Kate Johnson

BOSTON — Obstructive sleep apnea is a risk factor for cardiac arrhythmias, and the diagnosis and treatment of this sleep disorder should be considered in terms of cardioprotective benefit, according to Dr. Maria Teresa La Rovere.

In a study that she presented in a poster at the annual meeting of the Heart Rhythm Society, Dr. La Rovere found a significant correlation between oxygen desaturation in obstructive sleep apnea syndrome (OSAS) and bradyarrhythmias, but not tachyarrhythmias.

“We found strong evidence that bradyarrhythmias are related to sleep apnea syndrome—while for tachyarrhythmias, the role of oxygen desaturation is more controversial,” Dr. La Rovere said in an interview.

Other factors may contribute to tachyarrhythmias, such as β₂-agonist treatment, which was found to be more common among patients who had tachyarrhythmias, she said.

The study included 300 subjects who were referred for sleep studies because of snoring. OSAS was diagnosed in 248 (83%) of them.

Although there was a trend toward more arrhythmias in the patients with OSAS than in those without OSAS (18% vs. 11%), the difference was not significant, reported Dr. Rovere, a cardiologist at the Fondazione Salvatore Maugeri clinic in Pavia, Italy.

Patients who had arrhythmias were older than the nonarrhythmic subjects (58 vs. 52 years) and had more profound oxygen desaturation (23% vs. 15% total sleep time spent with less than 90% oxygen saturation).

Although no significant relationship was found between tachyarrhythmias and hypoxemia, bradyarrhythmias were significantly correlated. Patients with bradyarrhythmias had significantly more hypoxemia, compared with nonarrhythmic patients, with an apnea-hypopnea index of 54 vs. 31 and an oxygen saturation nadir of 69% vs. 77%.

Dr. La Rovere said a recently published study that was performed in the general population and that used a stricter definition of OSAS produced similar evidence that people with sleep-disordered breathing have between two and four times the odds of having complex cardiac arrhythmias, compared with those without sleep apnea (Am. J. Respir. Crit. Care Med. 2006;173:910–6).

That study showed that sleep-disordered breathing was associated with four times the odds of atrial fibrillation, three times the odds of nonsustained ventricular tachycardia, and almost twice the odds of complex ventricular ectopy, after adjustment of the data for age, sex, body mass index, and prevalent coronary heart disease.

Another recently published study showed that OSAS was associated with almost double the risk of stroke or death, even after adjustment for age, sex, race, smoking status, alcohol consumption, body mass index, diabetes mellitus, hyperlipidemia, atrial fibrillation, and hypertension (N. Engl. J. Med. 2005;353:2034–41).

Although treatment of OSAS with continuous positive airway pressure (CPAP) is well established for the relief of sleep disturbances and improvement in quality of life, Dr. La Rovere said that physicians should also recognize its value in preventing the development of cardiac arrhythmias.

“The mechanism of breathing disorders also affects cardiac functioning. So in the long term, these subjects may also develop heart failure,” she said. “I think there is an increasing awareness.”

Dr. La Rovere added that although CPAP not only prevents sleep-related heart rhythm disturbances, but can also correct them, it is advisable to consider a pacemaker for patients whose CPAP compliance is questionable.

“I know the CPAP will correct my patient's arrhythmia, but I do not know if my patient will use the CPAP,” Dr. La Rovere said.

BOSTON — Obstructive sleep apnea is a risk factor for cardiac arrhythmias, and the diagnosis and treatment of this sleep disorder should be considered in terms of cardioprotective benefit, according to Dr. Maria Teresa La Rovere.

In a study that she presented in a poster at the annual meeting of the Heart Rhythm Society, Dr. La Rovere found a significant correlation between oxygen desaturation in obstructive sleep apnea syndrome (OSAS) and bradyarrhythmias, but not tachyarrhythmias.

“We found strong evidence that bradyarrhythmias are related to sleep apnea syndrome—while for tachyarrhythmias, the role of oxygen desaturation is more controversial,” Dr. La Rovere said in an interview.

Other factors may contribute to tachyarrhythmias, such as β₂-agonist treatment, which was found to be more common among patients who had tachyarrhythmias, she said.

The study included 300 subjects who were referred for sleep studies because of snoring. OSAS was diagnosed in 248 (83%) of them.

Although there was a trend toward more arrhythmias in the patients with OSAS than in those without OSAS (18% vs. 11%), the difference was not significant, reported Dr. Rovere, a cardiologist at the Fondazione Salvatore Maugeri clinic in Pavia, Italy.

Patients who had arrhythmias were older than the nonarrhythmic subjects (58 vs. 52 years) and had more profound oxygen desaturation (23% vs. 15% total sleep time spent with less than 90% oxygen saturation).

Although no significant relationship was found between tachyarrhythmias and hypoxemia, bradyarrhythmias were significantly correlated. Patients with bradyarrhythmias had significantly more hypoxemia, compared with nonarrhythmic patients, with an apnea-hypopnea index of 54 vs. 31 and an oxygen saturation nadir of 69% vs. 77%.

Dr. La Rovere said a recently published study that was performed in the general population and that used a stricter definition of OSAS produced similar evidence that people with sleep-disordered breathing have between two and four times the odds of having complex cardiac arrhythmias, compared with those without sleep apnea (Am. J. Respir. Crit. Care Med. 2006;173:910–6).

That study showed that sleep-disordered breathing was associated with four times the odds of atrial fibrillation, three times the odds of nonsustained ventricular tachycardia, and almost twice the odds of complex ventricular ectopy, after adjustment of the data for age, sex, body mass index, and prevalent coronary heart disease.

Another recently published study showed that OSAS was associated with almost double the risk of stroke or death, even after adjustment for age, sex, race, smoking status, alcohol consumption, body mass index, diabetes mellitus, hyperlipidemia, atrial fibrillation, and hypertension (N. Engl. J. Med. 2005;353:2034–41).

Although treatment of OSAS with continuous positive airway pressure (CPAP) is well established for the relief of sleep disturbances and improvement in quality of life, Dr. La Rovere said that physicians should also recognize its value in preventing the development of cardiac arrhythmias.

“The mechanism of breathing disorders also affects cardiac functioning. So in the long term, these subjects may also develop heart failure,” she said. “I think there is an increasing awareness.”

Dr. La Rovere added that although CPAP not only prevents sleep-related heart rhythm disturbances, but can also correct them, it is advisable to consider a pacemaker for patients whose CPAP compliance is questionable.

“I know the CPAP will correct my patient's arrhythmia, but I do not know if my patient will use the CPAP,” Dr. La Rovere said.

BOSTON — Obstructive sleep apnea is a risk factor for cardiac arrhythmias, and the diagnosis and treatment of this sleep disorder should be considered in terms of cardioprotective benefit, according to Dr. Maria Teresa La Rovere.

In a study that she presented in a poster at the annual meeting of the Heart Rhythm Society, Dr. La Rovere found a significant correlation between oxygen desaturation in obstructive sleep apnea syndrome (OSAS) and bradyarrhythmias, but not tachyarrhythmias.

“We found strong evidence that bradyarrhythmias are related to sleep apnea syndrome—while for tachyarrhythmias, the role of oxygen desaturation is more controversial,” Dr. La Rovere said in an interview.

Other factors may contribute to tachyarrhythmias, such as β₂-agonist treatment, which was found to be more common among patients who had tachyarrhythmias, she said.

The study included 300 subjects who were referred for sleep studies because of snoring. OSAS was diagnosed in 248 (83%) of them.

Although there was a trend toward more arrhythmias in the patients with OSAS than in those without OSAS (18% vs. 11%), the difference was not significant, reported Dr. Rovere, a cardiologist at the Fondazione Salvatore Maugeri clinic in Pavia, Italy.

Patients who had arrhythmias were older than the nonarrhythmic subjects (58 vs. 52 years) and had more profound oxygen desaturation (23% vs. 15% total sleep time spent with less than 90% oxygen saturation).

Although no significant relationship was found between tachyarrhythmias and hypoxemia, bradyarrhythmias were significantly correlated. Patients with bradyarrhythmias had significantly more hypoxemia, compared with nonarrhythmic patients, with an apnea-hypopnea index of 54 vs. 31 and an oxygen saturation nadir of 69% vs. 77%.

Dr. La Rovere said a recently published study that was performed in the general population and that used a stricter definition of OSAS produced similar evidence that people with sleep-disordered breathing have between two and four times the odds of having complex cardiac arrhythmias, compared with those without sleep apnea (Am. J. Respir. Crit. Care Med. 2006;173:910–6).

That study showed that sleep-disordered breathing was associated with four times the odds of atrial fibrillation, three times the odds of nonsustained ventricular tachycardia, and almost twice the odds of complex ventricular ectopy, after adjustment of the data for age, sex, body mass index, and prevalent coronary heart disease.

Another recently published study showed that OSAS was associated with almost double the risk of stroke or death, even after adjustment for age, sex, race, smoking status, alcohol consumption, body mass index, diabetes mellitus, hyperlipidemia, atrial fibrillation, and hypertension (N. Engl. J. Med. 2005;353:2034–41).

Although treatment of OSAS with continuous positive airway pressure (CPAP) is well established for the relief of sleep disturbances and improvement in quality of life, Dr. La Rovere said that physicians should also recognize its value in preventing the development of cardiac arrhythmias.

“The mechanism of breathing disorders also affects cardiac functioning. So in the long term, these subjects may also develop heart failure,” she said. “I think there is an increasing awareness.”

Dr. La Rovere added that although CPAP not only prevents sleep-related heart rhythm disturbances, but can also correct them, it is advisable to consider a pacemaker for patients whose CPAP compliance is questionable.

“I know the CPAP will correct my patient's arrhythmia, but I do not know if my patient will use the CPAP,” Dr. La Rovere said.

TORONTO — Patients with endometriosis that is unresponsive to surgical and medical treatment may get relief from intravaginal injections with botulinum toxin, according to a case series from the National Institutes of Health.

“We saw an impressive period of relief beyond what we would expect,” said Dr. Melissa Merideth, an ob.gyn. with the Office of Rare Diseases at the National Human Genome Research Institute, an arm of the National Institutes of Health.

The study, which she reported in a poster at the annual meeting of the Society for Gynecologic Investigation, involved three women with chronic pelvic pain that persisted after laparoscopic excision of their endometriosis. Upon physical examination, all the women had palpable spasm of their pelvic floor muscles, Dr. Merideth said in an interview.

Because botulinum toxin relaxes muscle spasm and has been effective in the treatment of headache and myofascial pain, her group decided to test its effect on pelvic floor muscle spasm, she said.

“We felt the pelvic floor spasm was a component of their pain, and we wanted to see how addressing that would affect their other pain symptoms,” she said.

Working in an office setting in conjunction with a neurologist, a gynecologist injected a total dose of 100 U of botulinum type A toxin (reconstituted with 4 cc of preservative-free saline) transvaginally into between three and six injection sites in the women's levator ani muscles at sites of palpable spasm. The women were premedicated with Valium and the procedure was done using electromyographic guidance and lidocaine cream at each injection site. Five injection sessions were carried out in the three women.

The first patient had an 8-year history of unremitting pelvic pain, which was relieved for 9 months after her first injection session. A second injection session provided another 1.5 years of relief.

The second patient had a history of severe pelvic pain that limited her ability to walk. She had amenorrhea as a result of 5 years of treatment with leuprolide acetate and add-back therapy.

After one injection session, she had 1 year of pain relief, resumed normal menstrual cycles, and regained her ability to walk with minimal pain and normal gait, said Dr. Merideth.

And the third patient had pelvic floor spasm and bladder atony following laparoscopic surgery 1 year earlier. She was unable to self-catheterize because of the muscle spasm and therefore required a suprapubic catheter. Her first injection session decreased her pain and muscle spasm such that she was able to self-catheterize. After a second injection session 6 months later, she was able to decrease narcotic usage and return to work. The first two patients stopped narcotic usage entirely and also returned to work.

Spasm of the pelvic floor muscle is not a finding in all patients with endometriosis, and “one would anticipate this treatment would only work in patients who had spasm on exam,” said Dr. Merideth. “How it plays into their pain and the neural-immune response of the body is something we're still studying.” She said there are plans to proceed with a blinded study comparing the medication to placebo in a larger group of women.

TORONTO — Patients with endometriosis that is unresponsive to surgical and medical treatment may get relief from intravaginal injections with botulinum toxin, according to a case series from the National Institutes of Health.

“We saw an impressive period of relief beyond what we would expect,” said Dr. Melissa Merideth, an ob.gyn. with the Office of Rare Diseases at the National Human Genome Research Institute, an arm of the National Institutes of Health.

The study, which she reported in a poster at the annual meeting of the Society for Gynecologic Investigation, involved three women with chronic pelvic pain that persisted after laparoscopic excision of their endometriosis. Upon physical examination, all the women had palpable spasm of their pelvic floor muscles, Dr. Merideth said in an interview.

Because botulinum toxin relaxes muscle spasm and has been effective in the treatment of headache and myofascial pain, her group decided to test its effect on pelvic floor muscle spasm, she said.

“We felt the pelvic floor spasm was a component of their pain, and we wanted to see how addressing that would affect their other pain symptoms,” she said.

Working in an office setting in conjunction with a neurologist, a gynecologist injected a total dose of 100 U of botulinum type A toxin (reconstituted with 4 cc of preservative-free saline) transvaginally into between three and six injection sites in the women's levator ani muscles at sites of palpable spasm. The women were premedicated with Valium and the procedure was done using electromyographic guidance and lidocaine cream at each injection site. Five injection sessions were carried out in the three women.

The first patient had an 8-year history of unremitting pelvic pain, which was relieved for 9 months after her first injection session. A second injection session provided another 1.5 years of relief.

The second patient had a history of severe pelvic pain that limited her ability to walk. She had amenorrhea as a result of 5 years of treatment with leuprolide acetate and add-back therapy.

After one injection session, she had 1 year of pain relief, resumed normal menstrual cycles, and regained her ability to walk with minimal pain and normal gait, said Dr. Merideth.

And the third patient had pelvic floor spasm and bladder atony following laparoscopic surgery 1 year earlier. She was unable to self-catheterize because of the muscle spasm and therefore required a suprapubic catheter. Her first injection session decreased her pain and muscle spasm such that she was able to self-catheterize. After a second injection session 6 months later, she was able to decrease narcotic usage and return to work. The first two patients stopped narcotic usage entirely and also returned to work.

Spasm of the pelvic floor muscle is not a finding in all patients with endometriosis, and “one would anticipate this treatment would only work in patients who had spasm on exam,” said Dr. Merideth. “How it plays into their pain and the neural-immune response of the body is something we're still studying.” She said there are plans to proceed with a blinded study comparing the medication to placebo in a larger group of women.

TORONTO — Patients with endometriosis that is unresponsive to surgical and medical treatment may get relief from intravaginal injections with botulinum toxin, according to a case series from the National Institutes of Health.

“We saw an impressive period of relief beyond what we would expect,” said Dr. Melissa Merideth, an ob.gyn. with the Office of Rare Diseases at the National Human Genome Research Institute, an arm of the National Institutes of Health.

The study, which she reported in a poster at the annual meeting of the Society for Gynecologic Investigation, involved three women with chronic pelvic pain that persisted after laparoscopic excision of their endometriosis. Upon physical examination, all the women had palpable spasm of their pelvic floor muscles, Dr. Merideth said in an interview.

Because botulinum toxin relaxes muscle spasm and has been effective in the treatment of headache and myofascial pain, her group decided to test its effect on pelvic floor muscle spasm, she said.

“We felt the pelvic floor spasm was a component of their pain, and we wanted to see how addressing that would affect their other pain symptoms,” she said.

Working in an office setting in conjunction with a neurologist, a gynecologist injected a total dose of 100 U of botulinum type A toxin (reconstituted with 4 cc of preservative-free saline) transvaginally into between three and six injection sites in the women's levator ani muscles at sites of palpable spasm. The women were premedicated with Valium and the procedure was done using electromyographic guidance and lidocaine cream at each injection site. Five injection sessions were carried out in the three women.

The first patient had an 8-year history of unremitting pelvic pain, which was relieved for 9 months after her first injection session. A second injection session provided another 1.5 years of relief.

The second patient had a history of severe pelvic pain that limited her ability to walk. She had amenorrhea as a result of 5 years of treatment with leuprolide acetate and add-back therapy.

After one injection session, she had 1 year of pain relief, resumed normal menstrual cycles, and regained her ability to walk with minimal pain and normal gait, said Dr. Merideth.

And the third patient had pelvic floor spasm and bladder atony following laparoscopic surgery 1 year earlier. She was unable to self-catheterize because of the muscle spasm and therefore required a suprapubic catheter. Her first injection session decreased her pain and muscle spasm such that she was able to self-catheterize. After a second injection session 6 months later, she was able to decrease narcotic usage and return to work. The first two patients stopped narcotic usage entirely and also returned to work.

Spasm of the pelvic floor muscle is not a finding in all patients with endometriosis, and “one would anticipate this treatment would only work in patients who had spasm on exam,” said Dr. Merideth. “How it plays into their pain and the neural-immune response of the body is something we're still studying.” She said there are plans to proceed with a blinded study comparing the medication to placebo in a larger group of women.

Evidence for a gastrointestinal route for human avian influenza infection should be interpreted cautiously, according to Dr. William Schaffner, chair of the department of preventive medicine at Vanderbilt University in Nashville, Tenn.

As the H5N1 virus continues its global march amid fears that it may mutate to become more easily transmissible, a study published last year suggesting a gastrointestinal portal is getting renewed attention.

Last year, Dr. Menno D. de Jong, head of the virology department at the Oxford University Clinical Research Unit in Ho Chi Minh City, Vietnam, published a case report of a child who died of avian influenza after an atypical gastrointestinal presentation, fecal evidence of the H5N1 virus, and no respiratory symptoms at presentation (N. Engl. J. Med. 2005;352:686–91).

This case and several other published reports suggest that the gastrointestinal tract may also be vulnerable to the infection, Dr. de Jong was reported as saying.

“The presence of viable virus in the feces of our patient has important implications for transmission, infection control, and public health,” Dr. de Jong and his colleagues wrote. This “highlights a potential route of human-to-human transmission, especially in combination with crowded living conditions and diarrhea.”

To date, experts consider human-to-human transmission of avian influenza very rare, but they agree that if the H5N1 virus becomes easily transmissible among humans, it likely would trigger a global pandemic. Recent studies have suggested that the preferential attachment of the virus to cells in the lower rather than the upper human respiratory tract may explain why it is not easily spread by coughing and sneezing (Science 2006;312:399). But the possibility of gastrointestinal infection suggests the potential for much easier fecal-oral transmission.

Dr. Schaffner, who is also professor of medicine in the division of infectious diseases at Vanderbilt, says a couple of isolated reports of gastrointestinal evidence of the H5N1 virus should not cause alarm. “There is nothing we know about the general epidemiology of influenza that would suggest this is a form of transmission that is in any way noteworthy, although we should keep an eye on it,” he said in an interview.

A similar gastrointestinal presentation, with diarrhea as the initial symptom and with no respiratory illness, has been described elsewhere (Emerg. Infect. Dis. 2004;10:1321–4), Dr. de Jong said in an interview, and other researchers have also documented intestinal replication of the H5N1 virus in humans (Emerg. Infect. Dis. 2005;11:1036–41).

In addition, there are reports of human infection in which patients' only exposure to the virus was through the consumption of duck blood or undercooked poultry, Dr. de Jong said (N. Engl. J. Med. 2005;353:1374–85).

“The spectrum of influenza H5N1 is wider than previously thought,” he wrote. “Clinical surveillance of influenza H5N1 should focus not only on respiratory illness, but also on clusters of unexplained deaths or severe illnesses of any kind.”

Dr. Schaffner said that even if gastrointestinal infection is shown to be more common than previously thought, preventive measures are already being taken.

“We already have one public health response that works well for both respiratory and intestinal infections,” he said. “Hand washing is one of the most effective ways to interrupt intestinal transmission of known viruses and bacteria that are spread in stool.”

This limited gastrointestinal evidence of the H5N1 virus should not cause alarm, but 'we should keep an eye on it.' DR. SCHAFFNER

Evidence for a gastrointestinal route for human avian influenza infection should be interpreted cautiously, according to Dr. William Schaffner, chair of the department of preventive medicine at Vanderbilt University in Nashville, Tenn.

As the H5N1 virus continues its global march amid fears that it may mutate to become more easily transmissible, a study published last year suggesting a gastrointestinal portal is getting renewed attention.

Last year, Dr. Menno D. de Jong, head of the virology department at the Oxford University Clinical Research Unit in Ho Chi Minh City, Vietnam, published a case report of a child who died of avian influenza after an atypical gastrointestinal presentation, fecal evidence of the H5N1 virus, and no respiratory symptoms at presentation (N. Engl. J. Med. 2005;352:686–91).

This case and several other published reports suggest that the gastrointestinal tract may also be vulnerable to the infection, Dr. de Jong was reported as saying.

“The presence of viable virus in the feces of our patient has important implications for transmission, infection control, and public health,” Dr. de Jong and his colleagues wrote. This “highlights a potential route of human-to-human transmission, especially in combination with crowded living conditions and diarrhea.”

To date, experts consider human-to-human transmission of avian influenza very rare, but they agree that if the H5N1 virus becomes easily transmissible among humans, it likely would trigger a global pandemic. Recent studies have suggested that the preferential attachment of the virus to cells in the lower rather than the upper human respiratory tract may explain why it is not easily spread by coughing and sneezing (Science 2006;312:399). But the possibility of gastrointestinal infection suggests the potential for much easier fecal-oral transmission.

Dr. Schaffner, who is also professor of medicine in the division of infectious diseases at Vanderbilt, says a couple of isolated reports of gastrointestinal evidence of the H5N1 virus should not cause alarm. “There is nothing we know about the general epidemiology of influenza that would suggest this is a form of transmission that is in any way noteworthy, although we should keep an eye on it,” he said in an interview.

A similar gastrointestinal presentation, with diarrhea as the initial symptom and with no respiratory illness, has been described elsewhere (Emerg. Infect. Dis. 2004;10:1321–4), Dr. de Jong said in an interview, and other researchers have also documented intestinal replication of the H5N1 virus in humans (Emerg. Infect. Dis. 2005;11:1036–41).

In addition, there are reports of human infection in which patients' only exposure to the virus was through the consumption of duck blood or undercooked poultry, Dr. de Jong said (N. Engl. J. Med. 2005;353:1374–85).

“The spectrum of influenza H5N1 is wider than previously thought,” he wrote. “Clinical surveillance of influenza H5N1 should focus not only on respiratory illness, but also on clusters of unexplained deaths or severe illnesses of any kind.”

Dr. Schaffner said that even if gastrointestinal infection is shown to be more common than previously thought, preventive measures are already being taken.

“We already have one public health response that works well for both respiratory and intestinal infections,” he said. “Hand washing is one of the most effective ways to interrupt intestinal transmission of known viruses and bacteria that are spread in stool.”

This limited gastrointestinal evidence of the H5N1 virus should not cause alarm, but 'we should keep an eye on it.' DR. SCHAFFNER

Evidence for a gastrointestinal route for human avian influenza infection should be interpreted cautiously, according to Dr. William Schaffner, chair of the department of preventive medicine at Vanderbilt University in Nashville, Tenn.

As the H5N1 virus continues its global march amid fears that it may mutate to become more easily transmissible, a study published last year suggesting a gastrointestinal portal is getting renewed attention.

Last year, Dr. Menno D. de Jong, head of the virology department at the Oxford University Clinical Research Unit in Ho Chi Minh City, Vietnam, published a case report of a child who died of avian influenza after an atypical gastrointestinal presentation, fecal evidence of the H5N1 virus, and no respiratory symptoms at presentation (N. Engl. J. Med. 2005;352:686–91).

This case and several other published reports suggest that the gastrointestinal tract may also be vulnerable to the infection, Dr. de Jong was reported as saying.

“The presence of viable virus in the feces of our patient has important implications for transmission, infection control, and public health,” Dr. de Jong and his colleagues wrote. This “highlights a potential route of human-to-human transmission, especially in combination with crowded living conditions and diarrhea.”

To date, experts consider human-to-human transmission of avian influenza very rare, but they agree that if the H5N1 virus becomes easily transmissible among humans, it likely would trigger a global pandemic. Recent studies have suggested that the preferential attachment of the virus to cells in the lower rather than the upper human respiratory tract may explain why it is not easily spread by coughing and sneezing (Science 2006;312:399). But the possibility of gastrointestinal infection suggests the potential for much easier fecal-oral transmission.

Dr. Schaffner, who is also professor of medicine in the division of infectious diseases at Vanderbilt, says a couple of isolated reports of gastrointestinal evidence of the H5N1 virus should not cause alarm. “There is nothing we know about the general epidemiology of influenza that would suggest this is a form of transmission that is in any way noteworthy, although we should keep an eye on it,” he said in an interview.

A similar gastrointestinal presentation, with diarrhea as the initial symptom and with no respiratory illness, has been described elsewhere (Emerg. Infect. Dis. 2004;10:1321–4), Dr. de Jong said in an interview, and other researchers have also documented intestinal replication of the H5N1 virus in humans (Emerg. Infect. Dis. 2005;11:1036–41).

In addition, there are reports of human infection in which patients' only exposure to the virus was through the consumption of duck blood or undercooked poultry, Dr. de Jong said (N. Engl. J. Med. 2005;353:1374–85).

“The spectrum of influenza H5N1 is wider than previously thought,” he wrote. “Clinical surveillance of influenza H5N1 should focus not only on respiratory illness, but also on clusters of unexplained deaths or severe illnesses of any kind.”

Dr. Schaffner said that even if gastrointestinal infection is shown to be more common than previously thought, preventive measures are already being taken.

“We already have one public health response that works well for both respiratory and intestinal infections,” he said. “Hand washing is one of the most effective ways to interrupt intestinal transmission of known viruses and bacteria that are spread in stool.”

This limited gastrointestinal evidence of the H5N1 virus should not cause alarm, but 'we should keep an eye on it.' DR. SCHAFFNER

Diabetic patients with good preoperative glycemic control had significantly fewer postoperative infections in a retrospective analysis of data from the Veterans Affairs National Surgical Quality Improvement Program.

“If the association is confirmed in other studies, strategies to improve glycemic control prior to elective surgery can be employed to decrease infections and improve overall outcomes for diabetic surgical patients,” wrote Dr. Annika S. Dronge of Yale University, New Haven, Conn., and her colleagues.

The study included 490 diabetic surgery patients from the National Surgical Quality Improvement Program database, which prospectively collects preoperative, intraoperative, and 30-day outcomes on major noncardiac operations. All patients had a hemoglobin A_1c (HbA_1c) level recorded within 180 days prior to the surgery, with good glucose control defined as a level of less than 7%. The primary outcome of the study was postoperative infectious complications, including pneumonia, wound infection, urinary tract infection, and sepsis (Arch. Surg. 2006;141:375–80).

After adjusting for several factors known to be associated with postoperative infections, the researchers found that good long-term glycemic control was strongly associated with significantly fewer postoperative infections (odds ratio 2.13). Age, American Society of Anesthesiologists score, operation length, and wound class were also significantly associated with the risk of postoperative infection.

The authors noted that while long-term glycemic control in diabetic patients is widely recognized as decreasing both the incidence and severity of many chronic complications, only three studies have investigated its effect on postoperative infections. Two of these studies had opposite findings, but both used an HbA_1c level of 11.5% as the point between what they defined as good and poor glycemic control, a definition not consistent with current recommendations (J. Urol. 1992;147:386–8; J. Urol. 1998;159:1537–9). The third study used an HbA_1c level of 8% and showed twice as many postoperative infections in patients with high levels, compared with those with low levels (8% vs. 4%), although this did not reach statistical significance (Infect. Control Hosp. Epidemiol. 2001;22:607–12). However, a highly significant finding of this study was the increased incidence of postoperative hyperglycemia in the poorly controlled group, compared with the well-controlled group (78% vs. 43%).

The reason for the current study's finding of decreased postsurgical infection in association with good preoperative glycemic control could be linked simply to the better likelihood of postoperative glycemic control, as demonstrated by the third study, noted the authors. “Acute hyperglycemia has clearly been shown to be associated with poor outcome in a variety of clinical settings. … Tight control of glucose in the postoperative period results in fewer complications, including infections, and decreased mortality in both diabetic and nondiabetic patients,” they wrote.

Another possible explanation for their findings is simply “the overall improvement in general health and metabolic milieu of the well-controlled diabetic patient.”

They noted limitations of their study, including the fact that all subjects came from a single Veterans Affairs hospital and were predominantly male, making generalizability to a larger diabetic population more difficult. Additionally, the database they used did not control for factors such as smoking, nutritional status, and perioperative antibiotic use.

Diabetic patients with good preoperative glycemic control had significantly fewer postoperative infections in a retrospective analysis of data from the Veterans Affairs National Surgical Quality Improvement Program.

“If the association is confirmed in other studies, strategies to improve glycemic control prior to elective surgery can be employed to decrease infections and improve overall outcomes for diabetic surgical patients,” wrote Dr. Annika S. Dronge of Yale University, New Haven, Conn., and her colleagues.

The study included 490 diabetic surgery patients from the National Surgical Quality Improvement Program database, which prospectively collects preoperative, intraoperative, and 30-day outcomes on major noncardiac operations. All patients had a hemoglobin A_1c (HbA_1c) level recorded within 180 days prior to the surgery, with good glucose control defined as a level of less than 7%. The primary outcome of the study was postoperative infectious complications, including pneumonia, wound infection, urinary tract infection, and sepsis (Arch. Surg. 2006;141:375–80).

After adjusting for several factors known to be associated with postoperative infections, the researchers found that good long-term glycemic control was strongly associated with significantly fewer postoperative infections (odds ratio 2.13). Age, American Society of Anesthesiologists score, operation length, and wound class were also significantly associated with the risk of postoperative infection.

The authors noted that while long-term glycemic control in diabetic patients is widely recognized as decreasing both the incidence and severity of many chronic complications, only three studies have investigated its effect on postoperative infections. Two of these studies had opposite findings, but both used an HbA_1c level of 11.5% as the point between what they defined as good and poor glycemic control, a definition not consistent with current recommendations (J. Urol. 1992;147:386–8; J. Urol. 1998;159:1537–9). The third study used an HbA_1c level of 8% and showed twice as many postoperative infections in patients with high levels, compared with those with low levels (8% vs. 4%), although this did not reach statistical significance (Infect. Control Hosp. Epidemiol. 2001;22:607–12). However, a highly significant finding of this study was the increased incidence of postoperative hyperglycemia in the poorly controlled group, compared with the well-controlled group (78% vs. 43%).

The reason for the current study's finding of decreased postsurgical infection in association with good preoperative glycemic control could be linked simply to the better likelihood of postoperative glycemic control, as demonstrated by the third study, noted the authors. “Acute hyperglycemia has clearly been shown to be associated with poor outcome in a variety of clinical settings. … Tight control of glucose in the postoperative period results in fewer complications, including infections, and decreased mortality in both diabetic and nondiabetic patients,” they wrote.

Another possible explanation for their findings is simply “the overall improvement in general health and metabolic milieu of the well-controlled diabetic patient.”

They noted limitations of their study, including the fact that all subjects came from a single Veterans Affairs hospital and were predominantly male, making generalizability to a larger diabetic population more difficult. Additionally, the database they used did not control for factors such as smoking, nutritional status, and perioperative antibiotic use.

Diabetic patients with good preoperative glycemic control had significantly fewer postoperative infections in a retrospective analysis of data from the Veterans Affairs National Surgical Quality Improvement Program.

“If the association is confirmed in other studies, strategies to improve glycemic control prior to elective surgery can be employed to decrease infections and improve overall outcomes for diabetic surgical patients,” wrote Dr. Annika S. Dronge of Yale University, New Haven, Conn., and her colleagues.

The study included 490 diabetic surgery patients from the National Surgical Quality Improvement Program database, which prospectively collects preoperative, intraoperative, and 30-day outcomes on major noncardiac operations. All patients had a hemoglobin A_1c (HbA_1c) level recorded within 180 days prior to the surgery, with good glucose control defined as a level of less than 7%. The primary outcome of the study was postoperative infectious complications, including pneumonia, wound infection, urinary tract infection, and sepsis (Arch. Surg. 2006;141:375–80).

After adjusting for several factors known to be associated with postoperative infections, the researchers found that good long-term glycemic control was strongly associated with significantly fewer postoperative infections (odds ratio 2.13). Age, American Society of Anesthesiologists score, operation length, and wound class were also significantly associated with the risk of postoperative infection.

The authors noted that while long-term glycemic control in diabetic patients is widely recognized as decreasing both the incidence and severity of many chronic complications, only three studies have investigated its effect on postoperative infections. Two of these studies had opposite findings, but both used an HbA_1c level of 11.5% as the point between what they defined as good and poor glycemic control, a definition not consistent with current recommendations (J. Urol. 1992;147:386–8; J. Urol. 1998;159:1537–9). The third study used an HbA_1c level of 8% and showed twice as many postoperative infections in patients with high levels, compared with those with low levels (8% vs. 4%), although this did not reach statistical significance (Infect. Control Hosp. Epidemiol. 2001;22:607–12). However, a highly significant finding of this study was the increased incidence of postoperative hyperglycemia in the poorly controlled group, compared with the well-controlled group (78% vs. 43%).

The reason for the current study's finding of decreased postsurgical infection in association with good preoperative glycemic control could be linked simply to the better likelihood of postoperative glycemic control, as demonstrated by the third study, noted the authors. “Acute hyperglycemia has clearly been shown to be associated with poor outcome in a variety of clinical settings. … Tight control of glucose in the postoperative period results in fewer complications, including infections, and decreased mortality in both diabetic and nondiabetic patients,” they wrote.

Another possible explanation for their findings is simply “the overall improvement in general health and metabolic milieu of the well-controlled diabetic patient.”

They noted limitations of their study, including the fact that all subjects came from a single Veterans Affairs hospital and were predominantly male, making generalizability to a larger diabetic population more difficult. Additionally, the database they used did not control for factors such as smoking, nutritional status, and perioperative antibiotic use.

Parents' beliefs, rather than knowledge, are what drive their acceptance of human papillomavirus vaccines for their children, according to a new study.

Therefore, simply educating them about human papillomavirus (HPV) “may not be sufficient to influence their attitudes toward HPV vaccination, as attitudes may be driven by other, non-information-based preferences,” wrote Dr. Amanda F. Dempsey of the University of Washington, Seattle, and her colleagues (Pediatrics 2006;117:1486–93).

Their cross-sectional survey of 1,600 parents of 8− to 12-year-old children included a randomized intervention for half of them, which consisted of an HPV information sheet. The researchers hypothesized that those parents who received the information sheet would demonstrate increased HPV knowledge compared with controls, and therefore more openness toward vaccinating their children. However, among the 840 participants who completed the study, although those participants who received the information sheet (429) had higher scores compared with the controls (411) on the HPV knowledge assessment tool (5.57 vs. 4.17), there was no significant difference between the groups with respect to parental vaccine acceptability scores.

Instead, the most significant predictor of parental HPV vaccine acceptance was belief in the vaccines' benefits to society and to their children, noted the authors. In addition, five other predictors were peer group influence, physician recommendation, the perception that their children were susceptible to sexually transmitted infections and/or HPV, having had personal or close experience with genital warts, and answering questions about a female child.

“If policy-makers adopt a universal HPV vaccination policy (male and female), then addressing the benefits to male vaccination specifically may be necessary for these vaccines to be widely used,” they wrote.

Results of the study have “important implications for medical providers and public health practitioners when communicating with parents about HPV vaccines in the future,” noted the authors. “Focusing discussions on the benefits that are associated with giving HPV vaccines to children or on addressing general concerns that parents may have about the discomforts and/or dangers that are associated with vaccines may be useful strategies for promoting these vaccines,” they suggested.

Prophylactic HPV vaccines are expected to be licensed by 2007 or earlier, with preadolescent children aged 8–12 years as a proposed target population.

Therefore, parental acceptance of HPV vaccination is critical, explained the authors.

Parents' perceived barriers to vaccine acceptability included the belief that their children experienced significant discomfort or danger when receiving immunizations.

“Future HPV vaccination campaigns should attempt to stress the benefits of HPV vaccination for children and address the fears of parents about dangers or discomfort associated with vaccines,” the researchers concluded.

Parents' beliefs, rather than knowledge, are what drive their acceptance of human papillomavirus vaccines for their children, according to a new study.

Therefore, simply educating them about human papillomavirus (HPV) “may not be sufficient to influence their attitudes toward HPV vaccination, as attitudes may be driven by other, non-information-based preferences,” wrote Dr. Amanda F. Dempsey of the University of Washington, Seattle, and her colleagues (Pediatrics 2006;117:1486–93).

Their cross-sectional survey of 1,600 parents of 8− to 12-year-old children included a randomized intervention for half of them, which consisted of an HPV information sheet. The researchers hypothesized that those parents who received the information sheet would demonstrate increased HPV knowledge compared with controls, and therefore more openness toward vaccinating their children. However, among the 840 participants who completed the study, although those participants who received the information sheet (429) had higher scores compared with the controls (411) on the HPV knowledge assessment tool (5.57 vs. 4.17), there was no significant difference between the groups with respect to parental vaccine acceptability scores.

Instead, the most significant predictor of parental HPV vaccine acceptance was belief in the vaccines' benefits to society and to their children, noted the authors. In addition, five other predictors were peer group influence, physician recommendation, the perception that their children were susceptible to sexually transmitted infections and/or HPV, having had personal or close experience with genital warts, and answering questions about a female child.

“If policy-makers adopt a universal HPV vaccination policy (male and female), then addressing the benefits to male vaccination specifically may be necessary for these vaccines to be widely used,” they wrote.

Results of the study have “important implications for medical providers and public health practitioners when communicating with parents about HPV vaccines in the future,” noted the authors. “Focusing discussions on the benefits that are associated with giving HPV vaccines to children or on addressing general concerns that parents may have about the discomforts and/or dangers that are associated with vaccines may be useful strategies for promoting these vaccines,” they suggested.

Prophylactic HPV vaccines are expected to be licensed by 2007 or earlier, with preadolescent children aged 8–12 years as a proposed target population.

Therefore, parental acceptance of HPV vaccination is critical, explained the authors.

Parents' perceived barriers to vaccine acceptability included the belief that their children experienced significant discomfort or danger when receiving immunizations.

“Future HPV vaccination campaigns should attempt to stress the benefits of HPV vaccination for children and address the fears of parents about dangers or discomfort associated with vaccines,” the researchers concluded.

Parents' beliefs, rather than knowledge, are what drive their acceptance of human papillomavirus vaccines for their children, according to a new study.

Therefore, simply educating them about human papillomavirus (HPV) “may not be sufficient to influence their attitudes toward HPV vaccination, as attitudes may be driven by other, non-information-based preferences,” wrote Dr. Amanda F. Dempsey of the University of Washington, Seattle, and her colleagues (Pediatrics 2006;117:1486–93).

Their cross-sectional survey of 1,600 parents of 8− to 12-year-old children included a randomized intervention for half of them, which consisted of an HPV information sheet. The researchers hypothesized that those parents who received the information sheet would demonstrate increased HPV knowledge compared with controls, and therefore more openness toward vaccinating their children. However, among the 840 participants who completed the study, although those participants who received the information sheet (429) had higher scores compared with the controls (411) on the HPV knowledge assessment tool (5.57 vs. 4.17), there was no significant difference between the groups with respect to parental vaccine acceptability scores.

Instead, the most significant predictor of parental HPV vaccine acceptance was belief in the vaccines' benefits to society and to their children, noted the authors. In addition, five other predictors were peer group influence, physician recommendation, the perception that their children were susceptible to sexually transmitted infections and/or HPV, having had personal or close experience with genital warts, and answering questions about a female child.

“If policy-makers adopt a universal HPV vaccination policy (male and female), then addressing the benefits to male vaccination specifically may be necessary for these vaccines to be widely used,” they wrote.

Results of the study have “important implications for medical providers and public health practitioners when communicating with parents about HPV vaccines in the future,” noted the authors. “Focusing discussions on the benefits that are associated with giving HPV vaccines to children or on addressing general concerns that parents may have about the discomforts and/or dangers that are associated with vaccines may be useful strategies for promoting these vaccines,” they suggested.

Prophylactic HPV vaccines are expected to be licensed by 2007 or earlier, with preadolescent children aged 8–12 years as a proposed target population.

Therefore, parental acceptance of HPV vaccination is critical, explained the authors.

Parents' perceived barriers to vaccine acceptability included the belief that their children experienced significant discomfort or danger when receiving immunizations.

“Future HPV vaccination campaigns should attempt to stress the benefits of HPV vaccination for children and address the fears of parents about dangers or discomfort associated with vaccines,” the researchers concluded.

CHICAGO — Dexamethasone treatment can reduce the sequelae of pediatric bacterial meningitis when given prior to or concurrent with antibiotic therapy, according to Dr. Marianne Gausche-Hill.

“Although this issue has been controversial in the past, I think we are on the pro side now,” she said at a meeting sponsored by the American College of Emergency Physicians.

The goal of corticosteroid therapy is to reduce the inflammatory response that can lead to thrombotic changes, vasculitis, increases in cerebral pressure, and neuronal injury, she said.

“Reducing inflammation is the key to preventing sequelae,” she said. “Obviously, antibiotics are important, but early reduction of inflammation is essential—especially in reducing the risk of hearing loss.”

Until recently, there was some controversy about whether corticosteroid therapy was appropriate for pneumococcal meningitis because some studies suggested it might impair the cerebrospinal uptake of vancomycin, said Dr. Gausche-Hill, who is director of emergency medical services and pediatric emergency medicine fellowships at Harbor-UCLA Medical Center and professor of medicine at the University of California, Los Angeles.

Both the Infectious Diseases Society of America and the American Academy of Pediatrics Committee on Infectious Diseases previously released cautionary statements about the use of steroid therapy in pediatric pneumococcal meningitis, she said.

But a more recent study showing significantly improved outcomes with adjuvant corticosteroid therapy in pneumococcal meningitis (Arch. Dis. Child. 2005;90:391–3) has shifted medical opinion in favor of this therapy for both Haemophilus influenzae and pneumococcal meningitis, she said.

The study of 120 cases of pediatric pneumococcal meningitis included 15 children who died and 39 who sustained permanent neurologic impairment from the infection. Corticosteroid therapy either before or with parenteral antibiotics was associated with protection from death or severe morbidity (odds ratio of 0.21), Dr. Gausche-Hill said.

She suggested the algorithm for children with suspected bacterial meningitis should be an immediate lumbar puncture (if not contraindicated) and blood cultures, followed by dexamethasone and empiric antibiotic therapy.

In treating adolescents, she said, consideration of the adult literature is helpful. Although many authors recommend dexamethasone and antibiotics for all forms of adult bacterial meningitis, the Infectious Diseases Society of America recommends dexamethasone for pneumococcal disease only—noting inadequate data to recommend this therapy for other forms of bacterial meningitis, such as meningococcal disease, Dr. Gausche-Hill said.

CHICAGO — Dexamethasone treatment can reduce the sequelae of pediatric bacterial meningitis when given prior to or concurrent with antibiotic therapy, according to Dr. Marianne Gausche-Hill.

“Although this issue has been controversial in the past, I think we are on the pro side now,” she said at a meeting sponsored by the American College of Emergency Physicians.

The goal of corticosteroid therapy is to reduce the inflammatory response that can lead to thrombotic changes, vasculitis, increases in cerebral pressure, and neuronal injury, she said.

“Reducing inflammation is the key to preventing sequelae,” she said. “Obviously, antibiotics are important, but early reduction of inflammation is essential—especially in reducing the risk of hearing loss.”

Until recently, there was some controversy about whether corticosteroid therapy was appropriate for pneumococcal meningitis because some studies suggested it might impair the cerebrospinal uptake of vancomycin, said Dr. Gausche-Hill, who is director of emergency medical services and pediatric emergency medicine fellowships at Harbor-UCLA Medical Center and professor of medicine at the University of California, Los Angeles.

Both the Infectious Diseases Society of America and the American Academy of Pediatrics Committee on Infectious Diseases previously released cautionary statements about the use of steroid therapy in pediatric pneumococcal meningitis, she said.

But a more recent study showing significantly improved outcomes with adjuvant corticosteroid therapy in pneumococcal meningitis (Arch. Dis. Child. 2005;90:391–3) has shifted medical opinion in favor of this therapy for both Haemophilus influenzae and pneumococcal meningitis, she said.

The study of 120 cases of pediatric pneumococcal meningitis included 15 children who died and 39 who sustained permanent neurologic impairment from the infection. Corticosteroid therapy either before or with parenteral antibiotics was associated with protection from death or severe morbidity (odds ratio of 0.21), Dr. Gausche-Hill said.

She suggested the algorithm for children with suspected bacterial meningitis should be an immediate lumbar puncture (if not contraindicated) and blood cultures, followed by dexamethasone and empiric antibiotic therapy.

In treating adolescents, she said, consideration of the adult literature is helpful. Although many authors recommend dexamethasone and antibiotics for all forms of adult bacterial meningitis, the Infectious Diseases Society of America recommends dexamethasone for pneumococcal disease only—noting inadequate data to recommend this therapy for other forms of bacterial meningitis, such as meningococcal disease, Dr. Gausche-Hill said.

CHICAGO — Dexamethasone treatment can reduce the sequelae of pediatric bacterial meningitis when given prior to or concurrent with antibiotic therapy, according to Dr. Marianne Gausche-Hill.

“Although this issue has been controversial in the past, I think we are on the pro side now,” she said at a meeting sponsored by the American College of Emergency Physicians.

The goal of corticosteroid therapy is to reduce the inflammatory response that can lead to thrombotic changes, vasculitis, increases in cerebral pressure, and neuronal injury, she said.

“Reducing inflammation is the key to preventing sequelae,” she said. “Obviously, antibiotics are important, but early reduction of inflammation is essential—especially in reducing the risk of hearing loss.”

Until recently, there was some controversy about whether corticosteroid therapy was appropriate for pneumococcal meningitis because some studies suggested it might impair the cerebrospinal uptake of vancomycin, said Dr. Gausche-Hill, who is director of emergency medical services and pediatric emergency medicine fellowships at Harbor-UCLA Medical Center and professor of medicine at the University of California, Los Angeles.

Both the Infectious Diseases Society of America and the American Academy of Pediatrics Committee on Infectious Diseases previously released cautionary statements about the use of steroid therapy in pediatric pneumococcal meningitis, she said.

But a more recent study showing significantly improved outcomes with adjuvant corticosteroid therapy in pneumococcal meningitis (Arch. Dis. Child. 2005;90:391–3) has shifted medical opinion in favor of this therapy for both Haemophilus influenzae and pneumococcal meningitis, she said.

The study of 120 cases of pediatric pneumococcal meningitis included 15 children who died and 39 who sustained permanent neurologic impairment from the infection. Corticosteroid therapy either before or with parenteral antibiotics was associated with protection from death or severe morbidity (odds ratio of 0.21), Dr. Gausche-Hill said.

She suggested the algorithm for children with suspected bacterial meningitis should be an immediate lumbar puncture (if not contraindicated) and blood cultures, followed by dexamethasone and empiric antibiotic therapy.

In treating adolescents, she said, consideration of the adult literature is helpful. Although many authors recommend dexamethasone and antibiotics for all forms of adult bacterial meningitis, the Infectious Diseases Society of America recommends dexamethasone for pneumococcal disease only—noting inadequate data to recommend this therapy for other forms of bacterial meningitis, such as meningococcal disease, Dr. Gausche-Hill said.

TORONTO — Women whose first babies are delivered by cesarean section face an elevated risk of placenta previa and placental abruption in their second pregnancies. And with two previous cesarean deliveries the risk of placenta previa is increased further in the third pregnancy, according to a study by Dr. Darios Getahun of the Robert Wood Johnson Medical School in New Brunswick, N.J., and his colleagues.

The study, which was recently published (Obstet. Gynecol. 2006;107:771–8), was presented as a poster at the annual meeting of the Society for Gynecologic Investigation.

“Although cesarean section has previously been reported as a risk factor for placenta previa, it has not been previously associated with abruption,” Dr. Getahun said in an interview at the meeting. “Cesarean section causes scarring of the uterine wall, with the result that placentation may not be optimal. That's why it may be leading to abruption,” he explained.

The study included a cohort of women from the Missouri longitudinally linked live birth and fetal death data files. Singleton births were analyzed for 156,475 women whose first two consecutive births occurred within the study period of 1989–1997, and 31,102 women whose first three consecutive births occurred within that period.

Among 40,472 women whose first delivery was by cesarean section, the relative risk of placenta previa was 1.5, and that of placental abruption was 1.3 in the second pregnancy, compared with women whose first delivery was vaginal.

There was a dose response noted for the risk of placenta previa, but not for placental abruption risk. Therefore, when both the first and second deliveries were by cesarean section, the risk of placenta previa doubled in the third pregnancy, but the risk of placental abruption did not increase further, compared with women whose first two deliveries were vaginal.

The interval between pregnancies also was analyzed, and the study found that for cesarean deliveries, but not vaginal ones, an interval of less than 1 year was associated with a relative risk of 1.7 for placenta previa and 1.5 for placental abruption.

TORONTO — Women whose first babies are delivered by cesarean section face an elevated risk of placenta previa and placental abruption in their second pregnancies. And with two previous cesarean deliveries the risk of placenta previa is increased further in the third pregnancy, according to a study by Dr. Darios Getahun of the Robert Wood Johnson Medical School in New Brunswick, N.J., and his colleagues.

The study, which was recently published (Obstet. Gynecol. 2006;107:771–8), was presented as a poster at the annual meeting of the Society for Gynecologic Investigation.

“Although cesarean section has previously been reported as a risk factor for placenta previa, it has not been previously associated with abruption,” Dr. Getahun said in an interview at the meeting. “Cesarean section causes scarring of the uterine wall, with the result that placentation may not be optimal. That's why it may be leading to abruption,” he explained.

The study included a cohort of women from the Missouri longitudinally linked live birth and fetal death data files. Singleton births were analyzed for 156,475 women whose first two consecutive births occurred within the study period of 1989–1997, and 31,102 women whose first three consecutive births occurred within that period.

Among 40,472 women whose first delivery was by cesarean section, the relative risk of placenta previa was 1.5, and that of placental abruption was 1.3 in the second pregnancy, compared with women whose first delivery was vaginal.

There was a dose response noted for the risk of placenta previa, but not for placental abruption risk. Therefore, when both the first and second deliveries were by cesarean section, the risk of placenta previa doubled in the third pregnancy, but the risk of placental abruption did not increase further, compared with women whose first two deliveries were vaginal.

The interval between pregnancies also was analyzed, and the study found that for cesarean deliveries, but not vaginal ones, an interval of less than 1 year was associated with a relative risk of 1.7 for placenta previa and 1.5 for placental abruption.

TORONTO — Women whose first babies are delivered by cesarean section face an elevated risk of placenta previa and placental abruption in their second pregnancies. And with two previous cesarean deliveries the risk of placenta previa is increased further in the third pregnancy, according to a study by Dr. Darios Getahun of the Robert Wood Johnson Medical School in New Brunswick, N.J., and his colleagues.

The study, which was recently published (Obstet. Gynecol. 2006;107:771–8), was presented as a poster at the annual meeting of the Society for Gynecologic Investigation.

“Although cesarean section has previously been reported as a risk factor for placenta previa, it has not been previously associated with abruption,” Dr. Getahun said in an interview at the meeting. “Cesarean section causes scarring of the uterine wall, with the result that placentation may not be optimal. That's why it may be leading to abruption,” he explained.

The study included a cohort of women from the Missouri longitudinally linked live birth and fetal death data files. Singleton births were analyzed for 156,475 women whose first two consecutive births occurred within the study period of 1989–1997, and 31,102 women whose first three consecutive births occurred within that period.

Among 40,472 women whose first delivery was by cesarean section, the relative risk of placenta previa was 1.5, and that of placental abruption was 1.3 in the second pregnancy, compared with women whose first delivery was vaginal.

There was a dose response noted for the risk of placenta previa, but not for placental abruption risk. Therefore, when both the first and second deliveries were by cesarean section, the risk of placenta previa doubled in the third pregnancy, but the risk of placental abruption did not increase further, compared with women whose first two deliveries were vaginal.

The interval between pregnancies also was analyzed, and the study found that for cesarean deliveries, but not vaginal ones, an interval of less than 1 year was associated with a relative risk of 1.7 for placenta previa and 1.5 for placental abruption.

CHICAGO — The American Heart Association's renewed emphasis on compression versus ventilation in its latest cardiopulmonary resuscitation guidelines folds children and adults into the same category when only one rescuer is present.

In the hands of a lone rescuer, regardless of whether it is a layperson or a health care provider, children of all ages (excluding newborns) should be treated using a 30:2 compression-ventilation ratio, said Dr. Robert Hickey, one of the authors of the guidelines, past chair of AHA's pediatric subcommittee, and chair of the Emergency Cardiovascular Care Committee of the AHA.

A ratio of 15:2 is advised if there are two trained (not lay) rescuers present. “In children, rescue breaths are more important partly because they largely have asphyxial arrest,” he said in an interview at a meeting sponsored by the American College of Emergency Physicians.

Another pediatric specification of the guidelines is that cuffed endotracheal tubes are as safe as uncuffed ones for infants (except newborns) and children in the hospital setting—as long as rescuers use the correct tube size and inflation pressure, and verify tube position, he said. In fact, cuffed tubes may even be preferable under certain circumstances, such as poor lung compliance, high airway resistance, and large glottic air leak, he said.

Dr. Hickey said the most important overall message in the new guidelines (Circulation 2005;112 [24 Suppl.]:IV1–203)—for both children and adults—is the renewed focus on cardiopulmonary resuscitation (CPR). “Not enough people get CPR, and not enough people who get CPR get good CPR,” said Dr. Hickey, professor of pediatrics at the University of Pittsburgh and attending physician in the division of pediatric emergency medicine at Children's Hospital of Pittsburgh.

The new guidelines stipulate that either one or two hands can be used for chest compressions in children. However, he said studies show that most efforts at CPR—even when given by health care professionals—are still inadequate, involving too few chest compressions, compressions that are too weak, too many ventilations, and too many interruptions.

There is strong evidence pointing to the importance of optimizing chest compressions, even at the expense of ventilation, he said. In fact, some studies suggest that excessive ventilation might actually be leading to life-threatening hyperventilation-induced hypotension. A recent paper suggested that unrecognized and inadvertent hyperventilation could be contributing to the currently dismal survival rates from cardiac arrest (Circulation 2004;109:1960–5).

“Even if you do it right, there is a loss of coronary perfusion pressure each time you stop to do a ventilation,” Dr. Hickey said. “This is what fuels arguments for chest compression only.”

Chest compressions should take priority even over defibrillation, he added. One study showed an improved survival rate of 22% in patients when defibrillation was delayed until after the initiation of chest compressions, compared with a 15% survival rate among patients whose chest compressions followed defibrillation (JAMA 2003;289:1389–95). The same study showed that among patients with more than a 5-minute delay in rescue response following cardiac arrest, immediate defibrillation resulted in only a 4% survival rate, compared with a 22% survival rate in those who had chest compressions before defibrillation.

Dr. Hickey added that high-dose epinephrine is not recommended in children, based on a study showing that it did not improve return of spontaneous circulation and resulted in worse 24-hour survival (New Engl. J. Med. 2004;350:1722–30).

In neonatal resuscitation cases, current recommendations no longer advise intrapartum oropharyngeal suctioning for infants born after meconium staining of amniotic fluid, he said. Endotracheal suctioning immediately after birth for infants who are not vigorous is now recommended, Dr. Hickey added.

CHICAGO — The American Heart Association's renewed emphasis on compression versus ventilation in its latest cardiopulmonary resuscitation guidelines folds children and adults into the same category when only one rescuer is present.

In the hands of a lone rescuer, regardless of whether it is a layperson or a health care provider, children of all ages (excluding newborns) should be treated using a 30:2 compression-ventilation ratio, said Dr. Robert Hickey, one of the authors of the guidelines, past chair of AHA's pediatric subcommittee, and chair of the Emergency Cardiovascular Care Committee of the AHA.

A ratio of 15:2 is advised if there are two trained (not lay) rescuers present. “In children, rescue breaths are more important partly because they largely have asphyxial arrest,” he said in an interview at a meeting sponsored by the American College of Emergency Physicians.

Another pediatric specification of the guidelines is that cuffed endotracheal tubes are as safe as uncuffed ones for infants (except newborns) and children in the hospital setting—as long as rescuers use the correct tube size and inflation pressure, and verify tube position, he said. In fact, cuffed tubes may even be preferable under certain circumstances, such as poor lung compliance, high airway resistance, and large glottic air leak, he said.

Dr. Hickey said the most important overall message in the new guidelines (Circulation 2005;112 [24 Suppl.]:IV1–203)—for both children and adults—is the renewed focus on cardiopulmonary resuscitation (CPR). “Not enough people get CPR, and not enough people who get CPR get good CPR,” said Dr. Hickey, professor of pediatrics at the University of Pittsburgh and attending physician in the division of pediatric emergency medicine at Children's Hospital of Pittsburgh.

The new guidelines stipulate that either one or two hands can be used for chest compressions in children. However, he said studies show that most efforts at CPR—even when given by health care professionals—are still inadequate, involving too few chest compressions, compressions that are too weak, too many ventilations, and too many interruptions.

There is strong evidence pointing to the importance of optimizing chest compressions, even at the expense of ventilation, he said. In fact, some studies suggest that excessive ventilation might actually be leading to life-threatening hyperventilation-induced hypotension. A recent paper suggested that unrecognized and inadvertent hyperventilation could be contributing to the currently dismal survival rates from cardiac arrest (Circulation 2004;109:1960–5).

“Even if you do it right, there is a loss of coronary perfusion pressure each time you stop to do a ventilation,” Dr. Hickey said. “This is what fuels arguments for chest compression only.”

Chest compressions should take priority even over defibrillation, he added. One study showed an improved survival rate of 22% in patients when defibrillation was delayed until after the initiation of chest compressions, compared with a 15% survival rate among patients whose chest compressions followed defibrillation (JAMA 2003;289:1389–95). The same study showed that among patients with more than a 5-minute delay in rescue response following cardiac arrest, immediate defibrillation resulted in only a 4% survival rate, compared with a 22% survival rate in those who had chest compressions before defibrillation.

Dr. Hickey added that high-dose epinephrine is not recommended in children, based on a study showing that it did not improve return of spontaneous circulation and resulted in worse 24-hour survival (New Engl. J. Med. 2004;350:1722–30).

In neonatal resuscitation cases, current recommendations no longer advise intrapartum oropharyngeal suctioning for infants born after meconium staining of amniotic fluid, he said. Endotracheal suctioning immediately after birth for infants who are not vigorous is now recommended, Dr. Hickey added.

CHICAGO — The American Heart Association's renewed emphasis on compression versus ventilation in its latest cardiopulmonary resuscitation guidelines folds children and adults into the same category when only one rescuer is present.

In the hands of a lone rescuer, regardless of whether it is a layperson or a health care provider, children of all ages (excluding newborns) should be treated using a 30:2 compression-ventilation ratio, said Dr. Robert Hickey, one of the authors of the guidelines, past chair of AHA's pediatric subcommittee, and chair of the Emergency Cardiovascular Care Committee of the AHA.

A ratio of 15:2 is advised if there are two trained (not lay) rescuers present. “In children, rescue breaths are more important partly because they largely have asphyxial arrest,” he said in an interview at a meeting sponsored by the American College of Emergency Physicians.

Another pediatric specification of the guidelines is that cuffed endotracheal tubes are as safe as uncuffed ones for infants (except newborns) and children in the hospital setting—as long as rescuers use the correct tube size and inflation pressure, and verify tube position, he said. In fact, cuffed tubes may even be preferable under certain circumstances, such as poor lung compliance, high airway resistance, and large glottic air leak, he said.

Dr. Hickey said the most important overall message in the new guidelines (Circulation 2005;112 [24 Suppl.]:IV1–203)—for both children and adults—is the renewed focus on cardiopulmonary resuscitation (CPR). “Not enough people get CPR, and not enough people who get CPR get good CPR,” said Dr. Hickey, professor of pediatrics at the University of Pittsburgh and attending physician in the division of pediatric emergency medicine at Children's Hospital of Pittsburgh.

The new guidelines stipulate that either one or two hands can be used for chest compressions in children. However, he said studies show that most efforts at CPR—even when given by health care professionals—are still inadequate, involving too few chest compressions, compressions that are too weak, too many ventilations, and too many interruptions.

There is strong evidence pointing to the importance of optimizing chest compressions, even at the expense of ventilation, he said. In fact, some studies suggest that excessive ventilation might actually be leading to life-threatening hyperventilation-induced hypotension. A recent paper suggested that unrecognized and inadvertent hyperventilation could be contributing to the currently dismal survival rates from cardiac arrest (Circulation 2004;109:1960–5).

“Even if you do it right, there is a loss of coronary perfusion pressure each time you stop to do a ventilation,” Dr. Hickey said. “This is what fuels arguments for chest compression only.”

Chest compressions should take priority even over defibrillation, he added. One study showed an improved survival rate of 22% in patients when defibrillation was delayed until after the initiation of chest compressions, compared with a 15% survival rate among patients whose chest compressions followed defibrillation (JAMA 2003;289:1389–95). The same study showed that among patients with more than a 5-minute delay in rescue response following cardiac arrest, immediate defibrillation resulted in only a 4% survival rate, compared with a 22% survival rate in those who had chest compressions before defibrillation.

Dr. Hickey added that high-dose epinephrine is not recommended in children, based on a study showing that it did not improve return of spontaneous circulation and resulted in worse 24-hour survival (New Engl. J. Med. 2004;350:1722–30).

In neonatal resuscitation cases, current recommendations no longer advise intrapartum oropharyngeal suctioning for infants born after meconium staining of amniotic fluid, he said. Endotracheal suctioning immediately after birth for infants who are not vigorous is now recommended, Dr. Hickey added.

Community health centers are currently clinically understaffed and will likely face increasing shortages that may limit their expansion, according to a study by the rural health research centers of both the University of Washington, Seattle, and the University of South Carolina, Columbia, and by the National Association of Community Health Centers.

“Workforce shortages may impede the expansion of the U.S. [community health center] safety net, particularly in rural areas,” reported Dr. Roger A. Rosenblatt from the University of Washington, and his colleagues (JAMA 2006;295:1042–9).

The study surveyed 846 federally funded community health centers (CHCs) within the 50 states and the District of Columbia. Mailed questionnaires and telephone surveys asked CHC chief executive officers about staffing and recruiting patterns, use of federal and state recruitment programs, and perceived barriers to recruitment.

Responses were obtained from 79% of the population and revealed that funded clinical staff vacancies are common. The average CHC has 13% of its family physician full-time equivalent positions unfilled. Rural CHCs reported a significantly higher proportion of these vacancies, as well as recruiting difficulties, compared with their urban counterparts, with more than one-third of rural CHCs reporting that they had been trying to recruit a family physician for more than 7 months. “It would require more than 400 FTE family physicians to fill all the vacancies for this discipline,” noted the authors.

Some of the greatest recruitment difficulties were reported for obstetrician/gynecologists and psychiatrists; rural locations reported more than 20% of funded positions vacant, and they had more recruitment difficulties, compared with urban CHCs. Dentists' vacancies also were indicated, with more than half of rural CHCs reporting a vacant position for 7 months or longer. Less difficulty was reported in recruiting nurse-practitioners and physician assistants, with no significant rural-urban differences.

When asked to indicate perceived barriers to recruitment and retention of both rural and urban CHC physicians and nurses, respondents consistently noted the inability to offer competitive compensation packages.

“The lack of spousal employment opportunities, lack of cultural activities and opportunities, lack of adequate housing, and poor-quality schools were perceived as disproportionately greater barriers for rural centers,” noted the authors.

Survey respondents suggested three potential interventions to address these perceived barriers: better capacity to provide annual salary increases, more National Health Service Corps loan repayment incentives, and greater visibility of CHCs as desirable practice opportunities during training.

“The clinical role of CHCs is dependent on primary care clinicians, both physicians and nonphysician clinicians,” the authors wrote, noting that the declining production of family physicians from residency programs “may lead to serious workforce shortages, particularly in rural CHCs.”

Roughly 66% of the responding CHCs indicated their plans to expand as part of a federal 5-year initiative to increase spending on CHCs by at least $2.2 billion through fiscal year 2006. However, the decline in “physicians choosing generalist careers may be the rate-limiting step in the nation's ability to staff CHCs and may lead to renewed shortages of safety-net and rural physicians generally,” they wrote.

The authors made several suggestions, including the following, for federal and state governments, as well as for CHCs:

▸ Bolstering elements of the Health Professions Educational Assistance Act of 1976, the only federal program aimed at encouraging primary care clinicians who are likely to practice in underserved areas.

▸ Increasing the use of nurse-practitioners and physician assistants.

▸ Creating new alliances between CHCs and primary care training programs.

▸ Expanding the National Health Service Corps and related programs that provide financial incentives to attract health care clinicians to underserved areas.

▸ Developing new approaches to loan repayment plans.

▸ Creating additional incentives for rural areas.

Community health centers are currently clinically understaffed and will likely face increasing shortages that may limit their expansion, according to a study by the rural health research centers of both the University of Washington, Seattle, and the University of South Carolina, Columbia, and by the National Association of Community Health Centers.

“Workforce shortages may impede the expansion of the U.S. [community health center] safety net, particularly in rural areas,” reported Dr. Roger A. Rosenblatt from the University of Washington, and his colleagues (JAMA 2006;295:1042–9).

The study surveyed 846 federally funded community health centers (CHCs) within the 50 states and the District of Columbia. Mailed questionnaires and telephone surveys asked CHC chief executive officers about staffing and recruiting patterns, use of federal and state recruitment programs, and perceived barriers to recruitment.

Responses were obtained from 79% of the population and revealed that funded clinical staff vacancies are common. The average CHC has 13% of its family physician full-time equivalent positions unfilled. Rural CHCs reported a significantly higher proportion of these vacancies, as well as recruiting difficulties, compared with their urban counterparts, with more than one-third of rural CHCs reporting that they had been trying to recruit a family physician for more than 7 months. “It would require more than 400 FTE family physicians to fill all the vacancies for this discipline,” noted the authors.

Some of the greatest recruitment difficulties were reported for obstetrician/gynecologists and psychiatrists; rural locations reported more than 20% of funded positions vacant, and they had more recruitment difficulties, compared with urban CHCs. Dentists' vacancies also were indicated, with more than half of rural CHCs reporting a vacant position for 7 months or longer. Less difficulty was reported in recruiting nurse-practitioners and physician assistants, with no significant rural-urban differences.

When asked to indicate perceived barriers to recruitment and retention of both rural and urban CHC physicians and nurses, respondents consistently noted the inability to offer competitive compensation packages.

“The lack of spousal employment opportunities, lack of cultural activities and opportunities, lack of adequate housing, and poor-quality schools were perceived as disproportionately greater barriers for rural centers,” noted the authors.

Survey respondents suggested three potential interventions to address these perceived barriers: better capacity to provide annual salary increases, more National Health Service Corps loan repayment incentives, and greater visibility of CHCs as desirable practice opportunities during training.

“The clinical role of CHCs is dependent on primary care clinicians, both physicians and nonphysician clinicians,” the authors wrote, noting that the declining production of family physicians from residency programs “may lead to serious workforce shortages, particularly in rural CHCs.”

Roughly 66% of the responding CHCs indicated their plans to expand as part of a federal 5-year initiative to increase spending on CHCs by at least $2.2 billion through fiscal year 2006. However, the decline in “physicians choosing generalist careers may be the rate-limiting step in the nation's ability to staff CHCs and may lead to renewed shortages of safety-net and rural physicians generally,” they wrote.

The authors made several suggestions, including the following, for federal and state governments, as well as for CHCs:

▸ Bolstering elements of the Health Professions Educational Assistance Act of 1976, the only federal program aimed at encouraging primary care clinicians who are likely to practice in underserved areas.

▸ Increasing the use of nurse-practitioners and physician assistants.

▸ Creating new alliances between CHCs and primary care training programs.

▸ Expanding the National Health Service Corps and related programs that provide financial incentives to attract health care clinicians to underserved areas.

▸ Developing new approaches to loan repayment plans.

▸ Creating additional incentives for rural areas.

Community health centers are currently clinically understaffed and will likely face increasing shortages that may limit their expansion, according to a study by the rural health research centers of both the University of Washington, Seattle, and the University of South Carolina, Columbia, and by the National Association of Community Health Centers.

“Workforce shortages may impede the expansion of the U.S. [community health center] safety net, particularly in rural areas,” reported Dr. Roger A. Rosenblatt from the University of Washington, and his colleagues (JAMA 2006;295:1042–9).

The study surveyed 846 federally funded community health centers (CHCs) within the 50 states and the District of Columbia. Mailed questionnaires and telephone surveys asked CHC chief executive officers about staffing and recruiting patterns, use of federal and state recruitment programs, and perceived barriers to recruitment.

Responses were obtained from 79% of the population and revealed that funded clinical staff vacancies are common. The average CHC has 13% of its family physician full-time equivalent positions unfilled. Rural CHCs reported a significantly higher proportion of these vacancies, as well as recruiting difficulties, compared with their urban counterparts, with more than one-third of rural CHCs reporting that they had been trying to recruit a family physician for more than 7 months. “It would require more than 400 FTE family physicians to fill all the vacancies for this discipline,” noted the authors.

Some of the greatest recruitment difficulties were reported for obstetrician/gynecologists and psychiatrists; rural locations reported more than 20% of funded positions vacant, and they had more recruitment difficulties, compared with urban CHCs. Dentists' vacancies also were indicated, with more than half of rural CHCs reporting a vacant position for 7 months or longer. Less difficulty was reported in recruiting nurse-practitioners and physician assistants, with no significant rural-urban differences.

When asked to indicate perceived barriers to recruitment and retention of both rural and urban CHC physicians and nurses, respondents consistently noted the inability to offer competitive compensation packages.

“The lack of spousal employment opportunities, lack of cultural activities and opportunities, lack of adequate housing, and poor-quality schools were perceived as disproportionately greater barriers for rural centers,” noted the authors.

Survey respondents suggested three potential interventions to address these perceived barriers: better capacity to provide annual salary increases, more National Health Service Corps loan repayment incentives, and greater visibility of CHCs as desirable practice opportunities during training.

“The clinical role of CHCs is dependent on primary care clinicians, both physicians and nonphysician clinicians,” the authors wrote, noting that the declining production of family physicians from residency programs “may lead to serious workforce shortages, particularly in rural CHCs.”

Roughly 66% of the responding CHCs indicated their plans to expand as part of a federal 5-year initiative to increase spending on CHCs by at least $2.2 billion through fiscal year 2006. However, the decline in “physicians choosing generalist careers may be the rate-limiting step in the nation's ability to staff CHCs and may lead to renewed shortages of safety-net and rural physicians generally,” they wrote.

The authors made several suggestions, including the following, for federal and state governments, as well as for CHCs:

▸ Bolstering elements of the Health Professions Educational Assistance Act of 1976, the only federal program aimed at encouraging primary care clinicians who are likely to practice in underserved areas.

▸ Increasing the use of nurse-practitioners and physician assistants.

▸ Creating new alliances between CHCs and primary care training programs.

▸ Expanding the National Health Service Corps and related programs that provide financial incentives to attract health care clinicians to underserved areas.

▸ Developing new approaches to loan repayment plans.

▸ Creating additional incentives for rural areas.

TORONTO — A combination of maternal periodontal disease and high levels of maternal C-reactive protein is associated with a significantly increased risk of preeclampsia, compared with either risk factor alone, according to a new analysis of the Oral Conditions and Pregnancy Study.

“There seems to be some type of synergy when both are combined,” said Dr. Michael S. Ruma, who presented the findings at the annual meeting of the Society for Gynecologic Investigation.

A secondary analysis of 775 healthy pregnant women who had oral examinations and C-reactive protein (CRP) levels measured at enrollment (less than 26 weeks' gestation) found that preeclampsia was more common in those with high CRP levels alone (OR 2.6), and those with moderate to severe periodontal disease (PD) alone (OR 2.0)—but a combination of high CRP levels and moderate to severe PD increased the odds ratio to 7.0.

A total of 31 women (4%) developed preeclampsia in the cohort. The rate of preeclampsia was greater among women with a high CRP level (above the 75th percentile) than for women with a low CRP level (at or below the 75th percentile): 7% and 3%, respectively. The addition of mild PD to the elevated CRP level significantly increased the risk of preeclampsia from an odds ratio of 2.6 to 6.0 and moderate to severe PD increased it further (OR 7.0).

“Maternal systemic inflammation may be in the causal pathway between periodontal disease and the development of preeclampsia,” said Dr. Ruma of the University of North Carolina at Chapel Hill. However, he said, future research is required to further understand this phenomenon. “Both periodontitis and preeclampsia are multifactorial, but the implication is that inflammation in the mother is leading to systemic disease,” he said in an interview.

A separate study presented at the meeting suggests that such maternal inflammation may also be transferred to the fetus—particularly in the setting of maternal smoking. In a study of 277 women, Dr. John P. Newnham of the Women and Infants Research Foundation at King Edward Memorial Hospital in Perth, Western Australia, and his colleagues found that 12% of women with PD had babies who were small for gestational age (SGA), compared with 2% of women who had healthy gums (“Gum Disease Again Tied to Pregnancy Outcomes,” OB.GYN. NEWS, June 1, 2005, p. 28). Further analysis of this study, which was presented at the meeting, found this effect is significantly increased (25%) in women who smoke. Additionally, the researchers found that in smokers, both with and without PD, inflammatory markers (CRP and tumor necrosis factor-β) were significantly elevated in umbilical cord blood, indicating an inflammatory response in the fetus.

“The thing I found absolutely fascinating was this marked inflammation in the fetus at birth as a result of the woman smoking in pregnancy—and PD added further to it,” Dr. Newnham said in an interview. “Smoking not only increases the risk of PD, which everyone has known for a long time, but smoking increased the inflammatory markers in the cord blood and PD added to this.”

Although the absence of PD is associated with better obstetric outcomes, it is not known whether treating PD during pregnancy is beneficial or harmful, said Dr. Newnham. “We are in equipoise. We know inflamed periodontal tissue can release cytokines and prostaglandins,” he said, leading some to hypothesize that the treatment of PD could temporarily increase maternal systemic inflammation.

TORONTO — A combination of maternal periodontal disease and high levels of maternal C-reactive protein is associated with a significantly increased risk of preeclampsia, compared with either risk factor alone, according to a new analysis of the Oral Conditions and Pregnancy Study.

“There seems to be some type of synergy when both are combined,” said Dr. Michael S. Ruma, who presented the findings at the annual meeting of the Society for Gynecologic Investigation.

A secondary analysis of 775 healthy pregnant women who had oral examinations and C-reactive protein (CRP) levels measured at enrollment (less than 26 weeks' gestation) found that preeclampsia was more common in those with high CRP levels alone (OR 2.6), and those with moderate to severe periodontal disease (PD) alone (OR 2.0)—but a combination of high CRP levels and moderate to severe PD increased the odds ratio to 7.0.

A total of 31 women (4%) developed preeclampsia in the cohort. The rate of preeclampsia was greater among women with a high CRP level (above the 75th percentile) than for women with a low CRP level (at or below the 75th percentile): 7% and 3%, respectively. The addition of mild PD to the elevated CRP level significantly increased the risk of preeclampsia from an odds ratio of 2.6 to 6.0 and moderate to severe PD increased it further (OR 7.0).

“Maternal systemic inflammation may be in the causal pathway between periodontal disease and the development of preeclampsia,” said Dr. Ruma of the University of North Carolina at Chapel Hill. However, he said, future research is required to further understand this phenomenon. “Both periodontitis and preeclampsia are multifactorial, but the implication is that inflammation in the mother is leading to systemic disease,” he said in an interview.

A separate study presented at the meeting suggests that such maternal inflammation may also be transferred to the fetus—particularly in the setting of maternal smoking. In a study of 277 women, Dr. John P. Newnham of the Women and Infants Research Foundation at King Edward Memorial Hospital in Perth, Western Australia, and his colleagues found that 12% of women with PD had babies who were small for gestational age (SGA), compared with 2% of women who had healthy gums (“Gum Disease Again Tied to Pregnancy Outcomes,” OB.GYN. NEWS, June 1, 2005, p. 28). Further analysis of this study, which was presented at the meeting, found this effect is significantly increased (25%) in women who smoke. Additionally, the researchers found that in smokers, both with and without PD, inflammatory markers (CRP and tumor necrosis factor-β) were significantly elevated in umbilical cord blood, indicating an inflammatory response in the fetus.

“The thing I found absolutely fascinating was this marked inflammation in the fetus at birth as a result of the woman smoking in pregnancy—and PD added further to it,” Dr. Newnham said in an interview. “Smoking not only increases the risk of PD, which everyone has known for a long time, but smoking increased the inflammatory markers in the cord blood and PD added to this.”

Although the absence of PD is associated with better obstetric outcomes, it is not known whether treating PD during pregnancy is beneficial or harmful, said Dr. Newnham. “We are in equipoise. We know inflamed periodontal tissue can release cytokines and prostaglandins,” he said, leading some to hypothesize that the treatment of PD could temporarily increase maternal systemic inflammation.

TORONTO — A combination of maternal periodontal disease and high levels of maternal C-reactive protein is associated with a significantly increased risk of preeclampsia, compared with either risk factor alone, according to a new analysis of the Oral Conditions and Pregnancy Study.

“There seems to be some type of synergy when both are combined,” said Dr. Michael S. Ruma, who presented the findings at the annual meeting of the Society for Gynecologic Investigation.

A secondary analysis of 775 healthy pregnant women who had oral examinations and C-reactive protein (CRP) levels measured at enrollment (less than 26 weeks' gestation) found that preeclampsia was more common in those with high CRP levels alone (OR 2.6), and those with moderate to severe periodontal disease (PD) alone (OR 2.0)—but a combination of high CRP levels and moderate to severe PD increased the odds ratio to 7.0.

A total of 31 women (4%) developed preeclampsia in the cohort. The rate of preeclampsia was greater among women with a high CRP level (above the 75th percentile) than for women with a low CRP level (at or below the 75th percentile): 7% and 3%, respectively. The addition of mild PD to the elevated CRP level significantly increased the risk of preeclampsia from an odds ratio of 2.6 to 6.0 and moderate to severe PD increased it further (OR 7.0).

“Maternal systemic inflammation may be in the causal pathway between periodontal disease and the development of preeclampsia,” said Dr. Ruma of the University of North Carolina at Chapel Hill. However, he said, future research is required to further understand this phenomenon. “Both periodontitis and preeclampsia are multifactorial, but the implication is that inflammation in the mother is leading to systemic disease,” he said in an interview.

A separate study presented at the meeting suggests that such maternal inflammation may also be transferred to the fetus—particularly in the setting of maternal smoking. In a study of 277 women, Dr. John P. Newnham of the Women and Infants Research Foundation at King Edward Memorial Hospital in Perth, Western Australia, and his colleagues found that 12% of women with PD had babies who were small for gestational age (SGA), compared with 2% of women who had healthy gums (“Gum Disease Again Tied to Pregnancy Outcomes,” OB.GYN. NEWS, June 1, 2005, p. 28). Further analysis of this study, which was presented at the meeting, found this effect is significantly increased (25%) in women who smoke. Additionally, the researchers found that in smokers, both with and without PD, inflammatory markers (CRP and tumor necrosis factor-β) were significantly elevated in umbilical cord blood, indicating an inflammatory response in the fetus.

“The thing I found absolutely fascinating was this marked inflammation in the fetus at birth as a result of the woman smoking in pregnancy—and PD added further to it,” Dr. Newnham said in an interview. “Smoking not only increases the risk of PD, which everyone has known for a long time, but smoking increased the inflammatory markers in the cord blood and PD added to this.”

Although the absence of PD is associated with better obstetric outcomes, it is not known whether treating PD during pregnancy is beneficial or harmful, said Dr. Newnham. “We are in equipoise. We know inflamed periodontal tissue can release cytokines and prostaglandins,” he said, leading some to hypothesize that the treatment of PD could temporarily increase maternal systemic inflammation.