational age at delivery, 1-minute Apgar score, and Quintero staging each independently predicted severe neurologic abnormalities over time in a cohort of twin-to-twin-transfusion syndrome (TTTS) survivors treated with either endoscopic laser surgery or serial amnioreduction, said Dr. Ortqvist of Paris-Ouest University (France). Neither treatment modality independently predicted neurologic outcome over time, she said.

The population for this study included 135 children born to mothers who had been enrolled in the randomized Eurofetus trial, which compared aggressive serial amnioreduction for severe TTTS with fetoscopic laser ablation therapy (N. Engl. J. Med. 2004;351:136-44).

The Eurofetus trial results demonstrated a survival advantage associated with fetoscopic laser surgery with a lower risk of brain injury. The current investigation sought to evaluate the long-term neurodevelopmental outcome of children who survived beyond 6 months in both study arms, Dr. Ortqvist explained.

The study included 80 children from the laser therapy arm (29 donors, 51 recipients) and 55 children in the amnioreduction arm (29 donors, 26 recipients) followed for a median 5.3 years. Outcome data included physician-reported results from annual physical examinations and standardized neuroevaluations, parent-completed Ages and Stages Questionnaires yearly from ages 2 through 5 years, and cognitive evaluation at age 6 years using the Wechsler Intelligence Scale for Children.

Using the clinical data, the investigators classified the children into one of three groups based on degree of neurologic impairment. Group 1 included children with normal physical and neurologic examinations; group 2 included children with minor neurologic abnormalities, such as strabismus or mildly delayed motor/speech development; and group 3 included children with major neurologic abnormalities, such as cerebral palsy, hemiparesis, or spastic quadriplegia. Of the initial cohort, 11.5% were classified as having major neurologic problems, not including the children lost to follow-up, said Dr. Ortqvist.

In univariate analysis, Quintero staging, gestational age at delivery, female gender, and 1- and 5-minute Apgar scores were predictive of major neurologic problems, while procedure type, donor/recipient status, birth weight, and arterial pH values were not, Dr. Ortqvist reported.

In the multivariate analysis, “if we considered that the children lost to follow-up did not have major neurologic problems, only Quintero staging, gestational age at delivery, and 1-minute Apgar scores demonstrated a significant association with major neurodevelopmental problems,” she said.

Although there was no significant difference in neurologic impairment between laser treatment and amnioreduction, “Endoscopic laser surgery is associated with increased survival overall, and as such is associated with improved survival without long-term neurological impairment,” Dr. Ortqvist concluded.

SAN FRANCISCO — Long-term neurologic impairment among twin-to-twin transfusion syndrome survivors is mediated by perinatal factors but not by mode of treatment, reported Dr. Lisa Ortqvist at the annual meeting of the Society for Maternal-Fetal Medicine.

Gestational age at delivery, 1-minute Apgar score, and Quintero staging each independently predicted severe neurologic abnormalities over time in a cohort of twin-to-twin-transfusion syndrome (TTTS) survivors treated with either endoscopic laser surgery or serial amnioreduction, said Dr. Ortqvist of Paris-Ouest University (France). Neither treatment modality independently predicted neurologic outcome over time, she said.

The population for this study included 135 children born to mothers who had been enrolled in the randomized Eurofetus trial, which compared aggressive serial amnioreduction for severe TTTS with fetoscopic laser ablation therapy (N. Engl. J. Med. 2004;351:136-44).

The Eurofetus trial results demonstrated a survival advantage associated with fetoscopic laser surgery with a lower risk of brain injury. The current investigation sought to evaluate the long-term neurodevelopmental outcome of children who survived beyond 6 months in both study arms, Dr. Ortqvist explained.

The study included 80 children from the laser therapy arm (29 donors, 51 recipients) and 55 children in the amnioreduction arm (29 donors, 26 recipients) followed for a median 5.3 years. Outcome data included physician-reported results from annual physical examinations and standardized neuroevaluations, parent-completed Ages and Stages Questionnaires yearly from ages 2 through 5 years, and cognitive evaluation at age 6 years using the Wechsler Intelligence Scale for Children.

Using the clinical data, the investigators classified the children into one of three groups based on degree of neurologic impairment. Group 1 included children with normal physical and neurologic examinations; group 2 included children with minor neurologic abnormalities, such as strabismus or mildly delayed motor/speech development; and group 3 included children with major neurologic abnormalities, such as cerebral palsy, hemiparesis, or spastic quadriplegia. Of the initial cohort, 11.5% were classified as having major neurologic problems, not including the children lost to follow-up, said Dr. Ortqvist.

In univariate analysis, Quintero staging, gestational age at delivery, female gender, and 1- and 5-minute Apgar scores were predictive of major neurologic problems, while procedure type, donor/recipient status, birth weight, and arterial pH values were not, Dr. Ortqvist reported.

In the multivariate analysis, “if we considered that the children lost to follow-up did not have major neurologic problems, only Quintero staging, gestational age at delivery, and 1-minute Apgar scores demonstrated a significant association with major neurodevelopmental problems,” she said.

Although there was no significant difference in neurologic impairment between laser treatment and amnioreduction, “Endoscopic laser surgery is associated with increased survival overall, and as such is associated with improved survival without long-term neurological impairment,” Dr. Ortqvist concluded.

SAN FRANCISCO — Long-term neurologic impairment among twin-to-twin transfusion syndrome survivors is mediated by perinatal factors but not by mode of treatment, reported Dr. Lisa Ortqvist at the annual meeting of the Society for Maternal-Fetal Medicine.

Gestational age at delivery, 1-minute Apgar score, and Quintero staging each independently predicted severe neurologic abnormalities over time in a cohort of twin-to-twin-transfusion syndrome (TTTS) survivors treated with either endoscopic laser surgery or serial amnioreduction, said Dr. Ortqvist of Paris-Ouest University (France). Neither treatment modality independently predicted neurologic outcome over time, she said.

The population for this study included 135 children born to mothers who had been enrolled in the randomized Eurofetus trial, which compared aggressive serial amnioreduction for severe TTTS with fetoscopic laser ablation therapy (N. Engl. J. Med. 2004;351:136-44).

The Eurofetus trial results demonstrated a survival advantage associated with fetoscopic laser surgery with a lower risk of brain injury. The current investigation sought to evaluate the long-term neurodevelopmental outcome of children who survived beyond 6 months in both study arms, Dr. Ortqvist explained.

The study included 80 children from the laser therapy arm (29 donors, 51 recipients) and 55 children in the amnioreduction arm (29 donors, 26 recipients) followed for a median 5.3 years. Outcome data included physician-reported results from annual physical examinations and standardized neuroevaluations, parent-completed Ages and Stages Questionnaires yearly from ages 2 through 5 years, and cognitive evaluation at age 6 years using the Wechsler Intelligence Scale for Children.

Using the clinical data, the investigators classified the children into one of three groups based on degree of neurologic impairment. Group 1 included children with normal physical and neurologic examinations; group 2 included children with minor neurologic abnormalities, such as strabismus or mildly delayed motor/speech development; and group 3 included children with major neurologic abnormalities, such as cerebral palsy, hemiparesis, or spastic quadriplegia. Of the initial cohort, 11.5% were classified as having major neurologic problems, not including the children lost to follow-up, said Dr. Ortqvist.

In univariate analysis, Quintero staging, gestational age at delivery, female gender, and 1- and 5-minute Apgar scores were predictive of major neurologic problems, while procedure type, donor/recipient status, birth weight, and arterial pH values were not, Dr. Ortqvist reported.

In the multivariate analysis, “if we considered that the children lost to follow-up did not have major neurologic problems, only Quintero staging, gestational age at delivery, and 1-minute Apgar scores demonstrated a significant association with major neurodevelopmental problems,” she said.

Although there was no significant difference in neurologic impairment between laser treatment and amnioreduction, “Endoscopic laser surgery is associated with increased survival overall, and as such is associated with improved survival without long-term neurological impairment,” Dr. Ortqvist concluded.

BOSTON — A diagnosis of maternal depression any time between 1 year before and 9 years after giving birth is a risk factor for attention-deficit/hyperactivity disorder in school-age children, according to a study presented at a meeting of the Society for Research in Child Development.

In addition, the likelihood of an attention-deficit/hyperactivity disorder (ADHD) diagnosis in children is directly related to the chronicity of depression in the mother, said Anne Guevremont, M.Ed., a research fellow at the Manitoba Centre for Health Policy at the University of Manitoba, Winnipeg

Although previous studies have linked maternal depression to ADHD in children, none have specifically investigated whether and to what degree the timing of maternal depression has an impact on the relationship, Ms. Guevremont said.

Through computerized health care user files from the Manitoba health department, Ms. Guevremont and senior researcher Marni Brownell, Ph.D., reviewed data on 12,323 children born between April 1993 and March 1994 whose mothers were living in Manitoba the year before the child's birth and for whom follow-up information was available until the child was 7-9 years old.

The investigators ascertained the presence of maternal depression by hospital or physician claims for this diagnosis and categorized the depression into one of five groups according to the child's age at the time of the mother's diagnosis: within 1 year before birth, within 1 year after birth, between 1 and 3 years old, 4-6 years old, and 7-9 years old.

Approximately 36% of the mothers in the study had a diagnosis of depression during at least one time period, Ms. Guevremont reported in a poster presentation. Among the children, approximately 5% had a physician diagnosis of ADHD when they were 7-9 years old, she said.

With respect to chronicity, the investigators considered each time period in which a mother had a diagnosis of depression and counted the total number of years that the mother had the diagnosis outside of that time period, according to Ms. Guevremont. “Approximately 16% of the mothers had a depression diagnosis in 1 year only, while 8% of the mothers received a depression diagnosis in 2 years and 12% in 3 or more years,” she said.

In analyses of the effect of the timing and chronicity of maternal depression on child ADHD, children with depressed mothers were approximately 1.5-2 times more likely to have an ADHD diagnosis than children of nondepressed mothers, said Ms. Guevremont, noting that the odds ratio was highest, at 2.18, for mothers diagnosed with depression in the year before the child's birth. This finding “confirms the need to look for maternal depression at every stage of motherhood, including the prenatal period,” she said. “The prenatal period is an excellent time to screen for depression, as the vast majority of mothers seek prenatal care before their child's birth.”

In addition, the chronicity of depression was significant in each model, and the odds of a child being diagnosed with ADHD were higher for each additional year a mother was diagnosed with depression, regardless of the timing of the diagnosis, said Ms. Guevremont. The interaction between chronicity and timing was significant among children whose mothers were diagnosed in the year before birth, in the year after birth, or when the child was between 1 and 3. Children whose mothers were diagnosed during these periods and who had longer durations of depression were most vulnerable to an ADHD diagnosis, the results showed.

“Clearly, the number of years with a depression diagnosis is particularly important, and should be taken into consideration by clinicians caring for both mothers and their children,” Ms. Guevremont said. “The earlier depressed mothers are recognized and treated, the better for the health of both the mother and her children. Intervention at multiple time periods is possible and needed.” For example, in addition to prenatal screening, “another opportunity for screening is when mothers seek physicians for the children's behavior problems,” she said.

The study is limited by the potential for underreporting of both maternal depression and child ADHD, Ms. Guevremont noted. “Some physicians may not know a mother is depressed and therefore would not diagnose the condition if symptoms are not reported,” she stated.

BOSTON — A diagnosis of maternal depression any time between 1 year before and 9 years after giving birth is a risk factor for attention-deficit/hyperactivity disorder in school-age children, according to a study presented at a meeting of the Society for Research in Child Development.

In addition, the likelihood of an attention-deficit/hyperactivity disorder (ADHD) diagnosis in children is directly related to the chronicity of depression in the mother, said Anne Guevremont, M.Ed., a research fellow at the Manitoba Centre for Health Policy at the University of Manitoba, Winnipeg

Although previous studies have linked maternal depression to ADHD in children, none have specifically investigated whether and to what degree the timing of maternal depression has an impact on the relationship, Ms. Guevremont said.

Through computerized health care user files from the Manitoba health department, Ms. Guevremont and senior researcher Marni Brownell, Ph.D., reviewed data on 12,323 children born between April 1993 and March 1994 whose mothers were living in Manitoba the year before the child's birth and for whom follow-up information was available until the child was 7-9 years old.

The investigators ascertained the presence of maternal depression by hospital or physician claims for this diagnosis and categorized the depression into one of five groups according to the child's age at the time of the mother's diagnosis: within 1 year before birth, within 1 year after birth, between 1 and 3 years old, 4-6 years old, and 7-9 years old.

Approximately 36% of the mothers in the study had a diagnosis of depression during at least one time period, Ms. Guevremont reported in a poster presentation. Among the children, approximately 5% had a physician diagnosis of ADHD when they were 7-9 years old, she said.

With respect to chronicity, the investigators considered each time period in which a mother had a diagnosis of depression and counted the total number of years that the mother had the diagnosis outside of that time period, according to Ms. Guevremont. “Approximately 16% of the mothers had a depression diagnosis in 1 year only, while 8% of the mothers received a depression diagnosis in 2 years and 12% in 3 or more years,” she said.

In analyses of the effect of the timing and chronicity of maternal depression on child ADHD, children with depressed mothers were approximately 1.5-2 times more likely to have an ADHD diagnosis than children of nondepressed mothers, said Ms. Guevremont, noting that the odds ratio was highest, at 2.18, for mothers diagnosed with depression in the year before the child's birth. This finding “confirms the need to look for maternal depression at every stage of motherhood, including the prenatal period,” she said. “The prenatal period is an excellent time to screen for depression, as the vast majority of mothers seek prenatal care before their child's birth.”

In addition, the chronicity of depression was significant in each model, and the odds of a child being diagnosed with ADHD were higher for each additional year a mother was diagnosed with depression, regardless of the timing of the diagnosis, said Ms. Guevremont. The interaction between chronicity and timing was significant among children whose mothers were diagnosed in the year before birth, in the year after birth, or when the child was between 1 and 3. Children whose mothers were diagnosed during these periods and who had longer durations of depression were most vulnerable to an ADHD diagnosis, the results showed.

“Clearly, the number of years with a depression diagnosis is particularly important, and should be taken into consideration by clinicians caring for both mothers and their children,” Ms. Guevremont said. “The earlier depressed mothers are recognized and treated, the better for the health of both the mother and her children. Intervention at multiple time periods is possible and needed.” For example, in addition to prenatal screening, “another opportunity for screening is when mothers seek physicians for the children's behavior problems,” she said.

The study is limited by the potential for underreporting of both maternal depression and child ADHD, Ms. Guevremont noted. “Some physicians may not know a mother is depressed and therefore would not diagnose the condition if symptoms are not reported,” she stated.

BOSTON — A diagnosis of maternal depression any time between 1 year before and 9 years after giving birth is a risk factor for attention-deficit/hyperactivity disorder in school-age children, according to a study presented at a meeting of the Society for Research in Child Development.

In addition, the likelihood of an attention-deficit/hyperactivity disorder (ADHD) diagnosis in children is directly related to the chronicity of depression in the mother, said Anne Guevremont, M.Ed., a research fellow at the Manitoba Centre for Health Policy at the University of Manitoba, Winnipeg

Although previous studies have linked maternal depression to ADHD in children, none have specifically investigated whether and to what degree the timing of maternal depression has an impact on the relationship, Ms. Guevremont said.

Through computerized health care user files from the Manitoba health department, Ms. Guevremont and senior researcher Marni Brownell, Ph.D., reviewed data on 12,323 children born between April 1993 and March 1994 whose mothers were living in Manitoba the year before the child's birth and for whom follow-up information was available until the child was 7-9 years old.

The investigators ascertained the presence of maternal depression by hospital or physician claims for this diagnosis and categorized the depression into one of five groups according to the child's age at the time of the mother's diagnosis: within 1 year before birth, within 1 year after birth, between 1 and 3 years old, 4-6 years old, and 7-9 years old.

Approximately 36% of the mothers in the study had a diagnosis of depression during at least one time period, Ms. Guevremont reported in a poster presentation. Among the children, approximately 5% had a physician diagnosis of ADHD when they were 7-9 years old, she said.

With respect to chronicity, the investigators considered each time period in which a mother had a diagnosis of depression and counted the total number of years that the mother had the diagnosis outside of that time period, according to Ms. Guevremont. “Approximately 16% of the mothers had a depression diagnosis in 1 year only, while 8% of the mothers received a depression diagnosis in 2 years and 12% in 3 or more years,” she said.

In analyses of the effect of the timing and chronicity of maternal depression on child ADHD, children with depressed mothers were approximately 1.5-2 times more likely to have an ADHD diagnosis than children of nondepressed mothers, said Ms. Guevremont, noting that the odds ratio was highest, at 2.18, for mothers diagnosed with depression in the year before the child's birth. This finding “confirms the need to look for maternal depression at every stage of motherhood, including the prenatal period,” she said. “The prenatal period is an excellent time to screen for depression, as the vast majority of mothers seek prenatal care before their child's birth.”

In addition, the chronicity of depression was significant in each model, and the odds of a child being diagnosed with ADHD were higher for each additional year a mother was diagnosed with depression, regardless of the timing of the diagnosis, said Ms. Guevremont. The interaction between chronicity and timing was significant among children whose mothers were diagnosed in the year before birth, in the year after birth, or when the child was between 1 and 3. Children whose mothers were diagnosed during these periods and who had longer durations of depression were most vulnerable to an ADHD diagnosis, the results showed.

“Clearly, the number of years with a depression diagnosis is particularly important, and should be taken into consideration by clinicians caring for both mothers and their children,” Ms. Guevremont said. “The earlier depressed mothers are recognized and treated, the better for the health of both the mother and her children. Intervention at multiple time periods is possible and needed.” For example, in addition to prenatal screening, “another opportunity for screening is when mothers seek physicians for the children's behavior problems,” she said.

The study is limited by the potential for underreporting of both maternal depression and child ADHD, Ms. Guevremont noted. “Some physicians may not know a mother is depressed and therefore would not diagnose the condition if symptoms are not reported,” she stated.

Children with juvenile idiopathic arthritis are more likely to follow their medication and exercise regimens when their parents perceive that the treatments are helpful.

Adherence can be problematic in juvenile idiopathic arthritis (JIA) treatment, because therapy often is complicated, reported Debbie Ehrmann Feldman, Ph.D., of Montreal Children's Hospital, and her associates (Arthritis Rheum. 2007;57:226–33).

To evaluate the potential factors influencing patient adherence to JIA treatment over time, the investigators surveyed the parents of 175 children (mean age 10 years) with a mean disease duration of 4 years. The patients were receiving JIA treatment at two pediatric hospitals in Canada.

Several times over a 12-month period, parents completed questionnaires including the Parent Adherence Report Questionnaire; the Symptom Checklist-90-Revised; the Coping Health Inventory for Parents (CHIP); and the Child Health Assessment Questionnaire (CHAQ). The investigators also included clinical information obtained from each child's chart, and input from clinicians and physical therapists about prescribed treatment and opinions about patient adherence.

In terms of treatment adherence, the values for perceived adherence to medication were consistent between patients and physicians, whereas the perceived adherence to exercise was higher among parents than physical therapists. Parent-reported adherence to medication use ranged from 86 to 92 on a 100-mm visual analog scale in the PARQ, and the physician ratings for medication adherence ranged from 90 to 92. Perceived exercise adherence was substantially lower, with parent-reported values ranging from 54 to 64 and physical therapist ratings ranging from 35 to 50, the investigators stated.

“Adherence to medication was higher for participants who perceived exercise to be highly beneficial, as well as those who had children with lower disease severity [as measured by active joint count],” the authors wrote, commenting on findings from their generalized estimating equation analysis done to identify factors from all of the survey instruments associated with perceived treatment adherence. “Adherence to exercise was higher for participants who perceived exercise to be a highly beneficial treatment for JIA, for participants with younger children, and for participants with a child who was involved in the responsibility for his or her treatment.”

The findings underscore “the importance of patients' beliefs affecting adherence,” the authors wrote, noting that management strategies should incorporate explanations about the treatments, how they work, and why they are important.

Children with juvenile idiopathic arthritis are more likely to follow their medication and exercise regimens when their parents perceive that the treatments are helpful.

Adherence can be problematic in juvenile idiopathic arthritis (JIA) treatment, because therapy often is complicated, reported Debbie Ehrmann Feldman, Ph.D., of Montreal Children's Hospital, and her associates (Arthritis Rheum. 2007;57:226–33).

To evaluate the potential factors influencing patient adherence to JIA treatment over time, the investigators surveyed the parents of 175 children (mean age 10 years) with a mean disease duration of 4 years. The patients were receiving JIA treatment at two pediatric hospitals in Canada.

Several times over a 12-month period, parents completed questionnaires including the Parent Adherence Report Questionnaire; the Symptom Checklist-90-Revised; the Coping Health Inventory for Parents (CHIP); and the Child Health Assessment Questionnaire (CHAQ). The investigators also included clinical information obtained from each child's chart, and input from clinicians and physical therapists about prescribed treatment and opinions about patient adherence.

In terms of treatment adherence, the values for perceived adherence to medication were consistent between patients and physicians, whereas the perceived adherence to exercise was higher among parents than physical therapists. Parent-reported adherence to medication use ranged from 86 to 92 on a 100-mm visual analog scale in the PARQ, and the physician ratings for medication adherence ranged from 90 to 92. Perceived exercise adherence was substantially lower, with parent-reported values ranging from 54 to 64 and physical therapist ratings ranging from 35 to 50, the investigators stated.

“Adherence to medication was higher for participants who perceived exercise to be highly beneficial, as well as those who had children with lower disease severity [as measured by active joint count],” the authors wrote, commenting on findings from their generalized estimating equation analysis done to identify factors from all of the survey instruments associated with perceived treatment adherence. “Adherence to exercise was higher for participants who perceived exercise to be a highly beneficial treatment for JIA, for participants with younger children, and for participants with a child who was involved in the responsibility for his or her treatment.”

The findings underscore “the importance of patients' beliefs affecting adherence,” the authors wrote, noting that management strategies should incorporate explanations about the treatments, how they work, and why they are important.

Children with juvenile idiopathic arthritis are more likely to follow their medication and exercise regimens when their parents perceive that the treatments are helpful.

Adherence can be problematic in juvenile idiopathic arthritis (JIA) treatment, because therapy often is complicated, reported Debbie Ehrmann Feldman, Ph.D., of Montreal Children's Hospital, and her associates (Arthritis Rheum. 2007;57:226–33).

To evaluate the potential factors influencing patient adherence to JIA treatment over time, the investigators surveyed the parents of 175 children (mean age 10 years) with a mean disease duration of 4 years. The patients were receiving JIA treatment at two pediatric hospitals in Canada.

Several times over a 12-month period, parents completed questionnaires including the Parent Adherence Report Questionnaire; the Symptom Checklist-90-Revised; the Coping Health Inventory for Parents (CHIP); and the Child Health Assessment Questionnaire (CHAQ). The investigators also included clinical information obtained from each child's chart, and input from clinicians and physical therapists about prescribed treatment and opinions about patient adherence.

In terms of treatment adherence, the values for perceived adherence to medication were consistent between patients and physicians, whereas the perceived adherence to exercise was higher among parents than physical therapists. Parent-reported adherence to medication use ranged from 86 to 92 on a 100-mm visual analog scale in the PARQ, and the physician ratings for medication adherence ranged from 90 to 92. Perceived exercise adherence was substantially lower, with parent-reported values ranging from 54 to 64 and physical therapist ratings ranging from 35 to 50, the investigators stated.

“Adherence to medication was higher for participants who perceived exercise to be highly beneficial, as well as those who had children with lower disease severity [as measured by active joint count],” the authors wrote, commenting on findings from their generalized estimating equation analysis done to identify factors from all of the survey instruments associated with perceived treatment adherence. “Adherence to exercise was higher for participants who perceived exercise to be a highly beneficial treatment for JIA, for participants with younger children, and for participants with a child who was involved in the responsibility for his or her treatment.”

The findings underscore “the importance of patients' beliefs affecting adherence,” the authors wrote, noting that management strategies should incorporate explanations about the treatments, how they work, and why they are important.

Assessment of bone status with dual-energy x-ray absorptiometry alone may be an insufficient indicator of skeletal health in juvenile arthritis patients, reported Dr. Helena Valta and colleagues.

Although bone mineral density (BMD) and height z scores for a group of glucocorticoid-treated children with juvenile idiopathic arthritis (JIA) suggested normal growth and low prevalence of osteoporosis, spinal imaging uncovered a high prevalence of asymptomatic vertebral fractures, indicating that osteoporosis remains a concern in this population, according to Dr. Valta of the University of Helsinki and colleagues.

Multiple studies have demonstrated systemic skeletal complications in children with juvenile idiopathic arthritis as a consequence of both active disease and the medications used to treat it, the authors wrote. The introduction of new antirheumatic drugs in recent years has allowed for therapeutic alterations, including glucocorticoid dose reductions that might mitigate skeletal damage.

In a study designed to determine whether current treatment regimens have led to improved overall skeletal health in children with JIA, the investigators evaluated growth and bone health in 62 children with JIA treated with glucocorticoids and multiple drug combinations. The study included 19 boys, median age 11.8 years, who fulfilled the revised criteria for JIA; they were followed since diagnosis at Helsinki University's Pediatric Rheumatology Outpatient Clinic at least 2 years prior to the study (J. Rheumatol. 2007 Feb. 15 [Epub ahead of print]).

During the course of their disease, all had been treated with systemic glucocorticoids for at least 3 months; 12 children received combination therapy with glucocorticoids and methotrexate only; and 50 children received glucocorticoids, methotrexate, and additional antirheumatic agents, including 20 children treated with tumor necrosis factor-α (TNF-α) antagonists for treatment-resistant JIA, the authors reported. Four had nonvertebral fractures resulting from low-energy injuries after their JIA diagnosis. None had previously diagnosed compression fractures.

The median duration of systemic glucocorticoid treatment was 24 months, and the median cumulative dose (calculated as prednisolone) and weight-adjusted dose were 2.2 g and 88 mg/kg, respectively. All of the children were assessed clinically by a pediatric rheumatologist and all underwent dual-energy x-ray absorptiometry (DXA) scans to assess bone mineral content and areal BMD (aBMD) of the lumbar spine, left femoral neck, total hip, and whole body. Instant vertebral assessment (IVA) images of the lateral and posteroanterior spine were obtained to detect vertebral compression fractures.

A review of anthropometry and imaging data showed that all but two of the patients were of normal stature at study assessment and only a minority had bone age-corrected aBMD z scores indicative of significant osteopenia or symptomatic osteoporosis. “The bone age-adjusted aBMD z score was below −1.0 and below −2.0 at the lumbar spine in 12 and in 3 patients, respectively, and at the hip in 13 patients and in 1 patient, respectively,” the authors reported.

However, the IVA images demonstrated abnormal vertebral morphology suggestive of compression fractures in six patients (10%). Five had anterior wedge deformity, and one had a compression deformity affecting the anterior, middle, and posterior heights of the vertebrae, according to the authors. There were no statistically significant differences in the duration of glucocorticoid treatment or weight-adjusted cumulative glucocorticoid dose in any patients with abnormal vertebral findings, versus patients who had normal vertebral morphology, they wrote.

An evaluation of bone health correlates in the entire study population showed no link between aBMD and disease characteristics, combination therapies at the time of assessment, or cumulative glucocorticoid dose.

While the findings suggest current treatments have led to improved overall skeletal health in children with JIA, the detection of vertebral compression fractures and some subnormal BMD readings in the cohort “are evidence for the significant potential risks of JIA to normal bone health,” the authors wrote. “More attention needs to be paid to preventive measures such as optimizing vitamin D and calcium intake, and encouraging weight-bearing physical activity in patients with satisfactory disease control.”

The study highlights bone health evaluation questions in this at-risk population, for which there are currently no standards. “We don't know enough about bone health in these children yet to be completely confident in simply using standard DXA studies; however, better tools are not routinely available yet, and DXA provides more information than routine x-rays,” said Dr. Thomas J.A. Lehman, chief of pediatric rheumatology at the Hospital for Special Surgery in New York. “If DXA [measures] are way off, everyone agrees on therapy,” he said, but no consensus exists on the interpretation of mild abnormalities in arthritic children.

Assessment of bone status with dual-energy x-ray absorptiometry alone may be an insufficient indicator of skeletal health in juvenile arthritis patients, reported Dr. Helena Valta and colleagues.

Although bone mineral density (BMD) and height z scores for a group of glucocorticoid-treated children with juvenile idiopathic arthritis (JIA) suggested normal growth and low prevalence of osteoporosis, spinal imaging uncovered a high prevalence of asymptomatic vertebral fractures, indicating that osteoporosis remains a concern in this population, according to Dr. Valta of the University of Helsinki and colleagues.

Multiple studies have demonstrated systemic skeletal complications in children with juvenile idiopathic arthritis as a consequence of both active disease and the medications used to treat it, the authors wrote. The introduction of new antirheumatic drugs in recent years has allowed for therapeutic alterations, including glucocorticoid dose reductions that might mitigate skeletal damage.

In a study designed to determine whether current treatment regimens have led to improved overall skeletal health in children with JIA, the investigators evaluated growth and bone health in 62 children with JIA treated with glucocorticoids and multiple drug combinations. The study included 19 boys, median age 11.8 years, who fulfilled the revised criteria for JIA; they were followed since diagnosis at Helsinki University's Pediatric Rheumatology Outpatient Clinic at least 2 years prior to the study (J. Rheumatol. 2007 Feb. 15 [Epub ahead of print]).

During the course of their disease, all had been treated with systemic glucocorticoids for at least 3 months; 12 children received combination therapy with glucocorticoids and methotrexate only; and 50 children received glucocorticoids, methotrexate, and additional antirheumatic agents, including 20 children treated with tumor necrosis factor-α (TNF-α) antagonists for treatment-resistant JIA, the authors reported. Four had nonvertebral fractures resulting from low-energy injuries after their JIA diagnosis. None had previously diagnosed compression fractures.

The median duration of systemic glucocorticoid treatment was 24 months, and the median cumulative dose (calculated as prednisolone) and weight-adjusted dose were 2.2 g and 88 mg/kg, respectively. All of the children were assessed clinically by a pediatric rheumatologist and all underwent dual-energy x-ray absorptiometry (DXA) scans to assess bone mineral content and areal BMD (aBMD) of the lumbar spine, left femoral neck, total hip, and whole body. Instant vertebral assessment (IVA) images of the lateral and posteroanterior spine were obtained to detect vertebral compression fractures.

A review of anthropometry and imaging data showed that all but two of the patients were of normal stature at study assessment and only a minority had bone age-corrected aBMD z scores indicative of significant osteopenia or symptomatic osteoporosis. “The bone age-adjusted aBMD z score was below −1.0 and below −2.0 at the lumbar spine in 12 and in 3 patients, respectively, and at the hip in 13 patients and in 1 patient, respectively,” the authors reported.

However, the IVA images demonstrated abnormal vertebral morphology suggestive of compression fractures in six patients (10%). Five had anterior wedge deformity, and one had a compression deformity affecting the anterior, middle, and posterior heights of the vertebrae, according to the authors. There were no statistically significant differences in the duration of glucocorticoid treatment or weight-adjusted cumulative glucocorticoid dose in any patients with abnormal vertebral findings, versus patients who had normal vertebral morphology, they wrote.

An evaluation of bone health correlates in the entire study population showed no link between aBMD and disease characteristics, combination therapies at the time of assessment, or cumulative glucocorticoid dose.

While the findings suggest current treatments have led to improved overall skeletal health in children with JIA, the detection of vertebral compression fractures and some subnormal BMD readings in the cohort “are evidence for the significant potential risks of JIA to normal bone health,” the authors wrote. “More attention needs to be paid to preventive measures such as optimizing vitamin D and calcium intake, and encouraging weight-bearing physical activity in patients with satisfactory disease control.”

The study highlights bone health evaluation questions in this at-risk population, for which there are currently no standards. “We don't know enough about bone health in these children yet to be completely confident in simply using standard DXA studies; however, better tools are not routinely available yet, and DXA provides more information than routine x-rays,” said Dr. Thomas J.A. Lehman, chief of pediatric rheumatology at the Hospital for Special Surgery in New York. “If DXA [measures] are way off, everyone agrees on therapy,” he said, but no consensus exists on the interpretation of mild abnormalities in arthritic children.

Assessment of bone status with dual-energy x-ray absorptiometry alone may be an insufficient indicator of skeletal health in juvenile arthritis patients, reported Dr. Helena Valta and colleagues.

Although bone mineral density (BMD) and height z scores for a group of glucocorticoid-treated children with juvenile idiopathic arthritis (JIA) suggested normal growth and low prevalence of osteoporosis, spinal imaging uncovered a high prevalence of asymptomatic vertebral fractures, indicating that osteoporosis remains a concern in this population, according to Dr. Valta of the University of Helsinki and colleagues.

Multiple studies have demonstrated systemic skeletal complications in children with juvenile idiopathic arthritis as a consequence of both active disease and the medications used to treat it, the authors wrote. The introduction of new antirheumatic drugs in recent years has allowed for therapeutic alterations, including glucocorticoid dose reductions that might mitigate skeletal damage.

In a study designed to determine whether current treatment regimens have led to improved overall skeletal health in children with JIA, the investigators evaluated growth and bone health in 62 children with JIA treated with glucocorticoids and multiple drug combinations. The study included 19 boys, median age 11.8 years, who fulfilled the revised criteria for JIA; they were followed since diagnosis at Helsinki University's Pediatric Rheumatology Outpatient Clinic at least 2 years prior to the study (J. Rheumatol. 2007 Feb. 15 [Epub ahead of print]).

During the course of their disease, all had been treated with systemic glucocorticoids for at least 3 months; 12 children received combination therapy with glucocorticoids and methotrexate only; and 50 children received glucocorticoids, methotrexate, and additional antirheumatic agents, including 20 children treated with tumor necrosis factor-α (TNF-α) antagonists for treatment-resistant JIA, the authors reported. Four had nonvertebral fractures resulting from low-energy injuries after their JIA diagnosis. None had previously diagnosed compression fractures.

The median duration of systemic glucocorticoid treatment was 24 months, and the median cumulative dose (calculated as prednisolone) and weight-adjusted dose were 2.2 g and 88 mg/kg, respectively. All of the children were assessed clinically by a pediatric rheumatologist and all underwent dual-energy x-ray absorptiometry (DXA) scans to assess bone mineral content and areal BMD (aBMD) of the lumbar spine, left femoral neck, total hip, and whole body. Instant vertebral assessment (IVA) images of the lateral and posteroanterior spine were obtained to detect vertebral compression fractures.

A review of anthropometry and imaging data showed that all but two of the patients were of normal stature at study assessment and only a minority had bone age-corrected aBMD z scores indicative of significant osteopenia or symptomatic osteoporosis. “The bone age-adjusted aBMD z score was below −1.0 and below −2.0 at the lumbar spine in 12 and in 3 patients, respectively, and at the hip in 13 patients and in 1 patient, respectively,” the authors reported.

However, the IVA images demonstrated abnormal vertebral morphology suggestive of compression fractures in six patients (10%). Five had anterior wedge deformity, and one had a compression deformity affecting the anterior, middle, and posterior heights of the vertebrae, according to the authors. There were no statistically significant differences in the duration of glucocorticoid treatment or weight-adjusted cumulative glucocorticoid dose in any patients with abnormal vertebral findings, versus patients who had normal vertebral morphology, they wrote.

An evaluation of bone health correlates in the entire study population showed no link between aBMD and disease characteristics, combination therapies at the time of assessment, or cumulative glucocorticoid dose.

While the findings suggest current treatments have led to improved overall skeletal health in children with JIA, the detection of vertebral compression fractures and some subnormal BMD readings in the cohort “are evidence for the significant potential risks of JIA to normal bone health,” the authors wrote. “More attention needs to be paid to preventive measures such as optimizing vitamin D and calcium intake, and encouraging weight-bearing physical activity in patients with satisfactory disease control.”

The study highlights bone health evaluation questions in this at-risk population, for which there are currently no standards. “We don't know enough about bone health in these children yet to be completely confident in simply using standard DXA studies; however, better tools are not routinely available yet, and DXA provides more information than routine x-rays,” said Dr. Thomas J.A. Lehman, chief of pediatric rheumatology at the Hospital for Special Surgery in New York. “If DXA [measures] are way off, everyone agrees on therapy,” he said, but no consensus exists on the interpretation of mild abnormalities in arthritic children.

Routine use of aspirin or nonsteroidal anti-inflammatory drugs should not be recommended as preventive therapy for colorectal cancer in patients at average risk for the disease, according to a statement released by the U.S. Preventive Services Task Force.

The caution against prophylactic use of these agents applies to asymptomatic adults, including those with a family history of colon cancer, but not to patients with a personal history of colon cancer or polyps, familial adenomatous polyposis, or hereditary nonpolyposis colon cancer syndromes, the statement specified (Ann. Intern. Med. 2007;146:361–4).

The USPSTF issued its recommendation based on literature reviews conducted by the Agency for Healthcare Research and Quality (AHRQ). These reviews evaluated the role of aspirin, NSAIDs, and cyclo-oxygenase-2 (COX-2) inhibitors for the primary prevention of colorectal cancer and colorectal adenoma. On the basis of the relevant literature published between 1996 and 2006, the USPSTF determined that “the harms outweigh the benefits of aspirin and NSAID use for the prevention of colorectal cancer.”

The literature reviews showed that aspirin, COX-2 inhibitors, and NSAIDs reduce the incidence of colonic adenomas and that aspirin and NSAIDs reduce the incidence of colorectal cancer. However, these drugs were associated with adverse gastrointestinal outcomes and, in the case of COX-2 inhibitors, with important cardiovascular events.

But the USPSTF also said that clinicians should continue to discuss aspirin chemoprophylaxis in patients who are at increased risk for coronary heart disease, because there is “good evidence” that low-dose (less than 100 mg) aspirin therapy can reduce the risk of heart disease.

Routine use of aspirin or nonsteroidal anti-inflammatory drugs should not be recommended as preventive therapy for colorectal cancer in patients at average risk for the disease, according to a statement released by the U.S. Preventive Services Task Force.

The caution against prophylactic use of these agents applies to asymptomatic adults, including those with a family history of colon cancer, but not to patients with a personal history of colon cancer or polyps, familial adenomatous polyposis, or hereditary nonpolyposis colon cancer syndromes, the statement specified (Ann. Intern. Med. 2007;146:361–4).

The USPSTF issued its recommendation based on literature reviews conducted by the Agency for Healthcare Research and Quality (AHRQ). These reviews evaluated the role of aspirin, NSAIDs, and cyclo-oxygenase-2 (COX-2) inhibitors for the primary prevention of colorectal cancer and colorectal adenoma. On the basis of the relevant literature published between 1996 and 2006, the USPSTF determined that “the harms outweigh the benefits of aspirin and NSAID use for the prevention of colorectal cancer.”

The literature reviews showed that aspirin, COX-2 inhibitors, and NSAIDs reduce the incidence of colonic adenomas and that aspirin and NSAIDs reduce the incidence of colorectal cancer. However, these drugs were associated with adverse gastrointestinal outcomes and, in the case of COX-2 inhibitors, with important cardiovascular events.

But the USPSTF also said that clinicians should continue to discuss aspirin chemoprophylaxis in patients who are at increased risk for coronary heart disease, because there is “good evidence” that low-dose (less than 100 mg) aspirin therapy can reduce the risk of heart disease.

Routine use of aspirin or nonsteroidal anti-inflammatory drugs should not be recommended as preventive therapy for colorectal cancer in patients at average risk for the disease, according to a statement released by the U.S. Preventive Services Task Force.

The caution against prophylactic use of these agents applies to asymptomatic adults, including those with a family history of colon cancer, but not to patients with a personal history of colon cancer or polyps, familial adenomatous polyposis, or hereditary nonpolyposis colon cancer syndromes, the statement specified (Ann. Intern. Med. 2007;146:361–4).

The USPSTF issued its recommendation based on literature reviews conducted by the Agency for Healthcare Research and Quality (AHRQ). These reviews evaluated the role of aspirin, NSAIDs, and cyclo-oxygenase-2 (COX-2) inhibitors for the primary prevention of colorectal cancer and colorectal adenoma. On the basis of the relevant literature published between 1996 and 2006, the USPSTF determined that “the harms outweigh the benefits of aspirin and NSAID use for the prevention of colorectal cancer.”

The literature reviews showed that aspirin, COX-2 inhibitors, and NSAIDs reduce the incidence of colonic adenomas and that aspirin and NSAIDs reduce the incidence of colorectal cancer. However, these drugs were associated with adverse gastrointestinal outcomes and, in the case of COX-2 inhibitors, with important cardiovascular events.

But the USPSTF also said that clinicians should continue to discuss aspirin chemoprophylaxis in patients who are at increased risk for coronary heart disease, because there is “good evidence” that low-dose (less than 100 mg) aspirin therapy can reduce the risk of heart disease.

SAN FRANCISCO — Babies conceived via assisted reproductive technology are significantly more likely to have birth defects than those conceived naturally, a large Canadian study has shown.

Despite the observed increase, however, the incidence of birth defects in this population “is still relatively uncommon and should not discourage infertile couples from considering this reproductive option,” said lead investigator Dr. Darine El-Chaar at the annual meeting of the Society for Maternal-Fetal Medicine. Rather, “the risk information should become part of counseling for couples that are infertile in order to clarify the risk picture,” she noted.

In a retrospective study of 2005 birth data obtained from the Ontario Niday perinatal database, Dr. El-Chaar and colleagues observed a 1.58-fold increased risk of birth defects overall in babies conceived with assisted reproductive technology (ART), compared with babies conceived naturally.

Of the 61,208 births identified in the database for which information about reproductive assistance was available, 1,394 resulted from fertility treatments. For purposes of this study, “we lost some subjects in the ART [group] due to missing variables and other factors, and were left with 870 subjects, including 320 who used ovulation induction medications, 180 who underwent intrauterine insemination, and 370 who underwent in vitro fertilization,” said Dr. El-Chaar of the University of Ottawa.

In terms of patient and clinical characteristics, mothers in the ART group tended to be older, were less likely to have had a previous child, and were less likely to smoke than mothers in the non-ART group, said Dr. El-Chaar. Also, the ART mothers had a higher rate of cesarean sections and preterm births, and a higher number of multiple births—a factor that likely contributed to the higher preterm birth rate.

After adjustment for these factors using logistic regression, the statistical model showed an overall incidence of birth defects in the ART population of 2.62%, compared with 1.87% in the non-ART population, reported Dr. El-Chaar, noting that increased values fall within the 2%–3% rate of birth defects seen in the general population.

When analyzed by type of ART intervention, babies conceived via in vitro fertilization had the greatest increased risk of birth defects, at 2.97%, compared with 2.66% for intrauterine insemination and 2.19% for ovulation induction—a finding that suggests an association with the degree to which the various techniques manipulate egg and sperm, Dr. El-Chaar said.

“The highest increase in the ART group was seen in gastrointestinal birth defects, with an adjusted odds ratio of 8.86, followed by cardiovascular defects with an odds ratio of 2.27 and musculoskeletal defects with an odds ratio of 1.51,” said Dr. El-Chaar. There were no significant increases in the risks of neural tube or facial defects between the groups.

Some factors that may contribute to the increased risk of birth defects in the study population are the relatively advanced age of infertile couples, the medications used to stimulate ovulation or to maintain the luteal phase, and factors associated with the procedures themselves, such as the freezing and thawing of embryos or delayed oocyte fertilization, said Dr. El-Chaar. “Further studies are needed to clarify the contributions of these factors, infertility itself, and ART to the development of birth defects.”

SAN FRANCISCO — Babies conceived via assisted reproductive technology are significantly more likely to have birth defects than those conceived naturally, a large Canadian study has shown.

Despite the observed increase, however, the incidence of birth defects in this population “is still relatively uncommon and should not discourage infertile couples from considering this reproductive option,” said lead investigator Dr. Darine El-Chaar at the annual meeting of the Society for Maternal-Fetal Medicine. Rather, “the risk information should become part of counseling for couples that are infertile in order to clarify the risk picture,” she noted.

In a retrospective study of 2005 birth data obtained from the Ontario Niday perinatal database, Dr. El-Chaar and colleagues observed a 1.58-fold increased risk of birth defects overall in babies conceived with assisted reproductive technology (ART), compared with babies conceived naturally.

Of the 61,208 births identified in the database for which information about reproductive assistance was available, 1,394 resulted from fertility treatments. For purposes of this study, “we lost some subjects in the ART [group] due to missing variables and other factors, and were left with 870 subjects, including 320 who used ovulation induction medications, 180 who underwent intrauterine insemination, and 370 who underwent in vitro fertilization,” said Dr. El-Chaar of the University of Ottawa.

In terms of patient and clinical characteristics, mothers in the ART group tended to be older, were less likely to have had a previous child, and were less likely to smoke than mothers in the non-ART group, said Dr. El-Chaar. Also, the ART mothers had a higher rate of cesarean sections and preterm births, and a higher number of multiple births—a factor that likely contributed to the higher preterm birth rate.

After adjustment for these factors using logistic regression, the statistical model showed an overall incidence of birth defects in the ART population of 2.62%, compared with 1.87% in the non-ART population, reported Dr. El-Chaar, noting that increased values fall within the 2%–3% rate of birth defects seen in the general population.

When analyzed by type of ART intervention, babies conceived via in vitro fertilization had the greatest increased risk of birth defects, at 2.97%, compared with 2.66% for intrauterine insemination and 2.19% for ovulation induction—a finding that suggests an association with the degree to which the various techniques manipulate egg and sperm, Dr. El-Chaar said.

“The highest increase in the ART group was seen in gastrointestinal birth defects, with an adjusted odds ratio of 8.86, followed by cardiovascular defects with an odds ratio of 2.27 and musculoskeletal defects with an odds ratio of 1.51,” said Dr. El-Chaar. There were no significant increases in the risks of neural tube or facial defects between the groups.

Some factors that may contribute to the increased risk of birth defects in the study population are the relatively advanced age of infertile couples, the medications used to stimulate ovulation or to maintain the luteal phase, and factors associated with the procedures themselves, such as the freezing and thawing of embryos or delayed oocyte fertilization, said Dr. El-Chaar. “Further studies are needed to clarify the contributions of these factors, infertility itself, and ART to the development of birth defects.”

SAN FRANCISCO — Babies conceived via assisted reproductive technology are significantly more likely to have birth defects than those conceived naturally, a large Canadian study has shown.

Despite the observed increase, however, the incidence of birth defects in this population “is still relatively uncommon and should not discourage infertile couples from considering this reproductive option,” said lead investigator Dr. Darine El-Chaar at the annual meeting of the Society for Maternal-Fetal Medicine. Rather, “the risk information should become part of counseling for couples that are infertile in order to clarify the risk picture,” she noted.

In a retrospective study of 2005 birth data obtained from the Ontario Niday perinatal database, Dr. El-Chaar and colleagues observed a 1.58-fold increased risk of birth defects overall in babies conceived with assisted reproductive technology (ART), compared with babies conceived naturally.

Of the 61,208 births identified in the database for which information about reproductive assistance was available, 1,394 resulted from fertility treatments. For purposes of this study, “we lost some subjects in the ART [group] due to missing variables and other factors, and were left with 870 subjects, including 320 who used ovulation induction medications, 180 who underwent intrauterine insemination, and 370 who underwent in vitro fertilization,” said Dr. El-Chaar of the University of Ottawa.

In terms of patient and clinical characteristics, mothers in the ART group tended to be older, were less likely to have had a previous child, and were less likely to smoke than mothers in the non-ART group, said Dr. El-Chaar. Also, the ART mothers had a higher rate of cesarean sections and preterm births, and a higher number of multiple births—a factor that likely contributed to the higher preterm birth rate.

After adjustment for these factors using logistic regression, the statistical model showed an overall incidence of birth defects in the ART population of 2.62%, compared with 1.87% in the non-ART population, reported Dr. El-Chaar, noting that increased values fall within the 2%–3% rate of birth defects seen in the general population.

When analyzed by type of ART intervention, babies conceived via in vitro fertilization had the greatest increased risk of birth defects, at 2.97%, compared with 2.66% for intrauterine insemination and 2.19% for ovulation induction—a finding that suggests an association with the degree to which the various techniques manipulate egg and sperm, Dr. El-Chaar said.

“The highest increase in the ART group was seen in gastrointestinal birth defects, with an adjusted odds ratio of 8.86, followed by cardiovascular defects with an odds ratio of 2.27 and musculoskeletal defects with an odds ratio of 1.51,” said Dr. El-Chaar. There were no significant increases in the risks of neural tube or facial defects between the groups.

Some factors that may contribute to the increased risk of birth defects in the study population are the relatively advanced age of infertile couples, the medications used to stimulate ovulation or to maintain the luteal phase, and factors associated with the procedures themselves, such as the freezing and thawing of embryos or delayed oocyte fertilization, said Dr. El-Chaar. “Further studies are needed to clarify the contributions of these factors, infertility itself, and ART to the development of birth defects.”

SAN FRANCISCO — Women with preterm premature rupture of membranes who request pain medication twice within a 3-hour time period for regular painful contractions should be offered epidural analgesia, inasmuch as they are highly likely to deliver with the ensuing 24 hours, a study of more than 1,600 patients has shown.

A retrospective review of 1,608 women with premature rupture of membranes (PROM) and 74 women with preterm PROM (PPROM) showed that the majority of the PPROM group delivered within 24 hours of their second request for analgesia, yet they were significantly less likely to receive an epidural, compared with women in the PROM group, reported Melanie Chichester, R.N., and colleagues in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

Because digital examination is precluded in women with PPROM, onset of labor is difficult to determine and timely administration of epidural analgesia can be challenging, Ms. Chichester said.

For this reason, she and colleagues at Christiana Care Health Systems in Newark, Del., sought to assess whether contractions sufficient to cause a second maternal request for analgesia within a 3-hour time period could be substituted for contractions with cervical change as a maker of labor onset.

The investigators reviewed all admissions to their institution with confirmed PROM and PPROM from January 2004 through June 2005.

For analytical purposes, women with rupture of membranes after 24 weeks' and before 34 weeks' gestation were categorized as having PPROM and those with rupture of membranes at week 34 or later were classified as having PROM.

Among women with PPROM, the median time to delivery was 6.62 hours from the time of second request for analgesia, Ms. Chichester said.

Additionally, in the PPROM population, a total of 82% of the women delivered within 24 hours and 96% delivered within 48 hours of their second request for analgesia.

Compared with 79% of the PROM group who received an epidural following their second request for pain medication, only 42% of the PPROM group received an epidural, she said.

Although the study is limited by its retrospective design and small sample size, the findings suggest “it is incumbent upon the obstetrician to offer the same level of pain management to the laboring woman with PPROM as to any other parturient,” said Ms. Chichester.

For the relatively small percentage of women who do not deliver in the subsequent 48 hours, the epidural may be discontinued or active management of labor may be considered, depending on presence or absence of signs of infection, she said.

SAN FRANCISCO — Women with preterm premature rupture of membranes who request pain medication twice within a 3-hour time period for regular painful contractions should be offered epidural analgesia, inasmuch as they are highly likely to deliver with the ensuing 24 hours, a study of more than 1,600 patients has shown.

A retrospective review of 1,608 women with premature rupture of membranes (PROM) and 74 women with preterm PROM (PPROM) showed that the majority of the PPROM group delivered within 24 hours of their second request for analgesia, yet they were significantly less likely to receive an epidural, compared with women in the PROM group, reported Melanie Chichester, R.N., and colleagues in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

Because digital examination is precluded in women with PPROM, onset of labor is difficult to determine and timely administration of epidural analgesia can be challenging, Ms. Chichester said.

For this reason, she and colleagues at Christiana Care Health Systems in Newark, Del., sought to assess whether contractions sufficient to cause a second maternal request for analgesia within a 3-hour time period could be substituted for contractions with cervical change as a maker of labor onset.

The investigators reviewed all admissions to their institution with confirmed PROM and PPROM from January 2004 through June 2005.

For analytical purposes, women with rupture of membranes after 24 weeks' and before 34 weeks' gestation were categorized as having PPROM and those with rupture of membranes at week 34 or later were classified as having PROM.

Among women with PPROM, the median time to delivery was 6.62 hours from the time of second request for analgesia, Ms. Chichester said.

Additionally, in the PPROM population, a total of 82% of the women delivered within 24 hours and 96% delivered within 48 hours of their second request for analgesia.

Compared with 79% of the PROM group who received an epidural following their second request for pain medication, only 42% of the PPROM group received an epidural, she said.

Although the study is limited by its retrospective design and small sample size, the findings suggest “it is incumbent upon the obstetrician to offer the same level of pain management to the laboring woman with PPROM as to any other parturient,” said Ms. Chichester.

For the relatively small percentage of women who do not deliver in the subsequent 48 hours, the epidural may be discontinued or active management of labor may be considered, depending on presence or absence of signs of infection, she said.

SAN FRANCISCO — Women with preterm premature rupture of membranes who request pain medication twice within a 3-hour time period for regular painful contractions should be offered epidural analgesia, inasmuch as they are highly likely to deliver with the ensuing 24 hours, a study of more than 1,600 patients has shown.

A retrospective review of 1,608 women with premature rupture of membranes (PROM) and 74 women with preterm PROM (PPROM) showed that the majority of the PPROM group delivered within 24 hours of their second request for analgesia, yet they were significantly less likely to receive an epidural, compared with women in the PROM group, reported Melanie Chichester, R.N., and colleagues in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

Because digital examination is precluded in women with PPROM, onset of labor is difficult to determine and timely administration of epidural analgesia can be challenging, Ms. Chichester said.

For this reason, she and colleagues at Christiana Care Health Systems in Newark, Del., sought to assess whether contractions sufficient to cause a second maternal request for analgesia within a 3-hour time period could be substituted for contractions with cervical change as a maker of labor onset.

The investigators reviewed all admissions to their institution with confirmed PROM and PPROM from January 2004 through June 2005.

For analytical purposes, women with rupture of membranes after 24 weeks' and before 34 weeks' gestation were categorized as having PPROM and those with rupture of membranes at week 34 or later were classified as having PROM.

Among women with PPROM, the median time to delivery was 6.62 hours from the time of second request for analgesia, Ms. Chichester said.

Additionally, in the PPROM population, a total of 82% of the women delivered within 24 hours and 96% delivered within 48 hours of their second request for analgesia.

Compared with 79% of the PROM group who received an epidural following their second request for pain medication, only 42% of the PPROM group received an epidural, she said.

Although the study is limited by its retrospective design and small sample size, the findings suggest “it is incumbent upon the obstetrician to offer the same level of pain management to the laboring woman with PPROM as to any other parturient,” said Ms. Chichester.

For the relatively small percentage of women who do not deliver in the subsequent 48 hours, the epidural may be discontinued or active management of labor may be considered, depending on presence or absence of signs of infection, she said.